Phyllis Gotlib is CEO and co-founder of iMDsoft.

Tell me about the company and your products.

iMDsoft was founded in 1996 after a few years of development. We started with an alpha site in Tel Aviv and had our beta site at Mass General and Brigham and Women’s in 1997. Once we got clearance on our products, we decided to move to Europe and also to validate our implementation methodology.

Our first product was for ICUs. We went to Europe and decided on four different languages and four different countries. We received rave reviews.

Our first commercial installation with ICUs was in Lausanne, Switzerland in 1999. We went into the Netherlands in Dutch, Norway in Norwegian, and of course to the UK in English. Since then, we grew all over Europe, came out with a new product in 2001 for the entire perioperative environment — pre-op, inter-op, and the PACUs. We had a partnership with Fukuda Denshi, second largest medical device manufacturer in Japan, in 2000. We went back to the US in 2002 and set up our headquarters in Needham, MA where I spend most of my time.

Since then, we have close to 150 hospitals world-wide with more than 9,000 beds under license. We continue to grow beyond the walls of the ICU and OR as we expand outside of critical and acute care. We have a new product called MVgeneral that goes to the general floor.

We map the entire inpatient workflow in all these departments. Every type of ICU — all adult ICUs such as neuro, CCU, med-surg, NICUs, PICUs, and the entire perioperative environment, step-down, and general wards. We have supporting products that include MVmobile for ambulances and MVcentral, a tele-intensivist product, and others. All of our products share one database and provide a true continuum of care.

Most US healthcare IT vendors have customers outside the US, but most of their business is domestic. Is it an advantage or disadvantage to have a more balanced international footprint?

I see that definitely as a hedge. We started in Europe because, at the time, the R&D was in Tel Aviv and there was a blend of a lot of languages and people that came from the European countries to Tel Aviv. That was an easier way to start the company.

You can see similarities between territories. You can see similarities between the European market and Canadian market and between the UK market and Australia.

The US is different, but when we do user groups, the US customers are really happy to mingle with the European customers and vice versa. We believe in a sharing philosophy. Our US installed base is really high-visibility and very impressive, with Johns Hopkins, Mass General, Partners, Barnes-Jewish, Henry Ford, and so on. In Europe, we also have high-end academic hospitals, community hospitals, and smaller institutions.

They all like to mingle, to exchange protocols, and to share information. For us as a company, it’s definitely a hedge and allows us to lower the risks and to be able to answer the needs of the different regulations and initiatives in different countries.

You’ve described iMDsoft as a disruptive innovator, but I don’t know that many US healthcare CIOs are familiar with the company. Who are your competitors and what are your competitive advantages?

You will hear me quite often say that it depends on the segment and the territory. I would put them in buckets. The competition can be the old medical device companies like Philips and GE. Another bucket would include the bigger guys, like McKesson, Eclipsys, maybe Cerner. The others would be smaller, software-only companies like Picis. In Europe, in every country you can find a local vendor that is really specific.

You can differentiate the competition into OR competition, perioperative competition, and the ICU competition. But of course, I would tell you that we have very little competition [laughs].

Regarding differentiation, definitely I would talk about clinical data granularity. Secondly, I would say decision support. After that, our ability to customize — the flexibility of our products.

One of our fortes is interoperability. A good example is Barnes-Jewish Hospital. We are integrating and interfacing with eight different vendors. Giving you only US examples, at Lehigh Valley Hospital and Health Network, we have a full integration with, at the time, IDX Lastword CPOE, which became the GE product.

Another key differentiator for iMDsoft has always been our ability to impact not just the quality of care and clinical decision-making for our customers, but also to contribute meaningfully to their level of operational efficiency and resource deployment, and ultimately, to make a positive impact on the financial performance of their critical care department.

When I talk about customer impact, it can come from a number of different perspectives that cut across clinical quality, operational efficiency, and cost savings.

When I talk about clinical data granularity, every data item in our system is a user-defined and controlled parameter. They are stored in a hierarchical manner in the database, which allows them to have sophisticated relationships between them. Those parameters can be time-related or non time-related and can be from any type and they will have attributes … for instance, a formula can be a parameter, a drug can be a parameter, a change in position can be a text parameter, and so on.

A good example is saline solution, where the granularity will go down into water, chloride, and sodium. Every time a user gives one cc of such a solution, every minute you can see the trace elements in our system every minute. For instance, you can check the patient’s potassium minute by minute. These things are very important in critical care, where the patients are not eating or not drinking — they get intravenous nutrition or enteral nutrition and also all the volume that they get from drugs is documented.

A 2005 study I read described the use of MetaVision Event Manager to deliver alerts that are based on physiologic and order information in the ICU and the OR. What are the opportunities there?

It’s a huge opportunity. We hear that from all our customers. The Event Manager was endorsed by Harvard Medical School and by most of our hospitals. It’s a real-time decision support, a rules-based engine that provides alerts that can be clinical, administrative, or financial in nature. They can be delivered to the appropriate person and place as needed via screen, telephony, pager, and so on.

I can give you an example. First, we collect all the data. Once the granular data is in our database, you can then put rules on the data. You can write statements, like if-then statements.

One of our hospitals in the United States — I cannot say the name — conducted a study that showed that a certain generic anesthetic was as good as the brand name anesthetic for longer surgeries. The hospital gets reimbursed for the procedure at a set amount, paying for the anesthetic themselves. They did not have a reliable mechanism to remind anesthesiologists to use the generic drug in longer surgeries.

They programmed the alert to remind the anesthesiologist to consider switching to the generic if the surgery has already been more than X minutes. The statement was very easy. The alert took one day to produce, it took them a few days to test it, and in less than a week it was in production. Over a year, it saved them more than $500,000.

That’s an example of ROI using the Event Manager, but since every data item is a parameter, you can also use it to drive clinical improvements. In another hospital in the UK, they managed to reduce their drug costs per patient from $197 to $149 just by increasing generic usage, from 61% to 81% with MetaVision using the Event Manager.

I could go on and on with examples like that, but it’s actually using all the granularity, all the elements, all the parameters that we have in our very rich database and putting rules on top of them.

What about the use of reminder checklists and dashboards?

Our dashboard actually allows us to see the data in a global view, not only on the patient, but also on the unit. Along the way, we’ve also started implementing entire regions. We recently started an implementation for an entire province in Canada, another province in Australia, and also in Norway. Our dashboard provides a global view of a unit of a hospital, a region, or also something more like a network or province.

The checklist is something quite easy. It’s done all over the system. The entire system is rule-based and you can add alerts and mandatory fields. It’s really comprehensive and has all the functionality that is required to provide best practices and to give guidance.

Most of what I’ve written about iMDsoft involved the lawsuits with Cerner and Visicu over intellectual property involving remote monitoring technology. Did that turn out the way you hoped?

We are actually in the midst of our litigation. However, I can tell you that Visicu recently lost against Cerner for the same complaints and Cerner used our prior art to defend itself. So, I believe we are in very good shape.

A recent study, perhaps not very well done, concluded that remote ICU monitoring did not do much to improve outcomes or reduce costs. What was your reaction to that?

It was ambiguous. I’m never happy to see that the competition is doing a lousy job. If you look at the entire market and you see that we have only 10% penetration, we are beyond the early adopters. I need everyone to do a good job because if not, it will put up additional barriers. I know that we have ARRA, the stimulus, other regulations around the world helping us, but still, we need to do a good job.

So, there was something in my heart where I was glad to see that our competitors didn’t do a good job, but on the other hand, overall, that’s not the right thing.

It is interesting because, from our end, we have a study that shows in our tele-intensivist program, a customer was able to reduce the mortality rate by 30% by using MVCentral in their remote ICU.

You have some of the best hospitals in the US as your customers. Is the US market key to your strategy and if so, how will you get the word out?

Absolutely. I think our customers are our best advocates. We are investing in enlarging our channel distributors in the US and I hope that by the end of 2010, we will be able to have a balance between the rest of the world and the US revenues.

Do you think the stimulus incentives will affect your business here?

I think hospitals in the US will have no choice. The government, the payors, and the regulatory agencies have all begun to link clinical performance to reimbursement. It’s a first in the modern history of medicine. US government initiatives, such as PQRI, the various pay-for-performance initiatives launched by large payors, and European government initiatives have all been in the headlines.

Elected officials see these initiatives as crucial to contain health costs and improve quality of care. We at iMDsoft definitely believe the recent trend will continue and the amount of reimbursement at risk for hospitals will grow.

We see also that clinical data management and protocol enforcement now have important financial repercussions and making clinical information systems for critical care an even higher priority. There is not one CIO that doesn’t have this on his radar. They just need to prioritize it, whether it will be on the budget of this year or next year, but it’s definitely on the radar.

The start that everyone was hoping for the last 20 years is actually happening now, not so much because of the carrot, but because of the stick — the penalties and because it is impossible to manage so much data and so much information that is coming from so many different sources without having a clinical information system.

Final thoughts?

We are excited about what we are doing. We have a vision and a passion here. We are in 21 countries, supporting 18 languages, and hope to expand. We would like to continue to be a innovation leader and keep the level of quality of our products and services as we continue to grow.

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From Nurse: “Re: Community Hospital South (IN). The CEO has announced that the hospital’s problems with GE Centricity Enterprise going back to August will cause it go back to the old GE CIS inpatient system next month. Deployment of Centricity Enterprise is on an indefinite hold.” Unverified, but the e-mail snips included look genuine. Maybe this would have convinced them to stay on: GE Healthcare announces that Centricity Enterprise EMR is now in the ecoimagination portfolio, which the announcement claims was “rigorously tested in-house and by a third party in order to provide optimal satisfaction to GE clients.”

From Kate: “Re: B52s. Who’s having them? I need to crash.” It’s an invitation-only HIMSS event (which I know only because I was invited), so I blurred the vendor name. Cindy and Kate were warbling hotties back in the day, although they are now 52 and 61, respectively, so they may not hop around like they used to. If I were this vendor’s customer and not planning to attend the HIStalk event (whaaaat?) then I’d probably check them out since I can sing along badly with all of Cosmic Thing, especially Deadbeat Club and Dry County, with a few beers in me.

From Zippy: “Re: articles in Racine, WI paper about All Saints. Doctors are not happy with administration and a number may leave.” Doctors and administrators are feuding, with a third of the medical staff ready to bolt. The final straw, apparently, was the hospital’s contracting with a Florida anesthesia company, replacing a local group after failing to reach an agreement about pay, on-call policies, and the use of nurse anesthetists. Also noted as a key issue: the 2009 introduction of an EMR system, which the doctors complain wasn’t well supported.

From Wake Up: “Re: McKesson’s problems. All listed before: HERM cost $150 million and still isn’t ready for prime time, ambulatory and HAC are a shambles, the 10.xxx upgrade is needed for meaningful use, but is painful for customers,and the company likes to replace quality employees with green beans.” All unverified, although I’ve heard them all before, usually from disgruntled former employees. Others have speculated that Pam’s downfall involved ongoing Horizon Clinicals integration struggles, of which ER 10 was an early warning of the challenges ahead (not surprising since all of those apps were developed by different acquired companies, as I remember: Vanderbilt, CliniCom, HCS, and others I’m forgetting). On the other hand, I’ve talked to one HERM site so far and they had nothing at all bad to say, other than to observe that the requirement to upgrade to Horizon Clinicals ER 10 wasn’t clearly stated upfront. I’m trying to connect with a second site.

From Stealth: “Re: Oracle’s Sun Division. I heard an unconfirmed rumor that it’s about to announce that it’s not going to support its JCAPS for EGate interface engine. Has anyone heard this?”

From G-Dog: “Re: articles. I thought this article might be worth discussing on HIStalk.” It covers board certification in informatics for physicians, with the authors concluding that it’s not really like other subspecialties since it covers all other specialties to some degree. AMIA is hoping initial review by ABMS will happen next year or the year after.

From The PACS Designer: “Re: Pogo Stylus. iPhone apps and other new mobile phone accessories keep getting innovative and the Pogo Stylus from TenOneDesign is the latest innovation. You can use the stylus to be creative and design artful stuff. Perhaps, we can get postings from Inga using the Pogo Stylus on her iPhone to entertain us HIStalkers, while Mr. H. uses his BlackBerry to organize HIMSS 2010 entertainment!” It’s $14.95.

The lab division of Fresenius Medical Care North America goes live on McKesson Horizon Lab.

EHRScope releases its Spring 2010 issue (warning: PDF). I really like this publication since it’s a lot meatier than the fluff the rags usually run, with some thoughtful articles and editorials.

This article describes a study in which researchers used CDC’s diagnostic algorithms for acute hepatitis B to search 16 years’ of ambulatory EMR data. It found 112 of the known 113 positive patients, but also detected an additional eight cases, four of which had not been reported to the health department. The next step (obviously) would be to turn those algorithms into real-time alerts.

Duke University Hospital chooses Simplifi 797 IV compounding QA software.

Fallon Clinic (MA) cites several improvements in making Dragon Medical part of its EHR implementation.

Jobs: EHR Project Manager (CA), Systems Administrator (AZ), Senior Systems Analyst (GA).

Sleep well knowing that Weird News Andy is guarding the gate. He finds this article, with the key line being, “Each time the two had sex, documents say, the doctor would bill her Blue Cross Blue Shield Insurance for their ‘sessions’.” The psychologist involved, who called himself RHL (short for Red Hot Lover), is being sued by his former lover and investigated by the state. WNA also likes this story (he threw in a Subway $5 foot long pun at no extra charge) about surgeons in Czech Republic who left a foot-long medical tool in a patient’s abdomen after surgery, which stayed there until five months later.

Former Eclipsys VP Charles Tuchinda, MD is named chief innovation officer, healthcare of Hearst Business Media. He’ll also be a VP at properties Zynx Health and First DataBank.

iSoft will distribute iMDsoft’s MetaVision suite in Germany. It offers clinical decision support, CPOE, and reporting for critical care environments. Among its customers, iMDsoft has four of the top 10 US hospitals at 13 of the top 50 European hospitals, with a 100% retention rate in its 11 years. Coincidentally,  I’ve got an interview coming as soon as I have time to post it.

Orion Health gets some coverage of its recent large sales in the New Zealand business paper.

An ED doctor’s article in an Australian medical journal urges that hospital executives who fake quality data be prosecuted the same as corporate book-cookers. He claims that hospitals have submitted phony data ever since they started getting paid for performance, including discharging patients electronically and then re-admitting them to hit quality targets.

Odd lawsuit: a patient care tech brings a baby to the hospitalized mom of a newborn. The mom starts breast-feeding the baby, but a nurse walks in to tell her it’s the wrong baby. The mother is suing Evanston Hospital and its parent corporation, even though no harm was done and even though she herself didn’t notice (she says she couldn’t see in the dark). The tech apologized in tears, but the father said, “It’s not enough”.

E-mail me.

HERtalk by Inga

From Forest Green: “Re: Sage again. I just heard of another executive departure — Kat Henry, SVP of customer service. I hope the new president can turn things around for them!” Sage has confirmed.

From George Geef: “Re: patient survey. Obviously, we don’t quite agree with the ‘goofy’ categorization of the GfK Roper survey. Compared with the CDC and NEJM surveys, actual patients witnessing computers being used for charting seems to me more accurate gauge of the shift than doctors self-reporting on partial or full use of EMRs.” OK, goofy was not the most eloquent and descriptive word I could have used. Let’s just say I am suspect of the conclusions drawn. Just because a patient notices a PC does not mean the practice has an EMR. The study also noted that older and wealthier patients said their doctors have EMRs more often than younger and poorer patients, concluding that doctors treating older and wealthier patients are more likely to have EMRs. Perhaps, though I could come up with a few other equally plausible conclusions.

Yesterday I came across a mention of HIStalk on a one of our reader’s blogs. The writer’s note made Mr. H and me smile: “I am anxiously awaiting my annual trip to HIMSS. Should be interesting to see what companies are doing around ARRA. At least CCHIT finally released their test scripts today so that there can be a lot of buzz. I especially can’t wait to go to the HIStalk reception. It has been the highlight of the trip the last 2 years.” I have to admit it’s been a highlight for me as well.

After six years of no price increases, Surescripts drops the price of its e-prescribing services for pharmacies, pharmacy vendors, and pharmacy benefits managers. Surescripts says the move is part of its ongoing commitment to improve operational efficiencies and the result of economies of scale. And I bet Surescripts found a price adjustment was necessary in order to remain competitive since the market is a bit more crowded than it was six years ago.

Speaking of Surescripts, the company sets up an advisory committee to help with the development of a prescription history service for HIEs. Committee members include the heads of five HIEs.

Members of a federal HIT advisory group recommend relaxing the number of measures required for providers to demonstrate meaningful use of EHRs. The group wants to drop up to six MU measures for 2011, which still leaves about 80% of the measures originally proposed. The advisory group says the currently proposed 2011 measures set the bar too high, making it difficult for providers hoping to qualify for 2011 stimulus money.

Coming soon: a new post in our ongoing vendor executive series on HIStalk Practice. Several dozen industry CEOs provide answers to the following question: In addition to ARRA-related items, what will be some of the hot topics at HIMSS this year? The insights are diverse and include musings on interoperability, rapid deployment of EHR systems, data collection, mobility, and industry alliances and consolidations. If you’d like to receive a notification when the series is posted, make sure you are signed up as a HIStalk Practice subscriber.

I have to admit I found this press release a bit opportunistic — or at least cheesy. After four introductory paragraphs detailing the Olympic and professional accomplishments of speed skater Eric Heiden, it becomes obvious the piece is really an ad for the records management software used in Heiden’s orthopedic practice. To fully appreciate the message, I think you need to imagine Jim McKay saying these words:

Just as athletes benefit from high-tech gear, clothing and equipment that enables them to be faster, better, stronger, Heiden says Records Studio utilizes superior technology to help optimize the performance of all departments of his medical practice, not just patient care.

East Orange General Hospital (NJ) purchases GE Centricity Enterprise for its hospital-based EMR. GE’s data center will provide the hospital with remote application hosting.

Enovate releases its Enovate Lite Medical Cart services, which includes CompactLite, StandardLite, and UltraLite models. I see the Enovate guys will be showing off the new cart at HIMSS.

Kaiser Permanente reports 2009 net income of $2.1 billion, which is a vast improvement over 2008’s net loss of $794 million. Q4 net income was $214 million, which more than doubles 2008’s number. The turnaround was largely the result of improved financial markets. Meanwhile, membership numbers fell by 64,000 in 2009 after falling 30,000 the year before. Total membership is 8.58 million.

Nemours/Alfred I. duPont Hospital for Children (DE) goes live on GetWell Town, the pediatric version of GetWellNetwork’s Interactive Patient Care system.

The Camden Coalition of Healthcare Providers (NJ) selects Noteworthy Medical Systems to be the information hub for their multi-hospital HIE.

Mediware announces that Oregon Health Sciences University will implement its BloodSafe system.

MEDecision launches a new collaborative HIE service called InFrame that facilitates clinical data sharing, including diagnostic quality medical images.

E-mail Inga.

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The views and opinions expressed in this blog are mine personally, and are not necessarily representative of Texas Health Resources or its subsidiaries.

Meaningful Use Requires Meaningful Leadership
By Ed Marx

A few weeks ago, under authority of the Health and Human Services Secretary, the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator of Healthcare Information Technology (ONC) issued proposed regulations on the definition of meaningful use and the initial set of standards, implementation specifications, and certification criteria for EHR technology. Certification criteria specify the capabilities and related standards that EHR’s must include to support the proposed meaningful use Stage 1 requirements for eligible professionals and eligible hospitals. The comment period will end shortly with the final rules released this year. The industry’s wailing and gnashing of teeth is in full force.

As a taxpayer, I’m pleased with the IFR. My concerns that the industry would water down Stage 1 requirements have been largely dispelled. Meaningful use was designed as an incentive-based initiative. As such, it strikes a healthy balance between attainment and stretch. It’s not a welfare program, and not everyone reaches Stage 1 in year one. If that were the case, IFR would not be an incentive program. I praise the government for raising the bar high, and I urge them to stand their ground.

When does tolerance of low standards begin destroying value? Is not an underlying lack of fortitude detrimental to the overall fitness of our nation’s healthcare? I get invited to dozens of meetings and surveys all aimed at lowering the bar. Well-intentioned organizations exercise political freedom and amass collective resources (including financial and personnel). Online and traditional healthcare media are whipping activity into a frenzy. We’re inundated with position papers, press releases, mobilized lobbyists, and pundit opinions.

But I’m convinced that if we channeled the above energy and focus into meaningful use, more organizations would lift themselves over the bar.

Leaders. Avoid the temptation to jump on bandwagons that lower the bar. Make your opinion known and then get about the business of attaining meaningful use. While the lazy lament the IFR, you be the catalyst that makes meaningful use a reality for your hospital and physicians. Demonstrate meaningful leadership.

Ed Marx is senior vice president and CIO at Texas Health Resources in Dallas-Fort Worth, TX. Ed encourages your interaction through this blog. (Use the “add a comment” function at the bottom of each post.) You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook, and you can follow him via Twitter – User Name “marxists.”

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Data Entry and Quality Health Care
By Al Davis, MD

The enthusiasm generated for EHRs by the 2009 ARRA legislation is almost palpable and hospitals across the country are scrambling to install systems at a breakneck pace. Behind the enthusiasm, however, are two issues, related yet disparate, that have been the confounding factors of EHR adoption in the past and will continue to be so in the foreseeable future.

EHRs offer the promise of data aggregation which can be used to refine clinical treatments for both improved quality and, possibly, lower costs, but this aggregation is dependent upon standardized dictionaries and, importantly, standardized data entry. EHRs currently offer standardized data via the use of templates, boilerplates, and pre-defined order structures. But the standardized data entry model often (usually?) does not completely and precisely conform to the observed signs, symptoms, and problems displayed by patients in the physician’s office, and therein lies the rub.

Patient care, especially when dealing with complex problems, requires the clinician to differentiate subtle distinctions among less than obvious alterations from normal physiology. Shortness of breath, one of the most common problems encountered in the emergency room, can result from problems with the lungs, with the heart, with the vascular system, with the blood, from medications, or simply from pollution or toxins breathed in by the patient, and those are the direct causes. Indirect causes such as intra-abdominal pathology, skeletal deformity or muscle weakness must also be considered.

While there is a high statistical likelihood that shortness of breath will result from one of a relatively small number of potential pathologies, assuming a diagnosis based on statistical likelihood will lead to poor or even dangerous patient care. The reason a pulmonologist trains for 12 or 13 years, and a nurse practitioner for six or seven, is to allow the pulmonologist to learn not only the underlying basis of the more rare causes of disease, but also to be able to discern the subtle differences that those more unusual pathologies may display. The use of template- or boilerplate-driven clinical notes negates the benefits of the more refined knowledge and experience of the pulmonologist. Requiring the use of such standardized data inputs is antithetical to quality medicine, yet allowing free text entry is equally antithetical to the as yet unrealized potential of the EHR. It is this contradiction which has slowed adoption of EHRs and will continue to hinder their use.

The challenge is for IT designers to work out a way for experienced clinicians to be able to commit to the record the sometimes subtle thought processes and observations that lead to their diagnoses, while maintaining enough control and/or discipline over the input to allow the potential of data aggregation to be realized. Monetary issues, regulatory compliance, and usability are important as well, but the paramount concern of the EHR must be to ensure that the best quality patient care can be delivered. If the cost of the input restrictions needed to allow data aggregation is the loss of ability to place nuance and subtlety into the record, the EHR fails that most primary of tasks.

Al Davis, MD is in private practice in Elmhurst, IL.

A Meaningful Ruse?
By Frank Poggio

At the risk of being a called a Cassandra, or at best a contrarian, I will attempt to explain why the federal government’s HITECH Act and Meaningful Use (MU) incentive program is a wolf in sheep’s clothing and why the better response for a provider would be to run, don’t walk, from this wolf.

First let’s review the basics. When a hospital or physician’s practice purchases and implements an electronic medical record (EMR) or Computerized Physician Order Entry (CPOE) before 2011 and files with the federal Department of Health and Human Services (DH&HS) the yet-to-be-developed regulatory documentation to declare their meaningful use (MU), then starting in 2011 that provider will be potentially eligible for an MU bonus payment. For physician practices, that could amount to a total of $44,000 over three years. For hospitals, depending on the number of discharges, somewhere between $2million to $3.8 million total. These incentive amounts are to be paid over three stages, or years, starting in 2011.

On the other hand, if a provider does not implement an EMR or CPOE, or purchases and implements a system but cannot show meaningful use, then a penalty will be incurred on Medicare payments in years 2015 thru 2017. This penalty will be in the form of a reduction to the legislated increase in Medicare payments for that year. Note: this is not a reduction in overall Medicare payments, but a reduction on the yearly Medicare inflationary adjustment factor. The first year the penalty is a 33% reduction of the adjustment, the second 66%, the third 100% (or in effect, you will get no adjustment at all).

Before I explain why I believe there is a wolf at your door, let me say I am a believer in the benefits of EMRs and CPOEs. There can be significant benefits in both, but not unless they are incorporate a sound work flow re-engineering processes prior to installation. Unfortunately there are very few if any MUs that are workflow-focused.

There are at least four major reasons why I believe your facility will never see an MU bonus.

1) MUs are, by the DH&HS’s own admission, a moving target. As stated in the Interim Final Rule (IFR) published in the Federal Register, December 30, 2009, on page 314, “We expect to issue definitions of meaningful use on a bi-annual basis beginning in 2011”. Hence, MUs will evolve over time. That will allow DH&HS to make them as easy or as onerous as they choose. How can you predict you will hit a moving target that you can’t even describe today? And if you believe the Feds may try to make it easier to foster participation, read on.

2) If you hit all but one MU, will you get the full bonus, or 95%, or 50%? Nobody knows and the question is not addressed in any IFR or other documents. I am willing to wager you will get nothing, and my reasoning follows.

3) The federal government has stated they are funding the HITECH program with $34 billion for MU bonuses. They also have stated repeatedly they expect to save over $200 billion to help fund the new national health plan. That’s about a seven-to-one expected payback in only a few years. When was the last time you had a seven-to-one ROI on any IT project over three years? If the feds do not see the seven-to-one payback in time, how many providers do you think will get to cash an MU check?

4) Our government is under extreme pressure to cut the federal deficit. In the President’s recent State of the Union Address, he stated he will freeze the government budget for ‘non-essential’ items to save $250 billion, to alleviate the trillions of dollars in deficits predicted by the OMB. Essential is currently defined as Social Security payments, interest payments on debt, entitlement programs, Medicare benefits, and the defense budget. These taken together make up over 80% of the total government expenditures. So the freeze has to come from ‘non-essential’ departments and programs. Medicare payments to providers are not considered part of Medicare benefits, they come under the DH&HS /CMS department operating budget. So, although the benefits to the seniors will not be reduced, the payments to the providers are fair game. And therein lays our wolf.

I noted earlier that if you fail to purchase and install an EMR / CPOE, you will be penalized by a reduction in the increase in Medicare inflationary adjustment in future years. Based on the above reasons, I believe there will be little or no adjustment increase in future years. If you don’t think this will happen, look at what Congress and DH&HS had allocated for the adjustment ‘increase’ in 2010 for physician Medicare payments. DH&HS wants to apply a -21% adjustment for physician payments. Yes, that’s minus twenty-one percent. Then, to get the AMA on board with the national health initiative, the Administration and Congress was going to delay this adjustment, but now even that agreement is up in the air.

On the hospital side of the world, look at what the Medicare adjustment increases have been over the last five years. The most they have been is 2% and the average is around 1%. If you run those numbers for a typical 200-bed community hospital with a Medicare utilization percent of 50%, the one percent increase amounts to about $300,000. Hence, reduce it by a third and you will miss out on $100,000 that year. Again, and that’s assuming there is any increase at all in future years.

Lastly, let history be your guide. I have worked in the healthcare world for 35 years as a CFO, CIO and multitude of other roles. As a CFO, I saw Medicare renege on many case mix adjustments, TEFRA adjustments, and DRG adjustments,all in the name of national budget deficits and health care cost controls. At one point, they set up a Medicare Payment Advisory Committee, then disbanded it when the Committee disagreed with too many DH&HS adjustment policies. I doubt the future will be much different, in fact probably worse.

So, run the numbers again, in future years if the Medicare adjustment increase is zero – because the feds and DH&HS say we can’t afford an increase due to overall deficits and budget freezes, then reducing the zero adjustment increase by 33% will incur how many penalty dollars?

What’s a shepherd to do?

The bottom line is there is no need to “horse in” a new EMR/ CPOE regardless of what vendors say. Secondly, horsing in a system as complex and far-reaching as EMR/CPOE and while hitting the expected glitches along the way is going to cost you far more than any Medicare adjustment penalty.

My advice … take your time, do it right ,and install components that will give you the most ROI the fastest. And watch out for the wolves.

Frank L. Poggio is president of The Kelzon Group.

Accurate Patient Identification and Privacy Protection – Not an “Either/Or” Proposition
By Barry Hieb, MD

 

Whether you support federal government funding of HIT or not, it can’t be denied that healthcare is undergoing a major revolution as more and more clinical automation capability is being adopted. Funding of HIE projects, building toward the Nationwide Health Information Network (NHIN), will further these efforts. And clearly progress is being made, as noted in the recent KLAS report that verifies 89 active HIEs across the US. The ultimate vision of regional clinical information exchange crosses political, operational, and geographic boundaries using the NHIN’s network of health information exchanges.

However, we’re not addressing one of the most significant challenges that must be overcome for this scenario to work: the ability to accurately identify patients whose information may be scattered across a number of providers using disparate HIT applications and platforms.

The current state-of-the-art approach for patient identification centers on EMPIs that identify patients using demographic matching techniques. But industry experience indicates that EMPI matching techniques are only accurate 90 to 95% of the time, introducing a variety of potential errors in care delivery within and across provider organizations.

We know the answer to the problem — issue each patient a unique identifier that would be used to label their information across all participating provider locations. In fact, the 1996 HIPAA legislation mandated just such individual healthcare identifier. But, in 1998, Congress reversed itself on the patient identification issue based on valid concerns about the inability to protect the privacy of this data, and forbade the expenditure of federal funds on further pursuit of this essential component for accurate patient identification and data exchange. Since that time, there has been virtually no progress on this issue at the federal level, although recently a number of states have begun to pursue state-wide identifiers to support their HIE projects.

Since I left Gartner in 2008, I’ve been working with Global Patient Identifiers Inc. to build out the Voluntary Universal Healthcare Identifier (VUHID) system under the umbrella of a non-profit, private enterprise. The VUHID system is based on over 20 years of patient identification standards work done by the ASTM international E31 medical informatics group, and proposes a solutions that is both inexpensive and effective.

The VUHID system communicates with the EMPI system at the heart of each HIE. It issues identifiers upon request and maintains a directory indicating the sites that have information for each identifier. The VUHID system has been specifically designed to enhance the privacy of clinical information because it has no identifiable patient data — only the locations where each identifier is recognized.

VUHID identifiers are globally unique and are designed to support activities that the patient or others indicate need to be handled with privacy. The VUHID system represents a secure, cost-effective, currently available solution to enable error-free patient identification that extends across political and organizational boundaries.

Barry Hieb, MD is chief scientist for Global Patient Identifiers, Inc.

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An HIT Moment with ... is a quick interview with someone we find interesting. Chuck Demaree is vice president of product development with Access of Sulphur Springs, TX.

Absolutely. The focus of an EMR is to provide an electronic collection of medical information that can be used real-time during the clinical episode and historically as an archive. Generally, not all information will be fed electronically into an EMR. Forms provide a tool for the organized collection and presentation of information that will not be collected electronically.

In supporting the EMR, EHR and LHR, an electronic forms solution provides:

• Consistency in form quality, format and delivery.
• Accuracy in correct filing information through the use of patient-specific bar codes.
• Efficiency through the use of business rules by assuring that all the correct forms are generated (collecting ALL of the needed data).
• A standardized and structured presentation of data in the EMR, especially if COLD feed information is passed through the forms solution to provide a standard presentation.

Describe the typical workflows associated with using access-related electronic forms.

The most common entry point for Access EFM is in the registration area. A typical workflow would start with the registration of a patient. The resulting information generated by the registration system passes to the business rules engine in the Access EFM server where data elements are evaluated. The rules engine then determines what forms are required, what data needs to be applied to each form, and where and how those forms need to be distributed.

For example, a customer being registered as an inpatient would have a complete registration packet that is customized to them for this particular clinical event printed in the registration area, with bar codes and demographics applied. The only documents that would print there would be documents that the patient (or their family) needed to take with them or that needed to be electronically signed, such as consents. The bar codes on each form enable HIS staff to interface forms into the EMR with less effort, as the ECM/EDM system uses bar code recognition to auto-index the forms with the patient record. 

Electronic workflow would then route any other documents needed by the nursing unit, laboratory, pharmacy, patient finance and other departments directly to their location (or application) at the time of registration. Electronic notifications (via fax or email) would be sent to the primary care physician notifying them of their patient’s admission. 

In more advanced forms management projects, registration staff send forms to a monitor without printing. The patient reviews them, applies their electronic signature on an LCD pad, and the nurse submits the forms. They’re then interfaced into the ECM/EDM system, a paperless process that eliminates the financial and environmental costs of forms printing.

What is the Universal Document Portal?

The Universal Document Portal (UDP) is an interesting and exciting product. The purpose is to provide a method to feed the EMR electronically from systems or medical devices that do not have the ability to COLD feed today.

Some examples of how this is being used by our customers are:

• Passing medication orders which used to be faxed, from one vendor’s HIS system to a competing vendor’s pharmacy system.
• Providing an electronic import capability for clinical documentation from one vendor’s HIS system to another vendor’s EMR. This particular customer has well over 50 different feeds running through UDP
• Indexing the output from a 12-lead EKG system directly into the proper patient’s chart in an EMR.
• Migrating historical medical record information from a system that is being discontinued into the customer’s current EMR.

The uses for UDP are only limited by the output abilities of the system or device and the IT/IS team’s imagination.

How can electronic forms support patient safety?

The Access EFM system impacts patient safety both directly and indirectly.

Every form outputted from Access EFM has patient identification bar codes on it, enabling positive patient ID throughout the encounter. Bar coded wristbands are generated at registration and reconciled with bar coded medication labels also printed by the Access system, facilitating accurate bedside medication verification (BMV).

Documents that are passed into the EMR have a consistent structure which reduces search time for information. Because of patient and form specific bar codes on every form, all forms are accurately filed in the EMR
Notification of printed bar coded forms are sent to the EMR for the purpose of creating automatic deficiencies, which are resolved when the form is scanned in.

The indirect impact is the time saved by the use of the business rules engine and the staff efficiencies it produces. The business rules take the guesswork out of what forms need to be pulled and what data needs to be collected. If it needs to be done based upon the data entered for the patient, it gets done because of Access EFM.       

How common is it for hospitals to capture patient signatures electronically and how are they using them?

Electronic signature capture is becoming more common every day. The most common uses are obviously in the signing of consent forms, whether in registration or at the bedside. Other uses are the signing of discharge or patient teaching instructions, financial responsibility documents, and any other document that provides legal protection for the facility during the care delivery process.

The most important factor in choosing an electronic patient signature solution is how well those signatures will stand up in court. Basic electronic signatures like those used in a grocery store (TIFF on TIFF) are hard to defend if legally challenged as they could be copied, forged, or altered after signing. Access e-Signature creates a biometrics file that becomes part of the patient’s record and proves that the original signature was not forged or changed, positioning hospitals well for audits and e-discovery.

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