REP NOV 19 by BOC design Inc

vol.27 no.11 â&#x20AC;˘ November 2019

repertoiremag.com

Jeanne Mumford

Meet the Point-of-care Coordinator They bring order to many points of care

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NOVEMBER 2019 • VOLUME 27 • ISSUE 11

Meet the Point-of-care Coordinator They bring order to many points of care

Jeanne Mumford

PUBLISHER’S LETTER

Healthcare Innovation

Through the Air Walgreens announces pilot program to deliver health and wellness products to customers via drones

24 Trends

The Memories We Share Together.......................... 4

DISTRIBUTION Providers Tell Suppliers How It Is Issues on the table at HIDA Streamlining Healthcare................. 6

PHYSICIAN OFFICE LAB In With the New How distributor reps can help a product launch succeed.................10

IDN OPPORTUNITIES Supply Chain Executive Profile Tracy Griffin, Executive Director of Strategic Sourcing and Supply Chain, Cone Health, Greensboro, North Carolina...................16

Data Dump? It’s no easy task for physicians to make use of data from their patients’ wearables and apps

30 repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2019 by Share Moving Media. All rights reserved. Subscriptions: $49.00 per year for individuals; issues are sent free of charge to dealer representatives. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POSTMASTER: Send address changes to Repertoire, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publisher. Publisher cannot accept responsibility for the correctness of an opinion expressed by contributing authors. Periodicals Postage Paid at Lawrenceville, GA and at additional mailing offices.

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November 2019

NOVEMBER 2019 • VOLUME 27 • ISSUE 11

TRENDS E-visits Addressed with New CPT® Codes.................38

DIABETES

Diabetes Technology

Diabetes in the News...................46

QUICK BYTES Technology News...........................50

For the first time, the 2019 American Diabetes Association’s ‘Standards of Medical Care in Diabetes’ includes a dedicated section on diabetes technology.

HEALTHY REPS Health News and Notes..............54

HIDA INSIGHTS CMS Makes Payment Changes to Improve Healthcare in Rural America....55

INDUSTRY NEWS News ........................................................58 Products to Watch .......................60

Windshield Time

Automotiverelated News

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Rep Corner

Aim High! Aerospace defense contracting lays the groundwork for Seth Garcia’s career in GPO sales.

OUR $1 BILLION COMMITMENT TO HELPING END AMERICA’S IV FLUID SHORTAGES At B. Braun, we’re investing over $1 billion to help ensure the shortages of the past several years are really a thing of the past. Introducing Solutions for Life—our long-term commitment to help end America’s IV fluid shortages. With two modern IV fluid production facilities here in the U.S., and FDA-approved IV solutions manufactured in Europe, we’re creating sustainable IV solutions for the American healthcare system. Because it’s the right thing to do. See our story at BBraunUSA.com/SolutionsforLife ©2019 B. Braun Medical Inc. Bethlehem PA. All rights reserved.

PUBLISHER’S NOTE

The Memories We Share Together Each year when I get to write the November Publisher’s Letter, I do it with a smile.

As I’ve said over the years, Thanksgiving is my favorite holiday. There is just something about the fall chill in the air that brings us all a little closer together, and the Thanksgiving holiday itself is about spending time with friends and family. I feel so blessed to have spent 24 years in this industry, with the last 11 being here at Repertoire. I’m extremely thankful for the relationships that have been forged with individuals throughout the industry. There are the distribution relationships that have been so important to my success over the years. The friends that have come into my life through distribution have made doing business in this industry so rewarding. Thank you all for what you do each and every day to better the lives of the manufacturers you represent and the caregivers you call on. Then there are the mentor relationships that have been so life-changing for me. Bill Riddell took a chance on a 26-year-old kid with a Southern accent and sent me to the Northeast to call on distribution. Then Billy Harris challenged me in so many ways and truly taught me and so many others like me about business. And finally, Brian Taylor, who taught me the art of caring about people before you ever try to sell them something. Each of these men played a critical role in my life, and the lives of so many of you reading Repertoire today. I’d like to simply say thank you to each of you. Finally, the manufacturer friendships that I have been blessed with over years of doing the circuit together. I hesitate to name names because I don’t want to leave anyone out, but I would like you each to know how thankful I am for you and the memories we share together. As I sit and reflect there are countless stories that come to mind. I will be forever grateful for you and the impact you have made on my life. This is obviously not a normal Publisher’s Letter, so thank you for allowing me to just be grateful publicly for the relationships this great industry affords us all. My challenge to you this holiday season is to let the relationships in your life know how thankful you are for them. At the end of the day, all we really end up with are those that we hold close.

Scott Adams

Happy Thanksgiving, R. Scott Adams

repertoire is published monthly by Share Moving Media 1735 N. Brown Rd., Suite 140, Lawrenceville, GA 30043 Phone: (800) 536-5312, FAX: (770) 709-5432; e-mail: info@sharemovingmedia; www.sharemovingmedia.com

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Katie Educate

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sales executive - East

Lizette Anthonijs

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editor-in-chief, Dail-eNews

Alan Cherry acherry@sharemovingmedia.com art director

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sales executive - West

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publisher

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2019 editorial board Richard Bigham: IMCO Eddie Dienes: McKesson Medical-Surgical

btaylor@ sharemovingmedia.com

Joan Eliasek: McKesson Medical-Surgical

circulation

Doug Harper: NDC Homecare

Ty Ford: Henry Schein

Laura Gantert

Mark Kline: NDC

lgantert@ sharemovingmedia.com

Bob Ortiz: Medline Keith Boivin: IMCO Home Care

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DISTRIBUTION

Providers Tell Suppliers How It Is Issues on the table at HIDA Streamlining Healthcare By Mark Thill

CHICAGO – What’s top of mind for providers is often

top of mind for their distributors too. How about the two getting together to achieve some peace of mind? Providers appear to be open to the idea, especially as health systems expand and become more complex to manage. That much was evident during two panel discussions at the HIDA Streamlining Healthcare Expo & Business Exchange in Chicago. The first, “Improving distribution and logistics in health systems,” featured: •M ark Campbell, vice president, supply chain, Tampa General Hospital. • Mike Hopkins, vice president, supply chain distribution and logistics, Northwestern Memorial Health Care.

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• Josh Andrade, director, supply chain shared services, HonorHealth. • Brian Zuck, vice president, supply chain, Essentia Health The second, “Innovative strategies for managing the nonacute supply chain,” featured: • Jevon Hawkins, regional director, supply chain, Wellspan Health. • Jean Llewellyn, director, supply chain management, non-acute, MedStar Health. • Darrick Adams, director non-acute supply chain, AdventHealth. • Callie Klump, senior director supply chain logistics, Texas Health Resources.

Some key takeaways for distributors and providers. 1. Standardization of product and processes is a big – HUGE – challenge for supply chain executives as their health systems acquire hospitals, physician practices and other non-acute-care sites. Some supply chain executives rely on their GPO for help in this area, others look to their distributor to help lead the charge, particularly among non-acutecare sites. One supply chain executive at the conference recounted assembling 12 physician groups in a locked room for three days of uninterrupted, heart-to-heart talk about standardizing. 2. Direct-ship manufacturers aren’t helping matters. One supply chain executive half-joked that he’s considering charging rent to direct-ship manufacturers whose consigned implants clog valuable space in the hospital. Distributors might help by serving as a 3PL for direct-ship manufacturers – though that’s easier said than done. 3. Keeping tabs on purchasers in 400, 500 or 600 clinics isn’t easy. Given the turnover of support staff in physician offices and clinics, supply chain VPs continually struggle with educating new hires on the ordering process, formulary management and inventory control. 4. Physicians are getting it … but they’re not quite there yet. Physicians still enjoy the freedom to choose what they think is best for their patients. Supply chain has to respond with data about outcomes and cost-per-case. And though it’s true that physicians are more tuned in to cost than ever before, they still believe that if the hospital charges for something, they get paid for it. “We do not,” said one supply chain executive. 5. Customer service is just as important to supply chain executives as it is for distributors – and just as difficult. As health systems expand, so too does the number of clinical customers calling up supply chain about the status of an order or the reason for a substitution. The supply chain director’s task is made tougher given the rapid turnover of staff in their department. How do you train people to greet callers courteously, respond openly to questions, and resolve issues – instead of kicking them down the road?

6. From purchasing to utilization to demand planning. Health systems have a pretty good handle on what they buy, but they want to reach the next step. Using technology, they want information on what they use, who’s using it, and how much it costs per case. Some are willing to work with their distributor in gathering and analyzing that kind of data. 7. Cost-per-whatever. Health system supply chain executives are getting pushed by senior management to improve cost per unit of service, be that creation of a purchase order or a knee arthroplasty. One hitch: EMRs weren’t built with cost-per-case in mind.

The supply chain director’s task is made tougher given the rapid turnover of staff in their department.

8. RFID is definitely worth a look. RFID technology helps providers: 1) know where valuable assets are in real time, 2) reduce labor costs associated with tracking them down, and 3) avoid spending money on redundant items. 9. Mr. or Ms. Robot. Expect hospitals to pilot-test robots delivering food service and even med/surg supplies to nursing units.

10. Non-acute has traditionally been the stepchild of supply chain management for healthcare providers … and in a sense, it still is. One executive spoke of a “team of one” overseeing non-acute purchasing and distribution. That said, non-acute-focused supply chain executives depend on support from their acute-care contracting colleagues and senior management. 11. Get the word out, even if it’s unpleasant. Supply chain executives with non-acute responsibilities know the value of good communication with distributors and clinicians … and the price of poor communication. It’s especially important to keep the lines open when it comes to informing hundreds of offsite facilities about backorders, conversions and substitutions. 12. Wanna know the secret sauce of a great relationship between distributor and non-acute supply chain VP? Simple: Trust.

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November 2019

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PHYSICIAN OFFICE LAB

In With the New How distributor reps can help a product launch succeed By Jim Poggi

For this month’s column, I spent some time thinking

about the new product launches I’ve managed or experienced. Almost all of those launches started with boundless enthusiasm and excitement by me and the product’s supplier. Some were obvious winners like flu kits and reader technology. Others either failed outright or never met expectations.

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I plan to share my thoughts and experiences so you – the account managers tasked with understanding and selling these new products – can benefit from what I’ve learned. Many of my experiences are related to lab products, but the themes apply to any product category. Once your company has evaluated and agreed to launch a new product, you can be confident they’ve done

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PHYSICIAN OFFICE LAB their due diligence and have some well-established expectations about market acceptance and revenue and margin achievement. How should you do your due diligence and prepare to succeed?

Defining “new” First, understand what “new” means for this product. Just how new it is makes a big difference to your customers and you. Is the product or service unique and a revolutionary change in patient care? These types of products typically require more time to take hold in the market. I think of allergy and cancer immunotherapy as well as BNP when it was launched a few years ago when I think of truly revolutionary products. Sometimes new simply means a step forward, an improvement in current tests or products. Influenza test readers come to mind, as does EMR connectivity for smaller lab instruments. These incremental improvements are easier to explain to customers and typically address an unmet customer need. With the right amount of focus, they can take off quickly.

• Does it replace current technologies or simply represent “a better mouse trap?” • Is it only suited to your most forwardthinking customers? • Can it help you to finally bring an exciting new product to prospects you want to convert to customers? Setting your targets appropriately can save you a lot of time and wasted effort down the road. We all know that medical practice tends to adopt new tests and therapies slowly to assure proper performance and true value to clinicians and their patients. Adoption of EMR comes to mind. Despite generous incentives to adopt EMR, the massive change in the clinician/patient experience and questions about how to migrate current records into the new EMR solution held adoption back to a large degree. I also like to test the new product I am offered against well-established benchmarks of clinical customer value. Does the product improve clinical patient outcomes? Does it improve workflow? How about better economic outcomes for the practice? The more balanced the customer benefits are, the more likely it is to be adopted readily. We have all seen the challenges we experience when a benefit in one area leads to a disadvantage in another area. There are lab tests that offer exceptional clinical value but take longer than the 15 minutes typically considered the average patient visit time. It takes greater care to effectively sell these types of products, and practice acceptance is usually based on how well the benefits match their practice objectives. For lab products in particular, does the new product offer greater accuracy and faster time to result, or does it address an important patient condition clinicians encounter every day, such as heart disease, cancer and diabetes? Finally, does the product help to initiate or modify a patient treatment program?

Sometimes new simply means a step forward, an improvement in current tests or products. Influenza test readers come to mind, as does EMR connectivity for smaller lab instruments. These incremental improvements are easier to explain to customers and typically address an unmet customer need. With the right amount of focus, they can take off quickly. “New” sets the tone for much of our thinking about how much time, energy and focus to devote to the product. As you think about the new product you have been offered, it makes sense to direct your thinking to the customers you serve. •W hich of your customers will be most interested in this product? •W ill it be a mainstream product used widely by most customers?

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Cost and price How do cost and price fit into the equation? This can be tricky whether reimbursement is high OR low com-

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PHYSICIAN OFFICE LAB pared to end user cost. Make sure you can confirm with the supplier that your cost and the customer’s end user price are grounded in reality. All too often, list prices tend to be unrealistic in the marketplace. The distribution account manager needs to be confident in the margin based on anticipated average customer selling price. At the same time, beware of differences in end user cost to reimbursement that are so large that they cause different problems: risk of over-utilization and ultimately scrutiny, particularly by private payers.

Input What about customer input? Ask your supplier for references, especially local ones, and be sure to verify the customer perspective. What is the reason they adopted the

technology? Is it clinically better? Which types of physician practices do they see this product helping? When I had a territory, I used the “two types of customer” test. When I wanted to gain input on new products, I used to expose the products to two very different types of customers. I wanted to hear from my loyal customers who trusted me for products that delivered excellent clinical value along with my knowledge and expertise in lab. I also wanted to hear from the customers who considered me “just another sales guy trying to sell us something”. Their perspectives were typically very different and I learned different things from the input of both groups. When their opinions were similar, whether positive or negative, I could be confident that product acceptance would follow their opinion. When different, it caused me to seek further input. Finally, trust your supplier and colleagues. Every established supplier relies on product quality, market fit and credibility to gain your trust and acceptance and to assure that their solution fits smoothly into the customer’s setting as an important solution. Make sure to ask the right questions and ask to visit current customers with your supplier or to set up a workday to expose the product with your customers and prospects. Your colleagues in the field and the home office can help you gain additional perspective and help you formulate thoughts and questions you might not have thought about before. At the end of the day, while we are always looking for an answer to the often-asked customer question “What’s new?”, a little advanced planning can help us grow our business quickly or avoid needless fire drill management down the road. Time spent now assures happier customers, better references for you and an even stronger reputation as a consultant to your customers and prospects. Plan to win.

There are lab tests that offer exceptional clinical value but take longer than the 15 minutes typically considered the average patient visit time. It takes greater care to effectively sell these types of products and practice acceptance is usually based on how well the benefits match their practice objectives.

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IDN OPPORTUNITIES

Supply Chain Executive Profile Tracy Griffin Executive Director of Strategic Sourcing and Supply Chain Cone Health, Greensboro, North Carolina Editor’s note: Tracy Griffin was recognized among “Women Leaders in Supply Chain” last year by the Journal of Healthcare Contracting, sister publication to Repertoire. Here are comments from nominator Tim Nedley, vice president, materials management, UPMC: “Tracy and I worked together at Owens & Minor from 2000 to 2005, and she was later one of my customers when she moved to Cone. She is quietly one of the most forward-thinking supply chain leaders I know. Currently, Tracy has responsibility for all strategic sourcing and logistics, including a 53,000-squarefoot distribution center that supplies the six Cone hospitals, several surgery centers, three urgent care centers and over 150 physician practices.”

Cone Health at a glance: Six hospitals, several surgery centers, three urgent care centers, more than 150 physician practices Year joined Cone Health: October 2005 Born/raised: Henderson, North Carolina Degree(s): Business/eBusiness degree, University of Phoenix Tracy Griffin First “real” job out of school: Receptionist for human resources and purchasing for Maria Parham Hospital in Henderson, North Carolina, out of high school while attending Vance Granville Community College at night.

Some prior work highlights: 1. Worked for a cardiologist practice learning about coding, billing and reimbursement, and fostered interaction with physicians and surgeons.

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2. Created vision for an offsite distribution center to support not only five acute care hospitals, but also 150 physician practices, urgent care centers and other facilities. This allowed for cost savings and bulk purchases. 3. Created a Leadership Team focused on quality outcomes and looking at savings through a different lens. Example: First in the nation to implement a therapeutic linen as part of daily inpatient care, lowering length of stay, reducing wound ulcers, and resulting in savings. A key mentor or event in your life: There are a couple of key events/ mentors that shaped my focus on quality healthcare products, processes and cost. The first was my personal experience growing up with my mom, having multiple sclerosis, and seeing the lack of standardized products and processes of care – as well as the wide variation in cost. At age 11, I knew I would be in some field of healthcare. I had a knack for numbers, and analytics, so I began learning and exploring as much as I could about data programs, optimization and efficiency. One of my bosses – Barry Cunningham – had a huge impact on me. He called me into his office one day and said, “You are very smart and could really excel, but you need to get out of your own way. You need to show up believing in yourself and the capabilities you have. Set yourself apart. Come in dressed and ready for the position you desire.” So I began to interact as an operations manager over the distribution and office functions, which was a springboard into an ever-growing role in healthcare.

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Meet the Point-of-care Coordinator They bring order to many points of care Jeanne Mumford

November 2019

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Health systems keep growing in size, and so does the volume of point-of-care tests being conducted in their

acute- and non-acute-care settings. Needless to say, the management challenges associated with POC testing are growing as well.

Repertoire: The point of care coordinator: Is this a new position in the industry? Jeanne Mumford: It’s not new, but given the growth of point-of-care testing, it has become more widely recognized. In the past – and still, to some extent, today – point-of-care testing was overseen by bench techs who wear many hats in the lab. But quality oversight of a well-run POCT is a full-time job. Having other pathology duties in addition to the POCC role is very difficult to maintain.

or policy that tells you how to be a POCC – how to work with multidisciplinary teams in clinical settings, or even how to negotiate or work with vendor/industry reps. Each day brings a unique set of challenges and workload. Adaptation and critical thinking are key skills for this role. A typical day is spent “putting out fires” or fixing the one hot issue that seems to come up every single day. We inventory our reagents and supplies, and check in with vendors or supply chain for the next shipments and lot number delivery dates. Once we receive new shipments of reagents and supplies, we validate them and distribute to either our central supply folks or straight to the units doing the tests. We visit our units or satellite sites across the state or region daily, weekly, or on a set month-to-month schedule. With the units and testing personnel, we troubleshoot local issues, communicate changes or updates, and basically check in to see how things are going on a day-today basis. Visibility on the units is so important to establishing trust and a relationship with testing personnel. We also check in and validate new tests and new instruments, which could be replacements for broken ones, and we visit with units that are adding additional instruments. We train and document training and competency on testing personnel – sometimes by the thousands – on the procedures that we write for each test system. We monitor our middleware software for interface errors, manage connectivity, troubleshoot, and work to fix the errors in the system. If we are lucky, this is all done in eight hours a day, 40 hours a week.

Repertoire: Describe a typical day in the life of a POC coordinator. Mumford: One very difficult lesson to learn as a point of care coordinator is that you seldom have a procedure

Repertoire: In the past five years or so, has the POC coordinator’s job or responsibility been affected by developments in POC testing itself? If so, what POC developments or trends would you point to?

For example, who is doing testing in the hospitals and far-flung non-hospital sites? Who is overseeing their qualifications and work for quality control purposes? Is testing equipment monitored for quality purposes? Has anybody tried standardizing test equipment and kits across the system? Who’s minding the store??? Enter the point of care coordinator (POCC) – an influential person in the health system, and one with whom sales reps should become acquainted. Jeanne Mumford, MT, is pathology manager at Johns Hopkins Medicine in Baltimore. She has a staff of five point-of-care coordinators, located at two academic hospitals, and oversees quality at three community hospitals, and a physician-office system. She became a medical technologist in 2000, and has been in the Johns Hopkins system since 2010. Repertoire recently spoke with Mumford about the role of the point-of-care coordinator in today’s hospitals and health systems.

“Clinical teams want to treat patients. They don’t want to do laboratory testing.”

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Meet the Point-of-care Coordinator Mumford: Technology advancements do affect the role of the POCC. For the most part, they are positive attributes. Quicker turnaround times, convenience at the patient bedside, smaller instrument foot prints, better methodologies, etc., are characteristics sought after in the point-of-care-testing world just as in the central labs. Connectivity is the key word here. More and more, point-of-care testing programs across the country are looking to interface their POC tests. In the past, this was an area of IT in which only the central lab instruments fell. One of our new challenges is learning how to work with our hospital and system IT folks to connect and maintain our interfaces with our pointof-care instruments.

to the laboratory interface, to the POC middleware, the entire infrastructure should, ideally, be rebuilt to a single platform. The same goes for the central laboratory systems. They, too, should be standardized to one vendor/ methodology for financial and clinical efficiency. Harmonization refers to policies and procedures that cover all facilities under one document or manual. For instance, as we standardize to a single glucometer, we are working to have a single procedure in a manual for all of the hospitals and medical groups. Harmonization also refers to harmonizing all of the laboratory tests. Another challenge for expanding health systems is finding best practices for workflow, instrumentation, procedures and IT structure. Walking into these institutions and saying, “Switch to our instruments, policies, and workflow,” doesn’t work. It breeds discontent. It is prudent to sit down with all of the business owners and find out what is working and what isn’t working within the current systems. Then, work with purchasing or supply chain and find the right pricing model for your system. Sometimes the right price beats the best technology when it comes to decisionmaking for acquisitions and new instrumentation.

“ One of our new challenges is learning how to work with our hospital and system IT folks to connect and maintain our interfaces with our point-of-care instruments.” Five years ago, across all of Johns Hopkins Medicine, we began implementing a single middleware product, a single laboratory information system, and a single patient medical record. All of our point-of-care instruments are now connected through a single IT platform. This has made my staff ’s work much easier than it used to be. Repertoire: What challenges (or opportunities) are presented to the POC coordinator when the hospital or health system acquires another hospital, long-term-care facility, or a medical group with multiple clinics? Mumford: Standardization and harmonization are both the blessing and curse when establishing new partnerships. Standardization is the act of switching all the laboratory/POC instruments and test kits to the same instrument/system. It involves upgrading everyone to one centralized IT platform. From the patient medical record,

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Repertoire: How involved is the POC coordinator in evaluating and selecting new point-of-care testing systems. Mumford: In my particular setting – a large academic health system – our point-of-care coordinators are fully engaged in evaluating new POC testing systems. We work with our central laboratory and medical directors to evaluate the analytics of new point-of-care systems. We also work with research units or clinical teams when they perform clinical evaluations on new technologies. For coordinators who lack these resources to evaluate new technologies, networking with POCCs who can offer their data and feedback can help them to stay up to date on new tests. In a well-organized and well-maintained POCT program, sales representatives approach the pathology department with new technology before “selling” it to the

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Meet the Point-of-care Coordinator doctors. Our point-of-care coordinators and medical directors test new technologies in real world settings which go far beyond what the CLIA regulations and FDA 510(k) standards call for. Having a symbiotic relationship with manufacturers is the key to unlocking the potential in all technologies. Manufacturers who work with point-of-care coordinators as experts of the products or systems in which they are used can develop instruments and technologies that meet all the needs of the POCT program, current and future.

tend to use terms that we understand in the lab and that are in line with our regulatory bodies. But clinical teams, such as nursing, don’t comprehend laboratory lingo, despite their science-based field of study. Conversely, point-of-care coordinators don’t know nursing teaching models. The best outcomes revolve around capturing the most meaningful communication tools to mix the laboratory’s regulatory needs with the nursing/ clinical needs. Clinical teams want to treat patients; they don’t want to do laboratory testing. We try really hard to have relationships with our clinical teams that allow them the time they need to take care of their patients. Another challenge is the fact that in many POCT programs, lab staff seldom meet with clinical teams on a regular basis to hash out challenges, celebrate successes, and prepare for upcoming changes. Lab staff have their scheduled team meetings, and the clinical teams have theirs. Learning how to schedule time together without filling everyone’s calendars with needless meetings is a real challenge. Also, point-of-care coordinators lack authority to discipline testing personnel who don’t follow procedures. This goes back to communication skills and how to help testing personnel understand why and how to perform certain tasks. The misconception about POCT is that you put a sample into a device or instrument, you get a result, and you move on with your day. That is just a very small portion of what is done to maintain a point-of-care testing program according to regulations. One more challenge comes to mind: Disseminating information from the POCT program to all three shifts of testing personnel in every single unit that does point-ofcare testing. Some of our programs are so large, and testing personnel can number in the thousands. What’s more, geographic distribution can cover an entire state.

“ In a well-organized and wellmaintained POCT program, sales representatives approach the pathology department with new technology before ‘selling’ it to the doctors.” Repertoire: What are the two or three most challenging “people-related” issues the POC coordinator has to deal with in today’s multihospital system? Mumford: One challenge is learning how to communicate in a blame-free and meaningful way. It takes time and practice. Also challenging is learning how to help testing personnel from clinical teams understand the regulations that must be followed when performing laboratory tests – as well as the consequences we all face when these requirements are not met. Clinical teams don’t necessarily “speak the language” of the lab; nor do point-of-care coordinators “speak the language” of patient care teams. (We jokingly refer to these two languages as “nurse-ese” and “lab-ese.”) For example, when we write procedures for the lab tests, we

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The things you can do!

What you can do in the lab today that you couldn’t do 10-15 years ago Editor’s note: Have you stopped recently to consider just how far lab technology has progressed in the past 10-15 years? We asked Jim Poggi, Repertoire contributing editor and president of Tested Insights, LLC, to take a look at the big picture. Test Molecular tests for flu, strep and RSV Molecular GI tests (C. diff, MRSA) Waived hepatitis C test

Diagnoses Flu, strep, RSV

Important in POL? Yes, but also hospital

C. diff, MRSA

Benefit More sensitive; fewer false negative results Faster, more sensitive

Hepatitis C

Easier screening access

Waived CBC Lactate

CBC Sepsis

Yes. (CDC screening recommendation) Yes Limited; mostly hospital

Procalcitonin

Sepsis

High sensitivity Troponin I Fecal immunochemical Test (FIT) Waived A1C for diagnosis, NOT disease monitoring Waived meter-based testing for cardiac and drug tests

Heart attack, acute coronary syndrome Colorectal cancer

Easier screening access Early indicator of sepsis; speed is CRITICAL Early indicator of sepsis; Limited; mostly speed is CRITICAL hospital Fast, accurate diagnosis Limited; mostly hospital Improved sensitivity Yes and specificity Easier screening access Yes

Meter-based tests for PSA, TSH and tumor markers EMR connectivity for small to large POL lab systems

Diabetes diagnosis

Mostly hospital

Heart failure; drug use

Better cardiac Yes screening improves time to treat and better outcomes; drug screening can lead to counseling and intervention Prostate cancer, other Early screening Yes cancers, thyroid improves path to care disease and outcomes No, but makes data Patient test data needs Yes available for billing and to be widely available to patient history files the caregiver community

Source: Tested Insights, LLC

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November 2019

HEALTHCARE INNOVATION

Through the Air Walgreens announces pilot program to deliver health and wellness products to customers via drones

Walgreens announced a partnership to pilot drone de-

liveries beginning in October to local customers in Christiansburg, Virginia. Walgreens and Wing Aviation LLC, a drone operator certified as an air carrier by the Federal Aviation Administration earlier this year, will begin offering drone delivery service to eligible residents of Christiansburg, Virginia beginning in October, according to a release. The companies will utilize the pilot program to further explore the future of health and wellness product and retail delivery through the air, offering product availability and home delivery minutes after placing orders via the Wing app. “Walgreens continues to explore partnerships to transform and modernize our customer experience and we are proud to be the first retailer in the U.S. to offer an on-demand commercial drone delivery option with Wing,” said Vish Sankaran, chief innovation officer, Walgreens Boots Alliance, Inc. “With a customer-led focus, we continue to create differentiated shopping experiences that provide the products and services consumers need wherever, whenever and however they may want them. This is the kind of omni-channel partnership and offering that can redefine convenience for our customers and communities – delivering items to homes in minutes, not hours or days.” Why Christiansburg? The market was selected because Wing has been working closely with nearby Virginia Tech in Blacksburg to test drone delivery as part of

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the U.S. Department of Transportation’s Integration Pilot Program since 2016.

How it will work Eligible customers in the Christiansburg area will have access to more than 100 products and six convenient “packs” via the Wing app. Customers can either choose the individual products they need or choose one of the pre-built packs in the following categories: allergy, baby, cough/cold, first aid, pain, and kids’ snacks. Prescription deliveries are not available via this service, the release said. The drone delivery option meets use cases where customers may want health and wellness or food and beverage items immediately, but leaving home is not ideal. For example: • Parents at home with a sick child can order the “baby pack” with items such as children’s ibuprofen, water and more to nurse their little one back to health while never having to leave their side. • Those with a common cold or flu can avoid spreading germs to others by ordering the “cough/ cold pack” with a variety of cough and cold products needed to get healthy. Wing and Walgreens said they will reach out to Christiansburg residents to provide additional information about the new offering. The companies will also host a drone delivery demonstration for community members.

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spills can expose doctors, nurses, other healthcare workers and patients to elemental mercury. At room temperature significant amounts of liquid elemental mercury transform to a gas, exposing workers or patients in the area to potentially highly toxic levels. Ethyl chloride is another example of a HAZMAT material that can have even more serious effects. It can cause both short- and long-term health problems that range from mild to severe. For example, the precautions on ethyl chloride state that “Inhalation of ethyl chloride may produce narcotic and general anesthetic effects and may produce deep anesthesia or fatal coma with respiratory or cardiac arrest.” It is also highly flammable. Ethyl chloride is known as a liver and kidney toxin; long-term exposure may cause liver or kidney damage. It has also been listed on California Prop. 65 as a “chemical known to cause cancer.” since 1990.

A safer alternative to ethyl chloride Removing ethyl chloride from the physician office only makes sense if there is a safer alternative available that is also lower in cost. In this case there is an ideal, safer clinical and therapeutic alternative available. CryoDose TA is non-HAZMAT, non-flammable, non-toxic and requires no special storage or handling, and is disposed of with normal trash.

An ideal, safer alternative exists. ethyl chloride Extremely flammable

Non-HAZMAT & Non-flammable

Acute toxicity

No systemic toxicity

Inhalation precautions

No inhalation precautions

CA Prop 65 listing

No listings or restrictions

HAZMAT shipping

Shipped with regular orders

HAZMAT storage

No restrictions or procedures

HAZMAT disposal

Normal trash disposal

Taking immediate action Fortunately, physician offices can take immediate action on the most hazardous products in their office. Some HAZMAT products can be phased out or replaced with safer products that are now available on the market. For instance, glutaraldehyde can be replaced with ortho-phthalaldehyde (OPA) and a mixture of hydrogen peroxide and peracetic acid. It is also relatively easy to phase out the use of mercury because of the many safe, cost-effective non-mercury alternatives that exist for nearly all uses of mercury in health care. Ethyl chloride can be replaced with CryoDose TA by Nuance Medical, a safer clinical and therapeutic Sources:

www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200 www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1000TABLEZ1 www.osha.gov/SLTC/healthcarefacilities/otherhazards.html www.cryodose.com/toxicethyl/ www.cryodose.com/hazmat-resources/ www.psr.org/wp-content/uploads/2018/05/hazardous-chemicals-in-health-care.pdf www.hercenter.org/hazmat/steril.php

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alternative that is non-HAZMAT, non-flammable, nontoxic, requires no special storage or handling, and is disposed of with normal trash. By taking a safety-first approach to hazardous exposures in the physician office and choosing alternatives to these products, physician offices offer effective solutions while protecting healthcare workers, patients and the environment. For more information, visit cryodose.com

TRENDS

Data Dump? It’s no easy task for physicians to make use of data from their patients’ wearables and apps Editor’s note: This is the third part in a series on wearables and mobile medical apps. This month, Repertoire looks at the impact of wearables on the physician practice.

Fitbit says that 14 million U.S.

adults subscribe to a digital health/wellness service, and pay an average $174 annually for different apps. So … we can probably all agree on one thing: Wearables, or mobile medical apps, are popular with consumers. But how about their doctors? “In 2016 the American Medical Association conducted a survey to examine physician receptivity to various digital health modalities and determined there was considerable interest on the part of physicians,” says Michael Hodgkins, M.D., chief medical information officer for the AMA. “Specifically, physicians believed these tools could contribute to better patient care.

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“However, recent studies have shown considerable variability in the accuracy of data from wearables, such as Fitbit, and there is an absence of evidence supporting the actual contributions these tools can make to improving health outcomes.” Karl Poterack, M.D., medical director of applied clinical information for Mayo Clinic, echoes some of those misgivings.

“What if my patient walks 5K vs. 10K vs. 15K per day?” he asks. “A device can accurately measure steps – but is that a modality worth measuring? “On the other hand, as part of a plan determined jointly by the patient and physician, there are certainly physicians willing to utilize the ‘encouragement’ functions of fitness trackers,” he adds.

Swimming in data “The eagerness to incorporate mobile medical apps and wearables varies with the individual physician,” says Poterack, whose research interests are primarily directed toward the use of wearable devices. “There is a lot of appropriate reluctance to do so, for multiple reasons.” Among them: • Very few practices have the infrastructure to import and sift through the massive amounts of data these devices can generate. • Physicians lack control over wearables, with no ability to perform quality control, and even no visibility into who is actually wearing the device. • Physicians have concerns about the liability and responsibility for reviewing the data – something that has not been clearly defined. • Physicians have questions about what some of the data even means clinically.

In October 2018, the American Medical Association unveiled its Digital Health Implementation Playbook to present key steps, that is, “best practices and resources to accelerate the adoption and scale of digital health solutions.” Step No. 1? Identifying the need. “The predicate for innovation is to always ask ‘What problem am I trying to solve?’” says Hodgkins. “Many well-meaning entrepreneurs develop a passion for an idea but don’t necessarily have the background in healthcare to really understand if that idea is something that addresses a real need.” Poterack says that wearables historically have proved most valuable when used on a temporary or semi-permanent basis, e.g., to identify arrhythmia. “There’s a purpose to it, a question to be answered, and implications to the answer. There is good, solid equipment and a good reporting system. And at the end, you feel confident

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November 2019

TRENDS you’ve gone through the data and you’ve got the information you need to make a decision. “It’s purpose-built and has a defined question to be answered.” But as developers of mobile apps race to introduce new technologies, are they addressing these fine points? Hodgkins says that physician practices can take steps to protect themselves from the influx of data that can accompany these new technologies. “First, by designing specific protocols at the time of implementation, practices can empower other members of the care team to take the lead on monitoring and only involve physicians when there’s an abnormality or question,” he says.

“Second, some practices have partnered with the vendor to help limit the amount of data coming into the practice and/or EHR. [S]ome vendors provide resources to monitor data and escalate as needed. This allows physicians to only receive data that is required for decisionmaking related to a patient plan of care. “Finally, practices have also contracted with other third-party data analytics and monitoring companies if their vendor does not provide these services.” Even before the provider team can act on the data generated from mobile medical apps, they have to be able to access it. Which begs the question, ‘How can the practice incorporate all this data into the electronic medical record?’

Wearables in the news Samsung, Kaiser Permanente Samsung Electronics Co. Ltd. revealed in August the results of a home-based cardiac rehabilitation initiative, developed in collaboration with Kaiser Permanente. The initiative paired commercially available Samsung smartwatches that have built-in optical sensors – Gear S3 and Galaxy Watch – with Samsung’s HeartWise application to track each patient’s daily heart rate and activities. A report of patients’ activities was logged directly to their physician’s dashboard used to set exercise goals and monitor patients’ progress. Samsung says that the program, reported in the New England Journal of Medicine, showed significant improvements over traditional cardiac rehabilitation programs. While the U.S. national average hospital readmission rate for these conditions is approximately 10-15%, participating program patients experienced a readmission rate of less than 2%. The program achieved an 87 percent patient completion rate. Kaiser Permanente reportedly is evaluating expanding the program beyond Southern California.

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Fitbit Premium San Francisco-based Fitbit announced in August the launch of Fitbit Premium, a paid subscription service in the Fitbit app that uses a person’s unique data to deliver what the company says is a “personalized experience, with actionable guidance and coaching to help you achieve your health and fitness goals.” At launch, Premium included nine guided health and fitness programs – Intro to Healthy Habits, Get More Zzz’s, Habits for Restful Sleep, Get Active, Beginner Running, Run Training, Understand Calories, Kick Your Sugar Habit and Kick Your Salt Habit. Programs are said to include actionable coaching, daily tips and tricks, structured workout plans, relaxation tools, recipe suggestions and educational content. Fitbit says it will launch additional activity, sleep and nutrition programs by the end of the year. Premium will be available to any Fitbit user and to Fitbit Health Solutions customers through Fitbit Care.

NEW PAMA CPT codes now available in the app

Pama updated CPT codes 2018 Infectious Disease Tests Test - Panels Basic Metabolic Panel (9 tests) Comprehensive Metabolic Panel (17 tests) Electrolyte Panel (4 tests) Hepatic Function Panel (10 tests) Lipid Panel (6 tests) Renal Function Panel (12)

CPT 80048/QW 80053/QW 80051/QW 80076 80061/QW 80069/QW

2017 Fee $11.60 $14.49 $9.62 $11.21 $18.37 $11.91

2018 Fee $10.44 $13.04 $8.66 $10.09 $16.53 $10.72

Change -10% -10% -10% -10% -10% -10%

Cardiac/Liver/Other Tests Albumin (Serum) Albumin (Urine) ALP ALT Aspirin Therapy AST Bilirubin, direct Bilirubin, total BNP CK,MB CK/CPK GGT LD Microalbumin (Quantitative) Microalbumin (Semi-quantitative) Total Protein Troponin I

82040/QW 82042/QW 84075/QW 84460/QW 85576/QW 84450/QW 82248 82247/QW 83880/QW 82553 82550/QW 82977/QW 83615 82043/QW 82044/QW 84155/QW 84484/QW

$6.79 $7.10 $7.10 $7.27 $29.47 $7.10 $6.88 $6.88 $46.56 $15.84 $8.93 $9.88 $8.28 $7.93 $6.28 $5.03 $13.50

$6.11 $7.78 $6.39 $6.54 $26.52 $6.39 $6.19 $6.19 $41.90 $14.26 $8.04 $8.89 $7.45 $7.14 $6.23 $4.53 $12.47

-10% 10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -10% -1% -10% -8%

Lipid Tests HDL LDL Lp(a) Apolipoprotein Total Cholesterol Triglycerides

83718/QW 83721/QW 82172 82465/QW 84478/QW

$11.24 $13.09 $21.26 $5.97 $7.88

$10.12 $11.78 $21.09 $5.37 $7.09

-10% -10% -1% -10% -10%

Diabetes Tests Fructosamine Glucose on home use meter-type device Glucose Tolerance Test, each additional specimen > 3 Glucose Tolerance Test, initial 3 specimens Glucose, quantitative blood type Hemoglobin A1c

82985/QW 82962 82952/QW 82951/QW 82947/QW 83036/QW

$20.68 $3.21 $5.38 $17.66 $5.39 $13.32

$18.61 $3.28 $4.84 $15.89 $4.85 $11.99

-10% 2% -10% -10% -10% -10%

Renal Function Tests BUN Creatinine Creatinine (Urine)

84520/QW 82565/QW 82570/QW

$5.42 $7.03 $7.10

$4.88 $6.33 $6.39

-10% -10% -10%

Individual Tests Amylase Calcium Ferritin Iron

82150/QW 82310/QW 82728 83540

$8.89 $7.08 $18.70 $8.88

$8.00 $6.37 $16.83 $7.99

-10% -10% -10% -10%

Find the new codes in The Black Book

Other tools available for distributors are: vol.26 no.1 • January 2018

repertoiremag.com

January 2018

2 Minute Drill Videos

Podcasts

PAMA: The Stage is Set — How will the new rates impact providers, distributors and manufacturers?

PAMA: Jim Poggi, Tested Insights, LLC

The Stage is Set

How will the new rates impact providers, distributors and manufacturers?

Twitter

TRENDS “There is very little standardization among EMR databases, which presents an obstacle to easily incorporating data from mobile solutions – both wearables and apps,” says Hodgkins. “Much of what is occurring is at large healthcare institutions and is often accomplished through ‘brute force.’ “The most promising opportunity going forward is the use of standard application programming interfaces, or APIs, which are now being mandated. One standard API that is the focus of activity among EMR vendors is the Fast Healthcare Interoperability Resources (FHIR) API. But implementing this will still take considerable effort on the part of mHealth developers and EMR vendors.” Says Poterack, “With regard to ‘medical grade,’ physician-provided devices, there is usually the ability to generate a ‘summary page’ of key data that can easily be incorporated into the record. With regard to consumergrade devices, other than a couple of isolated examples that probably work better in theory than practice, I’m not aware of this occurring.”

“Physician practices aren’t all created equal, so they will likely have different workflows and processes for incorporating digital health technology.” – Michael Hodgkins, M.D.

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Workflow To accommodate the influx of data that comes from mobile devices, providers may have to reconfigure the roles and responsibilities of the office team. “There’s a lot of variation here,” says Poterack. “This is a big part of the difference between a device ‘prescribed’ and provided by the physician, where the workflow can be designed from the ground up, versus a consumer-grade device controlled by the patient, which is much more problematic.” Cardiology practices may be out front on this, he says. They tend to have more experience with wearables – many of which monitor the cardiovascular system – than other types of providers. But vendors of digital systems can help. “Some of these [devices] come with the ability to collect data, sift through it, find important things in it, and report that data,” says Poterack. “In a sense, it is ‘prepacked’ with the device, or the developers provide a very solid interface with your system.” Says Hodgkins, “Physician practices aren’t all created equal, so they will likely have different workflows and processes for incorporating digital health technology. “Planning is key, so it is important to ensure that the first six steps of the [Digital Health Implementation] Playbook are thoughtfully considered. If they are, then redesigning the workflow has likely already been considered, so practices are better prepared for when it’s time to do that work. For example, they’ve already decided that technology is the right solution to achieve a specific goal. And they know what level of support the vendor can provide related to training, EHR integration, etc.” Practices that successfully redesign workflow are those that fully understand their current method of operating, and then map out what areas require change with the integration of a new technology solution, says Hodgkins. “They have identified where internal resources can be used and if/when external resources and support are needed. “Again, planning and involving all necessary team members is key for long-term success. It’s also important to not think of this as a one-time activity. Practices should be prepared to continue iterating and improving as they learn. “Specifically, with remote patient monitoring (RPM), we’ve talked with practices that have had success

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TRENDS

“A device can accurately measure steps – but is that a modality worth measuring?”

“There is a tremendous amount of data that’s out there for the taking,” he says. “Vendors are collecting this data, and there are indications they understand the importance of it. But I’m not sure they know what to do with it. There’s a lot that can be done with the data out there. We have to figure out what that is.” Says Hodgkins, “In the Playbook, – Karl Poterack, M.D. we have proposed that practices view success as coming from some positive impact towards achieving the quaSuccess? druple aim of healthcare – improved outcomes, improved How would a practice define “success” in its ability to patient experience, reduced costs, and increased profesincorporate data from wearables and mobile medical apps? sional satisfaction.” “More broadly, at the AMA, we also “That’s very context-dependent,” says Poterack. aim to make technology an asset, not a burden, by providBut he offers this definition: The ability to “receive ing resources to help practices implement effective, validata that contributes to fulfilling whatever need you dated and trusted digital health solutions the right way.” have identified.” staffing RPM activities both internally (with medical assistants, nurses and advanced practice providers) and with external companies,” he continues. “Sometimes the vendor can support monitoring the patient data that comes into the system and alerting the practice when abnormalities arise. Some can also support training patients and serve as customer support.”

Digital playbook for docs The American Medical Association’s “Digital Health Implementation Playbook” offers physician practices 12 steps to follow to build a strong foundation for success in digital health. • Step 1: Identifying the need. (“What’s the problem?”) • Step 2: Forming teams. (“Who needs to be involved and when?”)

• Step 7: D esigning the workflow. (“What will we need to integrate this technology?”)

• Step 3: Defining success. (“What are we trying to achieve?”)

• Step 8: Preparing the staff. (“Does everyone know what they need to do to make this successful?”)

• Step 4: Evaluating the vendor. (“What’s the right technology?”)

• Step 9: P atient relationship. (“What does the patient need to know?”)

• Step 5: M aking the case. (“How do we get political and financial buy-in?”)

• Step 10: Implementing. (“How does it work in practice?”)

• Step 6: C ontracting. (“What’s our expected timing, budget and plan with our vendor?”)

• Step 11: Evaluating success. (“Did it work?”) • Step 12: Scaling. (“What’s next?”)

Source: Digital Health Implementation Playbook, American Medical Association, https://www. ama-assn.org/amaone/ama-digital-health-implementation-playbook

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TRENDS

E-visits Addressed with New CPT® Codes Six new CPT® codes for 2020 reflect the growth of non-

Self-measured BP monitoring

visual digital evaluation services, that is, electronic health Prior to 2020, the CPT code set never included self-mearecords and patient portals. sured blood pressure monitoring (SMBP), said Synovec. What’s more, for the first time, the CPT code set for Four ambulatory blood pressure monitoring codes (93784, 2020 will include two codes to support self-measured 93786, 93788, 93790) exist, but they only describe continublood pressure monitoring. ous monitoring over at least 24 hours. The CPT Editorial Panel “agreed that the expanded “These new SMBP codes are more closely aligned use of electronic health records and associated, HIPAAwith clinical guidelines that have shown the advantage of complaint secure patient portals has renewed focus on the collecting blood pressure outside of the clinic setting for important role played by non-visual digital patient-physician diagnosis of hypertension, which can result in measurecommunication (i.e. e-visits),” Mark ment errors, a smaller number of Synovec, M.D., chair of the CPT Edimeasurements, and white coat hyperCurrent Procedural torial Panel, told Repertoire in an email. tension,” he said. They are congruThree of the new codes – 99421, ous with recent recommendations by Terminology (CPT) codes 99422, 99423 – describe patient-inioffer doctors and healthcare the United States Preventive Services tiated digital communications proTask Force, which found that SMBP professionals a uniform vided by a physician or other qualified is a valid alternative method of conlanguage for coding healthcare professional. Three addifirmation when other methods are medical services and tional codes – 98970, 98971, 98972 not available. procedures to streamline – describe services provided by a nonCurrent Procedural Terminolreporting, increase accuracy physician healthcare professional. ogy (CPT) codes offer doctors and and efficiency. 2020 is not the first year that CPT healthcare professionals a uniform codes have addressed online evaluation language for coding medical serand management services. Since 2008, vices and procedures to streamline CPT codes 99444 and 98969 have described such services. reporting, increase accuracy and efficiency. They are also But “these codes were not widely adopted by payers due used for administrative management purposes, such as to a lack of clear definitions surrounding the work involved in claims processing and developing guidelines for medical these online visits,” said Synovec. “Furthermore, the current care review. online evaluation and management codes did not fully charThe CPT code set is maintained, updated and modiacterize the evolution that has occurred with these services.” fied by the CPT Editorial Panel, with authorization of With the CPT codes will come coverage, said Synovec. the AMA Board of Trustees. The panel is composed of In its Proposed Rule for 2020, the Centers for Medicare 17 members. Of these, 11 are physicians nominated by & Medicaid Services proposed assigning RVUs, or relathe national medical specialty societies and approved by tive value units, to codes 99421, 99422 and 99423, he said. the AMA Board of Trustees. One of the 11 is reserved Many private payers will follow Medicare’s lead, he added. for expertise in performance measurement. One phyThe agency has proposed that the non-physician sician is nominated from each of the following: Blue healthcare professional codes (98970, 98971, 98972) be Cross and Blue Shield Association, America's Health covered through HCPCS G-codes, for services and proInsurance Plans, American Hospital Association, and cedures that are under review for coverage. “[T]he Panel CMS. The remaining two seats on the panel are reserved will be working to revise these CPT codes to try and meet for members of the CPT Health Care Professionals the requirements of Medicare in 2020.” Advisory Committee.

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New CPT codes E-visits Code

Description

99421

Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

99422

Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes

99423

Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

98970

Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

98971

Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes

98972

Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

Self-measured BP monitoring Code

Description

99473

Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration

99474

Separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient

Source: AMA

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November 2019

SPONSORED:

PROVISTA

Everyone Wins How GPOs and distributors can work with end users to add new value Once distributors realize that group purchasing organiza-

tions (GPOs) are not their competitors but rather can serve as partners to provide advantages for their businesses, they can join forces to work with their customers to enable new benefits. For example, streamlining the relationship allows distributors to remove some of the administrative burdens that typically fall on reps by having the GPO handle them. In this Q&A, Patrick Turner, Senior Director, Contract and Program Services for Provista, a non-acute GPO, explains how GPOs and distributors can complement each other’s strengths to grow their businesses— and drive enhanced value to their end users. Q. What’s been the cause of tension between GPOs and distributors? Have those issues been resolved? Turner: Historically, there’s been a perception that GPOs and distributors have interacted in a competitive fashion to win customer favor. Over the past several years, that perception has evolved. I believe both parties now realize the value the other offers. GPOs recognize the service that distributors bring our members, and distributors realize that GPOs can help them bring value to the market and grow their business. Q. What’s the best approach for GPOs to remove administrative burdens from distributor sales reps? Turner: As the customer-facing entity in this dynamic, distributor reps are currently saddled with many of the administrative burdens associated with utilizing GPO contracts. Recently, GPOs have been successful in reducing some of this workload with programmatic offerings that focus on certain market segments or particular distributors. GPOs can continue to improve, but it starts with including procedural requirements in our vendor negotiations. Cost is not the only value GPOs should negotiate. “Ease of use” is also a value GPOs need to bargain for and provide. Q. In what ways can GPOs and distributors work together, and work with customers, to streamline relationships? Turner: The complexities of contract access, tier optimization, chargeback success, etc., are difficult to navigate. Fully utilizing a GPO contract takes two parties: the GPO to write and activate the contract, and the distributor to

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vend it. The ongoing operational cooperation between both parties to effectively access GPO-negotiated value is essential to truly delivering customer value. Furthermore, as our members become more engaged and educated, both distributors and GPOs gain additional influence to effectively advocate for our mutual customers. Q. How can distributors leverage GPOs’ purchasing power? Turner: In many ways, distributors are already leveraging the purchasing power of GPOs. Over the past few years, distributor utilization of GPO agreements has risen significantly. By utilizing GPO agreements, distributors can go to market with a much more competitive price point than they could otherwise. That said, there are always ways to dive deeper. The next evolution of how distributors partner with GPOs to leverage our complementary strengths could prove the most impactful to our customer base. Q. How should GPOs and distributors work together to enable new value for each other and for customers? Turner: In very tangible and significant ways, our world is driven by data. Thus far, both GPOs and distributors have taken a proprietary view of their own data—and rightfully so. However, tailored ways likely exist in which both parties could become more transparent with one another to unearth new sources of value for our customers. Q. Are there any specific or unique benefits that Provista brings to distributors? Turner: Provista has been a market leader in recognizing the value of a strong GPO-distributor relationship. We have invested in programs that are tailored to individual distributors to cater to their unique operational needs. We have made huge strides to ensure that our membership process is as simple and easy as possible for distributor sales reps and non-acute members. We have worked closely with our contracting partner, Vizient, to prioritize automatic contract eligibility. Provista has tremendous value to offer our membership. We readily recognize that much of this value is delivered through distributors and we have invested accordingly.

LIFT YOUR PROFIT. TEAM UP WITH PROVISTA, A LEADER IN GROUP PURCHASING, AND ENJOY: • Flexible margins to protect your profitability • Streamlined enrollment process • Dedicated contract implementation team to lift administrative burdens

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DIABETES

Diabetes Technology For the first time, the 2019 American Diabetes Association’s ‘Standards of Medical Care in Diabetes’ includes a dedicated section on diabetes technology.

In it first year, the Diabetes Technology section of the

ADA’s “Standards of Medical Care in Diabetes” focuses on insulin delivery and glucose monitoring. In future years, the ADA intends to include software as a medical device, privacy, cost, technology-enabled diabetes education and support, telemedicine, and other issues. The 2019 “Standards” were published early this year and updated this summer. Diabetes technology topics include: • Insulin syringes and pens. • Insulin pumps. • Self-monitoring of blood glucose. • Glucose meter accuracy. • Continuous glucose monitoring. • Real-time continuous glucose monitoring. • Intermittently scanned continuous glucose monitoring. • Automated insulin delivery.

Insulin syringes and pens For people with diabetes who require insulin, insulin syringes or insulin pens may be used for insulin delivery with consideration of patient preference, insulin type and dosing regimen, cost, and self-management capabilities, says the ADA. Insulin pens or insulin injection

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aids may be considered for patients with dexterity issues or vision impairment. Another insulin delivery option is a disposable patchlike device, which provides a continuous, subcutaneous infusion of rapid-acting insulin (basal), as well as 2-unit increments of bolus insulin at the press of a button, says the ADA.

Insulin pumps Most adults, children, and adolescents with type 1 diabetes should be treated with intensive insulin therapy with either multiple daily injections or an insulin pump, according to the ADA. Insulin pump therapy may be an option for all children and adolescents, especially in children under 7 years of age. Continuous subcutaneous insulin injection, or insulin pumps, have been available in the U.S. for 40 years. These devices deliver rapid-acting insulin throughout the day to help manage blood glucose levels. Most insulin pumps use tubing to deliver insulin through a cannula, while a few attach directly to the skin, without tubing. Common barriers to pump therapy adoption in children and adolescents are concerns regarding the physical interference of the device, discomfort with idea of having

a device on the body, therapeutic effectiveness, and financial burden, says the ADA.

Self-monitoring of blood glucose Most patients using intensive insulin regimens (multiple daily injections or insulin pump therapy) should assess glucose levels using self-monitoring of blood glucose (or continuous glucose monitoring). For patients with type 1 diabetes using continuous glucose monitoring (CGM), the greatest predictor of A1C lowering for all age groups is frequency of sensor use, which studies show is highest in those aged 25 years and over, and lower in younger age groups. Similarly, for self-monitoring of blood glucose (SMBG) in patients with type 1 diabetes, a correlation exists between greater SMBG frequency and lower A1C. In people with type 2 diabetes not using insulin, routine glucose monitoring may be of limited additional clinical benefit, according to the ADA. However, “[f]or some individuals, glucose monitoring can provide insight into the impact of diet, physical activity, and medication management on glucose levels. Glucose monitoring may also be useful in assessing hypoglycemia, glucose levels during intercurrent illness, or discrepancies between measured A1C and glucose levels when there is concern an A1C result may not be reliable in specific individuals.”

Glucose meter accuracy Patients assume that if their glucose monitor is FDAcleared, it must be accurate. But that is not always the case, says the ADA. Factors limiting accuracy include: •C ounterfeit strips. Patients should be advised against purchasing or reselling preowned or second-hand test strips. Only unopened vials of glucose test strips should be used to ensure SMBG accuracy. •O xygen. Currently available glucose monitors use an enzymatic reaction linked to an electrochemical reaction – either glucose oxidase or glucose dehydrogenase, says the ADA. Glucose oxidase monitors are sensitive to the oxygen available and should only be used with capillary blood in patients with normal oxygen saturation. Glucose dehydrogenase monitors are not sensitive to oxygen. • Temperature. Because the reaction is sensitive to temperature, all monitors have an acceptable

temperature range. Most will show an error if the temperature is unacceptable, but a few provide a reading and a message indicating that the value may be incorrect, according to the ADA. • Interfering substances. A few physiologic and pharmacologic factors interfere with glucose readings. Most interfere only with glucose oxidase systems.

Continuous glucose monitoring There are two types of continuous glucose monitoring: • Real-time CGM, which continuously reports glucose levels and includes alarms for hypoglycemic and hyperglycemic excursions. • Intermittently scanning CGM (isCGM), which is approved for adult use only. Intermittently scanning CGM does not have alarms and does not communicate continuously – only on demand. It is reported to have a lower cost than systems with automatic alerts.

Real-time continuous glucose monitoring should be considered in children and adolescents with type 1 diabetes, whether using multiple daily injections or continuous subcutaneous insulin infusion, as an additional tool to help improve glucose control and reduce the risk of hypoglycemia, says the ADA. Two CGM devices are now approved by the FDA for making treatment decisions without SMBG confirmation (i.e., without calibration using a blood sample from the fingertip, sometimes called adjunctive use): Dexcom’s G5 Mobile Continuous Glucose Monitoring System, and the FreeStyle Libre Flash Glucose Monitoring System.

Real-time continuous glucose monitors Real-time continuous glucose monitoring should be considered in children and adolescents with type 1 diabetes,

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DIABETES whether using multiple daily injections or continuous subcutaneous insulin infusion, as an additional tool to help improve glucose control and reduce the risk of hypoglycemia, says the ADA. For adults: real-time continuous glucose monitoring: •C an be a useful tool to lower A1C in adults with type 1 diabetes who are not meeting glycemic targets, in conjunction with intensive insulin regimens. • May be a useful tool in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. • S hould be used as close to daily as possible for maximum benefit. •M ay be used effectively to improve A1C levels and neonatal outcomes in pregnant women with type 1 diabetes.

2014 and was approved by the FDA for use in adults in the U.S. in 2017. The personal version of isCGM has a receiver that, after scanning over the sensor by the individual, displays real-time glucose values and glucose trend arrows. The data can be uploaded and a report created using available software. In the professional version, the patient does not carry a receiver; the data are blinded to the patient and the device is downloaded in the diabetes care provider’s office using the provider’s receiver and the software. Studies in adults with diabetes indicate isCGM has acceptable accuracy when compared with SMBG, although the accuracy may be lower at high and/or low glucose levels. Studies comparing the accuracy of isCGM with real-time CGM show conflicting results. isCGM may decrease the risk of hypoglycemia in individuals with type 1 or type 2 diabetes. A growing number of studies suggest similar good performance and potential for benefit in special populations, including pregnant women with diabetes, individuals with type 1 diabetes and hypoglycemia unawareness, and children, although accuracy could be decreased in younger children.

For people with diabetes who require insulin, insulin syringes or insulin pens may be used for insulin delivery with consideration of patient preference, insulin type and dosing regimen, cost, and self-management capabilities, says the ADA. Sensor-augmented pump therapy with automatic low-glucose suspend may be considered for adults with type 1 diabetes at high risk of hypoglycemia to prevent episodes of hypoglycemia and reduce their severity.

Intermittently scanned continuous glucose monitoring Intermittently scanned continuous glucose monitor use (isCGM) may be considered as a substitute for self-monitoring of blood glucose in adults with diabetes requiring frequent glucose testing, says ADA. isCGM (sometimes referred to as “flash” CGM) measures glucose in interstitial fluid through a <0.4 mm–thick filament inserted under the skin. It has been available in Europe since

Automated insulin delivery

Automated insulin delivery systems may be considered in children (>7 years) and adults with type 1 diabetes to improve glycemic control, according to ADA. These systems consist of three components: an insulin pump, a continuous glucose sensor, and an algorithm that determines insulin delivery. With these systems, insulin delivery cannot only be suspended but also increased or decreased based on sensor glucose values. Emerging evidence suggests such systems may lower the risk of exerciserelated hypoglycemia and may have psychosocial benefits. While eventually insulin delivery in closed-loop systems may be truly automated, meals must currently be announced. A so-called hybrid approach, hybrid closedloop (HCL), has been adopted in first-generation closedloop systems and requires users to bolus for meals and snacks. The FDA has approved the first HCL system for use in those as young as 7 years of age.

Source: “Standards of Medicare Care in Diabetes,” American Diabetes Association, https://care.diabetesjournals.org/ content/27/suppl_1/s15

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INTRODUCING THE NEW AFINION™ 2 ANALYZER

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DIABETES

Diabetes in the News In 2018, 10.1% of adults aged 18 and over had diag-

nosed diabetes, the Centers for Disease Control and Prevention reported in August. The majority take medication for this condition. Compared with those without diabetes, adults with diagnosed diabetes experience higher out-ofpocket costs for prescription medications and cost-related, medication nonadherence behaviors. Among adults with diagnosed diabetes who were prescribed medication in the past 12 months: • 1 3.2% failed to take their medication as prescribed, and 24.4% asked their doctor for a lower-cost medication. •W omen (14.9%) were more likely than men (11.6%) to not take their medication as prescribed to reduce their prescription drug costs.

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• Women (25.5%) were as likely as men (23.4%) to ask their doctor for a lower-cost medication. In addition, • Adults under age 65 (17.9%) were more likely than adults aged 65 and over (7.2%) to fail to take their medication as prescribed to reduce their prescription drug costs. • Those under age 65 (26.3%) were more likely than those aged 65 and over (21.9%) to ask their doctor for a lower-cost medication. • Among adults aged 18–64, uninsured adults (35.7%) were more likely than those with private health insurance (14.0%) or Medicaid coverage (17.8%) to not take their medication as prescribed to reduce their prescription drug costs.

THE SOLUTION IS IN SIGHT. Imagine a tomorrow where diabetic retinopathy is no longer the leading cause of blindness.1 With early detection, 95% of vision loss due to diabetic retinopathy can be prevented.2 The Welch Allyn® RetinaVue® Care Delivery Model enables simple and affordable teleretinal exams in less than five minutes during routine primary care visits.

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1 Centers for Disease Control and Prevention. Common Eye Disorders. Vision Health Initiative (VHI). http://www.cdc.gov/visionhealth/basics/ced/index. Published September 29, 2015. Accessed June 18, 2019. 2 National Eye Institute. Facts About Diabetic Eye Disease. https://nei.nih.gov/health/diabetic/ retinopathy. Published September 2015. Accessed June 18, 2019. © 2019 Welch Allyn. ALL RIGHTS RESERVED. MC16197

DIABETES • Among adults aged 18–64, uninsured adults (42.6%) were more likely than those with private (25.7%) or Medicaid coverage (18.8%) to ask their doctor for a lower-cost medication, while adults with private insurance were more likely than those with Medicaid to use this strategy.

Medtronic, Novo Nordisk Medtronic plc and Novo Nordisk A/S announced in September a collaboration to develop solutions to integrate insulin dosing data from future Novo Nordisk smart insulin pens into continuous glucose monitoring (CGM) devices from Medtronic, such as the Guardian™ Connect system. By integrating glucose monitoring and insulin dosing data, people with diabetes and their healthcare profes-

sionals and caregivers (with permission from the person with diabetes) will be able to automatically track these two items in a single place, according to the companies. Further, being able to view both glucose and insulin data together can facilitate more productive conversations between people and their doctors, enabling more informed decisions on how to better manage glucose levels and increase Time in Range, or TIR (i.e., the percentage of time people with diabetes spend in the optimal glycemic range of 70-180 mg/dL). Novo Nordisk said it expects to launch its durable smart insulin pens, NovoPen® 6 and NovoPen Echo® Plus, as well as its disposable, pre-filled injection solution starting in 2020. Once available, smart insulin pens will be compatible with both Android and iOS devices. The Guardian Connect system will be updated as well to integrate data from these Novo Nordisk smart pens.

Abbott gets nod by Health Canada

Adults under age 65 (17.9%) were more likely than adults aged 65 and over (7.2%) to fail to take their medication as prescribed to reduce their prescription drug costs. 48

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Abbott announced in September that it received public reimbursement in Ontario and Quebec for its FreeStyle® Libre system, becoming the first sensor-based glucose monitoring system to be listed by any provincial health plan in Canada. Quebec residents 18 years or older and Ontario residents using insulin are eligible for reimbursement under the public programs. The FreeStyle Libre system replaces traditional blood glucose monitoring and allows patients to dose insulin based on the results. The FreeStyle Libre system is indicated for measuring interstitial fluid glucose levels in adults aged 18 years and older. It was authorized for sale by Health Canada in 2017. The company reports it has secured partial or full reimbursement for the FreeStyle Libre system in 33 countries, including France, Ireland, Japan, the United Kingdom and the U.S.

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QUICK BYTES Editor’s note: Technology is playing an increasing role in the day-to-day business of sales reps. In this department, Repertoire will profile the latest developments in software and gadgets that reps can use for work and play.

Technology News WiFi 6: What’s the deal? The Wi-Fi Alliance announced in September that it would start offering WiFi 6 certification to device manufacturers. The main thing you need to know is that WiFi 6 provides much faster speeds than the WiFi we all use right now, reports Mashable. According to CNET’s testing, it can outpace the average download speed in the United States by 1,000 percent. One of the other selling points, per the WiFi Alliance, is that WiFi 6 can perform better in crowded environments (e.g., sports stadiums) where a lot of devices are connected to a single network. One caveat: We’re still in the early stages of WiFi 6 deployment, and devices need to be built with the standard in mind to take advantage of

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it. Most home networks can’t yet support it. But already, Netgear has produced some WiFi 6-compatible routers.

Instant photos by (who else?) Polaroid Polaroid’s new Lab instant photography device creates hard copies of any digital photo on your phone without the need for wires or fiddling with wireless settings, reports Gizmodo. Instead, light from your smartphone’s screen is projected and used to directly expose Polaroid’s instant film. The device – which looks vaguely like Polaroid’s instant cameras – has a platform on which users place their smartphones face down. Inside the Lab, three lenses focus the projected light from the phone’s screen down onto the

Steven Hummel, senior research analyst for the CTA. Although they indicate that “ensuring the well-being of their pets is of paramount importance, it’s unfortunate that pet owners are least aware of the various types of products which do just that. Less than one-fifth of pet owners have heard of devices that monitor a pet’s health and track their fitness, for example.”

Your reputation precedes you Israel-based Intellithings has brought its “presence sensing technology” to market with RoomMe, a personal location sensor that can identify you when you enter a room and trigger your smart home devices – e.g., smart lights, music, thermostat – to perform based on your personal preferences, reports Digital Trends. The sensor creates a virtual Bluetooth Low Energy curtain at room entrance and tracks smartphones that pass through it, says Intellithings. RoomMe can identify up to 16 individual family members.

Polaroid’s new Lab instant photography device creates hard copies of any digital photo on your phone without the need for wires or fiddling with wireless settings. Polaroid film, which creates the exposure. There are some trade-offs, reports Gizmodo. If you’re hoping for a crisp, 8x10 recreation of a beautiful portrait photo you snapped on your smartphone, this isn’t the solution for you. Polaroid film is still known for its lo-fi aesthetic (which some photographers still prefer), and the analog approach taken here will soften and desaturate images in the process.

Pet tech Interactive toys, automated feeders or fountains, and grooming devices lead the list of pet-tech products purchased by U.S. pet owners, reports Orlando Magazine. About 8 million additional households plan to buy pet tech in 2020, according to the Consumer Technology Association’s 21st annual “Consumer Technology Ownership and Market Potential Study.” That said, many pet owners, despite their reliance on their own Fitbits or Apple Watches, miss out on some of the biggest benefits of pet tech, says

Sniffing out diabetes Diabetes alert dogs are trained to use their acute sense of smell to alert their owners early of a peak or dip in blood sugar before it becomes dangerous. The founders of AerBetic thought up their wearable’s feature set by asking, “How does the diabetes alert dog do it?” reports Consumer Technology Association. AerBetic is a noninvasive wearable diabetes monitor that passively and continuously monitors blood sugar levels, along with a partner app that allows the user to set up alert communications to a network of caregivers or health care providers. To monitor changes in blood sugar levels, the AerBetic wearable uses a nano gas sensor, created by AerNos™, to detect certain gases that humans naturally emit at the ratios and ranges that scientists have identified as early indicators of hypoglycemia or hyperglycemia.

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REP CORNER

Aim High! Aerospace defense contracting lays the groundwork for Seth Garcia’s career in GPO sales. About 50 miles northeast of Dallas is Greenville, Texas, a city of about 30,000. The biggest employer is L3 Harris,

whose ISR Systems Greenville is an industry leader in the modernizing and maintenance of military aircraft and ground systems. (“ISR” stands for “intelligence, surveillance and reconnaissance systems).

(L to r) Leah, Sierra, Seth Garcia

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Growing up in Greenville, with friends and neighbors employed by the aerospace defense contractor, it’s no surprise that Seth Garcia joined L3 as a supply chain specialist in May 2007. Though L3’s emphasis is aerospace defense, for seven years, Garcia learned and exercised many skills that would eventually suit him well in healthcare supply chain. Today, he is sales executive for distribution for Provista, the non-acute-care GPO based in Irving, Texas. (Provista is a subsidiary of national GPO Vizient.) He works primarily with NDC members to promote the Provista portfolio to them and their customers. “All of my roles and responsibilities at L3 were in supply chain,” he says. “My career began in the warehouse, ensuring that the parts needed for the next phase of installation on an aircraft rebuild were stocked and ready to be installed. In my next role, I was responsible for determining whether materials needed to be purchased or manufactured in-house. After that I went into the Program Office (PMO), which included leading the proposal efforts for Air Force contracts, then executing on the agreed-upon scope of work within the agreed-to budget and schedule.”

As program manager, Garcia didn’t negotiate directly with parts manufacturers. (That was handled by subcontractors.) However, he did prepare the “statement of work,” which laid out for the customer – in this case, the U.S. Air Force – the total cost of the project, including parts and labor. “The challenge was making sure that the project would be profitable for us, and that we could complete it on time and on budget. It gave me a broad perspective on supply chain and its impact on projects. “Today, in my work with NDC members, I’m often dealing with owners of distribution companies, and I know they take that broad look too,” he says.

The healthcare community In 2014, Garcia, his wife, Leah, and daughter, Sierra, moved to the Dallas area so Leah could attend chiropractic school at Parker University. Though he could have pursued a job with a defense contractor in the area, Seth decided it was time to make an industry change. He got a position with Vizient, with responsibility for managing the surgical infection prevention portfolio. “The thing that has surprised me most about the industry change is the community within healthcare,” he says. “When I first got into the industry, I was told all the time, ‘It’s a small community and people don’t leave.’ I’ve only been here five years and I have found this to be so true! Over the years, you see the same people and you build lasting relationships and friendships. I’ve been very fortunate to meet a lot of great people that welcomed me with open arms. I’m very grateful for that.” In February 2017, Garcia joined Provista as sales executive for custom contracting. “Provista serves a very diverse member base,” he says. “My role was to identify gaps in the contract portfolio to ensure that we had contracts that met unique member needs and brought value to their organizations. As a part of that process, it’s crucial to gain buy-in from all stakeholders, including internal parties and potential external partners.”

One year later, he assumed his current position with the firm. It was his first time working in the field as a sales rep.

In the field “I’ve always had an interest in sales. When the opportunity presented itself to be a rep in distribution, I felt that it was a great fit. Having worked at Vizient as a portfolio executive, I had intricate knowledge of the contracts. That knowledge gave me the opportunity to help others who may not be as well-versed in them. I’ve also been very fortunate to have been taught so much about the distribution world by so many. “The thing I quickly learned about sales in Year One is that no sale is the same,” he says. “Specifically in independent distribution, where I spend all of my time. Each organization that I work with operates a little differently.

“ When I first got into the industry, I was told all the time, ‘It’s a small community and people don’t leave.’ I’ve only been here five years and I have found this to be so true!” “With that being said, I cater my visits with my distributors to their needs and what will be most beneficial for them. That can range anywhere from conducting live training with their reps to having high-level strategy discussions with the leadership team, or bringing in a colleague of mine to focus on operational efficiencies as it relates to contracts and rebates.” Over the past year, Garcia hasn’t really changed his approach to sales. It was – and is – all about providing value. “But I will say, I’ve become a much better listener. In my opinion, the biggest mistake new sales reps make is being too eager to sell their product/offering rather than listening intently to their customers’ needs.”

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HEALTHY REPS

Health News and Notes Vaping: Safer than smoking?

Something to chew on

E-cigarette “vaping” is widely assumed to be safer than cigarette smoking, but scientists at the University of North Carolina School of Medicine reported evidence in August suggesting that vaping promotes the same cellular responses found in smokers who suffer with emphysema. In a study published in the American Journal of Respiratory and Critical Care Medicine, the UNC scientists found that the lungs of vapers – like the lungs of smokers – have elevated levels of protease enzymes, a condition known to cause emphysema in smokers. The researchers also found that the nicotine in vaping liquids is responsible for the increase in protease enzymes.

A study of human stool samples reveals that people inadvertently eat thousands of tiny plastic particles every year, researchers reported in the Annals of Internal Medicine. Various types of microplastics were detected in fecal matter, suggesting that plastic particles are present in many different sources. More than 350 million tons of plastic are produced each year, and some of it pollutes the environment. Microplastics, or plastic particles smaller than 5 mm, may be ingested by marine organisms, where they can then enter the food chain. The scientists emphasize that further research is needed to determine the effects of plastic ingestion on human health.

Women’s Health Study The National Institutes of Health, Apple, and the Harvard T. H. Chan School of Public Health announced a research partnership for a major long-term study of women’s health. The collaboration will permit researchers to study conditions including pregnancy, infertility, polycystic ovary syndrome (PCOS), menopausal transition, and osteoporosis. Apple’s new Research App will help users participate in the study and will be a free download in the App Store later this year. The intention is to improve women’s health by identifying the factors that impact women from around the country. This new study will connect academic medical institutions, healthcare organizations, and Apple products.

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Risk-reducing medications and breast cancer The U.S. Preventive Services Task Force in September recommended that clinicians offer risk-reducing medications to women who are at increased risk for breast cancer and at low risk for adverse medication effects. This recommendation applies to women age 35 years and older without signs or symptoms of breast cancer. It does not apply to women who have a current or previous breast cancer diagnosis. The Task Force found that three types of medications – tamoxifen, raloxifene, and aromatase inhibitors – can reduce a woman’s chance of developing invasive breast cancer. When deciding whether or not to offer medications, clinicians should carefully consider their patients’ risk factors for breast cancer and balance these against the potential harms from the medications, some of which may be serious or even life threatening, such as blood clots or other cancers.

HIDA INSIGHTS

CMS Makes Payment Changes to Improve Healthcare in Rural America By Linda Rouse O’Neill, HIDA VP of Government Affairs

The Centers for Medicare & Medicaid Services final-

ized its reimbursement policy for hospitals over the summer. Overall, hospitals will see a positive update from Medicare. However, there was a focus in the final payment rule that reflects a substantial shift in the way rural hospitals are paid with an eye on providing these less-populated regions with better access to high quality and affordable healthcare. The payment changes took effect October 1, 2019 as hospitals are paid on the federal fiscal year. “Every single American deserves high-quality healthcare no matter where they live. However, 1 in 5 Americans who live in rural areas experience challenges receiving the healthcare There are about they need as provider-to1,875 rural patient ratios rise dramatihospitals, and it cally and more hospitals can be challenging close,” CMS Administrator Seema Verma wrote to woo staff to in a letter promoting the live and work in new policies. remote, sparsely Urban areas make up populated areas. only 3% of all U.S. land, but more than 80% of the nation’s population call urban areas home. There are 3,387 urban hospitals, according to an American Hospital Association 2019 report. Conversely, 97% of U.S. land mass is rural, but only a bit more than 19% of the population lives there. There are about 1,875 rural hospitals, and it can be challenging to woo staff to live and work in remote, sparsely populated areas. To diminish these rural and urban hospital payment disparities, CMS has finalized policies to: • I ncrease the wage index for hospitals with a wage index value below the 25th percentile; • Decrease the wage index for hospitals above the 75th percentile to maintain budget neutrality;

• Change the wage index “rural floor” calculation by removing urban to rural hospital reclassifications from the calculation of the rural floor wage index beginning in FY 2020; and • Institute a 5% cap on any decrease in a hospital’s wage index value beginning in FY 2020, so that a hospital’s final wage index would not be less than 95% of its final wage index of FY 2019. CMS predicts that it will distribute approximately $8.4 billion to Disproportionate Share Hospitals (DSH) hospitals in uncompensated care payments for FY 2020.

CMS makes broader medicare payment changes CMS also updated Medicare payment policies for all hospitals under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital Prospective Payment System (LTCH-PPS) for fiscal 2020 (started October1, 2019). • CMS projects an estimated total increase of 3% in IPPS payments, and estimates Medicare spending on inpatient hospital services to increase by $3.8 billion in FY 2020; • CMS finalized a new technology add-on payment for medical devices that receive FDA marketing authorization and is part of an FDA expedited program for medical devices. The device will need to meet the cost criterion to receive the add-on payment beginning fiscal 2021; • CMS expects LTCH-PPS payments to increase by approximately 1% or $43 million for FY 2020. It adopted two new quality measures addressing LTCH patient data related to admissions, discharges, and a care plan; and data elements used to calculate pressure ulcer measures. More information on changes to Medicare and Medicaid policy can be found in HIDA’s latest Medicare 360 and Medicaid 360 Policy Reports, available to HIDA members and nonmembers.

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November 2019

WINDSHIELD TIME Chances are you spend a lot of time in your car. Here’s something that might help you appreciate your home-away-from-home a little more.

Automotive-related News ‘Jeopardy’ on the road Jeopardy fans can now download the Drivetime app and play the trivia game on their next road trip, reports CNET. Each game is hosted by Alex Trebek and has trivia from the past 35 seasons. Jeopardy joins Drivetime’s other voicebased and hands-free games, and will offer a free game every weekday. Drivetime offers subscriptions for $10 a month and an auto-renewing yearly subscription at $100 a year. The app is available for iOS and Android devices.

Finance charges way, way up It’s going to cost you more to buy a new car this year, reported the AAA in September. Finance costs on new car purchases have jumped 24% in 2019, pushing the average annual cost of vehicle ownership to $9,282, or $773.50 a month. That’s the highest cost associated with new vehicle ownership since AAA began tracking expenses in 1950, and a reminder that the true costs of owning a vehicle extend far beyond maintenance and fuel. “AAA found finance charges rose more sharply in the last 12 months than any major expense associated with owning a vehicle,” said John Nielsen, AAA’s managing director for automotive engineering & repair. The spike in finance charges – which rose from $744 to $920 – comes as 72-month car loans have become increasingly common, meaning car buyers are paying more, and longer, for their vehicles. Long-term loans offer lower monthly car payments, but they ultimately cost the consumer more. AAA found that, on average, every 12 months added to the life of a loan adds nearly $1,000 in total finance charges.

Hand-me-downs In the U.S., battery-powered cars make up fewer than 2 percent of new vehicle sales, reports Wired. That desultory

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number, though slowly increasing, makes clear that for all the technology’s upsides in performance, design and environmental impact, consumers remain skeptical of the high prices and limited range that come with a charging cord. But new data shows that EVs are starting to catch on in used-car shopping sites. One site, Shift, says that in the first half of this year, electrics tripled their share of sales compared with the same period of 2018, to 4 percent. Add in hybrids and the number gets more impressive. “Twenty percent of what we sell is hybrid or electric,” Shift co-CEO Toby Russell is quoted as saying.

Jessi Combs remembered The newly created Jessi Combs Foundation is dedicated to educating, inspiring and empowering the next generation of female trailblazers and stereotype-breakers. Combs died in August while attempting a speed record on a dry lake bed in Oregon. She was driving the North American Eagle Supersonic Speed Challenger – a repurposed F-104 fighter jet which she had piloted to previous women’s four-wheeled speed records. She was 39. A submission to the Guinness World Records could give Combs the record as the fastest woman in the world, reports Motor 1. She successfully completed runs going 515.346 miles per hour and 548.432 mph, for an average of 531.889 mph. Kitty O’Neil set the existing record of 512.7 mph in 1976 – shattering the land-speed record for women by about 200 mph.

Gotcha! Electric-car owners: Enjoy – for now – the fact that you’re free from your state’s gasoline tax at the pump. The fact is, numerous states have crafted workarounds, and are charging EV owners far more than the standard gas tax, reports MSN. Among the 26 states that already impose fees, Arkansas, Colorado, Mississippi and Alabama charge the most, according to a study by Consumer Reports. Each state’s fees are 198%, 197%, 158% and 127% more than the gas tax, respectively. EV owners in Arkansas will cough up $200 annually to operate an electric vehicle on local roads, for example. The lowest current fee is Virginia at 5% more than the gas tax.

The 1st podcast about sales reps for sales reps. Hosted by Repertoire Magazineâ&#x20AC;&#x2122;s Publisher Scott Adams.

Episode 1 Brian Taylor

Episode 3 Brad Connett

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Episodes can be found at www.repertoiremag.com/resources/podcasts

NEWS

AORN calls for warming devices for all surgical patients New AORN guidelines released this summer call for all surgical patients to receive some form of hypothermia

prevention, with the OR team making the selection on a case-by-case basis. AORN is the Association for periOperative Registered Nurses. Based in Denver, the association has more than 40,000 members. “We see facilities that use a single method of warming, one which may not be the best in every patient care situation,” Byron Burlingame, MS, BSN, RN, CNOR, and AORN senior perioperative practice specialist and author of the guideline, told Repertoire in an email. Too many patients experience some form of unplanned perioperative hypothermia, in which their core body temperature drops below 96.8° F during surgery, according to the association. A drop in core body temperature can lead to adverse patient outcomes, such as myocardial events, infections, poor incision healing, postoperative pain, and increased blood loss. The updated guideline puts more detailed focus on preoperative selection of patient warming methods based on patient factors, procedure, operative position, location of IV access and warming device constraints. Identifying the patient’s specific needs is also discussed in the update in order to maintain a safe core body temperature prior to anesthesia induction. “The most important factors [in the selection process] are those that are procedure-related,” says Burlingame. “For example, this may be an underbody system if the patient is having a procedure that requires a large amount of the body to be exposed, or it may be a full body blanket if the patient is having a procedure on an extremity.”

Hypothermia prevention devices are referred to either as “passive” or “active.” Passive devices include cotton blankets, surgical drapes, or so-called space blankets. Active devices include circulating-water mattresses or garments, forced-air-warming devices, and heaters. It’s true that cost may be an issue to some health systems as they implement the new guidelines, says Burlingame. “And yes, staff time is another challenge, as there can be inconsistencies about where to apply the active warming device … in the preop area.” But the payoff for the patient and the provider is huge, particularly in the prevention of complications associated with hypothermia, he says. Those complications include myocardial events, wound infections, poor wound healing, postoperative pain, increased blood loss and need for blood transfusion, reversible coagulopathy (i.e., platelet dysfunction), impaired renal function, decreased drug metabolism, increased peripheral vascular resistance, postoperative protein catabolism, altered mental status, pressure ulcers, increased postanesthesia care unit (PACU) length of stay, prolonged hospitalization, and death. What’s more, patient satisfaction improves when hypothermia is prevented, Burlingame adds. “This increase in satisfaction is supported in the literature.” A subscription is necessary to view the updated hypothermia guidelines, at https://aornguidelines.org/guidelines/content?sectionid=173731777&view=book.

Industry News Henry Schein’s Practice Pink Program supports the global fight against cancer Henry Schein, Inc. (Melville, NY) announced it will again support nonprofit organizations dedicated to the fight against cancer through its Practice Pink program. Through the program, now in its 13th year, Henry Schein has donated more than $1.6 million towards promoting early cancer detection, improving access to care, and research and prevention efforts. Along with non-governmental organizations and supplier partners across North America and Europe, Henry Schein is helping dental and

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medical healthcare professionals to raise awareness and support for a cure for breast cancer and other cancers by offering its customers a range of pink products, including healthcare consumables, practice supplies, and apparel. The Practice Pink program supports U.S.-based organizations such as the American Cancer Society, Cohen Children’s Medical Center of Northwell Health, Stony Brook Children’s Hospital, and the Memorial Sloan Kettering/ Henry Schein Cares Women’s Health Center.

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NEWS Products to Watch Health o meter Professional Scales introduces height rod redesign Health o meter® Professional Scales announced an enhanced height rod design for the 1100KLHR scale and PROPLUSROD accessory. These products will now feature the Health o meter® Professional 201HR height rod along with simple, weigheasier® mounting brackets. The 201HR features a durable height rod construction and an easy-slide headpiece that allows caregivers to quickly and effortlessly measure and read a patient’s height. The 201HR upgrade also provides an increased measuring range of 2”-90” in 1/8” increments (6 cm-230cm in 1mm increments). The new and improved 1100KLHR and PROPLUSROD are available for purchase through Health o meter Professional Scales authorized distributors. Visit homscales.com or call 1-800-815-6615 for more information.

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Vice President of Sales • CLEARSPEC LLC Boca Raton, FL Employment Type: Full-time • Job Functions: Sales & Business Development ClearSpec LLC, a designer and manufacturer of disposable vaginal speculums, is currently seeking an experienced Vice President of Sales to lead our sales effort. In this position you will be required to drive sales through the already established distribution channel. In addition, you will establish and maintain high-level professional relationships with key-decision -makers for both physician offices and the acute care space and drive revenues to achieve sales objectives. Prior experience in the Ob/Gyn space is preferred but not required. This position reports to the CEO. Job Description: ClearSpec is a medical device designer and manufacturer based in Boca Raton, Florida. We are seeking an experienced Vice President of Sales to join our team! We are seeking a highly motivated individual that will develop an overall strategy to expand market share. The candidate will leverage previous experiences to drive forward customer development and generate new revenue. This is not a conventional sales role. As a Vice President of Sales at ClearSpec you are required to use a broad skillset to influence others through strong clinical and communication skills. Working closely with the CEO you will be given autonomy to develop business plans and ideas to fully exploit the strength of our products. Job Details: •W ork with distributor partners in analyzing business needs in the Gynecology, Primary Care and Hospital space •A nalyze geographical areas and develop business plans to capitalize on new business opportunities. •C onduct field Co-Travel with Distributor partners to present the products and contribute to the knowledge of our Distributor’s

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• Gain new and maintain existing business of the Company portfolio • Conduct on site in-service and training of new and existing customers • Attend Trade Shows and represent ClearSpec and its portfolio of products • Conduct webinars for remote learning • Answer any technical phone or email questions • Develop relationships with key Gynecology and Primary Care thought leaders and Physicians Work Requirements: • 80% travel is expected (3 weeks out of 4) • All travel expenses will be reimbursed through company credit card • Cell phone and laptop provided ClearSpec is an open work environment, where contribution and teamwork are valued. We seek to grow through common values and shared ideas. Employees are actively encouraged to challenge the status quo and seek new and better ways of doing business.

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