Why T-Sheets Work

Disclosure: I have no financial interest in T-System, Inc.

There is nothing particularly high-tech about a T-Sheet. A T-Sheet (designed by T-System, Inc.) is a particular design for a double-sided, single-page printed paper form used to chart patient visits. T-Sheets are extremely popular and have been widely adopted by emergency department and urgent care physicians.

Why do many physicians prefer using T-sheets to the more technologically advanced EHR solutions that they are increasingly being required to adopt?

There are of course many reasons. One is so basic — and is such a defining property of the paper form in general — that we tend not to even notice it: T-Sheets assign each category of data to a box of fixed size and fixed location on the page.

A second reason T-Sheets are popular is that each presenting problem (chest pain, abdominal pain, headache, and so forth) has its own customized T-Sheet template. But regardless of the specific problem and the specific data collected, the spatial layout of data categories is kept exactly the same.

Here is an example of the front side of a T-Sheet for an emergency department visit that I have redrawn and greatly simplified to emphasize its high-level spatial design.

Regardless of the reason for the emergency department visit (in this case, chest pain), the box on the top right has a fixed size and location. It is always set aside for the review of systems (ROS). Similarly, regardless of the reason for the visit, the box on the bottom right has a fixed size and location. It is set aside for the family history. And so forth.

This means that once I learn where each category of data is situated on the page, I can just glance at that box to retrieve the desired information. Its position doesn’t change depending on how much data is written in the boxes above or next to it. The information remains readily available when I’m viewing a different box. I don’t have to carry it in my head.

The locations become automatic after a while. I don’t have to read the box headings. And if I need to compare the current visit to a previous one, I can just place the two T-Sheets side-by-side and glance at the same location on the two sheets to find the comparable data.

In my last post, Computer-Centered versus User-Centered Design, we saw how the spatial arrangement of data allows us to solve certain problems visually with minimal cognitive effort. But even if our task is just to take in and organize a large amount of data, a fixed spatial arrangement is a very good design.

Humans are visual animals par excellence. The human visual system is very good at organizing objects in space. T-Sheets and similar paper forms work because they enable us to use our extraordinary visual and spatial processing abilities to make sense of abstract data, even though these abilities evolved to help us organize physical objects in the real world.

Despite its simplicity, the paper form — with every data category assigned to a fixed location on the page — is a powerful cognitive tool. By allowing us to use our perceptual visual system to organize and retrieve a large body of information, it leaves our finite cognitive resources available for patient issues.

This all may seem obvious. Unfortunately, many EHR designs did not go in this direction, only in part because of technical constraints. Instead, clinicians often are required to navigate to multiple screens in order to enter or view different categories of data, as in the example below:

Of course paper forms have their own problems — how do you record more information than fits in a particular box, bring historical information forward to the next encounter without laboriously re-entering it, read illegible handwriting, and so forth? But still, assigning each data category a fixed screen location is a good model. So in rethinking EHR design, one strategy is to retain fixed spatial location as a high-level design element, but improve the paper design by making it interactive.

We need interactive T-Sheets.

Next Post:

Humans Have Limited Working Memory

Rick Weinhaus MD practices clinical ophthalmology in the Boston area. He trained at Harvard Medical School, The Massachusetts Eye and Ear Infirmary, and the Neuroscience Unit of the Schepens Eye Research Institute. He writes on how to design simple, powerful, elegant user interfaces for electronic health records (EHRs) by applying our understanding of human perception and cognition. He welcomes your comments and thoughts on this post and on EHR usability issues.

The past week has been crazy, and unfortunately the crazy spilled into the weekend as well. I had visions of the perfect thought-provoking topic for this week’s Curbside Consult, but every time I tried to flesh something out, it escaped me. Instead, I found myself musing on what I planned to do at HIMSS and which vendors I wanted to be sure to check out. Mr. H and Inga are hard at work on their “must see” vendor list and I’m working on my personal CMIO hit list.

For the CMIO (or anyone involved in evaluating new products or making purchasing decisions) it can be a great way to sort the proverbial wheat from the chaff. Many products look great in brochures or on the Internet but pale when you see them in person. Last year one of my “hot items” (sad that I think this is hot, isn’t it?) was wall-mount swing-arm brackets for monitors. The true test of quality and sturdiness is being able to check them out in person rather than trust a marketing slick.

You may ask, why does a CMIO care about brackets, and should she? The answer is yes. If I have to use it every day, I want to make sure it’s going to work for me and for the hundreds of physicians I represent. That’s not to say that the CMIO should be out personally investigating everything that needs to be purchased. Generally I prefer that the engineering and purchasing folks work their magic first, culling the herd down to their top choices, then allow a small group of providers to make the final call.

This year I have a laundry list of things to look at. Some are a bit gadgety (washable keyboards, COWs), others are more esoteric. I want to see how vendors are progressing with natural language processing and where they stand with clinical decision support. Are they going home-grown, or incorporating third-party solutions? How are the attendees responding to them? Who has incorporated Medicomp’s Quippe product that blew our minds at HIMSS11?

Like last year, I hope to have some time to cruise the exhibit hall with Inga, but I will also have some time to peruse the booths with a few other CMIOs and share their opinions and thoughts. One of my friends is a first-time attendee, so watching his expression as he sees some of the people out there will be interesting. A note to ChipSoft: I see you’re exhibiting again. If you’re giving away the clog slippers this year, please stash some for Inga and me because we’ll be looking for them and you ran out last year.

The marketing materials from exhibitors are arriving much more slowly than I remember from last year. So far, my favorite marketing piece is from CDW Healthcare, with their “What happens at HIMSS definitely won’t stay at HIMSS” tagline and accompanying poker chip. Although I like the idea of taking home things I learn, based on the potential for Inga and Jayne to have a good time, I’m sure some things will be staying well within the 89109 zip code.

Speaking of marketing, I received quite a response to my comment on why the soles of Christian Louboutin shoes are red. One reader shared his shame:

I must know. During a Battle of the Sexes trivia contest, I and my fellow male panel of knowledge brokers failed to identify the maker of the famed red sole shoe. It was the tipping point in a tight contest that found us falling to the gals. I now must know why the soles are red…

A certain savvy reader provides the answer:

Just a quick comment to say I thoroughly enjoy your commitment to giving your readers a well-balanced education. Not just what’s up in healthcare, but why CL shoes have their distinctive red sole! A mundane process turned into a brilliant marketing differentiator. I’ll be looking out for them!

In short, it’s all about branding. Louboutin trademarked the red-soled look in 2008, fighting to protect the distinctive look when Yves Saint Laurent came out with a red sole in 2011. YSL claimed in court documents that red soles existed long before Louboutin trademarked them:

Red outsoles are a commonly used ornamental design feature in footwear, dating as far back as the red shoes worn by King Louis XIV in the 1600s and the ruby red shoes that carried Dorothy home in The Wizard of Oz.

There’s your fashion moment of the day, and hopefully some of you can leverage this newfound knowledge to win the hearts of your lady-friends who might have a thing for shoes, not to mention to triumph in the next battle of the sexes trivia night.

Have a favorite HIMSS (or other show-related marketing piece) to share? Does it belong in the Hall of Fame or Hall of Shame? E-mail me.

E-mail Dr. Jayne.

From Kit Carson: “Re: Fletcher Flora. I’m interested in knowing what’s going on with shareholders. The final distribution statement was supposed to go out in November 2011.” We broke the news in November 2010 that Merge Healthcare had acquired the LIS vendor (I forget how I found out, but it must have been sneaky since I worded it as “HIStalk has learned,” which means I was snooping.) I don’t know anything about its shares, but I’ll run an update if anybody has one.

From Adele: “Re: HIStalk. As a sponsor, thanks for all of your hard work toward making HIMSS as productive as possible for your subscribers and for your sponsors. We are grateful that you all actually make the time to track our news and offer your suggestions to us when there are so many larger ‘fish to fry’ in your universe. HIStalk is one of the only places that provides for an equal voice for all of its sponsors, regardless of size, revenues, or politics. As a smaller company, we just can’t write a fat check simply to pay to play in some other channels. Moreover, we wouldn’t. For us, that is just not responsible stewardship of our clients’ resources.” Sometimes Inga and I need a little boost and this gave us one. Thanks.

From Vendor_Neutral: “Re: Epic. Wondering if you came across the online discussion spurred by the NYT piece?” I did see it, but like a lot of Internet discussion, I found it to be mostly hot air pontificating by industry sideliners and self-referencing, self-appointed experts who have never used Epic, aren’t clinicians, and don’t even work in healthcare IT (if you’re going to criticize a restaurant, at least eat there a couple of times.) Some of the least-informed comments drone on about Epic’s outdated technology, a clear signal that the authors have no experience in a business software environment, where customers value applications that are solid, scalable, and expertly managed over the latest iPad app or cool Web site. To dismiss the business and software savvy of hospitals that are buying Epic in droves is ludicrous, even if you (as I) doubt that most of them have the organizational fortitude to get the rosy ROI and patient benefits they expect when they fork over mega-millions. Somehow I doubt that Judy is losing sleep worrying that all the armchair quarterbacks will redirect their expertise into building a better mousetrap that will renders hers as obsolete as the company’s persistent detractors claim it already is.

From CDS Observer: “Re: FDA regulation of clinical decision support. This could be serious since it could involve a wider range of systems to be regulated, such as EMRs and simple apps. This would be a big blow to many smaller companies. Our company has joined CDS Coalition to make our voice heard and to keep members informed in case their product ends up getting included in the regulatory net.” I found the CDS Coalition’s Web page here. Companies pay $1,200 to $30,000 per year to join.

From Ambergris: “Re: KLAS scores of publicly traded companies. Didn’t you post something at one time?” That was actually Evan Steele of SRS, who made the point in October that five of the six top-rated EHR products are offered by privately held vendors, while eight of the nine lowest-ranked products are offered by publicly traded companies. To be fair, he’s only looking at customer support rankings of a specific ambulatory EHR category. However, I will add from experience, having had a few incumbent vendors go public or be acquired by publicly traded companies, that every one of them got worse afterward (I’ve written many times on the KLAS “first to worst” product phenomenon.) Investors replaced me as the company’s most important customer. I’d like to say it doesn’t have to be that way, but I can’t think of many exceptions. On the other hand, if you buy from the company after they’re public, at least you know what you’re getting and have less reason to be disappointed compared to the folks who knew them before.

From Jess: “Re: fast track clinic model for expediting medical services to patients coming to the hospital. I was hoping I could tap into your vast knowledge base to see what you know about this model.” I think you are overestimating the vastness of my knowledge base since it’s coming up empty on this topic (although come to think of it, “vast” usually means big but empty.) I will call in the assistance of expert readers to fill my void.

From The PACS Designer: “Re: Jobs biography. The biography Steve Jobs by Walter Isaacson has some interesting comments. Jobs said of Microsoft’s Bill Gates, ‘Bill is basically unimaginative and has never invented anything, which is why I think he’s more comfortable now in philanthropy than technology.’ Isaacson said this about Steve: ‘He was not the world’s greatest manager. In fact, he could have been one of the world’s worst managers. He could be very, very mean to people at times.’" I think that’s what I enjoyed most about the book – trying to figure out how someone so narcissistic, uncaring, and downright nasty could not only create arguably the world’s greatest company, but run it as a publicly traded company CEO almost until the day he died despite seemingly lacking all the important skills for the job. The only other example I could think of was Neal Patterson of Cerner. And Bill Gates. I guess the bottom line is that if you’re a visionary who started the company (see: Mark Zuckerberg), you can mold it to your bizarre personality, unlike the typical gunslinger, committee-vetted musical chair CEO that big corporations love who are loaded with MBA school bean-counting competency but short on anything resembling risk-taking, innovation, and vision.

The good news about offshore programming is that half of responding readers don’t automatically assume it means shoddy work. The bad news is that the other half do. New poll to your right, and this should be fun: who is most responsible for the glut of clinically useless EMR information?

Inga and I forget ever year just how busy we get in January and February in the HIMSS build-up period: interviewing, plowing through increasing numbers of pointless press releases to find the occasional newsworthy tidbit, adding new sponsors, and planning HIStalkapalooza. If we’re slow to respond, that’s why. I came home from a nine-hour day at the hospital Friday, chowed down the Wendy’s salad and baked potato helpfully provided by Mrs. HIStalk on her way home from work since she knew I was overwhelmed and had approximately 15 minutes of free time to eat, and worked eight straight hours on HIStalk stuff without even leaving my chair. Six hours later, I was back up and at it for another long day Saturday, where emerged like Punxsutawney Phil only long enough to see my own shadow during a brief lunch with Mrs. H, then get back to work. That grind won’t end for us until the conference is over. I will need (and am taking) a vacation afterward, assuming I survive until then, and Inga will be away the week after. The worst thing is that, like a crack user, I enjoy it and can’t see cutting back even though it’s probably unhealthy. While I’m away, I’ll plan my self-improvement for the rest of the year, so if you have ideas of books I should read, conferences I should attend, or things I should do, let me know.

Speaking of HIStalkapalooza, thanks again to ESD for putting together an outstanding event. It’s a big effort to have planners visit potential sites, work out food and entertainment details, handle logistics like registration and decorations, and of course write a huge check when it’s all over. They have been outstanding to work with, and since they get what HIStalk is about, they suggested some fun surprises that I heartily approved. If you need consulting help with your clinical systems projects (training, implementation, support, optimization, Meaningful Use, etc.) I’m sure they wouldn’t be opposed to taking your call. If you got an HIStalkapalooza invitation, please thank them when you get there. I wasn’t even sure I wanted to do another event this year, but I think it’s going to be cool.

Also fun: Medsphere is bringing over its 1971 VW open source bus, which Chairman Mike Doyle tells me will be available “to shuttle HIStalk groupies to your event on Tuesday.” I don’t know what they’ve planned for routes and all that, so maybe just flag it down if you see it if you need a ride to the Palazzo.

I’ll put in just a brief placeholder for our Booth Crawl, which will offer provider attendees of HIMSS what I would guess is their best chance to impress the fam by bringing home an iPad 2. Think of it as a scavenger hunt where you visit the designated booths to get the answers to secret questions (you’re visiting booths anyway, so you might as well hit these and get in the running for a swell prize.) You enter those answers online by Wednesday evening and watch HIStalk to see if you are one of the randomly drawn winners. You don’t have to get stickers or stamps on a card, you don’t have to drop your entry into a hopper, and you don’t have to be present to win. We have 55 iPads to give away, so the odds should be pretty good, plus you’re supporting our sponsors just by playing (not to mention that I noticed that a couple of sponsors have added prizes of their own.) I’ll be posting the form shortly. Nobody’s making money off this since we’re doing the work on our end for free and the sponsors happily donated the prizes, so for everybody involved it’s all about putting iPads into the hands of readers.

One last HIMSS note: if you aren’t attending, we will try our best not to make you feel left behind even though we have to write a lot about it. I think I speak for most readers in saying that the more years you go, the less you enjoy it and the more it becomes work instead of fun. I stay up until all hours each night at the conference writing everything up so you won’t miss anything important. The educational sessions are always iffy if you don’t research the presenter’s credentials in advance – I should hire someone to help me put on independent Webinars that would provide similar education without the travel and time off expense, which I’ve been talking about doing for years.

I verified that RelWare has closed its office and let half the staff go, having lost the client for which it developed its EXR EHR, Henry Ford Health System. HFHS went live on the $100 million system, then decided less than a year later to have a $350 million fling with Epic instead (note to self: don’t ask HFHS for long-term IT strategic planning help.) RelWare is sitting on a certified EHR (Inpatient and Modular Ambulatory) that is running in six hospitals and 100 clinics that will soon be homeless, so they’ll consider licensing arrangements or outright sale of the source code to interested organizations. My RelWare contact is somewhat informal, so I guess you can e-mail me if you’re interested and I’ll forward.

Travis has been writing some really good stuff on HIStalk Mobile lately. The fun mixture of pieces includes, in the three most recent posts, (a) a hands-on review of the Zeo Sleep Manager; (b) a new post that contains a lot of items that I hadn’t seen elsewhere; and (c) his take on mobile strategies for pharma. He’s a doctor and an mHealth startup guy, so while I’ve seen splashier sites covering similar ground, I haven’t seen any doing it better.

Thanks to the following new and renewing sponsors that supported HIStalk, HIStalk Practice, and HIStalk Mobile in January (click a logo for more information). You have to admire them for mailing off a check to a post office box to an anonymous, smart mouth blogger without so much as a phone call to sooth any concerns they might have. They either sign up after reading the information sheet or they don’t, and we appreciate those who do.

Epocrates earns Ambulatory Complete EHR certification for its EHR v2. I had forgotten they had one, to be honest. They acquired the iChart mobile app a couple of years ago and rebuilt it into a full product, announcing GA in July 2011.

TrustHCS names Dianne Haas PhD, RN as executive director of its consulting services division.

Morton Meyerson joins the board of Encore Health Resources. He’s the former CEO of Perot Systems and runs Dallas investment firm 2M Companies, Inc.

Office for Civil Rights has cranked up their HITECH-mandated spot-check HIPAA audits, with the first 20 lucky organizations being notified in December that they had been chosen (with 130 more planned for 2012.) CynergisTek and ZixCorp are running a free Webinar next week featuring former HHS HIPAA enforcer and attorney Adam Greene and some folks who participated in those first 20 audits. If anybody has time to sit in, let me know the gist.

Vince’s HIS-tory lesson this week gets a bit more personal, honoring former SMS VP Jim Carter. Vince’s stuff isn’t just for the long-timers – whippersnappers can learn from the HIT history books, too.

McKesson acquires the oncology clinical decision support tools of Proventys.

Lawson announces that its Cloverleaf integration technologies have met the highest industry standards at the IHE Connecthon.

Joint Commission investigates a complaint against University of Michigan Health System that says it waited six months before telling police that child pornography had been found on a medical resident’s flash drive in the ED. Joint Commission is considering whether the delay qualifies as a sentinel event.

Revenue cycle vendor Accretive Health, already being sued by the State of Minnesota over a lost laptop, has its debt collections license suspended by the state until it provides information about how it was using patient information for collections and how its collectors interacted with patients.

Apple CEO Tim Cook, showing more support for charitable activities than his predecessor, says the company has donated $50 million to Stanford’s hospital, most of it for new building construction. Maybe he should have looked for charities that don’t run a hugely successful business already given that Stanford Hospitals and Clinics reported a profit of $186 million in its most recent government reports, paying its president almost $2 million and the CIO $680K. I’ll say this: when I donate to charity, it’s never to a hospital, including the several I’ve worked for. They are making plenty of money already, wasting significant amounts of it, and not really helping improve health as much as just providing more episodic healthcare encounters. I’d rather support public health causes that keep people from becoming their customers, such as those addressing obesity, disease management, and preventive care.

HIE vendor Sandlot Solutions names Joseph Casper, formerly  of MedPlus, as CEO.

Session # 55: Tale of Two Health Systems: Implementing an Enterprise Data Warehouse

• Two major health systems (Orlando Health and Essentia Health) present their lessons learned and benefits achieved via an enterprise data warehouse initiative.
• Rick Schooler, Orlando Health Ken Gilles, Essentia Health
• Tuesday, February 21, 12:15 PM – 1:15 PM

Session #31: Marketing the Healthcare IT Project

• Effective marketing is a crucial part of any IT project- We will discuss innovative ways you can market to end-users and provide real examples from premier health systems to amp up the marketing initiatives within your organization.
• Chuck Christian, CIO Good Samaritan Hospital Steve Bennett, VP Kirby Partners
• Tuesday, February 21 @ 11:00-12:00 Murano 3303

Session # 42: EHRs: The New Drug Safety, Liability and Efficacy Battleground

• The rapid adoption of EHRs by U.S. providers creates a new and powerful platform to improve patient safety, professional liability protection, drug efficacy and regulatory compliance.
• Edward Fotsch, MD, Chief Executive Officer, PDR Network David Troxel, MD, Medical Director, The Doctors Company
• Tuesday, February 21, 12:15 PM-1:15 PM (Marco Polo 803)

Session # 110: A Community HIE that Makes Cents while Improving Health Location

• MyHealth Access Network, a Beacon Community in Tulsa, is focused on improving health with a community-wide infrastructure for healthcare IT learn their approach and associated ROI evaluations.
• David Kendrick MD, MPH, CEO MyHealth Access Network, a Beacon Community
• Wednesday, February 22, 1:00 PM – 2:00 PM

Session# 211: Increasing Nurse Leaders’ Informatics Skills: Building from the TIGER Competencies

• Provides a discussion of the application of TIGER competencies to create institutional education programs to increase nurse leaders’ informatics skills.
• Melissa Barthold, MSN, RN-BC, CPHIMS, FHIMSS IT Senior Clinical Solutions Consultant University of Mississippi Medical Center Jackson, Mississippi
• Friday, Feb. 24th, 2012 10-11 AM

Session #66: Extreme Makeover – ICD-10 Code Edition: Demystifying the Conversion Toolkit

• ICD-10 translation engine tools, code mapping tools, crosswalks, GEMs, code simulation tools, medical language/content management tools, computer-assisted coding software, and more — what’s a healthcare organization to use?
• Deborah Kohn, MPH, RHIA, FACHE, CPHIMS Principal Dak Systems Consulting
• Wednesday, February 22; 8:30 – 9:30 am

Session #153: How to Create a Care Coordination Team Using Spare Parts

• Learn about a primary care group’s innovative model of care coordination which combines standard EMR functionality + clinical checklists + low cost staff to make life easier for physicians and patients, while improving quality and saving time and money for everyone!
• Lyle Berkowitz, MD, FACP, FHIMSS Medical Director of IT & Innovation, Northwestern Memorial Physicians Group (NMPG) Associate Professor of Clinical Medicine, Feinberg School of Medicine at Northwestern University.
• Thursday, Feb 23: 9:45 AM – 10:45 AM (Marcello 4502)

Session #32: The New Millennium of Enterprise Patient Centric Care across the Revenue Cycle

• This presentation will review how the Cleveland Clinic is transforming traditional revenue cycle management by implementing an enterprise patient administrative management system, aligned to their Patients First Initiative.
• Lyman Sornberger, Executive Director Revenue Cycle Management, at Cleveland Clinic Health System, and Dawn Mitchell, Principal, Aspen Advisors
• Tuesday, 2/21 – 11:00am – 12:00pm

Session #406:  IT Governance for Hospitals and Health Systems

• Learn how to create an IT governance process that increases the number of projects that support your organizational strategy and are completed on-time and on-budget.
• Roger Kropf, PhD, Professor at New York University, Wagner Graduate School, and Guy Scalzi, Principal at Aspen Advisors
• 1 of only 12 HIMSS eSessions

Session #9: The People of Clinical Decision Support

• I’ll present results of a qualitative study I conducted along with OHSU’s POET research team at seven hospitals and health systems across the US focused on the types of people needed to carry out a clinical decision support program.
• Adam Wright from Brigham and Women’s Hospital in Boston
• Tuesday, February 21 @ 9:45 AM in Veronese 2503

Session #163: Applying Lean Principles to Ensure Clinician Productivity while Securing PHI

• In this session we will explore the process and results of applying Lean principles at Mahaska Health Partnership to measure clinician productivity and minimize waste when implementing security technologies.
• Kristi R. Roose Information Technology Director, Mahaska Health Partnership Dan Nikkel Continuous Improvement Director, Mahaska Health Partnership
• Thursday, February 23, 1:00 PM – 2:00 PM in Lido 3103

E-mail Mr. H.

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

I wrote this piece in February 2007.

What Paul McCartney Can Teach Providers about Contract Penalties
By Mr. HIStalk

This is top-secret provider stuff. If you work for a vendor, why not skip on down to the news items? I’m about to tell your prospects to take actions that you’ll dread.

As a hospital IT person, I would never sign a vendor’s software contract without including a variety of specific and severe performance penalties. From recent Inside Healthcare Computing articles, many or most hospitals will. I’m shocked. I like vendors, but money makes people (and companies) behave badly. Be friendly, but get everything in writing.

Vendors (software or otherwise) can say anything they want about their product’s performance and reliability. Those statements 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 (but not necessarily the most common) 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, in which case you’ll use resources to work around the problems.
• 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 vendor that has already demonstrated its willingness to take your money under false pretenses. That’s the worst case.

The biggest mistake hospitals make is uncovering 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 aren’t your best buddies. They have their bottom line price and terms. You’ve got yours. Negotiation is meeting somewhere in that middle ground, fighting for the bigger chunk of the unclaimed territory on the table. If the vendor doesn’t visibly hate you during negotiations, you’re not pushing hard enough. Nice guys and gals don’t get good deals.

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 salesperson’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 you haven’t heard the truth.

A hard-hitting, predefined penalty is your best hope for getting undivided attention when a problem arises. The cash won’t be much consolation, but it does create an automatic escalation path respected by all.

I know we all like to throw harmless little love words around like “partner” and “shared vision,” at least until you’ve signed the deal. Vendors pretend to be wounded when you sully the honeymoon bed with legal requirements. 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.

Brian Sherin is president of Besler Consulting of Princeton, NJ.

Tell me about yourself and about the company.

I got started in healthcare accidentally. I was doing an internship while I was in college, in an accounting department of a hospital. I can still see the face of the controller who I worked for at the time when I walked in, that look of, “I’m going to deal with this kid all summer?” But we got along well and I did that for two summers. I got involved in a lot of aspects of accounting, although my major was finance, not accounting per se. 

When I came out of grad school, I ended up in a very a bad economy, pretty similar to now, and I didn’t have a job. One of the guys I worked with in the accounting staff there called me and said, “Are you interested?” and I said, “Well, sure.” So I did that, and then about eight months later the controller asked me if I wanted to take the business office manager position. I lost a lot of respect for them at that point [laughs] –I thought he had better judgment than that since after, all I had virtually no experience. But he told me he had confidence in me and I could do it, so away we went.

Over the next 11 years, I moved from patient accounting to managing the overall revenue cycle, worked closely with HIM and other clinical departments. I eventually I took over on more administrative responsibilities. To this day, I’m really grateful for the guy having confidence in me at the time. He gave me an opportunity to learn so much and to set me on my career path.

As you can tell by now, I’m not an IT expert in any way, but I think from the business perspective I am very much an advocate of using technology to every advantage possible. I guess I could stretch it and say that I’m an IT user expert, or maybe advocate is a better way to put it. As I look back at my career, some of the more positive and exciting experiences I had were overseeing several HIS system implementations for the hospital. I just found them really very rewarding once completed. I’d like to do some more of that, but I haven’t been involved with those for a while. 

While still at the hospital, I talked to Phil Besler one day. He had founded the firm back in 1986 — this was probably the early ‘90s. I joined him. It was really a reimbursement firm back then. That’s all we did except some charge master work. We began to expand that and we moved into doing hospital revenue cycle consulting in the mid ‘90s. Those areas grew pretty quickly. Finally we established a coding accreditation compliance service line, which rounded out our service offerings.

Now I would define us as a financial and operational consulting firm. We have about 200 customers in 20 states and roughly 50 employees. Most of our clients are hospitals, though we count physician groups as well as other types of providers as clients. A majority of our business has been traditional consulting. 

In 2002, we did a former company called Innovative Healthcare Solutions, which we began by taking the charge master review software we had developed in-house — which I believe was in FoxPro at the time — and we developed a Web-based tool that we marketed. It was pretty exciting. We’d never done anything like that. Eventually we developed other decision support products. IHS was eventually sold to Accuro in 2005, then Accuro became part of MedAssets, I believe in 2008. 

In the last two years, we began to focus on software again. We launched our BVerified line of solutions last year. Our latest two products were launched early in January. The idea behind getting back into software and creating these solutions is that we want to be able to provide our customers these software products that allow them to receive the benefits of our expertise we’ve developed over the years, while at the same time creating the potential to drive additional benefits for our client through that software.

Between your consulting opportunities and now you’re more productized offerings, what revenue opportunities do you typically find that even pretty good hospitals and even your competitors might miss?

Most of what we’ve been doing is on the consulting basis with regard to some of our revenue recovery opportunities. We do the majority of our work as the primary vendor. However, we have found pretty significant opportunities going in either behind just solely internal processes on the part of hospitals or after other vendors. Depending on the particular issue, whether it’s on the DRG transfer rule or IME, very often we find up to 30% or so of additional revenue.

I think a lot of that has to do with just our approach. We’ve refined it very much over the years. We’ve identified some areas that we think are often overlooked either through internal processes or by other vendors. But at the same time, we’ve focused very, very heavily on the compliance aspects of it. We also have seen some processes that are not very compliant. We had a lot of input from our clients that they wanted something that they could be assured was entirely in compliance with all the rules and regs. We put a lot of effort and resource into that.

Is there a lot of concern out there about the RAC audits and all the other audits that the CMS is talking about doing?

I think there is, but my sense is it depends on what part of the country you’re in. Here in the Northeast, we haven’t seen a lot of RAC activity, but it’s almost like everyone’s waiting for the other shoe to drop. They know it’s coming — they just don’t know when. With their hands full with what they already have — with all the organizations out there doing audits and all the other demands they have on them, especially from the IT perspective — they’re very concerned, yes.

Do you think it will be like the IRS, where they will take a small sampling and make a high-profile example of any problems they find?

I don’t think that’s the way it’s necessarily going to go. Even on the RAC side, they’re still finding their way as well. I think some of it will come to that, where they’re going to realize that it’s so labor intensive to get through some of this. If you look at the recent demonstration project that CMS put out where if you want to join on, you’re essentially giving up your right to appeal short stays that are denied as inpatients, but they will allow you to bill them as outpatients. My guess is that one the reasons they’re going forward with that demonstration project is just because of the volume of appeals they’re experiencing. 

I think it’s going to take some time for everything to settle out. Eventually, you may find more of the old style initial teaching hospital audits from way back in the ‘80s, when they looked at 30 claims or 100 claims and decided that they were due $18 million. I don’t think it’s going to be quite that bad, but I think there’ll be more of that practice as we go forward.

Describe the problem with hospital readmissions and what clients are asking you to do to prepare them for that.

CMS is going to begin looking at data with regards to readmissions. They’re going to essentially identify the top quartile in hospitals in terms of unnecessary readmits or related readmits. It’s going to reduce your overall Medicare-based payment. A lot of hospitals are looking at that. It’s fairly easy to look at the Medicare data that’s out there to determine where you fall yourself within the three categories of diagnosis they’re going to be looking at. It doesn’t really necessarily tell you where you fall in relation to what quartile you’re in.

It seems to us from talking to a lot of hospitals, those who have a problem know they have a problem. In a lot of ways, they feel like they’re in a situation where there’s not a whole lot they can do to effectuate any real change in those patterns quickly. Another factor is that a lot of people don’t realize is that the readmissions include if you discharge a patient and they get readmitted to another facility. You don’t even know that, but that counts towards your readmission number. And that data is not generally available to everybody.

I think it’s something that everyone is trying to do a better job of coordinating care. Once patients leave the hospital, they’re trying to do a better job of communicating with patients, making sure patients are following through on physician orders and seeing their physician within a specified timeframe and so on. But there’s limited resources to be able to do that, and there’s limited ability to really change people’s behavior in that way.

With the emphasis on making clinical care delivery less episodic, the billing stayed episodic and only now is moving toward billing for non-piecemeal work. Are hospitals going to be able to adjust quickly with the emphasis on ACOs?

I think that’s a real problem. Physicians have had that issue over the years too, where in some situations, they’re expected to manage care well beyond when they see the patient. It’s difficult. There’s really no reimbursement for that aspect of it. I think that ultimately hospitals understand that that’s the way it’s going. Whether you believe in ACOs or feel that they’re going to be the panacea some people think they’re going to be, nonetheless, that is the way things are going.

I don’t think anyone will argue the fact that a better process to manage patients once they leave the hospital — make sure they are following certain care plans, make sure they are seeing the right types of providers in the proper timeframe — is going to reduce readmissions, it’s going to reduce inappropriate admissions, it’s going to cut down on emergency room visits, and it’s going to overall have the great potential to lower the cost of healthcare. But we’re asking a lot of providers out there that are not going to be reimbursed in any way for a lot of those activities to take that on. I think that the funding for that is going to become a really critical issue.

There’s probably not much appetite to pay more for care, and not much ability since the government’s such a large payer. I guess it’s the equivalent of telling a steakhouse, “As of next week, you’re going to offer the same menu except as a one-price buffet.”

I agree. I don’t think there’s going to be much appetite at all for the government to put out any more money for this kind of thing. I think they feel that through some of these programs such as ACOs, with some of the incentives and whatnot, that’s going to effectuate some of this. And it may, for those who decide to become ACOs or maybe are positioned to do that.

The fact is that most providers are not really positioned to become ACOs and the incentives that are there for them. Even some of the premier facilities in the country have indicated that they don’t see the advantages to going to that ACO model and getting involved in that whole program. If they don’t see the value, it’s hard to believe that any inner city hospital is going to have the funds or the abilities to be able to put any kind of model like that in place unless they’re somehow funded for it.

Hospitals are imitative. If one does it, everybody does it. If a consultant starts recommending it or it shows up in a magazine, everybody jumps in line to do it. Do you think they’ll experiment with the ACO and either back out quickly or lose their shirts before they realize maybe it wasn’t as good as it sounded?

I don’t know. I’ve done some speaking engagements and have been in a number of meetings where someone would ask, “Who here from a provider side is going to plan for being an ACO?” Almost everyone raised their hands. I think that was just because it was early on — the rules weren’t defined.

As more and more comes out with regard to what’s expected from ACOs and what the cost is going to be and the type of infrastructure you had to have in place to effectively manage an ACO, I think you’re seeing more and more back away from it. My guess is there’s not going to be a whole lot of organizations that actually go all the way through and become an ACO and actively participate in that project. So we’ll see. My guess is that as providers dig through it, they’re going to realize that there’s really not a whole lot of advantage to them.

Do you have real-world examples of what you’ve found with your BVerified process?

The very first client we had for the screening verification tool, which was really the first BVerified product we put out there, we immediately found something which looked … I won’t get into the details, but it looked very questionable. We immediately called them and it was something that they were aware of. They were actually pretty impressed that we came up with it so quickly.

Everyone’s had some kind of finding. Sometimes as you go through those, you identify that there are things that were corrected or maybe it was incorrect information that was submitted to do the verification and whatnot. But our clients have been very happy with it thus far. To them, it’s a one-stop shop. They don’t have to have multiple screening tools in place. They’ve been happy with the product and the results they’re getting out of it.

It’s to check the HHS’s database for excluded parties, correct?

Yes. It goes through and checks both federal and state databases. We can adjust that, because with regard to some state databases, there are timeframes and “how often” rules in terms of how often you have to check. We built all of that into it. Essentially it’s looking for excluded individuals. It also has some additional functionality — it allows you to verify licensure and things like that as well.

You’ve done services related to point-of-service collections. Money is being left on the table by letting patients walk away without, but consumers are pushing back about being asked for a credit card before they’re seen. How do the hospital know that they’re ready to initiate that planning for point-of-service collections and what’s involved with transitioning to that?

The time is well past when those programs should be in place. In talking to our clients, I’ve always maintained – and this goes back quite a ways – you need to start this now, because it’s not like you just put someone with a cash register at the door. It doesn’t work that way. Most hospitals serve a pretty much a specified community, and it’s a matter of changing that community’s understanding of how you function. There’s a lot of communication that has to go on with both the patient population as well as the referring physician population. They need to understand what you’re doing and why you’re doing it.

Physicians have been doing this very effectively for a long, long time. Maybe it’s not some of the same dollars that are involved in terms of physicians who are merely collecting co-pays, but I defy you to find anyone who’s covered by any kind of a managed care or a PPO plan who’s gone to their physician who’s gotten to see that doc without paying their co-insurance first. They’ve done an effective job of that, so physicians understand the need for it. 

The dollars are significantly more on the hospital side, but that can be worked through in terms of an arrangement with the patient. It takes a long time. It’s an educational process, it’s a community educational process. It’s not something you just turn the switch on overnight. What I’ve seen mostly is that hospitals have implemented it in maybe a few different areas within the hospital, but not universally. They do get pushback.

There has to be a commitment all the way up the management string, right up to the CEO and the board, that this is what we’re doing and this is how we’re going to do it. They’ve got to resist those calls that come in and say, “I was there the other day and I’ve been coming there for 30 years and now you’re asking for payment up front.” Everyone has to be on board, because as soon as you start making exceptions, it quickly loses its effectiveness.

What do you see as major areas of concern in the next five years and what should hospitals be doing now?

We’re addressing a lot of things on our end. With some of the other software tools we’ve developed, we’re trying to come up with ways that hospitals can take our expertise and our experience with a lot of things. We put them into a software tool so that the hospital can internalize them and gain greater control over some of those functions. Instead of doing it on a consulting basis, they have the ability to do it on their own. That works for some, doesn’t work for others. 

We understand that a software solution isn’t automatically the solution for everybody. We’re trying to do that because what we’re hearing from some of our clients is that they need to bring some things internally and they want to reduce their costs a little bit. That’s why we’ve done those things with the transfer DRG tool and the Medicare advantage IME tool and our revenue integrity auditor.

At a higher level, my feeling is that over the next five years, hospitals have to begin to fully integrate their clinical and their financial operations. There’s still a separation there to a large degree with a lot of hospitals. While everyone’s moving in that direction, I think it needs to be looked at more as a business. There has to be a way to bring together those two aspects of the operation in one cohesive whole.

While obviously patient care is the business you’re in and you want the highest possible quality you can get, there needs to be some control over that, in terms of how you best do that. I think that’s the whole ACO concept, which is good. I’m not convinced on the ACO model, but I think the ACO concept is good in that it makes you bring it all together, operate more cost-efficiently, and coordinate care across the whole spectrum of the services the patient’s going to receive in their inpatient, outpatient, physician, physical therapy, specialists, whatever it may be.

The most important thing over the next five years is to start looking at healthcare delivery – and I don’t mean this in any kind of impersonal way — as a business, bringing together the financial delivery of care and the clinical delivery of care so that you’re getting the most sufficient product you can.

Any concluding thoughts?

We’re experiencing the most interesting and fast-paced changes we’ve ever seen in this industry. More so than ever, the changes we’re seeing now will dramatically alter the way healthcare is delivered and managed from this point onward. Everyone’s got to be ready for it, because I don’t think there’s any turning back. There may be some stumbling along the way, but everything that’s been started now is going to move forward. As Bob Dylan said, “You better start swimming or you’ll sink like a stone, because the times they are a-changing.”

We’re changing our approach and trying to meet the changing needs of our clients. We continue to focus on trying to find all the revenue we can for our clients. We won’t stop that. That’s the reason for developing some of these software tools — to give something to our clients that has a demonstrable, compelling ROI.

It’s pretty exciting times, but they’re also very challenging times. I think the pace is only going to pick up. We’re going to see incredible rate of change over the next few years.