Healthcare Data Security: Manual Incident Response is Not an Option

Guest post by Dave Willsey, CEO and co-founder, Integrify.

David Willsey
David Willsey

Data security is a top concern of every healthcare provider today. And for good reason. A recent news story from The Wall Street Journal reported that healthcare is “frequently cited as one of the industries most exposed to cyberattack due to large networks with numerous access points and vulnerable, legacy computer systems.”

If there is an industry more vulnerable to hackers today than healthcare organizations, you’d have to search far and wide to find it. Healthcare hacking is a growing problem.  It is a trend that will not change course anytime soon.

Unfortunately, hospitals and other providers present a target rich environment for criminals and malicious hackers. And, to make matters worse, a recent study by researchers at three leading universities concluded that additional threats are coming from within “the house” as clinicians and other staff are taking shortcuts and finding workarounds to security measures in an attempt to deliver better patient care.

The federal government response to this growing threat is two-fold: mandatory reporting of data breaches and financial penalties that sting when violations of protected health information occur.

When it comes to reporting and ensuring continuous improvement to guard against future risk to data security, the number-one best practice today is a well-conceived, executable and automated incident response plan (IRP).

The good news is seven-in-ten providers have an IRP in place. The not-so-good-news is most of those plans are based on manual, labor intensive, error-prone processes. What’s needed to step-up the game for healthcare providers is an automated IRP workflow process. Automation is the only way to protect your data as the threat continues to evolve in the future.

Secure data and information is the chief reason to automate IRP workflow. But ROI is another major business driver to invest in automation. Here’s why – you’ll get quick payback from more accurate information about threats and breaches sooner in the process before they get out of hand; your teams will be able to execute with rapid response times that lead to fast resolution when compared to manual processes; and, finally, automation will bring your leadership team and other key stakeholders a unique capability to apply analytics and intelligence to support and measure continuous improvement in critical processes against future threats.

Automated IRP can provide all users with a simple incident reporting tool across the healthcare ecosystem – if a doctor or nurse or someone in the pharmacy formulary, for example, notices a potential security issue, that user can immediately trigger an automated IRP process. This action would notify the front line responder teams who can then escalate a response if needed.

Effective incident response planning addresses three key areas – people, process and data. With people, it’s very important that the roles of each person handling patient data are well identified and this would include all clinical staff, billing and administrative personnel, insurance agents, IT personnel, outside vendors, contractors, and others.

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A Flexible Staff Is the Key to Billing for Small Practices

Guest post by John Squire, president and COO, Amazing Charts

John Squire
John Squire

Why do so many small medical practices give up a significant portion of their earnings to outside billers?  Depending on its geographic location, volume of billing, and other factors, a practice will pay an average of seven percent of its total revenue to a biller, which could be the difference between profit or loss, maybe even success or failure.

In many cases, the reasons given are that no one in the office has experience with medical billing and the physician doesn’t believe a small staff can handle the added burden of work. But if you dig a little deeper, these assumptions are often wrong.

As a developer of electronic health record (EHR) and practice management (PM) software for small practices, my company hears a lot about billing directly from physicians and staff. We’ve learned exactly who does the billing and how they do it once a practice starts using a PM system for the very first time.

In one case, a medical assistant was able to learn everything he needed to know about billing from the PM product training alone. That’s because the physician specializes in podiatry, so the practice uses a limited set of billing codes. With a relatively light patient workload, this Medical Assistant has more than enough time to handle billing functions during normal office hours.

At another practice, when a gynecologist questioned her staff, she learned that her receptionist was eager to start doing something else, preferably from home so she could care for young children. The receptionist became certified in medical coding at a local community college on her own time, and now uses the PM system remotely and visits the office once a week every few weeks.

In a third practice we know, the pediatrician himself shares the work of billing with two of his part-time staffers, who welcomed the extra hours of pay.  One staffer had knowledge of billing from a past job, while another was eager to learn. They all handle billing together as a team, so there’s no burden on any single person.

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How IoT is Helping to Address Chronic Disease Management

Guest post y Susmit Pal, healthcare strategist, Healthcare & Life Sciences, Dell

Susmit Pal
Susmit Pal

Aging populations and the rising incidence of chronic disease consume a disproportionate amount of healthcare resources. In the United States, about 75 percent of healthcare dollars go to chronic disease care and two out of every three Medicare recipients suffer from at least two chronic diseases.[1] The pressure for relief will grow as the population ages with approximately 10,000 new patients estimated to enroll in Medicare every day for the next 15 years.[2] The current demand for resources for chronic disease care combined with the imminent spike in Medicare enrollment beg for achievable solutions and strategies that address costs, care quality and outcomes in the short term.

Enter the Internet of Things (IoT), also referred to as the Internet of Medical Things (IoMT) within the healthcare industry. IoT is something that most are well-familiar with, but for the sake of clarity, we define it here as the purposeful connection of intelligent sensors, devices, and software to computer networking systems using Bluetooth, Wi-Fi, RFID or M2M wireless technology in order to promote an inter-functionality that serves a greater purpose. In healthcare, that greater purpose is the achievement of less costly and more information-driven and efficient patient care. Think wearable devices and wireless pill bottles, nanotechnology and ingestibles, and network-enabled medical devices like stethoscopes that can transmit cardiac data directly into a patient’s electronic health record (EHR).

The Impact on Chronic Disease Management
IoT shows great promise in helping to improve the health of patients with chronic conditions. Combinations of remote monitoring, analytics and mobile platforms have repeatedly cut re-admissions of high risk patients with congestive heart failure (CHF) by more than half.[3] Evermore affordable and easier-to-use devices, such as wireless scales and heart rate and blood pressure monitors are improving overall wellness for the chronically ill. In fact, some researchers estimate that the value of improved health in patients with chronic disease using remote monitoring could amount to $1.1 trillion per year by 2025.[4]

At the consumer level, the rapid increase in the type and variety of personal mobile fitness trackers like Fitbit®, and online fitness applications for consumers demonstrates comfort with IoT to monitor physical health. Their very existence has created an avenue for patients to become more accustomed to tracking and managing their health online. In response, healthcare organizations are beginning to incorporate them into their consumer engagement strategies, while payers are starting to offer discounts and incentives tied to wellness management.

IoT is also helping to spur on some rather exciting new technological advancements in chronic disease management. Connected wheelchairs, for instance, are enabling people with disabilities to engage with care providers on a whole new level, communicating health alerts to care teams and repair notices to manufacturers. A group from the University of Missouri is spearheading a development project to utilize home monitoring sensors in an effort to prevent falls among the elderly by providing alerts to the patient when there is a fall risk, while Dell Healthcare is working with hospitals to leverage the use of tablets with integrated card readers to enable remote healthcare for home-based treatments.

There exists an even greater potential for IoT to impact chronic disease management at a population-level when combined with data analytics. For instance, Health Net Connect (HNC) has initiated a population diabetic management program with the intent to improve clinical outcomes and healthcare savings for diabetes, one of the deadliest and most costly of chronic diseases—and the results are impressive. They captured vitals and blood work from study participants over a 6-month period to measure the impact that routine teleconferencing and patient monitoring had on outcome. Patients in the program showed a significant decrease in key biomarkers, including 9.5 percent lower HB A1C and 35 percent decrease in LDL. To put that into perspective, for every 1 percent drop in HB A1C they estimate an $8,600 annual savings, and for every 1 percent decrease in LDL there is a 1 percent decrease in coronary heart disease, which costs on average a million dollars over a lifetime. HNC is continuing this program, noting that “this project has, and currently is demonstrating return on investment with cost savings, improved access for program members to their physician, improved clinical outcomes, and improved knowledge by program members on their disease condition.”[5]

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The ABC of MACRA

Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.

Abhinav Shashank
Abhinav Shashank

Currently, one of the most discussed topics in the healthcare industry is MACRA; a complex 962-page document that is supposed to redesign the entire healthcare industry. Know all about MACRA in six questions.

What is MACRA?

MACRA stands for Medicare Access and CHIP Reauthorization Act. It’ll repeal the current Sustainable Growth Rate (SGR) Formula and extend CHIP for two more years. Extending CHIP for two more years (in total four years now) will help tens of millions of kids in retaining their insurance.

SGR was introduced in 1997, as a method to curb the Medicare expenditures. Under SGR the physician payments were cut if the overall expenditure was above the benchmark. This payment cut system turned out to be a major reason for significant losses incurred by physicians. Fearing payment cuts, many physicians started denying services to Medicare beneficiaries.

In 2015, “Doc Fix” or MACRA was proposed, which as the name suggests fixed the unprecedented payment cuts. If it weren’t for “Doc Fix,” physicians would have faced 21 percent payment cuts in 2015.

The Notice for Proposed Rulemaking (NPRM) was issued on Apr. 27, 2016, and the final rule will come in November. MACRA’s full implementation will begin from 1st January 2017.

What will MACRA change/replace?

The idea behind implementing MACRA is to create something that works and is enduring. MACRA would bring changes through its unified framework called “Quality Payment Program,” which has been further divided into Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APMs).

All those who will be eligible for MIPS are called Eligible Clinicians. The term has expanded from “Eligible Provider” to “Eligible Clinicians.” It will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and groups of such clinicians. This expansion has increased the number of people who will receive payments from Medicare. CMS might expand to Medicare part B after two years, which will include therapists, clinical social workers, clinical psychologists.

To keep health information flexible and user-centric, and bring all these changes with better care opportunities, MIPS will evaluate eligible clinicians on four measures namely: Quality Category to replace PQRS; resource use category to replace value-based modifier; Advanced Care Information (ACI) to replace meaningful use; Clinical Practice Improvement Activities (CPIA).

How will the four categories measure the performance?

Quality Category: Instead of reporting on nine measures, Clinicians will have the choice to pick speciality-specific measures. They can choose six measures to report to CMS that suits them the best reflecting their practice. But one of these measures must be an outcome measure or a high-priority measure and one must be a cross-cutting measure. Clinicians can also choose to report a specialty measure. Clinicians can report through Claims, Electronic Health Record (EHR), Clinical Registry, Qualified, Clinical Data Registry (QCDR) or Group practice reporting web portal.

For the year one, quality category will have 50 percent weight in the performance scoring procedure.

Resource Use: Clinicians are not required to report for this, CMS will calculate these measures based on claims and “availability of sufficient volume.” To account for the differences among specialties, CMS has proposed to add 41 episode-based measures. These episode groups have potential to provide more actionable insights on measure resource use than the various cost measures.

For the year one, resource use category will have 10 percent weight in the performance scoring procedure.

Advancing Care Information: Clinicians can report on the measures that suit their practices the best and reflect how the EHR technology is being used for daily needs, with particular emphasis on the interoperability and information exchange. The performance score does not use threshold and allows physicians to receive partial credits on measures.

For the year one, advancing care information category will have 25 percent weight in the performance scoring procedure.

Clinical Practice Improvement Activities: In this category, clinicians would be rewarded for activities that improves overall care delivery such as care coordination, beneficiary engagement, and patient safety. Clinicians can choose practices’ goal from a list of 90 plus activities. This category does not require a full year reporting. CPIA activities need to be performed for at least 90 days during the performance period.

For the year one, CPIA Category will have 15 percent weight in the performance scoring procedure.

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Patient-Centered Care and Its Impact on Healthcare IT

Guest post by Ali Din is GM and CMO, dinCloud.

Ali M. Din
Ali M. Din

Like retail and education before it, a major shift is underway in the healthcare industry that is putting power back in consumers’ hands. Similar to how retail outlets are delivering custom experiences based on consumer preferences, or how there is more attention to individual needs in the classroom, patients are able to play a more active role in their healthcare administration and decision-making than ever before. This means participating in a shared decision-making model with physicians, seeing their needs and preferences reflected in the course of their treatment, and easier access to their medical data, made readily available to both the patient and his or her medical team.

Patient centered care (also referred to as PCC), patient empowerment, patient participation, and shared decision making are all terms used to describe this phenomenon. While the reach of PCC is still expanding, its benefits are clear. As stated by PwC in its “Top Health Industry Issues of 2016” report, and reported by Fierce Healthcare, “care will begin to move into the palms of consumers’ hands.”  Going further, a Health Affairs blog states that, “it is well established now that one can in fact improve the quality of health care and reduce the costs at the same time.”

This article will explore the phenomenon that is PCC, a paradigm shift changing the healthcare industry at its core. So much so, PCC is driving adoption of three technology related trends that are in line with its principles. They include: telemedicine, cloud computing and mHealth.

Patient Centered Care and 2016 Healthcare IT Trends

Telehealth

While many assumed in-facility care would remain the norm after house calls faded from popularity decades ago, that may not be the case. Increasingly, telemedicine — or remote consultations, diagnoses, and treatment performed by medical professionals — is becoming a standard practice in the healthcare industry.

For example, the below ad from Anthem BlueCross and LiveHealth Online was released by one of the nation’s largest insurance agencies promoting remote consultations states the “doctor is always in” and sessions are “quick and easy with no appointments and no driving.”

In line with the principles of PCC, telehealth promises greater access to care for patients who don’t live in close proximity to a healthcare facility. For the greater population, telehealth offers convenience and the comfort of care delivered in a patient’s natural environment. Administering care in a patient’s environment instead of a traditional healthcare setting can also facilitate better care in some cases. Fierce Healthcare provides the example of blood pressure screening – taking a patient’s blood pressure in a natural setting, like their home or workplace, may more accurately reflect their blood pressure on a daily basis.

Telehealth and the benefits this practice offers to patients are perfectly in line with the patient-centric approach favored today. In light of this, it wouldn’t be surprising if telemedicine adoption continues to rise in the coming years, along with the demand for technology that can facilitate remote care.

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Security Requires Patient Accountability

Guest post by Edgar T. Wilson, writer, consultant and analyst.

Edgar T. Wilson
Edgar T. Wilson

In the age of the digital hospital and the connected patient, security will likely improve the less it depends on providers.

Everything from HIPAA to patient engagement treats physicians as the white hot sun of the healthcare universe, holding everything together and keeping it all in stable orbit. They are accountable for health outcomes, for patient satisfaction, for guiding patients to online portals, and for coordinating with care teams to keep data secure — even as mobility and EHR dominance complicates every node in the connectivity chain. All this digital chaos brings more diminished security.

Only as Strong as the Weakest Link

Every business out there has learned — usually the hard way, or by watching someone else learn the hard way — that whatever the security infrastructure, users are the weakest link. More devices means more users, and more connectivity and data-sharing means more weak spots all along the chain. By design, the EHR system adds vulnerability to healthcare data security through a long chain of users.

Patients don’t have a systemic, accountable role in all of this. Our whole approach fosters passivity on the part of the patient and paternalistic assumptions on the parts of caregivers and policymakers. We give tacit acknowledgement of this imbalance whenever malpractice law or tort reform is mentioned — and promptly left behind in the face of other, patient-exculpatory programs and initiatives.

Patients are a part of this. Clearly they are invested in their own security — the costs of health data breaches contribute to the rising costs of care, besides exposing personal financial and medical information that can carry its own universe of costs.

Patients are implicated, but they must also be accountable for security in the new high tech healthcare system.

An Old Problem with New Importance

Getting patients included in the evolution and delivery of healthcare requires engagement. The same goes for digital security. The ethical and financial dilemmas of the security situation is an expensive distraction for administrators and caregivers, but it is a learning opportunity that could empower patients. A new emphasis on digital security and privacy could be the start of a cascade of engagement with further questions of use and responsibility for outcomes.

Already, patients are key players in making telemedicine effective. Access is on the shoulders of the patients, and utilization depends on their technical literacy. The incentives–time and money savings, improved access to care–are powerful, but come with the obligation to learn the platform through which remote care is delivered. Utilizing any telehealth solutions requires patients to think about what information they want to share, whether they trust the new platform, communicating effectively with their provider, and gaining confidence for the new medium.

This same model can be applied more broadly to EHRs, and the patient role in the digital healthcare system.

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2015 Medicare ACO Results Reflect the Turning of the Deming Wheel

Guest post by Ken Perez, VP of healthcare policy, Omnicell, Inc.

Ken Perez
Ken Perez

Quality expert W. Edwards Deming was famous for many concepts, including the Deming Wheel or Deming Cycle, more formally known as the PDSA (Plan-Do-Study-Act) Cycle. It is a systematic series of steps for gaining valuable learning and knowledge for the continual improvement of a product or process.

The Centers for Medicare and Medicaid Services’ August 25 release of 2015 quality and financial performance results for Medicare accountable care organizations (ACOs) reflected the application of the PDSA Cycle by the participating organizations as well as CMS in its continued development and refining of its ACO programs.

At a high level, in 2015, the 404 reporting ACOs—392 in the Medicare Shared Savings Program (MSSP) and 12 in the Pioneer ACO Model—achieved $466 million in savings. A bit more than half of the ACOs (210 or 52 percent) held costs below their benchmark, and slightly less than a third (125 or 31 percent) generated savings above a minimum savings rate (MSR) and met quality performance standards, thus meriting shared savings.

As is common with most statistics and especially any material news coming out of Washington, D.C. nowadays, there were widely divergent interpretations of these results.

On the cheery side, CMS chief medical officer Patrick Conway, M.D., rhapsodized, “Accountable Care Organization initiatives in Medicare continue to grow and achieve positive results in providing better care and health outcomes while spending taxpayer dollars more wisely.”

In contrast, Clif Gaus, CEO of the National Association of ACOs, in an email message to FierceHealthcare, struck a negative tone in his appraisal of the results, sharing that his organization “was disappointed not to find stronger financial results that reflect the extensive financial and personal contributions invested by ACOs” and he also said that CMS and Congress must “take swift and decisive action to solidify the foundation of the Medicare ACO program.”

Despite these obviously divergent views, certainly neither Conway nor Gaus would disagree with the idea that the ability to learn is a critical success factor in ACO performance.

A deeper analysis of the data bears this out. As noted by CMS, more-experienced ACOs were more likely to generate savings above their MSR. In performance year 2015, 42 percent of ACOs that started in 2012 generated savings above their MSR. This compares with 37 percent for ACOs starting in 2013, 22 percent for 2014 starters, and 21 percent for 2015 starters.

The value of learning from experience was also reflected in the quality results. MSSP ACOs that reported quality measures in both 2014 and 2015 improved on 84 percent of the measures common to both years.

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Population Health Management 101: The One Where It All Starts

Guest post by Abhinav Shashank, CEO and c0-founder, Innovaccer.

Abhinav Shashank
Abhinav Shashank

Former US President Abraham Lincoln once said, “Give me six hours to chop down a tree and I’ll spend four hours sharpening the ax.” After having a look at the efficiency of the US healthcare system, one cannot help but notice the irony. A country spending $10,345 per person on healthcare shouldn’t be on the last spot of OECD rankings for life expectancy at birth!

A report from Commonwealth Fund points how massive is US healthcare budget. Various US governments have left no stone unturned in becoming the highest spender on healthcare, but have equally managed to see most of its money going down the drain!

Here are some highlights from the report:

The major cause of these problems is the lack of knowledge about the population trends. The strategies in place will vibrantly work with the law only if they are designed according to the needs of the people.

What is Population Health Management?

Population health management (PHM) might have been mentioned in ACA (2010), but the meaning of it is lost on many. I feel, the definition of population health, given by Richard J. Gilfillan, president and CEO of Trinity Health, is the most suitable one.

“Population health refers to addressing the health status of a defined population. A population can be defined in many different ways, including demographics, clinical diagnoses, geographic location, etc. Population health management is a clinical discipline that develops, implements and continually refines operational activities that improve the measures of health status for defined populations.”

The true realization of population health management (PHM) is to design a care delivery model that provides quality coordinated care in an efficient manner. Efforts in the right direction are being made, but the tools required for it are much more advanced and most providers lack the resources to own them.

Countless Possibilities

If population health management is in place, technology can be leveraged to find out proactive solutions to acute episodes. Based on past episodes and outcomes, better decision could be made.

The concept of health coaches and care managers can actually be implemented. When a patient is being discharged, care managers can confirm the compliance of the health care plans. They can mitigate the possibility of readmission by keeping up with the needs and appointments of patients. Patients could be reminded about their medications. The linked health coaches could be intimated to further reduce the possibility of readmission.

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Implementing New Technology: Working From the Ground Up

Guest post by Sivan Agranat, M.D., VP, Medical R&D, medCPU.

Sivan Agranat
Sivan Agranat

The successful implementation of new IT solutions can depend as much on user acceptance as on the technical aspects of implementation. Gaining that user acceptance is largely a matter of ensuring stakeholders are part of the conversation during pre-implementation, followed by fully accounting for and meeting end-user needs during roll-out and beyond. Nobody, especially busy doctors and nurses, appreciates having new technology dropped on them; nor should they. Their input throughout the process is critical not only to their acceptance, but also to solution optimization.

The following is a suggested course of action for gaining stakeholder buy-in and sustained satisfaction that can make new technologies a welcomed addition to clinical care settings.

The technology selection process

Provider organizations invariably have some clinicians who appreciate the benefits of health IT more so than others, and who serve as internal IT champions. When their opinions are respected by their peers, they can be invaluable allies in new implementation projects, which is why it’s imperative to loop them in as clinical representatives at the beginning of the vendor selection process. Their combination of clinical expertise and affinity for IT can be indispensable in validating vendor claims, ensuring the most promising solutions rise to the top. Additionally, having been involved from project start can help enable them to be better positioned to promote the solution internally and offer meaningful support to their peers as they gain user proficiency.

One important element that’s too often overlooked is: When gathering input from clinical representatives during vendor selection, pay close attention to ensure solution capabilities align with existing workflows. Making later adjustments to ensure the right information is delivered to the right person at the right time can be costly and time-consuming.

Before making a final decision on vendor selection, hold an all-stakeholder preview meeting. This can help head off resistance while gaining needed input. Include all targeted end users, not just nurses and doctors, but members of the nursing and clinical support teams as well. If the implementation is a major initiative, consider having meetings with primary stakeholders and include an introduction by the Chief Medical Officer, who can best explain the project’s importance.

In all stakeholder preview meetings, begin by describing how and why the project transpired and what it is designed to accomplish. Next demonstrate the solution and engage people and ask for their feedback. Most importantly, take all feedback to heart, and address stated concerns as clearly as possible. This attention and courtesy can help ward off skepticism at time of rollout, and help ensure acceptance. Also, you may learn from the end user feedback that will help foster enhanced final adjustments before the actual rollout.

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Healthcare IT Pros Earning More, Bullish on Prospects

Guest post by Valerie Gleaton, managing editor, Health eCareers.

Valerie Gleaton
Valerie Gleaton

Salaries for healthcare IT professionals are on the rise, but they aren’t growing as fast as some other healthcare positions. That may be impacting satisfaction levels, according to a recent survey. Healthcare job site Health eCareers polled nearly 20,000 U.S. healthcare workers and found that the average annual salary for healthcare IT professionals increased 2.2 percent from 2015 to 2016. However, some of the other positions included in the survey saw more sizeable gains. For instance, those working in academics, research, administration, operations and allied health saw compensation increases in excess of 10 percent.

With more available jobs than professionals to fill them, hospitals, healthcare clinics and other providers are increasingly willing to loosen their purse strings and pay higher wages to both current employees and new hires. These factors have created a perfect storm of opportunity for healthcare workers, and 87 percent report that their pay is the same or has increased compared to a year ago. Survey respondents pointed to merit raises or employer changes as the primary reasons for their increase. There were exceptions, however. Nurses and healthcare executives saw a 3 percent and 13 percent drop, respectively.

average-compensation-by-occupation

$91k is Average for Healthcare IT

Healthcare information technology professionals are enjoying robust job prospects, as healthcare organizations come under the gun to improve efficiencies, cut costs and find better ways share patient information. The study revealed that America’s healthcare IT workers earn an average of $91,251 a year, the fifth-highest paid healthcare profession, topped only by physicians/surgeons, healthcare executives, physician assistants and nurse practitioners.

Pay Fluctuates by Location, Experience and Position

Location seems to influence pay, with salaries varying widely from state to state. For instance, healthcare IT professionals in California earn an average of $95,224 per year, while their counterparts in Texas make nearly 6 percent less, averaging $89,758 a year.

Another large and unsurprising determinant of pay is experience. New healthcare IT professionals — those with five or fewer years of experience — earn an average of $74,815 per year, while those with more than 10 years of experience report an average annual salary of $104,343. Those that fall in the middle with 6–10 years of experience pull in an average of $98,082.

Health eCareers also found big pay discrepancies by types of healthcare IT disciplines. Health information technology executives are far and away the best paid, with a median annual income of $127,500. IT technology managers also do well, with median earnings of $111,500 per year. Further down the pay scale are healthcare informatics employees at $74,500, and toward the bottom are health information technicians, who report median salaries of just $50,500.

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