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Monday Morning Update 2/11/08

February 9, 2008 News 5 Comments

From Bill Kilgore: “Re: Cerner. Cerner opens an office in Dublin is kind of ironic since the Irish don’t have the money or the emerging market as the Middle East. Maybe they should consider Doha since there is fresher growth market in new hospital construction.”

From Gob Bluth: “Re: QuadraMed. QuadraMed’s recent layoff and offshore decision is for the entire Quantim HIM Suite. Management told the remaining Quantim employees that ‘some of you will get the opportunity to go to India to train the new team members.’ Sounds a lot like POWs being forced to dig their own graves before being summarily executed.”

From HITPundit: “You are starting to cross the line where you exalt your sponsors every chance you get. You have no practical or actual knowledge of the sponsors other than what they tell you. Are you a bought blogger?” Well, I noticed your IP address is of a vendor and not a charity, so you’re not working for free either, right? I believe that close reading will prove that “exalting” just means mentioning them along with anything factual that I happen to know -that they’re nice people or that they’ve announced something. Nothing more. I don’t think you’ll find a case where I recommended them or their products specifically unless I actually do have first-hand experience with them as a customer, which I do in some cases. The rules I’ve followed for years are here. Sponsors get only one thing that non-sponsors don’t: I’ll sometimes mention their announcements. The agreement they sign even says so, that they’re fair game otherwise. I’ll compromise with you since I’ve been thinking about doing this anyway: I’ll put sponsor stuff in its own subsection of HIStalk. Worth a read, but you can skip it if you like (you could do that now, of course, but I’ll even mark it clearly for you). Fair enough?

From Dr. Lisa Cutty: “Re. Wikipedia. Hi, since the English Wikipedia page about HIS is sadly nonexistent, I would like to suggest to create a competition about who writes the best definition. The winner text will be published in Wikipedia. Come on folks, let’s define us…” Say, you’re treading on government contractor work there, young sportsman. OK, I suppose we can accept volunteers. Anyone?

From Jerry Riggs: “Re: Halamka. His reputation was made before the BIDMC fiasco (give Cisco some blame for that, too) and his response just burnished it. Since then, HITSP, NEHEN, Harvard Med. He does a lot. It helps that he doesn’t need to sleep like the rest of us mortals. I’ve known John for a long time. Sure, he’s got a firm grip on marketing and spin, but what top-notch senior executive doesn’t? The difference with John is that he backs it up with dedication to his work, an impressively deep fund of knowledge, plain well-spoken openness, and as you noted, exemplary graciousness. I’ve seen him post-talks, where he politely takes time to speak to just about everyone who comes up to him. Add another category, above ‘seems like a good guy.’ John is one.” I dare you to test him at HIMSS. Walk up at the IHE booth or wherever you see him and strike up an excruciatingly dull conversation and do most of the talking yourself, spouting the most asinine nonsense you can think of. I bet he’ll listen attentively and make you feel like his equal and compliment you on your perspective. That’s my experience, anyway, from watching him in action. I’m jealous of him too, but willing to give credit where it’s due. Maybe I’ll do the black turtleneck under black jacket thing at HIMSS as my homage.

From Festus Peashooter: “Re: QuadraMed. That’s right, they were the first to see the value of care based revenue cycle … but alas, all we hear about is that they are cutting back on Misys /CPR staff. But this always happens in an acquisition like this. The staff that remain need to ask themselves: would they be better off with a ‘dead’ product that would be limping along under Misys, left eventually to die on the vine, or are they in a better place now that someone has taken a real interest in keeping it going, even investing money trying to improve it? If you are a QuadraMed CPR employee today … which do you want?”

From Soul Survivor: “Re: QuadraMed. Why the surprise about layoffs from QuadraMed? Keith Hagen is from the Tom Skelton/Misys school of leadership: focus on management weaknesses and blame the staff. ABC – anyone but the CEO.”

From Murphy Blue: “Re: care-based revenue. I don’t know whether this will go anywhere, but it’s the first time I’ve seen prominent press about an insurer’s proposal to help with health care costs (while believing they can also help themselves…novel idea.)” Link.

SIS, which has been pretty quiet lately, brings on Chris Giglio as SVP of customer operations and Eric Nilsson as CTO, coming from McKesson and Infor, respectively.

McKesson will move 500 people from its Louisville and Broomfield (CO) offices to Westminster.

Jim Burton, formerly of FCG, takes a VP job with Emerging Health Information Technology.

Richard Granger of NHS is officially finished there, to be replaced with two positions: a CIO and a project executive for Connecting for Health.

Revolution Health claims its sites have passed WebMD as the #1 health property on the Web, but it doesn’t sound all that convincing that it means much.

E-mail me.


Inga’s Update

Thank you Imelda M. for reminding me that in addition to finding the perfect party outfit, there is the shoe dilemma as well. Do you wear the sensible shoes for walking around the convention hall all day or do you become a fashion slave and get the 5” spikes? You guys just don’t understand how hard it is ensure we are objects of your fantasies.

A dress makes no sense unless it inspires men to want to take it off you. ~Françoise Sagan

I clearly opened up a can of worms about the LA hospital issues. From Dr. Webber: “When MLK-Harbor was forced to close, 75% of their ED patients starting coming to Harbor-UCLA (where I work). We are in the same “system” but we don’t get their medical records, so often we have no idea what their primary care looks like. We have asked for additional resources from corporate to handle the influx of patients, but have received few useful additional resources. In fact, our CEO had to take a 10% budget cut on top of more patients from King. That’s insult upon injury. CMS was explicit in their exit interview. They stated (!) they knew the problem was not a fault of the hospital, as we can’t stop people from coming in to the ED, and we have only so many staffed beds and ICU/PCU beds to hold them. We have minutes from our Governing Body meetings where we are quite literally yelling for help, but have been ignored. MLK-Harbor. Olive View. Now Harbor-UCLA. CMS is sending a message to the LA County Board of Supervisors to get out of the healthcare business. Did you know that the last time JCAHO did an unannounced there were 10 surveyors? How many hospitals get that type of scrutiny?”

And from Dr. Shepherd: “The next time you’re in LA, I doubt if you become ill you’ll end up at a county hospital. They are the symptom, not the disease. The disease is massive overcrowding and it isn’t just in county hospitals. Coupled with a 20% nursing shortage in the state and mandated nursing ratios, no money, no staff and no interest from a board of supervisors that only respond to crises, the safety net for LA is a warning for the rest of the nation. Hey, board, you’ve got a crisis to deal with now! It is a mess. As a practicing ED MD for over 30 years, LA is NOT unique. As a patient, I’m scared. As a doctor, I’m fatalistically depressed. As a consumer, I’m mad as hell and I don’t want to take it anymore. I think everyone is looking for a solution, but not willing to be so drastic as to throw out the entire system and start over. Think about 20% of our healthcare dollars going to big insurance management and what could be done with it. We must also re-introduce personal responsibility and buy-in. ‘Americans are willing to consume all the healthcare someone else is willing to pay for.”’

The NHS says there is no cause for alarm over the misplacement of 6,000 smartcards for accessing patient records. Why do I feel good over the news that the US is not the only country with ridiculous security lapses?

St. Mary’s Medical Center in Huntington, WV renews its agreement with MED3000 to provide revenue cycle management, PM services, consulting, and coding services for their physicians.

Encentuate is selected by the 80-provider group Northwestern Memorial Physicians Group in Chicago to provide single sign-on and authentication services.

E-mail Inga.


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Jerome H. Carter, MD, FACP Replies to Bignurse

I really enjoy your blog. I saw the post by BigNurse and thought I would respond since implementation problems are of particular interest to me.

The meaning of “implementation” is very important and is rarely formally defined for EHR projects. Heeks and Mundy published a white paper in the UK that I think addresses this matter quite well. They define types of implementation failures and by extension, successes. They define the following types of failures:

  • The total failure of a system never implemented or in which a new system is implemented but immediately abandoned. A much-reported example is that of the London Ambulance Service’s new computerised despatching system. This suffered a catastrophic failure within hours of implementation, leaving paramedics unable to attend health care emergency victims in a timely manner (Health Committee, 1995).
  • The partial failure of an initiative in which major goals are unattained or in which there are significant undesirable outcomes. Anderson (1997:87), for instance, cites the case of “An information system installed at the University of Virginia MedicalCenter [which] was implemented three years behind schedule at a cost that was three times the original estimate.”
  • The sustainability failure of an initiative that succeeds initially but then fails after a year or so. Some of the case mix systems installed under the UK National Health Service’s Resource Management Initiative fall into this category. They were made fully operational and achieved some partial use but with limited enthusiasm from staff for using them. Ultimately, they were just switched off (HSMU, 1996).
  • The replication failure of an initiative that succeeds in its pilot location but cannot be repeated elsewhere. Although presenters may not realise it at the time, every health informatics conference is jam-packed with replication failures about to happen; with wonderful innovations that are tested once and then disappear without trace. As an audience, we hear all about the pilot, but we tend not to hear about the replication failure.

In my experience partial failures are quite common with EHRs. Very common examples are:

  • Key features are never utilized or under utilized (quality and preventive care features)
  • Not all providers in the practice use the EHR for all patient documentation
  • Features are never implemented or do not work (lab interfaces being the best example).

Partial implementations are costly in a number of ways because paper/electronic hybrids are more difficult to secure, search, analyze and maintain. Also, ROI is not maximized until the implementation is complete. From this perspective “go-live” is simply the start of an implementation.

Unfortunately, I have seen my share of “declared” implementations as well. These are situations in which an organization flails at an implementation until everyone is tired of it (or someone has been fired). They then “declare” that whatever state of implementation they have achieved is what was intended. Alternatively they look for the most palatable excuse for their lack of success (the doctors were uncooperative, the software did not work as expected, the CIO was not the “right person” for the task, our organization is unique.)

Practically, I believe that organizations would do well to use at least a two-tiered approach to defining a successful implementation. Level One success would occur when all patient data that originate at the practice site are entered directly into the system. Level Two would occur when key features/functions (e.g. quality/safety) are used by ALL providers as part of routine care.

A Level Three might then be defined as all patient data, whether external or internally generated, are in the system. However, this requires interoperability capability that is beyond organizational control. I would guesstimate that maybe only 10-15% of organizations make it to Level Two. IMHO.

Jerome Carter is a principal with Neck, Time, and Money Informatics, Inc., an EHR consulting firm based in Atlanta.

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Currently there are "5 comments" on this Article:

  1. RE: Wikipedia. A quick note for Dr. Lisa: Anyone who wants to can create the HIS page on Wikipedia. All you have to do is register as a user, confirm your registration, then go to the place in the site where you think a HIS page ought to be linked from (I’d suggest maybe http://en.wikipedia.org/wiki/Category:Information_systems). Click the “Edit this Page” tab and start typing away. That’s the beauty of Wikipedia. No letters after your name? No institutional imprimatur? No alma mater? No matter! BTW: you might want to check out Clinfowiki at http://www.informatics-review.com/wiki/ which offers an example of you one can just start up their very own wiki. The old Happy Fingers are startin’ to itch just thinkin’ about it…

  2. RE: Dr Shepard (chuck?).
    an answer to the health care crisis is not necessarily HIT, or manpower, or money or universal healthcare or even socialized medicine. we need the UK tort system. in personal injury and medical malpractice claims, loser pays. end of frivolous lawsuits and all that follows (which is a lot). unfortunately not gonna happen in a country literally run by lawyers, so we tinker around the edges…

    and sorry inga, your “cutie” clearly already has a girlfriend(s)…http://stoplookingatmyvajayjay.blogspot.com/2008/02/jay-parkinson.html

    /do you really think he has the answer to healthcare crisis?
    //i do, but not ready for prime time yet due to substantial obligation of actually doctoring…
    ///but here’s a hint…what if all significant clinical interactions were (consensually) audio-video archived with increasingly cheap memory. this one digital record would serve as medical documentation, legal documentation, billing documentation and coding documentation. easily audited and payment based simply and soley on the digitally recorded “face time” (for simplicity would start with general med-surg inpatients). legal squabbles settle by arbitration based on observable facts. off video interactions allowed but not used for this new”digital” documentation, but rather supplementation, expansion, nuance, and internal/local use. pt and clinicians can opt out but lose the cost saving features (would have to buy conventional insurance with conventional documentation) and legal simplicity (ie could still sue in usual expensive and ineffective manner). if anyone wants to run with this, attribution please…

  3. Dear Festus Peashooter,
    Aquisition and layoffs are one thing , but to dump the enitre tech pubs population for CPR and leave 3 people for QC to train their successors has nothing to do with a buyout. Again Management is in charge of the direction of the product, not the employee. If you would just open your eyes and maybe talk to the people that were and are there you would know that they had high hopes for this product. These people have wanted to put in advanced clinical documentation, med reconciliation automation and much more on the enhancement home front, but instead they are cut back, sliced and diced and left out to dry. Why is it that big companies fail to speak or listen to the employees and go for the fast buck. QuadraMed is making the same move that others in their industry have tried and failed look at McKesson and Misys, India outsourcing only manage to harm the product and loose customers. If money is the bottom line as well as a quality product don’t you thing that a better long term goal should be looked at other than hacking at the experience level of your staff.

  4. While I appreciate Dr. Shepherd’s concerns, the 20% figure is a wild overexaggeration. Overhead, brokers commissions, and payer “profit” (and many are “non-profit”) come to 11% on average nationwide, down from 15%. In California, it can be higher, but that has to do with state regulations not inefficiencies. Yes, many payers certainly haven’t trimmed enough, but they will have to so if they wish to survive as independent entities. In the long-run, the non-medical cost ratio will wind up at 9% or less as more technology kicks in. So, yes, there may be issues with the system, but the blame should not be assigned to the payers, no matter how easy politically this is to do.

  5. RevolutionHealth’s claims seem a bit overblown to say the least. One need only look a their Alexa scores to see that if anything, their numbers are down in relation to the major competitor in he last month. Did a quick post/analysis of it over at http://www.chilmarkresearch.com for anyone that wishes o take a closer look.







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