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Monday Morning Update 1/4/10

January 2, 2010 News 14 Comments

calvert

From Ned Flanders: “Re: remote ICU monitoring. Publication bias apparently runs both ways. JAMA rejected a study evaluating the clinical and financial impact of remote ICU monitoring last year because although the results were extremely impressive, they claimed the study had a weak design (before and after) and did not shed light on the actual reasons why remote ICU monitoring helped (since it had already been shown to help). Curious considering the recently published study had the same design and flaws, with the only difference being outcome.” This highlights a little-appreciated reason for not believing everything you read: the most powerful influence wielded by publishers isn’t how they spin a particular story, it’s their choice of which stories to include in the first place. That process has zero transparency to readers, so it’s the most dangerous. The second most powerful is where the piece appears if it is published. The third is how the headline (or abstract) is worded since many people will base their conclusion, consciously or subconsciously, on that alone.

From FinSoft: “Re: QuadraMed. Jim Klein is out – read the 8K from December 30.” This was actually reported by Misys_ex to me in early December, but I always hesitate to run rumors about named individuals unless it’s public knowledge since I’d hate to see my own name in “he’s been fired” speculation (no need to give the boss ideas). Jim was SVP of product management and CTO until his “involuntary termination”. Some degree of executive change is all but mandatory when a company is acquired. Companies don’t generally buy other companies because they don’t want to change a thing.

From Anne Onymous: “Re: HHS rules. For years, vendors charged a fortune for simple interfaces to the systems of other systems. Now, in order to get certified, they have to offer this interoperability. In addition, they may not be able to charge for it! There are no provisions for them to charge for receiving patient data, although there is no mention about sending patient data (I could have overlooked it). I predict that in the final rules, certified vendors will have to receive select patient data and respond to inquiries for it from other certified systems at little or no cost. This is reasonable and necessary for patient care. The impact of these rules will be very positive for vendors that provide niche applications.”

statehie

From Downtown: “Re: meaningful use. Awesome summary. Will anyone other than attorneys read the whole thing? With an unusual lack of fanfare, ONCHIT seems to have published a new Web site, StateHIEResources.org. It was registered on the 13th by some Canadians. Now I’m really confused!” I signed up for the listserv and it’s apparently a follow-up to (and the same domain registrant as) the State Health Information Exchange Leadership Forum, run by AHIMA “through a cooperative agreement with the Office of the National Coordinator for Health IT.” The new site has no AHIMA reference. ONCHIT apparently offshored its Web development to Canada.

From ChiSalesChick: “Re: a big EMR vendor I won’t name. They are ‘restructuring’ a lot of their sales people right out of a job.”

From Cleveland Brown: “Re: HIStalk. I was scrolling down the sponsor list yesterday and thinking about how far your little blog site has come in the years that I have been reading. All of your hard work and your integrity surely has brought you well-deserved respect and fame (if not fortune). Thank you so much for producing the one blog that I turn to daily! I do admit, however, that I do not share your site with many of my peers. It is important for my ego to always know more than anyone else and reading HIStalk makes it so.” Lots of readers have confidentially told me they keep their HIStalk reading habits secret for the same reason, which is flattering and amusing. I guess that does slow the word-of-mouth effect, although I note that December’s HIStalk visits were up nearly 40% year-over-year, which is closer to shocking than merely surprising since I keep figuring that anyone who cares has already found it.

jama

Speaking of the remote ICU article, thanks to the reader who sent over the JAMA full text article. The article by a University of Texas Medical School associate professor looked at mortality, complications, and length of stay before and after implementation of Philips VISICU in six ICUs in five hospitals (in a single health system) from 2003 to 2006, using around 2,000 randomly selected patients (about half the total). Hospital mortality dropped a little, but that was not statistically significant after adjusting for severity. There was minimal effect on complications and length of stay. The big gotcha: two-thirds of the patients studied had doctors who allowed the intensivists to intervene only in life-threatening situations, i.e. they were not really letting the remote intensivists manage those patients. Also: the hospitals did not integrate their CPOE and progress notes into VISICU, so all the intensivists had to work from was a daily fax (note the irony that, among all that expensive technology, the only “interface” was a daily fax from one user to another). My conclusions (crediting Smalltown CIO for some thoughtful comments left on my original post about this article): (a) as is often the case, implementation decisions had more impact on outcomes than did the technology itself; (b) you could flip the conclusion around and say that, since tele-ICU had no negative impact, it provides opportunities to maximize use of scarce resources; (c) rural sites could use tele-ICU and keep the patient closer to family members without negatively impacting outcomes (and helping support those rural facilities instead of big academic medical centers); and (d) hospitals buying remote ICU monitoring technology should first see if local docs will support it by letting those remote intensivists do something more than just provide off-hours fire watch coverage.

advancedicucare

Speaking of tele-ICUs, Advanced ICU Care, a St. Louis ICU monitoring service whose 60 intensivists and ICU nurses use VISICU, raises another $2 million of investor money, bringing its total to $12 million.

It’s a new year – time for parades, bowl games, and HISsies nominations. Tell me your thoughts about 2009’s best and worst vendors, the smartest and stupidest vendor moves, and of course the granddaddy of all HIT industry awards: your choice for “HIT industry figure in whose face you’d most like to throw a pie.”

Another New Year’s tradition: newspaper profiles of the local hospital’s first baby of the year, which as I annually note, seldom involves married parents.

Listening: Boston-based Lyres, which sounds like the Animals or Seeds time warped from a 1960s garage into the 1990s with their Farfisa organ in tow.

muxls

HHS didn’t make its proposed Meaningful Use standards easy to work with, scattering them over two verbose PDF files (they didn’t exactly lead by example when it comes to discrete data and interoperability). I pored over the documents again in my usual nerdy New Year’s Eve (while watching some guy doing an Evel Knievel-style car jump on TV and all three hours of Rush in Rio) and put the actual criteria and thresholds into a handy-dandy Excel worksheet (note: it looks crappy in the preview, but perfect once you download). It spells out the provider parts of the MU requirements in concise detail. Certification and payment specifics means nothing if you can’t look down this list and nod your head that, hey, we can do all this stuff on the computer. Let me know of any additions or changes. I numbered the criteria just for reference, but it’s a made-up number.

Some thoughts on the proposed Meaningful Use criteria:

  • I’m trying to figure out who the big winners will be if these criteria are approved. Consultants for sure. Companies like RelayHealth that provide eligibility, claims, and information exchange services. Companies that can perform a security analysis. Vendors that offer a usable medication reconciliation function. Vendors with patient portals. Companies that can help put vital signs information directly into the EMR.
  • Losers: EMR vendors already strapped to pay for CCHIT certification who now have to cough up another million or two to meet the additional requirements. That’s another blow to small and innovative vendors who aren’t raking in the cash, meaning the market tilts even more in favor of the older, bigger ones whose sales were so limited that the government decided to intervene in the free market in the first place. Market consolidation is probably good, but I expect the development agenda will now be even more driven by Uncle Sam, not users (especially since the HITECH sales window is small, so even sales-driven innovation may dry up once everybody has chosen their dance partner).
  • Lots of folks, me included, expected the criteria to be a slam dunk for moderately tech-savvy hospitals and practices. Not so: considering the small percentages of them using CPOE and e-prescribing, the minority that can provide electronic copies of information to patients, and the small number of practices that can provide patients with fast access their online health information, the these are stretch goals. I bet those requirements will be dialed back in the final version for that reason.
  • Good luck with providing the denominator number for the reimbursement measures. You will need to know the total number of prescriptions generated, the number of orders issued, and the number of episodes in which medication reconciliation should have been performed. The document indicates an estimated time to generate the denominator at one hour using the EMR’s capabilities, which is surely a mistake since the EMR doesn’t help you count paper orders.
  • The CPOE requirement is generous to hospitals, which have been screwing around since the 1980s trying to get doctors to use CPOE with dismal results. They are required to hit only 10% CPOE usage since “CPOE is traditionally one of the last capabilities implemented at hospitals.” (like, decades after buying it?) Practices, most of them considering their first EMR in a quick ramp-up to earn HITECH money, need 80% usage right out of the gate. I expect changes here, too, with the hospital target raised and the practice one lowered.
  • With the minimal CPOE usage required for hospitals, the five required (and undefined) clinical decision support rules won’t have much impact on patient outcomes.
  • The report cites a pseudo-fact that, “Some vendors have estimated that EHRs could result in cost savings of between $100 and $200 per patient per year.” Vendors say a lot of things, but I believe only those that are enumerated in a contract, preferably with rewards or penalties to encourage backing up self-serving statements with risk. I’m not sure I would have included that stat.
  • The report used the high estimate of EHR cost from a range of $25,000 to $54,000 per provider, stating that “we believe the cost of such technology will be increasing.” Why should software costs increase when user bases are increasing, which should allow vendors to spread their fixed software development costs over more users? The only one factor that would raise the price is the vendor cost of complying with certification requirements (government meddling in free markets never comes free).
  • That higher upfront EMR cost makes the elusive $44K jackpot even less enticing. Doctors were already avoiding EMRs because of cost and negative workflow impact. Providers are questioning whether they can qualify for the incentives and whether they trust the government to pay them.
  • Conclusion: if you like the idea of having the government use taxpayer money to encourage the use of specific products in the pursuit of lofty and possibly unrelated goals, this at least pushes some theoretical behavior change in the users who choose to participate. If you’re a provider trying to decide whether the government money has too many strings attached, this might convince you that it does. And if you asked me how the odds of high EMR utilization changed with the release of these proposed requirements, I’d say they got worse.

poll010209 

Apparently we are not collectively certain that Epic is a proven solution for acute treatment of seriously ill patients, at least based on the results of my last poll. A new one to your right (or lower left if your screen resolution is set low): are the initial Meaningful Use criteria too easy for providers to meet, too hard, or about right?

I love this newspaper article because it reminds me how shocked I was the first time I saw what it describes first hand: the person in scrubs assisting a surgeon performing an OR procedure is sometimes an unlicensed salesperson of the medical device being used. In addition to the skilled medical personnel in the OR, “at the foot of the operating table, there’s Chuck Bates, a guy who studied biology in college and always wanted to go to medical school but never did. Instead, he began his career selling hot dogs to grocery stores. As the surgeon prepares to make an incision, Bates stares at the X-ray monitor. Come up one centimeter and make your incision there, Bates tells the surgeon.”

This is what the lure of taxpayer-funded EMR Welfare has done. An Indiana group holds its first planning meeting about applying for $15 million in federal HIT money (the Beacon Community Program) even though the representative of the only hospital involved (and the main beneficiary of the grant) skips the meeting because he’s on vacation. Their application is due January 8, so they met without him. The county health department director figured the financial windfall would be nice, but low EMR provider usage makes the group a pretty poor EMR beacon for the country to follow: “It’s been a real struggle. The hospital’s computer system has been crap. I’m not sure it is even 15 percent, let alone 25 percent.”

E-mail me.

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Currently there are "14 comments" on this Article:

  1. Regarding Downtown’s comment for the new ONCHIT website, What is wrong with employing web developers in the U.S.? Blumenthal is obviously in bed with AHIMA and HIMSS, “run by AHIMA ‘through a cooperative agreement with the Office of the National Coordinator for Health IT.'”

    HHS has billions of dollars to spend on EHRs in the U.S., but they outsource to an offshore entity its website development? The U.S. govt has put a halt to getting prescriptions from Canada to save U.S. taxpayers some money, especially in this recession, but feels it is acceptable to give Canadian’s jobs while unemployment rate continues to sky rocket in the U.S!

    HIMSS uses U.S. tax payer money to fund their International conferences. Now the govt is sending work abroad. UNBELIEVABLE!

    Sounds fishy and CORRUPT. We demand an explanation from ONCHIT and AHIMA (and HIMSS).

  2. Oh yeah, loved this one:

    I love this newspaper article because it reminds me how shocked I was the first time I saw what it describes first hand: the person in scrubs assisting a surgeon performing an OR procedure is sometimes an unlicensed salesperson of the medical device being used….

    A friend of mine is in Ortho sales (screws, nails or other ortho hardware) confirmed one day that he’s in the OR everday. Spent 3 weeks watching videos and reading for training and now advises his physician customers on “best practices”. Another motivation to stay healthy!

  3. Rust Belt Fan states: “Spent 3 weeks watching videos and reading for training and now advises his physician customers on “best practices”. Another motivation to stay healthy!”

    What is wrong with that? At least someone suipposedly knows the device. Is that not how the HIT companies train their travelling on site experts who teach the doctors during the “go live”? Of course, these CPOE experts are not in the OR, but they show up in the coronary care units.

  4. Your comment about the person in scrubs assisting a surgeon performing an OR procedure is sometimes an unlicensed salesperson of the medical device being used brings back fond memories. I worked for a company that sold cryosurgical devices to ophthalmology. They worked in the same manner as as puting your tongue on a frozen peice of metal. Your tongue sticks to it (i.e. the movie “Christmas Story”). The physician would slice the sclera around the cornea, raise the flap, and apply a frozen probe to the cataract. The lens would stick to the probe, the physician would wiggle it a bit and viola – out comes the Crystalline Lens. With my very adept instruction at the side of the ophthalmologist, the surgery was successful… I was a marketing major.

    Today, I have friends that are in sales that do exactly the same with lasers. They were football players in college.

    What a country..

  5. On salespeople in OR’s:

    When I was fifteen years old I attended a summer NSF-funded Advanced Preceptorship Training Program at a large hospital in the early 1970’s. It was a program designed to introduce high school students to bmedicine. I was assigned back then to watch surgery under a general surgical team. I was permitted to scrub in and hold retractors, and in one case to actually saw through a femur in a leg amputation for diabetes-related gangrene. I also made rounds with the surgical team. While today this practice would probably not be permitted on privacy and malpractice concerns, I can honesty admit I offered no advice on surgical procedures or other interventions. I simply didn’t have the background.

    These “salesmen in the OR” cases raise some questions:

    * Were patients and others in the O.R. aware of the lack of the sales representative’s medical credentials?
    * Are consents sought and signed routinely for allowance of medical device company reps in the operating theater?
    * What, exactly, was the purpose of having a nonmedical person in the O.R.? What, exactly, could such a person contribute?
    * Why would any patient want a nonmedical person in the O.R. with the potential for that person to give advice or affect the procedure in some manner?
    * If a consent was signed, what were patients told to convince them to sign the consent?
    * If advice was given of any kind to any clinician in the O.R., would that not constitute the practice of medicine without a license?
    * What were the rep’s obligations if they witnessed anything they thought could be misuse of the device, or any other practice they thought improper?
    * Did the rep follow the surgical team around in postop care?
    * Why couldn’t the companies actually hire people with medical backgrounds for such roles?
    * Might people with medical credentials and experience actually be better suited to make valid scientific observations in the O.R. setting?

  6. If greater than 50 percent of the cost of an EHR is labor (it is) and the amount of EHR functionality is increasing over the past (CPOE, patient portals, more interfaces) then the average cost of an EHR implementation is bound to increase.

  7. BlueDogSpirit Says: “HHS has billions of dollars to spend on EHRs in the U.S., but they outsource to an offshore entity its website development? The U.S. govt has put a halt to getting prescriptions from Canada to save U.S. taxpayers some money, especially in this recession, but feels it is acceptable to give Canadian’s jobs while unemployment rate continues to sky rocket in the U.S!”

    At least Canada contributed substantially to the bailout of GM and Chrysler. What’s even more disturbing is that almost all HIT Vendors that are going to be benefitting from the Hitech Act (our taxpayer dollars) outsource a large portion of their software development to China and India. Sorry, but I’m a lot more miffed about that.

  8. Re: Apparently we are not collectively certain that Epic is a proven solution for acute treatment of seriously ill patients

    It would be useful to know what percent of each vote categorey was represented by vendors /consultants /end users (hospitals).
    I think there must be a built in bias…

  9. Loved your distillation of the Meaningful Use Criteria documents into a simple (?) spreadsheet. Reminds me of RFP’s we used to respond to in the defense business. As in that industry, success in the healthcare records / analytics business will, I imagine, be heavily weighted to those firms who can apply cadres of professional analysts (i.e., marketeers) to demonstrate how their products meet the criteria bullet-by-bullet. I’d be curious to see, bullet-by-bullet, which of these criteria could be realigned to apply to consumers directly, with measures that have specific meaning to patients presenting with specific conditions. Or has the Consumer been overlooked?

  10. You are right on about the MU denominators Mr. H. Don’t worry though, eventually there will be an iPhone app for estimating those numbers!

  11. Anne Onymous wrote:

    >> For years, vendors charged a fortune for simple interfaces
    >> to the systems of other systems. Now, in order to get
    >> certified, they have to offer this interoperability. In
    >> addition, they may not be able to charge for it!

    Hallelujah! This has been a long time in coming. Medical software companies need to understand that interfaces aren’t accessories or add-ons – they’re actually part of the core functionality of the product.

    There’s an article on Healthcare Musings that digs into this idea – that the interface is part of the product – in more depth. Companies that charge for interface work and that can’t interface well are going to face some serious challenges in the months to come. Check it out:

    http://www.gibson-consultants.com/healthcare-musings-october-2009

  12. When you put together the Excel spreadsheet for meaningful use criteria, you have what appear to be additional items listed as ‘a.b.c.’ etc., such as for the smoking question criteria – current smoker, past smoker, never smoked. I do not find these detail items in the proposed rule. Where did you get the a. b. c. detail information from?

  13. Physicians are very busy and pressed by time to see pateints. To add the tasks of them entering orders to the CPOE is not going to increase their productivity. Currently, nurses obtain drs. orders manually and trust their staff to follow through with the order. A trusted and well trained employee can enter drs. orders to the CPOE. Physican productivity in the short run, or even in the long run, may not be increased. If the physician were to become more productive entering orders to the CPOE, then they will have to deal with the transition from ICD-9 to ICD-10, which will definitely impact and reduce their productivity and delay reimbursement as well. With ICD-10, their entire staff’s productivity will reduced. So, why do we hear all this talk about the increase in productivity, better quality patient care, when the physician is already heavily burdened with documentation hoops. I took my mother today for a minor surgery procedure and the amount of time that the nursing staff spent on entering and answering Medicare questions took longer than the procedure itself. In fact, there were two RN’s working on her at the same time. One was preparing her for the procedure, while the other one completed or answered all the questions on the EMR system. Just think, we are only in Stage 1 and entering Stage 2. It’s the back end of Meaningful Use that I am concerned with. Physician liability for business partners that leak or breach PHI and subsequent fines or penalties. What if a patient leaks their PHI, are physicians liable for that too and be exposed to fines? My overall question is that beyond that savings, increased physician productivity, and improved patient care, are we being setup to fail so the next step is socialized medicine? Personally, I think that is the path we are on, think about it.







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Reader Comments

  • Mr. HIStalk: Sorry, I forgot to add the link. I've added it to the post -- it's here: https://www.inc.com/magazine/201706/thomas-g...
  • Clarence: Could someone provide a source for Thomas Goetz's comments?...
  • DrLyle: Love the contrast of Iodine and CoverMyMeds... and the different takes on whether we can use HIT to solve the 3 gambit p...
  • Math: Actually scratch that, those numbers are 2 years old. This time last year they were over 20 million a month. Wonder wh...
  • Math: Well considering all Epic facilities are capable and do 5 million exchanges per month, I can't help but chuckle at your ...

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