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July 29, 2013 Editorials No Comments

GAO: Fed IT projects need aligned management

The Government Accountability Office releases a report chiding several government agencies for their failed IT projects and project management methods, including the VA/DoD iEHR project and the FDA’s MARCS program. The report says, "the federal government has achieved little of the productivity improvements that private industry has realized from IT” despite $600 billion in federal IT spending in the past ten years.

Oregon Health & Science University notifies patients of ‘cloud’ health information storage

Oregon Health and Science University is notifying 3,000 patients of a data breach after IT staff discover that medical residents have been using Google spreadsheets to help track patient care. The spreadsheets were password protected, but because Google was not a business associate with a contractual agreement to store OHSU patient health information, patients are being notified.

In leaving, Siemens CEO seeks to take down chairman

Seimen’s CEO Peter Loescher has reportedly agreed to step down from his position four years before his contract is up, but only if board chairman Gerhard Cromme is fired with him. Loescher is being forced out because of consistent weak financial performance.

HCA’s Bracken to Retire from CEO Role, Will Remain as Board Chair

Richard Bracken, CEO of HCA, will retire from his position at the end of the year and continue on as chairman of the board. He will be replaced by current president and CFO R.Milton Johnson. Nashville-based HCA is the nation’s largest hospital chain.

Despite Your Resolutions, I Know What You’ll Be Doing at HIMSS

February 20, 2008 Editorials 2 Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in February 2007. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

Punxsutawney Phil aside, you know spring is at hand when it’s time for HIMSS (already?) For those of us who go, it seems like the entire healthcare IT industry is there, most of them angrily checking their watches in the Starbuck’s line or barking self-important cell phone commands to their holding-down-the-fort underlings back home.

If you’re not going, don’t feel bad. It’s a great time to get work done without being interrupted, much like the dead week between Christmas and New Year’s. Or, if your boss will be there and you’re so inclined, to screw off with little fear of detection.

Everyone heads for HIMSS with a firm agenda, pledging this year to get serious work done instead of wasting time like at the previous ten conferences. Demos will be dutifully studied, job-related networking will be pursued, and vendor relationships will be cultivated for the benefit of the employer picking up the tab. You’re here to work. Or, so the rationalizing goes.

All those worthy goals evaporate once the first heady breath of conference air is inhaled deeply, that energizing tang of carpet cleaner, coffee, collateral, and cologne that puts you in conference mode. Like a recovering alcoholic vowing to take just one sip of beer, you’re off the wagon. Before you know it, your agenda looks more like this:

  • Plan shopping, golf, or spa time from the tourist literature left in your hotel room.
  • Find someone before or during the opening reception who might give you a drink ticket they don’t need.
  • Walk the halls trolling for people you know, encouraging a hearty greeting and keen interest about what you’ve been up to, then silently cursing the arrogant jerks when they pass by with a vacant stare.
  • Look soulfully into the eyes of vendor booth people and speak profoundly and positively about whatever they’re selling, hoping they’ll dig deep under the counter to furtively slip you an invitation to a really cool party that’s not open to the masses.
  • Expect profuse chumminess from booth people who pretend to remember you and harbor no ill will from that time you cut their product from the shortlist.
  • Decide just how much honesty everyone else applies when completing their CE forms, figuring that walking outside an auditorium door and catching a couple of words should be worth the full CE credit.
  • Blame the speaker’s boring delivery when you decide to bag their talk 15 minutes in, climbing fearlessly over the entire row of knees, in front of the projector, and against the tide of incomers and door-standers, figuring no one knows you anyway.
  • Check the agenda and decide to sleep in, leave the afternoon sessions early, and maybe sit out in the sun at lunch.
  • Thrust your chest out proudly, knowing that booth people will pretend to be impressed with your title, your employer, and your town, even though they are silently sniggering at all three and looking over your shoulder for a better prospect or an incognito competitor who might hire them.
  • Cruise the perimeter of the larger booths, trying to catch the eye of someone who looks like a doctor, executive, or hot rep, steering a wide berth around low-ranking losers who earned a HIMSS trip for some geeky company accomplishment like programming.
  • Gather lots of vendor material for take-home study, then chuck it all in your room’s trash can before you leave for the airport.
  • Having already planned to skip the Thursday sessions since everyone else does, call the airline on Wednesday afternoon to see if you can get out earlier.
  • Wear your Mardi Gras beads home, bring your kids crappy booth junk, and impress the spouse with fake doubloons and a box of Café Du Monde beignet mix purchased at the airport.

Have a safe trip to New Orleans.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.


Maybe Hospital IT Should Embrace a Non-Punitive Culture

February 13, 2008 Editorials 2 Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in June 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

Hospitals realized several years ago that medication errors are rarely the simple screw-up of a single nurse, pharmacist, or physician. They occur because an organizational system of assumptions, processes, and communication fails, the so-called “Swiss cheese effect” whereby a number of usually self-correcting practices sometime line up unfavorably like the holes in Swiss cheese. That alignment of individually unusual circumstances causes errors.

Knowing that’s the case, it doesn’t make sense to fire someone involved in a medication error. The underlying system is still broken. Disciplinary action also discourages others from reporting their own mistakes and near-misses, thereby depriving the organization and industry of the opportunity to learn from them.

Maybe we should think that way in hospital IT. We’re still stuck in the old “fire everyone involved” mindset when projects fail, which is disturbingly often. Software implementation is simply business change with a technology component. Therefore, when a project deviates from expectations, it doesn’t make sense to have a knee-jerk firing of the IT project manager, the CIO, or even the vendor. Supporting cast changes won’t improve the flawed underlying system that allowed them to fail.

A non-punitive IT culture would acknowledge that all executives, not just those in IT, bear responsibility for the success of business changes involving technology. It’s their job to support process change, contribute resources, and participate in project decisions. The kickoff meeting doesn’t happen until they’re on board and they don’t get to go incognito when the project blows up and the CIO lynch party is being formed.

Some of the worst CIO and vendor behavior involves rationalization and ass-covering once projects have failed spectacularly, much like the nurse who kills a patient through a mistake not entirely under his or her control. We’ve built incentives for people to keep quiet, to dodge blame, to avoid risk, and to criticize others. Eventually everyone gets tired of the finger-pointing, so the only remaining task is to ban mention of the project in polite conversation, at least until the same mistakes doom the next one.

When it comes to IT projects, hospitals are more like surgeons than internists. Cutting is the cure: the vendor, employee, or consultant must be removed and publicly blamed to provide closure. Everyone must believe that lessons have been learned and the chances for future success increased. To admit otherwise would require a lot more self-analysis and work, and after all, Men of Action believe in their keen ability to simplify complex problems and fix them with quick, skilled incisions.

We make a lot of mistakes, many of them eminently preventable if we could just learn collectively. Most of them are quietly buried away, often taking a few careers or contracts with them.

Hospitals are mostly non-profit and non-competitive. Maybe we could improve our odds of IT success by sharing our misses and near-misses just like we do for medication errors.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Charlie McCall 1, Pre-HBOC McKesson Shareholders 0

February 6, 2008 Editorials No Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in November 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

I didn’t even know Charlie McCall was on trial. The former HBOC chairman was acquitted of one securities fraud charge last week and got a mistrial on six more as a lone juror’s holdout deadlocked the jury. I feel deprived that I missed a blow-by-blow report of his being grilled and then left to await his fate.

Federal prosecutors had worked their way up through the HBOC food chain over the years, leading everyone to speculate: wonder when they’ll get Charlie?

In case you’re a newbie, HBO and Company was the pre-Enron corporate malfeasance poster child, a prodromal symptom of dot-coms in waiting that used its optimistically valued stock to buy everything in its path. The frenzied transacting caught the attention of drug wholesaler McKesson like the mating dance of a spider, which paid a mind-boggling $14 billion for the company in January 1999.

Industry long-timers chuckling knowingly, having watched similar companies take it in the shorts for the same expensive, ill-advised healthcare IT dabbling. Investors scratched their heads after running their calculators and finding no possible way that HBOC was worth that kind of money. The general consensus of all interested parties: what the hell was McKesson thinking? Three months later, McKesson’s stock tanked on charges of book-cooking by Charlie’s crowd. Shareholders lost $9 billion of value in a single day, thereby forcefully proving the true value of HBOC.

McKesson’s executives were perhaps the only people on the planet who weren’t suspicious about the Atlanta high-flyers. Everyone was swapping insider stories. I sent two anecdotes to a healthcare IT publication in 1998 (who missed out on the scoop of the century by ignoring them.) First: I’d heard from an HBOC employee that he was ordered to mail out empty tape boxes to customers for not-ready enhancements so revenue could be recognized anyway. Second: programmers were griping about the HBOC revenue quotas each was assigned (!) since all the Y2K remediation revenue had already been booked by late 1998, leaving the programmers to scramble for new bookings while doing the already-committed work. Recognizing revenue on the basis of a shipping receipt? Oh, my.

You know how it ended. HBOC’s brass were indicted, McKesson’s were fired. Charlie went off sailing (so the story goes.) The reeling McKesson lost many employees, came up with strange ideas like co-CEOs, jumped on the dot-com era right as it imploded (taking with it hastily conceived names like i-this and e-that), and retired the stench-ridden Pathways name. Throw in the nearly $1 billion they eventually paid to settle shareholder lawsuits and the grand total for those few weeks of consensual coupling is $10 billion. What they got for their trouble was a mongrel pack of products that Charlie had hastily snapped up without having any real plan except to keep the printing presses running off stock certificates.

Among those involved were certainly some crooks and some fools, but let’s not forget those who suffered most, those McKesson lifers who had stashed away years’ worth of shares of their unexciting company’s stock instead of risking it on flaky enterprises like Microsoft and Dell. When lonely old conservative widower Dad McKesson brought home a sexy young step-mom named HBOC, she stole the kids’ piggybank. The stock went from the mid-80s to the mid-teens. People I knew glumly tried to estimate how many more years they’d have to work until retirement, with 80% of their investments gone. Even today, after eight years and with good company management, McKesson’s stock has recovered only by about half.

Only the jury can decide whether Charlie McCall and his associates are guilty or innocent, but I can say one thing: if they are found guilty, then I hope the pain they receive is commensurate with the pain they caused.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission.  To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update.  To subscribe, please go to:  https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Conglomerate Vendors 101: Healthcare IT Customers Carry Little Weight with Corporate Toe-Dippers

January 30, 2008 Editorials No Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in October 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

I doubt most Misys Healthcare customers are following the company’s corporate drama as it plays out in England. They want to go private. Wait – no, they just want to sell it to someone! The CEO will lead a takeover group. Hold on, he just resigned! Their board chair is optimistic about their prospects. Shhh … did I just hear him say the company’s software was old and non-competitive?

Healthcare makes up about a third of the Misys portfolio. Within that, the lineup is a salad bar of old, mixed-heritage applications from Per-Se, Medic, Amicore, Payerpath, and Sunquest. Sometimes the blended family gets along, but often they don’t (and I’m speaking both technically and culturally.) If you know of any healthcare IT conglomerates where any of the above isn’t true, that makes one of us.

Why did a British financial software company get into the US healthcare IT market in the first place? Well, let’s just say it wasn’t a noble desire to better humankind. From their website, “The main objectives were to reduce the Group’s exposure to a single market (insurance) and to increase its size in an already consolidating software sector.” That’s about as passionless as an accountant’s nimble calculator fingers determining the net present value of three dinners with Myra the secretary vs. the potential payout.

With just two software sectors, Misys is focused, at least compared to bigger conglomerates that dip 1% of their corporate body (a toe) into the healthcare waters. Since Misys is the only company actively considering deconstructing healthcare IT out of the soup, what can we learn?

  • The best way to make money as a conglomerate is to break it up into parts that are usually worth more than the whole and are more affordable to prospective bidders.
  • Conglomerates often reduce corporate value unless they can harness some elusive benefit in supply chain management, reproducible management excellence, or marketing.
  • Conglomerates are fine until you want to sell to someone else who doesn’t share your love for some of the corporate children.
  • Product investment matters more than that impressive brand name. You may be getting free milk every day, but at some point, you better start saving up for a new cow.
  • In most cases, button-down corporate management saps out the innovation that made formerly independent companies interesting and successful in the first place.
  • Healthcare IT divisions of big companies live and die by the quarterly (or twice-yearly) numbers. Ambitious division executives will sell their souls to avoid being called out as company laggards among their peers.
  • Healthcare IT customers carry little weight with toe-dippers. Are GE brass more worried about the flat-lining former CareCast or sagging toaster sales at Wal-Mart? Does patient safety come up in Siemens corporate meetings as often as power generators?

Just about every outcome suggests that Misys Healthcare will be carved off and sold. If you’re a foot soldier, hang in there at least long enough to see if the change benefits you. If you’re a suit, well, Misys publicly labeled its healthcare unit as underperforming, which isn’t a highly valued resume bullet for the new owners. If you’re a customer, anything or nothing could happen, but you’re stuck either way. If you’re a prospect, there’s a lot of uncertainty ahead, so act accordingly. And if you’re a vendor focused only on healthcare IT, especially if you’ve resisted the urge to cash out by going public, I say thank you.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Leapfrog’s Big Leap Into Irrelevance

January 23, 2008 Editorials 1 Comment

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in October 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

I remember sitting in a hotel ballroom back in 2001 or 2002 hearing about The Leapfrog Group for the first time. I was both energized and worried. I liked their idea of pushing a short list of evidence-based quality measures for hospitals to follow. However, I was worried that my own hospital employer might not be able to meet their expectations, thereby raising the ire of the big-employer healthcare dollars behind Leapfrog.

Leapfrog didn’t sound like someone to mess with. The post-dot com era would be bleak, with too many hospital beds competing for the business of the newly savvy baby boomer consumers, capable of making shrewd healthcare decisions because they’d ordered books from Amazon.com.

If the IOM’s “To Err is Human” was embarrassing, Leapfrog was threatening. Their changes were downright prescriptive, encouraging no debate or deviation, and backed by the folks who pay the bills. Experts in their individual Leaps howled to see the evidence behind their choices, but it was not forthcoming.

Somewhere along the line, Leapfrog fizzled. Nowadays, they’re a quaint anachronism. Their role seems mainly to trumpet the accomplishments of other groups on their website.

In fact, I just compared their Members webpage with an archived version from 2004. Today’s count: 44 members. 2004’s count: 152 members. Among the missing: Allscripts, Cerner, Eclipsys, McKesson, Misys, Siemens. I hope no one got hurt in the mass exodus.

A new Leapfrog press release illustrates how little influence they have. They did a study that found over 90% of hospitals have ignored their CPOE mandate. Over 90% don’t meet their standards for two surgical procedures. 70% don’t use intensivists in the ICU as Leapfrog demands. Are they suffering from the financial retaliation of Leapfrog’s few remaining members? Not that I can tell.

Also unfortunate was their inclusion of Indianapolis’s Methodist Hospital as one of their Top Hospitals of 2006, fresh off headlines detailing the deaths of three newborns there due to a medication error. That could have happened anywhere, but the timing was terrible for Leapfrog. To cynics like me, that was yet another indicator of their irrelevance.

I’ll leave other experts to comment on some of the widely ignored Leapfrog standards, but I’m not about to pass up the chance to point out how ridiculous their CPOE requirement is.

CPOE prevents few patient errors. It prevents mistakes, but mostly those that would have been caught anyway by skilled professionals, such as transcription errors and clinically questionable orders. Just about every study done by AHRQ and others have said exactly that: there’s nothing wrong with CPOE, but just don’t expect it to make much of a difference in patient outcomes, particularly considering its immense cost and failure rate.

Leapfrog should have been smart enough to steer clear of the CPOE bandwagon. Maybe they didn’t look around at the available products, small in number and large in functional deficiencies. Maybe their healthcare IT members twisted their arms to sell a few CPOE systems by mandate. At any rate, Leapfrog’s urgings probably sold a lot of CPOE systems, but their own survey shows they aren’t being used. Millions spent with little to show for it, apparently.

It isn’t that healthcare won’t change, it was just that Leapfrog didn’t do it. For those making it happen, check out Don Berwick’s Institute for Healthcare Improvement. If you want to see research in action, look at AHRQ. If you want to see cutting-edge informatics, consider Kaiser or Intermountain Healthcare. For mass market mandates, even JCAHO’s core measures are getting the word out. And if you want to see a group living in its own formerly large shadow, check out Leapfrog.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Happy New Year – Now Get Back to Work

January 9, 2008 Editorials No Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in January 2007. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

Happy New Year! Considering the alternative, be glad that you were alive and well enough to eat and drink too much over the past couple of weeks. Now get back to work!

You’ll notice your local newspaper, having slyly given many of the real news staff time off for the holidays, is padding out their already-slim editions with time-insensitive material written in advance or copied off the wire services: witless phony New Year’s resolutions for local politicians, tired rosters of the biggest local stories and celebrity deaths of 2006, and pleas for donations to community causes.

I can see why. Healthcare IT news is sparse this time of year. No one wants to bring out new products, start implementations, hire or fire people, or make changes in the strategic plan when no one is paying attention (hmm: that would actually be good time to announce bad news, wouldn’t it?)

If our industry was a sport, the season would actually begin at the HIMSS conference in late February. It sets the tone for the year to follow, as everyone saves up positive announcements to coincide with the annual bacchanal. Vendors who make a bad impression at HIMSS will find it difficult to recover throughout the year, with attendees critically evaluating their demonstrations, booth size, staff attire, and cheery spirit or lack thereof. Even those companies in imminent danger of collapse spend the equivalent of a small country’s gross domestic product on one glorious, go-for-broke HIMSS splash, hoping against odds to get their money’s worth in new business.

Hospitals, too, get busy after months of letting IT projects lie fallow. No wonder ROI is hard to come by when projects come to a screeching halt because of non-IT staff refusal to get involved during (a) the November to January holiday block; (b) summer vacations; (c) school spring breaks; (d) impending JCAHO or state inspection visits; and (e) local, state, or national conferences involving anyone remotely involved. No wonder implementations take forever – they’re on hiatus half the year.

CIOs have plenty of work to do. All those clinical systems projects still need to be finished. Celebrate the completion of major phases with some downtime and reflection, don’t forget to keep pushing at needed process changes and system improvements, and then jump into the next round of work. Clinical systems projects are like painting the Golden Gate Bridge: they’re never finished.

Speaking of clinical systems, if you haven’t yet made a commitment to bedside barcode verification of medications, then now’s the time. Same, too, with tightening up your Pyxis access with biometric security, override vigilance, and double-checked stocking procedures.

Microsoft has a new operating system and Office version – yay! Users will be upgrading at home, scornfully wondering why your IT department is holding them back in the Stone Age with systems they shamefully underuse anyway. You needed that non-strategic headache, right? At least PC hardware keeps getting cheaper, right about the time Vista will eat up more of it.

RHIOs will want your attention in 2007. Your data, too. Maybe now’s the time to catalog all the electronic data elements you have available and to develop a plan to move important paper-based ones to electronic formats.

If you haven’t already, let one of your computer geeks play around (officially) with Linux, both server and desktop. If you aren’t running it at all now, you will be soon.

Stark relaxation means you may need to support a new class of impatient, computer-illiterate users: doctors in private practice and the inconsistent employees they hire. Keep stats to get budget dollars since those support hours have to come from somewhere.

Lastly, if you’re in management, please make sure to recognize and reward those who work for you. When you get too full of yourself, make a list of which essential personnel would be needed in case of system failure, natural disaster, or clinical emergency. You’re probably not on it.

I hope our industry and all of us working in it have an excellent 2007. If in doubt about a particular course of action, remember WWIWAAP (which you may pronounce WEE-WEE-WAP, since I just made it up): what would I want as a patient?

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Can EMRs Moonlighting as Research Databases Sweeten Their ROI?

December 26, 2007 Editorials 4 Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in December 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

I’d never heard of the Clinical Data Interchange Standards Consortium (CDISC) until last week. That’s when that group announced the kickoff of a new interoperability project, this one involving linking EMR systems to the information systems of clinical investigators who are performing drug or disease research. The audience might be researchers, the Centers for Disease Control and Prevention, or registries for patients or disease. The IHE is involved in the testing and will demonstrate the results at the HIMSS conference.

I’m not usually interested in this sort of project. I’ve seen first-hand what an insurmountable effort it can be just to get hospital systems to swap clinical data across the hall, much less with national third parties. Still, this is an exciting indicator of how quickly the now-common idea of interoperability has taken hold. If nothing else, RHIOs have made hospitals think about the value of their patient information and how to exchange it in a standard electronic format.

Getting and keeping drugs and devices on the market is expensive and information-intensive. Several small, highly profitable companies have sprung up to help enlist patients in studies, to do the rigorous paperwork required, and to design research methodologies. Their key commodity is information.

Hospitals have patient information that’s available nowhere else, the kind that arouses researchers and manufacturers with far deeper pockets. Repurposing that existing information by making it available to those willing third-party customers, even when motivated purely by mission-supporting cash, is at least more beneficial to society than running a McDonald’s or building medical office buildings.

Let’s say your hospital implements a well-integrated, information-rich EMR system that can easily tie together everything about patients from medical history to demographics to procedure history. Suppose you add genomic data to the mix, storing information about family history, lifestyle, and a longitudinal history of disease, treatment, and outcomes. All of that could be used to the advantage of your own patients and institutions, but it has an equally high value to those third parties trying to assemble or execute big research projects.

Drug companies and device manufacturers need the data that lives in your clinical systems. How else will they be available to target research to a very narrow range of patient types, maybe even those with a specific genomic profile? It could help them identify appropriate research subjects, design post-marketing surveillance, study population-based outcomes, and catalog adverse events. The information you provide could either be de-identified or made available only if individual patients opt in. The benefit to patients is access to a wider variety of treatments and protocols, most likely free to them if tied to a research project.

You wouldn’t just give that information away, of course. Hospital information is far deeper and more detailed than what’s available from any other source, with a wide scale to match. All you need is sophisticated EMR functionality and a relentless push to get every scrap of clinical information codified, categorized, and cross-referenced.

In the movie Wall Street, Gordon Gekko says, “The most valuable commodity I know of is information.” That is true of clinical data, especially when those who value it can afford to pay. Just don’t sign away too cheaply the rights to your treasure trove of data, even if the interested customer is a RHIO or third party data vendor.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Today’s First-Generation Decision Support Systems: Not Yet Able to Turn Doctors Into Sheep

December 20, 2007 Editorials 4 Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in July 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

My colleague Ross Koppel, a sociologist and Penn professor, wrote an editorial in The American Journal of Managed Care (released today) titled “Defending Computerized Physician Order Entry From Its Supporters.” In it, he stresses that CPOE and clinical decision support systems (DSS) are separate systems, despite popular perception. Their implementation is often divergent and their benefits and shortcomings confused (or intentionally misrepresented).

Ross is right, and his sociologist’s view is important to our little world of geeks and IT-friendly doctors. We’re expecting a lot from immature CPOE and DSS systems that most hospital executives can’t define, even when they’re plunking down hard-earned capital dollars for them.

I should mention that Ross wrote another article awhile back that riled up vendors, consultants, and HIMSS, in which he described one hospital’s increased error rate with CPOE implementation, finding that his one, small discouraging word was met with choruses of indignation from the “CPOE is Nirvana” crowd.)

CPOE is a smart typewriter that, standing alone, has little ability to improve patient outcomes. It prevents transcription errors, although those seldom harm patients because they’re caught anyway. CPOE makes it easy to choose common order defaults instead of “winging it.” Beyond that, the benefits (both clinical and financial) come from DSS, not CPOE, even though the hospital executives signing a multi-million CPOE deal as their cornerstone of patient safety automation probably missed that point completely.

DSS systems are, unfortunately, mostly frightfully immature, even more so than CPOE. Early adopters share war stories of sky-is-falling alerting, inflexible third-party rules, the inability to customize and personalize, and performance-sapping rules engines incapable of delivering alerts of any more sophistication than the old hard-coded screen edits.

Still, the real problem is right down Ross’s alley. Hospitals usually buy CPOE and DSS because they’ve failed to control physician behavior otherwise, often euphemised as “reducing practice variation” or “practicing evidence-based medicine.” They want software to do the dirty work that they can’t or won’t: telling physicians that they’re wrong and forcing them to change. When docs don’t follow the new cookbook medicine rules any better than the old ones, CPOE and DSS get the blame and everyone involved in the project pretends to have been somewhere else when the vote was taken to buy it.

I’ve been involved in two CPOE/DSS implementations, both involving large IDNs and well-known vendors. In both cases, hospital administration ill-advisedly shot their patient safety technology wad on CPOE, confident that it would improve patient care better than any other investment. Physician adoption was universal in one, minimal in the other, but one element was common to both: 90% of the expected DSS benefit never materialized. The carefully but naively drawn up list of post-implementation metrics was hidden away once everyone realized that we hadn’t really changed anything of importance for our multi-million dollar investment. We had bought ourselves a smart typewriter.

No software contains a switch that turns resistant physicians into docile, rule-following sheep who make better decisions under the watchful eye of Big Brother’s can’t-miss medical guidelines. But if your hospital has already spent a few million on CPOE and DSS thinking that was the case, you’ve learned that already.

Maybe the next generation of systems will offer value that physicians recognize. After all, they want the best outcomes for their patients, too. Where they disagree is that we have the answer right now with these first-generation CPOE and DSS applications.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission. To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update. To subscribe, please go to: https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Want To Anger a Nurse? Make Smug Comments about Grocery Store Barcoding

December 12, 2007 Editorials 5 Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in February 2007. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

One reason we hospital IT types aren’t taken seriously is the “grocery story” analogy. You know, when some well-meaning government official, non-healthcare CEO, or your next-door neighbor smugly proclaims, “There’s more automation in the grocery story checkout line than in most hospitals.” Ha, ha, what an insightful observation – first time we’ve heard that one.

Randy Spratt, McKesson’s CIO, recently trotted out the old warhorse in an interview with Fortune. I’m sure his intention was benign (i.e., “buy more of our barcoding stuff to enlarge my executive bonus”) but perhaps his lab systems background makes him insensitive to how steamed nurses get when someone trivializes the barcode verification process on their end. If it were easy, everyone would be doing it.

(Hint to Randy: those same nurses are often involved in barcode system selections, with one of their possible choices being your employer’s own AdminRX product, currently running last in a three-horse KLAS barcoding product race. Better stroke them a little next time.)

Ann Farrell, BSN, RN and Sheryl Taylor, BSN, RN sent me a list of why the grocery store analogy is not only inappropriate, but offensive to nurses. Their list was detailed, persuasive, and passionate, so naturally I decided to go more for the ironic and humorous with my own imitative list. Theirs will be published, I believe, and they’re working with HIMSS people and that same Fortune magazine. Until their more authoritative tome sees daylight, this will be your amuse-buche.

If grocery stores were like hospitals:

  • They would buy Doritos by the bag, but would have to repackage and label individual chips, and then track every chip – who bought it, who ate it, and whether they ate it in an appropriate quantity and with only complementary foods and according to dynamically calculated nutritional needs.
  • They would have to set up an internal barcoding factory since grocery makers would refuse to barcode their products until all stores collectively agree to pay extra.
  • Each clerk would serve 15 checkout lanes simultaneously.
  • Every customer would enter the store at precisely 9:00 a.m., 1:00 p.m. and 6:00 p.m., but having any of them wait more than 15 minutes is a fireable offense.
  • It would be the clerk’s job to prevent customers from buying both Doritos and potato chips since they serve the same purpose.
  • Barcode scanners would be so poorly designed that clerks would need a full two days of training to use them.
  • Stores would not be self-service. Instead, clerks would take the customer’s list, try to decipher their illegible handwriting, and run around the store to assemble several such orders for different customers at the same time. Each item would have to be documented twice: one when pulling it from the shelf and again when giving it to the customer. Customers would be encouraged to change their lists constantly. Most stores would not have the capability update the clerk’s list electronically, so items would be scratched off and handwritten on the same ratty sheet of paper.
  • Somber-looking inspectors could show up unannounced demanding to see a list of customers who bought hot dogs in the last year or the complete grocery purchases of a specific person named John Smith, but only the right John Smith.
  • Clerk supervisors, exasperated over loss of productivity, would suggest keeping paper copies of commonly used barcodes to save time over scanning the real thing.
  • Instead of wheeling their cart to the checkouts, customers would ring the little “I need help” button wherever they happen to be, requiring the clerk to lug the cash register to their location to scan their item.
  • The loyalty card of every customer must be scanned before selling them anything, even if they showered with it and ruined the barcode.
  • Soda would be sold like paint – the clerk would have to mix and label whatever flavor the customer wants using stock ingredients.
  • Once barcodes are scanned, instead of being recorded electronically, the information would print a duplicate receipt to be filed forever.
  • Clerks who ring up the wrong price could kill the customer, would be barred from future clerk jobs, and could be jailed.
  • When working alone in a 24-hour store after everyone else has gone home, the clerk would cut meat, mop the floors, make pastries, unload the truck, show compassion, attend to family needs, and humor abusive superiors who take credit for accomplishments that mostly occurred while they were offsite making ten times what the clerk is paid.


This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission.  To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.


Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update.  To subscribe, please go to:  https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Contracts Need Penalties: Sullying the Honeymoon Bed with a Vendor Prenup

December 5, 2007 Editorials 12 Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in February 2007. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

As a hospital IT person, I would never sign a vendor’s software contract without protecting my organization with a variety of specific and severe contractual penalties. From recent Inside Healthcare Computing articles, many or most hospitals sign penalty-free contracts. I’m shocked. I like vendors, but money makes people (and companies) behave badly.

Vendors (software or otherwise) can tell you anything they want about their product’s performance and reliability. That can have one of three possible outcomes:

  • If the company is both knowledgeable and honest, you will be pleasantly unsurprised when their product works as advertised, but at least you won’t be caught unaware by a major meltdown. That’s the best outcome.
  • If the company is honest but doesn’t have broad enough experience with their product in a setting like yours, you’ll probably be miserable together, hoping they’re as responsive as they are honest. That’s bad. Sometimes you hit architecture or design flaws that can’t be fixed.
  • If the company is lying or has wildly oversold their wares, nothing else matters because you’ve been suckered into a long-term, expensive, and contentious relationship with a company that has already demonstrated its willingness to take your money under false pretenses. That’s the worst.

For all three outcomes, your first line of defense is due diligence. Don’t whip out your checkbook until you’ve taken extensive site visits (of your choosing, not the vendor’s), performed acceptance testing, and documented every promise and important capability in a binding contract. Buying from a demo is just plain stupid.

The biggest mistake hospitals make is finding problems with previous implementations, but then buying the product anyway. The most common rationalization: “We’re smarter than those rubes who couldn’t make it work, plus we really like the product and the salesperson.” That combination of naiveté and misplaced bravado has lined many a sales rep’s pocket. It often benefits an executive recruiter, too, since the CIO who ignores a product’s well-known, spotty history often has plenty of free time to reflect after he or she has been shown the door.

Vendors may not be thrilled to see the list of penalties you want, but they’re not your best buddies. They’ve got their best possible price and terms. So do you. You both have the same job: to meet somewhere in that middle ground after fighting over what’s left between those numbers.

You can be chums when selecting a product and again after buying it, but not while the deal’s on the table. If the vendor doesn’t hate you during that time, you’re not pushing them hard enough.

Contracts without penalties are binding only to the customer. If the software fails to provide value, crashes constantly, or can’t be used like you were told, you still pay unless you were smart enough to write in penalties. Your want their skin in the game with yours.

The most important eventualities to cover with penalties:

  • If the software doesn’t do what you were promised in a way that makes it unusable.
  • If you have problems that will cause you the most harm: downtime, poor response time, or cancelled development plans.
  • If the software or vendor has weak areas that sound like trouble. If the vendor’s teeth clench up when you lay out penalty terms for failing to deliver a richly functional ED package or a CPOE-to-pharmacy interface, maybe they don’t really plan to.

Penalties and payments go hand-in-hand. Your contract should require lots of the former and none of the latter if performance slips. Without penalties, you have no leverage. Vendors know you won’t yank a CPOE system if they have a major bug that could cause patient harm. A hard-hitting, predefined penalty is your best hope for getting their undivided attention to fix it. The cash won’t be much consolation, but it’s a hammer to hit the vendor over the head with.

I know we all like to throw harmless little love words around like “partner” and “shared vision.” Vendors pretend to be wounded when you sully the honeymoon bed with legal assurances. Take a lesson from Paul McCartney – maybe the vendor is a wonderful partner who loves you for something other than your money, but make them sign an air-tight prenuptial agreement just in case. Secretly, they’ll admire you for it.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission.  To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update.  To subscribe, please go to:  https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

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Reader Comments

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