From Tabula Rosa: “Re: EMR usability. At one of the ONC Policy Committee meetings, Judy Faulkner of Epic supposedly declared that ‘usability would be part of certification over her dead body.’ I wonder if she has similar sentiments about making software accessible to people with disabilities?” Unverified. This inspired my new poll question – keep reading below. 

From ExXeroid: “Re: The Hospital of Central Connecticut. The Cerner staff is down to a skeleton crew. The IT people are leaving in droves. Cerner KC is the ACS takeover, but there’s hardly anyone left to support internally after the ACS disaster.” Unverified.

From The PACS Designer: “Re: Apple’s OS 4.0. Apple’s iPhone OS 4.0 will be available for the iPhone this summer and for the iPad this fall. While we are waiting, we get the opportunity to see some of the features that are coming. Also, Apple has a developer’s Web site to aid those who want to venture into application development for the OS 4.0.”

HIStalk readers donated generously to Sumter Regional Hospital (GA) after it was destroyed by a tornado in March 2007 (we collectively donated $11,264). The hospital, now Phoebe Sumter Medical Center and still being rebuilt, later received what appeared to be the highest vote total in a Siemens-sponsored contest to win an $800K Magneton Essenza MRI scanner, but somehow lost to another facility. Siemens decided to donate a machine to Sumter anyway. It has arrived and is already being used, with the picture above being one of the hospital’s first patients to benefit from it last week. The ribbon cutting will be this Friday, June 4 at 10 a.m. Former President Jimmy Carter, a Sumter County resident, may attend.

A whopping 79% of HIStalk readers say they would worry about the confidentiality of their electronic information if they had a psychiatric illness and their providers were sharing information electronically. That’s not to say that they are specifically concerned about electronic security, only that they would worry about having their information exposed in some unspecified way. New poll to your right: what’s the best way to raise the level of EHR usability in the marketplace?

I figured it was time to cruise around the sites of some of HIStalk’s sponsors and see what’s new with them.

• Rockingham Memorial Hospital (VA) says its use of Nuance’s Dragon Medical and eScription speech recognition products will save it $600K this year alone.
• A BridgeHead Software survey (warning: PDF) finds that hospital data storage needs are increasing dramatically, primarily because of PACS images, electronic medical records files, and scanned documents.
• Virtelligence will be exhibiting at MUSE this week.
• Lakeridge Health Network (ON) selects Access Intelligence Forms Suite to get forms into Meditech scanning and archiving without manual indexing. Access will exhibit at MUSE this week.
• Registration for the e-MDs user conference in Austin July 22-24 is open. It sells out every year.
• Ingenix Consulting SVP Joel Hoffman is named a “Top 25 Consultant” by Consulting magazine for his work in assessing financial outcomes of care management.
• Renaissance Resource Consulting has open positions for Epic installers and IDX/GE application and technical consultants.
• A native iPad version of PatientKeeper Mobile Clinical Results is now available.
• CynergisTek CEO Mac MacMillan is quoted in a new article called OCR Building HIPAA Audit Plan With Outside Help.
• Going to AHIP Institute in Las Vegas next week? MEDecision is hosting a party at PURE in Caesar’s Palace. You know from HIMSS that they throw a good one.
• O’Toole Law Group is offering (warning: PDF) contract assistance for Meditech 6.0 upgrades.
• Universal American Corp., a provider of Medicare Advantage and Part D prescription drug plans, chooses (warning: PDF) MedVentive’s care collaboration tools for members and providers, including real-time care and drug substitution recommendations.
• Charge capture automation vendor MedAptus will exhibit at HFMA’s Annual National Institute later this month in Nashville.
• Surgical Information Systems will exhibit at MUSE and HFMA this month.
• ACHE will publish a book on how consumer behavior is changing medicine by Lindsey Jarrell and Colin Konschak, partners of DIVURGENT Healthcare Advisors.
• Dentrix Enterprise is offering a free Webinar on the features and benefits of its Electronic Dental Record solution, the leading EDR in community health centers.
• Sunquest will exhibit this month at G2 Lab Outreach in Baltimore and Smart Health in London.
• Sentry Data Systems releases two case studies on using its Sentinel RCM 340B solutions, one from Alegent Health and the other from Saint Barnabas. They’ll be at HFMA and ASHP this month.
• Software Testing Solutions introduces its automated testing solution for Eclipsys Sunrise order entry that saves staff time and documents testing of procedure ordering, billing, interfaces, and validation of new releases.
• MED3OOO has June 3 and 17 Webinars on Assessing Readiness for Meaningful Use, presented by CMIO Jay Anders, MD.
• EHRScope has gone live with its EMR review site, where EMR users can read and write reviews and rate their product.
• Vitalize Consulting Solutions is #2 on the KLAS list of consulting firms that providers are considering.

Ed Meagher, former VA deputy CIO, CTO, and chair of the committee that prepared the VistA report that I mentioned last week, took exception to my comments about those committee members with ties to federal contractors. He said, “The [HIStalk] level of cynicism is almost toxic. I can tell you that the personnel who participated in the report did so as IT industry experts, veterans, and citizens and not as representatives of their companies.” I wasn’t doubting their integrity or lack of good intentions, but rather the inevitable and often subconscious world view that any company’s employee would bring to the table. He’s right that the real to-do is to review the report and suggest improvements. Feel free to e-mail your comments and I’ll publish them. Assume that the VA is correct in its assessment that VistA has become technologically obsolete, hard to enhance, and hard to support — do the committee’s recommendations make sense? (although we’re missing a big piece of the puzzle – the inevitably large price tag. The VA is huge, although I can’t readily find its total inpatient bed count.)

I also got some feedback on the AHRQ report on practice EMR usability that I mentioned. I said it was nice work, just limited in applicability because only eight EMR vendors were interviewed and most of the big ones weren’t on the list. From my source, apparently many more EMR vendors were asked to participate, but declined.

HHS CTO and athenahealth co-founder Todd Park is named as one of Fast Company’s 100 Most Creative People. He was recognized for making public health data more readily available. “It’s insufficient to just put data out there. We want to market them to people who can turn them into supercool apps.” Maybe he earned bonus points for correctly using “data” as plural. Cleveland Clinic CIO Martin Harris was #12. Both lost out to #1, Lady Gaga, but I’m sure she’ll sell more magazine copies, at least outside of healthcare.

Sevocity offers regional extension centers and educational organizations free access to its Internet-based EHR, set up as a demo clinic for up to 20 users and requiring them to have nothing more than PC with Internet access.

Inga has the latest in her series of questions for vendor executives: what advice do they have for David Blumenthal? She got some surprisingly frank and diverse answers, ranging from “start an EMR Lemon Law” to “stay the course.”

TELUS Health Solutions will announce this week that it is offering pre-built interface tools from Iatric Systems for quicker, cheaper interfacing of its Oacis EHR to Meditech. Offerings from TELUS include the Oacis Unified Patient Record (a Web-based clinical portal with longitudinal information), Oacis CDR, Oacis HIE, a data warehouse, and capabilities such as CPOE, clinical documentation, and ED tracking. TELUS will exhibit at MUSE this week. Frank Clark, CIO of Medical University of South Carolina, has told me several times that TELUS Oacis is a key part of his organization’s clinical systems strategy, particularly its physician portal.

I did some cleanup of the HIStalk e-mail update mailing list. Spam blockers (not on my end) were keeping some users from receiving their updates, so if you aren’t getting yours, you should now be able to sign up again at the upper right of the page.

I’ve been working on an HIStalk Toolbar for Firefox and IE (not for Chrome since it doesn’t support toolbars, unfortunately). I included some cool features: a search box that allows searching the Web as usual or HIStalk specifically (click the dropdown beside the Go button to choose); a Links dropdown with one-click access to all HIStalk sites; RSS feeds; an e-mail checker that will notify you when new mail comes to your online account (Hotmail, Yahoo, Gmail, etc.); a really cool radio player that I preloaded with some indie rock stations (you can choose any others easily); and a local weather widget. You can customize any or all of this easily. I’ve been using it at work and it’s really handy, especially the e-mail checker and radio player. It uninstalls easily in case you change your mind. I’m listening to the Indie Rock station on it right now and sounds super.

Cerner’s Neal Patterson still wants insurance companies to die (go, Neal!) but also says Cerner will become a healthcare company, not just a healthcare IT company.

Dell announces its Healthcare Print Station, which offers one-touch options to route orders from hospital nursing stations to the pharmacy, a “Scan to EMR” button, a forms-on-demand option, and card copy for scanning both sides of patient ID cards to a single sheet of paper. The $599 add-on is available for Dell’s Java-capable multifunction printers (3333dn, 3335dn, and 5535dn).

NextGen parent Quality Systems reports Q4 numbers: revenue up 19%, EPS $0.45 vs. $0.40, falling short of consensus earnings expectations of $0.49. 

Happy Memorial Day! Except for you non-US readers, who I confess I wasn’t thinking about when I talked about the holiday last week. Thanks to the reader from Canada who reminded me. According to my stats, the leading countries for HIStalk readers other than the US are Canada, Australia, UK, and India, with a significant drop-off before the next group from Ukraine, China, Israel, and France. As the programmers say, Hello World.

E-mail me.

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From Uncle Arnold: “Re: Cal eConnect. The state-sponsored HIE is interviewing CEO candidates this week. They are on a tight timeline and want to make an announcement within two weeks. The usual suspects are finalists: Roberts at HIMSS, Portale at Palomar, etc.” Unverified.

From Ms. Jones: “Re: Presbyterian Albuquerque. VMware installation caused two major network outages within 48 hours. The clinical system (McKesson) is still trying to recover: interfaces and prod down, pharmacy handhelds all needed hard booting, runaway processes triggered, unable to pull PACS studies, etc. Affected all eight facilities across the state.” Unverified. I also note that I still can’t spell Albuquerque in fewer than three attempts.

From Alan: “Re: hospital and TV reporter. A reporter is repeatedly touched by a hospital communications director. Hilarity ensues.” Bizarre. A TV talking head tries nicely to interview a Laguna Honda Hospital (CA) official about a reported misuse of patient gift funds. She’s on her way to a meeting, so she politely declines. The hospital’s creepy communications director gets in the reporter’s face and starts touching and patting him repeatedly, introducing himself about a hundred times (“Hello, my name is Mark Slavin”) as the TV guy warns him he’ll call the police if the guy doesn’t get his hands off him. Be glad they didn’t actually fight since I think it might have been embarrassing to humans everywhere.

A reader asked me to share the VA committee’s recommendations on the future of VistA. Nothing on it says its private, so I’ve posted it here. Your analysis is welcome. I notice that the working group included employees of companies that stand to benefit from an expensive rewrite (Lockheed Martin, Microsoft, IBM, HP, Deloitte, Northrop Grumman, etc.) so I might take their recommendations with a grain of salt. I also noticed one tiny recommendation that the VA shouldn’t build any software it can buy, provided the application meets standards.

A reader sent over the graphic above now that we’re all on Facebook. He thought it was funny. I agree, but Inga and I still love it when you friend us or click our “Like” button because we are insecure.

Weird News Andy notes that in the UK, lots of people can’t get the surgery they want, but at least one patient is getting surgery against their wishes. A judge’s ruling grants doctors permission to forcibly sedate a woman with uterine cancer and bring her to the hospital for a hysterectomy, claiming she is of unsound mind and the surgery is “plainly in her interests to have.” They’d better hope it goes well.

Allana Cummings, former SVP/CIO of Children’s Omaha, is named CIO at Northeast Georgia Health System. I think we probably mentioned that before, but now we’ve got a pic.

Listening: Fastball, one of my favorite guitar-and-harmonies indie pop bands.

A UCSD trend study says healthcare IT is the “hottest career option” for new grads.

Three Midwest hospitals that run McKesson’s Paragon sign up for its Practice Partner PM/EHR.

Allscripts will integrate IntelliDose chemo dosing into its products.

AHRQ releases a report on practice-based EMR usability, although only eight vendors were interviewed and big players like Epic, eClinicalWorks, Sage, Allscripts, etc. were not among them. Nice work, just a bit limited in scope to draw meaningful conclusions. Key points:

• All vendors interview claimed a “deep commitment” to making their products usable.
• Despite that, few (none?) of them said they do formal usability testing, follow user-centered design principles, or get real usability experts involved in their design.
• Vendor processes to address reported usability-related patient safety issues are inconsistent.
• Most vendors do not publicly share known usability-related incidents or enhancement requests.
• No vendor admitted to contractually prohibiting users from disclosing product-related patient safety incidents.
• “Many” vendors expressed interest in having an independent body develop EMR usability standards (great idea, since they also said that competitive pressure keeps them from collaborating on usability standards).

McKesson raises its quarterly share dividend from $0.12 to $0.18.

NPR reports on an interesting use of clinical decision support: analyzing the potential value of each individual outpatient radiology order based on patient condition and requiring the doctor to personally sign off on questionable ones. The iffy orders dropped from 5.4% of the total to 1.9%.

Drug company Wyeth, worried about being caught pitching drugs to doctors for unapproved indications, apparently modified its Salesworks software to prevent its sales reps from documenting their conversations with doctors, preventing future legal discovery. The company is also alleged to have dressed up salespeople in white coats, sending them on doctor rounds and into the OR during transplant surgeries.

The market cap of Microsoft at today’s market close: $227.9 billion. Of Apple: $230.5 billion. The five-year stock price chart is above (Apple is the green high-flyer, Microsoft is the blue dead money). The torch has been passed.

Speaking of Apple, the Chinese company that makes parts of the iPad, iPhone, and other consumer electronic devices urges workers not to kill themselves after 11 employees leap off buildings so far this year, with nine of them dying. The latest death was an employee who had been grilled over a missing iPhone prototype. Employees are now required to agree to let the company send them to a mental hospital if their behavior is “abnormal.” Safety nets have been installed around employee dormitories. Note to self: don’t take a job with a company that provides a dormitory or otherwise makes it obvious that you won’t have any free time.

HIStalk sponsor jobs: Clinical Informatics Professional, Sales Executive, Proposal Developer. Sponsors post their jobs free. On Healthcare IT Jobs: HIE Analyst, Instructional Design Manager, EMR Project Manager.

Harlem Hospital (NY) admits that it allowed 4,000 echocardiograms to be read by techs instead of doctors. Cardiologists are reviewing them and have found several patients with undiagnosed cardiac problems.

Here’s a nasty anti-business surprise buried in the healthcare reform bill, slipped in by Democratic politicians to help pay for it: every business must report on 1099 forms payments to any company that total more than $600 in one year. Right now, that’s required only for payments to non-incorporated entities. So if you buy Dell computers, Sam’s Club paper towels, or Fedex shipments, you’ll have to get a W9 form from them (for their particular in-state business identity) and send them a 1099 every year. That’s an estimated 12x increase in paperwork. Who is John Galt?

I’ll probably do the usual Monday Morning Update this weekend even though it’s a holiday and few of you will read it Monday (but I might slip in some really good stuff to reward the loyalists). Have a wonderful holiday, flying that flag if you’re so inclined.

E-mail me.

HERtalk by Inga

ONC announces that another $30.3 million in awards is available to fund two additional Beacon Communities. Letters of intent are due June 9 and we’ll find out the lucky winners in mid-August.

The tiny Guadalupe County Hospital in Santa Rosa, NM plans to add Medsphere Systems’ OpenVista EHR. Phoenix Health Systems will provide implementation and support expertise for the 10-bed hospital.

RCM service provider Zotec Partners aligns with Medical Business Services (MBS) to offer RCM tools to MBS’s hospital-based physician clients.

Zix Corporation launches ZixGateway Inbound, a new tool to help provider organizations identify unsecured PHI in incoming email.

EMRs cut the average treatment time for sexually transmitted infections from 11.5 days to 3.5 days, according to a UK study. The percentage of patients getting treatment within two weeks of diagnosis jumped from 38% to 94%. Doctors attribute the difference to faster patient notification of positive test results. Add that stat to your sales tool bag.

Surescripts bestows Gold certification status to eight physician software vendors.

HCA appoints Dr. Thomas L. Garthwaite to COO of the Clinical Services Group, charged with improving quality of care, patient safety, and clinical performance. He’s a former EVP and CMO for Catholic Health East and spent eight years with the VA, including a stint as Under Secretary for Health where he helped with the VA’s  transition to EHR.

Humana and BCBS-RI top the 2010 PayerView Rankings, an annual report that examines how well health insurers are paying physicians. Insurance companies as a whole seem to be paying an average of seven days faster than last year and are denying 12-18% fewer claims.Full list here. Or if you prefer, watch athenahealth’s Jonathan Bush and Humana’s Bruce Perkins discussing the rankings with CNBC.

Some generally positive Cerner news out of the UK, at least from one NHS Trust administrator. Kate Grimes, the chief executive of Kingston Hospital NHS Trust says its implementation of Millennium has gone remarkably well after a big-bang go-live. She acknowledges the platform will help improve quality of care, but also notes that Millennium needs further work to be more intuitive and forgiving of mistakes.

A couple of weeks ago, Mr. H shared the story about Brigid O’Gorman, a college junior who is working to implement EMR in rural Uganda. Here’s the story of Evelyn Castle, a college junior from UC Santa Cruz and clearly another extraordinary young lady. She received a $10,000 scholarship to support her efforts to improve health care in Nigeria. She leads eHealth Nigeria, an organization focused on improving maternal and child health through the implementation of reliable health information systems. Last year, she helped create the country’s first EMR system. This year, she’s going back to Nigeria to set up seven hospitals and five primary care clinics with eHealth Nigeria’s “Instant EMR” program. I wouldn’t say I was ignoring the world and its needs while I was in college, but I think I was more focused on creating sexy togas for frat parties then I was impacting the quality of life for millions. I’m humbled and inspired.

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.

Office Without Walls

I remember looking out the window of my 1,500 square foot, extraordinary office in Cleveland, Ohio and thinking, This is the life. To the north, I beheld Lake Erie. To the east, our vast academic medical center campus — a doubly breathtaking view. Behind me was an expansive work area, ample space for my wall of self-adoration, and a private conference room. But more crucial for a workout fanatic like me, I had a full bath. These luxuries helped take the edge off the intolerable winters.

I’ve arrived! So I thought.

My soul couldn’t reconcile with the setting. On one hand, I loved it. On the other hand, I hated it. Too remote. Pathetically rich. Overindulgent. Excessively comfortable. I found myself increasingly disconnected from those whom I had pledged to serve. It is not about you.

While serving as an army combat engineer officer, I learned that the best place to command on the battle pitch was wherever my people were fighting — the front lines, on the flank, from the rear, or from the air. But never could I lead troops from some corporate office. Lessons learned from this experience transferred to my civilian career.

A resolve to lead by example, coupled with the advances in collaborative technologies, I adopted the borderless office. This is not a new concept to those outside of healthcare providers. Many progressive companies embrace this concept, and telework has taken off. Study after study has proved the plethora of benefits generated by this approach despite its manageable downsides. Interestingly, most who disparage teleworking have actually never teleworked.

Two years ago, I sacrificed my office phone. I haven’t had an office in eighteen months — and the view still rocks. I’ve traveled the DFW Metroplex and beyond, yet don’t waste my organization’s funds by requiring or demanding multiple offices. I’ve typed e-mails from cubicles at one of our fourteen facilities.

I’ve met with hospital presidents on their turf and often surprised the local IT staff with a personalized word of encouragement. Clinicians share their gratitude when I engage with them i2i. I’ve set up conference calls in Panera and taken calls on the road. And occasionally, my wife lets me set up shop in her kitchen where the coffee is free. (Thanks, honey!)

How is this accomplished? My office is my laptop. It goes where I go. A soft phone, video, and built-in wireless network have liberated me from the confines of four walls. With fourteen hospitals to serve, I embrace mobility. If it makes sense for me to begin or end my day at home or at Starbucks, I do so.

Some of my direct reports have followed my lead and done the same. We do have a collaboration center, which we use for vendor meetings and team meetings when face-to-face interaction is necessary.

As of May 2010, well over 50% of our IT team telework a minimum of four days per week. They may be at a hospital or their home — anywhere they can best serve the customer. I expect this number to rise to 80% as more people choose to this option. The vacated space will generate material revenue for our health system, which can be reinvested into patient care, not cube farms.

For the past three years, we’ve been recognized in the Computerworld 100 Best Places to Work. (Actually, in the top 50.) I firmly believe our office-without-walls approach to operations was a key factor in this recognition. And I perceive a direct line between this award and the external recognition and accolades we receive as a healthcare system for the quality of care delivered. To boot, the borderless office helps us recruit and retain top talent.

Sadly, healthcare provider organizations in particular struggle with this concept; hence the low adoption levels. We acknowledge that we must change and transform, and yet when opportunity presents, we resist and find reasons not to embrace. We deem telework OK for the analyst but not the manager since they need to be visible. Visible to whom? Their analysts are all virtual. This is one example of the false perceptions yet to overcome before we see widespread adoption.

After experiencing the value it adds to our customers and ultimately our patients, I’ll continue evangelizing this work style and its benefits. With the pace of today’s society, if you’re not moving forward, you’re moving backwards. I’ll never go backwards.

And I’ll take the view from my virtual office over a lake or artifact any day.

Update 6/5/10

My typical spot at home, close to coffee, food, and bathroom.

Explaining the BlackBerry functions to Marlon Brando. It was a casual day for me.

I appreciate the comments, pro and con, on “office without walls”. A few answers/comments.

Managing remote workers is fundamentally a leadership question. If you need to physically see employees to manage them, than your leadership approach might need tweaking or you have the wrong employee. With knowledge workers, I believe a leaders job is to set the vision and then allow the expert employee to figure out the best way to get there. You can help by removing obstacles and then staying out of the way. We do have a policy around remote working and it includes an “agreement” completed by employee and manager to set expectations.

We have deployed VPN and other similar solutions that provide secure tunneling on remote networks. I can’t share specifics lest someone tries to hack me. LOL. Seriously, we believe our tools and policies meet or exceed industry standards for responsible computing.

Dr. Know, it is lame that this concept would be considered provocative. It is a sad reality. If we do not write about it and lead by example, nothing would change. We are behind. We need courageous leaders in medicine, healthcare, IT, medical staff, etc. Encourage, don’t discourage, and we will get there faster.

As Lacey pointed out, you can have an office and be transparent, and at the same time, you can have a borderless office yet be hidden. That said, these are not mutually exclusive. You can have the best of both worlds, being transparent and out there with your customers. That is certainly my objective, albeit I have work to do.

Ed Marx is senior vice president and CIO at Texas Health Resources in Dallas-Fort Worth, TX. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this 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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From The PACS Designer: “Re: Microsoft’s CDSA. The Clinical Documentation Solution Accelerator (CDSA) for Microsoft Office helps you create clinical document workflow by using Microsoft Office SharePoint Server 2010. CDSA is good for linking EMRs to other systems and also populating PHRs and CCRs.”

From Alan: “Re: Vermont Information Technology Leaders. It announces four more preferred partners.” They are athenahealth for revenue cycle, Concordant for consulting, MBA HealthGroup for implementation, and the University of Vermont’s Technical Services Partnership for services.

From LeBron Kydis: “Re: stats. I was charting the number of HIStalk visitors from day to day (I know, it’s a little neurotic) and realized the number of subscribers could be more interesting to watch as it climbs. Any chance you might include that number with the number of visitors?” Wow, that is compulsive. Bad news on the subscriber list, though: unlike the visitor count, there’s no widget to display it automatically. This will get you started: the confirmed count as of this minute is 5,565.

From FLgal: “Re: Epic. Tampa General (affiliated with USF) is implementing Epic. Shands (affiliated with UF) is also implementing Epic. Supposedly those two are collaborating with University of Alabama (not sure of the hospital name) to create a southeastern arc of Epic hospitals. Combine that with all the hospitals in Atlanta that are implementing (or thinking of doing so) Epic, and you’re got quite a nice chunk of the US covered by Epic.”

From A Family Affair: “Re: UPMC. A highly wired hospital with a highly connected leadership family.” UPMC paid $10 million last year to companies with ties to its directors and executive management. Relatives of the CEO, who himself made $5.16 million in 2009, received more than $3 million in payments, including his $265K daughter who was a contractor and is now executive director of UPMC’s technology development center. The CEO’s former son-in-law made $260K (until his wife divorced him and thus went his job) and his brother raked in $2.48 million for advertising. They didn’t ‘fess up until hearings convened by my hero, Senator Chuck Grassley.

Fletcher Allen Health Care lays off 23 transcriptionists who were rendered obsolete by technology such as EMRs and speech recognition. I feel bad for them, but that’s a nice plug for the cost saving potential of Nuance’s eScription, which I believe FAHC uses.

It was just over a year ago when Compuware inexplicably hired disgraced former Detroit mayor Kwame Kilpatrick to sell healthcare software, giving him a cushy six-figure job barely a week out of prison (what the hell were they thinking?) Well, today they got to fire him: he’s going back to the slammer for violating the terms of his probation. He tried the sorrowful apology route yet again, but the judge wasn’t buying it this time: he’s going away for at least 18 months and possibly up to five years. You can read up on his checkered background, but get comfy first because it will take awhile. Please hold for a job offer on Line 2, Mr. Blagojevich.

Michael from Bitwork offered an explanation of the article I mentioned that said a Hawaii clinic was saving 55 hours a month through some unspecified change. They were manually assembling quality measure information using standard reports offered by their EMR, he says. The change was to implement Bitwork’s solution, which collects the information in the background and presents it as a scorecard.

Stung by the defection of HIMSS and other conferences because of absurd costs, the governor of Illinois is considering signing a bill that would limit union shenanigans at McCormick Place. Naturally being Illinois there’s all kinds of dirty politics, union wheeling and dealing, and favoritism involved, not to mention that attendees will get stuck with newly increased bus and taxi fees to generate funds for marketing the convention center.

Weird News Andy labels this story as, “I’ve heard of dropping a transmission in a car before, but not a baby.” A Minnesota woman who is feeling labor pains drives off for the hospital, stopping to pick up the baby’s father, who can’t drive because he has epilepsy. Her water breaks while driving, she yells for him to take the wheel, and she shucks off her pants and delivers an eight-pound baby boy right in the driver’s seat. She summarizes, “I was just sitting on the seat and he just slid out.”

Some Epic youth filmed a video of the famous on-campus treehouse. I’m beginning to think I need one of those for philosophical reflection or something like that since I’ve always wanted one.

Inga and I have jumped on the Facebook bandwagon because so many of HIStalk’s readers are active there. I’ve made a site change that puts a little blue Facebook icon at the top right of every post. Click it and you can easily and quickly publish the article link with your comment to your Facebook feed.

Connecticut Attorney General and US Senate candidate Richard Blumenthal apologizes for not being “clear and precise” in claiming Marines service in Vietnam that he really spent stateside. That’s newsworthy here only because he’s the brother of national coordinator David Blumenthal, which I happened to see in one of the newspaper articles after thinking they sure look alike. You would think serving honorably in the Marines in any location would be enough without having to embellish, which hopefully he’s realizing.

Speaking of David Blumenthal, he was the commencement speaker at the University of Florida College of Medicine’s graduation this past Saturday. He told them most of what they had learned would be obsolete shortly, a sad but true fact and another reason to use technology to support pushing current best practices to the bedside.

The Raleigh, NC newspaper takes heat from UNC Health System employees after publishing the organization’s salary database online, including employee names and ages.

Tri-City Medical Center (CA) looks into alleged privacy disclosures involving employees and Facebook, denying a rumor that 26 employees have been disciplined. One conclusion is that hospitals need a social networking policy. Policies don’t usually work, of course, but at least you have grounds to fire violators.

Federal CTO Aneesh Chopra, speaking at the American Telemedicine Association conference, calls for great healthcare technology ideas and recites some examples: Voxiva’s Text4Baby (I interviewed head guy Paul Meyer in November), a Case Western Reserve telehealth project, American Well (which I just mentioned), and Project Echo (I interviewed Director Sanjeev Arora in October).

Speaking of innovation, I’ve had some conversations about scouting out more of those in HIStalk (I’m non-disclosed to say who those conversations were with, but you would probably be impressed) It could be as simple as doing interviews like those above, or it could be evaluating products with potential to benefit the healthcare system as a whole (not necessarily for their business potential, which others are doing already). If you have ideas of how to do this or want to help in some way, let me know. I was thinking of offering companies or developers the chance to pitch their wares and have them evaluated by a panel of expert HIStalk readers, but I always have high-falutin’ ideas that I don’t have time to execute properly because I’m working two full-time jobs already. In any case, if you know of cool, innovative technology that’s delivering results but not getting much attention (preferably as a user and not a company pitch person), let me know.

Monday is Memorial Day, set aside to honor men and women who have lost their lives in military service involving conflicts both popular and not. Flags are cheap, easy to find, and fun to hang (and I’m reminding you way ahead of time). And unfortunately, they stand out nicely in most neighborhoods since everybody’s too wrapped up in picnics and car races to think about dead service members and their families on the one day per year set aside to pay those respects. So if you’d like to be a rebellious contrarian like me, hoist Old Glory on Monday. End of good-natured soapboxing. 

The VA’s VistA Modernization Report

A reader sent over a copy of “VistA Modernization Report”, the work product of a committee that was convened to advise the VA about modernizing VistA. Its recommendations:

• Stabilize VistA by freezing the code to some degree, releasing only enhancements needed for patient safety or mandates.
• Contract with a research group to develop tech specs for a new open source VistA replacement.
• Contract creation of a prototype.
• Contract development of a foundation to manage the new, open source VistA.
• Get more widespread VistA deployment outside of the VA by creating an easier delivery model.
• Replace VistA’s functionality screen by screen.
• “Harvest everything of value” from VistA.
• Use commercial software where needed to complement VistA’s core functionality.

My reaction: big government contractors are wetting themselves at the prospect of getting a chunk of what is sure to be a massive cost. Remember VistA’s history: it was mostly developed by skunkworks programmers defying management orders and working directly with end users. It was not developed under an open source model and wasn’t cheap to build – it just happens to be free because taxpayers paid for it, which makes it available under the Freedom of Information act.

Software rewrites have ruined even nimble organizations who didn’t have to deal with bureaucrats and fat cat contractors. And let us not forget the $450 million taxpayer-raping by BearingPoint’s CoreFLS ERP system, overseen by an apparently napping VA IT management and mercy-killed during its beta testing when it nearly shut down Bay Pines Hospital in Florida.

All of this sounds like the usual feel-good consultantese, soothing and logical in a perfect world, dangerous when you’re dealing with the federal government and its cadre of trough-lappers. And who cares if VistA adoption is minimal outside of the VA? That wasn’t the point of writing it.

Software rewrites are usually a really, really bad idea, advocated by techies and mid-level managers who see the fun of working on something new instead of the gaping black strategic hole beneath them. The VA was lucky that VistA turned out as well as it did, but it’s a one-trick pony not likely to be repeated.

Open source or not, wanna bet this will be a billion-dollar project if it gets approved? Heck, HP got $784 million back in 2004 just to support VistA going for ten years, so imagine a stimulus-happy administration getting to announce this grand vision in front of veterans and former civil servants turned contractor lobbyists. Most vendors (including the ones that would provide commercial systems to the VA where needed) are selling systems that are just as clunky and outdated as VistA. Most of the time, they work just fine, especially if the whole package was built by the same company instead of being acquired from failing vendors anxious to sell out.

Maybe the VA should just do what everybody else seems to be doing if they really think VistA is on its last legs — buy Epic and install it using the Kaiser model. I wouldn’t want VistA replaced for the wrong reasons, but if it’s really necessary, then I’d rather see them writing Judy a huge check for a known quantity instead of a series of never-ending ones to the usual government contractors who have stars (and stripes) in their eyes.

That’s my uninformed opinion. What’s yours?

HERtalk by Inga

Baptist Health System (AL) selects Compuware’s EHR Service Delivery Solution to monitor performance and availability of its EHR.

All Children’s Hospital (FL) expands its relationship with Mediware, adding BloodSafe Tx for patient and blood verification.

The 107-bed Pioneers Memorial Healthcare District (CA) will replace its QuadraMed Affinity Clinicals with QuadraMedCPR.

Walmart cuts the price of the iPhone to $97, AT&T raises its early termination fee from $175 to $325, and rumors swirl that Verizon will soon offer service for the iPhone. Must be almost time for Apple’s Worldwide Developers Conference. June 7th is the date we’ll likely hear more about Apple’s 4G version (with video-chat, perhaps?)  plus maybe news of a Verizon deal.

Maybe one of our marketing genius readers could explain why a company would even bother to create and distribute a press release like this? Mr. H puts it on the short list for stupidest press release ever written. The company is obviously trying to raise money for programmers and designers. If they are successful, I suggest they put a few dollars aside for marketing.

If you are an HIT purist, mosey on to the next news item. A woman is denied entrance to Yankee Stadium because she is carrying an iPad. Seems the Yankees have a “no laptop” policy and a security guard placed the iPad in that category. Not be deterred, the woman put the iPad under her jacket and went in another gate. I gotta say I like this lady because she likes her technology, likes her baseball, and is willing to be a bit sneaky to get her way. Anyone who has ever scored a baseball game has to love the the idea of using an iPad to run the cool-looking iScore app.

A former University of Washington Medical Center patient complains to the local press when a hospital representative called his unlisted number to solicit donations. Turns out that HIPAA specifically allows medical centers to use patient information for fundraising activities. UWMC offers an opt-out alternative, but it requires patients write a letter to the hospital’s privacy office. I’m all for fundraising, but shame on any hospital using such tactics. At least make it easier to opt out on the front end.

Forty private equity firms form the non-profit Healthcare Private Equity Association to support the healthcare PE community. The association’s members represent about 500 healthcare portfolio companies and combined revenues of $200 billion.

Speaking of private equity investments, Phreesia announces the close of $16 million in Series D funding, led by Ascension Health Ventures. Phreesia’s technology platform automates patient check-in in physician offices and urgent care centers.

Coming soon to HIStalk Practice: a new question in our HIT Vendor Executive series (sign up for e-mail updates so you don’t miss it!) This month’s question is, “If you could give David Blumenthal one piece of advice, what would it be?”

A few quick updates:

• MEDecision names Eric Demers as SVP of life sciences.
• Three new hospitals select McKesson’s Practice Partner EHR and PM for their employed and affiliated physicians.
• Wolters Kluwer Health promotes Susan Driscoll from EVP to president and CEO of the company’s Health’s Professional & Education Business Unit. She takes over for Gordon Macomber.
• Pomona Valley Hospital Medical Center (CA) implements the Access e-Forms Repository, providing direct access to users from its Siemens Soarian portal.
• The Johns Hopkins Hospital goes live with iMDsoft’s  MetaVision AIMS in 39 operating rooms.
• St. Elizabeth Regional Health (IN) contracts with TeleHealth Services for interactive patient education systems.
• Healthcare Management Systems names F. Bradley Meyers its director of integration and Interoperability and Neal Reizer as chief architect.
• MEDSEEK awards Spectrum Health (MI) its 2010 eHealth Excellence Award for its use of eHealth technology.
• Halfpenny Technologies’ ITF-GoDoc solution now includes a new critical value alerting feature that allows hospitals or labs to send  results to physicians’ smartphones.
• Integrating the Healthcare Enterprise International names the College of American Pathologists as the primary sponsoring organization of the IHE Laboratory Domain.

E-mail Inga.

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Robert Murphy, MD is chief medical informatics officer at Memorial Hermann Healthcare System of Houston, TX.

Tell me about your priorities at Memorial Hermann.

I’m the system CMIO at Memorial Hermann. The organizational priorities really continue to be the same. We’re trying to drive quality, creating the best experience for our patients and our physicians.

The Meaningful Use thing that just came out has helped stimulate or augment the priorities, but really, they were things we were doing already. It may be helping us accelerate in some areas faster than others, but we already had CPOE planned across the enterprise. We already had CDS [clinical decision support] in a pretty deep fashion.

We’ll probably add a little bit more in the documentation and maybe getting more effort on the ability to exchange information with our physician practices. We had all of these elements in place even before the stimulus plan was announced.

What’s your reporting structure?

I report directly to Dr. Mike Shabot, who is the chief medical officer, and dual-report to David Bradshaw, the system chief information officer.

How about underneath you?

I have the area of medical informatics — CPOE and clinical decision support. I have the groups that do the order sets and support the CDS. Also, some pharmacist informaticists and some outcomes folks who work on my team.

What are your thoughts about the value of CPOE in outcomes and patient safety based on recent studies? You’ve done this in more than one place.

You know the history of the literature. You know some of the things that have come out with potential unintended consequences, and I guess I’ve been a consumer of whatever research and practices and articles that come out to learn from whatever those experiences are. I think there are certain things that, as a physician, clearly you see the benefit of simple things like handwriting. Having practiced for over 10 years, I saw quickly that handwriting is a contributor in many ways.

In addition, you start to see the benefits of what clinical decision support can do. That’s probably the area that I feel is the most valuable in all of this.

On the flip side, seeing the potential for unintended consequences has made me very thoughtful and exhaustive in preparation to make sure that we do everything we can to prepare the medical staff, prepare the clinical operation staff, and to be very dynamic in responding to issues that come up.

It’s clear to me that well-implemented physician order entry with decision support can make improvements in quality of care. Internally, certainly we are seeing some demonstrable quality outcomes from that. We’ve gone a slower approach than many, so our implementation, our first two hospitals, went service line by service line over a month. It took us almost two years to get to 75%.

That was really by design and slow and purposeful, but now as we’re bringing in additional campuses and departments online, I think we’ll be able to accelerate. I think the initial focus on careful, slow attention has been beneficial.

Are you a Cerner shop there?

We are.

Everything that you have on the clinical side is Cerner?

Everything but our OB department. That’s the only major clinical area that’s still not Cerner.

How should hospitals approach the clinical decision support requirements of the proposed Meaningful Use criteria?

You really start to see several buckets of where clinical decision support is important. The first is there’s just simple check objectives — do you have drug-drug interactions, drug formulary, drug-allergy checking? I would say that’s often the most rudimentary type of decision support.

In fact, the more and more we evaluate it, the more we are refining that from the simple tool that the vendors supply. For instance, the major pharmacy databases — First DataBank and Multum — come packaged with these drug-drug interactions. The longer we’ve gone, the more we’ve customized and turned off the alerts that are not that helpful clinically. To sites that are just going live, I think it’s some thoughtful caution and what level you set any of those settings. That’s the first big bucket of those simple ones.

Then you get into the current proposed objective that says you must have five CDS rules and those must be related to the quality measures. I think that was in advance from the original draft, and I think it’s one of which most of us embrace and are happy to see.

That gets into the more complicated type of decision support of workflow and how you’re going to capture these patients. What’s the correct trigger? What’s the correct notification to what user at what time? Folks here knew those quality measures.

If folks are just getting started, they need to keep it as simple and straightforward as they can. Simple things like on an order set for an acute MI — make sure the aspirin is checked or contraindication is documented. The one thing for some advanced hospitals is, if I look at that one — aspirin in acute MI — most of our hospitals are 100%, and have been so for the last six months.

Is that helpful for us to put a rule in place for something we’re already 100% for? For us, probably not. But for hospitals that aren’t 100% and need something simple to get in, those are thing kind of things I think you’ll see them focus on.

The third element is what clinical decision support can maybe bring as you continue to advance the tools that you have. One that we’re investigating right now is how do you correctly populate a problem list? For a large organization, on the inpatient hospital side, managing a problem has become very, very difficult with so many users — physicians, consultants, nursing, and others.

What is the most valuable part of a problem list? From a CDS perspective, we may, in fact, try to focus on identification of certain conditions — diabetes, high blood pressure, heart failure — that we can identify with good specificity and maybe add those as part of our CDS portfolio. You start to see, again, from the rudimentary to the more advanced organizations, will have to progress. I think most places will have several years to get there, but it’s still going to be a big challenge for small hospitals, I think.

Most clinical decision support isn’t guidance, but rather non-personalized canned warning messages that are either turned on or turned off for everyone. What about being able to tailor specific types of warnings to specific practitioners or types of practitioners?

We have those features in place and I would say most large vendors’ sophisticated CDS engines will have those capabilities. The problem is the work that requires for that customization. It takes an analysis of workflow and even certain elements of credentialing — which user can or cannot respond and answer to a request to initiate an order? Can it be a nurse or pharmacist or a mid-level provider, or must it be a physician? At certain places, is it the resident or the attending?

It gets into such role-based specificity it really is a challenge, even with the tools that are available. They often allow that flexibility. It’s a real burden for organizations how to effectively analyze, plan, monitor, and continue to improve those sorts of tools.

But in general, it seems there’s a gap between what outsiders who are setting these things up think physicians should need to see or want to see, versus those that the real practicing doctors actually find useful. How do you address that gap?

That, again, shows you the scale from the rudimentary — the drug-drug interactions. For instance, we’re a large organization, so we’re doing the specific work. We will turn off the Multum pharmacy formulary drug-drug interaction. We will most likely build a custom alert that will be able to analyze several parameters of that drug-drug interaction, not just this patient falls into a generic category, but your patient is this age, this weight, on these other medications all at the same time; you may want to consider X, Y, and Z. That’s the complexity that it’s going to be there for.

I do worry a little bit about the industry just trying to put in drug-drug interactions from a generic platform across large organizations or large populations. I think you’re going to see more and more refinement, and hopefully, tools for which we can all share that information.

You’re starting to hear discussion on how are we going to build these repositories of CDS knowledge through perhaps the AHRQ or other groups who could help us catalog that information that could then be more easily implementable. Right now, that’s the most basic, core format — things like drug-drug interactions that have very low utility.

The average hospital subscribes to First DataBank or Multum or whoever and then just selectively turns things on and off because that’s all the time and resources they have. How much of the value of decision support are they really getting by just looking at those warnings versus real guidance that let doctors make the right decisions instead of telling them when it looks like they didn’t?

I can share our internal experience once we began looking at specific drug-drug-based pairs. When I started five years ago, we had a large population of drug-drug interactions that were overridden 100% of the time. We had pairs that were 98-99% of the time. You start to see the incredible burden that has. That may lead to alert fatigue.

I think we need to continue to study alert fatigue. There may be a critical CDS rule or intervention that is very specific and very sensitive and very important to be addressed. If, however, that’s firing in a constant bombardment of 10 or 20 interactions and interventions, the truth is, you will begin to ignore the most important interventions.

Our attention in the last several years has been to turn off the generic, non-specific items and build more and more custom. I think it really does create some challenges for smaller organizations to address that. I just have to hope to continue to see the industry and some of the specialty societies in informatics and AHRQ who can then help us come up with more specific proposals for effectiveness in the CDS space.

The announcement just came about of the three big hospital systems that licensed their order set content to Zynx. That didn’t work so well when Eclipsys paid a fortune for Brigham’s BICS rules back in the ‘90s. Do you think that the rules that one facility creates are useful to others?

There again, you get into some of the local details that need to be built, as opposed to the medical evidence that needs to be somewhat codified. That’s where I look.

I know the AHRQ has a project underway to look at screening recommendations. Those are pretty straightforward on the evidence, but once again, that information is very helpful for us to share. Even our experience on the effectiveness of a certain rule may be useful. But as far as sharing the actual codified rule, even among Cerner clients, that’s often just a template to get started, but it often takes the customized work from the local environment.

I can give a couple of examples. What is the correct value of a potassium warning? Is it 5.0, 5.5, 6.0? You can look at it a lot of different ways, but often the sensitivity and specificity is inversely related as those levels go up. Somebody at some point must make an objective decision what it’s going to be. Is it going to be 5.5, 5, or 6? Most often, you’re going to need a local decision on governance to see what your final flag might be set at.

Isn’t that kind of a conundrum, though? All these rules that are very black-and-white specific, yet every hospital says, “I don’t like the way those come.” Is medicine really scientific enough that a rule ever fits?

You can continue to imagine, with a large amount of data points, to make them more and more specific. Like I mentioned earlier, the more specificity you can have on a patient’s age and weight and previous medications and previous problems, they give you more data elements to make the rules and interventions more specific. But once again, you’re looking at large computing power. You’re looking at ways to not negatively impact response time, for instance.

It remains, I think, one of the big challenges in the field is to have things that have a very high positive predictive value — that when an alert fires, it changes behavior. I guess the ideal state would be that’s the only kind of intervention that would fire is when it changed a behavior. Most groups think well, if you can get above 50%, you’re probably doing a pretty good job, but approaching 100% will be very difficult. If you can get above 50%, most of your users are finding things more helpful than annoying. That’s probably a reasonable goal for most interventions.

You can measure that. Are you shutting off those that don’t change behaviors?

Absolutely, and that is another component of the work required to have effective CDS is that monitoring. As I mentioned, we do analyze response to alerts. We look at the clinical outcomes, not just the response to the alert.

Another interesting fact we’re discovering is there are times in which the alert is overridden, yet later, the correct behavior is changed. At first thought you say, “Well, they overrode the alert; therefore, it was useless.” But it turns out, in certain situations, you’ve at least prompted them to think about things. You notice as you analyze more data that they actually did make a positive response.

Certain elements such as warfarin dosing with an elevated INR — that’s been a classic example where we’re seeing that those alerts are helpful even when they override the initial alert. They can maybe dose it more correctly later in the stay and during the days of administrations. It’s a component of correct design and monitoring and continuous feedback to make them better and better for the users.

I think people miss the fact that CPOE itself is clinical decision support even without all the warnings and alerts because it presents only the most common orders and the preformatted doses. Would you agree?

I absolutely agree. I think that’s what you find in the folks that do this work longer and longer. You realize that clinical decision support is really a comprehensive approach that includes how you structure your data. How you present information is even a form of decision support.

Then, the computer-based logic is only one component, but how you build the order sets, the choices you give for selections, are often — we use the phrase, “You want to make the right thing the easy thing.” You want to make the right thing in the information you present them; the right thing in the orders and the sequence of the orders, the choices that are most available; and the right thing in a clinical decision support rule that may help catch things that were missed at first. All of those elements together help you have that comprehensive approach that’s necessary, I believe.

You’ve done some work with mobile devices.

That’s been an interesting journey as well. We were a very early adopter, six or seven years ago, at Memorial Hermann. At that point, I think there were some big technology barriers — large devices, heavy batteries, needing an internal wireless network connection — that were a struggle.

Now we’ve advanced into more the iPhone-enabled group. Once again, it’s the right device with the right information at the right moment. The big one we’ve seen a huge success on is the AirStrip OB product, which allows fetal monitoring to be seen by our obstetricians. They can talk directly to the nurse about what patterns they’re seeing. It’s had a large and growing usage with our obstetricians. It’s wonderful to hear from the nurses that they feel so much more connected to the physician in being able to review strips remotely together and then making a good decision. That particular product has been very well received.

We’ve not really gone into clinical systems on our mobile platforms. We have a trial coming up this summer of one we’ve internally developed for the iPhone, and it’ll just be a snapshot of patient data. The great thing about iPhones and web development is that those things can be pretty straightforward to produce, and so we’ll be trialing our own internal version of that later this summer. We’ll continue to see.

We’ve understood vendors are out there with CPOE Lite products, but at a certain point … I’m not sure. It might be a nice bridge to help physicians though it, but for a large enterprise, I’m not sure it’s going to be the kind of solution that they’re looking for.

You mentioned that you’re pretty comfortable, or had an early start at least, on Meaningful Use. Based on the proposed criteria, how prepared is Memorial Hermann and what to-dos do you think you need to accomplish to be ready?

I guess the biggest one is going to CPOE at what percentage at our hospital. We have 11 hospitals. Our first two hospitals came live with CPOE.

We clearly had the strategy. The hospital would come up and we’d get the hospital totally up to a 75% or higher physician ordering usage. Once we had that, we quickly realized at that point, that was the inpatient ordering, and we then realized that it was critical to have our ER on the same system. So, we actually took a pause and we have installed the Cerner FirstNet product while that was going forward. With that, all of our ERs are going CPOE, so that’s really the first unit in all of the other hospitals that will go live with CPOE.

Well, Meaningful Use came out and said there’s a 10% threshold. We thought, well that’s great, because the ER would cover that 10%. Then, to find out they’ve actually excluded the ER from that calculus at present.

Once again though, we’re not going to alter our strategy. We’re going to finish our first wave of rollouts. Then this fall, we’ll have additional hospitals coming up. But we still believe that we need to have a hospital-wide approach. We don’t want to get on a partial 10% of every hospital just to get the number. Some of our hospitals will be delayed. 

That’s probably the most challenging of the measures to hit. Most of the other measures we have good plans for and projects in place. I think we should be able to meet the other objectives pretty straightforwardly.

Any concluding thoughts?

As a physician, I got into this field of medical informatics, you know, you want to make a big difference for an organization and for patient care.

The longer I’m in this, you start see that people, process, technology triangle that defines medical informatics. I think it continues to be in that order — the people, the process, and then the technology. I’m finding that with the right amount of money and the right engineering and support staff, you can get the technology right.

The people and process of healthcare are challenging in the nature of healthcare. Often they’re just challenging from being the cottage industry that we are. That individual autonomy is such a strong current. But you hope and you start to see that by providing tools that provide consistency and standardization and provide value that you can help drive hospitals and populations to improve care.

I think that’s what I continue to focus on, really — the people, process, and technology. If we can keep focused on that, hopefully we’ll continue to do good work.

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