From Scatman Crothers: “Re: Stanford Hospital and Clinics. Replacing Dell Perot, which has just a few months to transition and leave. Accenture is taking over the whole thing.” Unverified. Perot got that seven-year deal in 2004, so maybe Accenture won the next round.

From No Surprise Here: “Re: EMRs. A study of California hospitals shows minimal positive effects of EMRs.” I hesitate to comment because the article is not up in full text yet, but it concludes: “EMR implementation was associated with 6-10 percent higher cost per discharge in medical-surgical acute units. EMR stage 2 increased registered nurse hours per patient day by 15-26 percent and reduced licensed vocational nurse cost per hour by 2-4 percent. EMR stage 3 was associated with 3-4 percent lower rates of in-hospital mortality for conditions.” I’ll be interested to see whether the authors attempted to quantify before and after results from individual hospitals, and if so, how they handled the other variables that surely changed in the study’s nine-year timeframe. My experience with these database-driven analyses, usually conducted by publish-or-perish academics, is that they use public information that’s conveniently available but not terribly relevant, leaving logic holes you could drive a truck through. I’ll review the article once it’s out.

From Jennifer: “Re: CPOE and meaningful use. My hospital uses protocol orders for meds that are triggered by specific criteria. For example, a lady comes in with a troponin of 1.0, which orders a contraindication screening for the nurse to complete. If no contraindications exist, then aspirin and Toprol are automatically ordered. These orders go to the queue for the attending physician to sign and are driven by evidence-based practice, but aren’t considered written, verbal, or direct. How would these be defined under Meaningful Use?” I’ll say upfront that I have no idea and I doubt HHS does either, but it seems reasonable to count them as physician-entered (feel free to correct me if you know for sure). The physician has agreed to use of the protocol and is the first signer of the order, so that sounds like a CPOE order to me and it’s certainly not a paper order. I’ll also add that one of the seldom-discussed aspects of MU is that it resembles Most Wired in that you turn in your own numbers with minimal chance of being audited, so in the absence of definitive guidance, I’d count those orders. Not to mention that evidence-based order sets like this are exactly what the government should be encouraging.

From HIT Insider: “Re: Eclipsys. Another sales leader departs – Jay Colfer, SVP who managed the biggest revenue producing team in the company. Big loss.” Unverified, but not surprising if true. If you’re a sales stud, you can work anywhere without the uncertainty of an impending acquisition on prospects and your own career possibilities. I wouldn’t say it’s a negative development for either the company or the individual.

Listening: new Iron Maiden, slower and more complex than their frenetic 80s stuff, lapsing more into non-wimpy progressive (think Ritchie Blackmore’s Rainbow or Rush with some AC/DC admixed in). I never liked them much, but this is really good. It’s a long album, but I’m on my third listen and liking it better each time.  Based on this live video, I’d definitely go see them.

Weird News Andy warns ahead of time that this story might offend some sensibilities, so I shall word it carefully. A newly delivered mother in China claims that her midwife, unhappy with the insufficient tip given to her by the father, sutures shut a nearby but unrelated opening. Also from WNA: a quality analysis concludes that church-owned hospitals deliver better quality care than for-profit ones, with Catholic hospitals also outperforming community hospitals.

HIMSS is involved, for some reason, with a November advertising insert in Forbes called Transforming Healthcare Through IT. The pitch: “Produced in partnership with the Healthcare Information and Management Systems Society (HIMSS), Forbes’ special Health IT report offers participating advertisers the opportunity to share how your organization will contribute to healthcare transformation through IT.” Whatever happened to just doing it instead of preening in front of a business reader audience? I’d bet that the only companies that sign up are those that are publicly traded or those that yearn to be.

Thanks to AdvancedMD for supporting both HIStalk and HIStalk Practice at the Platinum level. The Draper, UT-based company offers a Web-based practice EHR, practice management, medical billing, scheduling, and e-prescribing. The company also offers its AdvancedBiller program, which connects billing service partners with practices. As often happens, our first contact with the company was when Inga interviewed CEO Eric Morgan a couple of weeks ago, apparently triggering the company’s interest in supporting what we do. It’s a good interview — Eric and Inga covered the pros and cons of being a privately held company, EHR market consolidation, how AdvancedBiller competes with companies like athenahealth, and the influence of hospitals on practice EHR adoption. Thanks to AdvancedMD for supporting HIStalk and its readers.

University of Chicago Medical Center partners with a technology company to produce an epilepsy monitoring system that uses Bluetooth and a smart phone to continuously stream EEG information to a monitoring center. Interesting: it won’t work in iPhones because Apple hasn’t opened up the APIs it needs. Also interesting: the company has patented a technology that uses text messages to trigger smart phone events, which I assume means that monitoring centers could “order” additional diagnostics remotely by cell phone.

Industry longtimer J. R. Hughes, most recently at McKesson, joins the nine-employee healthcare consulting firm The Winkenwerder Company, which has some impressive clients.

Patient Privacy Rights releases its Health Privacy Risk Calculator, which is really kind of pointless since just about every American will score in the High Risk red zone (it only takes three positive answers to questions such as do you have insurance, do you take prescription meds, and do you pay for any health-related products using checks or credit cards). Actually, I guess that was the point.

Holzer Consolidated Health System (OH) chooses help desk and performance monitoring services from CareTech Solutions.

I’ve joked that the VA and DoD should get rid of their expensive, contractor-managed systems and just buy Epic even though I’m not sure it could cleanly replace VistA or AHLTA. I recently mentioned the NextGov-generated nugget that the DoD is soliciting proposals for an AHLTA replacement. If that happens, there’s no way it will be any vendor except Epic, even though Cerner got its foot in the VA’s door by selling them Millennium lab (or nearly so — I’m not clear on whether a deal was ever signed). Epic’s the only company with experience with decentralized organizations of that size (Kaiser), not to mention that Epic’s nearly clean-sweeping the big hospital market. Benefits to DoD: it’s ready to implement instead of taking years of expensive AHLTA rewrites, it won’t choke like some of the bad software that the trough-lappers have written for the government, it will be a heck of a lot cheaper, and lots of clinicians will already know how to use it. Disadvantages: Epic’s “our way only” model won’t fly too well with the military brass, it will be missing quite a few key pieces that are unique to DoD, and there would be quite a culture clash between the Woodstock-like bunch from Wisconsin and the inside-the-beltway crew cuts.

Sponsor jobs: Web Developer, Regional VP, Project Manager/Web. On Healthcare IT Jobs: Sales Client Executive (New England), Health IT Sales, Director of Ancillary Systems, Senior Director, Applied Clinical Informatics.

I mentioned the Emendo CapPlan capacity planning software back in May. The New Zealand company wins a six-hospital deal in Canada and says it’s still planning to go after the US market.

Philips invests in a $250 million medical technology venture capital fund that will focus on home health, sleep improvement, image-guided therapies, and clinical decision support.

Rhode Island Congressman Jim Langevin visits fast-growing EHR vendor Amazing Charts, with the company’s presentation including such items as forced EHR adoption, overpriced EHRs, and the need for transparency of Regional Extension Centers (the company’s obviously got a bit of a ‘tude, which I like).

McKesson CEO John Hammergren was one of the HP board members who forced Mark Hurd out. Wonder if he’s a candidate to replace him?

Former TeleTracking sales VP Joseph Gentile joins another Pittsburgh company, healthcare robot vendor Aethon, in the same role.

MidSouth eHealth Alliance signs for the CareAlign HIE solution from Informatics Corporation of America (still my favorite company name).

Testing the North Carolina Healthcare Exchange: WakeMed and Moses Cone Health System.

Israel-based satellite services vendor Gilat Satellite, which wrote off its $4.5 million investment in Axolotl almost immediately after it made it 10 years ago, will get $24 million in cash from the proceeds of Axolotol’s sale to Ingenix, with the possibility of getting another $3 million per the contract terms.

I’m trying to strike at least a sham of work-life balance lately, so naturally I’ve fallen a bit behind as a result. I promise you’ll like me better if you indulge me by patiently awaiting any delayed e-mail replies.

E-mail me.

HERtalk by Inga

athenaHealth announces a standalone option for its athenaClinicals product. Clients had been required to use it with athenaCollector. Removing the billing and PM service requirement will likely help athenahealth get into more opportunities, especially those involving hospitals and their affiliated physicians. Pricing is expected to be a flat fee per provider per month, based on patient volume.

The Homeland Security Department plans to acquire an EHR to manage illegal aliens detained by immigration officials. DHS says the EHR could be a commercial, government-developed, or hosted service.

Over half a million Mississippi Medicaid beneficiaries can now use Shared Health’s HIE, whose contract with Mississippi Medicaid includes the implementation of an EHR and e-prescribing system for state Medicaid providers.

Now this could be fun. Jonathan Bush from athenahealth Girish Navani of eClinical Works square off to discuss their views on the future of HIT and how each is dealing with their larger rivals. It’s September 29th in Boston.

CMS names Ingenious Med an official 2010 PQRI Registry.

St. Edward Mercy Medical Center (AR) is scheduled to go live September 26th on Epic. The local paper shares some of the detail on training requirements for users: physicians 12-16 hours, nurses and LPNs 24 to 27 hours, CNAs 6 hours, and schedulers 4-28 hours. Physicians with the hospital’s cross-town rivals are also preparing for an EHR live. By the end of the month, Sparks Health System should have several practices operational on NextGen’s EHR.

From the latest HIStalk Practice: Good Neighbor Community Health Center (NE) selects Sage Intergy CHC; the AAFP’s Center for Health raises some concerns about Meaningful Use; and, compensation for doctors in hospital-owned groups now exceeds pay for those in other type practices.

St. Charles Health System (OR) selects Velocity Technology Solutions to host and manage its Lawson ERP and Kronos time and labor management applications.

Cumberland Consulting Group promotes Amanda Hage to principal.

Members of West Virginia’s Governor’s Office of Health Enhancement and Lifestyle Planning discuss the hurdles of adopting HIT and agree that EHR utilization is a problem. Stephen Sebert, MD, the council chair for the West Virginia Medical Association, provided this comment: “I have an electronic system already, but the thing is it’s not being used.”  Don’t you know his EHR vendor is cringing a bit.

Rebranding: the 20-year-old Medical Transcription Industry Association changes its name to Clinical Documentation Industry Association.

The interim administrator of Coshocton County Community Hospital (OH) says the hospital will begin a six-month installation of a new Meditech system in April. Financing for the $4 million project may be an issue: as of July, the hospital had a $3.5 million operating loss. The administrator says funds for the $246K software down payment are available from reserve funds and financing options for the rest of the project “will be researched” between now and April. The hospital hopes the system will eventually qualify them for $4.5 million worth of stimulus dollars. I wonder how many dozens (hundreds) of community hospitals around the country share similarly dismal financial pictures? Meditech, by the way, was chosen over two other vendors for “functionality, cost, and meeting government mandates.”

GetWellNetwork introduces a new interactive care solution designed for senior patients.

Orlando Health (FL) and Advocate Good Shepherd (IL) contract with PerfectServe for its clinical communications system. In addition, Hoag Hospital (CA) signs an agreement to expand its PerfectServe services to its new Irvine facility, scheduled to open later this year.

E-mail Inga.

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Peter Neupert is corporate vice president, Health Solutions Group, of Microsoft of Redmond, WA.

 

I haven’t heard much about HealthVault lately. How would you characterize that product and the personal health record market in general?

You have to remember that the personal health record market is a function of how connected is it, right? People don’t want to enter data on their own. They want to be able to connect with their physicians, or connect with their service providers. What we have been focused on is providing the plumbing to get the connections. 

I think there’s been a lot of interesting or exciting activity in the last year, mostly at the policy level. When you look at Meaningful Use and Blue Button and all those things that are saying, “Hey, let’s all get together to get the plumbing going, and then we can really unleash the power of HealthVault,” which is to say that I can share the data, I can reuse the data, I can have applications take advantage of this connectedness in addition to what I want to do direct with my physician or care provider.

I think it’s been an idea that has been very, very helpful in framing the debate, in framing what the right answer is, making people understand that it was feasible and doable, and here’s what it would look like and how to make it work. So, I’m really glad that we’ve invested in it. In the last couple of years, we’ve been investing in the plumbing to make reality happen faster when people start to open the connections.

That didn’t seem obvious up front. There wasn’t disappointment that it’s taken this long?

I’m always disappointed when things take a long time because I think, in general, the health industry moves more slowly than other industries when adopting these kinds of consumer technologies or other things. But it, I think, has more to do with industry structure than anything else. We always understood that we had to do the plumbing in order to make HealthVault a consumer success.

As somebody who’s grown up through the operating systems business, you understand that you have to do an awful lot of work to bring together the physical device and the compute power and the video and the other kinds of things together, and then have an application on top of it to make it really compelling for an end user.

So, no, it wasn’t a big surprise, but that doesn’t mean that I’m not still disappointed that it’s taking many years of investment and talking to get to this stage where I actually think people have put in plans to have consumer portals that will connect HealthVault in a meaningful way.

What about the Medstory search engine? That was one of the first investments in healthcare and I haven’t really heard much about it. I think the site still says its beta, but I guess there are parts of it in Bing?

Yes, more than parts of it in Bing. You know, I’m delighted to be able to say that that acquisition got integrated into our core platform. It was one of the four channels.

You’ll remember when Bing launched, they launched with four domains that were built out. Health was one of them, all based on that technology that we acquired in Medstory. So, the fact that the Medstory site is still out there and live is more an artifact of the acquisition than what the technology has turned into inside the halls of Microsoft.

What about Global Care Solutions? It was bought to some fanfare, but now it’s going away. What was so attractive about a hospital information system with a very limited customer base in Asia to begin with? And then, what changed in two years to make it something that wasn’t that important any more?

I think the way to think about the Global Care acquisition is we have always had a vision around a plug-and-play capability and the ability to have this data aggregation platform — our Amalga UIS — and being able to have flexible solutions that sit on top of that and enable a class of workflows that are important to enterprises.

The domain knowledge and the solution focus of the Global Care acquisition were what was interesting to us. We, perhaps, mis-estimated the amount of work it would take to take some of those solutions and make them easily available on our UIS platform. From a timing point of view, it didn’t happen in the way we’d hoped.

We want to focus on UIS, focus on the value creation of workflows that fit the gaps. You know — care coordination, patient safety, things that are not in the same transactional workflow that might be in a patient administration system or an order entry system. We figure that is a better use of our investment dollars today.

What is the strategy for UIS?

I think people in the CEO chair, as they evaluate their IT strategic roadmap going forward, have to say, “What are the right characteristics of my plan that allow me the agility and flexibility to meet the changing conditions in the marketplace? Am I going to get bundled payments? Am I going to buy more hospitals? How do I get closer affiliation with physicians? What are the right IT strategies to accomplish that?” While at the same time, “I’m getting pressure to do CPOE,” however that’s defined.

My view, in conversations with CEOs and CIOs, is that a one-size-fits-all is not the best strategic roadmap and not the most flexible one. Amalga UIS is a cornerstone piece of middleware that allows you to get more value out of your existing departmental systems or EMR system — depending upon where you are in that implementation — and gives you the flexibility to acquire; to create new workflows that deliver value; to deal with new payment models that deliver value; to take some risk because of some of the capabilities; to be more predictive; and is an important component of your future strategic roadmap. That’s the role for Amalga.

Is it a big enough product to be worth Microsoft’s time?

Yes.

Do you see it extending in some other way with other technologies? That rumor’s out there about mobile device integration with some other vendors, some workflow pieces. Is this just a centerpiece or is it going to stand alone?

I didn’t mean to be flip, but our strategy isn’t a product-specific strategy. Our strategy is how do we deliver value through technology to help users? Those users are integrated delivery networks, academic delivery networks, life sciences companies, and others. There are many components along the stack for Microsoft that allow them to meet the mission critical and business critical needs that they have.

Amalga’s a great component of that. HealthVault’s a component. Those two things get connected. We connect to SharePoint, we connect to SQL. We’ll connect to, yes, mobile applications.

The question is what’s the right framework and component architecture that really allows you to do what people wanted to do for forever? Whether they talk about it as interoperability or they’re talking about SOA, or they talk about it in some other sort of interchange mechanism, we’re bringing it to life and bringing it to life in a way that people can get value out of it today.

We believe in the extension model that says, “Hey, you’re not going to get dead-ended in a particular vendor perspective.” Ours is — any data that you get in, you can get out. We’ll make it easy to get out. We’ll make it easy to reuse. We’ll make it easy for you to get the BI components that you need to still use the tools you use when you do BI and you don’t have to change everything.

I think it’s a very compelling strategy. Yes, it’s going to extend in all different kinds of ways both up the stack, if you will, in terms of specialized uses or applications, and in a breadth way, and perhaps even in a depth way when you look at how do you add new sensor class information or real-time streaming information or other types of data sources?

The great thing about health is there’s a huge amount of economics. Data really matters. Big data really matters when you think about where imaging and discovery is going. There’s going to be a huge amount of computation, and it needs to be delivered in a mobile way and in different scalable ways — for the individual, for the population of a doctor, for the population of a county, for the population of a country. We need to be able to scale along that dimension as well. We think we have the right infrastructure and architecture to be able to do that.

What about the Sentillion acquisition?

We’re really excited with bringing Sentillion on board — making the connection with their customers, maintaining their momentum and their customer satisfaction, and beginning to build the integration into our environment and our Amalga products to where we have 1+1=3. So we’re pretty excited about that.

What do you think about the proposed Allscripts acquisition of Eclipsys given that you have relationships with both companies and in New York Presbyterian, in which you share a customer?

We share lots of customers with Eclipsys. I’m less knowledgeable about which of all of our customers are also using Allscripts.

I think the vision of the Allscripts and Eclipsys guys is a good vision of how do we bring together, in a modern architecture, inpatient and outpatients and a lot of things they have hanging off the sides that not everybody knows? I think any time you merge different code bases, you have both the opportunity and a challenge to make that easy for customers and seamless. We hope to be part of helping them to accomplish that.

From a competitive framework, when you look at what’s happening in the US marketplace, it seems to be that’s what customers are looking more and more for — how do you bring these inpatient and outpatient environments together for better patient coordination and different workflows? It was hard for either of them to get to alone, and it’s really going to be about how do they go out and execute and make the promise at the marketing level, at the customer level, a reality at the technology level? Which is true of all acquisitions, right? That is always the hard part.

New York Presbyterian, I think you signed some agreements with them for both HealthVault and Amalga. Do you see that relationship changing once their two other products are under a single banner, or do you think you’ll be involved in whatever it takes to tie those products more tightly together?

I’m really excited about our relationship with New York Presbyterian. If you talk to Steve Corwin or Aurelia Boyer, I think they would say the same thing.

I don’t think the change in the vendor relationship will impact us one iota. They have a very complicated environment. They have some Epic, they have some Allscripts, they have a lot of Eclipsys, they have lots of GE, they have some Siemens scheduling. I mean they have a lot of stuff in there. Amalga is playing an integrative role, as is HealthVault playing an integrative role.

New York Presbyterian is one of our flagship thinkers in terms of how do they use these components that they’ve now invested in to meet their strategic goals as a business, both for their internal employees and providing better tools for them; and as a customer-facing, how do they leverage the connected care environment for their own competitive positioning?

We are working on their strategic roadmap. I’m very optimistic that we will continue to do more with New York Presbyterian in establishing better ways to leverage technology for them, and for their customers, using the foundational components of HealthVault and Amalga.

What do you think the lessons learned are from the problems that Connecting for Health is having in the UK?

How much time do we have? [laughs]

I’m kind of an engineering kind of guy. When you looked at the problem 4-5 years ago, the concept of a large, centrally planned, standards-driven paradigm for a large integration care delivery like NHS is always interesting on paper, but at the architectural level, I think they made some mistakes.

At the operational level, I think they made some challenging things in terms of how, really, was it going to work? It was just a little bit ahead of its time, if you will, in terms of what it was trying to accomplish, and probably off focus with the means by which they were trying to accomplish it.

The goals of a national patient repository — they’ve largely accomplished the goals for a large DICOM repository and making that part of the workflow better. But in other parts on the enterprise side for the hospital and the integration with the primary care trusts hasn’t really happened, so the technology challenges that they have remain. Not dissimilar to the technology challenges that we have in the United States when it comes to data interchange, patient record interchange, the ability to do really good registries — patient-centered registries as opposed to disease-specific registries.

As the combined payers and providers in this country, they’re motivated to focus on improved chronic care management, and the technology infrastructure they built for Connecting for Health didn’t really help them accomplish that goal. They’re now looking at, how do we do that?

I don’t know if you’ve stayed up to speed on the policy conversations that are coming out of the NHS, but I find it fascinating that they not only are trying to devolve the technology implementation plans, they’re trying to devolve the whole approach to how they think about planning for care and empower different stakeholders in that and have it be more decentralized — decentralized in a sense that it’s really important to them to empower the consumer, the patient.

They’re thinking about how can they create a marketplace for services where the patient consumer is a key component of the voting, if you will, with their dollars or with their actions? And, they’re devolving it to the general practitioner in terms of what are the right care endpoints at the right point in time in working with consumers?

They are thinking radically about re-architecting their delivery system. What the right technology is to help do that in a more decentralized approach is definitely in the future because that is more likely to lead to successful experimentation and adoption.

I’m pretty excited about what the NHS is trying to do. I think it’s a big shift and change. It will be interesting to see how they manage that big shift and change going forward.

It’s a pretty expensive lesson so far to realize they were on the wrong track. Are we prepared to not make the same mistakes here?

I think there are two things. One, it’s not clear how much money they’ve actually spent. I know they spent some. I know they got some value out of what they spent, and I know they froze some spending in other dimensions. But actual dollars spent, it’s not the reported number. At least that’s what I’m told by leaders over there.

I think the lessons that the United States is going to go through is really about will incentivizing EMR adoption through the construct of Medicare and Meaningful Use lead to better outcomes in and of itself, or is it just a component of a series of changes that are required to lead to better outcomes?

In my Senate testimony over a year ago, before they passed the HITECH Act, I argued — or tried to articulate — that technology’s not an end in itself. It’s a means to another end. What technology is appropriate is partly a function of what goals are you trying to accomplish? When people talk about EMRs, they imbue an EMR with all kinds of things that are sometimes true and sometimes not true in what today’s EMR systems do. Or, in how they are implemented in today’s institutions.

I think we need a more precise conversation about the role of technology: the role of reimbursement systems, the role of how we adopt technology given what goals we’re trying to go after to, perhaps, learn the right lessons.

I sit on the Institute of Medicine roundtable that’s talking about a learning healthcare delivery system. George Halvorson, at the time of the policy debate, the health reform debate, made a pretty clear and compelling statement that we ought to focus,as President Kennedy said, “We want to go to the moon,” that the right way to focus our health policy debate is say, “Hey, we want to improve the number of people with H1BC under control by 80%, or have 80% of them be under control.” That’s the single, best way to manage the cost curve.

Then you say, “What technologies do I need, and how much do I spend to make that happen?” Which is different than saying, “Hey, let’s everybody incentivize to have EMRs.” So, I think there’s a lot to be learned on focusing on the health outcomes and the system outcomes we want, and then to look at the technologies that are most appropriate to deliver those outcomes.

And also, to recognize that we have a lot of data in the source systems already, you know? Lab data’s digital. Medical data’s digital. Even in the small primary care systems they’re digital at some point of the process. Being able to capture, aggregate, and identify would allow you to get more value for your technology spent, perhaps. We’ve been pretty consistent about that and we still believe that. I think we’re not a lone voice in that perspective.

In terms of global health, if you went to another country with problems similar to ours — whether it’s infant mortality or chronic disease — probably the last thing you’d want to throw billions of dollars at is to make hospitals more efficient inside the four walls. You’d address health issues, not healthcare delivery issues. Are we throwing too much money at too little of the problem?

The private companies — hospitals, CEOs, IDNs — they’re looking at it and saying they understand that they need to go beyond the EMR and that they need to go beyond their four walls. That they see the future of payment reform, meaning they have to figure out how to get paid for not doing things. And so they’re already acting as if a change to payment systems really happens.

Now they’re not doing it with 100% of their investments, but they are all investing in that’s where the future’s going to be. I don’t exactly know what I need to do, but I need to be investing in.

When I look outside the US, I think the politics really matter. When you look at what China’s doing, they’re trying to move more of their care delivery out of the hospitals. They’ve got lots of motivation to do that because their hospitals are overwhelmed and overcrowded and they still have a high length of stay. They’ve put in a lot of infrastructure to move people out, but their hospitals are really very different than our hospitals. They are big clinics in addition to being big, acute care delivery stuff.

When I look at what’s going on in Germany, they’re really struggling to figure out what promise … what’s their social compact? What promise can they do, and how do they think about primary care versus secondary care? And again, you have the private delivery system actually innovating more — both from a financial and a technology point of view — than the public system.

I would say that NHS, as we already talked about a little bit, is also very much looking at their investment level. I think what you see people saying both with dollars and with decision makers trying to put more into a “prevention regime” than in a “make me more efficient” inside the “once I’m already sick” regime. That’s where you have these combined payment systems where they have more incentive to really focus on doing that.

But yes, I see lots of stuff all around the world where people … there’s just no really good business model for prevention. It’s a hard problem.

Form factor passes for innovation in healthcare, such as having cool iPad and iPhone apps. That’s where Microsoft seems to be at a considerable disadvantage to Apple and probably Google as well. How do you get involved in that, or do you want to be involved in a market where it’s less about what the application versus just having it untethered?

I would disagree with your premise to start with. Not to say that there isn’t adoption of lots of cool stuff, and so when an iPad comes out or an iPhone comes out, you see a lot of adoption in healthcare. My observation would be, however, healthcare gets less value out of those kinds of investments than other technologies and that it’s a lot of noise. It’s not really where people are spending the money, or the things that they’re making mission critical.

We look at innovation as really enabling transformation in reengineering. The “wow” stuff doesn’t enable that kind of transformation in reengineering. I’m happy to focus on less cool stuff from an end user point of view, but if I can deliver ten times the power and actually get data sharing to really work at one-tenth the cost with some of the stuff that we’re doing, I think I’ll win a lot of business and delight a lot of physicians when the speed is faster; delight a lot of nurses when I make their job easy because they don’t have to go look for information, it’s all in one spot; and win in the trenches as opposed to winning on the “in” gadget or popularity group. I think that takes a deep understanding of what problems you’re trying to solve, what jobs are really important, and how the flow and diversity and heterogeneity of data meet in order to be able to do that.

I think Microsoft is way better situated than either Apple or Google to solve the hard problems. I think if you look at our investments in HealthVault and understanding the ecosystem, and building a set of applications, and keeping pace with the changing conversation around privacy and security and app sharing and all that other kind of stuff, that we have demonstrated the level of understanding and our willingness to continue to make incremental investments to make it a reality. So, I’m happy to compete with popularity, a brand, versus reality of technology all day long. We’ll win in the long run. We may not win in the short run.

What technologies do you see that are innovative and potentially influential that have not yet really taken hold in the market?

I don’t claim to be an expert. You know, there are all kinds of really cool stuff going on. I think if I’m a CIO today or a CEO today, I think the one thing I might be asking myself as I look at a five-year time horizon is, “How do I think about cloud computing? How do I think about really changing the cost environment and the serviceability environment of my application stack at a time when budgets are getting pressured?”

And yet, I’m going to have more data. I’m going to have more applications. I’m going to have more users. I’m going to have more everything, but I’ve got to do it with less dollars. What is the strategy that will allow me, as an enterprise, to really make that a reality and still give me the flexibility to meet my changing business needs? If I want to really cuddle up with a payer or take, at risk, a large percentage of the population and I need information systems to manage that, how do I fit that into my declining footprint? Do I get some leverage out of being able to do predictive analytics in the cloud? Or, how do I think about being able to contribute to solving cancer with a large population and connecting and sharing that kind of stuff in the cloud?

Those would be the kinds of innovations that I would want to have on my horizon before I go sink a bunch more money in physical hardware or a data center or some other thing that may have a short shelf life. And, it certainly doesn’t help my P&L.

I see lots of really interesting stuff going on there. I’m not sure that its stuff that the CMO gets that excited about, but one that probably folks should be thinking about.

Any concluding thoughts?

You know, I think we’ve had a great conversation. We’re excited to be part of the health IT community. We think we, as a player that has both the consumer and enterprise offering — and perhaps a slightly different approach at trying to solve the problem — to help remind people to think beyond the EMR. We’re really excited to be part of the community and look forward to making our customers and our lives better by the smart application of technology to the hard problems in health.

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From The PACS Designer: “Re: Box.net. With the Google Wave application headed to Google’s archives, another collaboration tool called Box.net may offer an alternative for developers. The path to Meaningful Use is being studied by many, and the Box.net collaboration tool can work with Google Apps to satisfy the need to work together to improve healthcare processes.”

From Jim: “Re: Ed Marx. Although I read HIStalk regularly, I haven’t paid enough attention to him. The recent mention of his strategic plan got me to go back a read many of his postings. I don’t know how I’ve missed him, but what a find. He is one of the more refreshing and inspirational voices in HIT. Very belated congratulations on spotting his talent and sharing it with us. Thanks.” I’ll accept those compliments on behalf of Ed and add my own since I agree completely. I should mention, though, that you didn’t actually miss Ed’s earlier postings here — he’s been posting only for a few months. He had been writing for one of the rags and decided to make a change, part of which involved my back-loading all of his earlier posts to HIStalk. I think he’s found a wider and apparently more appreciative audience. Inga gets some credit, too, since she was his main contact (everybody likes Inga, of course).

From Defiant: “Re: Tiger Institute for Health Innovation at the University of Missouri. Next month will be its anniversary. Would you be interested in interviewing leadership there about the progress made to date and what their vision is all about?” Sure.

Thomas Jefferson University Hospitals contracts with 3M for document management and abstracting solutions.

Sacramento Maternal-Fetal Medicine (CA) chooses the SRS hybrid EMR.

We reported a reader’s rumor awhile back that suggested the Department of Defense might be thinking about mothballing its multi-billion dollar AHLTA EMR system. That may be correct, according to some sleuthing by NextGov, which found this solicitation buried in TRICARE procurement documents. It suggests that the military is considering commercial alternatives. The scope (warning: .DOCX) includes inpatient, outpatient, intensive care, ED, expeditionary, and ambulatory surgery, with “integrated support” of lab, pharmacy, radiology, and PACS. The EHR piece must cover telehealth, referral tracking, decision support, identity management, secure messaging, NHIN integration, cost accounting, personal health records, and a patient portal.

Thanks to the readers who tipped me off early about the Ingenix acquisition of Axolotl. Actually, Ingenix itself was prompt in sending over the announcement. Much appreciated. I think many people had failed to notice the company’s impressive string of acquisitions until I listed some of them yesterday.

Pittsburgh paramedics are upset with the county’s $10 million dispatching system upgrade, which they say is incorrectly prioritizing calls.

QuadraMed will offer clinical practice guidelines from CPMRC to its QCPR customers.

HIMSS, WEDI, EHNAC, and NACHA (that’s a bunch of acronyms, but they’re spelled out in the press release) release a white paper covering HITECH and HIPAA compliance for financial institutions.

Australia’s prime minister funds $225 million for telehealth sessions, plus more money for provider hardware and a videoconferencing-based triage service.

An Australian doctor accused of defrauding Medicare in 90% of her hormone testing patients says the government is wrong in saying she maintained incomplete medical records that did not include complaints, procedures, and histories. She says she’s just one of the 90% of doctors with bad handwriting, but has since computerized and “now I write a big story and I don’t abbreviate anything.”

An odd medication error: a mother who had just delivered triplets by C-section is ordered morphine. She was holding one of the babies when the nurse pushed the morphine into the baby’s IV line instead of hers. The baby’s fine, but the mom is suing anyway. The hospital has since created a policy that prohibits giving meds to moms in the NICU.

E-mail me.

HERtalk by Inga

Former Siemens Healthcare CEO Jim Reid-Anderson  is the new president and CEO of Six Flags Entertainment. I’m sorry, but that statement is just a bad joke waiting to happen (chime in, if you are so inclined.)

Moses Cone Health Systems (NC) and WakeMed Health & Hospitals (NC) are working with their state’s hospital and medical associations, as well as Thomas Reuters and CareEvolution to develop and launch the North Carolina HIE. The HIE will initially connect seven hospitals, three EDs, and 57 physician practices.

Over 40 health systems join Premier healthcare alliance’s ACO Readiness Collaborative and work together on building the critical components of accountable care organizations. Those 40 health systems represent a lot of hospitals and doctors who are betting ACOs are going to have a big impact.

If ACOs aren’t enough to give you a bit of anxiety, perhaps consider the pending v5010 deadline. Robyn O’Connell  of Hayes Management Consulting shares information and advice for migrating to v5010 here.

The Methodist Hospitals (IN) intend to fully implement Epic’s EMR within the next 30 days.

The local business journal chronicles the leadership of API Healthcare CEO J.P. Fingado, who left Cerner two years ago to head up API. Francisco Partners bought API  shortly after his arrival. Since 2008, the 28-year old company has gone from serving 600 hospitals to 700, increased sales from $40 to $50 million, and grown its employee base from 250 to 330. Sounds like Fingado is doing something right.

Here’s a recap of some good stuff from HIStalk Practice, just in case you missed it:

• An interview with AdvancedMD Inc. CEO Eric Morgan, who shares some insights on industry consolidation, on the advantages of being a private versus a public company, and on some of his company’s recent successes.
• Dr. Joel Diamond rants a bit about statistics. Try not to grin.
• If you need some inspiration, read about the work of Kenyan pediatrician Dr. Sidney Nesbitt, who Dr. Gregg Alexander calls an “amazing pioneer.”
• I rally for the co-founder of DoseSpot, who may have been an entrepreneur longer than he’s been shaving.

MidSouth eHealth Alliance (TN) signs a multi-year contract with ICA to provide its CareAlign HIE solution.

Orlando Health partners with Isabel Healthcare to implement its diagnosis decision support checklist tool.

Patient Access Solutions intends to integrate the iMedicor portal into its offerings, plus provide users access to iMedicor’s ClearLobby platform.

Persuading influential medical centers to adopt EMRs helps speed adoption by neighboring hospitals. That’s the conclusion of a study published in Management Science, which looked at what mechanisms influence the rapid spread of technology in hospitals. Apparently hospitals seem to follow a “social contagion” model. Note the parallel with fashion: celebrities first, then the rest of us. Draw your own conclusions.

Governor Schwarzenegger and a bunch of dignitaries launch the $30 million California Telehealth Network initiative, which aims to connect over 800 healthcare facilities to a statewide medical-grade network of healthcare and emergency services.

Odd: the police are called to a Burger King, tasked with removing a woman taking blood and urine samples in the bathroom. The woman claimed to be an RN working for a mobile medical exam company and collecting samples for insurance screenings. At least she wasn’t working the drive-through.

Chinese hospitals are apparently not the safest placed to work. During the month a June, a doctor was stabbed to death by the son of a patient who died, three doctors were severely burned when a patient set fire to the hospital office, and a pediatrician was injured after he jumped out a fifth floor window to escape the angry relatives of a newborn that died under his care. Such violence is apparently standard fare for Chinese physicians. Now if I were a Chinese doctor, I might be asking Steven Slater some advice on how to resign.

E-mail Inga.

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Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

How Would You Define a Secure Database?
By Robert J. Rogers, MD

While driving to work in late June, my phone rang. I saw it was my office manager calling. For those of us who own our practices, an early morning call from the office manager is rarely good news.

“Dr. Rogers, someone broke into the office last night and stole the computers!”

Thus my partners and I began our saga of learning the ins and outs of dealing with a potential breach of protected data. We are the “Texas allergy clinic” referenced by Mr. H in the Monday Morning Update of 8/9/10.

(Let me briefly mention now that our database was purely for our practice management system. We do not use an EMR yet. More on that later).

Selfishly, my first thought was, “I hope our backup is good”. A few years ago, we experienced a server crash and learned that our backup was corrupted, requiring a manual rebuild of our database. Fortunately, we learned the backup was fine when the new computers were installed. I naively thought our biggest challenge was behind us.

We decided to check with the Texas Medical Association regarding our reporting responsibilities. We were directed to the AMA’s summary of the HIPAA Data Breach Notification Rule, which was enacted in September of last year. It was at this point that we learned the very important distinction between password protection and encryption.

As I suspect is true in most offices, we were under the impression that our database was secure since we needed a username / password combination to gain access to it. We use a well-known practice management system supported by a local reseller. Password protection was the only security measure discussed.

However, we learned that the database was considered vulnerable if it was not encrypted, thus triggering our reporting responsibilities (first class letter to each affected party, and notification of local media if more than 500 individuals are affected). I will leave it to your imagination to consider the logistics of sending letters to 25,000 patients.

This was a nightmare until we learned that commercial printers and mailing services can handle everything — stuffing, addressing, stamping, and mailing (for a fee, of course). [Mr. H -- I didn’t actually complain about the cost of this process. I just responded to the reporter’s question regarding the cost of the mailing.]

Being victims of this crime has triggered a number of questions that I hope some of you may be able to answer. Now that I have learned the importance of encryption, I wonder why encryption is not automatically provided by all vendors? Is it complicated and/or expensive?

In an informal survey of my physician friends, none of them understood the importance of encryption. None had asked their vendors about encryption. Many of these doctors host their own servers.

Our potential data breach was important mainly due to the potential for identity theft since we don’t use an EMR (fortunately, in this case). That’s bad enough, but I worry even more about the thousands of physicians who use EMRs and may not use data encryption, thus making sensitive medical information potentially accessible.

As a patient, should you ask your doctor about the security measures in place?

The Data Breach Rule requires notification of the local media if more than 500 patients are affected. I wonder about the wisdom of that requirement. Might the thief be unaware of importance of the stolen server until learning about it from media reports?

Because of our experience, we elected to change to an ASP model for our software, using an off-site server accessed through an encrypted virtual private network. We think this is an adequate level of security, but we thought our previous system was secure, too. Is our database now secure?

As we rush to encourage all physicians to use EMRs, how can we make sure that all involved understand these important security issues?

Robert J. Rogers, MD is a physician with Fort Worth Allergy and Asthma Associates of Fort Worth, TX.

The Business Associate “Relationship”
By Stephanie Crabb

We are working with many customers who are looking to implement Data Loss Prevention as part of their information security and compliance programs. The best-practice deployment of these solutions requires collaboration with the HIS application vendors that contribute to the ePHI data life cycle such that the DLP solutions can efficiently and effectively content fingerprint targeted data “at the source” in the applications themselves. To some, this might fall under the rubric of “integration” as we have come to define it in healthcare, a common practice.

One small client of ours, a hospital of just 20 beds with an unwavering commitment to patient privacy and data security, approached its core HIS vendor, Meditech, with a formal request to connect directly with the database (aka “dictionaries” in Meditech-speak) to accomplish the implementation of its DLP solution. The data set was minimal — six fields of basic, and I mean basic, data to start. 

This request, surprisingly to us, was met with a firm “no” from Meditech. Why? They consider this “customization.”

Respecting Meditech’s longstanding position in this area, I personally worked with our customer to develop the business case to present to Meditech as to why they needed Meditech’s re-consideration. We cited areas around breach notification, uses and disclosures, and the like to inspire cooperation from Meditech and to put into clear context that DLP was a technology being adopted specifically to demonstrate compliance with HITECH and MU.  

The Meditech account representative acknowledged that they would need to do better in the future, but until they had a “critical mass of requests” from their clients to work with another vendor (like the client’s selected DLP vendor), their answer was still no. Understanding that our client’s Meditech account rep only has so much authority, my CEO and the client CEO requested a personal meeting with Howard Messing, only to be told that Mr. Messing could not accommodate their request. 

This is about a simple permission that the vendor could absolutely grant and requires little to no effort on its part whatsoever. It is a permission that other HIS vendors have eagerly provided. Oh, the vendor did offer to sell our client a module that would make this “easier” to the tune of $40K, even though what the client needs to access is already present in their its implementation.

DLP is not the only emerging technology that holds tremendous promise for organizations looking to reduce their data loss / data breach risk, enhance the controls around their data and its uses, and protect patient privacy. Unfortunately, covered entities cannot accomplish the implementation of these technologies alone. They need the business associate to collaborate, facilitate, and, sometimes, participate. And let’s face it, the rise of technologies like DLP that offer compensatory controls for privacy and security has resulted, in part, because the HIS vendors have been slow to respond with their own system capabilities.

I really do not mean to single out Meditech here. There are certainly other vendors who subscribe to similar operational models. This is, however, precisely the client service mindset that needs to change and that HITECH is requiring, particularly when technology is not the barrier. If these implementations are technically possible and largely resource-neutral to the vendor "business associate," why delay or deny their clients the opportunity to close the privacy and security gaps that are requisite to achieving meaningful use?

While the content of the NPRM may set about a chain of events whereby business associates become even more conservative in their commitments to privacy and security collaboration with their covered entity partners, there really is no where to hide, regardless of how ambiguous HIPAA and HITECH may be written. If you are in this space and in the business of touching ePHI in any way, you have to be “all in” — technically, operationally, and in the way you serve your clients and the industry at large.

It is simply not acceptable to relegate privacy and security considerations to the back burner, or worse yet, leave leave your client holding the bag. OCR recently clarified that “willful neglect” includes failure to take action when one recognizes a risk. Business associates who fail to respond when requested by covered entities to address a perceived risk could find themselves in an uncomfortable and costly position if a breach occurs and it could have been avoided.

Stephanie Crabb is VP of client services with CynergisTek of Austin, TX.

Why Are Lab Orders from Ambulatory EHRs So Hard?
By Ken Willett

While hospitals with integrated inpatient EHR systems are claiming high adoption rates for CPOE (in some cases 100%), most providers in ambulatory settings are still creating lab orders outside their EHR. What makes it so much harder?

An integrated HIS system, which includes lab and radiology ordering, can present the provider with the correct choices for that hospital’s services. In the ambulatory world, the EHR is much more limited (being less expensive), yet the variety of external service providers is larger. There are generally multiple labs, with ordering rules governed by insurance contracts, and each has its own test catalog, data requirements for the order, HL7 dialect, and requisition formatting requirements.

The provider wants to quickly capture what tests to order and why. Their manual process is to make a few strokes on a preprinted superbill or order slip. It’s very hard for an automated system to compete with that. Ordering facilities in the EHR are often cumbersome, while at the same time too generic to capture the specifics needed by the lab or radiology provider.

The lab, on the other hand, needs an order which is complete, with billing information, the lab’s order codes, appropriate Ask at Order Entry (AOE) questions answered, and the correct requisition and specimen labels printed. To try to assure that orders coming to the lab are accurate and complete, the lab will generally provide an order entry application and workstation to the practice, for use by a phlebotomist or other staff person.

Having a lab-specific ordering application addresses the problem of making sure the order reflects the most current compendium data of that lab (test codes, AOE questions, specimen requirements, and medical necessity rules), at the expense of having a separate ordering application for each lab (and in many cases, due to Stark laws, separate workstations, printers, etc.). Re-entry of order data, together with the need to use multiple ordering applications, significantly increases the likelihood of error.

Improving lab ordering within the ambulatory EHR is difficult because ordering rules need to be configured for each lab and compendium data needs to be constantly updated. This is a significant burden for each practice to
undertake.

Given that we are now in an environment with much more seamless connectivity between applications (with web services and other technologies), I believe a better solution is to move the ambulatory ordering function out of the EHR itself and instead provide orders via a connected SaaS application. This can allow compendium data management to be done in one place for multiple practices and multiple labs while still giving the provider and phlebotomist direct access to a universal ordering interface.

Only some EHRs have the necessary integration capabilities to allow this sort of user interface extension. Still, this seems like a promising direction to improve provider adoption of electronic orders.

Ken Willett is president and CEO/CTO of Ignis Systems of Portland, OR.

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Ingenix announced after the market close today that it will acquire health information exchange technology vendor Axolotl of San Jose, CA. Terms were not disclosed.

”HIEs are bringing us closer to the point where all the health care professionals patients select to oversee their care can connect to share information and optimize outcomes," said Andy Slavitt, chief executive officer of Ingenix. "We will work with Axolotl to continue to meet the needs of multiple HIE stakeholders and to expand its technologies that serve health care communities."

We reported on July 23 that Axolotl was seeking a buyer that would be named soon, although the early rumors suggesting RelayHealth as that buyer were incorrect. We reported the Ingenix rumor earlier this afternoon.

Ingenix, a subsidiary of the Fortune 100 UnitedHealth Group, has acquired several healthcare IT companies this year: QualityMetric (outcomes measurement), Executive Health Resources (compliance), and Picis (high acuity systems). Other recent healthcare IT acquisitions by Ingenix include AIM Healthcare Services (payment solutions), Healthia Consulting, Lewin Group (consulting), CareMedic (revenue cycle), Global Works Systems (software), Integris (IT management), Claredi (e-commerce), HealthWatch (payment systems), Innovus Research (pharma software), Advana (claims management), Distance Learning Network (continuing education), and Symmetry Health Data Systems (analytics).

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