From Madison Reader: "Re: Epic. Big day for Epic news." First story: an interesting article on Verona’s "green sprawl," contrasting Epic’s eco-friendly campus to the urban sprawl it created by its commuting employees. The company’s track record of being a good community citizen is also mentioned. In a less-flattering news, Epic flexes its rarely used liberal political muscle in threatening to cease doing business with local companies that support a state business lobby. Wisconsin Manufacturers and Commerce, of which Epic is not a member, spent $1.8 million on campaign ads supporting a conservative judicial candidate and attacking the character of his incumbent liberal opponent. Epic’s statement says the election "was a travesty of ethics and many analyses pointed to WMC as a responsible party." And in a related event, Epic’s contractor (wouldn’t that be a great gig?) drops out of WMC and its president quits WMC’s board, claiming his company’s "corporate structuring and analysis" led him to that decision (riiiight).

A reader asked for my opinion on the Epic-WMC tiff, so here you go (you may be sorry you asked). Judge elections shouldn’t be knock-down, drag-out political slugfests. The thought that a pro-business organization should donate millions to an election campaign just because the candidate is supposedly business-friendly is repulsive, especially when that candidate seeks a non-partisan seat. Epic is a private company (and claims to be politically neutral — that also gets a riiiight), so it can do business with whatever companies it wants and for whatever reasons it chooses. On the other hand, it could have just done so quietly without making a public proclamation whose apparent goal is to coerce WMC members to quit or lose Epic’s favor. I was with them 100% until that last part; now I’m at about 75%. Bottom line: it’s a local issue that should not matter one iota unless you live or work in Wisconsin, and in that case, you’ll no doubt have a stronger and more well-informed opinion than the rest of us anyway.

The co-founder of 145-location retail clinic operator Take Care has some interesting comments on technology: "[Our] electronic medical record was not designed in a vacuum by our IT organization; it was designed with the aid of our nurse practitioners. We’ve created electronic check-in systems that are very similar to an e-ticket. If there are two people in front of you, the check-in screen will automatically give you the opportunity to go five minutes down the road to another Walgreens … We have an EMR (electronic medical record) system that’s capable of sending a record to any provider once the laws allow for that to take place … We created an industry based on integrating all the information and data and making it available to the traveler. We’ve brought that same thing to healthcare. A patient’s record is available in any Take Care center in the country. The next practitioner they see, whether it’s someone employed by Take Care or not, has access as well."

Cerner spent $180,000 for government lobbying in Q1, mostly aimed at DoD and the VA. Hmm … was it an eerie coincidence that VA decided to dump its own VistA LIS in favor of Millennium right about then?

NIH/NLM money is used to create the Appalachian Health Information Exchange in Ohio, which starts with 20 members and Ed Romito, CIO of Genesis Healthcare in Zanesville, as chair.

The usual housekeeping: you can sign up for e-mail updates or my Brev+IT weekly newsletter to your right. That Google search box sifts through the 5+ years of HIStalk for anything you want (hitting the old site where the previous articles live, too.) Click that hideous green Report a Rumor graphic that I unskillfully designed to send me news and rumors goodies. Wednesdays are Readers Write days, so e-mail me your master work (500 words or less) on relevant topics. And of course, thanks very much to the sponsors who sponsor and the readers who read.

Confluence Medical Systems, the consulting company started by former Misys-ers Tom Skelton and Rich Goldberg, will advise MedcomSoft on its marketing strategy. That’s the Canadian PM/EMR vendor that recently replaced its management to prepare for an attack on the US market.

Legislators on Friday voted down a measure that would have staved off a July 1 Medicare pay cut of 10.6% for physicians.

Identity management systems vendor Initiate Systems just pulled its IPO, but it also just got $26 million in sixth round funding, bringing its total funding to $62 million. One participant was data integration vendor Informatica, which bought identity matching systems vendor Identity Systems last month. Seems like they’ve got a lot of interest in Initiate, doesn’t it?

A research article coming out next week will provide interesting insight into workarounds with bedside barcoding systems, I’m told. In addition to pointing out human factors issues, it also documents intentional system bypassing that was observed: putting patient ID barcodes on clipboards or door jambs, commingling meds from multiple patients, and scanning doses after labels were removed. My conclusion: hospital leaders assumed that they bought a barcoding system and ordered nurses to use it, so medication errors should just go away. I know folks in a couple of hospitals who freely admit that their systems provide a false sense of security to the executives, but those in the trenches know of their inconsistent use. That’s no excuse for not using them, of course, but there’s work to be done beyond declaring a go-live victory, which we seem to do a lot in IT in our urgency to move on to the next scheduled crisis.

The husband of a Cerner employee who is accused of murdering her for a $250,000 life insurance payout by poisoning her with antifreeze did laptop searches for "antifreeze human death" weeks before she died, prosecutors say. His lawyer says the laptop wasn’t password protected, so anybody could have done that or maybe his client accidentally clicked a link somewhere. For a record third time this issue: riiiight.

The reverse split worked: QuadraMed gets Nasdaq’s listing permission, moving from Amex. The new ticker symbol QDHC kicks in July 9.

I’ve noticed that hospitals are getting free and easy with the "Chief" titles. In IT, there’s Chief Technology Officer, Chief Security Officer, and Chief Applications Officer (none of which are really "chiefs" in most cases since they report to the CIO). I’ve also seen Chief Pharmacy Officer, Chief Marketing Officer, and now Chief Technology Officer of the hospital lab. My thought: if you don’t report to the CEO, you’re not a chief, no matter what inflated title you were enticed with. If you’re a "real" Chief, it’s gotta peeve you a little to see Junior Chiefs flashing your title around.

Siemens, hammered by corruption and fresh off profit warnings, is rumored to be axing 17,000 jobs.

DEA is willing to allow e-prescribing of controlled substances if doctors use two-factor authentication and allow an annual audit. It’s accepting public comments on its chatty proposal (warning: PDF) released Friday.

I don’t watch TV much, but I was flipping channels the other night and ran across the debut episode of Hopkins, which caught my attention because I’d just interviewed Stephanie Reel (although I confess I alternated between it and Kathy Griffin: My Life on the D-List, which I’d never seen and found mildly amusing). It’s a pretty good real-life medical show, a little heavy on the human interest of the photogenic subjects, and not quite up to the dramatic standards of the old Lifeline (you may remember the cowboy surgeon "Red" Duke from that one, who’s now 80, shockingly). Thursdays at 10 Eastern, apparently, on ABC, and you can watch the first episode online.

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From Home Alone: "Re: Misys Homecare. What can anyone tell me about it? Will they run this into the ground much like the old Sunquest?"

From Jerry Rivers: "Re: job helper. I saw your ad that says 75% of HIStalk readers say it helps their job. I don’t believe it." The ad banner you mentioned is running on HealthcareITJobs.com and it refers to this exact question from the spring HIStalk Reader Survey: "Over the past year, HIStalk helped me perform my job better." 228 respondents answered, with 172 (75.4%) saying True and 56 (24.6%) said False. Hey, just because we make it entertaining doesn’t mean our information isn’t useful. Lots of folks are looking for competitive advantage out there and we try to give it.

From Tom Terrific: "Re: WellPoint. I’ve heard it mentioned in two separate areas that Wellpoint is rolling out EMRS to physicians. Do you know anything about this?" They did e-prescribing quite a while ago and were keeping some sort of PHR, but I hadn’t heard of new physician projects. If you know, tell me.

From Boba Fett: "Re: NextGen. Scott Decker to be named CEO of NextGen. Patrick Cline getting kick upstairs to head QSI." Unconfirmed and probably can’t be since QSII is publicly traded. But, Scott’s a reader (I interviewed him when he was with Healthvision) so you never know. Perhaps presciently, he mentioned Pat Cline then. Quality Systems CEO Lou Silverman announced Tuesday that he will resign effective August 16.

From E. Buzz Miller: "Re: Emageon. Perkins is out." An SEC document says COO and onetime heir apparent Chris Perkins has resigned, effective July 25, following all the proxy fight stuff with Oliver Press Partners.

A reader commented on my Odd Lawsuit from Tuesday that involved age discrimination, interpreting my remarks as defending the hospital where the 69-year-old employee with 42 years on the job was allegedly fired by her supervisor after a barrage of "old lady" comments. My usually full-bore sarcasm must have been masked since I’m all the way behind the lady who got canned, provided she’s telling the truth, of course. I’d much rather see the apparently obnoxious supervisor get nailed instead of the hospital, but that’s not how it works with age discrimination.

Listening: Beatnik Termites (reader recommendation). Infectiously fun summer, doo-woppyish surf-pop-punk. I was totally hooked in the first 15 seconds of Somebody Else’s Baby. Five stars. I’ve played everything on their MySpace page about a dozen times.

Royal United Hospital Bath delays its planned Millennium go-live in the UK, worried about Fujitsu’s interest in finishing the implementation now that the company is backing out of its NHS contracts.

New CIOs: Pardee Hospital (NC) names Harold Moore, formerly of Piedmont Healthcare Management Group. UPMC Magee-Women’s Hospital (PA) announces the promotion of Lou Baverso to CIO, replacing Bruce Haviland who has moved to UPMC Mercy. Antoine Agassi, chair of Tennessee’s eHealth Advisory Council, takes the CIO slot of hospitalist provider Cogent Healthcare of Nashville.

Jobs: Cerner Clinical Consultants, Epic Clarity Consultants, C++ Developer.

Sure to raise some eyebrows, including those of the FDA: an article in the new JAMA shows that RFID devices interfere significantly and sometimes hazardously with nearby ICU medical equipment. Especially prone devices: infusion pumps, with 8 of 9 models (five B. Braun and two Alaris) having problems ranging from false alarms to failure. Pacemakers were problematic, too, with erroneous pulsing, and ventilators also acted up. You will no doubt here conflicting interpretations, with RFID locating vendors claiming the study was a European lab experiment with minimal real-world applicability, while competitors whose systems use infrared and sonic waves (or maybe even barcodes) will point out that RFID was designed for warehouse pallets, not deploying to rooms full of life-sustaining medical equipment, and has the exact qualities you might expect to interfere with sensitive gear. Thanks to the reader who sent the full text article over. I’m open to comments from anyone who knows the topic and who has read the article.

CCHIT is looking for 13 new Commissioners to serve a two-year term. Senior execs are invited to apply in July for terms that begin in October. The current list is here and you can e-mail your resume to CCHIT to be considered.

Children’s Healthcare of Atlanta goes live on Epic CPOE. This may be the first time I’ve seen Epic mentioned in a significant press release, and even then only because it’s from the customer.

An Epocrates survey of medical students finds that only 20% of them believe widespread EMR adoption will happen in the next five years. Too bad they didn’t put a more reasonable timeline on there — in most cases, five years isn’t enough for a single hospital to bring up a full EMR. Still, they believe technology improves care and patient safety. When asked to rate the US healthcare system (such as it is), 40% gave it a D or F and 35% predicted healthcare reform in the next five years. It’s the Facebook generation: 6% spend more than 24 hours a month on the social networking site.

The local paper runs a story on MidState Medical Center’s (CT) implementation of Eclipsys Sunrise Knowledge-Based Charting.

West Virginia gets a nod for its EMR network covering 19 free clinics.

Politicians are knocking a healthcare IT bill around, but given how often this happens with no result, I’m not really paying attention yet.

Siemens Medical Solutions caves in to Acacia Research, which uses broad and questionable patents covering common technology to scare companies into paying licensing fees rather than court costs. This time, it was Acacia’s patent for PACS that got the company a Siemens check.

University Hospital (GA) gets a TV mention for its rollout of Horizon Enterprise Visibility, McKesson’s patient flow solution. We have good background in our February interview with McKesson’s Paul Gartman about the former Awarix product.

BIDMC CIO John Halamka tells a Red Hat Summit audience that healthcare can learn from open source initiatives. The Red Hat folks actually invited me to attend and report, which I appreciate, but the day job got in the way.

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Inga’s Update

A number of employers of HIStalk readers employers made Computerworld’s 100 Best Places to Work in IT, announced today. Included: Mount Carmel HS, VHA, Sutter Health, Palmetto Health, Partners, THR, NY Presbyterian, Intermountain HC, Englewood Hospital, Duke, and Cerner. (All the grief that Cerner gets and they still came in at #92 – and the only HIT-specific vendor to make the list.)

Picis is selected to provide high-acuity solutions to seven new Madrid hospitals. The applications will integrate with the hospitals’ Siemens systems.

Initiate Systems withdraws registration for a $75 million IPO, citing unfavorable market conditions.

Premiums were apparently not the only things that went up last year at several California health insurance companies. The California Medical Association reports that multiple CEOs earned $1 million+ salaries while their companies produced more than $4.3 billion in profits.

Connecting for Health announces that numerous companies and privacy groups have endorsed a set of practices to protect personal information and promote PHR adoption. The study also notes that the majority of the Americans see value in PHRs, though less than half were interested in using one. Only 2.7% of the public is using PHRs today and 57% of the non-adopters cited privacy issues as their biggest concern.

JAMA publishes a study that suggests RFID is potentially hazardous and, when implemented in the hospital environment, on-site EMI tests should be conducted. That could prove to be a boon for companies like Sonitor Technologies that use ultrasound for location and tracking devices instead.

KLAS announces an initial study of medical oncology vendors. IMPAC, IntrinsiQ, and Varian were the only three vendors with sufficient installations to provide statistically valid data. Varian got the overall highest rating, though all three were fairly close.

A record 24 million Americans, or 8% of the population, have diabetes, according a new CDC report (warning: PDF). That is a three million person increase between 2005 and 2007. Another 57 million have pre-diabetic conditions. There is no doubting that the disease and its complications continue to dramatically affect healthcare and the economy in general.

Former Misys Sales VP Scott Boyden is named senior VP of sales and marketing of Streamline Health Solutions.

Rex Healthcare (NC) announces that Novlet Mattis Bradshaw is the hospital’s new CIO. Bradshaw comes from The Seton Family of Hospitals (TX) where she was IT’s senior consultant and program director. We told you about this weeks ago, of course.

Catholic Health East will deploy Craneware’s Chargemaster Toolkit products for its headquarters and 16 acute-care facilities in eight states.

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Providers Facing Identity Crisis as NPI Vexes Claims Processing
By Martin Jensen

Hospitals, labs, clinics and physician practices large and small are used to the "flaming hoop" cycle — slicing and dicing the data each government and private health plan wants to see in order to get paid. The regulations enacted under HIPAA to establish a single National Provider Identifier were designed to correct a small but critical component of that: replacing the various payer-controlled identification systems with a single, universal numbering system that all payers would have to adopt, discarding all the state-specific Medicaid numbers, the half-dozen or more Medicare numbering systems, and various governmental and payer-specific legacy IDs.

The rule was that individual providers (i.e. human beings — doctors, nurses, physician assistants and the like) could obtain only a single number which would identify them in all contexts.  Organizational providers could obtain one or more identifiers as they saw fit, based on identifiable differences like location and care setting (acute inpatient hospital vs. rehab unit vs. outpatient surgery) and their own self-determined business requirements. Payers were specifically enjoined from telling providers how to enumerate.

But when the May 23, 2007 deadline approached, it was clear that, as usual, the industry was "unprepared" for the cutover. Providers weren’t ready to walk on their NPI legs and payers weren’t ready to drop their legacy ID crutches. Regulators at the Centers for Medicare and Medicaid Services (CMS) announced a one-year contingency period and CMS’s own Medicare division quickly adopted a phased contingency plan. First they would require billers to submit their own NPIs in combination with legacy IDs, then gradually wean them off to the mandated "NPI only" transactions. The critical issue of how to represent all of the other providers on the claims (such as the referring provider on a radiology claim, or the ordering physician on a lab claim) was left for a last-minute, untested cutover for May 23, 2008.

CMS, as usual, blamed the perennially unprepared providers for the delay. But the true culprits may lie a bit closer to home. Medicare, in what observers saw as direct violation of the regulation, issued a thinly-veiled threat (warning: PDF) to its providers to obtain NPIs according to their existing suite of Medicare numbers.

This wasn’t just a fairness issue. It was tantamount to an admission that Medicare was not gearing to deal with the post-NPI world of provider-determined identification schema. They also set an unhealthy precedent for other payers, including a number of state Medicaid plans, who subsequently communicated their own "expectations."

"If Medicare can tell them how to enumerate, why can’t we?" 

Well, how about, because if providers use one numbering system for Medicare and another numbering system for you, the claims which list both organizations as payers (many millions per day) will break down for lack of a consistent identifier? One ID per claim sort of requires that everyone use a common number, does it not?

The initial spike in claim rejections was startling, even to those familiar with the reports that some early adopters had gone unpaid for months. According to one source, Medicare rejections spiked by a factor of four, while Medicaid denials went up six-fold and Blue Cross rejections doubled.

Many of the problems have certainly settled out as providers regrouped for the new line of flaming hoops. But just as things seemed calmer, CMS imposed a new requirement: Employer Identification Numbers and Legal Business Names on NPI records needed to match an unnamed IRS data source or the NPI would be de-activated. While there was no recognition that such a change might trigger a mismatch downstream, our analysis indicates that virtually all of Medicare’s crosswalk logic relies on EIN, and nearly half of the matching goes against all or part of LBN. What’s more, secondary changes required on the Medicare side could, again, leave those claims unpaid for months, thanks to well-documented bureaucratic delays.

Catch more of our ongoing NPI coverage at the HIT Transition weblog.

It’s Time to Wake Up …
By Recruit Guy

In the realm of HIT, healthcare is unique. Healthcare is not unique. We have become so engrained that healthcare is a totally “different animal” with its own idiosyncrasies that we have totally ignored the advances and expanded maturity levels that exists in other industries. Sure, the clinical process is specialized and requires experienced trained clinicians and healthcare professionals to design and support advanced clinicals that support the care process. However, there are two broad general areas critical to any health delivery organization where we have not leveraged the advances and maturity levels that have been achieved in other industries.

The first area is often referred to as ERP that cover areas such as Supply Chain (Materials/Purchasing), HR, EDI, Accounting/Budgeting, etc. We are experiencing a severe shortage of capable practitioners that have experience in specific HIS solutions. The critical distinction here is differentiating between specialized clinical and reimbursement or revenue cycle application areas of I.T. and the other areas dealing with ERP applications. The shortages are not so much anchored around the lack of process expertise. The shortage relates to training and certification specific to the solutions (i.e. Cerner, Epic, Meditech, etc). The only way to expand or grow these qualified resources are to receive the build and design training associated with a client contract and play a principle role in the implementation project. This creates a very closed and restrictive supply of experienced professionals that very quickly join the ranks of consultants and installers that leave the provider organizations and join consulting organizations and go from project to project. These exits create an even greater shortage overall so we constantly have one organization stealing from another with many going to the highest bidder. Why exacerbate this phenomenon with the non-clinical HIS modules and applications for which there is greater expertise and functionality outside the traditional HIS solution sets?

The second area deals with technology infrastructure. Technical infrastructure is comprised of areas such as network and system architecture and processes that support the best practice components of ITIL (Service Support and Service Delivery). This expertise more abundantly exists in other industries in areas that are truly generic between healthcare and other industry environments and are substantially more advanced than healthcare.

Recruiting experienced personnel out of these mature and established industries achieves a much greater value for our organizations. Granted, a redesign of the departmental I.T. structure may be needed to align in the manner outlined. This model pushes the clinical application expertise more into the user departments that relate to clinical and revenue cycle processes. I’ve always been a proponent of this model because it fosters greater ownership and responsibility within these user departments.

Wake up healthcare. Let’s quit thinking we’re so unique in areas where we’re not and let’s join the big league. This massive amount of in-breeding has caused greater costs for less quality and we’ve created a treadmill we can’t seem to dismount.

Girls’ vs. Boys’ Clubs
By Wompa1

Ms. DeBell’s post on women moving higher into the IT ranks brought to mind a recent conversation I had with a candidate with whom I am working. For those that are unfamiliar, I recruit in the HIS field (five years). I thought some of the points of the conversation would be worth sharing. It may also help the perpetually offended to wad their panties. I promise to not refer to myself in the third person (we love you, TPD).

I called this fellow while working for one of his company’s local competitors. He returned my call months after I placed someone. For several reasons, the time had come to move on, not the least of which was the recent promotion (over him) of someone with lesser skills, but a master’s degree. His goal now is to complete either a MS/MIS or MHA.

This fellow had been in a variety of roles, including management (hospital administration, not IT), and he felt that IT need not be his only option. He asked what I thought about widening his options. I began with the usual disclaimer: “My field of specialty is Healthcare IS.” This is true; my market knowledge is limited to HIS. However, I did note to him that healthcare administration is more of a girls’ club than is IT (which is ALWAYS referred to as the boys’ club).

My response? Women earn the majority of undergraduate and graduate degrees, AND they are vastly over-represented within healthcare administration, which means more competition for the higher level roles (manager and director level for the case in point). My thought was (and I am interested in reader opinions) that he would have an easier time finding management opportunities in IT, since there are likely to be more men (fewer degrees) than women. I see him having better growth with fewer women around. The other factor is that he has spent the last 10 years in IT, not in administration.

Anyone disturbed by my analysis may send complaints to Lawrence.Summers@harvard.edu. Larry offered to field them for me. Let me also state for the record: my specialty is strongly focused on clinical IS. Women make up the majority of my placements. The rest are very likely to fall into other “protected” classes. I am curious if my perceptions match the reality (real or perceived) that you experience.

A final point that I did not share with this fellow: I’m asked all the time about “how the market looks.” Since that is the most frequent question I hear, I figured I would share. Now is not a bad time to look for something new. I’m not selling here; as far as I know, only Mr. H. and Inga know me by other than my pseudonym. Given the general perception of the economy, many people are reluctant to explore right now (being low man on the totem pole, can’t sell the house, etc). Less people exploring means less competition, especially if you work in a higher level role.

Thoughts on HCSC’s Proposed Acquisition of MEDecision
By Lazlo Hollyfeld

I’m not surprised that MEDecision got bought by HCSC, but the price they paid was pretty baffling. They were on the block since last year, when everybody in the C-suite except St. Clair was ousted/left. The way I figure it, HCSC folks wanted to have more a direct say in things, including development, and saw this as a way to compete with the other big plans who have already made these types of strategic moves (e.g, Aetna with Active Health Management). 

But why the crazy price tag? If anything, HCSC could have driven a hard bargain and picked it up on the cheap, potentially. MEDecision does it as a way to clear off a ton of debt and keep development moving forward. Otherwise who knows? That’s just conjecture, though.

While they have a solution (Alineo) that is pretty good and better than some of their competitors (e.g, CareAdvance) their client base is primarily Blues plans. It is just too expensive, really, for any mid-market plan with less than 200-250k covered lives. Say that they are focusing on TPAs and government plans but TPAs don’t have money to spend on a solution this robust (and expensive). Same for government plans. 

That means they really are just making money on customers that are migrating and upgrading to the new Alineo platform off a stable but limited install base. The only way to really upgrade their revenues there to win a whale (say at least 750k covered lives) but they’re facing a bunch of competition from existing vendors (Trizetto, McKesson Health Solutions, Landacorp) and a cost of small upstarts using newer technology (ZeOmega, others).
    
NextAlign is interesting and the Patient Clinical Summary actually does deliver some valuable data to providers (even if it’s administrative data). It makes particular sense in emergency rooms if select physicians can just get over their bias that all administrative data is garbage (yes, problematic, but is it really better than nothing or relying solely upon a patient’s recall when they have multiple chronic diseases? Problem is, it is just way too expensive for providers to seriously consider purchasing this even if subsidized by a local payer. Will providers take it for free?  Sure, and they will use it some select cases, but they balk at paying for it and they have a bit of a point.
 
This is really not an issue just for MEDecison. Every payer is facing this same challenge of how and where it makes sense to touch/interact with providers. Every large payer is conducting pilots this year with select providers, but they are mum about the results, either because they have nothing yet or regard it as too important of a differentiator from competitors.  My bet is a bit of both, but mainly the former reason. 

One thing I would love to see is some actual decent survey stuff on what/how physicians view using administrative data for clinical reasons, including diagnosis and treatment. My bet is that older physicians and those with a heavy bias against insurers are also those most likely to never use anything the payer sends regardless of its actual utility or value. 

I’m curious to see where this goes and what is actually under the hood of the latest version of  MEDeWeaver (RHIO/HIE play). Is it similar to what Ingenix is doing for State of Wisconsin with their recently announced deal? I’m also interested to see where the whole NextAlign thing goes, too.

The PACS Designer’s Open Source Software Review – Endrov
By The PACS Designer

Endrov is both a library and an imaging program. The design has made strong emphasis on separating GUI code from data types, filters and other data processing plugins. The idea is that the program can be used for most daily use or prototyping, and for bigger batch processing or integration, the code is invoked as a library.

As a program, Endrov can do what you expect from normal image processing software. It is meant to be hackable; integrating new editing tools, windows and data types is meant to be simple. The main features that set it apart from other imaging software is that it can handle additional dimensions (XYZ, time, channel) which is needed for more serious microscopy. Filters can also be used without being directly applied, and can be composed into filter sequences. Data (for example, derived from analysis) is stored together with the images.

The native image format is OST(Open Spatio-Temporal) Imageset Specification, but most other formats are also supported.

Version 2.10.0 is out, with a big overhaul of 3D rendering. It supports multiple transparent objects better and has many internal improvements to simplify writing new plugins. Other than reacting faster to user input and making use of all your CPUs/cores it comes with the following:

(1) New voxel renderer, render modes and improvements to the old one
(2) Clipping planes
(3) Scale bar
(4) Partial OST3-support
(5) Reworked Matlab bindings
(6) New nuclei rendering options

This new version supports expanded multi-modality viewing.

Endrov is for the image analysis professional who wants an open source solution that can be customized to their liking when downloading image files for interpretation. The files can contain images and data so better analysis can be obtained from a single image view. Version updates have been frequent and come from the highly regarded Karolinska Institute, a medical university in Sweden.

TPD Usefulness Rating:  8.

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From Maxwell Silverhammer: "Re: Patients’ Action Network. I received this in my e-mail and haven’t seen a lot about it." Link. Looks like the AMA is trying to enlist patients to petition Congress to not reduce Medicare doctor payments.

From The PACS Designer: "Re: cloud utilities. TPD has commented about clouds and their spread across the globe through employment of computing grids. Even Dr. Bruce Friedman of Lab Soft News has dedicated his web comments to the cloud phenomenon by quoting myself and others. Now, through a mention by Dr. Bruce, I’ve been reading the Rough Type web site by Nicholas Carr, who has a recent post about how far cloud computing has come and where it is about to go, which should prove interesting to HIStalkers. His post is titled On the trail of the itinerant computer." Link. That’s a thought-provoking read, the idea that computing and digital property can’t be constrained to time and place, with ensuing political and economic ramifications.

From Dr. Bernie Tupperman: "Re: MEDecision. The premium to share price is ridiculous to the point of being insane. I guess that’s the decision-making you get as a quasi-nonprofit when your accountability is totally limited. The fact that HCSC accounts for 25% of the revenue of MEDE just makes the multiple that much higher. I am surprised no political candidates have grabbed on to this. It’s great news for MEDE shareholders, but the cash to pay for it is coming out of the hides of consumers in Illinois, Texas, etc." I think I’m the only person to pick up on the fact (in Brev+IT, which you can sign up for to your right) that BCBS operator HCSC is MEDecision’s biggest customer. They’ve offered $121 million, quadruple the closing share price, to acquire the company.

From Slap Maxwell: "Re: CattailsMD. Will Weider is not the CIO of Ministry and Marshfield. They are completely separate organizations. Carl Christensen is the corporate CIO for Marshfield Clinic. Also, Ministry is not the alpha site. The system is already used by over 700 physicians and several organizations. Marshfield has been building its own systems for more than 20 years and has almost 200 programmers employed to build and maintain its CCHIT-certified EHR." Will is CIO over two organizations, of which I got one right (the other, I assume, is some kind of joint hospital project). I don’t know anything about the players, so I asked Will for dumbed down explanation. Ministry has its own 160-physician group that competes/collaborates with the 750-doc Marshfield Clinic, but Marshfield admits most of Ministry’s hospital inpatients. Ministry will implement a homegrown ambulatory clinical application from its competitor, in other words, chosen over the usual big-name commercial ambulatory EMR systems. Ministry’s inpatient clinical systems (Meditech and Centricity) aren’t going anywhere, though.

From RUKR: "Re: Royal Bath. First UK trust to go live with Millennium LC1." Link.

I ran an anonymized rumor from Rodney A. Rippy last Friday about a physician office EMR vendor supposedly in looking for an angel investor in a New York meeting. Not true, the company’s CEO tells us. His investment bankers met with execs from a competing EMR vendor to see if that company might be a good acquisition target and that was it so far. He promises to tell HIStalk first if anything changes, into which I read that the company will actually expand, not contract.

Regional Medical Center at Memphis (TN) implements Medseek’s physician portal, putting Meditech data in front of its docs. Other Medseek announcements: its sales doubled in Q1 and it will support HealthVault.

Jobs: Cerner Clinical Consultants, .NET 3.5/WPF Developer, McKesson Consulting Opportunities.

Columbia, MD-based business intelligence vendor Medisolv acquires Clinsaver, a Canadian decision support/dashboard vendor.

Mediware announces its BiologiCare transplant materials tracking system.

Drug companies spent $168 million on lobbying in 2007, double 2001’s total.

A hospital clinical informatics nurse is interested in a high-level, head-to-head comparison of clinical systems from Cerner and Meditech (either Magic or C/S) for an in-house decision. If you have experience with both and want to jot down some thoughts, I’ll send them her way. Thanks.

Premise CEO Eric Rosow will ride a bike 85 miles in the Pan-Mass Challenge on August 2 to raise money for Dana Farber’s The Jimmy Fund. I sponsored him (Premise does the same for me, so it’s only fair) and you are welcome to join me.

Sad news from Meditech President Howard Messing: "I don’t know if this is the kind of thing you print, but Darrel Lapierre has passed away. Darrel was well known and respected in the MEDITECH community, serving as Staff Master Sergeant in the Air Force (highest non-commissioned rank), then CIO of Hillcrest Baptist Hospital, then as CIO of Columbia/HCA Healthcare, and then as a consultant to many, many hospitals. He will be missed by many of us who deeply respected him.  Full obituary: Darrel John Lapierre was born April 13, 1944, married on  February 12, 1966 to his wife of 42 years Bonita Jacquetta McGaw, and died at the age of 64 on June 22, 2008 in his home after a courageous battle with cancer. Darrel was born in Montreal, Quebec, Canada. At a young age his family moved to Joliet outside of Chicago. He was an avid sportsman excelling in wrestling and football. After High School he joined the US Air Force while still as a Canadian citizen. The Air Force assigned him to Tachikawa, Japan. There fell in love and was married to his devoted wife Bonnie. Darrel became a proud US Citizen, and together they raised two children while traveling the world. He worked with the medics and hospitals of the Air Force and was assigned to many overseas posts, once being transferred from Thule, Greenland to Las Vegas, NV. By Federal law, only one percent of the Air Force enlisted force may hold the rank of Chief Master Sergeant. CMSgt Darrel J. Lapierre (Ret.) had a long and distinguished career making friendships that he treasured. After retiring from the Air Force he continued to work in hospital administration and focused on data management. Advancing in his field, he became the CIO of Columbia Healthcare (now HCA), one of the largest healthcare organizations in the nation. After retiring a second time he built a successful consulting business just to enjoy working with the people he cared about.His last career was maintaining a low handicap, a great yard, and a happy home. He is survived by his wife Bonnie, son Coady, daughter Eve, sister Debbie, 3 grandchildren, and countless friends." Condolences to the family and those who knew him.

Industry longtimer Nick van Terheyden joins speech recognition/physician documentation vendor M*Modal as CMO.

Anesthesia system vendor DocuSys will move its headquarters from Mobile to Atlanta.

Cardinal Health buys red tee shirts for 600 of its employees to wear on Fridays in the USA Cares "Red Shirt Friday – I Care Too" campaign to support US troops and raise money for the Military Family Assistance Center.

A New Jersey hospital has fired two nurses for HIPAA violations since last year, the nurse’s union says. The union is offering privacy training to its members, so kudos to them for taking that initiative (regardless of motivation).

Mayo Clinic’s two retail pharmacies re-opened Tuesday after being shut down since last Wednesday by an unspecified computer problem.

PubMed creator and NIH employee David Lipman, MD is one of three finalists in the 2008 Service to America Medal in the Citizen Services category.

Odd lawsuit: a 69-year-old woman fired after 42 years on the job at an Omaha hospital is suing Alegent Health for age discrimination. Her complaint says a new, younger female supervisor called her an "old lady" and a "dinosaur", said the was "older than dirt," and made adult diaper remarks before firing her.

Emageon caves in in its proxy fight with big shareholder Oliver Press Partners. CEO Charles Jett will leave the company’s board and OPP will get three board seats.

E-mail me.

Inga’s Update

I ran across a side-by-side comparison of McCain’s and Obama’s health care proposal. Helpful if you are interested in just the highlights of each candidate’s positions on access to health care coverage, cost containment, improving the quality of care, and financing.

Eclipsys announces the availability of a new revenue cycle dashboard tool. Children’s Omaha is one of the first organizations giving it a try.

Misys’ Center for Community Health Leadership releases a free handbook entitled “Best Practices for Community Health Information Exchange.”

Hoag Memorial Hospital Presbyterian (CA) is extending preferred pricing on Allscripts EHR/PM for qualified staff. If I recall correctly, Hoag is providing similar arrangements for several EMR vendors, following the assumption that one size does not fit all.

Covisint is partnering with AT&T and Microsoft to create an HIE over a secure broadband connection. Patients will use HealthVault to share their information with providers accessing AT&T’s Healthcare Community Online. If you build it, will they come?

The Indiana Family and Social Services Administration creates the Indiana Flood Victims eHealth Support Center, designed to provide doctors with medical information on flood victims. Regenstrief Institute, the Indiana HIE, and Electronic Data Systems (EDS) are also lending a hand.

We mentioned last week that Mercy Medical (IA) was evacuated due to the Midwest floods. Another facility suffering major damage (to the tune of $125 million) is Columbus Regional Hospital in Indiana. The floodwaters filled the basement and rose 2-3 feet in the first floor. Several areas got hit pretty hard, including the ER, lab, pharmacy, and IS department. As workers do their best to clean up, ER employees are setting up a temporary space in a mobile emergency room trailer borrowed from the Carolinas Medical Center. The mobile ER includes four ICU beds and a two-bed operating room.

CCHIT publishes its approved final criteria for inpatient and ED EHR certification. For the first time, it has also published standards for a new certification category – enterprise EHRs, for vendors providing interoperable outpatient, inpatient, and ER records.

Emerging Health Information Technology and Davincian Technologies are teaming up to help healthcare organizations further automate their revenue cycle billing processes. The strategic alliance positions Emerging to provide the professional services and Davincian the software solutions.

I went to Mr. H’s HIStalk Radio and found his selections fun but a bit too hip for me (go figure!) If his mix doesn’t work for you, my newly created Inga Radio includes hunky guy singers, legendary guy singers, hip chicks, lots of singer-songwriters, some indie, a bit of hip-hop, foot-tapping rockabilly, and a bit of country-folk-rock. Sort of the anti-Mr. H. In any case, I am now a total Pandora addict.

The Trizetto Group releases a survey that concludes information sharing and aligned incentive programs will reduce healthcare costs. Also, between 88 and 91% of patients responding saw some value in online information tools that help anticipate healthcare costs, select benefit options, and obtain customer service. Eighty-one percent of consumers expressed concern about their future healthcare costs, while more than 90% of both employers and payers considered wellness incentives at least somewhat effective at lowering employees and families’ healthcare costs.

Looks like McKesson is going to have to settle for as much as $15 billion in damages in connection with the lawsuit allegedly inflating prescription drug prices (we predicted the payout could be big in a Brev+IT earlier this year). That makes John Hammergren’s $26.8 million compensation for 2007 seem like chump change. Hammergren’s pay grew 18% from 2006, which is 9% higher rate than McKesson’s revenue growth for the fiscal year ending in March.

E-mail Inga.

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Photo: Johns Hopkins University

Stephanie Reel is the only CIO I know who runs both the academic and healthcare IT organizations for a university, and not just any university at that: Johns Hopkins is always high on the lists of best universities, best medical schools, and best hospitals. Among her many honors, Stephanie was a 2005 HISsies winner for most effective healthcare CIO. It was great of her to share her thoughts with the readers of HIStalk.

Why don’t we start with a little background about yourself and your job?

I’ve been at Hopkins for 18 years. I grew up in Baltimore in the shadow of Johns Hopkins. I always had enormous respect for the place. I remember my mother saying to me, "They don’t call it THE Johns Hopkins hospitals for nothing”. I grew up in all of the science and the wonderful things that happen here, but had no real interest in healthcare. I wanted to be a schoolteacher. So I played around with that for a little bit.

As it’s true with many fortunate people, I happened to meet someone who became a mentor for me. He said, “Boy you really like this IT stuff and you seem to like leadership. Why don’t you consider healthcare information technology?” This was about 25 years ago. I said, “I don’t know if I have what it takes.” And he said, “Why don’t you give it a try?” He introduced me to the president of a hospital here in Maryland, a small community hospital that happened to be searching for a director of information technology.

I talked to them and they thought that I had the right education background, skills, interest, and passion to become a director of IT. I took that job and worked at it for about five or six years. Then someone mentioned to me that Hopkins was searching for a similar kind of position. It wasn’t the CIO at the time. This would have been in the early 1990s. It was another Director of IT kind of role. I was approached to interview for the position and I did. I took the job July 1, 1990 and immediately became overwhelmed by the complexity of a place like this and the opportunities that were available.

I took the job and started out just getting to know the place. I was really placed in a wonderful position where I had an opportunity to sort of serve as an internal consultant for a little while and work at all our affiliate organizations. At the time, the Johns Hopkins Health System was growing up and I was given the chance to bring some of the affiliates into the fold and try to encourage them to work collaboratively together with the mother ship at the time, which was the Johns Hopkins Hospital, and look for opportunities where we could benefit from collaboration or synergy. And I loved every single minute of it.

One thing led to another. The CIO resigned in the late fall of 1993 and Hopkins conducted a national search, as places like Hopkins do. The search committee was kind enough to interview me for the position and ultimately offered it to me. In early 1994, I became the CIO of the hospital and the health system. A little while after that, Johns Hopkins Medicine was formed, which was the coming together of the university’s school of medicine and the hospital and health system. I was offered the opportunity to serve as the CIO of Johns Hopkins Medicine. 

In 1999, the president of The Johns Hopkins University initiated a search for the CIO for Johns Hopkins University. I was on the search committee. I assumed I was searching for a partner or a colleague with whom I would work. He or she would be responsible for IT for the university and I would retain responsibility for IT for the Johns Hopkins Medicine organization. One thing led to another and the president of the university offered me that position as well.

I became the CIO of the university in January 1999 and serve in that capacity as well as retaining the role of CIO for Johns Hopkins Medicine and have had a pretty good time ever since then. I have had an opportunity to serve people in all three walks of life: education, research, and patient care. It’s really been a wild ride, but pretty wonderful to get to live in these different worlds that define what Hopkins really is. It’s been fun. I guess that’s why I am what I am.

Is there anybody else that you know of that’s both over academic and healthcare sides of a university?

I don’t know for sure because the way people define their organization is a little bit different. There are a number of CIOs down in Emory and University of Chicago. By example, I know those two CIOs are responsible for the school of medicine and the hospital health system. I don’t know of any CIOs who are also responsible for the undergrad activity — arts and sciences, engineering, business, education, and those kinds of things. It doesn’t mean it isn’t true. I just haven’t met anyone who has that responsibility.

It is a bit of deviation, I guess, to serve that part of the population, but — I know this sounds almost Pollyanna-ish — but it really is amazing how much you can learn from different disciplines. What I do for medicine is absolutely informed by the great work that’s happening in physics and astronomy because they manage enormous data sets, far larger than what we manage in healthcare. They need high performance computing in ways that are somewhat different from what we need in basic sciences and medicine.

Learning from experiences in those other departments and divisions that are very different from medicine has been a really incredible learning opportunity. I don’t know if it’s easy to explain it, but it happens frequently that I get the chance to apply something I learned in one area with what we’re doing in another area.

It’s really been much more beneficial than I thought in the early days. I thought, "The great news here is that I’ll know the enemy." So, when the computer science department is going to do something really interesting with the network or with some high performance computing they are doing, it might have an adverse impact on the rest of the environment, but at least I’ll know about it ahead of time. Or, if there’s going to be some huge security breach that’s caused by one division, at least I’ll know about it.

But that didn’t become the benefit, although there were some opportunities to learn from that as well. The real benefit was to figure out what people were doing in really different disciplines that could be applied to medicine and vice versa. Even some of the issues with security confidentiality and privacy. Students and parents who were applying for financial aid want their information to be protected every bit as much as a patient does. People who are managing grants want their intellectual property to be protected every bit as much as a sick patient does. And so it’s been interesting also to see some of the similarities between those kinds of organizations.

What’s the total size and scope of the organizations that you’re responsible for?

All of Johns Hopkins is about $7 billion in annual revenue. Hopkins employees number about 46,000. The IT organization, IT Central, which is what I’m really responsible for, is about 650 to 700 people in total. Maybe it’s a little bit bigger now, maybe closer to 750. My annual budget, just looking at IT Central, is about $65 to 70 million. That’s the operating budget. Capital budgets run in the neighborhood of $25 to 30 million a year.

So, we spend $100 million a year in IT Central, including capital and operating expense. I would venture a guess to say another $50 million or so is spent out in the departments and divisions where there are small IT shops doing some really clever innovative things to support research or to support some scientific issue, some discovery. Our health system is not that big. We’re only three hospitals in size, plus community physician sites. So it’s a lot of money considering the size of the organization.

I assume that there was a sharp delineation between the academic and medical sides when you took over. How did you bring them together?

There were two completely separate organizations. One Central for the university and one Central for the health system and Johns Hopkins Medicine. They behaved very differently. In fact, even the one that was responsible for the university was somewhat bifurcated. There was a group responsible for academic computing — the teaching side of our world — and there was another responsible for the administrative computing.

Those two were actually pretty far apart even though they both served the university. They didn’t necessarily work well together because the education group perceived themselves as being very mission-driven, while the administrative group was all about business and ROI. So I had to bring together those two groups together with the Johns Hopkins Medicine group.

The first thing that we did was consolidated networking in telecommunications. That is where we knew we would see real value because we were buying Cisco routers on the heath system side and I think UB was the name of the routers on the university side. Purchasing power alone was reason for us to come together and look at opportunities for consolidation.

But aside from that, there were also opportunities for staff development, for user satisfaction, for standardization. Some of our customers had to live in both worlds, even though as IT folks, we didn’t see that. The first charge was really to bring together networking, telecommunications, and then some of the other things that are now considered to be infrastructure, like information security; e-mail services and post offices and gateways; collaboration tools. Things we now take for granted as being part of our infrastructure. They weren’t back then. They were really separately managed applications, so we had to bring all of them together as well. Most of that happened in 1999-2000.

By 2001, we consolidated our data center into one very large data center with a few satellite data centers for disaster recovery to improve continuity purposes. One large, 35,000 square foot data center now serves the university and the health system.

We brought real money to the bottom line in those first couple of years. Data center consolidation alone saved us about $1.3 million a year, some of which we’ve re-invested in more sophisticated tools and technologies. Just bringing those kinds of services together gave people an opportunity to grow and learn more from other people. It really was an attempt not just to improve service to the customers, which obviously it was, but to really improve satisfaction among the staff. I think it did do that. It gave people much broader exposure, and really an opportunity to make a difference, which some of them didn’t feel they had in their smaller organizations. That was actually a positive, maybe unanticipated, consequence. The staff got an opportunity to learn a whole lot more about other technologies and innovative things that they might not have been otherwise able to see.

How much of your job involves some sort of organizational politics?

Maybe 125%. I think there is clearly an understanding among senior leadership at the university and at the hospital health system, that we really are all about … at a place like Hopkins, it might sound trite, but we really are all about knowledge for the world, excellence, and patient safety. The things that are all over our web site are pretty sincere. Even though there may be some different approaches in the way the health system and the university might tackle a strategic imperative, at the end of the day, there really is a tremendous commitment to wellness, to science, to excellence in education.

I read a book one summer called Getting to Yes. I read it probably ten or twelve years ago, but I remember the author saying, “People come to the table with very different positions, but they often come to the table with very similar interests.” And I think that’s proven itself to be true in the world that I serve. People have different positions, but their interest areas are generally much more closely aligned. They want to make a difference; they want to do good things. Maybe it’s curing a disease, or maybe it’s figuring out how to solve global warming, or mapping the universe, or making our national infrastructure better; but most people come to the table because they want to make a difference. I think if you listen carefully enough, you can find those things that make us the same as opposed to worrying about those things that make us different.

It’s interesting that you were a home grown product put into a job that didn’t exist involving two different but highly regarded sides of the house. How would they replace you?

Well, we’re all sort of replaceable. for darned sure. I think the reason I was given the opportunity is because it was obvious that I had respect for the place and I still do. I think finding someone who respects what the place stands for is an important attribute.

I think the other thing that I have hopefully brought to the position is that I am genuinely humbled by the people who work here, It is so easy to be successful because all you have to do is leverage that excellence or that brilliance, the discovery, the passion. The thing that I’ve enjoyed most about my opportunity here is to work with all these smart people who really do most of the heavy lifting.

We have a clinical systems advisory committee, for example, and it’s been meeting for 15 years. This really is a true story. One Tuesday night a month, we have dinner, and that dinner is generally very inexpensive chicken and some potatoes and green beans. We’ve been meeting since 1993 and the group that meets is now larger than ever. At our June meeting, we had 68 people in attendance, half of whom are physicians who practice real medicine at Johns Hopkins. The other half are nurses or administrators or IT people.

We do this one a month and people come together because they see this as an opportunity to influence the direction of information technology at Johns Hopkins. I feel like I have this amazing group of partners and colleagues who are willing to give two hours a month to sit around and eat chicken and talk about what really matters and how our information technology really can make a difference. Honest to goodness, I don’t know any other CIO in the country who is as fortunate as I am in that regard.

These folks come selflessly. They absolutely come to listen, to share, to contribute to the overall strategy of IT at Johns Hopkins. It’s amazing to me. Every single month when I leave that meeting at about eight, I walk out of that room thinking. "I am incredibly fortunate to have people who are willing to give so much of their time to help us define strategies for the future." It makes the job so much easier.

We have similar advisory committees in some of the other areas, but this one has been in existence for the longest. The current chairman is Dr John Ulatowski, the chairman of anesthesiology and critical care medicine here at Johns Hopkins. Not only do all these other people give up their time and energy, but he sits at the head of the table with 65 or 75 people in a room and helps drive us toward the right decisions so that we do more than just support this place. He really drives us towards a vision for innovation and collaboration, collegiality, excellence — all those words that are all over our web site. He really helps the group coalesce around those things that matter. It’s pretty amazing really. I do feel very privileged to be able to learn from those experiences. They are pretty special.

Folks in a community hospital, who see doctors for an hour in the morning and again in the evening, might find it hard to picture that you’re constantly working with people who have won Nobel prizes or led world-changing research. I just remembered that I interviewed Peter Pronovost, for example, and he’s a pretty big star in my mind. That has to be humbling.

It is humbling. It truly is humbling. I remind my IT team all the time that we’re mere mortals here in the midst of all these folks who are doing remarkable science. Think about how amazing it is to be able to work at their elbow. That’s exactly what we do. The other phrase that’s become pretty common, especially here at Johns Hopkins, is “standing on the shoulder” of these guys. That’s exactly what we get a chance to do.

People who come to work in IT at Johns Hopkins either stay six months and say, “This clearly isn’t for me — I can’t live in this whitewater where it’s so intense” or they stay forever because you get so addicted to the adrenaline and to the opportunity to rub elbows with these amazing people.

This really is a true story. Once people are here six months or a year, retention is pretty easy because you get a chance to work with the best. You probably know the name Ben Carson, a famous pediatric neurosurgeon who does amazing work with children who have serious problems with their brains. He was all over the news last week because he did surgery on a young girl from Texas who had some very serious hydroencephalitis or something.

I had a young lady who worked for us about 20 years ago. She was leaving because she was offered a position someplace else. I said to her, “What will it take to keep you, because you’re a great member of the team?” And she said, “If you could arrange for me to meet Dr. Carson, I’d stay.” So I called Dr. Carson and he said, “Of course I’ll do that.” She got a chance to sit down with this amazing guy, who just this week President Bush named as a winner of the American Medal of Freedom. Ben agreed to meet with her and she’s still an employee here. I think that says it all. That’s what makes it so special. People are willing to do that kind of thing because we’re all in this together. People value that. I think it really does make a difference. 

Hopkins does another thing that makes it very special. Through Peter Pronovost’s leadership, we created this patient safety institute. We allow senior executives to adopt a patient care unit because we feel it makes them better in their jobs. As CIO, I would have no reason to spend my afternoons in the pediatric intensive care unit except for when we’re implementing CPOE, but the pediatric care unit has been my unit for six or seven years. Once a month, I spend an hour or two with the leadership of the pediatric intensive care unit. I’ll sit down and talk about what are those things that make them nervous. What are they worried about? What’s the next way a patient might get harmed? What can we do to make sure that doesn’t happen?

This is not at all about my day job. We do talk about information technology, but that’s not the purpose of the meeting. The meeting is to say, “Do you have enough needle containers? Is your housekeeper cleaning the floors properly at night? Do you have security if you need it if you have child in the unit who is threatened?” We talk about anything once a month. It’s my job to make sure they feel safe and that their patients feel safe. If there are things that we can do to make them feel more comfortable, it’s my job to make sure we do those things.

I have colleagues around Hopkins who do the same thing in other units. Over time, I’ve encouraged my directors to adopt units as well, so one of my directors adopted the blood bank. It’s his job to make sure they feel safe and they can do what they need to do. Another one of my directors adopted the Wilmer Eye Institute. These were areas where they had a personal interest and they adopted these places and get a chance to participate on a monthly basis on those things that make them special or nervous. It’s a way to remind yourself why you are here. That’s pretty important as we get separated from the mission a little bit when we’re putting in systems.

You mentioned clinical systems. What’s the status of electronic medical records there?

Many years ago, before my time, a number of people at Hopkins were fairly serious about building a homegrown electronic patient record. Soon after I became CIO, we did a major enhancement to it. A gentleman who works for me, Alan Coltri, who’s an amazing guy, decided there were a number of things we could do technologically to make our homegrown electronic patient record a more comprehensive solution.

Starting the early 90s, we began rolling out fairly comprehensive electronic patient record here at Johns Hopkins that ingested information from lots and lost of different ancillary systems. Believe it or not, I think it used a very early flavor of something that we now call Software as a Service. Alan developed this thing that he called a Book of Calls. This electronic patient record would place a call into another application and be able to absorb this service, therefore present to a care provider an integrated look at patient records, even though it wasn’t necessarily all being consolidated into one record or repository.

That system was enhanced over the past 12 or 13 years and, I think, and serves us very well. However, when we signed our contract with Eclipsys to deploy its entire portfolio of systems — beginning with CPOE and then moving into clinical documentation and then into the ambulatory record — it became clear that we were going to have some tension between these two environments. We didn’t want our care providers to be confused about where they should go to get the most accurate, timely, and complete information. We’ve made a strategic decision to move most, if not all, of our transaction-based activity from the Johns Hopkins Hospital into the Eclipsys suite of applications.

We have signed a development agreement with Microsoft to develop with them the Amalga product and use that as our repository, our longitudinal patient record across Johns Hopkins Medicine, because our two community hospitals run Meditech. Having all the Meditech data from those two hospitals, all the Eclipsys data, and then any other ancillary information that isn’t necessarily known to Eclipsys — our primary care sites, for example, use Logician — to have all that data resident in one longitudinal repository, so we can use it for not just comprehensive patient record if patient are seen across the continuum, but also for clinical research. We signed a contract with Microsoft last October and we are expecting the rollout of the first phase of the Amalga product in the fall. It will serve as a research repository as well as the early phases of our replacement of our electronic patient record.

IDNs used to insist that all their hospitals use the same clinical systems, but it seems that the emphasis in interoperability has made everyone realize that it doesn’t really matter what feeds the information as long as you can put it together on the back end.

Absolutely.

Is that the market that Microsoft is going after with Amalga?

Microsoft made it pretty clear at CHIME a year ago and at HIMSS that they recognize that many hospitals can’t afford to throw out the investments they’ve previously made. It’s no longer acceptable. It used to be that you could put Meditech in and it wouldn’t be terribly expensive, so if you had to replace it with whatever the institutional will might have been, it wouldn’t have been a big loss. But that’s no longer the case. I think it changed a little bit when the accounting rules changed and you were given an opportunity to capitalize on all the internal resources associated with the design, development, and deployment of a system. 

When you look at the investment that hospitals are making in even some of the smaller information systems, the money is enormous. People are loathe to throw that way. Not just because of the financial investment, but because of the people’s time, energy, commitment, and some of the intellectual property that’s embedded within it. I don’t think we can afford to throw out stuff.

Microsoft enters the scene and says, “We know you’re not going to be able to replace all of the stuff you’ve got in your environment, but we think we have something that will level the playing field a little bit and allow you to keep that other stuff, but give you one common place to collect and present it.” For a place like us, it makes a whole lot of sense. I’m not sure if it works in a community hospital, but I think for a place like us, Amalga seems to make a lot of sense.

The HopkinsOne ERP project has to be one of the most ambitious I’ve ever heard of in healthcare.

Oh, you had to mention that. We’ve had a whole half hour and it’s been so pleasant … [laughs] We implemented SAP in January 2007 after about 3½ years of working at it. It was the first time that the university and the health system as a whole came together around one application. It was a rocky road in the early days. We invested a tremendous amount of money. We put a whole lot of time and energy into it.

When it went live, I would say that it probably served the hospital and the health system reasonably well. Where it fell short — and I think we’re making real progress — was for the research community who had been accustomed to being able to conduct business in a very simplistic way from the administrative point of view. They didn’t have a lot of overhead administratively. If they wanted to order supplies through their grant, it was pretty straightforward. You filled out a little requisition and your administrator processed it. The next thing you know, the right test tube and the right equipment showed up.

When SAP entered into the scene … one of the good things about SAP is it allows your users to be 100% empowered. But that turned out to be the bad news as well because these investigators didn’t have the time to master how you buy things, order things, and pay for things. They were much more interested in doing science. SAP introduced a whole new level of rigor that they needed to do just to be able to conduct their science. I think it was unanticipated by us as to how much of a burden that would really be.

We’ve spent the last 18 months trying to reduce that burden and better inform the work force as to shortcuts and ways to get information out of SAP that are not nearly as cumbersome as in the beginning. I think we’re making progress. People often say how late a system went in, but everyone remembers the things that didn’t work. I think that’s where we are. Memories are still very strong as to what didn’t work in the beginning. And even though we starting to make some progress, people’s memories and the pain is still a little bit fresh. So we’ve got to really prove that we are willing to listen and make a difference.

I’m curious what that project cost and whether you think there’s a chance its actually going pay for itself.

The total cost of the project, looking over the life of the project for the university and health system, is about $240 million. It’s a horrible number, but it does include, as I referenced earlier, when the accounting rules changed back in 1998, it gives you an opportunity to capitalize much of the full-time user involvement. We moved a lot of people from the business units into this organization that we named HopkinsOne and it reported up to finance.

This whole HopkinsOne team was about 150 people from Hopkins and, at some point, as many as 100 people from varying points. So, 250 people over a three- or four-year period of time, all of their costs being capitalized. Along with that, all the hardware, all the software. When you add it all up over the life of the project, it came to $240 million to be allocated out to the university divisions and the hospitals that are within the health system.

When you look at how large Hopkins is, you could certainly argue that’s not a huge investment if we’re a $7 billion corporation, but when you boil it down to the individual departments and divisions and their appreciation for that huge investment, many of them are thinking about buildings they could have built, the faculty they could have recruited, and programs they could have funded. The mission is what matters most to many of these people, so there’s still a little bit of angst associated with the fact that there was such a large capital investment.

Will we get a return on that investment? I think in large part we will. I don’t know if it will ever truly pay for itself. I think the guys in finance are certainly looking carefully at how that will play out. They system was implemented for three primary reasons. One was compliance, because as you know, the regulatory requirements are increasing. The whole regulatory climate is pretty intense.

The second was service. It was clear that we had many different information systems in that ERP space. We had users who were needing to travel between and among all the different systems. It was very cumbersome to do that. There was a belief, and I think there still is a belief, that by bringing all this together in one set of applications, people will be able to do a better job of hiring and firing, paying for travel, and buying things. I think we are starting to see improvements in many of those areas. The research administration is still a little weak, but I think in the other areas, we’re starting to see improvement.

The third reason for doing it was productivity. Therein lies some of the financial ROI. I don’t believe that we’ve started to see those productivity gains yet. I think we will, but we’ve got to spend some more time on business process redesign. We’ve got to spend some more time on training. Those are two areas where we did not invest enough time, energy and people before we went live. Training and business process redesign are critical and that’s where we’re redirecting a lot of our energy.

People in Human Resources are leading a training activity and I think are going to turn out a phenomenal product in a couple of months. They are really building a whole new strategy for training. Business process redesign … luckily, Hopkins has an organization that does that for a living. It’s called Operations Integration. We’re just embarking on business process redesign in a few areas. I think it will definitely help the satisfaction levels and the user adoption.

I’ll just mention, not related to SAP or HopkinsOne, that we’ve put in a new emergency department system. It went live about a month ago in our adult ED and two weeks ago in our pediatric ED at the Johns Hopkins Hospital. It’s the Allscripts HMED [HealthMatics ED] product. Before we went live, this particular time, we all got together and decided that we had to do business process redesign first. The only way to do this right was to make sure we studied all the workflow issues in the EDs and made sure that we redefined and redesigned them before we implemented new technology.

In my career, it was the first time a system came in ahead of schedule and under budget. That’s because there was amazing commitment by the users to really drive change as a part of this technology implementation and really look at the way we’re doing work. It really was another one of those amazing experiences where the system went in, people used it really well … there were definite speed bumps — there always are — but it really has been a success story and I think the technology is a small part of it. It really was because the users were passionate about redefining the way they do work.

When CIOs get in trouble, it’s often because of either CPOE or ERP, which is the business equivalent of CPOE. With those two behind you, what are your biggest challenges and concerns?

I think they’re behind us in that they are implemented, but I think the really big challenge is now related to getting bang for the buck. We’ve got to get value out of these systems. In the area of CPOE and clinical documentation, I think we’re starting to see that benefit. I think it hasn’t come without a whole lot of hard work and pain on the part of the care providers who’ve had to learn how to do all this differently, but I think our patients are getting safer. I think that we’re making far fewer mistakes. We’ve had amazing success with medication error reduction through the implementation of CPOE.

Over the years, we’ve invested so much time and money that I think we owe it to the institution, to the patients, and to the faculty here to really start showing the value of these investments. I think that’s where the rubber meets the road. I think that’s biggest challenge we have ahead.

The thing that worries me is the rate of obsolescence. These systems no sooner get implemented than you have to do the next release, buy the new hardware, or move the web services. You’re never done. Even though we all know we’re never done, it would be nice to take a breather once in a while.

There’s so much change. Change largely driven by our own demand for better, quicker, slicker stuff, but it makes it hard. I worry a little bit about fatigue. We put in a new operating room system release this past weekend, so I had a large team of people who worked all weekend. The previous weekend, we had some major network enhancements we were doing, so we had a whole army of people worked that whole weekend. Sometimes it’s the same people working weekend after weekend. 

I do worry a little bit about the fatigue that the staff feels because we’re a pretty high energy place and we have pretty demanding customers. Everybody needs a bit of down time and its getting harder and harder to really get away. Everybody carries a portable device. Everybody’s logged on most of the night, it seems, by measure of the e-mails I get in the early hours of the morning. People deserve some down time and it’s getting harder and harder to get.

If you look outside of what you do at work, what healthcare IT related projects or organizations, conferences do you think are worth your time and attention?

I’m a member of CHIME and I think the world of the CHIME organization. Together with John Glaser and a few other people, we have been able to teach the CIO Boot Camp a couple of times a year for the past maybe five years. That’s really been a terrific opportunity to give something back to the younger people who are coming up in our industry.

I think HIMSS has, over the years, has been strong and not so strong. I think now they are making a difference again and are looking at the right kinds of things. My only concern is that the annual conference is just darned big. It’s hard to take it all in and hard to focus. It bugs me a little bit that the competition for who’s got the jazziest booth is a little bit disappointing, but it is what it is. It’s one way to learn what is happening in the industry. I don’t usually get a chance to go every year, but going every couple or three years has been a good thing. There’s a lot of opportunity to learn there.

I think the folks at AMIA are great. I’m a member of AMIA, but I don’t get a chance to participate actively. We have some physicians here at Hopkins who participate at AMIA. I try to read as much as I can because I don’t get a chance to travel as often as I would like, as there’s a lot to do back at the home front.

I think our industry is getting a little bit better at providing material that’s meaningful. I do read your blog and I really do think that you have a lot of trusted contributors, or people who ate least are willing to be candid with you and share what is happening in their organizations. I tell so many people about your blog. I spoke at an investors meeting last week and, as part of my bio, the gentleman that introduced me mentioned that I won the HISsies award. People ask what that was and I told them about the blog. I said it was a great way for the investment community to know what’s going on in the information technology in healthcare.

How do we make privacy less of an issue when it comes to information technology?

I probably am in the minority about this one. I think it’s much ado about nothing, in a way. I really do believe that until we put healthcare in the hands of the consumer, we’re never going to get better at this. I do feel that the personal health record strategies of Microsoft and Google Health are a step in the right direction, provided there’s not some huge breach. I think that we have to get people to trust and I think the way to get them to trust it is to give them some kind of way to control their own destiny.

I think we need to convince people that there are risks associated in using technology in healthcare, but there are risks associated with everything we do every day and the benefits outweigh the risks. We need to be able to manage our eating habits and our exercise habits and our glucometer readings and our EKG readings, all those kinds of things, to see if we’re managing our health. I think we can do it through better use of technology.

What would I actually do? I don’t know. I would encourage people to use technology to manage their health and do it any way that they are comfortable doing it. But I don’t think that Google and Microsoft are parts of the evil empire. It’s all about the money at the end of the day, but I think they are also trying to make a difference.

I had this amazing opportunity to have breakfast with Bill Gates a couple of months ago. He invited maybe 25 people in Washington, DC to come and have breakfast with him. Half of the room was filled with people who had military uniforms on because I know Microsoft is doing a lot in the national defense space. The other half of the room was people from all walks of life. I was the only healthcare person in the room. He sat right there and said, “We’ve got to do something about healthcare in this country. We have to make a difference.”

He mentioned Hopkins by name. We’re doing some good things at Hopkins with our work on Amalga, but we’ve got so much more we have to do. What I said back was, “You’re darned right. You have so much to do and you have the resources to do it, so do it. Help us dream big.” I said, “We want to dream big, but we need help dreaming big because we don’t have limitless resources or the deep pockets that everybody thinks we have. We’re non-profit organizations trying to make a difference here and you can do it.”

He said he really wants to do it, or he and his company really want to do it. He’s stepping out of that role. Craig Mundie was there as well and said, “We hear you. We really want to make difference in this space.” I hope they are telling the truth.

If you look at that whole aspect of consumerism, are you planning for a different environment where the consumer is more in charge, where it’s more about health and not treatment? And will the paradigm change right about the time we get the basics of pushing orders and paper around?

I think they’re readier than we think they are. We all read the statistics about the fastest growing part of the demographic using the Internet, people over 65 or over 75. Certainly young people are absolutely ready. Some of us in the middle may not be completely ready, but I think that the paradigm is changing. People are doing much more of their business online. Why not do healthcare there as well?

I don’t think they yet trust Microsoft and Google. I think many people who are venturing into the space of electronic patient records or personal health records are doing by the tethered approach, where their payor or their Kaiser Permanente is helping them orchestrate that migration of information into a personal health record. But I think there is also just as many who are doing locally on their own PCs in their own living room and not willing to let it be any place else. But that’s at least a beginning and I think we should be encouraged by that.

If we can figure out how to do the right mash-ups to integrate information from personal experiences and behavioral experience and primary care physician offices and tertiary activity that goes on; if we can figure out some way to bring it all together for patients and allow them to use that information to create a body of knowledge about themselves, then allow them to create social communities where they can get the support they need or search capability where they get the education they need so they get a chance to learn stuff and do stuff by using technology — I do think we’ll get better adoption. Nobody wants to die of anything, so if we make it easier to figure out how to live with disease and how to improve outcomes at a personal level, I think people will develop a little bit of trust. I hope so.

If you look ahead and try to pick out what the most important technologies or the most important change of the next ten years, what would you say?

I guess if you asked me this question two or three years ago, I would have said the PDA-cell phone world. I think it’s going to become, or has already started to become, the way we do almost everything we do. It feels to me like we can connect and learn and do lots of things through these portable devices. I’m not much of futurist, but I guess that’s where there is still a tremendous amount of opportunity.

I think wearable computers is what they are. We’re wearing these very sophisticated devices on our belts and I think it will allow us to do even more in the years ahead. I don’t think any of us understood two or three years ago the power we would have in these small devices.

I was sitting with my 87- and 88-year-old in-laws for Father’s Day. My mother-in-law said, “How old is Tiger Woods?” and within about 30 seconds, I was able to tell them his birthday is December 30, 1975. She said to me, “Wow. You have a window into the world right in your palm.” That’s a pretty impressive opportunity for all of us. I think that’s certainly one amazing technology going forward.

I think in healthcare, the technology opportunities for diagnosis and treatment of disease are the ones more impressive. Today I had a chance to shadow somebody in our Radiation Oncology department and walk through the department, look at some of the amazing technologies they use to target treatment for cancer. You look around and you see a lot of sick people, but you see people who are so hopeful and optimistic about their futures. I think it’s because people do believe there is great promise in these medical technologies that are prolonging life. Life matters, and I think a lot of these young men and women that I saw this morning — an extra year or two with your children or grandchildren really matters and these technologies are providing hope. The young physicians coming out of medical school today are so excited about making a difference in some of these technological areas. So I’m very excited. I think the future has got a whole lot to offer.

Who do you admire in the industry?

John Glaser is a rock star. I more than admire him. I think he’s amazing. I think John Halamka, for a whole different set of reasons, is amazing. He probably doesn’t even remember what he’s been to me in my career, but I’ve called upon him when I needed some advice about certain things that were happening and he’s been very helpful to me as well.

From a technology point of view, I have tremendous admiration for Sam Palmisano at IBM. I think he’s trying to make a difference in an interesting set of ways. I think he’s been successful in some interesting ways that are not obvious to a lot of the customers around the world.

Judy Faulkner. I think Judy is an amazing human being who has stuck to her guns and made a commitment very early in her career that she was going to make a difference and she certainly made a difference. Outside of technology, I love Michael Bloomberg. I wouldn’t have been disappointed to see him run for President of the United States. I think he decided against that, but I think he’s also brilliant and has done some cool stuff.

Is there anything else you want to talk about?

I guess the only thing I would add that we didn’t talk a whole lot about is people. How are we going to nurture, grow, and respect the people who have to do this hard job we have in information technology? How do we make them feel valued? How do we treat them with respect and have a life?

My children are grown and married and have children of their own. I’m grateful that’s the case, because if I had young children at home, I don’t know when I’d see them. These jobs have become so consuming that I worry a little bit that for the young people who are growing up in healthcare IT, the demands are so great that they are making some bad decisions sometimes abut where to be at 6:00 at night. Instead of going to a Little League game, they’re at the office dealing with a tough problem. One side of me loves that — to see their dedication and commitment — but I worry that they are missing out on some important parts of their lives that they won’t be able to re-create.

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