Privacy and Security
By Glen F. Marshall

The primary issue with healthcare privacy and security is the lack of ongoing risk management as a routine business practice, plus the failure to share data from existing risk analysis in a form that the general public can understand. For example, while anecdotal evidence says that provider employee snooping is the largest threat to privacy, real data are harder to find.

The evidence I have of this is anecdotal. I continually get questions from HIT people about what technology to implement or whether the latest gadget is a good thing to buy. If there was a body of risk analysis information to draw upon, the selection and implementation of mitigating technologies would more often be an informed business process. So would the selection and implementation of physical and administrative controls, e.g., locks on doors, privacy training for employees, or privacy-enhancing advisories for health care consumers.

It is more convenient for the general and HIT press to focus on sound-byte instances of breaches, versus the actual threats and outcomes in comparison to other threats to privacy. It is more readable to assess blame for breaches than identify and celebrate good privacy and security practices that provably prevent, detect, limit, and disclose breaches before damage occurs. The eagerness of the general public, provider community, and political leaders to consume this lazy news reporting amplifies the problem and crowds out the solutions.

Glen F. Marshall is the principal of Grok-A-Lot, LLC of  Berwyn, PA.


Patient Privacy and Information Accessibility: A Necessary Balance
By John Tempesco

In the original HHS privacy rule, a core component of HIPAA’s purpose was the ability to protect patient privacy while at the same time allowing the sharing of personal health information to facilitate patient care. And while healthcare has finally been dragged, kicking and screaming, to a more comprehensive use of technology, a serious divide has emerged between advocates of patient privacy versus the free flow of data needed to improve patient care.

As EHRs become more widely used by physicians and health information exchanges (HIEs) become more commonplace, the debate between privacy and the sharing of information for the purpose of enhancing patient care and lowering the costs of care delivery will only intensify.

As guidelines continue to be developed, it will be important to consider the mechanisms of how patients will determine the exchange of their health information. If restrictions are too severe, the goals of ARRA and HITECH will be in jeopardy. Patients will be driven by policy to “sit on” their data which will nullify the ability of the healthcare system to achieve its goals of improving patient care and safety, and reduce costs. But if data is exchanged too readily, patient privacy will certainly be in jeopardy. This dichotomy is the essential conundrum.

Opt-Out most closely resembles the state of fair and controlled information exchange as it exists today. Opt-Out protects patient privacy and enables the sharing of health records unless the patient specifically opts out. The Opt-Out provision requires that the patient is given an adequate amount of time to make a decision about consent, including urgent need of care. It also requires a clear explanation of consent choice that must be provided by the physician or hospital as well as the consequences of opting out.

Opt-In, on the other hand, would stop the sharing of patient information unless the patient opts in to the system enabling the transmission of health data. This option not only severely restricts health information exchange, and limits the ability of health information technology to improve patient care and reduce costs, it demolishes many of the core benefits of health information technology, particularly the multi-organizational and multi-community benefits of HIEs.

The ONC is still deliberating a final ruling on information exchange. While patient privacy must be attended to, clearly the critical exchange of patient information through HIEs is a central and key component to achieving the reforms of ARRA and the HITECH Act. There are numerous studies that point to health information technology as providing the necessary tools which enable improved patient safety and the improved efficiencies desperately needed to lower healthcare costs.

Let’s not throw out the baby with the bath water. Let’s move forward with a rational, forward-thinking approach that will ultimately get us to where we want and need to be.

John Tempesco is chief marketing officer of Informatics Corporation of America of Nashville, TN.

HIStalk Written on an EMR
By Robert D. Lafsky, MD

Given the mixed feedback regarding the recent HIStalk format change, it occurs to me that all available options have not been explored. The following sample report represents a modest proposal, which if adopted would allow Mr. HIStalk to enjoy the same efficiencies utilized by most EMR users. Apologies to 1960s-era MAD magazine and the late Jonathan Swift.  

SUBJECT
Goniff Group

CHIEF COMPLAINT
“Cash flow problems”

HPI
The COMPANY is complaining of INSUFFICIENT INCOME. DATE OF ONSET: 1/15/2010. DURATION OF PROBLEM: 14 months. The problem is made worse by LOWER SALES. The problem is made better by HIGHER SALES. The problem is aggravated by EMR WORKFLOW ISSUES. The EMR WORKFLOW is felt to be SLOW. The EMR WORKFLOW is felt to be TEDIOUS. The problem is aggravated by EMR DESIGN ISSUES. The DESIGN is felt to be AWKWARD. The DESIGN is felt to be UGLY. The problem is aggravated by LEADERSHIP ISSUES. The LEADERSHIP is felt to be INCOMPETENT. The LEADERSHIP is felt to be INDIFFERENT TO USER COMPLAINTS. The LEADERSHIP is felt to be INDIFFERENT TO USER FEEDBACK.  

PAST HISTORY
Problem List
1.  Insufficient capitalization
2.  Insufficient programmer staffing
3.  History of SEC sanctions

MEDICATIONS
1. Bank loans
2. Penny stock
3. Overdue payroll

FAMILY HISTORY
CEO’s brother doing 3-5 in Allenwood for stock fraud

ALLERGIES
Revealing stories in HIStalk

REVIEW OF SYSTEMS
Obfuscatory logorrhea (last stockholder’s meeting)
Bilateral buttock pain (participants last board meeting)
Spastic torticollis (CFO explaining financial picture)
Chronic corporate latrocinosis

PHYSICAL EXAMINATION
Blood pressure:  60/30
Pulse: Undetectable
Head: Spinning
Neck: Horizontally positioned
Chest: Heaving
Heart: Absent
Abdomen: Distended and firm along course of colon
Extremities: Erythematous from red ink stains
Genitalia: Numerous, especially CEO and CFO

DIAGNOSTIC IMPRESSION
537926 Corioliform Hydrodynamic Gravitational Descent (“Circling the Drain”)
872035 DDI: Database Design Defects, Congenital
472653 Ugly Interface Syndrome

PLAN OF TREATMENT
First class ticket purchases to BRAZIL for CEO, CFO
Cash transfers to OFFSHORE BANK ACCOUNT in CAYMAN ISLANDS
Urgent resume production by employees
Reduce thermostat settings in office during cold weather
Discontinue free coffee in break room

Robert D. Lafsky, MD is a gastroenterologist and internist in Lansdowne, VA.

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Top News

Allscripts opens two offshore development centers in Pune and Bangalore, India that will provide customer support and other services.

Golden Gate Capital offers to acquire Lawson Software for $11.25 per share, but significant shareholder Carl Icahn suggests that the company shop around for the highest bidder (probably hoping to bait Oracle and SAP into a bidding war).

Reader Comments

From Yeah But … “Re: Ministry Health Care in Wisconsin. They were already a GE Centricity Enterprise customer. They will be upgrading to version 6.9 this year, which is the MU-certified version. It is true that GE has not had many new customers. In the past two years, they have made a small number of sales of the ASP version of Centricity Enterprise. Despite this, their total number of customers has dropped to around 27 on Lastword / Carecast / Centricity, down from 55 when they bought IDX.” Unverified.

HIStalk Announcements and Requests

It’s just me (Mr. H) today since both Inga and I are on our respective spring breaks, although most of mine will involve working on HIStalk. Dr. Jayne pitched in to help cover by writing a great piece for HIStalk Practice called Meaningful Use: 15 Things Your Practice Can (and Should) Do Now.

Listening: Deer Tick, no-nonsense, hard-living Americana rockers from Providence, RI. They’re good.

I’ll probably run a Readers Write Wednesday evening, so now’s your chance to get something to me that will appear quickly since I have just a couple of submissions so far.

Acquisitions, Funding, Business, and Stock

The Greenville, SC newspaper writes up VidiStar, which sells a PACS system and Web portal for remote reading of digital images. 

The Wall Street Journal profiles Castlight Health, started in 2008 by Giovanno Colella MD (founder of RelayHealth) and Todd Park (now CTO of HHS). The company, which helps consumers understand the costs of their care, has attracted $81 million of capital funding so far, including an unnamed amount from Cleveland Clinic.

People

Streamline Health names Rick Leach, formerly with A.D.A.M., as SVP/chief marketing officer.

Announcements and Implementations

Children’s Denver (CO) will implement RemedyMD’s OutcomeTrack disease registry and outcomes tracking solution.

The local paper mentions the federally funded, six-month HITECH Workforce program offered by Indian River State College (FL), adding that Martin Memorial Health System had to fill almost all of its 60 Epic project positions internally because they couldn’t find anyone else.

Government and Politics

Dr. HITECH (aka Ross Martin MD of The American College of Medical Informatimusicology) releases the production video of The Meaningful Yoose Rap. You saw the live debut of the song at last year’s HIStalk reception at HIMSS in Atlanta, now check out the video, apparently filmed on location in Washington DC, including in front of the Capitol and HHS headquarters. Video credits here, lyrics here. Ross has kind of a Marky Mark thing going on that’s pretty cool. He’s obviously musically brilliant, like you didn’t already know that from his amazing Interoperetta. He also has some kind of HIT day job, but hey, we have plenty of people who do whatever that involves but not many who can entertain the industry.

Sponsor Updates

• Quality IT Partners is celebrating its 10th anniversary.
• MEDecision will incorporate Health Language Inc.’s Language Engine into its health management portfolio to help customers with the transition to ICD-10.
• Dutch imaging solutions distributor Fysicons signs a deal to incorporate imagine viewing tools from Merge Healthcare into its EVCOS Web viewer for the BeNeLux market. The company is also reviewing Merge’s vendor neutral archive and kiosk products.
• Technology from Carefx will be used by Northgate Managed Services to develop a clinical portal for a group of UK hospitals in a $10 million contract that Northgate just won. 
• Capario announces that VP Angela McKenna has been appointed president of the executive committee of Cooperative Exchange, an association for healthcare transaction clearinghouses.
• Zynx will offer content from Thomson Reuters Micromedex in its evidence-based order sets.
• Main Line Health (PA) is implementing eClinicalWorks for its affiliated physicians.

Other

I was thinking about paper towel dispensers while in the airport restroom today, the kind where you wave your hand in front of the red light to have it dispense some preset length of towel. Some machines give an impossibly short length while others are more generous, leading me to speculate that they are networked devices using artificial intelligence (maybe adopted from slot machine technology) to determine the optimal mix of how much to dispense initially vs. how likely you are to begrudgingly accept the too-short length and leave with still-wet hands vs. just waiting until the red light comes back on to request another round by re-waving.

A UK woman dies of breast cancer after a doctor says her breast lump is benign, but then sends two appointment notices to the incorrect address, typing 16 instead of 1b for her street. Nobody followed up from the doctor’s office.

A family physician urges the same female patient to seek emergency care on two different occasions, once for an aneurysm and another for uterine swelling, after reviewing mislabeled CT scans belonging to other patients. The doctor says her actions were correct based on the information she was given, but the jury finds that she should have known the CT scans were someone else’s. They award the patient $75K for emotional distress. The two hospitals and the radiologist had already settled.

E-mail Mr. HIStalk.

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Thomas Carson is president and CEO of MD-IT of Boulder, CO.

Tell me about yourself and about MD-IT.

I’m a product of a Midwestern farm upbringing, so I’m probably a little bit conservative. I’m an operations and finance exec by formal training. I’ve been very, very fortunate in my professional career to have been part of several companies that grew from humble beginnings to plus-billion dollar revenue experiences.

Right before starting MD-IT, I was the chief financial officer for a computer products company that grew from $40 million on startup in 1990 to over $2 billion eight years later. In the three companies I was with before MD-IT, it’s not that we came up with something that was so revolutionary the world couldn’t stand it — it was that the markets we were in were changing dramatically. The changes were largely driven by customer demand and technology availability to satisfy that demand. That’s a key point when I look at the healthcare industry.

What prompted the founding of MD-IT ten years ago was a customer experience in the last company I was with. It was a VAR for Medical Manager. I went out to get acquainted with the guy and he gave me my first education into the healthcare space. Frankly,  I was astonished. I had seen several industries make technology adoption a priority and it changed the way they worked, and here was the largest industry in the country that was clearly underinvested.

I remember thinking to myself at that time that this should be another opportunity to ride what has to be an impending wave of technology adoption and dramatic change. Nothing quite prepared me for the sort of resistance to change that I experienced when we got into it.

I think one of the big observations that I had after getting into MD-IT was that it wasn’t really market driven. The things that were being imposed on doctors – or attempted to be imposed on doctors – weren’t anything of their choosing. The dynamics that I saw occurring in other industries weren’t occurring here. 

MD-IT was started ten years ago to provide doctors in the ambulatory space with easy ways of completing the chart note. We believed that we had a better idea for doctors. We embedded speech recognition into a relational database system that doctors could put in their offices, complete their own documentation in real time, and have access to their charts. It would be faster and cheaper than the traditional transcription model.

We had modest success in finding early adopters who were excited about this. But what we discovered was that most doctors actually had pretty legitimate reasons for preferring a dictate-transcribe model. We said that if they have legitimate reasons for that preference, and if the technology is all that good, we should be able to accommodate that preference on the back end and create the digital useful records that all the rest of us have legitimate reasons for wanting, and to provide a solution that the doctors and the rest of society need.

That was what changed our business model five years ago. It was realizing that if you ever wanted to get adoption of electronic medical records in the ambulatory portion of the market, then it was going to require a melding of the service portion – the transcription portion – with the technology portion — the EMR. It wasn’t because we were in love with transcription. It’s because the doctor, who was our customer, preferred dictation. 

Whether that dictation happens with a human, some kind of a technology, or a combination of the two didn’t really matter to us, but the second realization is that transcriptionists fill a pretty important quality role in the process. Recent studies support the fact that doctors, left to their own devices, aren’t terribly accurate documenters. The combination of dictation and experienced transcriptionists creates a high quality product.

So the elevator pitch is that your application is built around text documents and search technology, It’s not doctor-entered information and it’s not scanned documents information, it’s documents built from transcription.

The reality is that we accommodate all of the above. Effective medical documentation can come from all kinds of places. Doctors document this stuff in all different kinds of ways.

If they want to scan in documents, which typically happens when we take on new customers, we can accommodate that. We can scan them and parse them and get the data collected to be useful for archival and search purposes. If they want to import data from other sources, such as lab reports or images, that’s fine. We certainly accommodate that and import those electronically and tie them to a specific visit. If the doctor prefers to write by hand, that’s fine, we can accommodate that through a forms process and tablet technology. But certainly the bulk of the 20 million documents in our system are dictated and transcribed notes.

It seems that transcription firms are consolidating and I know  MD-IT has acquired a number of them over the years. What do you see as the role of transcription? Are other EMR vendors wrong when they say that transcription and document management are not the way to move the EMR forward?

We’ve taken a whole generation of doctors, some 600,000 or 700,000 of them, and tried to move them from the way they’ve been taught. Most of them learned dictation as the primary means of documenting patient visits. All of a sudden, we’re trying to flip them from a process that they’re very familiar that drives how they were taught about clinical encounters. We’re saying all of a sudden that, yep, you have to change all that, and you have to change it now.

I think there’s a much more pragmatic approach to getting to electronic records. If we’re serious about trying to get everybody to usable records, it strikes me that step one is get doctors to use a system of some kind.

What MD-IT is all about is providing an incremental or gradual approach for a practice. And even doctors within a practice, because it’s not uncommon for a six-doctor practice to consist of maybe a couple of young guys who want to do their own input, maybe an older guy or two who isn’t going to change or will retire before they have to, and some folks who are sitting on the fence.

The experience we had with MD-IT early on was that we needed to find the early adopters, but in reality, that’s a problem for a practice. Now you’ve got different ways of doing things. The records end up in different places. If you provide a system that anybody can use, regardless of where they are in the adoption curve, then the possibility of getting everybody on is much higher. It may be that transcription diminishes dramatically as a part of this and we’re perfectly fine with moving that along. At the core of it, what we have is a medical documentation system that’s agnostic to how the data gets in.

Your competitors probably use eliminating transcription costs as a selling points. They probably also don’t really want to open up their products to transcription. Is it hard to make your case when competing with them?

No. For years, EMR vendors have sold as a key part of their value proposition the elimination of transcription costs, but it’s an argument that breaks down under examination. I think people are starting to catch on to that.

One of the things that just absolutely appalls me is that we read account after account of the economic benefits of practices adopting electronic medical record systems, yet I know first hand that what goes on in those practices is that doctors are all of a sudden spending a lot of unpaid time documenting and learning to use these systems. There’s a permanent productivity loss that just doesn’t go away.

If anybody really sat down and tallied up those costs in physician dissatisfaction and extra time spent, I don’t think it will be a bargain. You’ve got the most expensive resource in the healthcare delivery chain who’s doing an awful lot of clerical entry. It just doesn’t make sense unless they happen to have time on their hands. 

There’s something peculiar to me about this notion that you’ve got a vendor group that tells their customers, “Look, suck it up and get used to this. This is how the world is changing.” At least in the last year and a half, people have begun to have that conversation. We have EMR vendor partners with whom we have deep interfaces and we’ve been very effective in creating what we think of as EMR optimization on behalf of those vendors.

Do you think the idea of doctors as data entry clerks won’t play and they will refuse to buy those systems, or do you think they’ll buy them but replace them down the road when they realize the HITECH money wasn’t worth it?

Probably a combination. A recent study found that there is an appallingly high rate of rescission once people get into this. The vendors aren’t stupid, but people aren’t talking about the bad experiences as much as they need to. 

The way I think it finally gets resolved is that you’ll have a new generation of vendors such as MD-IT and others who are much more responsive to what the real needs of the customer are. Shareable Ink is one. If you look at Stephen Hau’s attitude about supporting his customer, it’s very much what a real world commercial transaction should be like. Listen to what the customer needs, and if they don’t like what you’re trying to get them to take, then give them something else. Don’t keep insisting that it’s their fault, not yours, that they aren’t adopting your product.

What about certification?

We’re in the process. We have a relationship with SLI in Denver, which is one of the six certifying bodies. We’re in the queue for sometime later this month to begin that whole process. We don’t see certification as an issue.

As an issue meaning for you to get certification, or that you don’t really need it?

Oh, no, we think you need it. You wonder if people really care about it, but I think it’s one of the validations that you’re committed to the EMR direction and that you plan to be around and you’re willing to make the investment in that. So no, I think it’s very, very important.

We’ve been challenged on how you certify a product that depends on a narrative. It’s just not a problem that we can tell. We begin the process at the end of March.

You have an HIE application that I saw mentioned on your website. Tell me how that works.

We generate something on the order of 450,000 chart notes a month. Some fairly significant number of those, perhaps 25 or 30%, get delivered to other parties. It may be a referring physician, to and from a surgery center, or maybe to a billing company. The vast majority of that stuff moves around by fax or postal service.

We realized that since it’s all in our Web-based platform, you don’t really have to fax this stuff. Why don’t we just give the recipients electronic access to our platform as guest users? That was the birth of our own little HIE. We think of it as an intra-state or the state highway system. Everybody who’s either a customer or affiliated with a customer can get access through our own HIE. 

We’re also members of the Verizon Medical Data Exchange for getting to other states, if you will. They’re the federal highway system.

I wanted to ask you about that. How big of a deal is the Verizon Medical Data Exchange?

I think the Verizon Medical Data Exchange has the potential for being huge. It solves just a ton of problems that individual vendors would find very, very expensive to get at.

Let me give you an example. One of the requirements for Meaningful Use is that you be able to deliver selected medical records to appropriate state or governmental agencies, regulatory bodies. If you discover bubonic plague, you probably have to tell somebody. If you had immunization records, there’s probably a county agency that gets those, but nobody’s going to go out and write interfaces to the 5,000 or so of these entities. 

Verizon can, because they can do it one time for each of those. They’re big enough to have the resources to do that kind of thing. They even have a manual process to assist their regulatory agencies that don’t have that capability. So, if you can get into the medical data exchange, you just solved that whole problem for all the reporting requirements of the country. That’s an example of the kind of clout and quick answers they can bring.

Looking at the provider purchasing decisions and vendor product decisions, where you see it being in 5-10 years?

People will make bad decisions today, but they’re not unrecoverable. I see the technology getting far cheaper than it’s been in the past. If you look at the legacy vendors, you see an awful lot of high expense in the form of client server applications that are expensive to purchase, that are time consuming, and are high risk to implement.

I think that generation starts changing, and the reason it starts changing is that there’s been so much attention to the need to adopt electronic medical records. Even if the government hadn’t come along, I think consumers were going to insist on it anyway.

The good thing about the HITECH act — we can quibble all day whether the government should be paddling around in this kind of stuff –  but at the end of the day, they got the conversation going and out on the table. It’s brought a lot of voices and lot of folks in to mediate the discussion.

I think it will lead to a new generation of folks who are a little more nimble. They can take advantage of technologies that weren’t there 10 or 15 years ago, much as we are, to deliver products that are more use-appropriate. I see price points for ambulatory EMRs down somewhere in the sub-$500 a month range, probably delivered as a Software as a Service model. 

For our customers, the implementation period is measured in a week or two, if you’re not a current customer, as opposed to six to nine months. There are no upfront costs, I think you’re going to see more of that kind of a model than out there. I think that the interface capabilities are going to be much, much stronger. 

A lot of this stuff may start forcing even doctors to be more consumer-oriented because those are likely to be the maybe a more important driver than everybody else. I’m currently involved with care for an aging parent. The difficulties I’ve had trying to get information out of a fairly sophisticated EMR is very, very frustrating. It becomes a huge, time-consuming part of the whole process. That’s not where people ought to be spending time. There’s certainly not a problem to get information out of other systems and to share that easily.

But I see all that changing. I’m a huge optimist about how technology solves problems and people are very creative at applying technology when it’s available.

Any final thoughts?

It’s a very, very exciting time to be in this industry because I do think a lot of changes will happen. I don’t even believe, like a lot of people do, that it’s going to be a $4 trillion industry in ten years. Those kinds of projections are based on assuming that nobody learns, nobody grows from the experience; but I doubt that will happen.

Growing up in farm country, I know that the real cost of corn, beans, and wheat really hasn’t changed much in the last 40 or 50 years. It’s because we’ve gotten better at meeting the demands for food production That’s just one examples of many, many examples out there. You can see this, and this is something that technology does for us.

I see healthcare as the same. I think we will all be much smarter healthcare consumers. I think a new generation of companies is solving these problems will be able to create a nimble and cost-effective way.

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From Tobias: “Re: privacy and security. Local and state legislatures are afraid of HIEs and other electronic data because they perceive that because data is electronic, it will be easier to hack. I’m curious if you have any data or can use your network to find any that speaks to this.” I’m interested in anyone’s contribution. The question made me ponder – why do consumers fear healthcare data breaches, which have no financial ramification, and even though despite splashy headlines, haven’t resulted in much of anything other than some tabloid articles and lots of free credit checks? My conclusions: (a) people trust banks a lot more than healthcare providers when it comes to privacy, probably rightly so because banks have a much more straightforward mission that is aligned well with security investments; (b) they still incorrectly believe that the greatest threat to electronic data is mysterious foreign Internet hackers instead of inquisitive provider employees; and (c) a financial breach affects thousands of people scattered everywhere, but friends and neighbors wouldn’t know you were affected, while medical disclosures have far less dramatic outcomes (instead of draining your bank account, someone finds out you’ve had a yeast infection) but involve the people you see every day. I don’t trust hospitals either, but not because of their electronic systems – any organization that believes that a shower curtain drawn between the gurneys of ED patients provides adequate privacy has already given up the charade. Not to mention that people fear being denied insurance coverage or being fired because our hodgepodge medical system encourages dumping the expense of their care on someone else. Electronic data hacking is the least of healthcare’s privacy and security worries.

From Bobby Orr: “Re: Francisco Partners. Running away from HIT? That’s API, AdvancedMD, and Healthland all in about 3-4 weeks.” I ran Healthland as an unverified rumor, but I wouldn’t be surprised. What better time to cash out an HIT company than right now? It’s like selling your house at the market top. You can make money by buying at the right time, but even more by selling at the right time. What’s more interesting to me is where they invest the proceeds.

From The PACS Designer: “Re: OsiriX HD. OsiriX has been a popular open source DICOM viewing platform for a long time and now has recently migrated its software to the mobile platform. OsiriX HD V2.0 was released last month for iPhone and iPad. This new release should gain popularity amongst mobile users for the speedy processing of image files, and also promote collaboration between radiology and referrers to enhance the interaction of radiologists with other departments.”

From Hank Redmond: “Re: Microsoft HSG. I work there and the reader got one part right – the move to MBS happened. We like this change because we’re out of the incubation phase. The company’s commitment to healthcare remains as strong as ever.” Unverified.

From Wowed in Wisconsin: “Re: Ministry Healthcare. Hear they’re considering putting GE inpatient at all their sites. Does anyone even buy GE any more?” Unverified.

From A Fan: “Re: survey. I am an avid HIStalk reader and was wondering if your readers could help a team of MBA students assigned to perform a brand analysis on Google? Survey time is less than a minute. I am also trying to prove a point to my professor about how powerful social media are (he does not think it’s of any value) and that with the right following, a la HIStalk, great insight could be obtained. Our goal is 100 respondents and we only have 35.” I took the survey and it take even less than a minute, so willing readers can do the same. 

I’ve decided to use the old layout for the Monday Morning Update post, as you can see. This is for several reasons: (a) it’s only me (Mr. H) writing for the MMU, so it’s not hard to follow whether an item is Inga’s or mine; (b) the MMU has less hard news since it’s really a catch-up from Thursday night on, so it has fewer items and fewer categories; and (c) it’s easier for me to put together on the fly, like right now as I sit in a hotel room watching the Pacific Ocean and quietly writing while Mrs. HIStalk slumbers peacefully a few feet away. It also occurred to me that I’ll then be using the new format two days a week and the old one once, matching the proportions of poll respondents who preferred those formats.

A 2,400-bed hospital in India that treats 15,000 patients a day loses all of its electronic medical records when five of the seven HIM department computers get nailed by a virus. The surviving computers don’t have the HIM software loaded, so the only thing the seven HIM employees can do is keep a paper log of admissions, discharges, and deaths. The Indian newspaper article also mentions that its “medical records officer” position has been vacant for years since nobody in the entire state is qualified for the job, so nurses have to create the records themselves and they’re short on nurses too. The hospital can’t load the medical records software because they don’t have IT people.

A Yale study finds that the rate of prostate surgery goes up when hospitals buy expensive robotic surgery gadgets that have no proven medical benefit. The lead author’s conclusion is common knowledge, but a refreshingly blunt indictment of the US healthcare system: “Policymakers must carefully consider what the added-value is of costly new medical devices, because, once approved, they will most certainly be used.” He wasn’t referring to information technology, of course, which has the opposite problem.

Welcome to HIStalk Platinum Sponsor H/P Technologies of Phoenix, AZ. The company provides direct permanent staffing and consulting for all the big healthcare and managed care IT systems. On the provider side, that includes Epic, MEDITECH, Allscripts, eClinical Works, Siemens, GE Centricity, Cerner, McKesson, and NextGen. They can help with clinical transformation, workflow analysis, technology, architecture, ERP, integration, application development, ARRA, and ICD-10, to name a few. For the payor market, Facets, Trizetto, Amisys, DST Health, QNXT, Diamond, Paradigm, XCELYS, and more. They’ve been around for 12 years, are on the Inc. 5000, have more than 200 consultants, and are standing at the ready to provide the highest quality professional services to allow their clients to focus on their core mission. If you’re a highly trained professional, you can search their jobs database for that next step up the career ladder. Thanks to H/P Technologies for supporting HIStalk.

Thanks, too, to our recently renewing sponsors, who also deserve a little shout-out for keeping the keyboards clacking around here:

• iSirona, medical device connectivity experts. This is a pretty hot company, right in the sweet spot of medical device integration into EHRs. They just announced at HIMSS a software-based connectivity solution that runs on standard computing hardware.
• iMDsoft, which offers proven clinical information systems globally such as its MetaVision solution for ICU and anesthesia and the mvCentral tele-intensivist patient monitoring system. I was impressed when I interviewed CEO Phyllis Gotlib just over a year ago.
• Software Testing Solutions, the automated software testing experts. I interviewed CEO Jennifer Lyle in January. You may recognize her and account rep Kara if you were at HIStalkapalooza because they were our lovely and quick-witted red carpet interviewers.
• Wellsoft, which focuses on doing one thing very well – supporting the emergency department with its top-ranked EDIS. It’s been Best in KLAS since 2006, which is a nice arrow to have in your quiver when you’re trying to turn your ED clinicians into Meaningful Users.
• CynergisTek, a renowned provider of business-driven IT security consulting (risk management, IT security, technical security, compliance and audit, and managed security services). CEO Mac McMillan is well known in HIMSS circles for volunteering in a number of roles related to privacy and security.
• Salar (pronounced SAY-lar since I don’t know how to make the little bar-over-the-long-A character). I’ll try to stay neutral, but I really like these guys (VP Greg Wilson was our polished King and Queen judge at HIStalkapalooza), they impressed me with their poise when I anonymously cruised their HIMSS booth, and President Todd Johnson’s interview a year ago was one I really enjoyed doing. Their clinical documentation product seems cool and I think we’ll be hearing more about it.
• Vocera, a Founding Sponsor of HIStalk Mobile and a Platinum Sponsor of HIStalk, is the company with the Star Trek communicator gadget that I swear conveys instant power when you caress it in your hand like I did at HIMSS. Their 700 hospital customers enjoy instant, portable access to the information and resources they need, improving patient flow, safety, and staff efficiency. Business must be quite good because they have made several acquisitions lately.
• Access, a Platinum Sponsor of both HIStalk Mobile and HIStalk, is known worldwide for its e-forms solutions that turn paper into seamlessly interfaced electronic, workflow-driven, EHR-integrated information. Its Intelligent Forms Suite provides money- and environment-saving forms on demand with pre-filled text and barcode information ready for indexing in your ECM system. And they have an award-winning championship Texas barbeque team that I keep trying to convince them to bring to HIMSS in a variation on Willie Nelson’s Fourth of July Picnic (music, smoked brisket, and beer – who doesn’t like those? That could be the next HIStalkapalooza.)
• The Huntzinger Management Group, led by the ultra-successful George Huntzinger, former president of CSC Healthcare and president of Superior Consultant. HMG’s consultants help organizations run better through services that include business strategy, IT assessments, vendor management, project management, and procurement. They have a few juicy job openings, too. They’ve been a sponsor for quite awhile, which I appreciate.
• EHR Consultant, EHR Scope, 1450, EHRtv, and related businesses from the very smart mind of one of our favorite people, Dr. Eric Fishman. Dr. E can help you find an EMR, buy and implement Dragon in your medical practice, or use the Frisbee system for digital dictation and transcription between author and transcriptionist. EHRtv contains interviews, EHR news, reviews and demos, and that highly sought after HIStalkapalooza 2011 video that includes the full HISsies presentation with Billy Bush’s funnier brother (I’m watching it now and snickering all over again at JB). I’ll put that directly on HIStalk once Dr. E’s video whizzes get it loaded up to YouTube.
• Healthcare Growth Partners was one of HIStalk’s first sponsors. They provide investment banking and strategic advisory services, not to mention that Jon Phillips is the first guy I e-mail when I need help understanding some business announcement or financial transaction. I’m sure their phone is hot from calls related to mergers and acquisitions and corporate strategy these days. I always forget that Jon’s kind of a big deal since he’s pretty funny and casual when I bug him about something, but in addition to founding HGP, he’s the board chair of Streamline Health.
• MED3OOO and InteGreat. Their list of offerings for physician practices is extraordinary – EMR and PM, revenue cycle, coding and compliance services, data warehouse and decision support, third-party administrator services, and a variety of management services and technologies for hospital-employed physicians. They are Platinum Sponsors of both HIStalk and HIStalk Practice.

A reader asked about RSS feeds for for HIStalk and HIStalk Practice. I always forget to mention those since Google Reader finds them automatically. If your reader doesn’t, just click the Archives link at the very top menu of either HIStalk or HIStalk practice, then look on the lower left of the page for a list of RSS feeds.

Inga and I have been talking about the need for a consultant-type person to write for HIStalk Practice to provide detailed advice to practices about increasing their efficiency with any kind of technology, signing agreements with hospitals to provide an EMR, and specific recommended actions to meet Meaningful Use. Tell Inga if you’re interested and would like gain some major exposure.

Most folks aren’t all that keen on banning the usual HIMSS exhibit hall shenanigans, but if they were, they’d pick the related activities of booth babes and suggestive dress. New poll to your right: are the proposed Stage 2/3 Meaningful Use requirements too hard, too easy, or about right?

Speaking of Meaningful Use, CMS will hold a May 17 session on that topic for New York City hospitals.

Former Sage COO and Cerner VP Lindy Benton is named CEO of National Electronic Attachment / Medical Electronic Attachment, replacing retiring founder Tom Hughes. The Norcross, GA company provides technology for providers to submit electronic attachments with dental and medical claims. I had meant to Google her since I saw her at HIMSS.

Former St. Luke’s Northland Hospital CEO James Brophy is named the first CEO (and only full-time employee) of eHealthAlign, a Kansas City HIE.

Microsoft announces that Tampa General Hospital (FL) will use its Exchange Online and SharePoint Online, while Advocate Health Care (IL) has moved to Exchange Online.

I can’t decide if this is the stupidest press release ever written, but I’m sure it’s right up there. I blurred the names because I don’t want to give the company any exposure. When your key news item is “interest continues to grow” and your big accomplishment is that 600 people connected with you on social networking sites (not that I saw: 10 Facebook likes and 16 LinkedIn connections, almost all of them company employees). The release includes no contact information and no PR company (which surely would have advised them to rethink putting this drivel out), so there’s a cautionary tale against do-it-yourself PR.

Microsoft’s Connected Health Conference will be April 27-28 in Chicago. Registration is $699, but you get two for the price of one if you sign up by Friday, March 18. The speaker list is long and has a few moderately big names. 

I see the visit counter rolled over the 4 million mark on Saturday. Thanks for being part of that.

E-mail Mr. HIStalk.

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Top News

The Center for Health Information and Decision Systems at the University of Maryland announces its HIE Evaluation Framework, which assesses HIEs on sustainability, organizational structure, technology, community engagement, and trust. The announcement points out that of 200 HIE initiatives, only 18 are covering expenses.

Carilion Clinic (VA) will collaborate with Aetna on an ACO initiative

Reader Comments

From Klaatu: “Re: Healthland. About to be acquired by [company name omitted]. [company name omitted] is also about to be acquired.” Unverified. I redacted the company names because both are publicly traded and I don’t want to be like the bawling Bud Fox (Charlie Sheen) getting hauled off in SEC handcuffs in Wall Street. I’d rather be Tiger Blood Charlie, the male equivalent of a smarter but even goofier version of Meltdown Britney. Winning!

From HITChat: “Re: HIEs using the Practice Fusion or RealAge model of selling de-identified data. What do  you think?” First, I don’t think there’s any such thing as sure-fire de-identified data. If there’s enough information to be useful, it can probably be matched back to patients. That you don’t hear of that happening isn’t a confirmation that the information is secure – it’s that there’s not much payoff for re-identifying it. Otherwise, my main objection is that I don’t trust companies that buy data, not because they aren’t operating legally or ethically, but because they’re looking for new ways to increase healthcare costs by lining their own pockets. Providers, unfortunately, are often illogical consumers who just happen to be wearing white coats and suits, and they are often unreasonably susceptible to data-fueled sales pitches. We discussed that in a hospital benchmarking meeting today – drug vendors are getting some very detailed information on our treatment outcomes from somewhere and trying to use benchmark data to shame us into using their product. You wonder, too, with everybody and his brother peddling de-identified patient data, how does the purchaser know they aren’t buying duplicate information?

From Dabney: “Re: former Sentillion exec departures from Microsoft. Microsoft transferred their 800 Health Solutions Group people into the small-to-medium commercial sector group (Microsoft Business Solutions) last Monday. Peter Neupert and his whole organization have been pushed out of the incubation group in Microsoft Research with the guys who sell Microsoft Axapta ERP and CRM for small commercial customers. That will mark the end of acquisitions and spending of Microsoft on health because they haven’t had any significant sales of Amalga UIS in the past year after already withdrawing Amalga HIS and Amalga RIS/PACS from the market. Microsoft is slowly edging towards an exit stage left in health IT.” Unverified.

HIStalk Announcements and Requests

Two-thirds of readers prefer the category-based layout you’re reading now, so we’ll stick with it for a couple of weeks (and fine tune along the way). A suggestion, however: don’t get so enamored with the categories that you skip everything else – we wouldn’t include something if we didn’t think it was worth reading. From our end, we promise not to lose our quirky and sometimes funny commentary, although it may have seemed like it last time since I was really struggling to get finished with the changes right up until I had to go to bed.

Speaking of which, a reader suggested tagging each item in front with a tiny avatar, which sent Inga furiously to her photo editing software. We won’t tag most of the posts, such as the straight news items. We’ll save that for when we write something that might be clearer if you knew who was “talking.” We’re willing to experiment to make HIStalk as good as we can make it, so bear with us – we’re day job amateurs. 

What you missed this week if you aren’t properly tuned into HIStalk Practice: the first-year cost for EMR in a five-physician family practice averages $233,927, or $46,659 per doctor. Vermont and Alabama RECs add to their preferred EHR vendor lists. Emdeon triples its revenues in the Q4. NextGen VP Dr. Jan Lee heads to the Delaware Health Information Network. ONC recruits Meaningful Use champion providers. By the way, 78% of readers say HIStalk Practice helps them do their job better; ergo, sign up for the instant updates on HIStalk Practice and perform your job better.

The comfortingly familiar usual reminders: (a) put your e-mail address in the Subscribe to Updates box so I can tell you immediately what’s new; (b) check out HIStalk Practice and HIStalk Mobile; (c) show your love on Facebook, that thing that just put six kids on the billionaire’s list; (d) send me rumors, news, secret e-mails, or whatever you think we’ll enjoy; (e) support our sponsors by perusing and clicking in the obvious locations; and (f) send us good karma on occasion, which we’ll reciprocate. Thanks for reading.

On the Jobs Board: Clinical Project Manager, RVP Sales – Western Territory, Performance Management and Revenue Cycle Director. On Healthcare IT Jobs: Business Intelligence Lead Developer, Epic Clin Doc or Orders Analysts, IS Manager General Financial Application, Programmer/Analyst III.

Sales

Catholic Health Partners (OH) signs a multi-year agreement with RealMed to provide RCM products to its affiliate providers.

Beloit Health Systems (WI) selects TeleHealth Services as its interactive patient education and entertainment partner for its 10 locations.

People

UK-based Clarity Informatics Group replaces its CEO founder with Tim Sewart, a 32-year-old law firm partner who leads a technology practice (and who will continue in that role as well). The company provides the NHS Clinical Knowledge Summaries (evidence-based medicine clinical information) and the Clarity Drugs Suite drug database. Ian Purves, the professor who founded the company, seems like fun: his company bio lists titles of MBBS, MD, FRCGP, MIoD, DRCOG, DCCH, RYA Ocean Yachtmaster.

Announcements and Implementations

Hoboken University Medical Center (NJ) is scheduled to go live on Medsphere’s OpenVista EHR March 22. Pharmacy already made the switch in January.

St. Luke’s Health System (MO) deploys Central Logic ForeFront to facilitate logistics and documentation requirements for patient transfers in and out of its 11-hospital system.

University of Utah Health Care System goes live with Epic’s MyChart for patient records access on smart phones.

Meridian Health (NJ) goes live with ICA’s CareAlign solution for its multi-county HIE.

Government and Politics

Grace Community Health Center (KY) secures $150,000 as part of Kentucky’s Medicaid EHR Program. They have selected but not yet implemented NextGen’s Ambulatory EHR, and thus got HITECH money without having yet achieved Meaningful Use. I mentioned this on yesterday’s HIStalk Practice and commented that if I were selling EHR, I would be knocking down the doors of all eligible Medicaid providers and telling them to sign my contract because that’s all it takes to get their money from the government. A reader suggested that I didn’t have my facts right and that providers were in fact required to “install” the certified EHR technology. However, a CMS representative confirmed that I’m correct and forwarded this link from the CMS website. A couple of key passages:  “a provider does not have to have installed certified EHR technology” and all a provider must do is demonstrate the “acquiring, purchasing, or securing access to certified EHR technology.”

The state of North Carolina and CSC successfully implement the first phase of the state’s EHR Medicaid Incentive Payment System. The system is scheduled for full release in April.

Innovation and Research

Jardogs, an 18-employee subsidiary of Springfield Clinic (IL), is profiled in the local paper for its FollowMyHealth patient portal. Says John Pacione, the company’s president, “We’re creating data exchange, just like an HIE, but we’re putting the patient at the middle of it, to authorize that information to be released.” The company has eight large customers, including its parent organization, of course. Most intriguing is the company’s name, which it declines to define, saying only “it’s a closely guarded secret.” A smart one, since every Google search hit is theirs (something to think about when choosing a company name). Also interesting: CEO James Hewitt is also CIO at Springfield Clinic and formerly held that role at Allscripts, which was also the previous employer of both John Pacione and chief architect Ron Ward.

Researchers at the University of Minnesota are using Xbox Kinect in project to improve diagnosis of mental disorders in children. Said the researcher, “Is a $100,000 system being outsmarted by a $150 toy? Indeed this is the case … I don’t think Microsoft has realized that [Kinect] is something that could change medicine.”

Technology

VMware announces availability of its free VMware View Client for the iPad, which allows users to run their virtual Windows desktops from anywhere. The announcement mentions Children’s Hospital of Central California, which will use the technology to provide “follow-me desktops” for iPad users.

A column in The Atlantic covers the InstyMeds vending machine for drugs, leased to physician practices for dispensing prescription medications.

Other

I feel like I have barely unpacked from Orlando, yet HIMSS is announcing the deadline for HIMSS12 proposals. The proposal form will be available March 21 through May 23. I wonder how many relevant topics are overlooked by having a deadline this far in advance?

The average cost of a data breach in the health care sector jumped from $301 per compromised record in 2009 to $345 last year.

Listening: the debut album of Beady Eye, the Beatles-esque reincarnation of Oasis. It sounds as though it could have been recorded straight to four-track tape in 1965, which is refreshing if you’re tired of electronica, music written for hammy dance moves instead of listening, and writers who can’t write songs for singers who can’t sing. And watching (sometimes painfully): the lowbrow but hilarious Fat Actress. Kirstie Alley is fearless, I’ll say that.

University of Toledo’s medical school is placing first- and second-year medical students in a scribe program in its ED. They transcribe into the EMR, keep an eye on lab and rad results, and get 100 hours of ED experience before their clinical rotations start.

A patient sitting in an overcrowded doctor’s waiting room sues the doctor, claiming a heavy filing cabinet toppled over on her, causing head, neck, and back injuries. I guess you could say that it was paper medical records, not the electronic kind, that reached the tipping point.

Sponsor Updates

• COSSMA, a Puerto Rico-based community health center, selects Sage Intergy EHR and PM to replace its existing HealthPro PM system. Sage says it’s not charging the clinic for the new software.
• dbMotion and Matrix Knowledge Group partner to market and deploy the dbMotion solution throughout the UK.
• Space City Pain Specialists (TX) chooses the SRS EHR.
• Parkland Memorial Hospital (TX) picks ProVation MD from Wolters Kluwer Health for its gastroenterology procedure documentation and coding.
• Pacific Oral & Maxillofacial Pathology Laboratory (CA) increases its collection rates from 55% to 90% after contracting with Orion Health for billing and practice management services.
• HANYS Solutions, the for-profit-subsidiary of the Healthcare Association of New York State, expands its relationship with RelayHealth as the preferred partner for RCM solutions. The agreement includes the RelayClearance, RelayAssurance, and RelayResolution offerings.
• Speaking of RelayHealth, the company just upgraded its Website. Very 2.0-ish and easy to navigate.
• Windham Hospital (CT) chooses the Intelligent Forms Suite from Access, the Siemens Strategic Alliance Partner for electronic forms management, to create barcoded electronic forms on demand form MS4.
• Merge Healthcare announces the release of Financials 6.1, which adds ANSI 5010 and PQRI capability.

From Charles Babbage: “You say vendors are trying to make their products better and better and then list scores of issues that should have been fixed decades ago… More important, after the hospital spends $150 million on the system, and $500 or $600 million implementing it … the vendor has little worry about making the customer happy.”

Looking at some of the vendors and products in question, they weren’t around decades ago. Don’t get me wrong, some were, and they should be appropriately criticized.

I’m sure there are some organizations out there that fall into the figures you specify, but not the vast majority of implementations. Even with smaller implementations, given the dollars out there and the competition, vendors seem to be keenly aware of the need to make the customer happy. The last thing they want is for a significant install to fail. They know it takes ten happy customers to make up for one aggressively vocal and unhappy customer.

I don’t disagree that there are bad apples out there, but I also don’t believe in painting all vendors with the same brush. Even with their flaws, many systems provide measures of patient safety that couldn’t exist in the pre-electronic world. (Think allergy and drug interaction checking – it just didn’t exist on paper. How many people were killed by those kinds of basic medical errors?)

Like many of you, I’m a practicing clinician too (not just a suit) and have seen both good and bad systems. But then again, I’m an active and constructive participant in my organization’s choices and decision-making and understand why things are the way they are. I’ve spent most of my efforts in improving the system, not just yelling. That has allowed for real change to come, not only with my hospital, but with our vendors. (Although believe me, I’ve done some yelling, and sometimes that’s what it takes.)

From Sherry Reynolds: “One challenge that we see with OBs who deliver and work at multiple clinics and hospitals is the cognitive overload when they have to learn multiple different systems and workflows.”

I hear you! This is extremely frustrating. Coming from a “best of breed” hospital, that’s my reality. Different vendors for emergency department, labor and delivery unit, inpatient units, etc. … and this is within a single hospital. Add on the different ambulatory system and it’s even worse. And then if you are on staff at multiple hospitals in different health systems? Forget making sense of it.

I think this is why Epic has done so well with their integrated platform — it’s a really strong selling point. On the other hand, the so-called integrated platforms of some vendors really aren’t that integrated at all, but people keep buying them.

Looking at other technology platforms, those with great usability lend themselves to emulation (think Apple phone technology). Since we are still in an unregulated industry and this is a free market economy, customers need to vote with their checkbooks for the vendors that support cross-vendor standardization and uniform workflows.

From MIMD: “Many vendors are working hard to remedy these and to implement aggressive protocols to bake quality into their products and design defects out. What took so long for them to do this?”

I agree this question deserves an answer. For some of the products out there, there is NO excuse. Patient safety-related defects should be fixed — end of story. And they should be fixed in a timely fashion.

The short answer: vendors didn’t clean up their act because they didn’t have to.

I don’t believe in blaming the victim, but there are customers out there whose actions reinforce bad vendor behavior and vendors take advantage of it. Customers can band together through regional or specialty organizations and apply pressure to vendors to change the way business is done. They can refuse to accept releases that are known to be problematic at other institutions.

When vendors don’t respond, consider exercising contractual remedies. Unfortunately, too few people have done this — it’s messy and time-consuming when your goal is caring for patients.

The market has also reinforced this. People continue to purchase systems from dysfunctional vendors due to pricing, perceived product sexiness, etc. I’ve helped some small practices select systems and have seen them choose systems that their consultants specifically advised against (due to known defects, poor service, etc.) just because the price was right. Ultimately, you get what you pay for, although there are some expensive lemons out there, too.

No one wants to de-install and go through it all again. Having done it myself, trust me, it’s not the worst thing that can happen.

If you choose wisely, it just might make you go from spending four hours a night entering your notes after dinner to finishing on time and walking out the door before the last patient has left the building.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

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