Hardly an HIStalk posting goes by without an insightful commentary by The PACS Designer. TPD always seems to be up to speed on various emerging technologies, particularly in the PACS world. I was curious to learn what made him tick and was able to have a chat with him recently. Thank, TPD, for sharing your story.
Inga: How did you select the name The PACS Designer?
TPD: Since I have been working in the medical field for years and designed a PACS system in the mid-90s with some great partners, I thought, why not use the name as a blogger? I am also trying to promote PACs. Shahid Shah encouraged me to blog. I am an electronics engineer and wasn’t really working in the PACS area but found an opportunity. I got to like what I was doing and some good things happened out of it.
When did you first begin reading and posting on HIStalk?
I first started about two years ago, when Shahid Shah from Shahid’s Perspectives and creator of HITsphere told me about it. I decided to get involved with blogging. I love teaching people. In my prior job, I taught courses in PACS and other medical technologies and even did SAP software teaching.
What was it about HIStalk that interested you?
I thought the style was good, because sometimes you see blogs where the posts are very infrequent. But HIStalk had the right formula to get people to respond to the posts in the Web 2.0 sense. It promotes 2.0 through interaction. Bloggers are becoming an important part of society, as everybody knows.
What about your background has made you an expert in HIT in general and PACS specifically?
I worked with PACS behind the scenes in design. Before that, I was a purchasing manager and I always knew the latest technology. The combination of purchase evaluation decisions and designing helped me, development-wise.
I love technology. It is a small point, but in 1958 my mother bought me a transistor radio that came from Japan, made by Matshushita, now better known as Panasonic. I got so fascinated with the transistor radio that I decided to go into an electronics engineering program. I’ve been an electronics buff ever since. It is really becoming a digitally connected world and that is where healthcare needs to be.
So, what really got me into PACs goes back to the 1980s, when hospitals were using telephone technology with PACs and it was a very slow teleradiology. In the late 1980s, a company my employer partnered with discontinued their product line, so it killed our product line. I was looking for ideas for the next version of PACs and eventually hooked up with a company to design the next generation of radiology PACs.
What did you do after helping to design the radiology PACs systems?
I looked at how we could help cardiology. I designed a cardiology PACS that has had good success and is used all over the world. I am proud of both things, the radiology and cardiology products, but I am proud that the cardiology images in the cardiology PACS I designed can be viewed all over the world with the PACS I designed.
What do you do professionally today?
Today I am an independent healthcare software developer, working with major universities and vendors on the next generation of software.
PACS software?
Not just for PACS, but Web-enabled software solutions that are available by accessing a Web browser. No software is loaded on your PC. It’s downloaded to you just like YouTube is. Healthcare is going to see a lot more of that technique in the next 10 years.
So you are hired by the different universities to develop applications?
Yes, to do integration of DICOM, HL7, and Java technologies to create Web-based solutions for healthcare.
Do you find your current job rewarding? Fulfilling?
I love delighting my customers and really like innovation and like to pursue it with excellent partners that will make customers happy with the end result. I will be starting a major project with a Top 10 university next month. 2007 is turning out to be a transition year for technology that is going to excite end users.
I am also a member of the ASTM International. I’m a member of the E31 Health Informatics Committee that developed the Continuity of Care Record. The E31 Committee that created the CCR used the Massachusetts Patient Care Record that had been used for many years as the basis for the CCR. I am still on the committee and another health informatics committee called Privilege Management Infrastructure to design enhanced security for HIPAA so users only see information that they’re entitled to see.
HIPAA is great, but there is a lot of structure out there that needs improvement, security-wise. The ASTM PMI standard will be coming out within the next year or so.
Do you actually meet with your fellow ASTM members?
We work remotely, but I get all my information sent to me over the Internet. I approve or disapprove information online. It is very interactive, but it is all done remotely. They do meet in person, but I’m very busy and don’t have the time and funds to travel all over the place.
I believe I have noticed that you have posted on other blogs.
I randomly contribute to others. Do you want to know some of the other blogs I read and post on?
Sure!
The Healthcare IT Guy, Shahid Shah. He got me started. LabSoft News. Dr. Friedman is very good at presenting concepts and I like his highlighting techniques. Dalai’s PACS Blog. He is a radiologist who is a very good blogger. Candid CIO. Will Weider lets us know what’s happening in the real world of healthcare IT, which I enjoy reading, and then I post comments on his blog to educate his readers. Scott Shreeve, MD. I also like Scott’s blog and we’ve seen his HIStalk interview and the numerous posts about him. Christina’s Considerations. Christina is not as well known yet, but she covers RHIOs, a controversial subject today. HealthBlog from Dr. Bill Crounse at Microsoft. He tries to let us know what Microsoft is focusing on next, like Azyxxi.
HIStalk is the best one, right? [laughs]
Of course! Actually, HIStalk is more consistent about their format. There is a lot of interaction with readers. There is Inga, Tim, and other posters, I was so happy when you joined. It made it better.
Thanks. Well, there are some amazing posters. Next question, how is the PACS world going to change over the next few years? What companies will survive and what will the hot technology be?
PACS is becoming a vital modality as far as hospitals are concerned. PACS takes away the cost of X-ray films, which is a very expensive thing. And PACS is expanding to include a mini-EMR through HL7 interfacing techniques and open software solutions.
Everything is going digital. The patients are becoming more involved. Here is a new term – Digitally Connected Patients (DCP). The patients from home will be able to be wirelessly monitored by the hospital. That will be the next big wave over the next 10 years. Patients who live alone with health problems would definitely want to be connected. We’ll actually see that in less than five years. We already have the ability to send heart rate, blood pressure, and other vitals information from remote locations, such as ambulances in route to emergency departments, and also remote digital storage for redundancy.
The infrastructure of companies will change a lot. With EMR companies, they will be bought up or go out of business because everything is going to be Web-enabled. If you are not Web-enabled, you won’t survive. The EMR and PHR will be a partnership involving the patient, hospital, and doctors all submitting information into the combined record. It will be Web-based and a lot of the EMR companies will need to change their business plans to go Web-based, or go out of business, or merge with larger companies.
EMR/PHR will be viewed similar to having an online bank account. You can call up your account any time as long as you have an ID and password. If you can do it in banking, why not do it in medical?
I didn’t mention this earlier, but XML, Extensible Markup Language, will become a big part of how we capture information. Any time you enter information via a Web browser, you can capture it in XML and store it in an EMR or PHR. Currently I can’t talk much more about this because I am in the middle of a patent application. I have developed a new technique for this.
2007 is becoming a year of major transition because a lot of things are happening and it is exciting for the healthcare field.
You have been in this business a long time. Any plans to retire soon?
I love the healthcare field so much that I plan to do software development as long as I can, no matter how old I am. I am not inclined to retire in the immediate future. I love being independent. I have a great group of partners ready to work with me. Being free and independent lets me innovate the way I want to innovate.
Thank you for interviewing me. Hopefully HIStalk readers will enjoy some of my comments and I hope readers will benefit from them in the coming years.
I ran across Eric Fishman, MD a few months back when I stumbled onto his EHR Scope, a compendium of information about physician system and speech recognition. Ambulatory systems continue to be very hot in the marketplace and it was interesting to find a practicing physician who was putting so much time and expertise into that market.
Since then, Eric has decided to put his full time and attention into his business, which also includes a free service to help physicians choose an EMR/EHR and a package of products and services related to speech recognition for physicians (based around Dragon NaturallySpeaking). Note: I’ll mention as a disclaimer that Eric’s company recently decided to sponsor HIStalk, although our plans for the interview had already been made by then.
Thanks to Eric for bringing me up to speed on the complex world of physician practice systems. Big changes are happening.
Give me some background on yourself, the company, and how you got interested in physician automation.
I’m an orthopedic surgeon. About 14 years ago, one of my secretaries came to my office and said, “I know you like computers. I just took my son to a pediatrician and he was talking to a computer.” He was using a voice recognition product from a company called Kurzweil, which had been started by Ray Kurzweil.
I decided to buy it. Ours was a three-physician office at the time. The $26,000 cost was hard to swallow, so I opened a company to sell voice recognition software 13 years ago. And so the rest is history, although I didn’t want to say that because it sounds overly grandiose. [laughs]
I always refuse to use the term EHR since vendors started using that name in talking about their old EMR products without changing anything. Am I being too much of a stickler?
Yes. I have a treadmill in my garage with a wireless mouse and keyboard and I do a lot of Internet surfing. I don’t call it by the time, but rather by the mile. When I surf, I can do five miles.
John Naisbitt is the author of Future Trends. He made the rational conclusion that what is important to the present and what will be important in the future can be measured by how often items come up in newspapers. I compared “electronic medical record” and “electronic health record” to see how often they showed up in Google. I wrote in an article that the term “electronic medical record” would have become less prevalent when the lines met. Right now, “electronic medical record” is 46 million in change in Google hits and “electronic health record” is 71 million. Three years ago, it was exactly the opposite.
There are subtle distinctions. An EMR is used by a physician in the office to take care of patients. An EHR is more connected and takes care of the community. Connectivity is the distinguisher.
The manufacturer calling it so doesn’t make it so. The terms are very frequently interchanged. I changed the name of my company from EMR Consultant to EHR Consultant in recognition of that change, although you’ll see Word changing EHR to HER. [laughs] In EHR Scope, we talk about how Microsoft Word versions can be corrected to stop doing that.
Notwithstanding all the above, I frequently use the terms interchangeably.
What’s holding back widespread adoption of practice automation?
It’s a few basic issues. Physicians are the ones who pay for it, both with cash and, more importantly, blood, sweat, and tears from the angst of changing how the office functions. Third parties are the ones that benefit, like government and patients. That disequilibrium is disconcerting to many physicians.
I’m a strong proponent of using voice recognition. It substantially minimizes the inconvenience of electronic recordkeeping. It allows physicians to alter the way they interact with patients to a lesser extent.
Despite the significant amount of time and cost, essentially every physician who has been involved with a successful implementation says they would never go back to a paper office, myself included.
I saw recently that a physician insurer is offering a discount for EMR users. Is that common and will that benefit be attractive to fence-sitters?
I believe it’s common. It’s probably not a sufficient amount of money to pay for the software, but it could be meaningful. I was pushing that idea in 1994 with insurance companies to use Kurzweil and structured reporting systems. Physicians who prove they can provide greater quality of care will not only have greater gross revenue due to pay-for-performance, but will also be offered more meaningful malpractice insurance discounts.
Can a one or two physician practice implement a good EMR with reasonable cost and effort?
You used the term EMR either intentionally or not, so I’ll speak to an EMR specifically. Yes. But, you can’t implement a state-of-the-art, easily interconnected EHR with all the bells and whistles and billing capabilities for $5,000. However, if you want to take a substantial step in the right direction and automate reports, absolutely. In fact, a number of those systems are CCHIT-certified, surprisingly.
Speaking of CCHIT, is it accomplishing what it was intended to accomplish?
I’m not positive that I know what it was supposed to do. I feel badly about specialty-specific programs that were not offered the opportunity to be CCHIT-certified. If you wrote a state-of-the-art, phenomenal program for OB-GYN or ophthalmology, you won’t be certified because you don’t have the features they require. Certainly that will change.
I’ve heard scuttlebutt about the $28,000 certification fee and the hundreds of thousands of dollars needed to bring products up to CCHIT specs and whether that has caused a material increase in the cost of software. It probably does weed out some of the mom and pop operations.
I spent a substantial about of time and money developing what I called an EMR that was more of a documentation product. I stopped developing it about three years ago, so I can feel the pain of someone who spent years to develop software that helps people accomplish what they need to in their specialty, but because of CCHIT certification, may be put out of business. Over time, under-funded companies will go out of business.
If its purpose was to give comfort to physicians buying software or to make it easier, I’m not sure it accomplished that. I’m not seeing it. One of the bits of data I maintain from people going to EHR Consultant and telling us what they’re looking for is whether they want a product that is CCHIT-certified. Maybe 20% of our clients say they won’t look at non-CCHIT certified programs. That means that 80% will. Many say it’s of no consequence to them. Smaller offices seem to care less and larger offices care more, but that’s a subtle trend.
You offer a free EMR evaluation service. How does that work and are other companies offering something similar?
I went to HIMSS 3½ years ago and rapidly realized that most mortal human beings would be incapable of learning about the wide variety of programs in order to support them, which is what is consultants do. I decided to do an evaluation. I devised a vendor questionnaire of 600 questions and then asked doctors 200 to 300 questions.
If you look up electronic medical records on Google, a surprisingly large number of responses are from companies that will gladly help you find the proper EMR. My experience is that many of them ask name, address, phone number, number of docs, when purchasing, and not much else. They’ll say, “Here are the top five products.”
Our methodology is that there are dozens of qualified products and not all are appropriate for an individual office. There are a number of cars, Mercedes and BMW, all of which have different styles in the marketplace.
By matching the 200 to 300 questions the physician has answered against the 660 the manufacturer has answered, we can make a qualified match of the appropriate technology. It’s a matter of judgment, but we give large positive grading for EMRs designed specifically for one specialty for somebody of that specialty. In that way, we’re best able to give a good number of very appropriate software program recommendations to each individual physician.
Is speech recognition software underrated in its ability to help physicians save time?
Absolutely. I’ve been doing it and selling it for 13 years. You’re not supposed to take returns of open software, but if someone returned it, I took it back. In 1994 to 1995, I had a 50% return rate. Nobody asks me to take it back any more. You get 99% accuracy. You can speak like a New Yorker. It’s like transcription with no fees.
The sweet spot is a rich EHR. I can click through the physician exam, click through the review of systems and family history, and social history. I dictate the history – how the accident happened, what restaurant they were at when they started choking. The specific factors that make each individual’s history unique are important. Speak those first two paragraphs. Minimize the transcription cost and let the EHR do what it’s supposed to do, which is get good data capture.
I have some confidential information as a distributor. It used to be a meaningful event when a medical group would buy five or 10 Dragon licenses. With increasing frequency, we’re quoting and selling 100- and 500-license opportunities. If somebody bought 10 licenses, then 50, by the time they’re buying 500, they know it works.
What’s the penetration of speech recognition in practices?
Tens of thousands of physicians use Dragon NaturallySpeaking. That’s probably still single-digit percentages, but it’s increasingly rapidly. I have no visibility into the market of companies not selling Dragon NaturallySpeaking. They’re clearly the market leader, but I don’t know the percentages of the others.
We’re a distributor, so we sell to 100 Nuance-certified solutions providers. At the present time, I’m doing an ambitious project, which is finding out from each reseller which EMR packages they’ve installed Dragon with. I’m putting together a series of Google Maps. I can point them to a page on the Web that will have a map point for each qualified, certified Dragon reseller that has experience with their particular EMR program.
I just sent an Excel worksheet to 160 resellers with 362 EMRs listed down the left hand side and a dozen different qualifications across the top: have they used it, have they developed macros, do they help install it, etc. We’ll tabulate that onto Web pages to display that data.
What do you think about AcerMed’s situation?
As I understand it, there was an intellectual property infringement lawsuit that led to substantial legal fees. That was the immediate cause of the demise of AcerMed, not the fact that the program didn’t work. I’ve spoken to people who liked it and people who didn’t.
Functionality didn’t lead to AcerMed’s demise. I don’t believe that CCHIT is in the business of looking at the financial aspects of companies.
Will that event change how doctors look at software?
If you’re a single doctor spending $10,000 or $15,000 on software, I don’t think you need to pull out all the stops. Larger installations spending hundreds of thousands should get financial information and do a Dun and Bradstreet or Hoover’s check.
What changes would you predict in the physician office system market over the next 3-5 years?
There will come a time where a specialist is no longer getting referrals from their general MD because that doctor has an interoperable software program with the specialist across town. When that happens, you’ll see rapid adoption because they’ll need to stay competitive.
You’ll see greater use of non-MDs putting medical information into the history, either the patient or less highly paid people to enter the data, whether a physician assistant or nurse practitioner or medical assistant. I think that’s an inappropriate use of an MD’s time. They should be spending their time diagnosing people. It can be a substantial change of physician time to document an encounter and I think it will be attacked in different waysE
The EMR industry seems to be polarizing, with legacy, expensive vendors on one end and modern, inexpensive products on the other. How will that shake out?
That’s absolutely an accurate depiction. I am somewhat surprised, and I’m not politician, but hospitals are permitted to pay 85% of software costs that are compatible with hospital legacy systems. I was expecting to see a sea of change where legacy systems would run over these new companies. I haven’t seen the new companies being quashed like I expected.
What does that mean?
New companies that are selling 10, 20, 50 million dollars of software a year in to medium and increasingly larger practices have a very bright and rosy future. As I think should be self-evident, I do analysis for physicians for free, but I have some referral agreements with a very few vendors. I’ve been doing this for 3½ years and I used to get an intermittent check from these companies for sales to a one -or two-physician practice. Now I’m seeing small companies selling to 10-, 20-, or 100-physician practices.
Are they taking away business from the legacy vendors or selling to first-time customers?
In 2010, they’ll be taking their business away. I don’t think that the current sales being made in physician offices for a few thousand dollars would have been made for $75,000 if the smaller companies weren’t there. Those sales would not have been made.
If I were a large public company with product installed in hospitals, I’d rapidly provide an inexpensive offering to the local physicians to stay competitive.
So you like the Misys-iMedica deal, where Misys will resell the small vendor’s product instead of developing their own so they can get to market faster?
From Misys’s perspective, it was the proper thing to do. I have the pleasure of having thousands of offices telling me what they like or don’t like. Misys will likely benefit from having a new, up and coming, recently written, capable software program. They’re a billion-dollar company with long marketing reach and having a product that physicians are happy to use will be a welcome opportunity for them.
Will the smaller vendors be bought by the larger ones who worry about the competition?
I don’t think big companies will buy them because they’re a threat. They will buy them because they provide an opportunity.
I live in the same county that Dr. Notes was headquartered in. I was appointed by the bankruptcy court to sell the company’s source code to its .NET version. They had a Windows-based program and were allegedly 90 days away from shipping a .NET program. They went into bankruptcy and I’m helping sell the 400,000 lines of code.
I sent 360 e-mails at 9:00. By 9:01, I started getting responses. People from the up-and-coming companies wanted to buy the code. They wanted a billing module, which Dr. Notes didn’t have, or wanted their customers, or wanted their code.
Then, I noticed that the people calling me were saying things like, “Well, Dr. Fishman, since you seem to be in the business of buying companies, can you find someone to buy mine?” That happened dozens of times. Others said it wasn’t exactly what they wanted, but wanted to hire me to find them an ASP CCHIT product within 30 days.
There will be a lot of churning of these 1, 2, and 5 million dollar companies in the near future. That’s a particular interest of mine. In next EHR Scope, we have half a dozen pages about recent transactions written by an investment banking firm.
Was it a surprise that McKesson bought Practice Partner?
Andy Ury did a great job having a company of McKesson’s stature helping them do the marketing. I don’t have any insights into McKesson. The phenomenon of having billion-dollar companies snapping up EMR companies with eight-figure revenue will continue.
Do doctors like the idea of personal health records?
I don’t think it’s happening in doctors’ offices. Companies are interested.
I’m potentially involved with a PHR company and a clinical practice guidelines company interested in getting more entrenched into the personal health records. I think it’s something that will be very important and I’m surprised it hasn’t taken off more quickly. I stopped practicing 3 1/2 months ago and had zero patients express interest in interacting with me in that way. It’s not happening yet.
What about Google Health’s rumored PHR project?
It amazes me what Google knows. I think if they set their mind to it, they will do it. I understand they had some change in staffing at that level. I’m not qualified to offer an opinion as to whether they will or won’t do it, but I spend money advertising on Google and thinking about their algorithms and how much they know about people.
They certainly have the computing power to enter this space and pharmaceutical companies spend tens of billions of dollars in advertising their products. Google would certainly be willing to accept some of that.
A magazine just released its 100 Most Powerful healthcare people. If someone asked you, “Who are the most powerful and influential people when it comes to physician use of software,” who would you say?
The CEOs of those dozen up-and-coming EMR companies that I refuse to name. [laughs] They are involved in determining what the software that they’re producing will look like. They are profitable companies with millions or tens of millions of dollars of free cash flows without the shackles of having it burdened to something from their past.
They will decide whether to encourage or discourage interaction with patients, like personal health records or smart cards or thumb drives. They have the resources and knowledge and motivation to be in the doctors’ examining rooms around the country showing how healthcare will be delivered. They have the wherewithal to acquire technology, like clinical practice guideline technology, and integrate it in their software.
I know a little about nanotechnology. A friend asked me where to buy a portfolio of nanotechnology stocks, but they’re mostly privately held. If I could invest in a portfolio of smaller EMR companies, I’d do it in a heartbeat. You could reasonably choose a handful that will be successful, though I can’t pick them all, but the small ambulatory EMR industry will do very well financially.
My specialty is the smaller office, but two weeks ago, I got call from hospital CIO with 525 physicians on staff. He mentioned two legacy EMR systems they were interested in. I mentioned a couple of smaller systems and there appears to be some interest. Some of these up-and-coming players may play a role in hospitals
What about retail medicine?
I don’t want to grow old and decrepit in this country because healthcare won’t be as good as it is today. Retail healthcare is here to stay. Healthcare should be touching and care, but it’s clear that retail clinics aren’t going away any time soon. I don’t get my care at one.
Will retailers develop their own software or buy from those sexy companies?
I have made successful introductions between retail pilots and one or more of those dozen hot, sexy companies I won’t name. I don’t mean to be evasive, but I have relationship with those companies.
If an HIStalk reader is interested in ambulatory EMRs, what information do you provide?
EHR Scope is a free publication, over 150 pages, and the next issue is in October. It has a meaningful amount of information on over 200 ambulatory products. It comes out in a PDF and if somebody’s a cardiologist, they can search cardiology and find systems appropriate for them. They can quickly get their Web sites and contact information. I think it’s a very valuable resource. The electronic version is free.
Any final thoughts?
I love what I’m doing.
A couple of readers suggested I talk to Danny Sands. He’s an assistant clinical professor of medicine at Harvard Medical School and senior medical informatics director for Cisco Systems. If anything interesting happens in the industry, he will hear about it while wearing one of those two significant hats. I have to figure out what whole bicoastal, two paychecks thing since he seems to be having a ball.
Dr. Sands earned his medical degree from Ohio State and a master’s from Harvard. He did his medical residency at Boston City Hospital and an informatics fellowship at Beth Israel Deaconess Medical Center. He’s also on AMIA’s board and is a fellow in both the American College of Physicians and the American College of Medical Informatics.
Thanks to Danny for spending time with me.
Describe your job at Cisco.
My position is as the senior medical informatics director. I work in a part of the organization called the Internet Business Solutions Group, or IBSG.
Cisco has always been organized around engineering and sales. There was no verticalization of the organization at all. Five or six years ago, the company started to understand how it could do verticals better and created IBSG. We have maybe six to eight verticals and healthcare is one of the most mature.
IBSG can be thought of as the global, no-fee consulting organization of Cisco. We’re vertical-specific. We do consulting in a limited way with important customers around the world. In healthcare, our job is to help Cisco understand healthcare in a very deep way and to let our customers know we understand healthcare.
Given our size, our consulting engagements aren’t like Accenture’s. They’re just six to eight months. We work with CxOs to understand business and clinical problems and develop solutions, often employing technology. We think deeply about the industry, always thinking about what’s happening in healthcare and healthcare IT and how we can effect change in healthcare through our writings and working with Congress and ministries of health around the world. We’re transforming health to practice in the most clinically safe and high quality and cost-effective manner possible.
Everybody’s talking about Cisco’s recent announcement about its healthcare growth. What’s driving that growth?
Healthcare is an industry in which organizations have under-invested in technology for so many years. Back when computers were just becoming ubiquitous, every industry that viewed itself as information-intensive was investing in infrastructure to put in the fundamental applications. Now, they’re investing 8-10% of revenue and doing very sophisticated things.
Healthcare has not viewed itself as an information-intensive industry, which is quite a shock to those practicing in it. It hasn’t viewed itself that way, except for billing, and hasn’t built up infrastructure and put in fundamental applications and databases to deliver care effectively.
Healthcare is investing 2.5% of revenue and still falling behind. For years, it was even less, under 2%, and there’s a lot of catching up to do. Many organizations are behind the eight ball and it will take awhile to catch up. They’re beginning to understand that this is an information-intensive industry, and for quality metrics, they will need technology.
There’s a huge market in healthcare. What we’re interested in doing isn’t just selling stuff, but helping people do business and clinical work effectively. Cisco started investing several years ago because we saw the technology was underutilized and we could really help the industry.
Does Cisco manage healthcare the same as other vertical markets?
Yes. The IBSG has verticals in retail, public sector, entertainment, financial services … so we have a bunch of these things. In this consulting group, we have 225 peple around the world, so it’s not a huge organization. Intel has more than 200 in just their digital health organization.
My counterparts do similar things to what we do. Some of them do more traditional consulting instead of the thought creation we often do. So, healthcare is pushing into areas that not all the verticals have done yet. We also have a sales force dedicated to healthcare.
I think we go about things differently because we’re offering to be a partner that understands healthcare. In our group, we have expertise across the spectrum: healthcare consulting, nurses, nurse practitioner. People who understand networking, homecare … someone from life sciences, someone in the payer market. We have a breadth of expertise becaue we’re coming at it from so many different sides.
What are the biggest technology challenges in healthcare?
The biggest challenge is the lack of capital to invest. Still today. If we look at organizations, larger healthcare organizations will spend more money and will be more forward-thinking. Intermountain, New York Presbyterian, those centers of excellence. We have these name brand organizations that have clearly spent a lot on IT and have done neat things.
You have others that big who have the margins to invest. You have others that are struggling financially. Hospitals are running near-negative margins. If you’re in a business with no margins, you’re just trying to keep your head above water.
It’s similar in practices. They mirror hospitals in that larger ones have infrastructure and staff and revenue, but in the smaller practices where most care is delivered, no margin, no infrastructure. The biggest problem is appropriate investment in technology.
One barrier is a misalignment of incentives. Who is investing the money and who is benefiting? Clearly, if a hospital invests in technology, they need to see some return on investment. Some may come from reduced cost of handling records. It’s a lot harder for practices to make these justifications. Larger institutions are doing better in being able to step back and look at their issues. We’re focusing on large enterprise users for that reason.
We have a very hands-on business in healthcare. We can’t replace people, but we must keep them in mind all the time. We need to remember that people have a limited capacity to change, so you have to help people apply the technology in their work. Healthcare is hands-on and so is introducing technology into it, so we want it to be done appropriately. There have been too many situations where hospitals have invested money and their projects haven’t been successful, often because they didn’t involve clinical staff from the beginning.
Is “medical grade network” a technology or a marketing approach?
That is a technology. When I talk about setting an appropriate infrastrucrtre, that’s what I’m talking about. It is an architecture for building a network that is resilient and reliable and secure and has survivability, those things we need in a mission-critical environment.
You can’t afford to have a network go down in healthcare. It must be hardened and tough. This is like plumbing or running water and electricity and needs to be that reliable. We say the fourth utility is a converged network. It brings together all the low-voltage circuits into a very reliable, robust network that’s expandable and can be managed. You need to be able to grow a network as you add more functionality and nodes. Sometimes that means adding to it, sometimes shutting parts down without bringing down the whole network.
You were at Beth Israel in 2002 when network failures caused what might be the biggest patient-impacting systems outage in history. Is it ironic that you’re working for Cisco?
It’s a great point. I tell that story often. Fortunately, I had no responsibility for the network management there. [laughs] The situation was that nobody was minding the infrastructure.
A network is a living, breathing entity. One needs to not only create an architecture, but maintain it to ensure it performs well. At Beth Israel, we weren’t investing in maintaining the infrastructure. Not only was it no longer architected correctly, it wasn’t managed over time, so it was vulnerable.
That sort of travesty could not occur with what we’re architecting now. I’m sure that will never happen again at Beth Israel. [laughs]
Wireless networking in hospitals is suddenly prevalent. Have caregivers and clinical software vendors embraced the concept that computer users aren’t chained to desks any more?
That’s one of the big waves that’s coming. We no longer have to think in terms of desktops, but can think of devices. Whether tablet or desktop or biomedical engineering equipment, everything becomes a node on the network. That’s the way that more progressive IT groups are thinking about things. That doesn’t mean there’s no role for the desktop PC, but there are roles for other wireless devices.
We need to think more about untethering hospital personnel from walls so they can interact with their hospital information system while sitting at a patient’s bedside. It could be a wireless phone so patients can communicate with them. Because it’s an IP phone, it’s part of the network and can share any information from the network. We can ID a patient, get a test result.
It shouldn’t matter what kind of device it is, whether it’s a wireless phone or tablet computer or PDA or desktop. All of these can interoperate on the medical grade network. The last mobility trend in hospital was COWs. Those are fine, but there are a lot of places you can’t wheel one in. It’s nice to have something that’s truly portable. The interoperability becomes important.
As we introduce new varieties of devices, whether phone or PDA or tablet, we’ll need to reinvent some of these applications, creating applications that are customized to that form factor. We have already seen some of this, like PatientKeeper and MercuryMD. We will have to see more hospital information systems that run on a tablet computer, for example.
Cisco is building unified communications. It doesn’t matter what device you’re using. You can communicate with all. Open a directory and communicate with anyone in whatever manner they want to be communicated with. Dr. Smith may say they’d like to be text messaged first. Everybody can have their own preferences. That’s a more effective way to start communication with people, by not annoying them by contacting them in a way they don’t like.
They can seamlessly move from a text sesson to a phone system or a collaborative session on the Web where we’re sharing a screen. Unified communications will change healthcare. So much of what we do in healthcare is communicating, yet our technologies are primitive.
Give me the Cisco perspective of the Cisco-sponsored HIMSS Community for Connected Health.
We wanted to form a community of people thinking about the connected health concept. That’s almost the form of a user group, but it’s a community. People can share ideas with each other and with us. I don’t know how this worked with HIMSS, but we’re really just trying to reach out and think about community.
As an aside, Cisco has embraced the idea of Web 2.0 and groupware and collaboration. We’re trying to experiment with that in many different ways, like wikis and a new directory that’s almost like Facebook. We think the future is collaboration. When I watch my teenaged daughters on the computer, they’re collaborating all the time. They don’t use traditional means, even e-mail. They skip that and go right to Facebook and MySpace. We’re trying to do these things in Cisco.
Cisco tries to do the things that it gets other people to do. If we think it’s a coming trend, we try in on ourselves first. Another example is Second Life. We have a community there, where we’re trying to push the envelope. We don’t think we can continue to grow the way we’re growing unless we’re collaborative.
John Chambers says he wants us to reduce our travel 20% over the next year using the technologies we sell. TelePresence is a totally game-changing technology. It is totally unlike videocoferencing. It does what videoconferencing promised to do. You really hear people in high definition, see people and even see them sweating, and feel like you met the people on the other side of the table. It’s almost entirely transparent to the users. We’re not really aware it’s there. The problem with videoconferencing is that you’re always aware it’s there, with jerky motion and synchronization problems.
We’re using TelePresence internally. The first customer was Cisco. We put it in all our major offices all over the world and we’re encouraged to use it so we don’t have to fly anywhere. I’ve been able to avert flights all over the country by using TelePresence.
Are today’s electronic medical records systems too tied to the paradigm that physicians have to enter their own data to give and receive value from those systems?
There are many potential sources of information. Some are machines, some are people, and some are people and machine at other institutions. We have to figure out what is the most efficient way to get information from these places and present ot to the clinicians.
There is a large amount of information that we acquire in the course of interaction with patients. Much of it has to be entered by us, one way or another. There’s a large body that clinicians are responsible for entering that should come directly from the source. It would be preposterous to look at a printout of a lab test and type that into a computer. Likewise, why is it that we interview a patient and enter their information into the clinical information system? There’s a practical barrier if the patient is lying down with a gunshot wound, but in many situations, we can take advantage of the patient. The patient is the most important yet underutilized source of information in healthcare.
We’re often very keyboard-centric. There are lots of ways I can interact with a computer – a stylus on a tablet; dictating and having it trabscribed by computer or human; and typing, which can be templated or free-texted.
There’s another aspect to your question, which is that our information systems tend to be very doctor-focused, or let’s say clinician-focused. Just as we don’t ask our patients to enter information into a computer to help their health, we often don’t share the information in the computer with our patients. Patients need to play a bigger role in healthcare.
We don’t think of them this way, but patients are our customers. That leads to problems where we don’t share information and don’t make it easy for patients to make an appointment or get a referral or get test results. We should do these if we’re truly patient-focused. When patients have access to information, it can be more satisfying to both doctor and health.
The physician brings a complementary skill set. You’re an expert in you. If we have a common database and bring our expertise together, we can make tremendous things happen and improve the way we deliver care. There’s some preliminary evidence that patients engaged in this way have better health outcomes.
What about other information types, such as video and voice?
We need to be storing more rich multimedia information about our patients. The first wave was the PACS movement and that’s terrific. It’s amazing as a doctor to be able to see the image instead of just reading the text report. We need more of that. PACS was developed separately from the HIS.
We need a convergence of text and multimedia and it shouldn’t just be radiology images. Cardiology images, photos of a wound, video of a patient walking, pathology images, voice files -– all should be part of the record.
That necessitates data acquisition that we don’t have right now. We’re lucky in a clinic if there’s a digital camera around. We need to think in terms of multimedia acquisition devices. There are digital ophthalmoscopes and otoscopes. We need to acquire that information, capture it, and store it in the record. That requires a new set of input devices and interfaces to the hospital system so that multimedia objects can be stored and retrieved as part of the record, not as a separate system.
A digital image is not only far more effective at delivering information, you can manipulate it. It also requires efficient storage and an efficient network to convey those large objects. Those last two areas are what Cisco is interested in. We do storage area networks to store information more cost effectively. We’ve also pushed network convergence, where video can travel across the network. We’re partnering with some of the big HIT vendors to develop new functionality.
You were an advocate of electronic patient-physician communication. What’s the status of those projects?
A lot of doctors haven’t yet embraced the technology for the same reasons – time, liability, and reimbursement.
An exciting trend is the number of practices and institutions offering patient portal services that offer patient-provider communication. Kaiser rolled out Epic MyChart to millions of patients. That’s huge. It’s far and away the largest deployment of that kind in the world.
We’re seeing adoption among larger practices and more enlightented healthcare institutions in deploying patient portals that provide secure communications. I choose to look at it as a positive trend, even though figures haven’t taken off like I would have thought. The volume of messages a doctor gets from patients is very modest, even when you’re not charging a fee. At Beth Israel, for every 100 patients registered on the system, they’ll generate less than one e-mail a day to the doctor.
What IP-connected devices will have the most impact on healthcare delivery in the next 5-10 years?
Home care. I think there is no question that we need to be reaching into patients’ homes. That’s where patients are sick with chronic conditions. I think we’lll go beyond that and catch patients earlier in their disease or when they’re pre-symptomatic. It will be commonplace to interface with your set-top box or glucometer.
Home care, along with nursing homes, is quite technologically backward. It’s a real shame because these are our most vulberable and sickest people. These will be new markets where we can make a huge impact.
Location-based services, like tracking of things in a hospital,will be successful. Once you’ve deployed a robust wireless network, you have two ancillary benefits. One is the ability to do tracking, or location-based services. I can put a tag on my wheelchairs and infusion devices and code carts and track them throughout the institution through the wireless access points. It’s exciting that you can find out where the equipment is that you need.
You can also create a second wireless network for guest use. When you’re going to visit someone, you can connect your laptop to a public network that’s separate from the secure internal network. Most hospitals aren’t set up this way. They have one wireless network that’s for staff. Offering this for patients, especially for those in units like cancer units where they’re in for a long time, is a great service.
Any final thoughts?
This is a very exciting time to be in healthcare IT. Because of the robustness of the technologies and the ability to implement them effectively, it’s a tremendous time and I’m excited to be part of the industry and Cisco.
I really salute all the people working in this space. We need to remember that we need all kinds of players to effectively implement these systems. It’s not something an IT department alone can do. Vendors, C-level executivess, providers … it’s an important collaboration pushing IT out to physicians, nurses, and patients. If we do this intelligently, we can make a huge difference. That’s why I’m in this business.
by Inga
HIStalk has a surprising number of great posters who provide thoughtful commentary. One such reader is Art Vandelay, whom I decided was a genius after he provided a terrific analysis of how healthcare would be impacted by Wal-Mart. I had to think of a creative excuse to talk to this great mind, so I convinced Mr. H that Art would be a great interview subject.
Inga: Art Vandelay is not your real name. How did you select it?
Art: I really enjoy Seinfeld and saw a few references to it in HIStalk, so I took it to see if anyone knew what I was talking about. Art is not a real person. He is an artificial character, so I can relate it to my alter ego.
How long have you been reading and posting on HIStalk?
I have been reading since mid to late 2006 and never really went too far back on old posts, but definitely read it as soon as it comes out. I find it interesting and timely. An interesting phenomenon is that some of my old colleagues have left healthcare. HIStalk replaces some of the old shop talk I used to have with my colleagues. It’s a good bridge for that.
What can you share about your background? What do you do besides write interesting commentary on HIStalk?
[Laughs] Right now I am working for a large delivery system. Essentially, I am responsible for a lot of their different initiatives. It’s a lot of project-based work. It involves pieces and parts of an enterprise architecture, but they really don’t call it that.
Prior to that, I was working for a large healthcare outsourcer and had done some cutting edge development work on that. It was really interesting work. I got to work with some old legacy systems and integrated them with newer technology using Web services.
Before that, I worked with a Big 6 consulting firm, back when there was a Big 6, primarily helping with system selection, organization strategic reviews, and package system implementation. I burned out on that really fast. You do double the work you do with other organizations. But it was a great experience.
I graduated with a Masters in healthcare management and was really intent in landing on the business side of healthcare, but the money was on the technology side and I’ve really enjoyed it.
What would you say is your primary area of HIT expertise?
Wow, I never really thought of that. I have a very strong understanding of the vendor space and a general understanding of the architecture. I am more of an apps person than an infrastructure person. I operate more at a business interface level and have worked more with business unit sponsors on the projects I have worked on.
Some of your postings are fairly technical.
Yeah, I have gotten to know a lot of that because of a lot of the things I was involved with before. You can’t work with all the vendors without knowing all the blemishes around them. But I consider myself more on the business side.
Do follow other HIT blogs?
Actually, let me check my RSS reader [Inga laughs because it is such a techy thing to do – even if Art is just on the “business side.”] Shahid Shah The Healthcare IT guy, Medical Connectivity, Neil Versel, Candid CIO, Ignacio Valdes, MD – Linux Medical News, NeoTool Healthcare IT, Running a Hospital, and LabSoftNews.
You are well read.
Yes. I like reading little snippet things. The blogosphere is good for that.
Are there any HIT companies that you believe are doing things right?
I think overall that some of the niche vendors are more innovative. Companies like SCI. They have made a good niche for themselves, but need to more aggressively market themselves. They need to promote their value proposition, to get in there and push their story better. I have heard really good things about them.
NeoTool has an interesting niche around interface delivery using BizTalk. Offering a competing product is a bold move because it may cause channel conflict. Medseek has done some interesting work and is addressing some unfulfilled niches. Emergin is very innovative, have a great niche. It will be interesting to see what do they do next, if they will they take their product to the next level. They have a very strong position from which to build.
The biggies aren’t doing a lot right now or at least not showing a lot of value. Cerner, Eclipsys, Siemens, Epic. They are trying to be too many things at one time right now.
Are there any up and coming trends that you think are going to be big?
A lot! [laughs]. I could talk about that for a long time. Retail, I think, diverse delivery locations and anyone doing medical storefront. Consumer-driven health plans. With high deductibles, consumers will have more control over where they go if they have a particular condition and they can choose their specialist. Medical tourism will probably pick up because of consumer-driven healthcare. It might be overseas or in a vacation spot.
So, what I really see being pushed is more continuity of care record, CCR. There will be a bigger push because you are going to receive your care in different places and you need to bring your medical record back with you.
You are definitely going to see a lot of virtual alliances, like people partnering with Wal-Mart locally to meet referral patterns or Cerner working in Dubai and Cleveland Clinic in the Middle East. A lot of health systems are trying to take their brand images overseas, essentially putting their Good Housekeeping seal of approval on the overseas facility. From a practicality standpoint, that means more network linkage. Some growth of teleconsulting will come with that.
Really, when you start to look at consumer-driven healthcare, it might lead to patient liability estimators. If I go to health system X, I can expect to pay $10,000 on a surgery and $12,000 at health system Y. Then I can decide how I spend my money.
There is going to be a big push on outcomes information, high-level stuff. Everyone defines an outcome in a slightly different way. When we capture it, we discretely capture it, but, each entity defines it differently.
With consumer-driven healthcare, you probably will see more push for access statistics. How quickly can you can get into a location? If you can’t get in to see a physician, who cares how good he is?
The pay-for-performance trend will drive the need for more metrics. There needs to be a lot of work to define things and there needs to be standardized data definition. I could keep going …
Great! Keep going.
Direct contracting will make a comeback. Health systems will try to directly work with employers to get the every last bit of margin out. But they will have to watch what they are getting into. I can see payers trying to prevent entry of providers, which will affect costs even more. Managed care contracting, referral management, decision support around cost modeling – all will make a comeback.
Increased consolidation among payers and providers. Who would have thought someone would partner with Wal-Mart?
Another big trend is centralization. You see this within organizations and in a technology-enabled way with remote monitoring. A lot of people are making moves in the home monitoring space. Folks are discharged as inpatients, but need some monitoring at home. Monitoring elderly folks with RFID to make sure they are eating, not wandering, going to the bathroom.
PACS, allowing remote diagnosis. As that becomes more prevalent in other specialties, you will see a push for some health systems trying to brand themselves. Wouldn’t you want a Mayo doctor to look at your EEG?
With that, a lot of the remote consults would come up. Get a second opinion with Cleveland Clinic. Within organizations, I see consolidation between clinical engineering and IT. The medical device manufacturers are introducing mainstream technology with a whole new slew of challenges in terms of maintenance, integrating, and day-to-day maintenance. Integration is a new skill set that IT companies can bring to them.
Labsoft News talks about convergence between lab and radiology departments. That will definitely come about. Nicholas Carr, a Harvard professor, talked about “IT doesn’t matter”. In my mind, it gets down to our IT departments. Will they deliver commodity services, or, will they become partners with the business side? Organizations are expecting their investments to show return. IT departments either will step up or will be relegated to utility.
Because of the economy, I think there will be a big focus on value. How do I squeeze the most amount of capability in all the technology I have invested in? Which goes back to IT partnering on the business side. IT has to really get involved in the business.
I would expect a growing number of organizations to have CIOs take over the business function. You are seeing it a little in other industries and I think it will come out in healthcare. CIOs are ready to take another step. For CIOs that have made promises, they are going to be asked to step forward and show ROI.
I think we are going to see a return of some best-of-breed. As purse strings get a little tighter, I think best-of-breed will come to show the best ROI, rather than a full Cerner or Epic system.
There is focus on squeezing the value out of investments and a lot of vendors are acquiring because of that. They will go for some of the niche vendors that can add value to their systems. Around revenue cycle systems, who really has done anything new? No one has any investment in R&D that is showing anything. The big vendors will buy small niche players to tap on to the maintenance stream and fill the product gaps.
Who do you admire in the industry ?
Mr. HIStalk, because he makes some very good observations and has great commentary. It’s true. I think I have made some comments about Emergin’s CEO. It’s going to be interesting to see what they do next.
I admire the Epic leadership team. They have created a brand around themselves. I don’t know if it was meant to be that way, but I think it gets them a lot of attention. Among a lot of the biggies, they have delivered the best and kept promises.
Anything else you would like to add?
One question that you forgot to ask, my dream job. A consultant who really didn’t have to travel that much. What drugs am I on – no travel? Think tank analyst. I’d love to be able to what-if all day, debate with someone, and get paid for it.
Realistically, it is anything where I could feel I am making a difference that would provide a solid standard of living so I could consistently be with my wife and kid.
