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!

Structured and Unstructured Data, I Adore You Both
By Deborah Kohn

Calling all electronic patient record systems (EPRS) structured data! Yes, all you electronic health / medical, administrative, and financial systems’ data elements that are binary, discrete, computer-readable, and, typically, are stored in relational databases with predefined fields … you tidy, typically core, transactional and mined elements. Hello? I’m talking about all you digital, patient demographic, financial, and clinical health data that are sitting in master patient indices, insurance claims, clinical histories, problem lists, orders, test results, care plans, and business intelligence reports — to mention just a few.

Meet unstructured data! Yes, all you EPRS data that are non-binary, non-discrete, sometimes only human-readable, and sometimes not stored in relational databases. This means all you digital, bit-mapped images, text, videos, audios, and vector graphics that are harnessed in word-processed summary reports, electronic forms, diagnostic radiology images, scanned document images, electrocardiograms, medical devices, and web pages – again, to mention just a few.

I know this might be an awkward introduction. However, I’m really happy to finally get you two data formats together. And, while this might be jumping the gun a bit, I really hope one day you two will get married! I know, I know. That is, after you’ve carefully sorted out all your differences and learned how to live together in peace and harmony for the betterment of patient care.

After all, I’m certain you heard the rumor that the “adoption” and “Meaningful Use” of “certified” diagnostic image-generation and management systems, such as a PACS for one or more of the “ologies”, might be included in Stage 2. In addition, heaven help if, given the revised Federal Rules of Civil Procedure Governing Electronic Discovery that became effective December 1, 2006, a patient’s electronic health/medical, administrative and financial episode-of-care records (I mean x-rays, bills, ECGs, orders, progress notes – the works!) are subpoenaed for that Weird News Andy case we recently read on Mr.HIStalk! So, don’t you think it’s time at least to begin acknowledging one another in public?

Who am I, you ask, to be so bold to introduce you to the other? I’m just one, frustrated HIT professional who specializes in most of the EPRS unstructured data and who observes that these data are rarely considered in EPRS strategies and purchases … until after the fact. Once considered, they divide provider organization departments right down the middle; those working with you, structured data, vs. those working with you, unstructured data. Don’t even get me started about integration and usability issues!

Come close, structured data, so I can tell you that I do adore you – especially when I search a database for one or more of you, and, quickly and easily, the search engine finds, retrieves, and even manipulates parts or all of you. On the other hand, what often makes me want to delete you is when you insist on snubbing unstructured data. I’ve even watched you try to convert some unstructured data, such as rich-text or video data, to your popular religion, using pretty-good-but-not-perfect artificial intelligence and recognition tools … just so that you can brag about how you were able to generate the complete health story with your qualities.

Unstructured data? After so many years working with you, you know that I love being able to retrieve your gorgeous, bit-mapped, raster images generated by that digital chest x-ray or computed tomography (CT) scan stored in a diagnostic image management system; or, listen over and over to your brilliant sound bytes generated by that digital stethoscope; or, fast forward your streaming videos / frames generated by that important cardiac catheterization study; or, admire the perfect lines connecting the series of points plotted by that fetal trace recording. On the other hand, what I can’t tolerate is when I am required to search, for example, a valuable narrative text for one or more of you, and after hours I still can’t find you!

Today there is no complete electronic patient health / medical, administrative or financial record system without both of you. Let me see a hand shake.

Deborah Kohn is a principal with Dak Systems Consulting  of San Mateo, CA.

Problem Lists:  Avoiding the Tragedy of the (Coded) Commons
By Dr. Jim

If we want to take better care of patients, we have to know what we did. To know what we did across a whole group, we need computers to crunch concepts that computers understand.  

But here lies a paradox. While we need structured data entry to enable useful analysis, too much structure complicates both data entry and analysis. The splitters (and payors) among us can create use cases that force the lumpers to accede to ever finer divisions until, for instance, a single ICD-10-PCS procedure code represents nearly an entire chart summary: “ICD-10-PCS 027334Z Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Approach” e.g. There are upwards of 1,000 more angioplasty codes within ICD-10-PCS, all with a General Equivalence Mapping to a lesser number of ICD-9-CM Volume 3 codes.

Are my fellow clinicians napping off yet? If so, put on a hazmat suit before you do. What is hitting the fan now will be splattering you shortly if it is not doing so already. In the interest of being able to use our electronic records meaningfully, the movement is toward collaborative problem lists with structured entries documented by clinicians. This would be a good thing—an excellent thing—were it not for the concomitant explosion of  “structure” detail, the de facto  requirement that clinicians do the structured entry as part of their workflow, and the variety of workflow places and coded sources that potentially populate the “Problem List.” 

These sources include the SNOMED-CT and ICD-9/10-CM libraries for diagnoses. I won’t be surprised if a typical Problem List ends up including Procedural Codes as well from the  ICD-10-PCS and CPT/HCPCS libraries. While these procedural codes are not technically “problems,” and not currently Meaningfully Used (the current standard is for “ICD-9 and SNOMED-CT” pending the swap to ICD-10), it does not take a Workflow Scientist to predict that a clinician who documents a percutaneous angioplasty as a CPT code will have an expectation that the Problem List is automatically populated with that (coded) “diagnosis.” 

We are about to see electronic record-generated collaborative Problem Lists that are essentially a repository for the “workflow” output of every clinician who touched the patient. Diagnoses attached to ordered tests; diagnoses entered during a Hospital stay; ED diagnoses; prescription diagnoses; ambulatory diagnoses; imported diagnoses carried by CCDs … perhaps even diagnoses entered by billing services after discharge. It will be the plethora, and not the dearth, of finely-split coded data, which renders the Problem List less functional and the analytics related to it problematic. 

The challenge is to find ways to get to Meaningful Use without letting it prevent the record from being used meaningfully. It’s a great idea to have a collaborative Problem List from which every workflow can read and to which every workflow can write. But we must also focus on finding ways to preserve a Problem List which readily communicates a plain-English problems summary for all caregivers so that Meaningful Use does not morph it into an unnecessarily long and noisy collection of all the code-speak entered on a patient.

There is a need in the electronic record for good, coded, structured data. This does not mean it should replace clear communication.

Real-World Epic from the Ground-Level View
By Informaticist RN

I have worked as a nurse with Siemens Invision, Cerner, and Meditech and an implementation consultant for a leading HIS vendor (not Epic). I’ve also worked as an IT analyst at a major medical center implementing Epic ambulatory.

We had two Epic employees assigned to the ambulatory application, an application coordinator (AC) and an application manager (AM). Both were fresh out of college and obviously green to healthcare.

Our AC/AM would come out for a week at a time, with no agenda given in advance. When they were here, it was disorganized. Whether this was the hospital’s fault or Epic’s, I’m not sure.

Usually, the two Epic people would be typing away on their laptops and not meeting with anyone from the hospital. When I did have one-to-one meetings with them regarding the build we were working on, they were constantly on "Epigoogle" (Epic’s search engine) because they did not know answers to what seemed to me like basic questions.

After their visits, we received no follow-up on outstanding issues or status reports of things they were working on for us. Reaching them was always a challenge. Either by voice mail or e-mail, it could take days or weeks to get questions answered. Generally, it took escalating issues through our project manager just to get a response. We didn’t even get, "Saw your e-mail, working on issue, will get back to you." Nothing! Very poor customer service from them.

During what Epic calls validation sessions, we ran into many problems where scripts weren’t sent ahead of time for our review. Some sessions ended up with last-minute cancellations because Epic wasn’t prepared or hadn’t shared the necessary info with us. Very frustrating.

When build questions arose, the Epic AM preferred to fix the problem in our system herself rather than explain the answer to us so we could learn the system. Frustrating again!

These same AC/AM were also responsible for grading projects for certification. When clarification was needed for me to understand what I got wrong, they were unable to. That was actually a final answer I received from our AC — "I don’t know," and no offer to find who might know more or send on my project to someone more senior for grading.

It was really very disappointing because I was a better IC at the vendor I worked for than either of these two, but everyone at the hospital acted like they were so great because they come from Epic.

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From THB: “Re: Cheyenne Regional Medical Center. Going Epic.” The 218-bed hospital gets board approval to replace McKesson Horizon with Epic in a $19 million deal, saying it will cost about $5 million over five years to implement Epic. It says Meaningful Use money will offset that amount, and after that, Epic will actually be cheaper that McKesson. Epic doesn’t usually sell to hospitals that small, so either CRMC is affiliated with a larger Epic customer or Epic is started to push down into Meditech territory.

From WSDiner: “Re: HCA. At a Credit Suisse Healthcare conference investor dinner Thursday night, HCA’s management said they piloted Meditech 6.0 this year and will pilot Epic next year. They said that no other vendors (i.e., Cerner) were under consideration.” The reader provided a Credit Suisse contact to confirm, but he didn’t respond to my e-mail. This will be interesting if it’s true – my read has always been that HCA just wants to scare Meditech into better pricing by bringing in competitors, but Epic doesn’t walk away without a contract in most cases. HCA is Meditech’s largest customer, contributing 8% of the company’s revenue in 2010.

From Commodore: “Re: Cerner running poorly on the iPad. Do other inpatient vendors have native apps?” The only one I know of is Epic, which has Canto (above.) There may well be others. I tried using a couple of my hospital’s clinical apps the iPad using the Citrix portal and that’s definitely not something that’s workable for clinicians. The shrunken screen is impossible to comfortably read, you have to constantly zoom to hit tiny drop-downs with your finger, and the clicking doesn’t feel sure-footed at all. I think it’s safe to say that for most vendors, there’s not much to brag on if your iPad capability consists of running an emulated desktop screen. Only your marketing people will be impressed.

From The PACS Designer: “iPad viewer. The FDA has now approved an iPad viewer from Carestream called Vue Motion. The application permits the viewing of image files from many different PACS platforms, including cloud-based offerings, and can be integrated into EHR solutions to permit viewing of image files and patient records through a single sign-on.”

Here’s my summary of business lessons learned from the Steve Jobs biography. 

My Time Capsule editorial from October 2006:  Economics 101 and the Healthcare IT Market (that’s a pretty lofty premise to cover in 500 words). A Sam’s Club tiny paper cup-sized sample: “Hospitals can be convinced by questionable claims of product superiority or patient risk, and even more so by seeking vendors just as prestigious as they fancy themselves (no Walmart shopping for big academic medical centers, even though patients are the ones paying.)”

Note the reduced number of animated ads to your left thanks to those overachieving sponsors who have already traded out their animated ads in advance of the January 1 target date. I always feel bad when requiring changes like that, but it will benefit sponsors as well since readers will pay more attention to more subtle ads. I’ll digress by saying that while few things surprise me these days, one that does is the non-financial support I get from sponsors. Not all of them, since a few are purely ad placements without much personal connection, but the majority have executives and regular employees who keep in touch, send me music recommendations, e-mail me a well-timed attaboy right when I’m feeling overwhelmed or under-accomplished, or send off-the-record snarky comments about one thing or another. HIStalk is an after-work hobby for me rather than business and I like that the connections aren’t always business related.

Venture capital superstar and billionaire Peter Thiel, speaking at Practice Fusion’s conference (he’s an investor), says highly paid salespeople can land big businesses as customers and relentless marketing can get consumer sales, but companies that can sell to small businesses (like most medical practices) are rare since those small businesess are reluctant to change. He gave as examples QuickBooks and PayPal (implying Practice Fusion as well, naturally.) Also at the conference: Practice Fusion rolls out its iPad app, although I’m not clear if that’s a new native app or just the LogMeIn remote control version that was announced at HIMSS.

Doctors and hospitals in Boulder, Colorado are questioning whether joining Colorado’s statewide RHIO (CORHIO) is worth the subsidized cost. Small practices say the upfront training costs and $85 per doctor monthly fee are steep, and doctors at Boulder Medical Center says there’s not much value to them since they’re already connected via their NextGen systems. CORHIO’s five-year business plan called for taking in $26 million in federal grants and $19 million in subscriber fees.

Polls that list companies always bring out ballot box stuffers, but they’re fun nonetheless. Epic wins this one handily, with a fairly even spread among the losers. New poll to your right: how will ONC respond to the IOM’s report that criticized patient safety efforts related to electronic medical records?

We already know what HIMSS thinks of the IOM recommendations since Steve Lieber quickly released a statement. He zoomed right past all the patient safety concerns, preferring to focus on one sentence that says paper records are also risky, thereby summarizing the entire work as “a strong endorsement for the path healthcare is on.” Well, OK. He also is somewhat dismissive in saying IOM looked at only at the patient safety aspect of HIT and it’s already fussed about that before (which is exactly what you’d want IOM doing given that there are plenty of loud voices, especially that of HIMSS, extolling the virtues of technology for purely commercial reasons and ignoring IOM’s previous recommendations). A critic might say, “Who’s this association executive  with no credentials in medicine, research, or technology speaking on behalf of his unpolled membership to critique the work of a large group of unbiased and extremely well-credentialed IOM medical experts whose thoughtful opinions were commissioned by ONC?” but to question the authority (audacity) of HIMSS to weigh in on complex national matters is just not done. If you say anything even slightly negative about commercially sold healthcare IT, HIMSS is going to hit the PR airwaves, often cherry-picking a few HIMSS-friendly members to chime in for credibility support. Choose your side: an unbiased group of scientists vs. an exhibit hall-funded trade group. I like some (maybe even most) of what HIMSS does, but its predictable knee-jerk defense of the industry and federal grants just annoys the heck out of me as a dues-paying member, especially given that so many of us members pride ourselves in spotting and debunking shoddy research methods, investigator bias, and inconclusive evidence, all in the interest of improving patient outcomes and reducing healthcare costs just like IOM is trying to do.

Here’s Vince’s latest HIS-tory, highlighting Healthcare Information Systems. I’m cringing a little because he attacks someone at the end, to be named in the next installment. I don’t know who it is, but I’m hoping that person is (a) not a reader; (b) dead; or (c) one of Vince’s pals he’s just joking around with.

Thanks to the following sponsors (new and renewing) that supported HIStalk, HIStalk Practice, and HIStalk Mobile in April. Click a logo for more information.

Epic hosted a college team programming competition in its offices this past Saturday. You wonder how many of the geeky combatants left with job offers, and also how the reporter kept a straight face in writing up details: “Winners and awards will be announced after the 4:30 p.m. conclusion of the competition, which will be held in the Nebula room in the Heaven building. Parking is available in the Yoda underground garage.”

Jackson Memorial Hospital takes part in a quickly assembled telemedicine project that will connect Miami specialists with hospitals in Iraq, part of a $1 billion contractor’s project as the State Department takes over field hospitals and medical care when US troops pull out December 31.

Weird News Andy wonders how many EMRs have edits that would prevent documenting this. In Mexico, a 10-year-old girl gives birth. You have to either admire or detest the creativity of the UK-based newspaper’s accompanying photo of a girl packing a toddler along in some kind of serape, clearly desperate for a visual, yet struggling with the lack of an Enquirer-like picture of a 10-year-old: the photo has nothing to do with the actual story and was “posed by models.” Its readers are apparently so stupid that reading text without even an irrelevant picture is unthinkable.

WNA also notes that health conditions are leaning toward the Third World in the Occupy Wall Street encampment. The unfocused unemployed there are coming down with a variety of respiratory infections as they sleep among their trash, pee in bottles without washing their hands, pass cigarettes and alcohol mouth to mouth, and refuse free flu shots because they’ve concluded that vaccines are a government conspiracy. They have a volunteer-staffed medical tent, but it only stocks herbal remedies.

ONC’s blog (which is actually written by its contracted PR company – it’s not like Farzad’s going to bare his innermost thoughts or music recommendations there) highlights the VA’s Blue Button initiative in honor of Veterans Day.

As Dr. Jayne mentioned, Walmart is denying that it plans to develop some kind of national primary care program, but they might want to check with their RFI people they’re clearly looking for partners to “rapidly create a comprehensive healthcare solution to deliver low-cost, high-quality primary healthcare services nationally.” The RFI lists specifically that partners should be able to offer chronic care services (diabetes, hypertension, etc.), lab tests, vaccinations, physical exams, health screenings, and durable medical equipment support. They say they will consider vendors who offer only “enabling technologies” as well, and the RFI requires prospective vendors to describe their proposed information system and “data sharing model.”

Ed Marx updated his most recent post to respond to reader comments. He’s always gracious, even to his anonymous attackers. And here’s the secret I shared with Ed: I don’t usually delete negative comments because I’d rather let readers provide the majority opinion via their own responses.

Speaking of Ed’s pieces, a few folks howl if I dare run anything that’s not directly related to their jobs, but many (most, maybe, especially at the senior levels) enjoy a mental break with personal stories about patients, working in HIT, or life’s lessons learned. Yours are welcome.

An Investor’s Business Daily article notes that its medical software sector dropped from #2 a month ago to #67, mostly due to the huge drop in CPSI’s share price after it missed expectations. The article says Cerner beat estimates but profit margins slipped in the most recent quarter, while Quality Systems shot itself in the foot in its earnings conference call by implying (but later clarifying) that most of its new sales were coming from replacements, suggesting that the market was past its peak. Athenahealth is mentioned for beating expectations but not by enough (double expectations?) and took a 7% share price drop as a result. On the positive side, shares in MedAssets jumped 14% and later 17% after beating estimates and Allscripts share price took a slight turn north after reporting results. Above is a one-year price chart of the shares of all those companies: Allscripts (blue), Cerner (red), Quality Systems (dark green), athenahealth (yellow), MedAssets (brown), and CPSI (light green). Leading the pack are Cerner and athenahealth. Looking at just the past three months, the clear winner is Allscripts, with MedAssets and Cerner basically tied for #2 but pretty far off the pace. Looking back five years, your best return would have been Cerner and Quality Systems. Always amusing is that ever-vigilant stock analysts flip-flop their recommendations a day or two after unusually good or bad news is announced, providing no benefit whatsoever for the clients paying them for non-retrospective advice.

I’m beginning to be annoyed by research companies selling expensive reports under the headline, “XX Market to Reach $X.XX Billion by XX.” One of these days I’m going to check the accuracy of their past predictions, which I suspect is minimal. Inga loves to run those press releases like they’re real news, along with the splashy results of questionably conducted surveys that are favorable to the companies paying to have them done. She’s usually good natured about my edict that she’s allowed only one survey mention per post.

Inga notes that Sage’s new name, Vitera, is also a band’s name. She and I don’t usually like the same music, but they’re good for an unsigned band, a Latin-style pop with a harder guitar edge, like a Spanglish Guns N’ Roses. Check out this live video and the flying V fiddle, which sounds to me like prog rock meets Texas swing. 

A Jacksonville, FL woman starts a booming business that provides scribes to do patient care documentation for ED physicians. The scribes, often pre-med or nursing students, are contractors billed out at $20-25 an hour, a bargain according to the company’s medical director. “For every hour we spend, we get about 15 minutes at the bedside of patients and 45 minutes of every hour documenting everything … part of it’s insurance. Part of it’s medical-legal. Part of it is a federal mandate to have everything documented electronically.”

Startup accelerator Rock Health signs on UnitedHealth Group as a sponsor. It joins Microsoft, Nike, Qualcomm, and Quest.

Outsourcer and iSoft acquirer CSC reports Q2 numbers: revenue up 1%, EPS –$18.56 vs. $1.19, cutting guidance. The ugliness was caused by a massive $2.69 billion write-down of goodwill and a settlement of a contract dispute with the US government. Shares predictably tanked.

Two nurses file a class action lawsuit against Aurora Medical Center (CO) after being written up for trying to clock in before putting on their hospital-provided scrubs. They say they should be paid for the time it takes to go to the scrubs room, find some that fit, put them on, then go clock in.

History Mingles with Innovation in Atlanta
By Erin Sweeney, Director of Marketing
The Friedman Marketing Group

The “who’s who” on the Atlanta healthcare scene met at the historic Fox Theatre this week to discuss innovation and opportunity—along with military weaponry. The HealthIT Leadership Summit, founded by the Technology Association of Georgia, Metro Atlanta Chamber, and Georgia Department of Economic Development drew nearly 200 attendees and such notables as Drs. Robert Kolodner, Mark Dente from GE, and Kenneth Wilson, a U.S. Army Major who served three tours in the Middle East.

Key takeaways from the eyes of this healthcare marketing guru include:

• There is a whole new generation of healthcare IT experts ready to lead the charge.
• Analytics are a key capability for all healthcare IT systems.
• There are some really cool virtual reality glasses being tested in Afghanistan to help military medics and other first responders save lives—may come stateside soon.
• Vendors that enable ACOs through harmonization of multiple systems will be winners.
• Vendors that are behind can easily get ahead using new technology.
• Cloud computing is here to stay, on-premise is antiquated.
• Patients will spur providers to innovate.
• Boards will be more involved in quality improvement.
• Interoperability must happen between states.
• Average venture capitalist investment in healthcare IT is $3 – $5M.
• VCs are more interested in companies where technology is driving a service; and the two are not treated separately.

Amidst all the innovation, attendees did hear one reality check offered up by a panelist and based on research from Cigna Health: the average patient has 200 documents located in 19 different places.

And finally, Justin Barnes from Greenway Medical painted a gloomy picture for physician reimbursement and suggested groups ask themselves, “Do we interoperate or join an ACO?” Another panelist encouraged groups to look around and decide who they’ll affiliate with instead of waiting until the best dance partners are taken.

Overall, the Summit was interesting and a bit eye-opening. The TAG speakers and panelists added some fun and humor to the discussions. Dr. Dente pointed out that women are caregivers for not only their own elderly parents, but also their in-laws. Doctors’ appointments, prescriptions, transportation to and from check-ups — the women do it all. Looks like the upcoming holiday gatherings will be a walk in the park compared to what’s in store for this gal.

E-mail Mr. H.

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An HIT Moment with ... is a quick interview with someone we find interesting. Stuart Long is president of Capsule Tech, Inc. of Andover, MA.

What’s new in the world of medical device connectivity?

I think the biggest change is that more and more hospitals understand the need for device integration and have moved on to the realization that clinical workflow improvement is a significant factor. This means that when hospitals are evaluating connectivity, that they are not only looking at the technical components, but are really investigating whether the solution fits the way the nurse works. They realize that doing so not only ensures successful adoption, but ensures that the benefits of device integration are
truly realized. 

We’re seeing actual data from our customers indicating their clinical staff gains as much as one-fourth of their time back to bedside caring of their patients. This is significant. I also think this is why you see the role of CMIOs and CNIOs increasing in the industry — understanding the importance that IT plays in the evolution of improved clinical care. They are leading the way at bridging the gap between IT and clinical and ensuring that the technology not only fits technically, but clinically as well.

Why is vendor-neutral device connectivity important?

There are hundreds of devices throughout a hospital. There are dozens of receiving systems that want data from those devices. Without a vendor-neutral solution, hospitals end up with vendor-dependent solutions that only solve connectivity for one device or one system and can significantly drive up the cost of deployment, management, and upkeep. The result of this type of connectivity is multiple points of integration that are nearly impossible for the hospital to manage and that offer no flexibility to add,
change, or upgrade their devices or IT systems. As connectivity evolves, there will be even more points of integration to manage.

Vendor-neutral connectivity is the optimal way for a hospital to ensure that their architecture is as clean as possible, that it minimizes points of integration for easier management, that it helps manage costs, and that it offers the flexibility and scalability to allow hospitals to add and change devices or IT systems as needed.

However, we consider this basic vendor neutral connectivity. Customers want to connect more devices, but they also want a visual status display at the bedside. They want a solution that allows them to validate and send vitals from the bedside in lower acuity areas such as med-surg. They want to expand their solution to do more advanced connectivity, such as reporting and analytics, that could result from the collection and comparison of all collected data. 

Many of our customers understand the burden of managing many third-party applications on a PC not originally intended for this type of use. They tell us with FDA being a priority, “We want you to own it cradle to grave.” This way there’s no ambiguity as to who owns what. The point of demarcation between what is our responsibility and what is the customers is crystal clear.

Our product is a medical grade platform that delivers basic connectivity and enables connectivity across the hospital, fits into workflows, is dedicated to connectivity management, and is field-upgradeable. Customers can realize the benefits of improved patient care, workflow efficiency, and patient safety today and grow without having to overhaul their solution to add features and applications later.

Are we at a point where our ability to collect medical device data exceeds our ability to do anything useful with it?

There is always a need to automate the basic charting process. Manual vital sign collection and charting is simply a waste of nursing time. Even if the only goal for a hospital is to implement the basic connection of devices to systems to automate this charting process and improve patient care at the bedside, this in and of itself justifies the implementation.

However, I think the industry is in the early stages of the next big growth cycle for device connectivity. Clearly the connection to the EMR is still the biggest driver for connectivity today, but there are many applications that have been emerging over the past few years that require not only the discrete device parameters, but also the alarms and waveforms from devices. Some of the emerging drivers are decision support, remote surveillance and monitoring, mobile devices, alarm management, and device-to-device
interoperability.

There are definitely many current and future uses for all this device data. The challenges are in being able to process, format, and ultimately serve up the data to these applications. We are experts at doing this. Providers also need and want to get more useful data to help improve decision making. In fact, there is already much progress on the BI and analytics aspect of healthcare.

Do you have examples of providers that have demonstrably improved patient outcomes by using medical device data integration?

Yes. The key benefits of medical device connectivity are improved workflow efficiency and patient safety. Our customers have documented amazing progress in this area and reported improvements in the amount of time vital signs are now available in the patient’s record.

One customer nearly eliminated the delay of vital signs to the patient record, going from six hours to just seconds. Another customer recognized an annual savings of $265k in reduced waste previously caused by vital sign delays. Another reported a 23% reduction in documentation time post medical device connectivity. Ultimately, this translates to more time in direct care activities and supports improved patient care and satisfaction. This leads us to the results of one customer that reported a 61% Gallup improvement in their nursing satisfaction pertaining to their job.

Patient safety is positively impacted by medical device connectivity as well. Charting errors are reduced and patient data errors are avoided. Accurate vital signs are available in the EMR and accessible to physicians and clinicians, which improves patient care coordination. One of our customers is linking near real-time vital signs with their early warning system and using it as patient surveillance to track deterioration of the patient status and the need for rapid response intervention. They are also using the benefits of device connectivity to monitor the potential for sepsis in lower acuity environments.

Exact metrics on errors and omissions are hard to come by since hospitals are sensitive to report this information. However, we are seeing our high reliability customers more willing to study this metric so they can continuously improve and initiate actions to create a safer environment for all their patients.

What changes do you predict over the next few years that will affect your products?

The largest changes will be related to improvements in clinical workflow and the use of data. This includes the collection and management of alarms and waveforms and the ability to integrate smart pumps. Closely related to all of this is the industry shift from collecting data based on the patient’s location to a workflow, whereby the data is directly linked to a confirmed patient ID.  All of these areas are huge challenges for hospitals. 

We have been working with our customers and our device and information system partners to solve these needs. There are a lot of technical details to sort through to make it happen and a lot of testing that needs to be done end to end. But that work has
started and connectivity will, in my opinion, be rapidly changing in the years to come.

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I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in October 2006.

Economics 101 and the Healthcare IT Market
By Mr. HIStalk

You’ll remember this example from your MBA economics class. If sports tickets are priced perfectly, the venue will sell out precisely, leaving neither disappointed fans nor empty seats. Since the tickets aren’t priced perfectly, scalpers provide a valid economic function by ensuring that seats are available to those who value them more than others. The intersection of supply and demand is the correct price, which as scalpers know, is sometimes higher than the face value of tickets. That arbitrage goes right into their pockets.

Software isn’t a perfect model for supply and demand. Its incremental cost to the seller is nearly zero and those sellers work hard to dispel the “commodity’ notion that all products are equally acceptable.

Still, signs seem to point at some rationalization of supply and demand in the PM and EMR business in physician offices. Pricey vendors are getting squeezed hard by new entrants with cheaper products. Doctors aren’t as easily enamored with “Cadillac” offerings as hospitals seem to be. Another economic principle is working there, too – when companies make excess profits, newcomers will come in and undercut them, thereby shaking out inefficient players.

Hospital system vendors haven’t felt that pressure yet. The choice of enterprise systems is limited. Marketing-issued smoke and mirrors have kept hospital prospects thinking that Product A is far superior and/or acceptable than Product B, thereby keeping prices high. The cheapest vendor doesn’t always win and neither does the most expensive one. Neither does the “best” one, for that matter.

One explanation is that maybe hospitals aren’t a price-sensitive market. There’s some evidence of that: expensive drugs and medical equipment sell just fine even when cheaper alternatives are available. Hospitals can be convinced by questionable claims of product superiority or patient risk, and even more so by seeking vendors just as prestigious as they fancy themselves (no Walmart shopping for big academic medical centers, even though patients are the ones paying.) CIOs trying to keep their jobs and to develop a marketable resume are suckers for the “bigger is better” approach, even when the bigger vendor has a horrendous failure rate in hospitals just like theirs.

Hardware and services costs also skew the market. Even free software comes with a high price tag because hardware costs are similar for all products and hospitals demand lots of fixed-cost, on-site help. A vendor that can develop a turnkey product with low hardware costs should theoretically do very well, at least if they can overcome the marketing spin of the big boys.

Yet another anomaly is that the HIT market isn’t perfect. Hospitals don’t necessarily know what everyone else is buying, how it worked for them, and what they paid.

I’ve advanced my “Big Three” theory of broad-line systems vendors. Could the also-rans move more product if they cut software prices? Should they give their systems away just to start earning maintenance fees? Hospitals area always starved for capital, so maybe a monthly fee paid out of operational funds would be appealing.

We’ll learn by watching companies like Medsphere, which has a heavy R&D product that costs them nothing since Uncle Sam already paid for it. They can succeed only if they can find price-sensitive hospitals who believe that information systems are a commodity. They’ll also have to compete with Meditech, whose products are already relatively low in cost and whose huge customer base throws off recurring revenue that will let it meet any price threat.

It’s interesting to review the healthcare IT market using what you learned in economics and marketing. Vendors and upstart competitors should be doing that. HIT 2.0, anyone?

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Top News

National Coordinator Farzad Mostashari says ONC will beat the IOM’s suggested 12-month deadline in rolling out a program to accept and analyze patient safety reports related to computer systems.

From Duck Hunter: “Re: West Johnson. West Johnson, vice president for healthcare revenue cycle consulting at Huron Consulting Group, is leaving at the end of December. He was an original Stockamp person.” West sent me a note confirming his departure.

From Phone Geek: “HIT Policy Committee meeting. This afternoon I have been listening to the HIT Policy Committee meeting. There’s now a rah-rah session about consumer access to their EHR records. President Obama wants every person to access his personal health record by 2014. I keep wondering if we should be more concerned about every person having access to healthcare and ensuring that rural America has access. And maybe making sure that we have good EHR implementations delivering systems that clinicians like to use and that they and their delivery systems receive value from.” Well, the HIT Policy Committee really has no influence on healthcare accessibility, however important the need. On the other hand, isn’t there a workgroup that focuses on EHR adoption and certification – and presumably considers usability?

From B.S. Walks: “Re: Cerner finally fulfilling the façade prophecy. Look at the stock dump that happened 10/27 and 10/28, dropping from $72.88 to $63.67. They are going counter-market, which isn’t a good sign unless you’re a short seller.” Above is a three-month share price graph of CERN (blue), DJIA (red), and Nasdaq (green). The trend line definitely looks better over a full year, but there was a big dip in August and the second starting in October. It could be more of a reflection on the sector since some of the HITECH luster seems to be wearing off as some companies haven’t met lofty expectations that were built into the share price.

From Horned Frog: “Re: Epic. Salaries are in line with what most new college grads get, or better I suspect since many of them are liberal arts majors. However, their incomes rise quickly, often exceeding what the typical med tech, nurse, or hospital IT person might make, although they typically work more than 40 hours a week. And with regard to requiring everybody to live in Madison, there’s a lot of advantage in having people show up at corporate, sharing knowledge and networking. Corporate offices often had the greatest product expertise, and vendors allow road warriors to travel from wherever. It doesn’t necessarily cost more to travel across the company than to take a shorter trip.”

From Porcini: “Re: Vince’s article on Epic. Hiring fresh grads isn’t new – Cerner started that. I doubt you can attribute cost overruns to training cost since organizations plan for those and it’s a good investment. Regarding ‘the Epic way.’ how do you define success in allowing user to customize – inefficient workflows? Unhappy clinicians? Epic charges so much because it can, and because it delivers what it promises in a timely fashion for a price that customers seem to find justifiable. And if Epic brainwashes its users to earn high KLAS scores, why aren’t other vendors doing that? I’ve never seen anything like Epic’s most collegial user group meeting. The amount of education and information sharing is absolutely astounding.”

From Buffalo Tom: ”Re: IOM report. Maybe I’m reading too much into it, but organizations with internally developed software fall under this definition, at least with regard to certification. I’m involved in the certification program and have seen firsthand how good ideas and intentions can create a lot of extra (and arguably unnecessary), like developing EHR modules that will be never used beyond earning certification. Compounding these recommendations is the discussion of mobile healthcare applications falling under FDA purview. Imagine if all of our clinical projects required certification or FDA approval before go-live. That might push hospitals to third-party solutions exclusively and we know there is no vendor that has a solution for every provider and scenario. I’m for safety checks and resources to help develop safer software are needed and valuable, but with regard to in-house development, I don’t think they need to jump through additional regulations imposed because of some shop that popped up last month to hurry up to get into the healthcare space.”

From Hat Creek: “Re: TEDMED 2012. Are you going?” Probably not – registration is $5,000, the attendee list is “curated” (meaning you don’t automatically get to come just because you have $5,000 to wave around), and it’s not all HIT-related. They had fun speakers last time around, including Dean Kamen, Michael Graves, Tim O’Reilly, Loudon Wainwright III (I could have sworn he was dead, but he’s not), Steve Wozniak, and some semi-celebrities.

From Lugubrious: “Re: Health IT Leadership Summit in Atlanta. SoloHealth won the Intel Innovation Award for their health and wellness kiosk. Bart Foster, the CEO and founder, was a very nice guy who accepted the award with a lot of humility and brought his team up on stage with him.” I found the above video on YouTube. The touch screen kiosk checks vision, blood pressure, weight, and BMI and lists doctors and “valuable offers from healthcare partners” (meaning ads, I assume.) I’d skeptical that a glorified, electronified scale and eye chart can have a significant impact on health (the people who need to hop on the scales tend to steer a wide berth, no pun intended, around them), but the technology itself seems interesting and the direct-to-consumer approach is different. I like the idea that users can create an account and access their information from any of the company’s kiosks. Maybe it should include a one-click connection to a nurse-staffed telemedicine center where you swipe your credit card to get a consultation for $20 or something. Ask Walgreens – they are clearly the leader in putting technology and innovative services right in their existing stores, turning what used to be “the pharmacy” into a “health center.”

Wondering what treasures await you on HIStalk Practice? A few gems from the last week: 52% of office-based doctors are e-prescribing. Greenway Medical is named a preferred EHR vendor for at least 10 RECs. MGMA’s Rosemarie Nelson provides great recommendations on improving EMR adoption. athenahealth earns a spot on a list of Top Places to Work in Boston. Brad Boyd of Culbert Healthcare Solutions tackles ICD-10 and 5010 readiness.  Sign up for your HIStalk Practice e-mail updates because you never know what booty you may find there (and I mean the treasure kind, though the foot kind often makes an appearance on HIStalk Practice as well.)

I perused my calendar last night and realized that HIMSS is just over three months away. Wow! Mr. H mentioned that HIStalkapalooza is on the calendar for February 21, which means it’s time to start shopping for the perfect party outfit (new shoes!) Returning this year: our always-popular “Inga Loves My Shoes” contest, sashes for the sassy, and the crowning of our HIStalk King and Queen (for the best-dressed partygoers.) Of course we will name the winners of the HISsie awards and hope that Jonathan Bush will return as emcee (Neal Patterson has agreed to step in if JB is unavailable.) We’re also considering a few new things for both the party and HIMSS in general, so stay tuned.

Friday, which contains the 11th hour of the 11th day of the 11th month that marked the end of World War I hostilities, is Veterans Day. Unlike Memorial Day, which is set aside to honor those who died in military service, Veterans Day is when we honor all American veterans (hopefully we do that on other days as well.) It’s a refreshingly non-commercial commemoration that involves no Hallmark moments, mandatory gifts, or heavily sponsored sporting events, so why not start your own tradition and take the opportunity to tell a veteran that you appreciate their service and sacrifice? If you served, are serving, or have loved ones in the military, thank you.

Listening: reader-recommended Ratatat, a couple of Brooklyn guys with a spare bedroom full of synthesizers (and a few guitars) that somehow make rocking instrumentals that are real songs (not background music) that sound like a non-computerized mad stew of Genesis, Boston, and Muse with some hip hop drum loops for rhythm. Sometimes the occasion calls for soaring, dramatic music free of unskilled singing of uninspired lyrics and these fellas deliver. Like most reader recommendations, this one was spot on with what I like. If I were making a movie, I’d want them to do the soundtrack.

On the Jobs Board: Support Consultant, HIM Coding Manager, Director Client Programs – HIE Architect. On Healthcare IT Jobs: Research Informatics Analyst, Epic Revenue Cycle, eGate Integration Analyst. 

Inga, Dr. Jayne, and I work day jobs, so we do the best we can with HIStalk given the time we have, trying to compete with well-funded armies of full-timers running around and reporting for various magazines and sites. You can help by reading, telling others, and supporting our sponsors. We can always use guest articles, insightful comments, and news tips. There’s the usual stuff I always mention (friending, liking, connecting, and signing up for e-mail updates) but we’re open to ideas if we can figure out how to find the time to do them.

Emdeon reports Q3 numbers: revenue of $282.1 million (14.7% increase); non-GAAP adjusted EBITDA of $76.7 million (15.3% increase.)

Siemens AG announces that it ended its fiscal 2011 with record operating results that included several orders worth over $100 million for Soarian Revenue Cycle. Siemens Healthcare also just finalized a $28.7 million contract with Hawaii Health Systems.

Millennium HealthCare Inc. completes its acquisition of medical billing and consulting firm Premier Technology Resources.

Vista Equity Partners completes its acquisition of Sage Healthcare Division and renames the company Vitera Healthcare Solutions. Matthew Hawkins, previously CEO of library software vendor SirsiDynix, is named CEO, replacing former Sage Healthcare President Betty Otter-Nickerson. The ambulatory product line remains intact.

Northwest Michigan Surgery Center selects the Versus Advantages RTLS to automate process flow management for the clinical staff.

SUNY Upstate Medical University (NY) signs an agreement with TeraMedica to implement Evercore Enterprise Vendor Neutral Architecture, which will support integration for SUNY’s Epic EMR. 

John C. Lincoln Health Network (AZ) selects iSirona to connect medical devices to its Epic CIS.

Lakeland Regional Health System (FL) chooses RelayHealth for its enterprise HIE.

Twelve-bed Sedgwick County Health Center (CO) selects the ChartAccess Comprehensive EHR from Prognosis.

Four-hospital Lifeline Hospital Group will partner with Optum to bring that company’s billing and collection systems to Lifeline’s hospitals in United Arab Emirates and Oman. Optum says it will take what it learns there to aid its expansion in the Middle East.

People

Merge Healthcare appoints Peter Urbain (IBM) SVP of partner sales and Steven Tolle (OptumInsight, Allscripts) SVP of solutions management.

Omnicell founder and CEO Randall Lipps is named to the board of outsourced radiology provider Radisphere.

Announcements and Implementations

The Tri-State REC announces that it has met its enrollment goal of 1,739 primary care providers in Ohio, Indiana, and Kentucky.

North York General Hospital (ON), the first hospital in Canada to go live on CPOE and bedside bar code scanning of medications, earns the Innovation in the Adoption of Health Information award from Canada’s Health Informatics Association. The Cerner customer had been previously been recognized as HIMSS EMRAM Stage 6 hospital.

LSU Health Shreveport goes live on electronic medical records (Epic?) The implementation moves on to E.A. Conway and Huey P. Long hospitals.

Web-based PM/billing vendor Kareo launches its electronic patient statements and payment portal for practices.

Government and Politics

HHS’s Office for Civil Rights will begin conducting HIPAA compliance audits this month for office-based physicians, hospitals, and health plans. Twenty audits will be performed in the initial round and selected entities will be notified in writing within 10 days. Officials will visit the audited sites within 30 to 90 days of notification.

A Senate technology subcommittee chaired by Sen. Al Franken (D-MN) frets over recent healthcare data breaches at Minnesota hospitals, with Sen. Franken saying, “The same wonderful technology that has revolutionized patient health records has also created very real and very serious privacy challenges.” Ranking committee member and physician Sen. Tom Coburn, MD (R-OK) opines that maybe electronic records aren’t all that great. “They gotta get into my office to get it when it’s on a piece of paper.” Above is the Senator in his former life as a comic with partner Tom Davis (old timers will remember them from SNL) in an excellent Rolling Stones parody. Franken should get the band back together and run for governor with Davis as his lieutenant.

Technology

Steve Jobs gets his first posthumous nod for being right yet again: Adobe is abandoning its attempts to make Flash work on mobile browsers, and in fact, may be admitting that Flash is obsolete for the Web in general. Steve refused to allow Flash to run on Apple’s mobile devices, saying it’s proprietary, buggy, full of security holes, a CPU pig, incapable of responding to a touch screen interface, and a battery-eater. He said Apple mobile users enjoy videos and games just fine without Flash and that Adobe should dump Flash and focus on HTML5, which they apparently are now doing. Adobe canned 750 employees this week with the usual “restructuring to focus on core business” excuse, taking a $94 million charge for eliminating 7% of its work force.

Indigo Identityware announces iDNA for the iPad, which it says offers password-free strong authentication via a four-digit PIN to access a virtual desktop (including Citrix.)

A CIO article reports that a few clinicians at Seattle Children’s Hospital tested the iPad for running a virtual desktop in patient care areas. The verdict: every one of them returned their iPad, saying Cerner apps that were designed for desktop-and-keyboard users sucked big time on the small touchscreen.

Several states and technology vendors in the EHR/HIE Interoperability Workgroup define standards by which EHRs connect to HIE in a plug-and-play (their words) fashion.

Other

Epic goes before the Verona (WI) Planning Commission to present an expansion project that will add 900 offices and 700 underground parking spaces. Three buildings will make up the “Farm Campus” and may feature barn siding rather than brick, and possibly a silo. Epic, by the way, expects 2011 revenues to reach $1.1 billion, up from last year’s $825 million. A Verona city administrator estimates the new project will cost Epic $75 million.

Kudos to the eClinicalWorks employees who spent time this week volunteering with Habitat for Humanity in Boylston, MA. The eCW folks helped with painting, laying down floors, and assorted other projects.

The rate of healthcare employment fell from 45,000 new jobs in September to only 11,600 in October. Physician offices accounted for 8,000 of the new opportunities in October.

A new report estimates that the combined ambulatory and inpatient EMR market will grow to over $8.3 billion by 2016. Allscripts hold the largest share of the ambulatory EMR market while Meditech leads in the acute care segment.

The Clark County Commission (NV) considers a $30 million proposal for a McKesson EMR system for University Medical Center. The contract includes a one-time fee of $27 million, $4 million in annual fees for the next four years, a $1 million reserve, and $1.3 million to backfill employees and perform ongoing system maintenance.

A three-year study from the RAND Corporation concludes that providers are interested in bundling payments to cut health costs, but find the strategy difficult to implement. Technical challenges include deciding what problems should be subject to bundling and providing clinicians with the information needed to improve care. Cultural issues include convincing providers that cost cutting measures will not reduce the quality of care.

Elected officials urge residents of Freetown, MA to show their support for a proposed Meditech facility to be located in their town, an option Meditech walked away from in September after tangling with the state’s historical commission over preservation issues. Given that the unemployed citizenry vastly outnumber the archaeologically astute, just about everyone is trying to neuter the commission’s authority in their pleas urging to Meditech to reconsider.

Notorious patent troll Acacia Research Corporation announces that EMR vendor Aprima has decided to pay the company off in the form of a “license agreement” rather than spend money defending itself against a nuisance infringement lawsuit. Acacia’s intellectual property is, “The generation of a document utilizing user-modifiable document structures, a database including information to be placed into a particular document structure, and a computing device which combines the particular document structure with relevant information stored in the database.” Legal chest-puffing is good business: Acacia booked $63 million the most recent quarter. The company owns patents for such medical innovations as catheter insertion, cardiac stents, performing laparoscopic surgery, medical monitoring, PACS, and wireless physiologic monitors.

• On the first day of its go-live, Baptist Healthcare System’s (KY) ED exceeds Meaningful Use thresholds using T SystemEV.
• Passport Health releases its November schedule of live demonstration webinars.
• Trustwave’s security and compliance portal TrustKeeper is named a 2011 Chicago Innovation Award winner.
• MED3OOO announces upcoming dates for its webinars featuring InteGreat EHR with Quippe technology. MED3OOO will give away an iPad 2 at each session.
• e-MDs and TMF Health Quality Institute offer free assistance to Texas e-MDs customers interested in earning incentives under PQRS 2012.
• Covisint releases a report on three PQRS misconceptions that could prevent providers from obtaining CMS incentive dollars.
• Scott Besler and Jonathan Besler of Besler Consulting  will present Medicare Hot Topics at the HFMA NH/VT Annual Health Care Reimbursement Seminar December 8.
• The Kansas and Missouri regional extension centers select Greenway Medical’s PrimeSUITE EHR for their combined 2,548 providers.
• Wolters Kluwer Health announces the addition of general surgery to its UpToDate clinical knowledge system.
• Baptist Hospital (TN) is using MyHealthDIRECT to schedule community provider appointments for its discharged patients.
• Healthcare Integration Strategies enters into a Provider Consulting Organization agreement with CapSite, enabling Healthcare Integration Strategies to offer the CapSite service as part of its consulting engagements.
• An Aspen Advisors case study covers its engagement by Indiana University Health to analyze the personal health record market and best practices use of PHRs by health systems.

EPtalk by Dr. Jayne

It seems as though we’ve had a couple of slow news weeks lately, but the past few days have been what you could call a target-rich environment. Of course, the Institute of Medicine report is tops on many colleagues’ minds. Mr. H did a great job with his digest, which thankfully gave me enough talking points to look as if I had read the whole thing, when in fact I had spent my time watching Fast Five rather than doing actual work in the evening at home as I usually do.

Personally, I’m intrigued by the comments about regulating software, but I also think we need to hold users accountable for certain behaviors. I have physicians who regularly strive to defeat EHR safety features and others who complain about every safety feature which is introduced. No matter how non-intrusive the code, they take it as an assault on their profession. Maybe for those physicians who demand to wear the mantle of medicine as it used to be rather than living in the present, I say adepto super is: get over it.

Merritt Hawkins releases the 2011 Survey of Final-Year Medical Residents, which looks at career preferences and plans of those completing their training. Not surprisingly, over the last decade there has been a ten-fold increase in the number of physicians who are looking for hospital employment. Solo practice continues to be a non-starter. The number of residents who owe between $200,000 and $250,000 in student loan debt has grown from 7% in 2003 to 19% in 2001. My take on it: more validation of the impending primary care shortage. It’s much harder to pay off that kind of debt as a PCP than as a radiologist or dermatologist.

Speaking of the primary care shortage, the headline “Walmart wants to be your MD” certainly caught the eye of THIS medical doctor. Just when you thought that we’d seen the worst of the worst ideas in healthcare reform, this one comes along. Apparently Walmart requested information from partners looking to reduce healthcare costs and then had to issue a statement correcting its position, stating it was “not building a national, integrated low-cost primary health care platform” even though that’s what the statement said.

Walmart’s track record of driving jobs out of the economy in the name of low prices is well known. I hardly think a company that hasn’t even figured out how to offer affordable health insurance to its own employees has any business getting into the healthcare fray. Within days of this request, they also announced that they will no longer offer health insurance to new part-timers. As the article states, primary care isn’t what is driving up the cost of healthcare in America. My favorite quote from the article summarizes this as just another retail clinic attempt to gain market share: “If you get someone in the door, you can also sell them milk and a shotgun.”

Speaking of great quotes, I love this one from an article on transitioning from paper to electronic records. When asked what data should be transferred to the EMR, one physician answers, “depends on how anal-retentive you are.” This absolutely hits the nail on the head.

A friend of mine just went through the grueling process of prepping all of her charts for bulk scanning. She quickly discovered that her practice had kept every scrap of paper that ever came into the office, regardless of relevance or utility (and independent of liability as well.) She falls into the “slash and burn” camp and quickly rid her charts of duplicate and meaningless information, but not every provider is that motivated or has that much free time. Most want to keep everything, which often results in simply converting a messy paper chart (where nothing can be found) into a messy electronic chart (where nothing can be found.)

An interesting survey finding mentioned in the article: 44% of organizations are not explicitly measuring the effectiveness of productivity of their scanning process. My final quote of the day comes from Pretty Woman:  Big mistake. Big. Huge.

Considering the massive effort involved in converting from paper to EHR, scanning is one of the places where the work is reproducible as well as being amenable to applying lean manufacturing principles. Unlike work with patients or families, you can look at cycle time, accuracy, and per-page outputs when you look at scanning. Charts CAN be treated like widgets. Unless you just want to spend more money than you actually need to or prefer to be scanning for years, this process should be looked at carefully.

Have a question about milk and shotguns, takt time, or what’s next in my Netflix queue? E-mail me.

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

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