From EMRNurse: “Re: Epic. Reporting from the Emergency Nurses Association conference in Salt Lake City. Lots of IT vendors, most of the big ones that have ED or Health System wide products. One seems to be missing – Epic. There is also a group forming to write a best practices document on ED applications. See the ENA technology listserv for details in the next few weeks. It can be found at ENA.org.”

From Phillip Elliott: “Re: tamper-proof prescriptions. I disagree that the tamper-proof paper script mandate is anti-EMR. Making paper harder to work with should drive people to e-prescribe, no?”

From Mike Bossy: “Re: Siemens. Bobby Orr wonders about Siemens’ focus with MS4, Soarian, and INVISION. What about their relationship with NextGen? Is NextGen their partner du jour until they toss them aside when their EMR is finally ready (or they think it is ready)? Where does Soarian Clinicals end and NextGen EMR start for Siemens customers?”

From The PACS Designer: “Re: iGUARD. iGuard keeps you updated on the latest findings on drug interactions and their side effects along with any new safety alerts. There’s a live webcast October 4th on this subject.” I tried it and was less than impressed. You enter your list of drugs and then wait for an e-mail back on each one, but most of mine said to wait several days for a response. All I could figure out that it does is flag a “risk rating” once you finally get the e-mail, but I’m not sure exactly what benefit that offers. Ask your pharmacist, look up your drug on any of thousands of patient information sites, buy a drug reference book — all provide more actionable information. I don’t see the point of it at all, but that’s just my opinion.

From HITman: “Re: HIPAA. What Ivinson Memorial Hospital is doing is right on track with HIPAA. Employees, when it comes to their own medical records, are no different than any other patient under HIPAA. They must follow the same policies and procedures to request access to their records. The reasoning that they have a computer password or the key to the file room doesn’t make them exempt from HIPAA. Covered entities must protect PHI. They must treat every record the same and every patient the same. Accessing records outside the scope of the minimum necessary or the need to know the information in order to perform job duties is not allowed under HIPAA. Kudos to IMH for sticking to their guns and HIPAA!”

From Philip Rivers: “Re: Ted Borris. Ted came to QuadraMed with CPR. We are excited to have him.”

John has a summary of this week’s AHRQ meeting. Nuggets: research hasn’t proven that healthcare IT improves quality, NHIN is a pipe dream, PHR privacy is getting no attention, and AHRQ-sponsored studies show that e-prescribing doesn’t reduce adverse drug events. I’m not surprised since AHRQ’s HIT studies are usually inconclusive at best. Could it be because it’s the user and not the system that drives the results, especially when looking at an unrelated marketbasket of healthcare organizations as though it were a population-based healthcare study? IT, if deployed wisely with process change, can sometimes make good organizations better. That’s it. Anyone who expects more is being naive. It isn’t what you have, but how you use it, a concept that somehow seems lost in the pre-purchase optimism of hospitals convinced that their carefully aimed checkbook can painlessly cure all organizational ills.

Scott Shreeve opines on athenahealth’s IPO. I like reading his stuff because he’s so energetic and positive. It’s like the standard war movie scene where the wisecracking fresh recruits are marching excitedly off to battle and pass a returning group of battle-weary veterans whose gaunt faces show the horrors of war they’ve witnessed and possibly committed. I realize I’m in that latter group.

Advice from a BI consultant to providers: “Stop thinking like a healthcare company. Providers are notorious for making known vendors and established consultants their trusted advisors. Instead, they should think like retailers. ‘Cerner and McKesson don’t have all the answers,’ one HMO administrator confided to me recently, as if it were a secret. ‘What we’d really like to know is what McDonald’s and Target are doing.’”

Thoughts on the healthcare IT vertical market from the perspective of Microsoft channel partners: “Moreover, some larger hospitals are hiring partners to build their EMR applications from scratch. Once you factor in annual maintenance fees, Velu says, some packaged EMR products can actually cost more over their lifetimes than handmade systems do … Hospitals, for example, tend to be wary of risk. ‘They’re followers, not leaders’ … Doctors can be tough customers too. ‘They’re notoriously cheap’, says Summers.” I don’t know of any hospitals building EMR applications from scratch. If you do, let me know, because I’d be interested to learn more.

A hospital CFO blames its new Dairyland system for not getting bills out on time. From the article: “The hospital has had many problems getting its issues solved with the software company.” Somehow I doubt it’s all Dairyland’s fault since they’ve installed quite a few systems in their time, but every patient accounting implementation starts out rough.

Strange: a UK government official was late for a hospital construction group picture, so his image was Photoshopped in (not all that skillfully, judging from the result). The kicker: he’d just scolded the press for faking footage.

The Australian Medical Association wants airlines to pay doctors who treat fellow passengers or upgrade physician passengers upfront for being “on call”. Once doctor was refused an upgrade for helping vomiting fellow passengers, so she sent the airline a bill.

A big UK hospital will use Sentillion for single sign-on and context management.

Thanks to these sponsor supporters of HIStalk. Please click their ads to your left and consider their offerings. I admire their bravery in convincing the beancounters to send money off to some anonymous blogger. Anyway, these vendors support HIStalk, so I appreciate your support of them in return.

Design Clinicals, LLC
EHRConsultant
EnovateIT
eScription
Hayes Management Consulting
Healthcare Growth Partners
Healthia Consulting
Inside Healthcare Computing
Intellect Resources
InterSystems
John Muir Health
Lucida Healthcare IT Group
Medicity
MedMatica Consulting Associates
Noteworthy Medical Systems
Novo Innovations
Picis
Premise
Pring|Pierce Executive Search
R. Gaines Baty Associates
SCI Solutions
Sentillion
SolCom
Stratus Technologies
The White Stone Group, Inc.

Inga’s Update

Sue Ellen Mischke: Ever noticed there are two HMAs and they couldn’t be more different except their names are exactly the same? Health Management Associates, the hospital chain. For-profit to the nth degree. Then, Health Management Associates (www.healthmanagement.com) the consulting firm, which specializes in public hospitals, public health departments, and Medicaid agencies. They couldn’t pick customers with less money if they tried. Actually, I never quite put that together, but that is a great observation. I’m learning that I am not always great at observing little details. Like I just found out yesterday that when a major league baseball team plays at home, their jerseys say the team name (e.g., Yankees), but, when they are away, the jerseys say the name of their city. Who knew?

The market for physician financial information systems is expected to grow from $3.5 billion in 2006 to an anticipated $6.22 billion by 2013. This according to a Research and Markets study.

Susquehanna Health, the first facility to go live on both Soarian Clinicals and Financials, has signed on with Siemens for additional technology and service solutions. The Williamsport, PA-based health system plans a “facility revamp” project to be completed over the next five years.

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From Bobby Orr: “Re: Siemens. There were some positive postings about the old MedSeries 4 a week or so ago. If they are now developing MS4 again, along with Soarian and Novius, and supporting their huge Invision base, doesn’t that make them a little bit unfocused? Where is the R&D really going for the future? Is anyone else confused by what they are doing?”

From Brad Majors: “Re: tamper-proof prescriptions. How’s this for punishing EMR users? New York mandated ‘official’ prescriptions two years ago, giving hospitals using EMRs two options: use double-tray, secure printers, or put ‘official’ state stickers on the printed prescriptions. Hospitals mostly went with the sticker option to avoid replacing printers. CMS regulations go into effect October 1 and those stickers won’t be available until the end of October or in November. How could they not have considered hospitals with EMRs?” The Senate stepped in at the last minute to delay implementation for six months. Stickers on paper prescriptions? Only in healthcare. We might as well drip wax to seal parchment scrolls.

From Janet Weiss: “Re: KLAS report on nursing adoption. The lead clinical system vendors had pathetic scores, with the highest score 23.3 out of a possible 40. EMRs pretty much suck for nurses. All that rush to market and to re-create the paper chart while meeting Wall Street numbers. Well, this is what we get.” Someone sent me a copy of GE Healthcare’s internal response to the KLAS report, in which the company seems collectively embarrassed for the whole industry: “None of the vendors evaluated performed above the level of a ‘D’ grade. The overall results of the vendor scores speak to the fact that as an industry we are not sufficiently focused on how IT supports the nurses’ work in delivering patient care. No vendor should be pleased with the results.” Kudos to KLAS for doing the study and GE for coming clean, even thought it only bought the problems along with IDX. Now would any of GE’s nursing system competitors care to take the same level of public responsibility by admitting that they’ve done a lousy job in meeting the needs of healthcare’s largest and arguably most important constituency? On the other hand, it might not have mattered: in most places I’ve worked, nurses were frequently asked for input on software and project plans, but were invariably overrruled by a CIO who could not accept the fact that collective user wisdom might exceed their own. I honestly can’t recall even once when nursing’s choice ended up being purchased, always for some CIO-friendly reason like hardware platform or resume-building cachet.

Oldie but goodie: Neal Patterson on David Brailer, circa November 2005: “He wants to create new entities without true business models … That’s not sustainable … His model [is that of] Beltway bandits – a group of people who live off government grants. He’s aligned himself with the grant babies.” Could he have been any more correct, or any ballsier saying something as outrageous as that in the RHIO hand-holding frenzy two years ago?

More good Cliff and Neal quotes in IBD, although one isn’t true: Neal claims the last time the word ‘employee’ was used at Cerner was when he met with pharmaceutical bigwig Ewing Kauffman, who called them ‘associates’. Only if that meeting came after the infamous “tick tock” e-mail, in which Neal used it repeatedly and sarcastically (and capitalized for extra effect).

Heard: Ted Borris, assistant general counsel of Misys Healthcare, has left the company.

Listening: new H.I.M and Entwine. Both from Finland, coincidentally.

DTE Consulting (stands for Down to Earth), started in 2005 by former Lourdes Hospital (KY) CIO Gary Wood, will work with Optio on forms projects.

The voting public, not surprisingly, isn’t really all that interested in healthcare IT. Mitt Romney’s domestic policy director was honest: “I think it’s fair to say that’s not the sexiest issue in the world.” Do what vendors do: bring on the booth babes!

Johns Hopkins will install TeraMedica‘s Evercore clinical content manager.

This doesn’t sound right: looking at your own medical records is a HIPAA violation? This hospital is putting the fear of God into employees, using Meditech’s HIPAA auditing capabilities to scare them into confessing for looking at their own records online. Sounds like a compliance officer on a power trip.

An Indianapolis in-store retail clinic chain backed by Cardinal Health is kaput. Corner Care locked the doors and left creditors unpaid.

New York’s state health department offers $106 million in grants for RHIO-type projects. I’ll defer to Neal on that one.

The University of North Carolina’s Institute of Pharmacogenomics and Individualized Therapy implements a genotyping analysis system from InforSense. Cool: it analyzes information from DNA analyses, EMRs, and other databases to individualize drug therapy. How it works otherwise: the drug company SWAGs a dose that seems to work when given to a bunch of patients, then hopes no one dies when lots more people start swallowing it after free-lunch docs start cranking out the scripts. Now you know why progressive health systems are working to integrate genomic information into their clinical data repositories (and why the next step will be to use it for clinical decision support). See if this doesn’t sound like a clinical system.

My editorial this week over at the newsletter: “Lay Your Hands on the TV to Be Healed: The Emergence of the Superstar Remote Physician.” I may not be the most insightful editorialist, but I bet I’m the only one working a Suzanne Somers reference into a healthcare IT paper.

Lucida Healthcare IT rolls out a new Web site, which includes an Express Application for consultants looking for opportunities and a Resource Request Form for hospitals that need resources.

PSS World Medical, which picked up 4.6% of athenahealth pre-IPO, sees its investment go from $22.5 million in July to $52.2 million two months later. The market cap of athenahealth: about $1 billion, a little less than Allscripts and Eclipsys. Sweet.

E-mail. I’ll read it, but the rest depends on what you have to say.

Inga’s Update

This article didn’t surprise me too much. Few women hold high academic positions at the top science and engineering research universities. And, women have more advancement barriers than men in the corporate world. The chancellor of UC Berkeley notes that this puts the US at a competitive disadvantage worldwide. Discrimination, lack of female role models, and lack of corporate champions were some of the reasons cited. Just this week I happened to be looking at the web sites of a couple of the major computer vendors – one had no women executives (14 men) and the other had just two women out of the 16 execs. I doubt it is because women aren’t interested in the jobs.

Mr. H listening to Megan McCauley? I have shoes that look older than her. Try some Paolo Nutini. He may not be much older than Megan, but he sure looks adorable. Something for the ladies to enjoy while working to take over corporate America.

Bassett Healthcare in Cooperstown, NY selects McKesson for additional products for its four hospitals and 23 community health centers. Bassett is already using Horizon Patient Folder and Medical Imaging solutions. The latest contract is for CPOE and clinical decision support, bar-code medication administration and a Web-based business intelligence tool.

GE Financial Services and the Healthcare Financial Management Association (HFMA) release a study suggesting that hospitals will make themselves more competitive if they make strategic investments in technology. Furthermore, hospitals shouldn’t wait around for policy changes or public or private funding for projects such as EHR. Don’t you just know that GE Financial was dying to add something in the press release saying how much they would love you to borrow money from them to finance all those technology projects?

Surescripts announces a Prescriber Vendor Advisory Council made up of 10 EMR/eRx vendor executives. Their mission is to advise SureScripts on programs designed to increase the adoption and use of e-prescribing.

Health Management Associates (HMA) has contracted with NextGen for the purchase of software licenses for EMR and enterprise practice management. This is a second phase purchase of the NextGen products for HMA, which owns and operate 59 hospitals and medical centers. Earlier this month we mentioned that a class action lawsuit had been filed against HMA, charging it with insider trading.

MedComSoft announces year-end financials through June 30th. Revenues went up 59% over the previous year, expenses grew 27%, and their net loss increased by 18% ($4.5 million.)

From the Archives of Internal Medicine: a new study by the RAND questions the value of preventative health exams. It doesn’t say stop going to the doctor – it just suggests we can’t assume the value outweighs the costs for every patient.

Here are IBM’s predictions for the top healthcare industry trends over the next five to 10 years:

• Secure sharing of patient data with interoperability
• Fully-informed diagnosis (shared between all care-givers while preserving patient privacy)
• Speeding drugs to market
• Stemming the spread of pandemics

And of course IBM has announced all sorts of radical innovations that will address the changing landscape.

E-mail Inga.

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Hardly an HIStalk posting goes by without an insightful commentary by The PACS Designer. TPD always seems to be up to speed on various emerging technologies, particularly in the PACS world. I was curious to learn what made him tick and was able to have a chat with him recently. Thank, TPD, for sharing your story.

Inga:  How did you select the name The PACS Designer?

TPD:  Since I have been working in the medical field for years and designed a PACS system in the mid-90s with some great partners, I thought, why not use the name as a blogger? I am also trying to promote PACs. Shahid Shah encouraged me to blog. I am an electronics engineer and wasn’t really working in the PACS area but found an opportunity. I got to like what I was doing and some good things happened out of it.

When did you first begin reading and posting on HIStalk?

I first started about two years ago, when Shahid Shah from Shahid’s Perspectives and creator of HITsphere told me about it. I decided to get involved with blogging. I love teaching people. In my prior job, I taught courses in PACS and other medical technologies and even did SAP software teaching.

What was it about HIStalk that interested you?

I thought the style was good, because sometimes you see blogs where the posts are very infrequent. But HIStalk had the right formula to get people to respond to the posts in the Web 2.0 sense. It promotes 2.0 through interaction. Bloggers are becoming an important part of society, as everybody knows.

What about your background has made you an expert in HIT in general and PACS specifically?

I worked with PACS behind the scenes in design. Before that, I was a purchasing manager and I always knew the latest technology. The combination of purchase evaluation decisions and designing helped me, development-wise.

I love technology. It is a small point, but in 1958 my mother bought me a transistor radio that came from Japan, made by Matshushita, now better known as Panasonic. I got so fascinated with the transistor radio that I decided to go into an electronics engineering program. I’ve been an electronics buff ever since. It is really becoming a digitally connected world and that is where healthcare needs to be.

So, what really got me into PACs goes back to the 1980s, when hospitals were using telephone technology with PACs and it was a very slow teleradiology. In the late 1980s, a company my employer partnered with discontinued their product line, so it killed our product line. I was looking for ideas for the next version of PACs and eventually hooked up with a company to design the next generation of radiology PACs.

What did you do after helping to design the radiology PACs systems?

I looked at how we could help cardiology. I designed a cardiology PACS that has had good success and is used all over the world. I am proud of both things, the radiology and cardiology products, but I am proud that the cardiology images in the cardiology PACS I designed can be viewed all over the world with the PACS I designed.

What do you do professionally today?

Today I am an independent healthcare software developer, working with major universities and vendors on the next generation of software.

PACS software?

Not just for PACS, but Web-enabled software solutions that are available by accessing a Web browser. No software is loaded on your PC. It’s downloaded to you just like YouTube is. Healthcare is going to see a lot more of that technique in the next 10 years.

So you are hired by the different universities to develop applications? 

Yes, to do integration of DICOM, HL7, and Java technologies to create Web-based solutions for healthcare.

Do you find your current job rewarding? Fulfilling?

I love delighting my customers and really like innovation and like to pursue it with excellent partners that will make customers happy with the end result. I will be starting a major project with a Top 10 university next month. 2007 is turning out to be a transition year for technology that is going to excite end users.

I am also a member of the ASTM International. I’m a member of the E31 Health Informatics Committee that developed the Continuity of Care Record. The E31 Committee that created the CCR used the Massachusetts Patient Care Record that had been used for many years as the basis for the CCR. I am still on the committee and another health informatics committee called Privilege Management Infrastructure to design enhanced security for HIPAA so users only see information that they’re entitled to see.

HIPAA is great, but there is a lot of structure out there that needs improvement, security-wise. The ASTM PMI standard will be coming out within the next year or so.

Do you actually meet with your fellow ASTM members?

We work remotely, but I get all my information sent to me over the Internet. I approve or disapprove information online. It is very interactive, but it is all done remotely. They do meet in person, but I’m very busy and don’t have the time and funds to travel all over the place.

I believe I have noticed that you have posted on other blogs.

I randomly contribute to others.  Do you want to know some of the other blogs I read and post on?

Sure!

The Healthcare IT Guy, Shahid Shah. He got me started. LabSoft News. Dr. Friedman is very good at presenting concepts and I like his highlighting techniques. Dalai’s PACS Blog. He is a radiologist who is a very good blogger. Candid CIO. Will Weider lets us know what’s happening in the real world of healthcare IT, which I enjoy reading, and then I post comments on his blog to educate his readers. Scott Shreeve, MD. I also like Scott’s blog and we’ve seen his HIStalk interview and the numerous posts about him. Christina’s Considerations. Christina is not as well known yet, but she covers RHIOs, a controversial subject today. HealthBlog from Dr. Bill Crounse at Microsoft. He tries to let us know what Microsoft is focusing on next, like Azyxxi.

HIStalk is the best one, right? [laughs]

Of course! Actually, HIStalk is more consistent about their format. There is a lot of interaction with readers. There is Inga, Tim, and other posters, I was so happy when you joined. It made it better.

Thanks. Well, there are some amazing posters. Next question, how is the PACS world going to change over the next few years? What companies will survive and what will the hot technology be?

PACS is becoming a vital modality as far as hospitals are concerned. PACS takes away the cost of X-ray films, which is a very expensive thing. And PACS is expanding to include a mini-EMR through HL7 interfacing techniques and open software solutions.

Everything is going digital. The patients are becoming more involved. Here is a new term – Digitally Connected Patients (DCP). The patients from home will be able to be wirelessly monitored by the hospital. That will be the next big wave over the next 10 years. Patients who live alone with health problems would definitely want to be connected. We’ll actually see that in less than five years. We already have the ability to send heart rate, blood pressure, and other vitals information from remote locations, such as ambulances in route to emergency departments, and also remote digital storage for redundancy.

The infrastructure of companies will change a lot. With EMR companies, they will be bought up or go out of business because everything is going to be Web-enabled. If you are not Web-enabled, you won’t survive. The EMR and PHR will be a partnership involving the patient, hospital, and doctors all submitting information into the combined record. It will be Web-based and a lot of the EMR companies will need to change their business plans to go Web-based, or go out of business, or merge with larger companies.

EMR/PHR will be viewed similar to having an online bank account. You can call up your account any time as long as you have an ID and password. If you can do it in banking, why not do it in medical?

I didn’t mention this earlier, but XML, Extensible Markup Language, will become a big part of how we capture information. Any time you enter information via a Web browser, you can capture it in XML and store it in an EMR or PHR. Currently I can’t talk much more about this because I am in the middle of a patent application. I have developed a new technique for this.

2007 is becoming a year of major transition because a lot of things are happening and it is exciting for the healthcare field.

You have been in this business a long time. Any plans to retire soon?

I love the healthcare field so much that I plan to do software development as long as I can, no matter how old I am. I am not inclined to retire in the immediate future. I love being independent. I have a great group of partners ready to work with me. Being free and independent lets me innovate the way I want to innovate.

Thank you for interviewing me. Hopefully HIStalk readers will enjoy some of my comments and I hope readers will benefit from them in the coming years.

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From John Stryker: “Re: Wal-Mart. Any speculation on who Wal-mart will choose as a vendor? I hear that they are down to three and plan to decide this week.” Maybe a Chinese software firm willing to sell systems for $200 each? Actually, I have no idea. If you do, spill. I bet Eric Fishman knows since he dropped hints when I asked him about retailers and the new wave of vendors.

From Desert HISer: “Re: QuadraMed. QuadraMed’s long-time customer, Sun Health in Phoenix, may be at risk with the recent announcement that Banner Health would be acquiring  them. In an article in the AZ Republic, Banner Health was quoted that IT upgrades would be a high priority for Sun Health under Banner’s ownership and Banner is not a QuadraMed customer.”

From PTSD: “Re: CE. Illinois passed a new Nurse Practice Act requiring professional nurses to have CE courses to maintain their license. Almost half of the states out there do not require nurses to take CE to maintain their license.” Surprising. I assumed all states required CE.

Vince Ciotti checked in to drop some kudos about two small but innovative clinical systems vendors: VisualMED and IntraNexus. On VisualMED, Vince found their system functional, robust for nursing documentation, and designed by a great MD, Art Gelston. I’ve seen their system and have met Art and agree on both counts. Vince mentions that one hospital is using VisualMED as a clinical front-end to Meditech and it was apparently designed to work that way for any other system. I interviewed CEO Gerard Dab last year. I know less (nothing, actually) about IntraNexus, the keepers of the old SMS Allegra system, but the company is introducing a new system called Sapphire. There are few clinical systems to choose from and fewer still that don’t cost gazillions, so give these a look if you’re so inclined.

While I’m talking about Vince, I’ll give him a plug: H.I.S. Professionals will be having its “Mini-HIMSS” in Chicago on October 3-4. He invited Inga to cover it for HIStalk, but I don’t think she’ll be able to go.

Listening to now: Megan McCauley.

Found: Kim Pederson, former Excellian VP at Allina. I wanted to see what she’s up to after Allina won the Davies Award for the Epic implementation she led. She left Allina in June (right after I interviewed her) and has hung out a consulting shingle as KP Healthcare Consultants, she told me in an e-mail. On the Davies win: “I’m thrilled about the Davies Award. I had a great team that gave it their all and they deserve the recognition. I couldn’t be more pleased.” On her new business: “I’m focusing in healthcare. My two big experience areas are large scale implementations and revenue cycle. The work I’m doing to date is around project assessment & improvement, strategy, planning and budgets, executive level coaching, project governance, risk management, and scope management. I’m looking to help organizations at the start of their implementations get set up to succeed and to go to troubled implementations to help get them back on the right track.” She put in Epic in a 11-hospital, 350-employee, $250 million program and won the Davies doing it, so you might want to contact her if your project needs help.

Amazing: Microsoft wants to buy 5% of Facebook for $500 million, thereby valuing the three-year-old, teen-heavy social networking site at $10 billion. The founder and CEO is 23. Too bad we’re wasting our time working on systems that save lives.

The folks at eScription tell me they’ve earned their first speech recognition patent. Their AutoScript background speech recognition uses “adaptive playback speed” to intelligently adjust audio speed based on the transcriptionist’s editing proficiency, their efficiency with that clinician, and their preference for playback speed. It was developed under code name “The Lucy Chocolate Factory”, referring to the Lucy episode where she’s unable to keep up with the assembly line. User quote about the system’s ability to learn the preferences of transcriptionists: “The speed increments are slowly introduced so you are not even aware of them until you notice your gain in productivity.” Nice.

Frank Pecaitis and Medsphere have parted ways, I hear. He’s working for GE Healthcare as GM/VP of Sales.

In the UK, a newspaper runs some examples of NHS errors. One of those listed: “A further incident involved a software company failing to activate a neonatal screening system, leading to a series of false negative results.”

Confirmed: Epic will start work on a Web transition shortly, but has yet to choose a development tool. Their previous switch from character-based to GUI wasn’t too smooth, I’m told (hearing the words “hyperspace transition” apparently causes early customers to seize involuntarily), so they’re taking it slow.

QuadraMed closed its Misys CPR acquisition yesterday, so that’s probably why some San Bernardino CPR staff were let go.

Stock of RFID vendor InfoLogix began trading on Nasdaq Monday. Market cap is $91 million, not bad.

Duplicate patient records caused a Nightingale Informatix health department system to delay some test results in Nova Scotia.

Cardinal Health CEO Kerry Clark will replace founder Robert Walter as chairman. A painful tidbit in the announcement, since I owned CAH stock in the 1980s: “An investment of $10,000 in Cardinal Health stock at the time of its public offering in 1983 would be worth $8.2 million in 2007, an appreciation of more than 80,000 percent.”

Inga’s Update

I heard Epic invited 3500 of their closest friends to an open house to tour the new facility. Since I didn’t make the guest list, I was wondering if any readers were invited and if they cared to share their impressions.

And speaking of Epic, I was amused by a blog I came across called, The Rantings of an Angry Security Kitteh. (I know “kitteh” is some sort of urban lingo, but I don’t get it.) Anyway, the writer is apparently an Epic employee who sat in on some of the recent user group meetings and was less than impressed with one of the speakers.

Mr. H suggested we might want to “wangle” an interview from Isacc Kohane of Children’s Hospital Informatics Program of Boston. This is the organization that is taking over development of the personal health record program for Dossia, after Omnimedix and Dossia split sheets. I asked “Zak” Kohane for his impressions, to which he commented: “Many years ago, when I was single and dating, I found that it was not a good idea early on in a relationship to probe too deeply into prior relationships. Also, even I knew enough to not ask her why she had chosen me. I might not like the answer.” Obviously this does not give us any more insights into the issue, but it sure makes me wish I had dated Zak back in the day.

A study by the Center for Studying Health System Change (HSC) found significant variation in IT adoption exists across specialties. Highest usage specialty: oncology, followed by internal medicine and family practice. Lowest IT adopters: ophthalmology, followed by psychiatry and orthopedics. If you are an EMR vendor, this study provides some good insights.

What does this suggest about the state of RHIOs? The Patient Safety Institute (PSI) is closing shop. PSI was founded six years ago to provide the healthcare industry with a commonly owned, inclusive network utility to support RHIOs and provide ready access to patient healthcare information. PSI promoted a private sector self-funding model similar to that used in the financial services industry, but claims that in the end the model proved to be ahead of its time, pointing to lack of cooperation between parties as a primary issue. So what, if any, RHIO business model(s) will ultimately prove financially successful and widely embraced?

E-mail Inga.

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I ran across Eric Fishman, MD a few months back when I stumbled onto his EHR Scope, a compendium of information about physician system and speech recognition. Ambulatory systems continue to be very hot in the marketplace and it was interesting to find a practicing physician who was putting so much time and expertise into that market.

Since then, Eric has decided to put his full time and attention into his business, which also includes a free service to help physicians choose an EMR/EHR and a package of products and services related to speech recognition for physicians (based around Dragon NaturallySpeaking). Note: I’ll mention as a disclaimer that Eric’s company recently decided to sponsor HIStalk, although our plans for the interview had already been made by then.

Thanks to Eric for bringing me up to speed on the complex world of physician practice systems. Big changes are happening.

Give me some background on yourself, the company, and how you got interested in physician automation.

I’m an orthopedic surgeon. About 14 years ago, one of my secretaries came to my office and said, “I know you like computers. I just took my son to a pediatrician and he was talking to a computer.” He was using a voice recognition product from a company called Kurzweil, which had been started by Ray Kurzweil.

I decided to buy it. Ours was a three-physician office at the time. The $26,000 cost was hard to swallow, so I opened a company to sell voice recognition software 13 years ago. And so the rest is history, although I didn’t want to say that because it sounds overly grandiose. [laughs]

I always refuse to use the term EHR since vendors started using that name in talking about their old EMR products without changing anything. Am I being too much of a stickler?

Yes. I have a treadmill in my garage with a wireless mouse and keyboard and I do a lot of Internet surfing. I don’t call it by the time, but rather by the mile. When I surf, I can do five miles.

John Naisbitt is the author of Future Trends. He made the rational conclusion that what is important to the present and what will be important in the future can be measured by how often items come up in newspapers. I compared “electronic medical record” and “electronic health record” to see how often they showed up in Google. I wrote in an article that the term “electronic medical record” would have become less prevalent when the lines met. Right now, “electronic medical record” is 46 million in change in Google hits and “electronic health record” is 71 million. Three years ago, it was exactly the opposite.

There are subtle distinctions. An EMR is used by a physician in the office to take care of patients. An EHR is more connected and takes care of the community. Connectivity is the distinguisher.

The manufacturer calling it so doesn’t make it so. The terms are very frequently interchanged. I changed the name of my company from EMR Consultant to EHR Consultant in recognition of that change, although you’ll see Word changing EHR to HER. [laughs] In EHR Scope, we talk about how Microsoft Word versions can be corrected to stop doing that.

Notwithstanding all the above, I frequently use the terms interchangeably.

What’s holding back widespread adoption of practice automation?

It’s a few basic issues. Physicians are the ones who pay for it, both with cash and, more importantly, blood, sweat, and tears from the angst of changing how the office functions. Third parties are the ones that benefit, like government and patients. That disequilibrium is disconcerting to many physicians.

I’m a strong proponent of using voice recognition. It substantially minimizes the inconvenience of electronic recordkeeping. It allows physicians to alter the way they interact with patients to a lesser extent.

Despite the significant amount of time and cost, essentially every physician who has been involved with a successful implementation says they would never go back to a paper office, myself included.

I saw recently that a physician insurer is offering a discount for EMR users. Is that common and will that benefit be attractive to fence-sitters?

I believe it’s common. It’s probably not a sufficient amount of money to pay for the software, but it could be meaningful. I was pushing that idea in 1994 with insurance companies to use Kurzweil and structured reporting systems. Physicians who prove they can provide greater quality of care will not only have greater gross revenue due to pay-for-performance, but will also be offered more meaningful malpractice insurance discounts.

Can a one or two physician practice implement a good EMR with reasonable cost and effort?

You used the term EMR either intentionally or not, so I’ll speak to an EMR specifically. Yes. But, you can’t implement a state-of-the-art, easily interconnected EHR with all the bells and whistles and billing capabilities for $5,000. However, if you want to take a substantial step in the right direction and automate reports, absolutely. In fact, a number of those systems are CCHIT-certified, surprisingly.

Speaking of CCHIT, is it accomplishing what it was intended to accomplish?

I’m not positive that I know what it was supposed to do. I feel badly about specialty-specific programs that were not offered the opportunity to be CCHIT-certified. If you wrote a state-of-the-art, phenomenal program for OB-GYN or ophthalmology, you won’t be certified because you don’t have the features they require. Certainly that will change.

I’ve heard scuttlebutt about the $28,000 certification fee and the hundreds of thousands of dollars needed to bring products up to CCHIT specs and whether that has caused a material increase in the cost of software. It probably does weed out some of the mom and pop operations.

I spent a substantial about of time and money developing what I called an EMR that was more of a documentation product. I stopped developing it about three years ago, so I can feel the pain of someone who spent years to develop software that helps people accomplish what they need to in their specialty, but because of CCHIT certification, may be put out of business. Over time, under-funded companies will go out of business.

If its purpose was to give comfort to physicians buying software or to make it easier, I’m not sure it accomplished that. I’m not seeing it. One of the bits of data I maintain from people going to EHR Consultant and telling us what they’re looking for is whether they want a product that is CCHIT-certified. Maybe 20% of our clients say they won’t look at non-CCHIT certified programs. That means that 80% will. Many say it’s of no consequence to them. Smaller offices seem to care less and larger offices care more, but that’s a subtle trend.

You offer a free EMR evaluation service. How does that work and are other companies offering something similar?

I went to HIMSS 3½ years ago and rapidly realized that most mortal human beings would be incapable of learning about the wide variety of programs in order to support them, which is what is consultants do. I decided to do an evaluation. I devised a vendor questionnaire of 600 questions and then asked doctors 200 to 300 questions.

If you look up electronic medical records on Google, a surprisingly large number of responses are from companies that will gladly help you find the proper EMR. My experience is that many of them ask name, address, phone number, number of docs, when purchasing, and not much else. They’ll say, “Here are the top five products.”

Our methodology is that there are dozens of qualified products and not all are appropriate for an individual office. There are a number of cars, Mercedes and BMW, all of which have different styles in the marketplace.

By matching the 200 to 300 questions the physician has answered against the 660 the manufacturer has answered, we can make a qualified match of the appropriate technology. It’s a matter of judgment, but we give large positive grading for EMRs designed specifically for one specialty for somebody of that specialty. In that way, we’re best able to give a good number of very appropriate software program recommendations to each individual physician.

Is speech recognition software underrated in its ability to help physicians save time?

Absolutely. I’ve been doing it and selling it for 13 years. You’re not supposed to take returns of open software, but if someone returned it, I took it back. In 1994 to 1995, I had a 50% return rate. Nobody asks me to take it back any more. You get 99% accuracy. You can speak like a New Yorker. It’s like transcription with no fees.

The sweet spot is a rich EHR. I can click through the physician exam, click through the review of systems and family history, and social history. I dictate the history – how the accident happened, what restaurant they were at when they started choking. The specific factors that make each individual’s history unique are important. Speak those first two paragraphs. Minimize the transcription cost and let the EHR do what it’s supposed to do, which is get good data capture.

I have some confidential information as a distributor. It used to be a meaningful event when a medical group would buy five or 10 Dragon licenses. With increasing frequency, we’re quoting and selling 100- and 500-license opportunities. If somebody bought 10 licenses, then 50, by the time they’re buying 500, they know it works.

What’s the penetration of speech recognition in practices?

Tens of thousands of physicians use Dragon NaturallySpeaking. That’s probably still single-digit percentages, but it’s increasingly rapidly. I have no visibility into the market of companies not selling Dragon NaturallySpeaking. They’re clearly the market leader, but I don’t know the percentages of the others.

We’re a distributor, so we sell to 100 Nuance-certified solutions providers. At the present time, I’m doing an ambitious project, which is finding out from each reseller which EMR packages they’ve installed Dragon with. I’m putting together a series of Google Maps. I can point them to a page on the Web that will have a map point for each qualified, certified Dragon reseller that has experience with their particular EMR program.

I just sent an Excel worksheet to 160 resellers with 362 EMRs listed down the left hand side and a dozen different qualifications across the top: have they used it, have they developed macros, do they help install it, etc. We’ll tabulate that onto Web pages to display that data.

What do you think about AcerMed’s situation?

As I understand it, there was an intellectual property infringement lawsuit that led to substantial legal fees. That was the immediate cause of the demise of AcerMed, not the fact that the program didn’t work. I’ve spoken to people who liked it and people who didn’t.

Functionality didn’t lead to AcerMed’s demise. I don’t believe that CCHIT is in the business of looking at the financial aspects of companies.

Will that event change how doctors look at software?

If you’re a single doctor spending $10,000 or $15,000 on software, I don’t think you need to pull out all the stops. Larger installations spending hundreds of thousands should get financial information and do a Dun and Bradstreet or Hoover’s check.

What changes would you predict in the physician office system market over the next 3-5 years?

There will come a time where a specialist is no longer getting referrals from their general MD because that doctor has an interoperable software program with the specialist across town. When that happens, you’ll see rapid adoption because they’ll need to stay competitive.

You’ll see greater use of non-MDs putting medical information into the history, either the patient or less highly paid people to enter the data, whether a physician assistant or nurse practitioner or medical assistant. I think that’s an inappropriate use of an MD’s time. They should be spending their time diagnosing people. It can be a substantial change of physician time to document an encounter and I think it will be attacked in different waysE

The EMR industry seems to be polarizing, with legacy, expensive vendors on one end and modern, inexpensive products on the other. How will that shake out?

That’s absolutely an accurate depiction. I am somewhat surprised, and I’m not politician, but hospitals are permitted to pay 85% of software costs that are compatible with hospital legacy systems. I was expecting to see a sea of change where legacy systems would run over these new companies. I haven’t seen the new companies being quashed like I expected.

What does that mean?

New companies that are selling 10, 20, 50 million dollars of software a year in to medium and increasingly larger practices have a very bright and rosy future. As I think should be self-evident, I do analysis for physicians for free, but I have some referral agreements with a very few vendors. I’ve been doing this for 3½ years and I used to get an intermittent check from these companies for sales to a one -or two-physician practice. Now I’m seeing small companies selling to 10-, 20-, or 100-physician practices.

Are they taking away business from the legacy vendors or selling to first-time customers?

In 2010, they’ll be taking their business away. I don’t think that the current sales being made in physician offices for a few thousand dollars would have been made for $75,000 if the smaller companies weren’t there. Those sales would not have been made.

If I were a large public company with product installed in hospitals, I’d rapidly provide an inexpensive offering to the local physicians to stay competitive.

So you like the Misys-iMedica deal, where Misys will resell the small vendor’s product instead of developing their own so they can get to market faster?

From Misys’s perspective, it was the proper thing to do. I have the pleasure of having thousands of offices telling me what they like or don’t like. Misys will likely benefit from having a new, up and coming, recently written, capable software program. They’re a billion-dollar company with long marketing reach and having a product that physicians are happy to use will be a welcome opportunity for them.

Will the smaller vendors be bought by the larger ones who worry about the competition?

I don’t think big companies will buy them because they’re a threat. They will buy them because they provide an opportunity.

I live in the same county that Dr. Notes was headquartered in. I was appointed by the bankruptcy court to sell the company’s source code to its .NET version. They had a Windows-based program and were allegedly 90 days away from shipping a .NET program. They went into bankruptcy and I’m helping sell the 400,000 lines of code.

I sent 360 e-mails at 9:00. By 9:01, I started getting responses. People from the up-and-coming companies wanted to buy the code. They wanted a billing module, which Dr. Notes didn’t have, or wanted their customers, or wanted their code.

Then, I noticed that the people calling me were saying things like, “Well, Dr. Fishman, since you seem to be in the business of buying companies, can you find someone to buy mine?” That happened dozens of times. Others said it wasn’t exactly what they wanted, but wanted to hire me to find them an ASP CCHIT product within 30 days.

There will be a lot of churning of these 1, 2, and 5 million dollar companies in the near future. That’s a particular interest of mine. In next EHR Scope, we have half a dozen pages about recent transactions written by an investment banking firm.

Was it a surprise that McKesson bought Practice Partner?

Andy Ury did a great job having a company of McKesson’s stature helping them do the marketing. I don’t have any insights into McKesson. The phenomenon of having billion-dollar companies snapping up EMR companies with eight-figure revenue will continue.

Do doctors like the idea of personal health records?

I don’t think it’s happening in doctors’ offices. Companies are interested.

I’m potentially involved with a PHR company and a clinical practice guidelines company interested in getting more entrenched into the personal health records. I think it’s something that will be very important and I’m surprised it hasn’t taken off more quickly. I stopped practicing 3 1/2 months ago and had zero patients express interest in interacting with me in that way. It’s not happening yet.

What about Google Health’s rumored PHR project?

It amazes me what Google knows. I think if they set their mind to it, they will do it. I understand they had some change in staffing at that level. I’m not qualified to offer an opinion as to whether they will or won’t do it, but I spend money advertising on Google and thinking about their algorithms and how much they know about people.

They certainly have the computing power to enter this space and pharmaceutical companies spend tens of billions of dollars in advertising their products. Google would certainly be willing to accept some of that.

A magazine just released its 100 Most Powerful healthcare people. If someone asked you, “Who are the most powerful and influential people when it comes to physician use of software,” who would you say?

The CEOs of those dozen up-and-coming EMR companies that I refuse to name. [laughs] They are involved in determining what the software that they’re producing will look like. They are profitable companies with millions or tens of millions of dollars of free cash flows without the shackles of having it burdened to something from their past.

They will decide whether to encourage or discourage interaction with patients, like personal health records or smart cards or thumb drives. They have the resources and knowledge and motivation to be in the doctors’ examining rooms around the country showing how healthcare will be delivered. They have the wherewithal to acquire technology, like clinical practice guideline technology, and integrate it in their software.

I know a little about nanotechnology. A friend asked me where to buy a portfolio of nanotechnology stocks, but they’re mostly privately held. If I could invest in a portfolio of smaller EMR companies, I’d do it in a heartbeat. You could reasonably choose a handful that will be successful, though I can’t pick them all, but the small ambulatory EMR industry will do very well financially.

My specialty is the smaller office, but two weeks ago, I got call from hospital CIO with 525 physicians on staff. He mentioned two legacy EMR systems they were interested in. I mentioned a couple of smaller systems and there appears to be some interest. Some of these up-and-coming players may play a role in hospitals

What about retail medicine?

I don’t want to grow old and decrepit in this country because healthcare won’t be as good as it is today. Retail healthcare is here to stay. Healthcare should be touching and care, but it’s clear that retail clinics aren’t going away any time soon. I don’t get my care at one.

Will retailers develop their own software or buy from those sexy companies?

I have made successful introductions between retail pilots and one or more of those dozen hot, sexy companies I won’t name. I don’t mean to be evasive, but I have relationship with those companies.

If an HIStalk reader is interested in ambulatory EMRs, what information do you provide?

EHR Scope is a free publication, over 150 pages, and the next issue is in October. It has a meaningful amount of information on over 200 ambulatory products. It comes out in a PDF and if somebody’s a cardiologist, they can search cardiology and find systems appropriate for them. They can quickly get their Web sites and contact information. I think it’s a very valuable resource. The electronic version is free.

Any final thoughts?

I love what I’m doing.

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