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Monday Morning Update 7/30/12

July 28, 2012 News 27 Comments

7-28-2012 9-23-13 AM

From Meaningful Juice: “Re: GAO report from last week. Of 4,855 eligible hospitals, 776 were awarded eligible $$$ juice for 2011. Phew – my tax dollars are not being wasted!” Among the GAO’s recommendations was that CMS needs to beef up its scrutiny of whether providers really were eligible to get their payouts.

7-28-2012 3-12-03 PM

From Dave: “Re: Michael Stearns, before being fired as e-MDs CEO. See this document.” This is old news that has been mentioned here before. The Maryland State Board of Physician Quality Assurance suspended the medical license of Dr. Stearns in 1997 after he pleaded guilty to four counts of assault and battery in a US Navy court-martial case in which four female patients claimed “inappropriate sexual touching” during his examinations of them. David Winn, who as e-MDS board chair fired and replaced Stearns as CEO on July 2, defended him in this 2011 write-up, saying that Stearns was never convicted of a felony and was perhaps misled by poor legal counsel in a Tailhook-sensitive environment and inconsistent behavior by the Maryland board after the fact. Mike Stearns says he will address this and other issues in an HIStalk Readers Write article in a couple of days. He hasn’t said that he’s suing his former employer even though he claims the allegations behind his termination are meritless, but one might assume that’s his only remaining option. I’ve heard from several folks who extolled the character and capabilities of both Dr. Stearns and Dr. Winn, so hopefully they will avoid the public debate, reach some kind of agreement, and move on without further embarrassment.

From Happily Hosted I Hope: “Re: host environment performance. Do any of your readers have language around system performance and high availability in a hosted environment that they could share? We’re going to be installing an EMR through a hosting arrangement with a local hospital and I’m looking for advice.” Given the high-profile downtimes that have come up recently, I think it’s a great topic to address. If you’ve put terms and conditions into a contract with an EMR hosting provider and would care to share details, please send them my way. I won’t mention either client or vendor and will strip out anything identifiable, so your non-disclosure terms are safe.

7-28-2012 2-09-17 PM

From EHR Warrior: “Re: NextEHR. Looks like it’s finally dead as the company that bought the intellectual property changed its name to iPenMD.”

From ITKnowsTheScoop: “Re: [vendor name omitted.] Under FDA review regarding surgery and anesthesia solutions. They had to remove or reclassify features, which halted sales for four months.” Unverified, so I’ve omitted the company’s name.

From IT Director: “Re: Cerner. I have an unfortunate trove of horrid experiences related to extended planned or unplanned service interruptions, some of them due to a shoddy corporate implementation of Cerner Millennium. Our implementation spanned time zones, so we had a six-hour downtime twice a year when Daylight Saving Time changed. We has spectacular outages where the entire hospital system went dark with no local backup whatsoever. The corporate implementation was insistent on a paperless workflow, so we weren’t even allowed to print periodic paper backup copies of order synopses or MAR summaries. During our first major downtime, a little girl was left in writhing pain for most of the night because the house officer didn’t know the timing and dose of her pain meds. This downtime was rumored to have been caused by a profound error in hardware sizing, but poor database design didn’t scale well even with additional hardware. I don’t blame Cerner as their staff were truly engaged and helpful, but rather a centrally managed health system corporate mentality of arrogance and ignorance that discounted the local reality and specialized workflows. Perhaps the morale of the story is simply that any given implementation is only as good as its implementation team. If they’re evil, then the implementation will be similarly evil. In some ways, Cerner as much as a victim as the hospitals of setting poor implementation leadership.” Your experience matches mine. Unless every vendor’s implementation has been a disaster, it can’t be their fault alone (i.e., one successful comparable client means the stuff basically works). The main problems usually involve: (a) lack of customer technical and implementation resources; (b) poorly developed, self-deceiving project budgets that don’t support enough headcount, training, and hardware to get the job done right; (c) letting IT run the project instead of getting users involved, which is especially problematic if the corporate IT people are clueless; (d) unreasonable and inflexible timelines as everybody wants to see something light quickly up after spending millions; and (e) expecting that just implementing new software means clearing away all the bad decisions (and indecisions) of the past and forcing a fresh corporate agenda on users and physicians, with the vendor being the convenient whipping boy for any complaints about ambitious and sometimes oppressive changes that the culture just can’t support. I might also mention sloppy contracting on the client’s side, since I’ve seen hundreds of contracts and am often amazed that the interests of the vendor weren’t legally aligned with those of their customer via a few standard terms and conditions.

From Commando: “Re: Cerner. Cerner has two electronic downtime solutions for remote hosted clients. The read-only methodology referred to requires the user to be able to log into the system back in KC, which wouldn’t be possible with the DNS servers out of business. There is another level of downtime service – something I guess his/her organization decided not to purchase. That next level dumps patient information to local computers (at our hospitals, at least one on each floor) at regularly scheduled intervals. i.e. updated every 5 minutes. That way, even if all connection with KC is lost, staff has information (including meds, labs and more) locally on each floor which is accurate up to the time of the last update. Finally, since this outage was due to a DNS problem, anyone logged into the system at the time it went down was able to stay logged in. This allowed many floors to continue to access the production system even while most of the terminals couldn’t connect.” Assuming this is an accurate description of the available options with Cerner hosting, it might be a good time to check out the local caching option. That would be protection against even internal network problems, which in a lot of hospitals is not uncommon. I recall that Kaiser uses that with good success for its Epic/HealthConnect system that’s deployed regionally. You could probably create a poor man’s solution by running specific reports (MAR, active orders, recent lab results, etc.) to a PDF file and dropping them in specific folder locations on a frequent schedule, like maybe once an hour.

7-28-2012 4-50-48 PM

From West Coast: “Re: John Muir Health. Hires a CIO.” The internal memo sent my way indicates that Jim Wesley has been announced as SVP/CIO of John Muir Health. He was most recently a consultant, but has healthcare CIO experience. John Muir’s hot button is getting Epic up and running.

From Maryann: “Re: Epic. I work directly for a hospital that is implementing several Epic modules over the next 5-7 years. I have two Epic certifications. I applied to several consulting companies and each one told me that they couldn’t hire me if my hospital was in the middle of an Epic implementation because of an agreement with Epic. Is this legal? How long to I have to wait if I leave my hospital before a consulting company will hire me?” Welcome to the murky world of Epic non-competes and recruitment restrictions. Epic controls your opportunities with potential employers via separate agreements and/or implied punishment for poaching Epic-certified people. Is their practice legal and binding? Almost certainly not, but you’d need a lot of lawyer money to find out, and by the time you got a ruling, you could have just sat out your time as an untouchable by working in a non-Epic role somewhere (I think it’s a two-year timeout, but it may just be a year … I seem to remember there was discussion about changing it.) Epic’s practices are designed specifically to thwart exactly what you want to do – use your short-term Epic experience and certification to bail out on your employer and cash in with a consulting firm. Even if you had the financial resources and extended timeline needed to mount a legal challenge, there’s still no guarantee that you’ll get hired, because legal or not, nobody wants to cross Judy for fear of choking their own particular gold egg-laying goose. Not to add more rain on your parade, I’m not sure you can even easily move to another Epic hospital, but I’ll let those who have first-hand experience explain how all of this works.

From The PACS Designer: “Re: waterproof accessories. If you want to limit infection from entry devices, there’s now a solution from Seal Shield. They feature waterproof keyboards and other computer input devices that are easily washable and ready for reuse, thus reducing the spread of infections that could come from multiple users of those devices.” I’ll say this – they make a fantastic commercial. You can waterproof your iPad for $30 or your iPhone for $20.

7-28-2012 3-53-48 PM

Welcome to new HIStalk Platinum Sponsor M*Modal. The company’s cloud-based Speech Understanding solutions that are used by 2,400 customers include Fluency (converts physician’s narrative into electronic documentation that can be integrated into workflows, in effect speech-enabling EHRs); Catalyst (retrieving information from unstructured encounter documentation, with the first in a series of tailored versions being Quality and Radiology); and SpeechQ (dictation capture for radiology). The company also offers transcription services via its 10,000 transcriptionists (it’s the largest in the US) as well as coding services for clients struggling with Discharged Not Final Billed accounts and the possibility of negative audit findings. We know from recent headlines that M*Modal is a very successful company since arguments have been made that JP Morgan is getting too good of a deal in acquiring it for $1.1 billion, so that’s a nice debate to be having. Thanks to M*Modal for supporting my work.



Here’s an M*Modal video I found on YouTube.

Listening: new from Citizen Cope, which is primarily singer-songwriter Clarence Greenwood. A uniquely American mix of soul, blues, and roots music. Eric Clapton is a fan.

TPD has updated his list of iPhone apps.

I have zero interest in the sprawling commercial spectacle of the Olympics for a variety of reasons (athletes itching to bag endorsement deals the day the flame and their short-lived fame are simultaneously extinguished, smug US cheerleading, glorification of photogenic participants and sports to the exclusion of most of the others, participation of state-sponsored and chemically altered participants and richly compensated professionals like LeBron James that make a joke of the phony, feel-good “amateur” aspect) so I won’t have anything to add to the already smothering media coverage that I won’t be following (except for articles involving widespread Olympic Village debauchery.) Inga bah-humbugged me and says she’ll pipe in with anything HIT-related (like the frequent GE commercials she’s already mentioned to me), so we’ll count on her to make it interesting.

Speaking of Inga’s Olympics chime-in, she sent this newspaper article criticizing the UK’s NHS promoting itself to a worldwide audience just after several high-profile incidents of patient harm that occurred under its supervision:

Sitting in a home somewhere while fireworks lit up the Olympics opening ceremony would have been the family of Kane Gorny. They watched their cherished teenage son die of thirst at the hands of incompetent doctors and nurses … The letters ‘NHS’ dazzled in bright red like some triumphant advert. All around these pranced self-indulgent nurses who had volunteered to take a few days off to be part of the ceremony … That such a politically divisive subject was included at all is utterly shocking. Not least because it glossed over the cracks in a system that is creaking at its seems crying out for urgent reform.

And speaking of NHS, it apologizes to the family of a 76-year-old hospitalized cardiac patient who died right after her son discovered three workers drilling holes in the ceiling above her head to install a patient entertainment system.

7-28-2012 9-01-39 AM

Readers say the future of public HIEs is bright, at least if you count dying a screaming death in a giant nuclear fireball of failure as bright. New poll to your right: in which HIT-related company would you invest $100K today? (assuming you have to choose one).

7-28-2012 5-02-52 PM

Defense Secretary Leon Panetta disappoints a House committee by advising them that integration of the respective electronic medical records systems of the DoD and VA (AHLTA and VistA) won’t be finished until at least 2017, and he didn’t even sound confident about that date. VA Secretary Eric Shinseki observed that simply reaching DoD-VA consensus on a open architecture system was quite an accomplishment given previous discussions with “a proprietary contractor.” Rep. Bill Johnson (R-OH) wasn’t happy with that answer: “I understand that you can’t account for the last 10 years, Mr. Secretary. And I understand that you’ve got two bureaucracies that don’t necessarily like to be told what to do and (don’t) get along all the time. But I will submit to you that another five years is unacceptable (and) ought to be unacceptable to you.”

HIE Networks and Hillsborough County Medical Association (FL) announce their collaboration to deploy a county HIE. HIE Networks operates the Florida Health Data Network.

Some quotes I highlighted from the McKesson earnings call:

  • The clinical conversions — when we talked about our Horizon to Paragon strategy, we talked about the fact that we believe it is a viable solution for our customers, and that over time they need to evaluate that as an alternative because of its more tightly integrated infrastructure and its lower cost of operations … we’ve seen many of our Horizon base evaluate the products. We’ve seen some of that base already contract to move to Paragon, and some already have moved because of whatever remaining development is necessary and Paragon was not of import to those customers. Others have said, you know what, we’re going to go, but we want you to build out another module or we’re going to go after we get our Meaningful Use dollars settled.
  • We are really pleased with our position in RelayHealth. I have to admit that the e-prescribing portion of the market’s transition is not a particular profit driver for us. We’re in that transaction both in our electronic medical record businesses as well as in Relay. But that’s not really where the opportunity lies. The opportunity lies in the continued build out of our financial systems.
  • And if it’s a surprise to anyone that clinical buying is beginning to wane, they must not be deep in the industry. We believe that our customers have largely made their clinical decisions … We’re in the implementation phase now. Actually if you look at our results under the cover, you actually will see that our hospital buyers are beginning to come back to purchasing other solutions beyond clinicals. And I think those companies that don’t have a portfolio beyond clinicals are probably feeling the effect of a pipeline that is probably headed in a different direction.

Some quotes I highlighted from the Cerner earnings call:

  • While there is one competitor that remains a challenge, our competitive position against them continues to strengthen. At the same time, their weaknesses are becoming more known in the marketplace. As we’ve discussed, our significant improvements to our physician solutions and the workflow is neutralizing one of the primary areas they used to compete. And we believe the capabilities we are rolling out in Millenium+ and PowerChart+Touch surpass their capabilities. In addition, our investments in our operability, data analytics and population health management are becoming an increasingly important differentiator against them as their platforms make interoperability and data analytics very challenging. We also believe they will face an inevitable upgrade from their MUMPS-based platform that is needed to catch up in these areas, and this will be very disruptive and expensive.
  • Currently, approximately 45% of our core hospital clients have attested for Stage 1 Meaningful Use, and we expect approximately 85% of them to have attested for Stage 1 by the end of the year.
  • As background, our experience with data and analytics dates back to 1996 when we started Health Facts, which is a research database that now has over 150 million patient encounters and nearly 2 billion lab results. While in the past this data has largely been used to support pharma and biotech research, our server map organization is now using it along with published evidence to accelerate the development of predictive clinical agents.
  • But we clearly have a significant amount of cash on the balance sheet. We think we are in a situation in kind of part of the market that there could be some interesting opportunities for us to deploy that cash in a way that could be — either supportive of Millennium, get us more quickly into some of the new businesses that we’re looking at. I think, relative to the existing traditional HIT market, the window is getting very close to being closed for that being interesting to us. So I think the status of many of those competitors are a little bit on the downhill side of the hill.
  • I think probably the one country that’s got a lot of demand is going to really be — just a funding issue — is the UK. As more and more of those trusts are becoming foundation trusts, which means they control their capital outlet — outlay as opposed to the government putting the dollars out there, we think that’s going to turn into a more normalized US- type market where each trust is going to go out to the market and look to acquire technology. In 2015, the current NHS contracts expire. So almost all of those trusts are going to be looking in the market in some form or fashion, probably depending on their access to capital.
  • The RFP volume, I’d attribute a lot to the failures of many of our competitors to be ready for the changing landscape. And so they’re in the midst of either — they’ve done acquisitions and they’re trying to put things together, they’re trying to move to new platforms, they’re sunsetting existing platforms, they are on old technology. And those types of things, as people look to what the future is, they know that they have to have data liquidity, their systems have to be interoperable, and they’re going to need that data no matter where the person is in the entire care cycle, inclusive of the home … the recognition that Cerner can do that work, that their current providers can’t do that work.

Vince’s HIS-tory continues with the story of Keane and its Threshold product that could run on any hardware vendor’s UNIX platform.

E-mail Mr. H.

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27 Responses to “Monday Morning Update 7/30/12”

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  1. 27
    Looking deeper Says:

    I worked for Epic and consult on their software now. I’m not going to take sides on whether the Epic noncompete is okay or not, morally okay, hurting clients, etc. I’ll just share my experience and that of several friends to give a perspective from the ex-Epic side.

    First, I’d like to note that calling the agreement that employees sign a “noncompete” is a bit of a misnomer (maybe Epic calls it that?). Epic does ban employees from working with direct competitors, which is a traditional noncompete, but this is banning employees from working with clients and consulting firms. The employees wouldn’t really be competing with or supplanting Epic staff – if an Epic employee left, another Epic employee would just take their place and Epic would continue receiving their customer’s licensing, support, and consulting fees. Sp the employment restrictions do not prevent “competition” from the ex-employees; instead, they are meant to do is prevent Epic’s clients from poaching their employees. This helps to keep salaries for Epic employees below their market value. Most Epic employees are being paid well (I never heard anyone complain that they weren’t being paid well enough) so it would be hard to say that they are suffering in the salary department, but Epic is certainly paying them significantly less than a consulting gig would pay for the same work and the same travel but for fewer hours per week. (in my experience, 55 hours was an “average” employee, and the really “good” ones were closer to 70 – but I think most Epic employees in Implementation under-report their hours)

    Anyway, back to my experience and friends’ experience: You can absolutely work for other HIT companies in your noncompete year. I was hired by another company in the HIT space. It was nice to learn a completely different app and new processes. Epic knew where I was going, and did not raise any fuss at all because they weren’t on the official competitors list which is given to every employee when they’re hired and is clearly announced whenever it’s updated. So the idea that ex-Epic employees cannot use their skills is only somewhat true: you can absolutely use your HIT knowledge and experience, just not on an Epic project or a direct competitor (Cerner, eClinicalWorks, etc) for a year after you leave.

    Moreover, I have several friends who have gone to work for an Epic client immediately after leaving Epic (in fact, they went on interviews and were given offers while still working at Epic), but they are banned from working on Epic software for a year. This is a barrier, but not a huge one. Hospitals are complicated places, and Epic is not the only system that Epic clients use. So these sorts of jobs are out there, and I have not heard of any cases of this being a problem as long as the ex-Epic employee plays by the rules and stays away from the Epic project for a year. I’m not saying the limited restriction is okay, but it’s not as broad as it might seem at first.

    I’m not going to say whether Epic’s policies are acceptable; I haven’t made up my mind, and I don’t really think about it much because my “Epic year” is long since over. But the restrictions that Epic places on its employees are somewhat limited. Whether these are reasonable limits is tough to say. But it is definitely not a case of Epic pursuing its departing employees and trying to destroy their careers, or driving them out of HIT entirely. Mostly, Epic is putting up a barrier that makes employees think twice about bailing for lucrative consulting contracts because they’ll have to wait a year to start. But this barrier isn’t an extremely high one; I’d call it “medium.”

    On a slightly different note: considering the salaries, working hours, and constant complaints (analysts hear “the system you set up stinks!” almost weekly) why are hospitals surprised when most of their project teams are ready to leave ASAP? I’ve looked into full-time employment at Epic clients. Consultant salaries for analysts are 3-4 TIMES greater than for full-time employee analysts. (Yes, I did my math correctly: Consultant salaries I’ve been offered usually = analyst salary x 3 or x 4) And a smart consultant will bill hourly, meaning they’re paid extra for those 60 and 70-hour weeks. Employed analysts simply have to work 60 hours if management says so. I’m surprised that hospitals can hold on to anyone at all. How did hospitals come up with their analyst salaries? Did some HR temp go to Salary.com and look up “systems analyst?”

  2. 26
    Vonlay Says:

    We at Vonlay have thought about the non-compete and come up with a different synthesis:

    “This time away from healthcare information technology & the Epic ecosystem is critical for long term career success in consulting.

    A non-compete spent undertaking a wide breadth of cross-disciplinary challenges is necessary for meaningful personal growth & professional development. Moreover, it’s an important sabbatical from the esoteric jargon that a myopic focus on HIT-centric implementation/project management, development or technical service can bring.

    Because the ideas that will make a real difference in healthcare often come from lessons learned in a tangential experience in a different industry/endeavor.”

    Read More: http://www.vonlay.com/blog/noncompete

  3. 25
    skimpynightie Says:

    I am an Epic alum as well – much longer than 3 years in fact – I went through the “sabatical” and back. At Epic a 55 work week is the minimum and if you’re in implementation you travel every week of the year you are not on vacation or it is a holiday. You are Absolutely paid well for this and if you plan well and live low you can wait out the length of the non compete (mine was 6 months). I did and I’m glad of it. I also had an under the table offer waiting for me so that helped immensely. I was lucky – I, and my future employer, took a gamble and it paid off for both of us.

    Could I (David) have taken on Epic (Goliath)? Being young and idealistic at the time I DID consult a lawyer in Madison who wouldn’t touch my case with a ten foot pole and she told me the painful truth – it would be expensive and there would be no ‘winner’. Maybe, my lawyer was a UW alum or maybe if you show me a lawyer willing to take on this ‘case’ I’ll show you a fool.

    The noncompetes imposed by Epic on their clients is actually much worse than the ones they put on their employees. As you say, as an Epic employee you are required to sign the agreement or you will not be hired. I declined to sign it originally and they told me it was a condition of employment. What can I say, I needed a job. As an employee of an Epic client you probably don’t even hear about the agreement your leadership made until you want to leave.

    It really does seem to be a case of punishing the many for the sins of the few. Most people who work in healthcare are not in it just for the money, and if you find some that are then why not take the high road and instead of blackballing everyone, blackball that person?

  4. 24
    Suffocating Non Compete Says:

    Working Stiff –

    I can appreciate the point about loyalty to the employer. And if you work for Epic and then want to leave so you can compete against Epic, I can see how that triggers a non-compete in the traditional sense of the work.

    But the original poster works for a client of Epic’s, and now she is boxed out of working for a whole segment of consulting firms and (it appears) other Epic hospitals. I wonder if the other hundred or so applications that the hospital has purchased over the years place the same restrictions on her, even though she probably was trained on many of them. I doubt not.

  5. 23
    Working Stiff Says:

    @MaryAnn – so who exactly paid for your 2 Epic certifications? While I may not agree with all of the Epic employment restrictions, do you not have any sense that you might actually be exhibiting a lack of integrity towards your current employer by taking the training that they paid for to another employer? Or is the concept of loyalty too quaint to be a consideration in this debate?

  6. 22
    Lazlo Hollyfeld Says:

    It baffles my mind how employee in any industry could agree with the use of a minimum 1-yr non-compete by an employer especially in the manner in which Epic tries to enforce it. One of the few times I am for trial lawyers who find a convenient federal court district and bring a class action lawsuit against Epic.

  7. 21
    DrM Says:

    I have a bunch of friends who have recently left the employ of an Epic installation site (i.e., they weren’t consultants or Epic employees) and they’ve had no problem finding work either at other sites or at consulting firms, and were hired specifically for their Epic experience.

    There’s two things that employees doing this need to consider:
    1) If they want to get hired at another site, that site might be risking part of their “good install” credit by hiring them. Two solutions: get an off-the-books offer, quit your existing job, get a formal offer the day after = no problem; go to a site that has already lost this part of the credit (many have), or doesn’t care (it’s not much money anyway).
    2) Consulting firms are going to be pickier about hiring you because the fear of pissing off Epic, but they still will if they’re in dire need, and most of them are for most Epic positions.

    The market has already shifted on this, and it works against Epic. Epic has become so popular that Epic certified build skills are essentially non-existent on the market, and all the consulting firms and install sites are desperate for certified staff and will hire them anyway. Epic can’t do anything because they can’t sever ties with any of the big consulting firms without shutting down several of their ongoing deployments. I predict this whole non-compete nonsense is going to have to vanish completely, or Epic will be shooting themselves in the foot.

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