From afh15: “Re: EHR data. I’d love to read your thoughts on this study and the long-term uses of EHR data in preventive care.” I don’t have access to the full text of the article, but I truly believe that once the pain of getting EMRs running as data collection appliances is over (meaning we’ve got data collection clerks known as doctors and nurses in place, which is the “pain” part), the benefit will be incredible. This article apparently deals with having nephrologists automatically consulted when the EHR finds problems. There are other benefits. You could do society-improving medical research by just slicing and dicing data from millions of patients, at least the parts of it that aren’t just clinical-sounding billing events that are useless or even misleading. You could find candidates for research trials. Patients could be followed over many years, even as they move around and use the services of a variety of providers. And for individual patients, there could be great value in putting research findings into the hands of front line doctors. Not to mention giving patients a platform whereby they can participate in their own care and add non-episodic information related to lifestyle, personal health assessment, etc. Clinical systems will not save time, as clinicians know – they exist to create data whose value mostly accrues to someone else. My advice to providers: much of your future income may be based on the data you create and the ownership in it you retain. Don’t be like the Native Americans and let greedy outsiders buy your land for trinkets.

From Anonymous: “Re: Craneware. Interesting question to ponder: How did two young Scot lads, with no US healthcare knowledge, manage to visualize and create Craneware, the country’s first automated CDM software based on complex Medicare regulations? The designer of Craneware’s core CDM products is a US healthcare consultant and not a Scot. Nora McNeil (NJ) is Keith Neilson’s American mother-in-law. She co-founded Craneware with KN and his partner Gordon Craig and taught the Scots everything they needed to know about US healthcare policy and regulations. She was  also the sole marketing and salesperson of Craneware’s CDM products for the first two years of the company’s existence. So why have the duo not publicly acknowledged Nora’s existence as a founding partner and her primary role in creating a successful company?” The company’s documents say it was founded by Keith Neilson and Gordon Craig “following on from discussions with Nora McNeil.” I would guess there’s a family squabble somewhere in the mix. And when that happens, the lawyers are usually not far behind. I don’t have a horse in the race, so I’m neutral.

From Cracker: “Re: Nuance. Nuance’s domination of health care speech recognition gets more scary when you also consider the current M*Modal customers taking a serious look at Nuance. I know second hand of two current M*Modal customers looking at Nuance and will do some research to find some more.” Cracker references a news piece describing an anti-trust investigation of Nuance’s $96 million acquisition last year of Philips Speech Recognition systems (the old SpeechMagic). My assumption, reading between the lines, is that a competitor complained and the investigation is just making sure Nuance isn’t raising prices after knocking off Philips (not likely since Philips had minimal US presence). I don’t know much about M*Modal so I don’t know how they stack up to Nuance, but they and a few other vendors are facing a large, highly successful, and aggressive competitor whose name is nearly synonymous with speech recognition.

From Captain Hook: “Re: Valco rumor. We are a current client and since the announcement have spoken with a couple of our prior contacts at Valco (and they appear to still be working for the company). It is clear that some of them have been let go. Spoke to AJ Hyland as well. No indication that Valco technology will be sunsetted, at this point but it would make sense to do so. It is clear that Hyland bought the client base and entree into Meditech clients.” Valco sold portals, electronic forms, scanning solutions, and other healthcare tools.

From Commander Cody: “Re: Medical Center Odessa. They paid $6.2 million for CPOE, but their regional neighbor Midland Memorial paid only $7 million for their entire clinical transformation project. After five years, Odessa is just now doing McKesson CPOE, two years after Midland has fully implemented OpenVista hospital-wide. Taxpayers paying for high-priced proprietary EMR systems is a bad idea.”

Should CPOE be a requirement for demonstrating meaningful use of hospital-based EMRs? Yes, according to 69% of those who answered my poll. New poll to your right, inspired by the comment above: should hospital CIOs consider open source clinical systems?

McGill University Health Centre is working with Medical.MD to develop its MedforYou PHR.

The local paper covers EMR implementations in two Arizona hospitals. Banner Health, the story says, will spend $30 million (hardware, software, and training) each at two of its hospitals: 430-bed Banner Boswell and 272-bed Del E. Webb. They’re Cerner, I believe. I hope that dollar figure is a misprint, but then again, Banner paid its CEO $2.7 million, the CFO $1.7 million,  and its CIO $600K in 2007, so maybe big numbers don’t bother them. Its 2007 profits … sorry, “surplus” …, was over $300 million. Since they’re not paying taxes, I guess the money has to go somewhere.

Say hello to TELUS Health Solutions, supporting HIStalk as a Platinum sponsor. The company, which took a big jump up the HCI Top 100 this year from #33 to #20, offers a wide range of healthcare solutions (claims management, the new TELUS Health Space personal health platform, pharmacy management systems, telehealth, patient and resource scheduling, and the renowned Oacis Unified Patient Record). The open architecture Oacis, in fact, has been supercharged into an integration platform that offers an integration gateway, EMPI, CPOE, ED tracking, clinical documentation, Web-based Enterprise EMR, and data warehouse/BI portal, making it suitable for healthcare organizations and entire regions. I remember from talking to the folks there awhile back that Oacis has two big strengths: it can handle the interoperability requirements of regional deployments and for hospitals, it can be implemented without ripping and replacing (it also excels at being customizable, as I recall). OK, I’m prattling on because I was pretty charged up with Oacis when people started telling me about it years ago, but for now, let’s leave it at this: thanks to TELUS Health Solutions for supporting HIStalk.

Cerner moves up to the Nasdaq-100 Index, replacing the Oracle-acquired Sun Microsystems.

HIMSS is thinking more and more like a vendor. How do they improve (“reposition”) the perception of its CPHIMS certification credential? Hire a marketing company to develop a “correlating creative platform and 12-month integrated communications plan.” Because of the tsunami of federal HIT dollars, “the CPHIMS new brand positioning will be more essential than ever,” at least in the eyes of the marketing people (a knowing wink to fellow grammar zealots: “more essential” makes no more sense than “more pregnant”).

The California Nurses Association union files a complaint with the state’s Department of Public Health, alleging that UC Irvine Medical Center has overdosed at least five patients with narcotics by using malfunctioning Curlin infusion pumps that let patients control the flow of pain med IVs. The hospital disagrees, saying keystroke logs indicate that in at least three of the cases, nurses entered the wrong dosage. Meanwhile, an enterprising group of ambulance-chasing lawyers has bought Google search ads trolling for victims who have “sustained damage” after a Curlin pump recall, helpfully noting that companies have to pay out even if they weren’t negligent under current strict product liability laws. Maybe the lawyer proceeds of healthcare-related lawsuits should be taxed at some reasonable rate (90%?) to help fund healthcare reform since the former lawyers in Congress keep avoiding tort reform.

Industry long-timer Bob Fetters died Tuesday at 70 in Kennett Square, PA. He worked for over 20 years at SMS and had already RSVP’ed for Vince Ciotti’s November reunion. The memorial service was Saturday morning, but messages for the family can be left here. Condolences.

I like this fresh thinking: if we’re already paying double what most countries pay for healthcare, why should healthcare reform cost anything? I also like this answer: “We owe the insurance companies, pharma, etc. a severance package, payable into the future for some undisclosed period of time. Like the Hotel California, their lobbyists are making sure we can check out anytime we like, but in fact, we can never leave.”

Former Cernerite Anne Jamieson is named CEO of Portsmouth Regional Hospital (NH).

A hospital in Canada whose computer network was infected with the CoreFlood trojan horse sends warning letters to 11,500 patients, warning that the trojan was designed to capture information and send it to hackers and therefore may have done so. The virus was not detected by the hospital’s unnamed antivirus software (considering that Symantec has been protecting against it since 2002, maybe it’s time to check the updates, change vendors, or fire employees who disabled it on their PCs). CoreFlood was written by hackers in southern Russia to capture secure information such as passwords, e-mail contents, and bank records. It’s doing its job, collecting 500G of personal financial information in just six months, including details on thousands of banking and credit card accounts.

Siemens will provide Soarian to 37 hospitals and 300 clinics in South Africa as a subcontractor. That’s a huge and much-needed deal for Soarian, which was always loaded with unrealized promise.

The VA gets $3.3 billion to spend on IT in 2010, up 30% from 2009.

West Jefferson Medical Center (LA) gets a mention from the local TV station for its implementation of GetWellNetwork, explaining that it’s not for just patient entertainment, but also patient education. The article says patients can also find a hotel, check their bill, and send an instant message to hospital departments.

I like this opinion piece on Taj Mahospitals: “If your competitors have serious woodwork, you can’t get by with woodgrain Formica. If they have armies of PR people on staff, you need them, too. If they have billboards touting the No. 1 rating conferred on their pediatric nephrology team by a local magazine, you too need billboards. If they offer their patients such amenities as wireless Internet, on-demand video, room service-style dining and concierge service, you’d better follow suit. In fact, a recent study published by the National Bureau of Economic Research found that such amenities are three times as effective in increasing demand for a hospital’s services as improved clinical results are. (What? We don’t care if we get better as long as we can have YouTube and American Idol on tap?) The irony is that it’s all necessary, even though it’s a total waste in the sense that none of it improves anybody’s health one iota.”

Scary stats out of California, not like to improve now that the state is nearly bankrupt: the state’s nursing board takes an average of three years to investigate and discipline problematic nurses, gives probation to offenders but doesn’t crack down when they mess up repeatedly, and doesn’t have records to keep fired and disciplined nurses from moving on to the next hospital. One nurse kept his license for five years after hospital complaints that he had stolen and used drugs and fell asleep while performing CPR; he admits he was high at work.

Cleveland Clinic launches its health and wellness portal.

Dossia announces an API for its PHR platform, allowing programmers of new personal health tools to exchange  information with it. Documentation for it is here.

Insurance company UnitedHealth Group announces that it will spend tens of millions of dollars to build a national telehealth network based on Cisco’s Telepresence technology. It has hired former MinuteClinic CMO Jim Woodburn to run the program. More details will be announced on July 15.

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From John Q. Seriously: “Re: Eclipsys. In a morning blind-side, Eclipsys has released former MediNotes CEO Don Schoen and former Bond Technologies President Travis Bond. Bond created the EHR Bond Clinician, which was acquired by MediNotes in spring of 2008. It was subsequently acquired in the the acquisition of MediNotes by Eclipsys in the fall of 2008 and renamed Eclipsys PeakPractice. Schoen was co-founder of MediNotes, known for their Charting Plus and MediNotes EMR products.” Several readers e-mailed with the same rumor, saying that business unit had been merged into an existing Eclipsys one. I’ve offered Eclipsys the chance to respond and haven’t heard back yet. It’s unusual for entrepreneurs of acquired companies to stick around after an acquisition, but they usually leave under their own power.

That rumor follows news that Chris Perkins has been named CFO of Eclipsys, rejoining his former Per-Se colleague, CEO Phil Pead. He gets an immediate 22,222 ECLP shares ($362K worth) plus options for another 133,334 shares to “align Mr. Perkins’ interests with those of Eclipsys shareholders,” who are unaligned in the sense that they had to pay for their shares with their own money. He’s also getting $400K in salary and a targeted bonus of $200K with $100K guaranteed. Also announced are severance deals with Pead and Perkins: a year’s salary, 100% of target bonus, an extra year of vesting, and 18 months of health insurance.

From Ken Kashimoto: “Re: Valco. Heard through the grapevine that as a result of Hyland Software’s acquisition of Valco Data Systems last week, all Valco employees were let go last week.” Unverified. Valco’s headcount was around 35, I’ve heard.

From The PACS Designer: “Re: Google OS. Google has announced a new web operating system called The Google Chrome Operating System. The Google Blog states, ‘Speed, simplicity and security are the key aspects of Google Chrome OS. We’re designing the OS to be fast and lightweight, to start up and get you onto the web in a few seconds. The user interface is minimal to stay out of your way, and most of the user experience takes place on the web. And as we did for the Google Chrome browser, we are going back to the basics and completely redesigning the underlying security architecture of the OS so that users don\’t have to deal with viruses, malware and security updates. It should just work.’ It appears that Microsoft and other major operating system vendors have something to worry about when it comes to competition from open source web operating systems.” Don’t underestimate the benefit of having a change-resistant customer base. Chrome is already out there and not making much of a dent in IE. Linux, on which Chrome OS will be based, is also free but has taken only a tiny percentage of PC users. People don’t like change even more than they don’t like Windows. I like all the Web emphasis, but they better not make Microsoft’s Vista mistake and tell users that dysfunctional and outdated plug-and-play drivers aren’t the fault of the operating system. Google is smart to be going after Microsoft’s cash cows of Windows and Office, though. For Netbook users and those who really don’t need anything running locally on the desktop, Chrome OS will probably be just fine, but that’s not a big bunch of users so far.

From Rhythm n’ Blues: “Re: CareFusion. I’d be interested in your response to this unique marketing tactic. Hope they’re stopping in a city near you!” Cardinal Health’s planned technology business spinoff and IPO, CareFusion, will sponsor a jazz festival series that’s going to Newport, Chicago, Montery, Sydney, Paris, and NYC. They’re using a lame excuse for it, saying that “there is a clear connection between jazz and medicine.” Dear Saint Obama, while you are looking into ways to cut massive healthcare costs by throttling the incomes of the people who deliver care, please make sure not to forget to save a little of Uncle Sam’s well-intended meddling for those companies that make a fortune from patients in the form of Pyxis and Alaris patient care devices whose high prices and market penetration have allowed them to hoard enough healthcare cash to stage an international festival series for jazz music, which nobody likes anyway except pedantic posers not quite up to classical and secretaries who aren’t allowed to play real music on the office radio. Sincerely yours, the people paying for it.

I get e-mails every few days from people aren’t getting the update blasts any more. I’m still sending them, so if you aren’t getting yours, your e-mail server is rejecting them as spam. I can’t fix that on this end, but you can contact your e-mail administrator to ask to have my e-mail address added to the “white list” of known non-spam e-mailers. If you use Gmail or one of the other free accounts, you can probably set it up yourself. I send HIStalk e-mails at least three times a week and usually 4-5, plus HIStalk Practice is good for two at minimum and sometimes 3-4. if you aren’t getting them, that’s the problem. You can also use the Subscribe to Updates box to your right to add your home e-mail address in addition to your work one since it’s usually the work one that is overly aggressive about discarding suspected spam. I don’t want you to miss anything.

Readers have added several new events to the HIStalk Calendar, which is how they got them listed and linked on the main page of HIStalk (to your right). Notice the cool way the event listings include links, direct links to a location map and weather, options to download to your e-mail calendar, etc. You can submit your HIT-related event for free. Here’s a tip for those doing so: if you click “Check If Recurring,” you can enter the event once and choose the days it covers, which is a little bit easier than making separate entries for each day.

My guest editorial for Inside Healthcare Computing this week is titled A Day in the Life of IT-Visionary Hospital VPs: Laying Out CPOE Benefits to Luddite Doctors. See if you can detect the thinly disguised sarcasm: “One was late in responding because her top-of-the- line hospital laptop had failed after her teenaged son had used it for several consecutive hours of doing Internet research for a school project in his locked room, necessitating a call to the VP-only IT support hotline so that a technician could be dispatched to her house on a Friday evening.” The publisher tells me that 88% of readers like my stuff there, with 12% chiming  in with the person who wants them to get rid of me and my “clever cynicism.” I was hoping for at least a 40% disapproval rating as validation that I’m stirring people up enough.

Origin Healthcare Solutions adds patient payment collection tools to its Origin Manager practice management system. I couldn’t follow the references to Connecticut and SSIMED, but anyone interested in that news will probably know what it means.

Jobs: Business Systems Analyst-Pharmacist, Laboratory Requirements Analyst, Regional Sales Director.

In the UK, the entire 26-member EHR team at Royal Berkshire NHS Foundation Trust has been let go as the hospital breaks away from NPfIT and implements Cerner via its vendor, UPMC (yes, a non-profit US hospital is also UK vendor, as confusing as that is). They can apply for one of 19 available one-year contracts. In the meantime, since Pittsburgh’s infrastructure is crumbling because of a billion dollars’ worth of debt, entrenched unions, a declining population (even smaller than what’s left of New Orleans, which is actually growing) and a plethora of big-income organizations that don’t pay taxes, the city is considering surcharges on its hospital admissions and college students, which would hit UPMC directly other than it will probably just pass it along in one form or another.

GetWellNetwork announces several new clients for its PatientLife System for patient engagement, including big names Florida Hospital East Orlando, Children’s National, Miami Children’s, and several Adventist facilities.

Don Miller, MD, founder of prenatal care system eNATAL, e-mailed to mention to tell me that the company has several iPhone applications for obstetrics in Apple’s App Store. The application itself is sold in an interesting ASP pricing model: OBs buy “tokens” that are good for one per pregnancy. Here’s what Don had to say about certification: “eNATAL is not CCHIT-certified, never will be, and highlights what is wrong with CCHIT certification. eNATAL is an affordable niche EMR that adds tremendous clinical value, improves patient safety, incorporates clinical decision support functionality that the ‘big boy’ EMRs only dream of, saves money for all healthcare stakeholders, and is used in a ‘meaningful’ way every day across the country. But our subscribers will not receive a nickel from Obama for its use.”

More on the government of the Philippines investigation of who spilled the beans on the rumored leaky breast implant repair of its president: the National Bureau of Investigation is interrogating employees of a hospital that it claims asked for government help to make sure its employees didn’t breach patient confidentiality.

Hospitals in New York State have readmission rates that are much worse than average. The local hospital association (trade group) blames poverty, but didn’t offer an explanation of why Harlem Hospital Center excels and IT-loaded and $3 million CEO-led Montefiore Medical Center lagged.(I noticed while snooping around Montefiore’s federal records that even its chairman of dentistry makes $1.7 million a year, which seems absurd).

Medical Center Hospital of Odessa, TX says implementing its $6.2 million McKesson CPOE system will be a “massive, difficult project,” but its seems eager to snag $5.4 million of that amount from us stimulating taxpayers. A good line from the CFO about the CIO: “I’m looking forward to the day when we have a meeting when Gary [Barnes] doesn’t speak.”

A Canadian medical malpractice jury awards more than $5 million to a man who suffered injuries from spinal tuberculosis after he ignored his radiologist’s urging to come back for more tests to investigate problems he’d spotted. The judge found the patient 30% liable as punishment for not cooperating, but made the excuse for him that he was probably to busy to follow the doctor’s advice. The hospital says it has since implemented software that will prevent misfiled records and miscommunication.

Florida-based Metropolitan Health Networks chooses eClinicalWorks for its nine internal medicine offices.

Microsoft tries to use an Obama-like pitch to get people to “join the movement” and sign up for HealthVault on its I am Enabled site. It’s loaded with the usual cliche Facebook, Twitter, and YouTube connections. Jerry Seinfeld isn’t mentioned.

Speaking of which, I think spammers are going to kill Twitter if it doesn’t die of natural causes before they can do it. It seems like most of the new followers are just the same old pests who nearly ruined e-mail.

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iPhone for Clinical Data – A Different Approach
By Mark Moffitt, MBA, BSEE

Many hospitals are using the iPhone as a tool for physicians to view clinical data. There are two ways to integrate the iPhone with an EMR:

• Buy a package from a vendor to display clinical data on the iPhone.
• Build a Web-based or native iPhone application.

The first option is the most common approach. Benefit: no development costs. Disadvantage: limited ability to customize the application to an organization’s specific needs.

We elected to build a Web app for the iPhone because we wanted to customize the solution to our needs and did not have funds to purchase an application from a vendor. Some of the features in our iPhone web app include:

• Sign on with four-digit PIN using large numeric virtual keypad (see image) versus entering username and password on the iPhone virtual keyboard.
• Lab data displayed as three most recent values in a simple table (see image). Lab tests grouped using common categories.
• Select and play a radiology dictation when viewing a patient’s record.
• Rounding list defined and built to physician specification. Physicians can add and delete physicians in their group using the iPhone.
• Length-of-stay information from our Case Management and Bed Tracking application, also written in-house.

It’s the subtle features that make the difference in user acceptance of software. This is especially true in healthcare for reasons too numerous to list here.

For example, physicians don’t like entering their username and password on the iPhone’s virtual keyboard, an approach many vendors use. Using the virtual keyboard takes a certain touch that is difficult for some physicians to master. We built a security feature that ties a specific iPhone to a specific physician to a specific PIN they choose. The PIN is only valid on the physician’s iPhone and is entered using a large, virtual numeric keypad that mimics an ATM. Users need only enter their four-digit PIN to log in.

The ability to ask physicians, “How would you like it to work?” versus “This is how it works” makes the difference between good software and software that physicians accept. This can best be accomplished by building the front end custom to your needs. While building software is harder and more difficult (for IT personnel) than buying vendor software, the ability to build initiative, easy-to-use software makes training, implementation, and support much easier. And the extra effort makes it much easier for the user to incorporate into their work.

It really is that simple. And why “generic” software requires much more training and process redesign than custom software. Another advantage of build versus buy is we can continue to deliver applications without being dependent on available capital dollars.

Future plans include using the iPhone with the Web app to record dictations and use of the iPhone for eMAR.

Mark Moffitt is director of information systems at Good Shepherd Medical Center of Longview, TX, proof that you don’t have to live in a big city to innovate in healthcare IT.

Meaningful Use Criteria Comments
By Arlen Dominek

I thank the members of the Health Information Technology Policy Committee and, in particular, the members of the Meaningful Use Work Group for their time and effort. I would like to provide my own comments upon the draft presentation of Meaningful Use.

I think that it will be very difficult for all ambulatory and acute care provider organizations to implement an EHR by 2011 simply because of ramp-up time and change management considerations. It takes time for an organization not only to put together an implementation team, but to ensure that the appropriate governance structure is in place. The organization must also formulate a clear focus of where it wants to go, a plan for how it’s going to get there, and how it can assess its progress in getting there.

The organization must identity the members of the implementation team. Often, the organization must recruit additional personnel or retain consultants. In addition, there is training to take into consideration. Equipment must be ordered.  Appropriate telecommunications must be in place.  Interfaces must be implemented. In addition, simultaneous implementations of ambulatory and acute applications by a delivery system can be onerous, yet a certain amount of collaboration is necessary to promote maximum utility.

Vendors will have constraints as well. Many vendors are running very lean implementation organizations today; this minimizes the number of implementations that any one vendor can support at a time. It’s no different than any other manufacturing environment;  there are capacity limitations. Moreover, any rapid implementation cycle provided by a vendor should be carefully evaluated to ensure that the needs of various provider and patient populations are being adequately met.

It’s one thing to provide content satisfying a general med/surg model, quite another to meet the needs of a pediatric BMT program. Rapid provider adoption of workflows and clinical documentation applications will be effected if provider needs are considered during the initial build of content and workflows. Workflows should be designed to meet the particular needs of the provider, e.g., a diabetes clinic or a nephrology clinic. Such consideration can minimize costly re-engineering at a later point and contribute to the success of an implementation.

Hence, Meaningful Use criteria should:

• Be sensitive to the ability of an organization to initiate its EHR implementation and in meeting Meaningful Use criteria, that is, no organization should be penalized because of implementation delays that are out of its control or the population it serves has minimal broadband connectivity;
• Be cognizant of ramp-up time;
• Reflect the maturity of any particular implementation, for instance, if evidence-based order sets comes two years after CPOE implementation, then the criterion should reflect the stage of a particular implementation and not simply a calendar year.

CDS at the point-of-care is somewhat ambiguous and restrictive. Are we referring only to those kinds of CDS that present during CPOE or are we also considering alerts which reflect changes in patient conditions and availability of new data to alert a provider and inform a decision? 

Meaningful Use calls for the capture of clinical data that can be queried and trended. I can appreciate the issue of data capture with which the Work Group has contended;  however, I feel that the objectives have minimized the value of these data and other data for data warehousing and analysis as well as for interoperability through such mechanisms as ELINCS. Hence, such data should utilize standard classification systems such as LOINC, SNOMED, and ICD-10CM to support data warehousing and analysis. Such requirements should be clearly called out so that provider organizations and vendors will incorporate this into their project plans.Such classifications are essential and often mandatory for reporting to quality, epidemiological and public health agencies and to various registries.  Meaningful Use should clearly call this out.

Moreover, there is far more information within a patient chart that could be subject to further structure and encoding. The use of standard classification systems or languages should be implemented so there is a consensual, meaningful and useful framework which governments, providers and consumers can use as a common language.Internationally endorsed classifications facilitate the storage, retrieval, analysis, and interpretation of data. They also permit the comparison of data within populations over time and between populations at the same point in time as well as the compilation of nationally consistent data. (http://www.who.int/classifications/en/) It appears to me that CCHIT and vendor organizations have avoided the issue of incorporating standard classifications or the usage of common classification languages.

Our goal should be to maximize the value we obtain by automating CPOE, clinical documentation, and result reporting.

Order sets are often viewed as provider productivity tools and are conducive to provider adoption of CPOE. Considerable effort is entailed in adopting and implementing evidenced-based order sets. The effort to implement an organization’s existing order sets only to be followed within two years by the adoption of evidenced based order sets is considerable.Perhaps such adoption should be moved up in the timetable.Reimbursements and grants should reflect the licensing cost of evidenced-based order sets. Available evidenced-based order sets tend to focus on medications;  however, standard classifications would encourage incorporation of evidenced-based data for other procedures such as radiology and laboratory.

Multi-media support capabilities are existent in many commercially available EHRs. Perhaps this objective could be moved to an earlier year.

The Meaningful Use Matrix calls for the use of bar coding in medication administration, yet it does not call for the bar coding in the administration of blood products or for positive identification of patients on whom procedures are to be performed, e.g., specimen collection. While CCHIT addresses medication administration in its category Decision Support for Medication, Immunization, and Blood Products Administration requirements, there is no mention of similar functionality for blood product administration, etc. It’s important that Meaningful Use expand beyond current CCHIT requirements and vendor offerings.

It’s admittedly difficult to elaborate workflow efficiencies, but there are some examples

• CDS for administration of immunizations and blood products and positive patient identification as mentioned previously.
• Use of commercial databases to quickly inform the provider whether a medication or procedure is covered by a patient’s payor, thereby reducing time spent in remediation or in losing revenue.  (And payments should reflect the expenses of these databases.)
• Reduction of labor costs in collecting specimens and increasing patient satisfaction by reducing needle sticks when a central line is available.
• Centralized coordination of appointments.
• Automated patient referrals.
• Improved patient satisfaction when the provider has the patient’s information at the right time and place.
• Improved transfer of information between providers.

I apologize if any of my comments have been redundant or because of my failure to notice their having been addressed elsewhere.

Arlen Dominek is practice director at Peer Consulting of Mercer Island, WA.


Subrogation
By William O’Toole, O’Toole Law Group

Regarding the SubroShare(R) press release, Mr. HIStalk was understandably a little off in his assessment; this is not about a policyholder suing the healthcare provider. It is all about personal injury claims.

Subrogation is a legal remedy that enables an insurance company to recover amounts it paid for the care of its customer (the injured patient) in situations where the patient also receives payment covering the same services from a third party (the one that caused the injury to the patient and was sued by the patient).

The key here is the third party. There must be some other party that caused the injury to the patient and from which there is the possibility of payment resulting from a lawsuit (damages) or settlement of that lawsuit.

I will go out on a limb and state that I cannot imagine any health insurance policy not having a subrogation clause. Whether or not attorneys have an obligation to inform the insurance carrier of secondary (duplicate) payments is irrelevant, because where there is a subrogation clause, there is also the obligation for the insured patient to inform the insurance company that the patient’s injuries were caused by a third party, thereby raising the flag for the insurance company.

That said, unfortunately there are those patients that do not, and processes are not always what they should be and some claims "fall through the cracks" and are not identified properly up front. Consequently insurance companies are left to hunt down reimbursement in these situations.

What I believe SubroShare(R) offers is a method to assist insurance companies in identifying situations where they may recover, through subrogation, some payments made on a patient’s behalf.  The trigger seems to be the request for the patient’s records by an attorney, which might mean third party involvement in the patient’s injury, and consequently might mean the possibility of payment to the patient directly for services already paid by the patient’s insurance company.

William O’Toole is founder of O’Toole Law Group, Duxbury, MA.

Provider Profitability
By Dichotomous Dweller

I watched with sardonic amusement as a whopping 19% of readers voted that healthcare providers are sandbagging on IT to keep the public from seeing how profitable healthcare delivery is. Really? 19% of people who read this site think that patient care plays second fiddle to profitability when it comes to EHRs?

Given the way the question was phrased, I’m supprised the number was so high, but then I think the poll question missed the point, so maybe others saw through it as well. Some better questions might have been:

• Do you believe that profitability (here defined as free market economics) enhances or threatens the quality of healthcare received by the general public?
• Do you believe that healthcare providers are have a vested interest in keeping the public from seeing how profitable healthcare delivery is?

There are lots of trick questions like these, but the answer is always both ‘yes’ and ‘no’.

The simple truth is that a dying person will usually give their last dime for a shot at one more day. Healthcare in these circumstance is every man for himself. If you are sick or dying, you’re not going to mind that the person in the bed next to you is subsidizing your stay at a rate of $100 per tablet for over the counter drugs or 33% year in income taxes. Profitability can be created by reducing costs as easily as by increasing sales, but in these circumstances, money doesn’t mean much.

Do you really think that there aren’t people profiting in healthcare from deals that they’d rather the public not know about?  (Thank god we have people like Mr H to keep us up to date on the salaries of major ‘non-profit’ executives). But why stop there? What about those doctors with lucrative research deals with pharmaceutical companies, or pharmaceutical companies who perk doctors who use their products? 

Now I have no idea if such profiteers are going to be exposed by EHRs.  Indeed, it seems EHRs can be their own unique breed of profiteering. But let’s be honest, we all know people who profit from healthcare, and no matter what happens next, single payer, socialized medicine, co-ops, EHRs, RHIOs, status quo, bankruptcy of Medicare, etc., there will always be people profiting from healthcare.

The real question is: is it fair? And it is this question, no matter how simply stated, that we can’t possibly come to agreement on. So we’ll let the market decide for us. I bid 10% of my salary. And rising.

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From The PACS Designer: “Re: Palm Pre. Since the Palm Pre has employed its own Web operating system called the Palm webOS, TPD thought it would be good to give HIStalkers information on this new application. O’Reilly Media has posted the first chapter of a new book to the web on the Palm webOS covers some of the basics for this new system.”

From VSM: “Re: HITECH lawsuit. The supposed nurse (could not find evidence of license) who has filed a suit against Obama and HHS Secretary for HIPAA privacy violations due to HHS requiring EHRs has a history of legal issues. Her husband is a plaintiff’s attorney. See the court documents on their bankruptcy filing.” She’s licensed, according to the New Hampshire nursing database, and I don’t think her previous suits are relevant. It will be tough to prove her claim (warning: PDF) that HITECH is illegal because it forces disclosure of medical information from patients not on either Medicaid or Medicare. The suit’s claims wander all over the place, reading like a wacked out conspiracy theory rather than a serious challenge and making it less viable, I suspect.

From Joy: “Re: poll showing most readers don’t think providers are resisting IT to hide their profits. Isn’t this group of HIStalk readers already biased as medical and hospital informaticians?” Yes. But, we know the real reason hospitals aren’t adopting IT: they aren’t all that competent and confident about it. Still, when it comes to connecting to the outside world, I would guess that a fair number of practices and hospitals would be worried about outsiders seeing information like how much they charge and how much they make.

Listening: 10-year-old Britpop from The Charlatans.

Some calling himself or herself THR-IS Staffer left a scathing comment on Ferdinand Velasco’s interview that I deleted. It was curious for three reasons: (a) it was the only negative comment posted; (b) it was quite nasty and personal; and (c) the electronic footprints indicate that it actually came from someone inside arch-competitor Baylor Health. I like catching would-be scammers in the act, which I believe I just did.

SRSsoft bags another customer willing to drop their CCHIT-certified EMR in favor of the SRS hybrid EMR. Southeastern Orthopedic Center thought they were good to go with regard to HITECH, but says, “The CCHIT EMR we had purchased would have placed overwhelming demands on our physicians and resulted in a significant loss of productivity, even if we had overcome the initial implementation hurdles.”

A nurse poll finds that 50% would not want relatives receiving care at their workplace, 72% think staffing on their unit is inadequate, and 53% are considering leaving their jobs, most often because of staffing problems.

Emdeon, gearing up for its IPO, acquires claims processor eRX Network LLC.

Vince Ciotti is arranging a November get-together of former SMS’ers to celebrate the 40th anniversary of the company’s founding. The shindig is aimed at those who worked in King of Prussia in the 1970s, but Vince says the Malvernians who don’t mind listening to “what I did in the big war” stories are invited as well. Full details, including some cool old customer newsletter scans, phone lists, etc.

Bill O’Toole will have to explain this healthcare-related lawsuit product to me since I don’t understand it even after reading the press release and the Web site (and unless “subrogration” is in your lexicon, you won’t understand it either). It seems to be related to insurance companies being able to find out which policyholders are planning to sue providers and to get their attorney contact information. I’m sure the people who might use it would understand the description, so this is my gift to all of those folks reading.

A study of VA data finds that abnormal CT findings are often recorded in the EMR a long time afterward, if at all.

Detroit Medical Center connects to an HIE whose bizarre, contrived, and entirely forgettable name could have only come from a committee of clueless marketing people: my1HIE(R). I’m including the provided italicization to make sure you see just how weird it looks in print. Maybe it’s the same perky, brand-obsessed bunch who decided that GE-owned The Sci Fi Channel would be much more of a hot property if it “relaunched” itself as Syfy. This quote from the Syfy (gag) president should really wow its entirely geeky audience: “We really do want to own the imagination space … It made us feel much cooler, much more cutting-edge, much more hip, which was kind of bang-on what we wanted to achieve communication-wise.” They’re even mimicking GE’s “healthymagination” assault on grammar, coming up with the radical variant “Imagine Greater”, which it says is “a call to action … an aspirational, optimistic message about enhancing people’s lives.” That’s asking a lot from ancient reruns of Battlestar Galactica and Mork and Mindy.

I don’t have the records to look it up, but I wonder if Barry Chaiken is the first HIMSS board chair who works on the vendor side of the fence instead for a non-profit hospital? I’m not sure how I feel about that.

Kaiser’s Health Care Innovation Center in the San Francisco area gets a mention in the Fort Wayne paper for some reason. I think someone invited me there once, so maybe I’ll check it out one of these days.

Another use of Twitter: selling “medicinal marijuana”, including home delivery (driver tips are appreciated).

In the UK, the conservative party says they would dump NHS’s Connecting for Health and replace it with HealthVault, Google Health, or other online services. “This is an agenda we are massively keen on. We’re thinking about how in government the architecture of technology needs to change, with people ‘owning’ their own data, including their health records.”

A reporter in the Philippines says the government there is monitoring his activities after he wrote a newspaper story last week claiming that the country’s female president had breast implant repair surgery.

Merge Healthcare announces preliminary Q2 numbers: revenue up 13%, net income less than $1 million vs. $2.8 million, all complicated by its pending offer to buy etrials and the sale of its equity interest in Eklin Medical Systems.

A former Red Hat VP launches the Axial Project, which will be some kind of open source clinical information delivery system. I’m not seeing any healthcare background among the principals, so we’ll see what they come up with.

Researchers from Carnegie Mellon University (misspelled in the article) have figured out how to guess the Social Security number of people born after 1988, sending their method to the Social Security people with the suggestion that maybe they ought to start randomizing the numbers. A Social Security guy pooh-poohed the findings, saying that the code-cracking suggestion is “a dramatic exaggeration,” but simultaneously admitting that  Social Security numbers will be randomly assigned starting next year.

Sunquest names Patrice Nedelec, previously with AMICAS, as VP of Quality and Regulatory Affairs.

A Canadian woman gets a $3 million jury award for a 1999 incident in which she sat on a hospital chair that collapsed under her, causing her no physical injury except claimed fibromyalgia, an ongoing pain whose diagnosis is entirely based on what the patient says they feel.

E-mail me.

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What are the most important projects you are working on at Texas Health Resources?

The project is our EHR deployment. We’re an Epic customer. We’re in the middle of deploying the EHR. We’re live now with probably close to three-quarters of our beds. We’re a 14-hospital health system.

We’re very busy with the implementation, but we’ve been live at our earliest hospitals for some time. The focus there is more on optimization, really leveraging the EHR for things like patient safety, quality, and core measures reporting.

With some of our newer sites and sites where we’ve yet to go live, it’s still obviously very much in the early implementation focus — getting physicians on board, that kind of stuff. We’ve had the whole spectrum of the maturity of the implementation even within our health system.

You’ve done a lot of work with first-generation systems. Do you find it easier to work with something like Epic or are the challenges similar?

There are similar challenges. Certainly when I worked at New York Presbyterian we were rolling out Eclipsys. Back then, it was definitely very first generation. The systems have matured, so we don’t run into the same kinds of technical obstacles than we did with those first-generation systems.

Largely, what we run into now is more of the cultural adoption issues, overcoming physician skepticism with respect to health information technology and the workflow issues. I think now what’s different compared to the 90s is that there’s a higher expectation for what these things can do. It’s not enough to just be able to deploy systems and get the physicians on board using it. There are expectations for medication reconciliation and core measures that really didn’t exist in the early days of EHR systems. The bar has been raised higher.

As you know from the meaningful use discussion, the bar will continue to be raised, so there are expectations for barcode medication verification and the whole closed loop process and real-time clinical surveillance. Those are the kinds of things we’re keeping an eye on because we don’t have that yet, but we are certainly gearing up to have those things implemented in time for the expectation for meaningful use.

What are the endpoints needed to be to justify the expense and the effort?

They are always moving. [laughs]. Initially, just getting it installed and getting the docs to use it, but now there’s the expectation that it has to meet the Joint Commission requirements and help us with pay-for-performance. The endpoint now is satisfying meaningful use. The bar keeps going up. We’re just trying to stay ahead and chug away. It’s all of those things.

Where we are today is still implementing the system safely and not killing patients, but we want to go beyond that and realize benefits in terms of reduction of ADEs and improvement in operational efficiency. Our challenge is managing the expectation because that doesn’t happen Day 1. It takes time, there’s a learning curve.

Part of our problem is our own success. The more successful we are, the higher the expectation. That’s a bit of a challenge.

You mentioned the tentative definition of meaningful use. What are your thoughts on what HHS has put together?

From our perspective as an organization that has been on this journey for some time, what I like about the meaningful use is that it gives us a framework. It helps us prioritize those things that we may not have yet planned for or that we don’t have in our timeline. Things like automated surveillance, closed loop medication management including the barcode piece, and medical device integration. That helps us argue for funding those initiatives and putting the plans into place so we can get that implemented on top of our existing implementation. That’s helpful.

It’s helpful for us to use that as a yet another lever with our physicians who are not yet live with the system so that we can say, “Here’s yet another message that this is a mandate and we need to be compliant with this stuff.”

On the ambulatory side, the THR, like many health systems, is providing and making available ambulatory EHR solutions, the Epic solution, as a subsidized offering. Many of our physician practices are too small to be able to buy Epic, so we are providing Epic as a sort of ASP model. This is another sell, if you will, for that offering, this moving meaningful use intended and ultimately the stick that’s the penalty for not having an EHR system by after 2015. That’s how we’re looking at it.

Are they helping you justify what you wanted to do anyway or are they taking you in direction you didn’t want to go?

I think there’s a lot of alignment there. We were very fortunate to get on board with investing in HIT early on and defining what our vision should be. There’s a lot of alignment with what came out in that initial draft and the matrix. We’re pretty pleased — I am, anyway — with that initial draft.

Obviously it’s very aggressive and ambitious so all the organizations have come out cautioning about being so aggressive. It will be interesting to see how that shakes out over the course of the next couple of weeks before the next meeting of the HIT Policy Committee. We’re keeping an eye on that, but from our perspective, because we didn’t wait until something like this came out of the Fed, we feel pretty well positioned and, if anything, it helps clarify our future direction.

You’ve worked a lot with CPOE. AMDIS is saying it’s too much to bite off early on in the meaningful use criteria. Where do you think CPOE fits in the overall strategy?

I think it has an important role. A lot of the important benefits of deploying HIT and, more specifically, EHR is dependent on physician participation. A lot of that is based on clinical decision support. The earlier people tackle CPOE, the better positioned they’ll be to realize those benefits.

I can understand AMDIS and others pushing for it to be not quite 2011. Their point of view is that health systems that haven’t yet selected a system, haven’t yet budgeted for it — there’s no way they’re going to be able to be ready for CPOE in 2011. I think that’s where they’re coming from. I think it sends the wrong message to interpret that to mean that you can delay CPOE.

We’re in a market area where our major competitor is deploying an EHR system but not pushing CPOE. They’re deploying basically all the functionality of Eclipsys and then they’re going to go back and do CPOE, which was what David [Muntz] was going to do if he’d stayed here. That was basically the philosophy that we had here, so we had a change in leadership. I think there’s some benefit to that. You can work on the physicians and soften them up while you’re deploying the nursing components and the pharmacy and all that, but you’re not really going to get a lot of bang if you hold off on the physician engagement piece.

Ultimately you’re going to have to do it anyway. That’s how they’re approaching it at Baylor, that’s how we opted not to do it, and if CPOE stays in 2011, they’re going to have to rethink their strategy.

Just before our implementation, I asked our docs how long they thought it would take before we got to universal CPOE, The results fell into a similar distribution as from the recent CHIME survey, with about two-thirds predicting it would take three or more years. The reality is that at our first two hospitals, it took one year, At our third and fourth, 6-9 months. And at the last three, we are achieving universal CPOE within one week of our big bang implementations.

Folks are being paralyzed by a handful of failed implementations when there are scores of successful implementations at community hospitals throughout the country. Healthcare needs to get beyond this fear factor and move forward with meaningful use. Yes, this is challenging, but we can’t afford to sit still.

What are the secrets of implementing CPOE?

Physician leadership. Getting some really influential thought leaders behind the initiative, buying into it, participating in the design process, being early adopters. These are the things we did and I think we’ve been very successful.

All seven of our hospitals that are live have essentially universally adoption of CPOE, including our most recent three hospitals, which basically went mandatory CPOE on their own accord. We didn’t as an IT department or hospital administration really push it. It was the physicians themselves saying dual workflow isn’t going to work, it’s unsafe, let’s get on board early. We basically had that Day 1 with these go-lives.

I couldn’t be more pleased. I’m really quite excited about where we are with getting the physicians on board. Obviously you have to have a good system and a good build, but if you don’t have the physician leadership, all of that is really secondary.

You’ve worked with a lot of technologies such as Microsoft Surface. What of those technologies have the most promise to improve patient outcomes?

The iPhone certainly seems to be the most promising in terms of the handheld platform. It seems to be the best form factor. I’ve done some work with the tablet PC and it’s got some promise, but I really think the iPhone may be the next killer technology for healthcare.

Are you seeing pressure to have applications reconfigured to be optimally used with the iPhone?

Yes. We’re applying that pressure. We’re putting pressure on Epic to do that. Meditech has a nice iPhone client. A few others may have some as well or in development. A lot of physicians have iPhones. There are a number of medical apps for the iPhone. It’s a compelling device for use at the bedside or at the point of care. It’s a ubiquitous kind of thing — you can use it anywhere. I’m very excited about it.

Are you building anything for the iPhone or looking at other applications that physicians want for it?

We have a physician portal that’s Web-based. It’s the access point for Epic and other clinical applications and other hospital-based resources. We definitely are planning to build an iPhone-compatible portal.

We have a couple of applications that we have deployed that are iPhone-based. For instance, our fetal monitoring system. We have several physicians using the iPhone client that allows you to see that wherever you are. We obviously have Epocrates and an assortment of electronic resource that are available through the iPhone.

We have an internal development shop and we’ve done some add-on work on top of Epic, some calculators and other value-add applications that are launched from within the Hyperspace platform. We’re looking to see if we can port some of those applications to the handheld for the iPhone. That’s all future stuff. It’s not live yet.

Let’s say a well-funded startup came to you and said, “We’ve got money, backers, and technology. We’re ready to build applications that the healthcare market needs. What should we build?” What would you tell them?

Since it’s very top of line for me and we’re struggling with it, core measures and the submission of quality data. That’s the 2013 criteria right now for meaningful use. That would probably be something that would be an attractive offering. More generally, just BI tools, analytical tools, something to enhance the value of EHR systems.

Unfortunately, most of the EHR vendors fall short in terms of being able to provide BI tools. On the other end of the spectrum, you’ve got the Oracles and IBMs. There’s a little bit of a gap between the analytical capability of the software vendors on the one end and the ability of the traditional BI technology vendors that could be filled with a niche player or the EHR and BI vendors coming together in the middle.

So you don’t think Amalga is that product?

I don’t known enough about Amalga. Although we’re a strategic partner with Microsoft, we haven’t had conversations with them about Amalga. I’m somewhat familiar with them because I came from New York Presby, but they are really eclectic as far as all the different systems they have in place. They’ve got the Presby hospital, the old New York Hospital, they’ve got faculty practice plans at each of the medical colleges, so definitely you need an Amalga just to put all that together.

We’re moving more toward the integrated approach, so I don’t know that we really need Amalga. That would almost duplicate what we already have with our data warehouse. But it may be that Amalga has some front-end tools that can help us. To be honest, I haven’t evaluated it enough to be knowledgeable, but from what I’ve heard from our experts on the subject, they would say that Amalga is more hype than reality.

I assume you’re doing a lot with how to manage and use all that data you are now collecting by having physicians directly involved.

That’s a supply-demand kind of thing right now. We have a lot of physicians live with the system and using it. Their appetite and thirst for the data is growing. Our ability to keep up with that is going to be a challenge, particularly since we’re still in implementation mode.

The challenge for us now is prioritization — what do we focus on and where do we place our efforts in delivering this kind of analytical capability. It’s on the core measures and those quality measures that the organization has selected as our key initiatives, things like blood management, glycemic management, VTE prevention, and pressure ulcer prevention.

Our challenge is to keep focused on those things and not get too distracted by people that want information just because they’re curious or they have a localized initiative. We want to focus on those things that have broad value across the entire enterprise.

Now that the federal government is driving much of the IT agenda in healthcare, are physicians and patients in the field being asked for enough input?

I would like to think so. Dr. Blumenthal is a practicing physician. Several physicians on the two steering committees, the advisory committees, are physicians. Certainly there is an openness and transparency to the process so far. It has given physicians an opportunity to participate and comment on the process. I feel pretty comfortable about it.

I come from the perspective of a health organization that is very much in the midst of this. I think there may be challenges with physician practices that haven’t invested in IT and are pretty far behind. They might question whether their voice is being heard. I don’t know that answer to that question, but those physicians in our market area are interested in what we can offer to help them. We’re available to help.

Anything else?

No, we’ve covered quite a bit. I appreciate the opportunity to chat with you about what we’re doing and how we’re working to make the most out of health IT. It’s a very exciting time to be in it. Thank you for your Web site, your blog. It’s been a great resource for all of us. Thanks for the opportunity to contribute.

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