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!

View from the Healthcare Recruiter’s Chair
By Don Calhoun

Happy Holidays! As this year comes to an end, I thought I’d share some insight into the job market, hiring trends, tips for candidates, and tips for clients. Not to mention some observations that may or may not have anything to do with any of the above. The following are educated opinions with some fact sprinkled in.

The Job Market

We continue to see strong demand for implementation consultants, project managers, and practice directors. Shocking, right?

Instead of just trying to find one of the 1,000 Epic Certified “X” consultants to fill one of the 4,000 Epic Certified “X” consultant openings, we have employed a new strategy. Starting in 2012, we will be working with George Lucas on a controversial project. I can’t say a lot more at this time, but DNA will be involved.

Tips for Candidates

You may be looking for a better position, going through RIFs, or just putting EMR on your resume in the hopes that will create a bidding war for your services.

Tip #1. Recruiters see hundreds of resumes per week. They can become lazy. If you have experience with a vendor product, a particular system, or an integration tool, make sure it is on your resume. This is a world of keyword searches. If you don’t list these, you could be missing out.

Tip #2. If you have been at the same firm for sometime and have a feeling that they are underpaying you, talk to a recruiting firm. Some companies pay below-market value, and if you get comfortable in that role, you may be shortchanging yourself.

Tip #3. If you don’t mind travel, put that on your resume. If we stick with the theory that recruiters see hundreds of resumes per week and need to prioritize who to call first, the biggest slam-dunks will get that call. The slam-dunk has all of the pertinent information available – skills, software, general idea of rate/salary, and ability to travel.

Tips for Those Laid Off

Tip #1. Get on LinkedIn and make it known that you are looking for a new position. Put all of your skills, training, etc. on your profile.

Tip #2. Network like crazy.

Tip #3. If you have the drive and ability, think about starting your own firm. It doesn’t cost much to get incorporated in most states. You may be surprised about local work you can pick up.

Editorial Comment Section

When are large companies who think they can buy their way into healthcare going to learn that they are five years late to the dance? And that IT NEVER WORKS?? I wouldn’t be surprised if General Motors is a “healthcare” firm next year. Sorry – had to be done.

Clients

(Not ours — they already know this.)

Tip #1. Being thorough and expedient is a difficult trick to pull off when hiring, but it is a must in this market. Whoever dies with the best healthcare consultants wins. You must make this a priority in order to grow, create a great reputation, and have a happy work force. A couple of phone interviews are great, but at some point it is time to lock all decision-makers in a room with the candidate and make a decision. Some companies are hiring people two weeks after starting the process. Are you able to compete with that? If not, talk to HR/Recruiting and figure out a way to streamline your process. You will save yourself lots of recruiting dollars, disappointment with candidates you missed out on, and will ultimately have a stronger workforce.

Tip #2. Before deciding on a hiring initiative, reach out to some people in the recruitment business to see what the market is commanding in terms of salary, bonus, travel, time off, etc. Salary surveys run by third parties don’t seem to be in line with the real healthcare market (just my opinion). Ensure that you are making strong offers. I view the current healthcare market like NFL free agency. The best players want the top teams, the most dollars, and the best situation. Everybody wants the top free agents. Playing the lowball and hope they accept game isn’t going to get you anywhere.

Tip #3. If you decided to engage a search firm, make sure you know who is actually conducting the search and talking to candidates. You need experienced healthcare people talking to these candidates. I may get threats for saying this, but some firms put the big gun on the phone with you to sell you their services and then turn the search over to a “just out of college, took a recruiting job to pay the bills until my band makes it” recruiter. Make sure you talk to the people that are going to talk to your future employee.

I hope some of this provided some value. We’re off to an undisclosed location to meet with Mr. G. Lucas. An update should be coming soon.

Don Calhoun is founder and managing director of Executive Search Recruiting, LLC of Cornelius, NC.

Breakfast of Physician Champions!
By Daniela Mahoney

Culture eats strategy any day.

I think we have all heard this saying. More than ever, it proves to be true when I think of any initiative that involves providers, changes to their workflow, perceived loss of autonomy, and the sacrifice of something very, very precious — TIME.

Yet when introducing a new initiative, hospital and project leaders must somehow get everyone on board in a relatively short time frame and also convince them to embrace the new way of doing business.

So, you ask, where are the challenges?

Unwritten Rules

The relationship between organizations and their providers varies based on structure, history, leadership culture, and vision of the future. Therefore, for any organization, every new initiative is challenged by implicit unwritten rules that define and govern certain expectations, organizational design and behavior.

And moreover, initiatives that involve the introduction of advanced clinical systems to providers — particularly CPOE — are subject to the greatest scrutiny. These projects subsequently pose serious challenges to the unwritten rules because they raise a very fundamental question from providers: “If our present rules will no longer support what we know and feel comfortable with, what will it take to change these rules so we can create an environment that better aligns with the new vision of the organization?”

These days, most hospital leaders encounter this challenge when implementing a new system. Regardless of motive —whether implementing CPOE because the organization is on the fast track to meeting Meaningful Use or, more nobly, because “it is the right thing to do” to improve patient care and outcomes— the reality is that the unwritten rules must be rewritten upfront and early to successfully transform the staff culture and ensure quality and predictable patient outcomes with the new system in place.

Great Expectations

It’s about inclusion from the get-go. The staff culture has to be given serious consideration and be honestly and fully included in implementation plans from the time you begin talking about these new initiatives to the time they are executed and realized. I have witnessed noticeable and successful changes in culture only when the majority of the providers are aligned with the vision of the organization (I say “majority” because in most cases, non-academic organizations have difficulty achieving 100% buy-in from all providers.)

How do we go about learning what is important to your providers? What are their expectations and what are their fears? The answers to these questions are the elements that eventually create the adoption strategy map. And the pursuit for these answers is a concerted effort executed in the early phases of the implementation (although sometimes we get pulled in at the tail end of an implementation when things do not go as planned. This makes the recovery efforts more difficult and at times delays the initiatives!)

If done well, this initial Q & A or interview exercise yields a fairly clear plan, yielding one strategic decision to make about it:

• Should things be mandated and, if so, when and how?

Or,

• How will the support and training strategies need to be structured to make things manageable?

Constant Compromise

To me, the decision is a basic balance of give and take, a constant compromise where the art of negotiation reaches amazing peaks. This is when it is important for the CEO to have a close relationship with the medical staff and be actively involved and visible with these new initiatives. The CIO needs to think outside the box and not lead with the technology as the value proposition. A strong CMIO or physician champion should truly understand his/her peers and their workflows and master the art of negotiating.

The unwritten rules have to be explored. These are the rules that might imply that “nothing can be mandated to physicians”, that “physicians must always have individual choice and prerogative”, that if “I am not involved in a decision, I will not support it”, or that “variability is desired.” It reflects the true art of medicine and the uniqueness of every individual patient, that the art of medicine always trumps the science of medicine.

Understanding the unwritten rules from the beginning helps establish the appropriate path to implementation. For example, in one of our cultural assessments this year, we learned that the initial plans included a very aggressive deployment of CPOE, house-wide at once, with rapid expectations toward universal adoption (“mandate” is an ugly word.) As much as this approach is desired, it is more important to know if it could be executed successfully. In this particular case, the expectations of the medical staff were not integrated into the original plan. During the cultural assessment process, these expectations surfaced and were far from being consistent with the original plan.

Now, one can push and try to keep the plan as defined initially but, in the long run, this would alienate many (or probably most) of the providers. Why not take another look at the plan? And by employing a much more collaborative approach, see how it can be adjusted and eventually executed —successfully — while still attaining the same goals. Also, by doing this, the unwritten message from the CMO and other organizational leadership would be clear: “We do care about what you [providers] are telling us. We know it will not be easy to implement CPOE. But we are committed to working with you for all of us to succeed.”

Personal to Us, but System Agnostic

Culture is something personal to all of us —to any organization. CPOE touches clinicians at many different levels and inarguably creates significant disruptions in everyone’s routine. I truly believe that CPOE is the best thing we can do for our patients, but as I say this, I know that not all CPOE outcomes are the best. With a failure rate somewhere in the neighborhood of 30%, along with a long list of unintended consequences, it makes us realize that technology is only 15-20% of the challenge. The rest is all the change and optimization that needs to be done for this to work as intended.

We should also recognize and accept that provider culture is system agnostic. We can hope that the more advanced systems become easier to design solutions that support clinical processes. But it is naïve to believe that CPOE will be an easy project simply because you install the Cadillac version of a system. We have seen many successes with more modest versions of clinical systems and failures with very sophisticated ones and vice versa.

A system alone does not guarantee a successful outcome. It needs much more than that. As part of the team planning clinical initiatives for your hospital, please listen to your providers and understand your organizational history and its culture. Many of the answers to what it takes to succeed are right in front of you— you just have to look to see them.

Time for Breakfast!

I just returned from a visit oversees and came across this wonderful blini (Russian pancakes) recipe. I guarantee the entire family will love them, especially on cold winter mornings. I serve mine with 1 cup ricotta cheese, 1 tablespoon sugar, 1 teaspoon vanilla extract, and a scant ½ cup golden raisins added at the end once all other ingredients are mixed well.

Till next time, when we will talk more about the CPOE value proposition to providers. Safe and happy holidays to all!

Daniela Mahoney, RN BSN is vice president of Beacon Partners of Weymouth, MA.

iPatients?
By Vince Ciotti

An interesting week of news for our EMR world.

On Tuesday, the National Transportation Safety Board (NTSB) called for the first-ever nationwide ban on driver use of personal electronic devices while operating a motor vehicle. According to NHTSA, more than 3,000 people lost their lives last year in distraction-related accidents. NTSB Chairman Deborah A.P. Hersman stated, "It is time for all of us to stand up for safety by turning off electronic devices when driving. No call, no text, no update, is worth a human life."

The heart of their argument can be found in a few statistics:

• Globally, there are 5.3 billion mobile phone subscribers, or 77% of the world population. In the United States, that percentage is even higher – it exceeds 100%.
• A Virginia Tech Transportation Institute study of commercial drivers found that a safety-critical event is 163 times more likely if a driver is texting, e-mailing, or accessing the Internet.

Hersman concluded, "The data is clear; the time to act is now. How many more lives will be lost before we, as a society, change our attitudes about the deadliness of distractions?"

On Thursday, an article on the front page of The New York Times caught my eye while driving my RV down I-4, As Doctors Use More Devices, Potential for Distraction Grows. Wow, doctors? That’s our business! Reading on (while occasionally checking my mirrors before changing lanes), I read these amazing factoids:

• A peer-reviewed survey of 439 medical technicians published this year in Perfusion, a journal about cardio-pulmonary bypass surgery, found that 55% of technicians who monitor bypass machines acknowledged to researchers that they had talked on cellphones during heart surgery. Half said they had texted while in surgery.
• Scott J. Eldredge, a medical malpractice lawyer in Denver, recently represented a patient who was left partly paralyzed after surgery. The neurosurgeon was distracted during the operation, using a wireless headset to talk on his cell phone. “I’ve seen texting among people I’m supervising in the OR,” said Stephen Luczycki MD, an anesthesiologist and medical director in one of the surgical intensive care units at Yale-New Haven Hospital. “Amazon, Gmail, I’ve seen all sorts of shopping, I’ve seen eBay,” he said. “You name it, I’ve seen it.”

So who am I to pontificate on this seeming bit of common sense? Some of you may know I am also an avid vintage motorcycle buff (not loud Harleys, but quiet Hondas) and have published a few articles in bike magazines. My most recent was last year in Motorcyclist entitled Driven To Distraction. In it, I admonish my fellow bikers to wear bright clothing, flash headlights, etc. — anything so their 500-pound motorcycle gets the attention of the driver of a 5,000-pound SUV.

So after all our Herculean efforts the past few years to get our RNs to use BMV and eMARs and to coerce our MDs to use CPOE and EHRs, now some of them are over-using the technology! I guess it had to happen in this world of cell-phonies.

What’s a CIO to do? My suggestion: send the Times article to your CMO and CNO. They’ll do the rest. Clinicians are such consummate professionals, all they need are a few facts like the above and they will caution their staffs in a hurry. Will it be a total cure? No more than I’m likely to stop keying on my GPS while dodging semis. But it will make them aware of the problem, which is always the first step to addressing one.

Vince Ciotti is a principal with H.I.S. Professionals LLC.

My Christmas Wish
By Chip Perkins

I’ve been reading quite a bit lately about how important sharing data is to improving healthcare quality and outcomes, and reducing costs. The ability to share health data between patients, providers, specialist, and health plans is a key building block for patient centered medical home (PCMH) or accountable care organization (ACO) initiatives. 

But there is one more thing about data to consider. The data needs to be discrete. The data needs to be actionable. The data needs to be standardized. The data needs to be semantic. 

As healthcare systems ramp up their efforts to transition to ICD-10-CM/PCS, launch clinical documentation improvement projects, report Meaningful Use quality indicators, implement electronic lab reporting (ELR) to public health, and build analytic tools to monitor improvements in health outcomes, organizations will recognize the importance of leveraging controlled clinical vocabularies and terminologies such as SNOMED CT, LOINC and RxNorm. 

The standards exist. The standards turn raw data into semantic data. Now we have to build the use of standard terminologies into our health information technology infrastructure. 

I’m hoping Santa will put a little semantic interoperability into everyone’s stocking for Christmas.

Chip Perkins is managing director, CAP STS of College of American Pathologists of Deerfield, IL.

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From EpicNews: “Re: HCA. Any rumors about HCA signing with Epic?” I’ve mentioned here several times that HCA is putting up an Epic pilot as they choose between that option and upgrading Meditech. I haven’t heard anything more than that, although a couple of less well-placed rumors seem to think Epic is the likely choice (I’m guessing that’s due to Epic’s track record rather than any real insider knowledge.)

From CIO Lookin’: “Re: company that has a contracts database. One of your sponsors offers a database of vendor contracts with full details about pricing and terms. I don’t remember the company’s name. Can you help?” It’s CapSite. Very useful. It’s cool looking at the actual scan of the contracts but also having all the numbers broken out into a worksheet for easier review.

Aetna reveals at an investor conference Thursday that it acquired mobile app developer Healthagen “about a month and a half ago.” Aetna says it will add cost estimation functions for patients to its iTriage app. Aetna’s chairman, president, and CEO also told investors that the company will make the software development kit for the Medicity iNexx platform available free so that anyone can write apps for it.

Micky Tripathi’s breach article on HIStalk Practice has raised the interest of The New York Times, which will apparently be running a story about his experience in Monday’s business section.

My Time Capsule editorial from 2006 for this week: Embrace FDA Oversight If You Want Clinical — not Clerical — Systems.  A snippet:

It’s like Lucy working on that candy assembly line – reams of often irrelevant information are unceremoniously dumped faster and faster into the laps of physicians and nurses, who are expected to manually figure out what’s useful and then “process” it, often by entering even more on-screen information. Eventually, the administrivia buries someone who ought to be making patient care decisions instead of romancing a keyboard.

TPD has updated his list of iPhone apps.

A reminder for McKesson folks whose jobs will be eliminated in February: check the comments left on the past few posts since I invited companies who might have jobs for you to leave their contact information.

Another newspaper picks up on Newt Gingrich’s dichotomy on stimulus money, which he called a “pork-laden bill” that should be stopped even as he cheered the $19 billion it contained to pay providers to use EHRs sold by clients of his consulting firm, Center for Health Transformation. It mentions his participation in 2009’s EHR Stimulus Tour, where his company helped its clients Microsoft and Allscripts encourage providers to use federal incentives to buy their products. Gingrich also pressed his former House colleagues to block efforts to dismantle Stage Children’s Health Insurance Program while being paid by drug companies and insurers that would have lost profits, as well as urging them to support the expansion of Medicare’s prescription drug benefit, which benefited his center’s $200K per year founding member, drug maker Novo Nordisk. Novo listed their payment as a lobbying expense, although Gingrich says that’s not the case.

In related news, the former CEO and VP of the Center for Health Transformation and Gingrich Group join Leavitt Partners to create Health Intelligence Partners, a membership organization that will offer advice to healthcare executives. The founder and chairman of Leavitt Partners is Mike Leavitt, former HHS secretary and Utah governor. The president and CEO is his former HHS chief of staff and the managing director is Leavitt’s former HHS senior executive advisor.

Some readers are getting their HIStalk e-mail blasts long after I’ve sent them out. It’s a worsening problem, primarily affecting users of free e-mail services (Hotmail, Google, Yahoo) since those are apparently ramping up their inspection of incoming e-mails for spam. Those services are also slowing down my sending speed since my server has to wait on theirs and they have throttled back their connection rates. My web host has taken a couple of steps to hopefully reduce the scrutiny and therefore increase the delivery speed, but it’s somewhat out of my hands.

Here’s my latest pet peeve (I know you were anxiously awaiting it): publications that refer to doctorate holders as “Dr. John Smith.” It’s perfectly legitimate (but damned obnoxious) to introduce yourself socially as Dr. John Smith, but that form should not be used in a publication of any kind since it provides no clue to exactly what kind of doctorate is held (MD, non-research based EdD, mail order fake PhD, etc.) Honorary doctorate holders should never be addressed either as (a) Doctor, or (b) listing their unearned PhD. If you see a professional advertising their white-coated services as Dr. John Smith instead of stating their actual degree (it’s usually chiropractors who do that) or using bookended vanity titles on both ends of their names (such as Dr. John Smith, MD) run fast and far since at least in my experience, these folks are often seriously incompetent, insecure, ill-informed, or all of the above.

Welcome to new HIStalk Gold Sponsor Macadamian, a global firm headquartered in Quebec that provides user interface design and software innovation services for clients that include HP, Cisco, and Adobe. They help product management executives turn ideas into market-ready products, including working with mobile apps. The company offers design services, usability consulting and testing, and user services (focus groups, task analysis, and field research). Healthcare IT vendors they’ve worked with include Sage (updated Intergy’s encounter note function), Cardinal Health (designed a touch-screen interface for a bedside patient information system), and Elsevier (developed a fresh user interface for the online Mosby’s Nursing Consult). The company offers a one-day EHR Usability Workshop to help vendors understand the implications of NIST’s usability draft and to develop a usability plan. Thanks to Macadamian for supporting HIStalk.

I’m getting an increasing number of requests from companies and organizations that want to get me involved in their projects in some way (conferences, education, contests, etc.) I almost always turn those down, and just to save future time all around, here are my standards, which I don’t think I’ve explicitly stated until now:

1. I have almost no time between work and HIStalk and I have no employees, so I will always turn down anything that would require much of my time.
2. I won’t do anything to compromise my ethics (endorse products, further a hidden agenda, or write anything that I don’t believe.)
3. The only item I offer is sponsorships. I don’t rent my e-mail list, run paid article placements, or shill my services for speaking or consulting (easy since I don’t do those things anyway).
4. I don’t entrust HIStalk’s reputation to anyone else, so I don’t get involved with activities unless I’m offered control over them (HIStalkpalooza being a good example.)
5. I’m not very motivated by money, so it’s easier to raise my interest for projects that will benefit HIStalk’s readers or that involve undeniably good deeds, education, industry enlightenment, or something offbeat and fun.

Only 22% of respondents reacted positively to Mckesson’s Better Health 2020 product realignment plan. New poll to your right: it’s the same as this one, only regarding Microsoft and GE forming a new HIT company.

Here are some products from HIStalk sponsors that topped out their respective category in the Best in KLAS report that just came out:

• 3M Codefinder (medical records coding)
• 3M APCfinder (medical records other)
• Allscripts Sunrise EPSi Decision Support (decision support – business)
• API Healthcare Time and Attendance (time and attendance)
• CareTech Solutions (IT outsourcing – extensive)
• Cerner CoPathPlus (anatomic pathology)
• Cerner Millennium PharmNet (pharmacy – community)
• Cerner (application hosting CIS/ERP/HIS)
• Clairvia (staff/nurse scheduling)
• Cumberland Consulting Group (planning and assessment)
• eClinicalWorks Electronic Health eXchange (private HIE)
• GE Healthcare Centricity Perioperative Anesthesia (anesthesia)
• GetWellNetwork PatientLife System (interactive patient system)
• Greenway Medical PrimeSuite Practice (practice management 1-10 physicians)
• Greenway Medical PrimeSuite Practice (practice management 11-75 physicians)
• Hayes Management Consulting (staff augmentation)
• Iatric Systems MobiLab (specimen collection barcoding)
• Impact Advisors (clinical implementation principal)
• iSirona DeviceConX (medical device integration system)
• McKesson Paragon (community HIS)
• McKesson Paragon Clinicals (acute care EMR – community)
• McKesson Paragon Financials (patient accounting and patient management – community)
• MedAptus Professional Intelligent Charge Capture (mobile data systems)
• MedAssets Contract Manager (revenue cycle – contract management)
• MedPlus ChartMaxx (document management and imaging)
• Merge Healthcare Hemo (cardiology hemodynamics)
• Nuance eScription (speech recognition)
• Nuance EXText (dictation and transcription)
• Orchestrate Healthcare (technical services)
• Passport BatchSource (patient access – eligibility checking)
• RelayHealth ePREMIS (revenue cycle – claims management)
• TeleTracking Capacity Management Suite (patient flow)
• Wolters Kluwer ProVatation MD (clinical procedure documentation)
• ZirMed (claims and clearinghouse services)

Ignis Systems releases EMR-Link ResultsAnywhere, which works with the company’s lab outreach solution to create patient-friendly lab results. It meets the new guidelines under which patients can access their own lab reports. Video here.

Weird News Andy says he has a nose for news with this article: Louisiana’s state health department warns consumers about the use of neti pots, a pitcher-like container (aka “nose bidet”) used to flush the sinuses with salty water to relieve nasal congestion. Two people have died from amoeba infection of the brain after apparently using tap water instead of the manufacturer-recommended distilled water. WNA also finds this Grinch-like story: a UK hospital cancels more than 80 surgeries, some of them involving cancer patients who had waited for months to get on the schedule, after the broad daylight theft of the copper cabling from the hospital’s backup electrical generator.

An interesting item came up at athenahealth’s stock analyst day this past Thursday. The company is trying to turn its athenaCoordinator product (from its acquisition of Proxsys in July 2011)  into a private HIE so that practices in a given geographic area can manage referrals through it, something that was hinted at in this request from an unnamed (but easily identified) vendor for an HHS ruling that was rendered on December 7. Athena would charge fees for use of its network, with a somewhat complex set of rules deciding which practice (referring or receiving) gets the bill. Athenahealth would reduce the monthly subscription cost of athenaClinicals, using the new referral transaction fees to offset its reduced revenue.

Meanwhile, it was a wild ride for ATHN shares this week, with guidance below expectations sending shares down 15%, but conflicting investment opinion pushing it partly back up (Leerink Swann and Oppenheimer upgraded, Piper Jaffray cut its price target, Morgan Stanley stuck with its Underweight rating.)  

Rep. Tom Price (R-GA), an orthopedic surgeon, says paper medical records are insane and practices should be using technology to communicate and to give patients access to their own records. He’s not a fan of HITECH, though:

Instead, what does the federal government do and think it’s getting high tech? It is defining every little thing, every box that the physician or nurse has to check every time you see a patient, in order to get an extra 1.5% of reimbursement from the government. Or, not getting dinged for an extra 1.5 or 2%. These are the Meaningful Use things.  Washington always has these great lines, right, these wonderful Meaningful Use standards. They’re neither meaningful nor useful and they’re so ridiculous that they actually incentivize pathologists to have to ask on every single patient that they care for how old they are, how many allergies they have, what medications they’re on, when was the last time they saw their primary care physician, on and on and on, including of a slide of a patient … the pathologist never actually sees that patient … or a corpse for an autopsy. This is no lie. The federal government wants the pathologist to determine whether or not a corpse has any allergies. How you feeling today, right? This is nonsense.

So what do you do with technology to make it so it actually works for healthcare? I think the proper role of government in the area of technology in healthcare is to say, OK, this is the platform we will use. This is the highway upon which we will ride. Everybody needs to have a system that allows it to speak to another system within these parameters. And not dictate what the docs are doing on a day-to-day basis for a given patient, because it doesn’t make any sense. It’s a waste of time. They can never, ever put in place the right standards for a bureaucrat to determine whether or not the doctor’s doing the right thing.

An MSNBC article says aides of former Massachusetts Governor Mitt Romney arranged to buy the hard drives of their office computers for $65 as his term ended, thus eliminating the only record of official e-mails and details about his health insurance mandate since they had also had the servers replaced. Romney says the hard drives might have contained personal information, such as medical records and job applications, but reporters noted that government officials could use that excuse to keep every paper record from the public eye by just writing their Social Security number on the bottom of every page.

Here’s the latest HIS-tory from Vince, which contains the answer to this trivia question: what hospital programmer started a one-person consulting practice that eventually grew into a company of over 1,400 employees?

Zach Mortensen of CareFusion picks up on Barry’s comment on HIStalk about a possible change in Epic’s sales strategy, speculating that Epic may be willing to sign ambulatory-only contracts because they’ve hit capacity, run out of new customers, or fear low-cost ambulatory competitors. I’m not convinced Epic is changing strategy at all just because a couple of unnamed consultants speculated as such (Epic has always sold ambulatory-only deals), but if they are, I’d infer the opposite. Epic has not hit the predicted wall on scalability, customers keep giving its products industry-leading KLAS scores, nobody is de-installing or grumbling about value, and prospects keep signing up in droves despite high project costs. Each time Epic sells an ambulatory-only deal, it (a) deprives a competitor of a new sale, and (b) plants a flag that has a decent percentage chance of yielding an easy inpatient sale down the road. If anything, I suspect Epic is gaining confidence given the near absence of significant competition and is willing to ramp up sales, which by definition means they will be selling to smaller hospitals and practices. The company’s favorite statistics involve not the number of hospital customers it has, but rather the percentage of physicians and patients using its systems. I think they want that number to keep rising for reasons beyond financial, and any change in strategy can be attributed to unchallenged dominance rather than newfound desperation.

Analysts speculate that Research in Motion (BlackBerry) may be on its last legs, with bad earnings, grim forecasts, delayed new products, and a continue share price slide (down 77% year to date).

Allina Hospitals & Clinics is involved in an unusual but minor patient privacy breach. It sends an e-mail blast to 250,000 patients promoting Epic’s MyChart, but eight of those e-mails bounce back as undeliverable. Its mail software then tries to re-send the message to those eight recipients, but mistakenly blasts it back out to the 250,000 original recipients, only this time including the name, employer, and e-mail address of the eight patients (whited out above).

A California patient opens up her medical records to an investigative reporting agency to show how medical upcoding happened at Shasta Regional Medical Center (CA), which claimed that almost 20% of its patients suffered from the mostly third-world nutritional disease kwashiorkor. A DRG coding firm analyzed the records, which mentioned nothing about nutritional issues, and found that the correct payment was $4,708. Adding the kwashiorkor diagnosis raised the payment for the same stay to $11,463. Irrelevant but interesting: the patient’s daughter reviewed her mother’s bill and noticed charges that included $273 for a cloth sling and $22 for a 4×4 gauze.

Texas Health Resources is holding a Nursing Informatics Boot Camp April 28-29 in Arlington, TX to prepare nurses to take the ANCC certification exam.

The Alaska State Medical Association is providing DocBookMD to all physicians in the state to allow them to share information, including referrals, using mobile devices.

A jazz singer unhappy with her new nose job creates a Web site criticizing the work and credentials of her plastic surgeon, files complaints with the state medical board, and posts negative reviews on several Web sites. The doctor says his practice went from $4.5 million to two patients a week. He files a defamation lawsuit against the patient and is awarded $12 million. That’s a lot of jazz.

Every year about this time (when we remember it, anyway) we like to get in the Christmas spirit by asking our sponsors what holiday and charitable activities they’re involved with, preferably with photos since the usual half-hearted hospital door decorating contest just doesn’t stir up much Christmas spirit.  Here are a few.

DIVURGENT sponsored a Winter Wonderland event at Children’s Medical Center at Legacy (TX) last week for children hospitalized there. Every child got a teddy bear, shown being delivered above.

Hayes Management Consulting donated $1,000 worth of toys to Toys for Tots and sent an equal amount of money to the Susan G. Komen Foundation.

Surgical Information Systems held its Coins for Kids fundraiser contest, where each of its departments decorated a piggy bank to collect money (the above entry from sales and marketing was branded as Miss Barbie-Q). It has raised $6,000 so far for The Giving Tree, EduNations, and the Westlake Estate Home for Girls. Employees also donated time and supplies to stuff 50 stockings for the troops and collecting DVDs for Children’s Hospital of Atlanta. Employees also held coat and winter weather drives and continued their support for Cool Girls, Inc.

maxIT sponsored the Beads of Courage Beads in Space Tour to honor Childhood Cancer Awareness Month. It’s a non-profit that works with children experiencing serious illnesses to use beads to tell the story of challenges they have overcome during their treatment, such as spending a night in the hospital or undergoing chemotherapy treatments. The organization took its program on the road, stopping at 10 hospitals to show a display of beads that few on the space shuttle, with one design from each being incorporated into a real bead and the top ten to be featured in a book.

Software Testing Solutions donated $10,000 to Heifer International, a non-profit that focuses on long-term sustainability and self-reliance by purchasing llamas, sheep, goats, chickens, and honeybees and providing agricultural education for poverty-stricken communities around the world.

The business development team of World Wide Technology volunteered at Kingdom House, a neighborhood community center in downtown St. Louis, where they repaired tables and chairs, cleaned the food pantry, and reorganized the thrift store.

Aspen Advisors held a fun walk/run at its annual all-associate retreat in Fort Lauderdale, FL and raised $1,500 for Broward Health.

Quality IT Partners supported Habitat for Humanity, the American Heart Association, Special Olympics, the Scott Hamilton CARES Initiative, the American Cancer Society, the American Association for the Study of Liver Diseases, and local schools and food banks.

Sunquest held its annual fundraising barbeque this month, this time supporting Tucson-based Aviva Children’s Services, which provides support services to children under the care of Child Protective Services after experiencing abuse, neglect, or poverty. Employees received lunch in return for their donations of toys, gift cards, and money, raising $3,500 for Aviva’s Christmas giving program.

Cynergis Tek supported OPERATION Hug-A-Hero and its Holiday Hugs program. It provides children with dolls that contain an image of their deployed service member parent or other relative, providing a tangible, comforting connection with their loved one.

E-mail Mr. H.

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David Lareau is chief operating officer of Medicomp Systems of Chantilly, VA.

Tell me about yourself and the company.

I was in Baltimore in the late 1980s and had my own practice management reselling company. One of my customers in 1990 came to me and said, “Dave, we’re real happy with your services, your billing system — we want to start looking at EMRs.” I said, “What’s that?” He said, “We think they’re going to be the thing of the future. Would you help us look at them?” 

We set up a process where once a month they would come into my office and I’d bring in a vendor. After a few months, they said, “Nope. All this makes us data entry clerks. It’s all template-based. We hate it, can’t use it. Thanks. Here’s what we need you to find.”

A couple of years later, maybe ’92, I happened to see Peter Goltra and his team at Medicomp and I was intrigued. I thought, “This sounds like what those guys were talking about. Let’s bring them in.” They looked at it and said, “That’s exactly the way this stuff needs to work, but it’s just ugly as hell.” It was a Unix-based system, the old green screens and stuff dropping down. They said, “If you put a decent user interface on that and integrate it with a billing system, that would really be something.”

I talked Peter into letting my little company do that. I eventually came home to my wife one day and said, “Honey, I just found what I want to do with the rest of life. Can we move to Virginia? I really want to work with this company. I love what they’re doing. I think it’s the thing of the future.” I figured at that point, yeah, 10 years from now everybody will have an EMR. You know how it was in 1992. 

I joined Medicomp. I found that they provide clinical content for documentation and patient care that thinks and works the way a physician does. It’s just simply that. We’ve been doing that ever since, with changes along the way in response to the markets, technology, etc.

You said you had to find Medicomp. I always got the feeling that both the company and Peter Goltra aren’t as widely recognized as they ought to be. Is that low-key approach intentional?

The low-key approach is somewhat intentional. We provide a really critical component to about 10 to 12 different vendors in the space. That’s growing all the time.

We leave it them to do a couple of things. Differentiate themselves from each other. And, we want to make it clear to the marketplace that if you want an EMR that uses our content, you need to go to our customers, not to us. 

We’re very low-key at industry events. We really only concentrate on going to industry events like HIMSS and MGMA, where we’re there primarily to support our customers, who are EMR vendors, and educate their potential customers about the benefits of an EMR that uses MEDCIN.

The other way we stay in the background is when a new vendor decides to license our technology and put it into their product, we leave it to them to time the announcement to let their installed base know. As you know, once somebody announces a change in direction, even if it’s a good thing – which we think implementing our MEDCIN engine and Quippe is — it still tends to freeze what is then perceived as a legacy product, and these people need to maintain that revenue stream.

For readers who don’t know, describe the MEDCIN engine and how it’s used.

MEDCIN at its core is a clinical knowledge base that has about 280,000 clinical concepts in it. For the most part, they are pre-coordinated. The purpose of the engine is to present the relevant information to the physician at the point of care given a specific clinical scenario. 

For example, there are 293 concepts in MEDCIN whose relevance is scored for a patient with asthma. In that case, adding more concepts to MEDCIN doesn’t do anybody good. We can focus on the relevant items given almost any clinical situation, which is what makes it valuable for a providers treating a specific patient for a specific problem or a set of problems at a specific point in time.

What’s nice is is that it thinks and works like a clinician, and then all those concepts are mapped to ICD-9, ICD-10, SNOMED, CPT, LOINC, RxNorm, and all the 44 Meaningful Use criteria. All the nonsense — from the doc’s point of view — is taken care of in the background. The engine presents to the physician the things that they would care about for a patient with that condition.

We came up with that in 33 years of working with physicians saying, “OK, here’s the presentation. What would you want to be in your note? What will you want to look at? What kind of lab results would you want? What are potential orders? What would you do for the review of systems? What history? What physical?” It presents the things that real docs who are treating patients every day tell us they would want. We’re not trying to tell them what to do – we’re presenting to them what they said they would do.

Describe where your content comes from.

We have at any point about 20 to 30 active clinical consultants. We tried in the mid-80s having medical MDs on staff and nurses on staff to do that, but we found that when we brought guest experts in — consultants to help us build the data engine — all they did was argue with each other over, “You were trained here, you were trained there. I wouldn’t do it that way, I wouldn’t do it that way.”

We ended up saying, OK, we’re going to be clinical knowledge management engineers. Let’s engineer an editing system, where we can bring these people in and we have editing facilities. Now with the Web, you don’t have to do it locally, but when we did, we had an editing facility in Martha’s Vineyard, we had one in New York, whatever’s convenient. We’d typically bring somebody in for two or three days at a time. Some of these guys come in regularly, some come in every six months, some once a year for a week or so.

We sit with them and say, you’re seeing a patient with asthma. What would you normally expect to have to think about or address? They’ll say wheezing, difficulty breathing, is the wheezing episodic. What do I see in the lungs? Auscultation. Family history. Do they have exposure to dust mites? What’s the spirometry? What’s the O2 sat? Do they have any other conditions, maybe nasal polyps?

We say, is they’re anything else that might help you differentiate asthma from something else that we should put in the asthma – we call them indices – in the asthma index that you’d need for rule-out? So there’s things in there that have both a positive and a negative correlation. 

We put those in, and then we’ll go back and say, now for each one of those things, wheezing … somebody comes in wheezing, it doesn’t mean they have asthma. Means they might, but what else might it be? Let’s built out the index for those things.

You do this in an iterative process over years. We’ve ended up with about 293 items in the asthma index, one of which is wheezing, which has 260-some links of its own to diagnoses other than asthma. You can attack it from either point. This is iterative. Then we’ll have pulmonologist come in and say, we just did this recent work with somebody who was a specialist in asthma. How does this intersect with other things that you see? Does it raise the risk factors for pneumonias? 

It’s iterative. It’s one of the reasons why it’s so hard to replicate this with a template system, because we’ve been at it so long. Everybody says you can’t take nine women and have a baby in a month. That’s sort of what we’re dealing with here.

Does the MEDCIN engine have competition other than templates and text-based literature look-ups?

In terms of what we do and the way we do it, no. But in terms of competition, there’s tremendous competition all throughout the marketplace for our approach and any other approach. We define competition as anything that causes somebody to say, “Hey, your stuff looks great, but I don’t really need it.”

You can fake some of this activity for a single-problem patient with loads of templates, but eventually it doesn’t scale up when you start to have multi-problem patients whose conditions progress over time with clinical sequelae, complications, comorbidities, etc. Nobody really does or is close to doing what we do, but as long as people think that there are reasonable alternatives … sure, we have competition, and now you’re hearing about Watson’s going to do this and Zynx has protocols and Wolters Kluwer is getting into the market. 

One of the things that we do that those folks don’t do is we actually have the concepts for documentation linked to E&M, linked to all the other stuff designed for use at the point of care. It’s not a knowledge resource — it’s a documentation and patient care resource. In that regard, there’s really nobody else that I know of that does what we do.

Explain the advantages of Quippe and why physicians like using it.

When we first started designing this stuff, we were a little bit limited by the current technology at that time, by the state-of-the-art of user interfaces, and that kind of stuff. We made the decision in 1997 to make the knowledge engine its own component without a UI. When some of the browser-based technologies and some of the performance stuff for cloud type services came along in 2002 to 2005, that enabled us to think about a completely new way to deliver two things to the user at the point of care: deliver the content and give them control over the presentation of it.

What we’ve managed to do with Quippe is take 25 years — from 1978 to about 2003 — of clinical content development and what would now be looked on as rather primitive user interface options, and bring a bunch of docs in here and say, “We can deliver any of this content anywhere you want in millisecond time. What is it you really want, and what control over it do you want at the point of care in a user interface?

We had docs come in here over a period of about two years, probably 10 different sessions, and just say “Give me what I want to know when I need to know it. Give it to me in a format that I can control, that can learn from me as I go along, adapt to my needs, and not fix me into a template, but actually push the information to me that I want to see for any condition I treat without me having to go and find it or ask for it.”

Quippe is a note-like user interface that has all this data behind it ready to serve whatever action the clinician takes and give it to them on almost any device. Right now tablets are the hot new thing, but it doesn’t have to be that way.

How is it different selling to vendors rather than end-users? You had a significant presence at HIMSS, including sponsoring HIStalkapalooza. You have to develop interest by the user, but through their vendors.

There’s two ways to do it, and we have to do a little bit of both. Going with MEDCIN and Quippe as your platform is a major strategic and management decision. You have to get the interest of probably the busiest people at HIMSS, who are the CIOs, the CEOs, the clinical people of the vendors who are there to do business with their potential customers. They’re not there to talk to me. We have to get their attention and we have to prove to them that we can provide value. 

One of the reasons we do the iPad giveaways at HIMSS that we just did at MGMA is to show these vendors that we can provide to them something that I can train their customers to use in 20 minutes on a busy show floor. They look at that and say, “Wow. That means I can scale up. I can get implementations up. The docs seem to love it. Tell me more about Medicomp and MEDCIN.”

It’s a two-pronged strategy. We’ve got to appeal to the end user, but we’ve got to also get the attention of the busiest people at HIMSS and MGMA.

I knew nothing about documenting an encounter or using an iPad, but it really was just that easy to use Quippe. What response did you get and are getting at conventions where you just sit people down cold in front of it and say, “Here you go?”

They can’t believe it. It looks so easy they think we’re faking it, which is why we have to put it in their hands. 

I don’t know anybody else that puts software with the complexity underneath it and power in a user’s hand on the show floor at HIMSS and just says, “Have at it.” That’s a very powerful message and one we’ll continue to use over the next couple of years. 

That all comes from those docs coming in here. Every time I had an idea for the user interface or somebody here did, the docs said, “No, no, no. Just give me what I want and get out of my way because I already know how to treat patients. I already know what a note looks like. I know how to document. Just give me the information I want and a format I’m used to looking at it.”

That’s really all that we do. There’s a tremendous layer of technology underneath that, but MEDCIN is like the wizard behind the curtain of Quippe, except there’s really something there, not just some guy pulling strings. The only way to prove that is to put it in somebody’s hands and let them do it.

Like the iPad it runs on, that’s an Apple-like strategy to replace complexity with elegance, but let the user do what they need to do efficiently.

Exactly. One of those light bulb moments for me was I went out to visit the end user of one of our customers about five or six years ago. She was not happy with how much the user interface that we had in the old VB6 days slowed her down. She was vocal about it, but she made some really good points. She gave me a lab coat and said, “You’re an intern for the day. You’re following me around. Let’s go see two patients.”

We went into see one. Lights were on, computer, etc. She did what she did using the software of one of our vendors, who will go unnamed. She went to document and do all this and do all that. At the end of that and said, “Did you see how excruciating that was? Let’s go in to the next patient.”

She pulled up the shades so that light came in. She unplugged the computer and pulled out a pad. Saw the patient, did what she did, gave the patient a prescription, walked out, and she said, “I already knew how to do everything. Without your technology, it took me 11 minutes. With your technology, it took 15. Don’t slow me down. Get out of my way.”

I came back to the guys and I said, “We’ve got to kill the idea of fixed templates. We got to kill the idea of checkboxes on forms. We got to come up with a different model for this. What do physicians know? They know medicine, they know what they’re thinking, and they know they have to produce a note. Let’s marry all that together.”

As it turns out, our engine was almost perfect to serve up that sort of solution. We brought the docs in here and said, “Help us do this.” They just kept saying simplify, simplify, simplify. That’s how we did it. That’s what makes it possible for us to teach people to document on an iPad on the show floor in 20 minutes.

That gets into the area of EHR usability, which is, along with ICD-10 and Meaningful Use, is a hot topic. What is Medicomp doing to address those?

A couple of things. Back in 1997, when the National Committee on Vital and Health Statistics decided to set up a standards committee, we were very involved in that. One of the big decisions they made in maybe 1999 or 2000 was ,”We’re going to set reference terminology standards for the exchange of information between systems. We’re not going to dictate user interface terminologies. We think those have to adapt to users and it’s not going to be the same for everybody ,so let’s establish standards.”

In July of 2003, they said that LOINC, RxNorm, and SNOMED were going to be some of the voluntary standards for this. We immediately said everything we do from now on is geared at making sure we maintain that layer of usability and map to all these standards in the background. We probably added 30% to our staff, we added consultants, and we just started cranking out those mappings, just doing them reiteratively over and over again.

When we saw that ICD-10 was going to happen eventually, we prepared for it. We’re now implementing that. We did the same thing for E&M, which is another kind set of coding mappings back in 1999, 2000. We continue to do all that mapping in the background.

We adopted Virginia Saba’s clinical care classification system for nursing and built a nursing engine and documentation index that integrates with the physician index that we’ve been talking about, so that nurses and allied health can both treat the patient based on the same information in the note, but their documentation overlaps in some cases, but is very different in other cases. That’s what’s getting us now into the enterprise market more deeply.

So you think you’ll have an inpatient clinical documentation system for nurses?

We do have it. I expect that we will make … as I said, we let other vendors make the announcements. I’m virtually certain we’ll make an announcement of a major vendor in the next six months and possibly two by the end of next year. They don’t announce until they’re almost ready to deploy. I think it’s going to stun people.

These are vendors that are committing to retool their product to have your version of the MEDCIN engine as the front end?

Yes. We found an interesting thing. We did a project in Asia about three years ago. I went to Asia and I demo of Quippe in English and they said, “Forget about that. Let’s see it in Mandarin, in simplified Chinese. When will you have that done?” We hadn’t even started and that wasn’t my intention. What would be acceptable? They said, “If you can document 95% of what you do in Chinese, that’ll be fine.”

We pulled the MEDCIN index out for the top 500 diagnoses, all the index records for those, plus 200 other areas of our clinical hierarchy that weren’t represented in the 500. We merged them all together and it came 10,104 of our 285,000 items. We got translations for those done in less than three months for positive and negative. I went back and did a demo — 98% of everything came out in Chinese.

That was pretty cool, but when we started dealing with the enterprise vendors and they said, “You know Dave, we’ve got existing content that covers most of what anybody does” – this is two different vendors independently – and I said. “How many others do you have?” They said just over 10,000.

How weird is that? It pretty much told us that even in a large population, 10,000 to 15,000 of our elements constitute 97 to 98% of total data occurrences, but the struggle that the continue to have to add items, they continue having to map them. The more items you add without some intelligent way of presenting them, the more templates you have to build and maintain over time. 

The big vendors, for the most part, are coming to the conclusion that they do not want to be in the clinical content business. There’s a couple of big exceptions, one located in the Midwestern state south of Chicago.

You’ve been good at predicting the future and being ready for it. Where do you go from here looking down the road a few years?

We have to be ready for a couple of things. Whether anybody likes it or not, if you’re a clinical provider and you’re treating a patient, you have to be prepared to deal with what we think of internally as the coming data tsunami. Once these HIEs are in place and once these standards are in place and people are required to send this as LOINC or RxNorm or SNOMED or ICD-10, and I’m treating a patient and they’re under my supervision now – maybe I’m their caretaker under an ACO model — I’m responsible for that data coming in. I’ve got to be able to make some sense of it.

I might have a patient with the classic big three in America — hypertension, obesity, and diabetes — plus two other things. Maybe today I just want to deal with this.  I’ve got to find the relevant information in there, because I’m probably going to be held responsible for it, and I’m probably going to be held responsible for whatever I do and making sure that patient, once I treat them, if I admit them to a hospital or I discharge them from ambulatory care; if we got to outcomes-based reimbursement, I’ve got to take that data in, treat them, and keep them from coming back.

All of our tools are built to enable that. That’s one of the reasons we got into integrating the nursing care. If somebody gets discharged or somebody comes in even to an ambulatory practice with an open wound, I’m going to be responsible if they show up with an infection coming back. I’ve got to teach them hand hygiene, I’ve got to teach them wound care, I’ve got to teach them signs of infection. I’ve got to do all that. That’s why we built that stuff and then integrated it, because whether it happens or not – and I think it will, I think it’ll take longer than people think – we’ve got to be ready for that data tsunami that’s coming.

We also have to be ready to make it possible to scale up – and I’m including implementation and training and updates of software – quickly as medical knowledge changes and get it deployed out to the places where care happens, which is why we started building our cloud-based model about six years ago. Whether or not ACOs push integrated care, information is going to increasingly be … you’re going to need to be able to integrate it quickly, absorb it, find what you want, treat the patient successfully, and manage them on an ongoing basis.

We’re building all of our tools as if we have to do that. We also know from our experience, now with about 100,000 people using MEDCIN everyday, that training consists of, “You’re new here. Let me show you how I use this.” They get about 20 minutes of training, it’s done, and they’re on they’re own. That thing had better push the information they need to them. It better be intuitive. It better be easy to use, maintain, train, deploy.

That’s what we’re focused on. It’s a lot, but it’s really one problem. Giving them the information they want when they want it so they can do what they need to do and not require massive support to do that.

Any concluding thoughts?

We think there are going two be major challenges. How do enterprises handle data and account for their outcomes? How do you get the tools to do the individual clinicians on the front lines to do their job, which is patient care, and take care of all of that other stuff in the background? That’s what we’re trying to do.

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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 December 2006.

Embrace FDA Oversight If You Want Clinical — not Clerical — Systems
By Mr. HIStalk

Most hospital information systems are old. Faded pictures of the original system architects feature bushy-haired guys wearing plaid pants, wide ties, and leisure suits. Given their unfortunate fashion sense, it’s not surprising that their precognition of today’s healthcare environment didn’t include having physicians and other clinicians use their creations directly. The goals of information technology were simple: capture charges, batch-bill the heck out of Medicare and Medicaid, and maybe provide a simple order entry function just good enough to support those first two items.

Today’s so-called “clinical” systems mostly sit atop that antique and unsuitable foundation, outdated not because of old programming languages and hardware platforms, but because their original design mindset is now hopelessly obsolete. Clinical applications are really just green-screen type data entry forms that happen to accept clinical information. It’s the mainframe mentality at its worst – the all-knowing system that requires regular data feedings from subservient users who, despite their occupational disposition, are relegated to being keypunchers.

Eventually, some company will actually design a new inpatient clinical system from the ground up. We can fervently hope that when they do, they’ll start with a blank slate and not simply port outdated, monolithic thinking to a newer technology platform. With that innovation, though, will come the crossing of a huge chasm: that no-man’s land between “information systems” and FDA-approved medical devices.

Clinicians gripe that systems are user-unfriendly, do little to help them perform their jobs, and add minimal value to personal productivity or patient outcomes. They’re just accounting systems whose widgets are clinical. One reason: HIT vendors are terrified of FDA regulation. It’s easier to make sure systems are too dumb to require it than risk exposing sometimes bad software practices to government oversight.

Clinicians are overwhelmed by too much raw data whose presentation can’t be individualized, i.e. they insult bone marrow docs with low platelet warnings (if they have alerting capability at all, that is.) That picture that’s worth 1,000 words can’t be included because 1980s-era programmers didn’t see cheap multimedia and storage coming. Failure to rescue can’t be detected in crashing patients. Systems deliver data like an obedient mailroom clerk, adding equally unimpressive value. The average automobile, riding on even older design, has better data aggregation and presentation capabilities, replacing data lists with idiot lights, navigation capability, and easy-to-comprehend gauges.

It’s like Lucy working on that candy assembly line – reams of often irrelevant information are unceremoniously dumped faster and faster into the laps of physicians and nurses, who are expected to manually figure out what’s useful and then “process” it, often by entering even more on-screen information. Eventually, the administrivia buries someone who ought to be making patient care decisions instead of romancing a keyboard.

IT vendors have good reason to fear the FDA, which won’t be happy to hear about buggy code, poor testing practices, slow updates for known defects that have clinical implications, and head-scratching user interfaces that merited no more than an afterthought. Maybe that level of scrutiny would slow development and increase costs, but accepting possibly dangerous software as long as it’s fast to develop and cheap (both debatable) doesn’t seem like much of a bargain.

A smart clinical systems vendor would include FDA approval into their long-term plans and build killer applications around it, thereby scooping their competition by years. Redesign the first-generation systems, step boldly into the FDA-regulated space before the device vendors instead invade the IT space, and build systems that improve patient care, not just turn paper forms into on-screen forms.

Today’s software was designed around old constraints and its design shows it. Someone should get clinicians together (no programmers allowed) to design the systems of tomorrow, software whose effect on patient care is less interruptive and more assistive. Doing that right will require FDA approval. For that reason, the industry should welcome it.

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Top News

KLAS publishes its 2011 Best in KLAS Awards for software and professional services. A few highlights:

• Epic is named the top overall software vendor and takes the #1 spot in seven categories, including acute care EMR and ambulatory EMR over 75 providers. Epic’s winning margins in these categories were significant. In acute care, Epic earned 90.3% satisfaction score compared to second place Cerner PowerChart at 78.5%. In the ambulatory EMR75+ provider segment, Epic scored 89.8% compared to eClinicalWorks’ 76.1%.
• If you compete against Epic on inpatient core clinicals and ancillaries, you’ve got your work cut out for you. Epic tops every application category except lab, including EMR (orders, results, documentation), pharmacy, radiology, and surgery, not to mention that Epic also is #1 in patient accounting and patient management. And, all of those products run on a single database and are fully integrated. It’s not shocking, then, that vendors are trying to beat Epic on price since that’s about the only competitive point that’s up for grabs.
• McKesson Paragon beat Cerner PowerChart by 10 percentage points in the community acute care EMR segment. Interestingly, Paragon was not ranked in the acute care segment because that’s not Paragon’s primary market (according to KLAS.) Paragon’s scores in the acute care segment would have been good enough for a fourth-place ranking, beating out Horizon and others.
• It’s pretty impressive to have 100% of your users (those participating in the survey, anyway) say they would buy your product again. Among those achieving that distinction: Epic (multiple categories), SCI Solutions (enterprise scheduling), Sunquest (community laboratory), Allscripts (patient accounting/patient management), Nuance (speech recognition), iMDsoft (anesthesia), GetWellNetwork (interactive patient systems), athenahealth and SRSsoft (ambulatory EMR), athenahealth and OptumInsight (practice management), and ZirMed (clearinghouse services.) Interestingly (to us, anyway), all but two of these companies are HIStalk sponsors.
• maxIT was ranked the top overall services firm, edging Hayes Management Consulting by 0.2 points.

Reader Comments

From DtwlnLax: “Re: iPhone users. Check this out – 25 GB of free cloud storage for iPhone users.” Sign up for Microsoft SkyDrive and its yours.

From Non Sequitur: “Re: holiday greetings! HIStalk provides a great service and somehow ties us all together into one common community in some way that I don’t entirely understand, but it works. You should enjoy knowing how common an occurrence it is around this setting (and in my former life as a vendor) to walk in on a conversation where someone is saying, ‘Did you read such and such in HIStalk this morning?’ or counters an argument in a meeting with, “There was an article on HIStalk recently where they addressed this, and the gist of it was…’ I really appreciate the news, the good articles, the inside story, and of course the delicious pithy comments! An e-mail from HIStalk or HIStalk Practice is like getting a little gift from my Secret Santa. Your industry insight amazes me and those of us in the trenches really, truly appreciate the effort and commitment! Happy Holidays to Mr. HIStalk, the long-suffering Mrs. H, and to the Intrepid Inga! My hero!” That was maybe the best e-mail anybody has ever sent us. Inga wanted me to run it unedited, but I argued that it was indeed great, but it seemed distastefully self-promoting to run it publicly instead of just basking in it privately. We compromised: I edited it to the version above to reduce the volume of the shameless tooting of our own horn (from 11 to 10, at least). Non Sequitur, who works for the hospital of one of the finest public universities in the country, made our day, needless to say. She’s sweet.

From All Hat No Cattle!: “Re: Partners Healthcare. Sent an internal memo stating they have decided to buy a new EHR for their facilities. Wanna bet whether it will be Epic or Siemens?” Glaser connection or not, Siemens wouldn’t seem to be a great choice given Soarian’s limited (non-existent?) track record with facilities their size and complexity, although they’ll surely get lots of promises of extra-special hand-holding that might sway their opinion from the obvious choice.

From Patti: “Re: ACO training in four hours. Check out this Craigslist ad for the Prognosis ACO. The ACO sales rep would get four hours of education on ACOs and ‘the sales pitch’ and would then be ready to recruit physicians to sign up, pushing their EHR as well. Reps get the equivalent of $30K per year plus $500 per enrolled doc, but their contract ends in March.” The big spiff for reps is that the company provides business cards. The Craigslist ad is here. There’s not much listed about who is behind the hard-selling ACO, but domain registrations seem to point to an Illinois oncologist.

From Larry: “Re: McKesson. They wanted to get rid of Paragon years ago, but worried about the viability of old products like Series and HealthQuest with ICD-10 coming and let Jim Pesce talk them into Paragon as a clinical solution. About the same time, Michael Simpson, now running the GE-Microsoft thing, swore he could get HERM done if they let him take it offshore like he had with his previous employers (check out Unisys and Novell to see how well that worked out.) Paragon was to be the hedge bet, to be killed off if Simpson was successful. Obviously he wasn’t.”

From Wet Willy: “Re: the new company of former Allscripts CTO John Gomez. I hear they are working on a search and analytics platform for healthcare, a hybrid of Google and Amalga done right with a huge emphasis on usability for outcomes-focused analytics. I also heard they are introducing an Allscripts-to-Epic migration tool and service that will allow a hospital to migrate Sunrise facilities, printer locations, patient records, medical history, formulary and other data and map it to Epic’s schema with 80% accuracy.” I asked John. His answer for #1: “It is true, we are working on that.” For #2: “We really can’t comment.” Above are his company’s guiding principles.

HIStalk Announcements and Requests

This week on HIStalk Practice: athenahealth’s Jonathan Bush calls for greater transparency and accountability in the Meaningful Use program. The White House says the government has recovered more than $2.9 billion in healthcare fraud this year. HHS issues an advisory opinion that concludes a vendor would not be violating anti-kickback statutes if it facilitated payments between providers for the exchange of EHR data in a patient referral situation. The Chicago and Maine RECs say they’ve met their enrollment targets. If you can’t send me a pair of Christian Louboutins for Christmas (size 8), then the next best thing would be to faithfully read HIStalk Practice and sign up for e-mail updates.

A reader from a large hospital system in Shanghai, China is looking for a vendor to provide an outpatient PM/EMR/dental system that can then be expanded to the inpatient hospital. I don’t know of any US-based vendors that offer these capabilities with support for customers in China, but if yours can, I can forward your contact information. I was just happy to brag to Inga that one of our readers needed our help, and oh by the way, she’s in China.

Say hello to new HIStalk Platinum Sponsor Ingenious Med of Atlanta, GA, whose company name is one of my favorites. The physician-founded company has been around for more than 10 years, offering workflow-intelligent physician solutions for charge and data capture, coding and documentation, quality, reporting, and inter-staff communication. “Physician-friendly” means “mobile” these days, and Ingenious Med just this week won its third consecutive Mobile Star Award. The company has 9,000 users in 800 facilities that include Emory Healthcare, WakeMed, Kaiser Permanente, Texas Health Resources, Sentara, Geisinger, BJC, and a bunch of other high-profile providers. So why would a hospital be interested in solutions like these? Simple: hospitals spend tons of money subsidizing the P&L of their docs, eating the loss with the hopes of offsetting it via increased hospital business, while the company’s tools soften the blow by increasing collections by $30-40K per doc per year just by capturing information accurately (they’ll put it in writing, and show you their 97% customer renewal rate). Hospitals also like reduced exposure to RAC audits and insight into whether individual physicians seem to be over- or under-coding based on industry standards. Thanks to Ingenious Med for supporting HIStalk.

On Healthcare IT Jobs: McKesson STAR Analyst/Consultant, Cerner PathNet Consultant, EMR Application Specialist.

Acquisitions, Funding, Business, and Stock

athenahealth reaffirms its existing guidance for fiscal 2011, predicting earnings of $0.78 to 0.85 per share and revenue of $320-$325 million. Analysts had predicted $0.86 per share. The company also projected 2012 revenue of $410-430 million, in line with expectations, but non-GAAP net income of $0.85 to $0.97 per share vs. the Street’s anticipated $1.16 per share. The share price slipped over 15% Thursday to $49.04.

Spectrum Equity Investors and Trident Capital  take a majority position in HealthMEDX, LLC, a provider of long term and post-acute care technology. Former McKesson Technology Solutions President Pam Pure joins the company as CEO. Former Visicu SVP/CFO Vince Estrada was also named EVP of business development and CFO.

People

Orion Health appoints Andrew Ferrier, former CEO of Fonterra, to its board of directors.

CHIME elects Melinda Costin (VP, Baylor Health Care) and Randy McCleese (VP/CIO, St. Claire Regional Medical Center) as board trustees.

Diversinet Corp. names Hon Pak, MD as interim CEO, succeeding the retiring Albert Wahbe. Pak recently retired as CIO of the US Army Medical Department and had served as president of the American Telemedicine Association.

The New England chapter of HIMSS names Daniel J. Nigrin MD, MS as Clinician of the Year. He’s SVP/CIO and a pediatric endocrinologist at Children’s Hospital in Boston, not to mention a faithful HIStalk reader.

National eHealth Collaborative announces new officers: Kevin Hutchinson (My-Villages), Holt Anderson (NCHICA), Tom Fritz (Inland Northwest Health Services), Paul Uhrig (Surescripts), and Janet Corrigan (National Quality Forum).

Announcements and Implementations

Catholic Healthcare West’s north state division will deploy MobileMD to connect its hospitals to physician offices, clinics, and other hospitals.

St. Rita’s Medical Center (OH) goes live on Ohio’s statewide HIE with the transmission of clinical data to Greenway EHR customer Health Partners for Western Ohio.

Emerus Emergency Hospital (TX) goes live on the InsightCS revenue cycle solution of Stockell Healthcare Systems at six Texas locations.

Birmingham VA Medical Center (AL) implements GetWellNetwork’s interactive patient care solution in its tertiary care facility.

Government and Politics

A healthcare blog post in The Hill observes that Republican presidential front-runner Newt Gingrich isn’t talking about electronic medical records like he used to, possibly because conservative voters weren’t thrilled with his support for spending taxpayer money on technology for private businesses (some of which were his consulting firm’s customers.)

CMS will announce the first Medicare accountable care organizations on Monday, rumor has it.

North Carolina legislators criticize the state’s Department of Health and Human Services for allowing cost overruns for building a new Medicaid claims system. The final tally for the state’s $265 million contract with CSC is now pegged at $495 million. It will also take 22 months longer to complete the system and will cost $91 million more to keep the old system running in the mean time. One state representative called the project a “money pit” and added that if it were a private sector project, heads would have rolled, but when the agency’s IT head was asked to give herself a grade, she said she deserves an A. CSC originally got the bid when a 2004 contract with ACS was cancelled, costing the state $10 million to settle the resulting ACS lawsuit. When the CSC contract was signed in 2009, the current DHHS secretary was a lobbyist for CSC.

In the UK, vocal NPfIT critic MP Richard Bacon says BT and CSC are charging NHS trusts triple the market price for Cerner Millennium and iSoft Lorenzo.

Innovation and Research

Mount Sinai Medical Center (NY) will start a pilot project in January that will link the genomic sequence of patients to their electronic medical records, allowing physicians to incorporate the patient’s genetic characteristics when choosing drugs and dosages.

The safety institute of Johns Hopkins Medicine, led by Peter Pronovost MD, PhD, will collaborate with Lockheed Martin to create a new generation of hospital ICU. An example given of its potential work is a patient alarm prioritization system. According to Pronovost, “A hospital ICU contains 50 to 100 pieces of electronic equipment that may not communicate to one another nor work together effectively. When an airline needs a new plane, they don’t individually select the controls systems, seats and other components, and then try to build it themselves.”

Technology

Fujifilm Medical Systems announces the availability of Synapse Financials, a billing solution that integrates with Fujifilm’s Synapse RIS platform.

Axial’s Care Transition Suite wins first place in the "Ensuring Safe Transitions from Hospital to Home" initiative, sponsored by Health 2.0 and HHS’s Partnership for Patients Initiative.

Other

Wes Wright, CTO of Seattle Children’s Hospital (WA) says its deployment of 2,600 Wyse zero client devices for Citrix will save $400,000 per year in power consumption.

MoneyWatch reports the top-compensated US CEOs for 2010, with McKesson’s John Hammergren in the #1 spot with $145 million (5,370 times the median US income.) Two other healthcare CEOs made the Top 10: Joel Gemunder of Omnicare ($98 million) and Ronald Williams of Aetna ($58 million.) Another site says Hammergren’s payday will get a lot bigger if McKesson changes ownership at some point — his contract calls for him to be paid $469 million.

Making sure to place this item for maximal ironic effect, soon-to-be-displaced McKesson employees can check the comments left on my earlier post, where some vendors who are looking for Horizon or other talent have posted their contact information (I entered a few myself from information e-mailed to me).

An interesting article in The New York Times ponders whether clinicians are becoming distracted by their growing arsenal of smart phones, tablets, and other gadgetry. It cites a research article that asked technicians who monitor heart bypass machines during surgery whether they used their electronic devices right in the OR, with 55% saying they had talked on their cell phone and 50% admitting they had texted. Funny: a Stanford doctor and author calls the attention-demanding screens “the iPatient,” and says the iPatient is getting wonderful care. In a sobering example, a patient was left partly paralyzed after surgery, with evidence presented in the ensuing malpractice lawsuit documenting that the neurosurgeon had made at least 10 personal calls from a wireless headset during the surgery.

A Boston Globe article covering a visit by the head of HHS’s HIPAA enforcement organization, Office for Civil Rights (which it mislabels as Office of Civil Rights), cites Micky Tripathi’s breach article on HIStalk Practice. It’s also being reprinted in a Canadian information security journal after they requested his permission and he graciously deferred to us.

Sponsor Updates

• Jeffrey DiLisi MD, associate VP of medical affairs at Virginia Hospital Center (VA), will discuss motivating physicians to improve documentation during The Advisory Board Company’s December 16 web conference.
• MD-IT releases a case study on the ability of neurologist Gordon M. White, MD (TX) to maintain productivity while qualifying for the EMR incentive program.
• Nuance joins 11 other organizations as a strategic partner with the Center for Connected Medicine.
• Billian’s HealthDATA announces an alliance with  HealthLink Dimensions to add hospital-affiliated physician data to Billian’s existing offerings.
• Nuance releases findings of a managing paper records in a medical practice.
• Ignis Systems releases its EMR-Link Maintenance Training webinar schedule.
• Greater Glasgow and Clyde Health Board (EU) announces that over 15,500 active patients have adopted its Orion Health clinical portal.
• Practice Fusion shares its top seven healthcare IT predictions for 2012.
• The Micromedex mobile drug information app from Thomson Reuters earns a spot on the WIRED App Guide to 400 Essential Apps.
• Covisint works with Intermountain Healthcare (UT) to earn nearly $1 million in PQRS incentives.

EPtalk by Dr. Jayne

Medicare announces that starting in January, recovery audit contractors (the dreaded RAC auditors) will offer a new service to amuse and delight physicians: prepayment reviews. The audits will be piloted in states with a relatively high percentage of fraudulent and inaccurate submissions, as well as states with a high percentage of short hospital stays. Another demonstration project will require prepayment review for motorized wheelchairs and scooters, with a goal of requiring prior authorization within the next year.

It is unclear why Medicare chose to use the RACs to do this instead of the Medicare Administrative Contractors that actually process the claims. I do like the idea of looking at the process for payments covering powered mobility devices. A couple of vendors are entirely too pushy and work very hard to convince patients that every Medicare beneficiary deserves a scooter “at absolutely no out of pocket cost” because they’re not cheap and all of us are paying for them.

CMS plans to offer up to $1 billion in grants for healthcare innovations. The Health Care Innovation Challenge program targets public-private partnerships, multi-payer groups, and groups caring for patients with complex health care needs. Administered by the Center for Medicare and Medicaid Innovation (CMMI – ooh, a new acronym!), the grants stem from $10 billion in funding from recent health reform legislation. Proposed projects have to be rapidly deployable (less than six months) and able to be replicated, expanded, and sustained. I’m interested to hear from anyone who is considering an application. Letters of intent are due Monday and applications are due January 27, so if you want to wait until after the deadline so no one steals your ideas, I understand. The minimum award is $1 million, so get those keyboards moving.

Based on the content so far, I might as well make this the “all CMS, all the time” column this week. The House of Representatives passes a bill this week to postpone the scheduled 27% pay cut for Medicare physicians that is only a few days away. However, it is not expected that the Senate will follow, and even if they do, President Obama is expected to veto it.

HIMSS will open the process to solicit volunteers for its 2013-14 committees on January 2. Individual members and corporate members who are not already in HIMSS leadership positions are eligible as long as they have maintained membership for the past 12 consecutive months. Watch the Committees home page for more information.

We talked about flu vaccines recently, but right now there’s an outbreak of pertussis (whooping cough) in Chicago and surrounding counties. Vaccines are effective and are now recommended for adults as well as for children.

I mentioned last week that I had something big planned. Since our last get-together was at HIMSS11, I thought it was time that I paid my BFF Inga a visit. Although I frantically searched the racks at Nordstrom looking for something appropriate to wear, I suspected my efforts would be fruitless because I could never keep up with Inga. Seeing her walk through the door having paired these with jeans for a casual dinner, I knew I was right.

So what do the sassy ladies of HIStalk discuss over drinks? The enigma that is Mr. H, recent events at McKesson, who has the best date for HIStalkapalooza, and potential beauty queen sashes. We also discussed our no-longer-secret project. As Inga mentioned, you’ll want to make sure you include a pair of new or gently used shoes for our charity event when you make your packing list. (Sorry, no stiletto dash for those of you who suspected that’s what we were up to. I don’t want to be called upon to treat any orthopedic injuries while I’m enjoying the evening.)

It was nice to actually get together since we typically connect via e-mail and the occasional text message. I usually have at least one good physician war story for Inga, and this time she topped me with the writeup of a new book: Stuck Up! You’ll have to read for yourself what it’s about. Let me just say that it’s wackier than anything even Weird News Andy would send.

Contacts

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

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