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 May 2007.

All Government Agencies Agree – You’re Free to Buy EMRs for Physicians, Even When it Doesn’t Make Sense
By Mr. HIStalk

The Internal Revenue Service clarified its position this week on hospitals donating technology and related services to physicians. The bottom line is that non- profits can do so without fear of losing their non-profit status.

Lots of folks (most of them vendors) were excited about loosened up Stark laws, so this announcement removed what appears to be the last barrier before the EMR spending orgy gets officially underway.

Vendors love it. Docs weren’t buying their wares when their own money was involved, so creating a misaligned incentive is the best possible outcome. If someone else is paying for dinner, I’m having both the steak and the lobster, even if I’m not likely to finish them.

I’m not sure that getting the green light to give away expensive products is great news, but I’ll try not to rain on the parade of those who do.

I’ve worked for big IDNs that provided practice management systems to affiliated physician groups. Our doctors were fairly willing to use the software we chose on their behalf because it got them paid. Even then, we heard plenty of gripes about product design, reliability, and most of all, cost (this was a simple, character-based scheduling and billing system that only the office staff used anyway.)

As little of a picnic as that was, I don’t envy bright-eyed hospital IT types who think they want to be in the physician EMR business.

One problem we had was allocating ongoing costs. Being a bureaucratic IDN, we were known for high overhead and low performance, especially compared to the doctor’s A+ certified, college dropout nephew who was willing to design networks and develop software for $15 an hour after his grocery bagging shift was over. He was cheaper, so that made us thieves, our doctor customers assumed (doctors always assume that hospitals are getting rich, underestimating the profit-sapping effects of inefficiency and inertia.)

We thought we could cover our relatively fixed cost with the number of physicians who signed on. A few bailed out, though, because of cost (or maybe value.) That forced the pie slices of those remaining to get larger, which caused a few more to reconsider — well, you get the idea. Allocation is hard, especially when the user base is shrinking.

If you’ll be charging ongoing fees, you’ll be competing solely on cost and willingness to rush over to the office (or even the doctor’s house) any time something’s not working. It’s your fault, even when the doctor’s wife/office manager brings down the network by unplugging your router to make a space for her curling iron.

The worst scenario is if the stuff you’re paying for isn’t used. Remember, your doctors weren’t buying when it was their money. Try to structure a vendor deal where they get paid only if the system gets used, otherwise, it’s just you trying to strong-arm doctors and we know how well that works (cough*CPOE*cough.)

CCHIT has certified 81 ambulatory EMR products, so cast a wider net than that handful of old-line, CIO- friendly vendors with correspondingly high price tags and old technologies. That was the whole point of certification, after all. While you can’t trust a doctor who swears he or she will use a product, you can definitely trust one who swears they won’t.

Don’t whip out the checkbook until you’ve developed an integration strategy. If you just want to give away free software, that’s fine, but otherwise, what information do you want to send and receive from your new doctor buddies? Doctors don’t want a portal, they want your information dropped into their EMR – can you do that?

Lastly, don’t be swayed by what seems to be an unstoppable trend of hospitals paying for physician systems. Magazines, consultants, vendors, and member organizations love to encourage the bandwagon effect, detaching your wallet from your brain to their benefit. If return on investment is shaky, surely you have other IT projects you can fund instead.

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Top News

Government investigators applying statistical tools to sift through HHS data find $5.6 billion in questionable Medicare billings from 2,600 pharmacies, many of them in the Medicare fraud hotbed of Miami. Some beneficiaries received hundreds of prescriptions each year (two patients received more than 1,000 prescriptions per year), while pharmacies in Baltimore, Detroit, and Tampa had unusually high narcotics dispensing. CMS administrator Marilyn Tavenner said she agrees that oversight should be improved, but doesn’t want CMS to be flooded with false leads, especially since the report does not provide examples of proven fraud.

Reader Comments

From Not a Smurf: “Re: insourcing in healthcare. What do you think about this book’s premise that American workers are being left unemployed because of the importation of RNs and MDs to work at American hospitals & other healthcare settings?” I assume we do import a lot of doctors and nurses. I’ve worked in rural hospitals where we had basically no American-born physicians, creating odd communities of extended families of doctors from mostly India, the Philippines, and Colombia taking care of people who had never been more than 50 miles from home and who often couldn’t understand a word their doctors said. Those docs were smart enough (or maybe just more ambitious) to have chosen procedure-based specialties like surgery, radiology, and cardiology instead of the lower-paying general medicine and pediatrics. And, to open their own practices instead of working for someone else. We had some horrible ones that were certainly harming patients with their obvious incompetence, but I don’t know that the numbers were disproportionate to some equally bad good old boy docs who didn’t pay much attention in their med school classes. I agree with the premise that we have more foreign healthcare workers than you might expect, but I don’t see that as necessarily bad. Foreigners usually take jobs that Americans either aren’t smart enough to do (engineering, computer science) or are too lazy to do (farming, restaurant work). I don’t buy the idea that foreign docs and nurses are stealing desirable jobs from equally qualified and willing American candidates. In the backwater places I worked, you couldn’t pay enough money to get American docs to move there from the more desirable cities — it was foreign-born docs or none at all. The supply of doctors and nurses is artificially limited by schools and licensing boards to keep incomes high anyway, so I like the idea of breaking that monopoly. We’re going to need a lot of healthcare people to care for entitled baby boomers. All the docs I know are keeping plenty busy no matter where they were born. But as I gaze down from high on my soapbox, I’ll ask: what do you think?

From ORISpilot: “Re: Andrew Brearton, CIO of St. Joseph’s Health Center in Toronto, Ontario. Resigned today due to ‘health reasons’ and will be replaced by an interim CIO until a full-time replacement is found.” Unverified.

From Pickle_Juice: “Re: heard two rumors. Partners is dumping their Soarian install in favor of Epic. Lifespan in Providence, RI is switching from Siemens (I think they were Invision, tried Soarian, but pulled back to Invision) to Epic.” Rumor #1: true. Partners has indeed chosen Epic as vendor of choice, but I haven’t seen a definitive list of what they’ll be replacing (knowing Epic, probably everything possible, but the business apps weren’t mentioned in the e-mail from the Partners CEO that was forwarded to me). Rumor #2: not true yet. I asked Lifespan SVP/CIO Carole Cotter (above) and she says Lifespan is considering five vendors, with the incumbent Siemens being one of them. The selection will take several months.

From Joey: “Re: Partners. This is a dream sale for Epic. The private offices are latched onto Partners as part of their IPA, so Epic’s sale goes far beyond the hospital itself. Partners will tell them that to stay in the IPA, they will have to get on Epic, and they will.”

From Eagle Driver: “Re: St. Luke’s in Kansas City. Just heard a wild rumor that they’re going Epic. I think they’re McKesson inpatient, Allscripts outpatient. No real information, but maybe you can check with your sources.” VP/CIO Debe Gash says they’re evaluating products, but haven’t made a decision yet. The fact that they’re evaluating products says a lot (are any Horizon customers not actively looking?)

From Blue Dog: “Re: [hospital system name omitted]. Re-evaluating their EHR strategy for owned practices in over 100 cities. [product name omitted] was picked in 2010, but has been an epic (no pun intended) failure, with no successful implementations and three botched ones. They are moving to athenaclinicals for at least a quarter of future installs. Hospital and vendor staff can’t get along and hospital leadership is so frustrated with the IT department that it’s beyond reality. Huge internal struggle. Many of the EHR issues are actually related to IT issues.” Unverified, with names removed for now. The CIO didn’t respond to my inquiry, but I’ll allow a bit more time.

HIStalk Announcements and Requests

This week on HIStalk Practice: ONC launches an Health IT Dashboard. Sermo says its iConsult app is a hit with physicians. ONC publishes a guide to privacy and security for physician offices. A Tennessee practice agrees to pay $4.36 million to settle a fraudulent claim lawsuit. ChartLogic makes a big EHR sale to a 25-provider group in Arizona. Dr. Gregg shares a juicy (and unconfirmed) rumor about his EHR vendor. It’s all good stuff, but I think Dr. Gregg’s piece is particularly thought provoking. Sign up for e-mail updates when you stop by. And thanks for reading.

We are always looking for interesting and fun content for HIStalk Practice, including contributions from providers, consultants, road warriors, or other ambulatory HIT enthusiasts. We can’t promise fame and fortune, but our other regular contributors will likely tell you that Mr. H and I are highly appreciative, occasionally offer constructive feedback, and every now and then send amusing off-the-record information. Drop me an e-mail if you are interested.

Thank you very much to those 45 generous readers who have contributed to the hat-passing I’m doing to support the four young daughters of Tim Dodson, a long-time HIStalk reader who passed away suddenly last week at 34. He was an Epic analyst with Children’s Medical Center (TX). I’ll leave the Donate button in the right column of this page for a couple of days, also mentioning that two readers (Ed Marx of Texas Health Resources and Dave Shaver of Corepoint Health) have offered to do as I did and match $250 in contributions dollar for dollar, just in case you need to be convinced to slide off the fence. I’ll be sending the money to the fund that’s been set up for the girls shortly and will give you the total. I’m sure I speak on the family’s behalf in saying that they appreciate any and all support, both emotional and financial.

Acquisitions, Funding, Business, and Stock

MEDSEEK announces that private equity firms Silver Lake Sumeru and  Essex Woodlands will finance a management buyout of the company. CEO Peter Kuhn says the change will allow the company to accelerate the expansion of its platform.

e-MDs reports a 20% increase in revenue and a 10% increase in employee count over the last year, also saying the company was profitable in 2011 and that it invested 40% of its annual revenue in R&D.

Enterprise data management vendor CommVault announces Q4 numbers: revenue up 27%, adjusted EPS $0.29 vs. $0.25. The $2.4 billion market cap company has never done an acquisition.

Vocera turns in its first quarterly report after its April 2 IPO. Its Q1 results: revenue up 26%, adjusted EPS $0.06 vs $0.07. Full-year 2012 was given as $100-102 million in revenue and non-GAAP earnings of $2.5-$3.0 million. Shares that were IPO priced at $16 are now at $23.35, including a 7% jump after the earnings announcement.

Ireland-based startup Cara Health is profiled in an Irish publication for its Patient Journey Record readmission avoidance software that will be aimed at the US market. Recently discharged patients are called by telephone and their responses to specific questions are linguistically analyzed and compared to a database of key phrases that may predict a need for readmission, allowing earlier intervention. Clinical trials of the software found that 30-day readmissions were reduced by 51%.

UK-based hospital patient care software vendor Ascribe engages William Blair & Company to explore its strategic alternatives, with speculation being that the investment banker might find a US buyer.  

Nuance announces Q2 numbers: revenue up 22%, adjusted EPS $0.43 vs. $0.32, beating expectations. Healthcare revenue was up 24%.

Greenway reports Q3 results: revenue up 52%, adjusted EPS $0.08, beating revenue expectations and with year-ago quarterly EPS not stated due to tax changes.

Sales

Banner Health Network and Aetna expand their ACO relationship to include HIE technology from Medicity for population health management and patient services.
Lutheran Healthcare (NY) selects Merge Healthcare’s iConnect solutions as its enterprise imaging platform.

Dossia (NY) selects NexJ Connected Wellness platform as part of a NYC Health Department pilot program to give patients PHR access.

People

Cognosante appoints John Calabro (OK HIE Trust) as leader of the company’s HIE practice.

EHR provider Spring Medical Systems promotes Mark Benvegnu to president and CEO. He will continue as chairman of the board.

iSALUS Healthcare, developers of OfficeEMR, names Chuck Dietzen MD (Timmy Global Health – above) chief medical officer, Randy Kidd (Stratice Healthcare) EVP/CIO, and John Brady (Stratice Healthcare) EVP/chief marketing officer.

The National Council for Prescription Drug Programs elects First Databank VP Thomas R. Bizzaro to its board of trustees.

Scott West (STC/SeeBeyond/Sun Microsystems) joins NextGate as SVP of global sales.

Announcements and Implementations

Michigan Department of Community Health, Michigan Health Connect, and Michigan Health Information Network activate real-time electronic reporting of public health information to the State of Michigan’s Care Improvement Registry using Medicity’s platform.

Baptist Health South Florida deploys Centrify Suite for access management and centralized user management.

BCBS of North Carolina and SAS announce their collaboration, with BCBSNC using SAS database analytical tools to identify patients who could benefit from specific interventions and to allow the insurance company to target its offerings and communications.

PDR Network and the iHealth Alliance announce a drug safety certification program for EHRs and e-prescribing platforms. Products earning a PDR Certified seal must contain full FDA drug labeling for prescribers, drug alerts and warnings (safety alerts, boxed warnings, recalls, and REMS Communications), adverse drug event reporting, and patient education content, all updated at least weekly. 

Veriphyr donates its patient privacy breach protection service to Gillette Children’s Specialty Healthcare (MN).

M*Modal launches its cloud-based speech understanding platform and M*Modal Fluency Direct for enabling speech in EHRs.

Government and Politics

In compliance with the HITECH Act requirement, CMS publishes the names, NPI numbers, business phone numbers, and addresses of Medicare EPs and hospitals that have successfully demonstrated MU as of March 2012. If you happen to need a free list of 44,000 providers or almost 1,000 hospitals, the lists can be downloaded in either CVS or PDF file formats.

HHS issues final rules to streamline reporting requirements for hospitals and to retire older versions of e-prescribing transactions for Medicare Part D. The regulation changes are expected to yield over $1.1 billion in savings the first year.

The Utah Division of Occupational and Professional Licensing puts its upgraded disciplinary action database online, including records of physicians, nurses, pharmacists, and other licensed healthcare professionals.

I’m impressed with The Health Datapalooza taking place in Washington, DC on June 5-6, put on by the Health Data Initiative. Speakers include some VC guys, the CEO of Aetna, Matt Miller of NPR, the executive editor of Wired magazine, former Senate Majority Leader Bill Frist, Todd Park (US CTO), Kathleen Sebelius (HHS Secretary), Atul Gawande (physician author), Dominique Dawes (former Olympian), and Farzad Mostashari (ONC). Sessions look interesting. Hospital guys like me find it hard to get time off to run around to conferences, so if you’re going and want to be my on-the-ground reporter there, let me know.

Speaking of government conferences, I’m excited that EHR design guru and HIStalk contributor Dr. Rick saw my mention of the May 22 ONC/NIST EHR usability conference and has decided to attend (and to provide a post-conference report, I assume.)

ONC announces its Health IT Dashboard, with geographic maps covering its various grant programs and HIT adoption.

Other

Imprivata announces the results of its Fifth Annual IT Trends Survey, including findings that single sign-on, virtual desktops, and remote access are the top three enablers for engaging physicians to adopt CPOE.

Speaking of Imprivata, here’s their latest cartoon (insert your own orthopedist joke here). If you’re a Scott Adams wannabe, submit your cartoon ideas here.

Finding it hard to keep track of which vendors have acquired which other vendors over the years? Check out this acquisitions family tree, graciously offered to HIStalk readers by Constantine Davides, senior analyst with Boston-based JMP Securities. It could be turned into a fun HIT trivia game, with questions such as, “ What was the coding solution vendor that Cerner bought a few years ago?” or, “What vendor bought Intelus?” I bet it will jog some good stories out of Vince for future HIS-tory presentations.

Here’s another video in honor of Nurses Week, this one recommended by a reader since it makes her think of her sister, a pediatric oncology nurse, and her patients.

University of Miami’s medical school will lay off up to 800 employees because of state budget cuts and reduced payments from struggling Jackson Health System, which itself laid off more than 900 employees earlier this year.

An employee of Waukesha Memorial Hospital (WI) is charged with embezzling $1.5 million from the hospital by submitting invoices from his wife’s painting company. Management got suspicious five years later at the large number of invoices paid to a single company, then determined that nobody had seen anyone doing any painting other than hospital employees. The employee told investigators that he wanted to make restitution, saying he estimated he owed the hospital $100K. When shown the deposited checks for $1.5 million, he said, “So I guess I probably owe them more.”

Sponsor Updates

• A group from the University of North Carolina Hospitals wins a prize for their abstract on LVAD at the UNOS Transplant Management Forum. Their work was sponsored by OTTR Chronic Care Solutions. Above are Paul Kenyon of OTTR, Randy Watkins of UNC Hospitals, and Tim Stevens of Providence Sacred Heart Medical Center & Children’s Hospital (WA) and chair of the OPTN/UNOS Transplant Administrator’s Committee.
• Bloomberg Businessweek profiles Digital Prospectors Corp.
• At this week’s Healthcare IT Institute Conference, Aventura SVP Brian Stern discusses comprehensive solutions to change the way clinicians work with HIT.
• Passport Health reports that more than 50% of the facilities listed on Thomson Reuters Top 100 Hospitals for 2012 use Passport’s eCare solution for RCM.
• Orion Health announces the release of Rhapsody Integration Engine V5.
• Medicomp Systems offers a free webinar May 24 and 30 on navigating future demands in healthcare.
• Practice Fusion profiles Andrew Bronstein,MD, an orthopedic surgeon who uses its EMR.
• Emerson Hospital (MA) goes live on the Intelligent Forms Suite from Access, launching its forms on demand functionality from Meditech.

EPtalk by Dr. Jayne

An article published in the Journal of the American Medical Informatics Association demonstrates that linking a personal health record medication review tool to the provider’s electronic health record can reduce potentially harmful medication discrepancies. The trial was cluster-randomized and included 11 primary care practices using the same personal health record. Over the 18-month study period, some practices received an intervention that provided access to a medication module capable of prompting patients to review their medications and identify potential discrepancies.

Now that the comment period for Meaningful Use Stage 2 is over, there seems to be a preponderance of medical associations commenting against it. Nearly 100 groups joined the American Medical Association in sending a 37-page letter to CMS Administrator Marilyn Tavenner. Highlights:

• Non-participants in Stage 1 should be surveyed to identify barriers to participation prior to finalizing Stage 2 requirements.
• New core measures (or Stage 1 menu measures moved to core in Stage 2) should be evaluated for “evidence of efficacy, administrative burden, costs to physicians, and technological standards.”
• Measures assessing elements outside a physician’s control (such as patient use of technology) should be avoided.
• Providers should not have to meet all 20 core measures plus clinical quality measures. Allowing providers to opt-out of a few would allow them to achieve MU with a good faith effort.
• MU rules should only apply to Medicare/Medicaid patients.
• Disparate health IT programs need to be synchronized so that providers are not penalized for participating in one over the other.

Interesting note: state medical societies not signing include California, Montana, and New York. Major organizations not signing include the American Academy of Family Physicians and the American College of Physicians.

The American Medical Association Journal of Ethics (online at virtualmentor.org) publishes an editorial discussing the need for physicians to counsel patients on material they obtain from the Internet.

HIMSS13 calls for both proposals and reviewers are still open. If you have a great story to tell, now’s the time to ensure your boss has to fund your trip to the Big Easy.

For my friends in clinical engineering, Fluke introduces a new device for simulating vital signs during patient monitor testing and calibration. I noticed the website says it’s 17 pounds lighter than its predecessor, which apparently also had the ability to simulate the new onset of a hernia.

We’re wrapping up National Nurses Week, so if you haven’t taken the time to thank a nurse (or several), you still have a couple of days to do so. On further thought, how about making it part of your everyday routine?

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

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Jonathan Teich MD is chief medical informatics officer of Elsevier.

Tell me about yourself and about Elsevier.

Elsevier is the world’s biggest producer of scientific and medical information. Traditionally that has come in the form of journals and books, and then ever increasingly over the past 20 years, more about electronic information. First as just electronic representations of those same things, but now more and more as specific electronic delivery of information for a particular need. It’s been very interesting to watch this evolution about how to turn information from these huge amounts that you have to go find into something that’s delivering what there is to you. 

I am an emergency doc in one life, still practice at Brigham and Women’s, and an informaticist for the past 20-something years. I helped with a lot of the design and led the clinical systems charge at the Brigham, working for John Glaser over about 12 years, and then went into the industrial side to try and see if I could make an even broader impact.

I spend my time between working with Elsevier in an R&D capacity and a strategic capacity, as well as representing them and the field in government and industry conversations. I’ve also spent a lot of time working with ONC over the past three years as their CDS gopher, and a lot of interesting things have come out of that. It’s a broadly motley career that seems to be working out pretty well.

There’s a lot of information out there in the form of literature and reference material, but clinical decision support never seems to quite realize the promise of actually applying that knowledge in a manner that measurably improves measurably frontline patient care. What are we doing right and what do we need to do better?

I think you’ve really hit the problem. There are places that are doing it very well, places that haven’t quite been able to do it very well, and places that have given it up altogether.

You’re right about information. A company like Elsevier … I’ve been told that we produce seven million distinct pages every year of medical content. Books, journals, whatever else. As I’m going through it, I’m an emergency doctor and I’m seeing a new patient and I have a question — the answer’s in there somewhere. One of those seven million pages has what I want to know.

Clinical decision support has a lot to do with saying, “Where is that information? Can you get me that spot without me doing a lot of work? Can I get that information and then can I make use of that information?” Typically, that’s a wide range of things. People know about alerts, order sets, care plans, and pharmacy information. More and more, how do I deliver the intelligence that I need at a particular point? 

It really has been an up and down situation. There were a number of leading institutions through the ‘90s and early part of the last decade that showed that you could do a great deal of change with preventing adverse events, reducing costs. Work we had done at the Brigham with Dave Bates and myself and others showed that we could knock off about 55% of the significant adverse drug events and the corresponding cost savings. We could show we could save a couple of million dollars a year on certain kinds of drug overuse costs and so on. Z

There’s certainly the potential for it, and certainly under some circumstances it works very well. But then as you’ve seen, when it comes to bringing it out into the open and having 6,000 hospitals and all the ambulatory practices use it, many places have been able to use it very well, other places have not.

I think that a lot of this has to do with two things: culture and information delivery. I think the culture, in terms of places where I’ve gone to see what hasn’t been working, have often led to problems with communication, problems with not involving people in the clinical decisions before the decision support goes live, problems with not getting everybody to see what’s about to happen before it happens. I think that’s been probably one of the biggest issues on that side.

On the information delivery side, some of this information is just not in its most usable form. If you try and build this 6,000 times at 6,000 hospitals, sometimes it works well and sometimes it doesn’t. There should be a way to pool everybody together to get the best delivery systems and the best information to be used by everybody.

It’s interesting the Brigham’s BICS rules that Eclipsys bought were very sound, but not widely used. Is the challenge that the underlying data just isn’t there in a way that can connect the rules to the real world? Is there a gap between what rules could do vs. what information is available to allow them work?

I haven’t had anybody ask me a question directly about BICS in a while. That’s good to hear.

The BICS rules were using data that was unique in its time, but I think it’s not unique anymore. I don’t think the problem is that we have insufficient data to get these things done. I’m sure I could construct rules that are making use of obscure data, but a great deal of what I need to know to handle basic quality measures, to handle Meaningful Use, to handle accountable care, and to handle just good practice are things that are are generally available. Most of this comes from medications and laboratory and problems and so on.

I don’t think it’s a matter of data. I do think that there hasn’t really been a good systematic way of showing somebody else at the next hospital what I’ve done at this hospital. I think that maybe some of the things that we did at the Brigham have been ported to other places that use the same IT team. But, it’s very hard to convey this in, say, a research paper and have that go along. I think that if I was going to put a technical finger on it, it’s that it’s been hard to share the techniques very well.

It’s hard to measure success or failure because when a clinician accepts the guidance, they may not enter the order and you don’t have anything documented as to why. On the other hand, then they override 95% of the warnings, you have a record of that and the implication is that warnings in general weren’t really very useful. Can decision support work without allowing clinicians to tailor their desired levels of messaging and without using more patient-specific information, making it less about interruptive warnings and more about guidance?

I think that’s a lot of it. If clinical decision support in a given institution relies on alert after alert after alert, then it’s simply not going to be something that’s accepted. Quality of care is important, but getting your work done in a timely fashion is also important. If you start getting hit with 50 alerts that are taking time out of what you’re supposed to be doing, you’re going to find a way pretty quickly to game that system and get around those.

You need to have a couple of things. There need to be ways to measure what these things are doing. I think you need to be able to understand upfront that this month, this year, we are going to make diabetes care better in our primary care population. You need to be able to be a cheerleader and do the personal side, and tell people, OK, it’s three months later — we’re getting a little better. It’s six months later, we’ve kind of planed out. Nine months later, we’re getting a lot better. I think people respond to knowing that what they’re doing is having an impact.

I also think that you need to get away from kind of doing alerts for everything. In the newer edition of Improving Outcomes with Clinical Decision Support: An Implementer’s Guide that we just published through HIMSS, we’ve said that there are 10 different types of clinical decision support. They include data displays, order sets, analytics, and they also include providing information. A lot of the things that people use that should be clinical decision support is simple information to say, how do I figure out what to do next? How do I figure out where I’m going?

I see a patient in the department. They’ve got a problem I’m not familiar with. What happens? I go off to the computer and I go look up things. I go look them up in MD Consult, or Clinical Key, the new version. I go look it up in other references. You see that all around our department, people are looking up things. But it takes time, and it’s hard to get exactly what you want. A lot of what decision support ought to be doing is giving you the knowledge that I need to get through the next task. I say that clinical decision support is all about telling me what should I do next.

At Elsevier, that’s a lot of what we’ve been doing with the development of two things. One is Clinical Key, which is the complete overhaul of the MD Consult framework. It is designed to try and filter down your questions. It’s based more on the kinds of questions that we know people to have asked in the past and tries to do as best it can in terms of funneling down the information to match up with your question.

We do that, and that’s been lying on top of the framework that we call Smart Content now. Smart Content is our effort to put semantic tagging under almost everything we do. Books are tagged. Journals are tagged to the paragraph level. The order sets are tagged. Care plans are tagged. The idea of that is that I need to be able to jump from one thing to the other, because my first task is going to be, what am I supposed to know? That may lead me to, OK, I’d better order that. That may lead me to, OK, I’d better do a procedure on that. I want to have some way of connecting these things together. 

You need to use a variety of different types of decision support for different situations. They need to be really focused and task based.

There’s a philosophic underpinning to how people view decision support. On the one hand, people think, “All those other doctors need to get these warnings, but I don’t, because I’m smarter than they are and I don’t have to worry about it.” But on the other hand, the guy who’s getting the warnings says, “I don’t need them either.” Everybody seems to want the other guy to have constant oversight via clinical decision support. Should we trust clinicians to know when they need help instead of constantly trying to find reasons to warn them?

There’s a balance. You need to have something that’s usable and friendly and acceptable to gain acceptance. Physicians and others are smarter than the baseline, but not quite as smart as we think we are.

The history of something like order sets is that whenever someone implements order sets in a hospital, everyone has this big clamor for personalized order sets. So it’s, “I’m going to do these things differently, so I want mine to look different.” People  go along with that at first because that’s what you need to do to build acceptance. Very often, about two years, later the Pharmacy and Therapeutics Committee comes around and says, “We’ve got all these things that were invented two, three years ago and they haven’t been touched and they haven’t been reviewed and they’re using things that are now considered dangerous.” They eventually decide to abandon personalized order sets. That’s one example.

In the area of alerts, should I say that I shouldn’t get a certain alert? I think that it depends on the criticality. I think I should be able to put away certain less-important things or things that I’ve seen repeatedly. I think there should be systems that do smart things like, if I’ve already heard something once on a patient, I probably don’t need to hear it again on that patient during that same admission. I would stop short of saying that I should have a switch that says, “Don’t tell me about this.” But I might have a switch that says, “Don’t tell me about this too frequently.”

The perfect decision support system is order sets. You’re repetitively using things that have been vetted and that keep you from doing anything too crazy. Somebody with enough of those could get rid of a lot of the standardized warnings about doses and drug interactions because everybody is following the same guidelines. Do you think there will be a point where order sets become so prevalent that we can move to the next level of decision support, where instead of saying, “What you did was wrong,” we say, “Here’s what you should be doing that maybe you didn’t think of?”

Order sets are excellent. One reason that order sets are so capable is, well, two reasons really. One is that they are helping you become more efficient at a task you have to do anyway. You have to write orders anyway. CPOE sometimes takes longer than the old way of handwriting. Order sets tend to make it much faster and bring that equation back even or even better. People like order sets because they’re efficient.

The other nice thing about order sets and why they are so acceptable is that you’re usually using them to support a decision and to help you with things before you do them, as opposed to changing a plan. Where decision support tends to be more onerous is where I’ve already made a plan and something comes up and says, “No, you’ve got to change your whole plan” Order sets are timed nicely.

Same thing with nursing care plans, which we don’t hear so much about. Those are timed nicely. They can help you as you’re making the decision. It’s the right timing. 

Order sets are strong and I think they can be a lot stronger. Most order sets are giving you the standard ways of doing things. We’ve been looking at order sets and how you can do them better. I think a lot of that resolves around, “Can I fine tune it in certain ways? Can I help you get down to certain nuances, certain situational aspects that take you away from the standard of care?” Because the problem with order sets sometimes that they’re too big in their quest to support everything.

I think that you’re right. Order sets are a great form of CDS, and again care plans on the nursing side. They have all the right user aspects. I think they will become more common. Probably every hospital has some anyway, but I think that they will become more common. The next step is to say, “Can we make these a little bit more data sensitive? Can we make these a little bit more flexible? Can I share them from one place to another?”

Some people would say that what clinicians want is the same tool they would use to make other decisions – a smart search engine to help them find and sift through all this wealth of material that’s out there. If you had a single body of literature like what Elsevier publishes, you could just search the whole thing and have it somehow graded or weighted or personalized in such a way that it would return meaningful data without having to actually do any thinking.

In a sense, that’s exactly what we’re trying to do, and we are. 

You’re right on target. People need information. They want to get it with as little effort as possible, which is perfectly human and perfectly reasonable. You need different information when you’re first assessing a patient than when you’re on rounds and when you’re preparing someone for discharge and so on. You want to be able to have smart filters that can give you information that is geared to a problem, geared to a set of circumstances, and geared to where you are in the workflow. Then you need to be able to get smart enough to deliver just that. 

Among Elsevier’s book catalog, there’s certainly all the things you’d want in books and among the journals. It’s a combination of things that we publish and things that are published elsewhere, of course. But, really, there’s a hierarchy of what people want to know for different tasks. We are really attempting to do exactly that, which is to focus down on a given task process, a given problem, and try and deliver it, ideally down to the paragraph level, down to the table level. Whatever we can do that’s more focused, that’s quick, the better.

I’ve said in lectures that nowadays, given a choice between good information and quick information, people will take quick information every time. We have to make something that’s both good and quick, because that’s the competition.

It’s like imaging. Everybody says, “It’s not a diagnostic quality imaging,” but they are diagnosing from it anyway. In reality, people will settle for whatever they have available, especially in your field. In the emergency department, you can’t wait for perfection. Maybe asking a system to be perfect is not only not realistic, it isn’t even necessary.

I think that’s true. You obviously want to be correct. What you don’t want to do is put out incorrect or inconsistent information. But you don’t have to put out exhaustive information. Maybe this is the mindset of the emergency physician, where I want to do something that’s good, but something that I can do in the next 15 minutes to an hour.

There is a focused amount of information that I need for anything. I don’t need to know the entire pathophysiology of a given disease to treat it when my question is, “Do I need to do a CT or an MR, or do I need to include angiography?” What I really need is the answer and a reasonable amount of information that can help me justify the answer for the clinical purpose. But when I want to read about exactly the full history of it, let me make a bookmark and let the same system hang it up for me and I can read it when I go home.

Some folks say it just needs to work as well as Amazon, which gives me what everybody else is reading and things I might want to order with a particular product. You’re not reading every factoid in a 20-year-old medical journal. Maybe you say, “Most of what’s in that journal is not important. You just need 2% of it, and we’ll make you smart about that 2%, but then you can go find the rest when you need it.”

We have to explore what new technologies are doing, particularly new social technologies. I don’t necessarily want to have everybody in the country writing into a medical textbook because that has to be carefully curated, has to be carefully checked and triple checked. But there is the possibility, for example, that you could use a social media tool to let people say to each other, “This is by far the best article on diagnosing a pulmonary embolism.” 

Imagine residents in particular, who talk all the time and who rely on each other for their training and their information. Imagine if you could put up your catalog of literature, and people wouldn’t necessarily add to it, but they could say, “This is the place to go. This is the place that I like.” Eventually if 4,000 people say that, maybe there’s something to it. That’s the concept we’re looking at. It’s got its ups and downs.

I do a lecture on social media in medicine. Certainly there’s a lot of space on the curve between reliable information and well-shared information. But I think that you can use certain kinds of crowd techniques and social techniques to great advantage in this world, especially when sifting through all the millions of pages.

People are used to the idea of grading evidence, but maybe not grading each piece of literature. It seems that another alternative would be to  ask each time that that warning, recommendation, guidance is presented whether that information was useful. If not, then downgrade it so it doesn’t come up as high.

Potentially. I think that you have to look carefully at, is there a difference between what someone wants to see and what someone should see? Usually those things line up, but you have to be careful about being so faithful to that that you miss something important because it’s inconvenient.

There’s also the challenge of how vendors implement the hooks into that information. The clinicians might say, “I’m a nephrologist. I’m tired of seeing serum creatinine warnings,” whereas the data vendor says, “Look, it’s not our fault. We’ve got the data. Talk to your systems vendor who doesn’t use it correctly and tell them to fine tune it in a way that makes sense to you.”

Very much so. As I’ve said a couple of times, the ability to share effective CDS across sites is really important. One of the reasons why we haven’t seen universal acceptance is that there’s too much rework going on, and the rework is inconsistent.

I’ve been working with ONC. I’ve been working with the Advancing CDS project that RAND and Partners did, and on how to make a practical way of taking the various types of CDS interventions and putting them into a form that can be easily shared, and that therefore can be easily integrated. 

If I’m Epic and Siemens and Cerner, I may say, “Gee, I really can’t do this right now because I don’t what’s going to win, what going to be the national standard.” But if we can get enough agreement on how these things should look, enough to make a reasonable XML schema that corresponds to certain CDS interventions, then I can get the big vendors to say, “Now we’re confident enough that this is what’s going to happen that we can go and bring this in.”

I think that it’s really important. I think that integration of knowledge and CDS into data and EHRs should be more advanced, and needs to be more advanced if we’re going to fulfill our mission of best care for all the best people.

I had lunch today with a fellow ED doc who’s doing a small project. He’s a child abuse specialist. He’s doing a small project on building a system that allows you to document certain kinds of aspects of a child’s exam and then be able to come back to you with best practices, recommendations, referrals, and so on. He asked me, “Can I get this to work inside all the different vendor systems?” I said, “You know, today that’s a little hard to do because each one’s going to be different and even different implementations of the same system is going to be different.” I suggested that he probably needs to put this out as a service that his practitioners can call on independently. That‘s going to be a way to do things smoothly and a way to do things consistently, but I think if I was an EHR vendor, I’d want to be able to incorporate those.

Any concluding thoughts?

The reason we’re doing electronic health records, in my mind, is that they facilitate the efficiency and the quality of care and the safety of care. CDS has always been an obvious choice of something that can help facilitate that. If you just use the EHRs as data sources, that’s good, but if you can do it and also get recommendations on the right thing to do, that’s even better.

A lot of us, like myself, struggle to know what the right answer is in a given time. Anything we can do to make this more universal, more implementable, more valuable, is going to be utterly good. We really need this. I think we need to see this incorporated more deeply into systems.

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Top News

Merge Healthcare announces Q1 results: revenue up 16%, EPS -$0.02 vs. –$0.04 GAAP, $0.13 vs. $0.15 non-GAAP. Both revenue and earnings fell short of expectations, sending shares reeling to a 36% drop on Tuesday and trimming the company’s market cap to $229 million. The company also announced that it will divide itself into two operating divisions, with CEO Jeff Surges continuing to lead the Merge Healthcare group (85% of revenue) and Justin Dearborn leading Merge DNA, which will focus on consumer health stations and clinical trials software (the former eTrials Worldwide, which Merge acquired in 2009). Both groups are moving to subscription-based pricing, with the resulting revenue recognition changes causing the Q1 numbers miss, according to Merge.

Reader Comments

 

From Smith: “Re: Accretive Health. Pulling out all the stops, having Chicago Mayor Rahm Emmanuel ask the Attorney General to back off.” There’s never a shortage of political scumbaggery in Chicago, but in this case it’s hard to decide which is more unsavory: Accretive presumably calling in favors or Emmanuel granting them. The mayor provides his unsolicited counsel, saying he doesn’t want the Minnesota AG talking to Accretive customers about its alleged strong-arm hospital collections tactics until she first talks to Accretive CEO Mary Tolan. AG Lori Swanson was unimpressed, saying Tolan has declined to meet with her, also declaring, “This is a law enforcement matter. Unfortunately, Accretive appears to address it as a political one. It has retained or contacted numerous heavyweights in the national Democratic Party.” That’s Emmanuel hanging out with Tolan in the photo above from the Chicago Tribune and Swanson on the right. Being an Obama coattail-rider doesn’t seem to carry the clout it once did given that fellow Democrat Swanson is happy to tell Emmanuel to take a hike.

From Gino: “Re: HIStalk from Epic. It’s a sign of a healthy atmosphere when a number of employees can’t access an industry blog so they bring it up to their supervisors, who bring it up to the COO, who contacts the blog.” I agree. Carl gets extra points for not only taking ownership of the problem reported to him by employees, but also for slyly slipping in my grammar pet peeve in closing his e-mail to me with, “Any way (not anyway) you could help me out?”

From Reality TV Watcher: “Re: The Amazing Race. The finale reminded me of an EHR implementation – no shortcuts to completing an install. Also typical that the Epic team made it work, regardless.” Dave and Rachel Brown of Madison, WI were revealed Sunday night as the million-dollar winners of CBS’s The Amazing Race. She’s a project manager for Epic. If she stays at Epic, you’ll know it’s a pretty good place to work, just like that billionaire lady who hasn’t given up her day job there either.

From Not Very Innovative: “Re: CMS’s first round of innovation grants. Winners announced this morning from thousands of submissions. I’m probably being a sore loser, but I really do think we would see more mileage out of this taxpayer money if awards were given to younger, smaller organizations (maybe some private companies, too). If these huge hospital systems and research universities were going to be doing the kind of innovation that CMS is looking for, one might think they would have already done it out of the hundreds of millions CMS pays most of them each year. Total grant funding may eventually get to $1 billion.” The only project I’d heard of (and was impressed by) was telemedicine-based Project ECHO, and that was because I interviewed its director, Sanjeev Arora MD, in 2009. Otherwise, I have no idea if any of the projects will amount to a hill of beans, and for those large organizations you mentioned, I’m just as skeptical as you are. If those highly profitable non-profits had it in their power to improve outcomes and reduce costs but didn’t bother to do so until Uncle Sam made it rain, shame on them.

From Kathy: “Re: Nurses Week. We have a talented HCA Communications Group who wrote, sang, and starred in this video.” Nice and catchy.

From Charles Rivers: “Re: Partners HealthCare. Rumor is they’ve started to notify physicians of their decision to implement Epic. Any truth to that? I’m curious if how they’ll switch PCHI practices from GE Centricity or LMR.” Unverified, but several folks have told me that Partners has chosen Epic, which is hardly surprising news if true other than that former Partners CIO John Glaser runs Siemens, which I’ve heard was the other vendor being considered.

HIStalk Announcements and Requests

I mentioned previously that long-time HIStalk reader Tim Dodson, senior analyst with Children’s Medical Center in Texas, died unexpectedly this past Friday, May 4 at 34 years of age. Here’s what Ed Marx had to say about him:

Tim Dodson’s death is tragic on many levels. He will be missed by his beautiful family, community, and those who ever had the opportunity to work with him. Tim was a reverse mentor of mine and I learned so much from him. One quick fun memory to share. Tim revered Epic and especially CEO Judy. The bulk of Tim’s career was working for health systems that used Epic and he had just about every Epic certification known to man. One day Judy was in our HQ to meet with our C-Suite and was making her way up to our Board Room. I called Tim to our Board Room and the timing worked out that we were in our foyer as Judy walked in. So Tim was able to meet one of the people he most admired in life. He was beside himself and ironically had worn an Epic polo shirt that day. Judy was gracious with her time and completely engaged. I will never forget the glow on his face. The only times I saw Tim with a brighter glow was when he was with his family. Tim, you are missed already. You will not be forgotten.

The memorial service will be Saturday at 1:00 PM at Park Springs Bible Church in Arlington, TX.

Tim leaves his wife Wendy and four daughters. I’ll hazard a guess that a 34-year-old hospital analyst isn’t leaving a million-dollar trust fund, so if you’d like to help his family out, click the Donate button in the right column below the poll and give whatever amount you like. I’ll match the first $250 in donations dollar for dollar. Our collective donation, which I’ll flag as being from Tim’s fellow HIStalk readers, will go to a fund that has been set up to help raise the little girls. Thanks.

Note: this is a PayPal donation function, which I’ve used before for other charitable endeavors. You don’t need a PayPal account – instructions will be displayed on the left side of the page for making a straight credit card payment and printing a receipt. If you have trouble with it, let me know how much you’d like to donate and I will e-mail you a money request from Google Checkout.

Acquisitions, Funding, Business, and Stock

The board of directors of Allscripts approves a Stockholder Rights Plan that would allow stockholders to buy Allscripts shares at a 50% discount in the event of a hostile takeover attempt. Allscripts says the move was not done in response to any current  attempts, but says the stock price does not adequately reflect the company’s long-term potential. The plan effectively means management has to approve any takeover, even one that would represent a financial windfall to its shareholders.

Mediware reports Q3 numbers: revenue up 22%, EPS $0.22 vs. $0.17. The company attributes the improved numbers to its blood bank and blood center systems and its Department of Defense projects.

Emdeon acquires TC3 Health, a provider of cost containment solutions for healthcare payers.

Israel-based RTLS vendor AeroScout will be sold to an unnamed “international infrastructure and services company” for $240 million.

Sales

Stilwell Memorial Hospital (OK) selects Medsphere’s OpenVista.

Beaumont Health System (MI) contracts for the HealthShare platform from InterSystems to share patient information and analytics across internal and external systems.

The VA awards Harris Corporation a one-year, $1.2 million contract to design and develop a rules-based eligibility system.

University of Louisville Physicians (MO) contracts with Peak 10 to provide IT infrastructure and disaster recovery services.

UC Irvine Medical Center (CA) selects iSirona’s device connectivity solution to connect its medical devices to Allscripts EMR and to export data to a research database.

People

Mission Health (NC) appoints Marc B. Westle DO as SVP of innovation. He was formerly president and CEO of Mission Medical Associates.

Press Ganey hires Greg Ericson (Maxim Healthcare) as corporate SVP and CIO.

Ernst and Young names MedSynergies CEO J. R. Thomas a finalist in its Entrepreneur of the Year 2012 program for the Southwest Area North.

Jocelyn DeWitt PhD is named VP/CIO of University of Wisconsin Health. She was previously with University of Michigan Hospitals and Health Centers.

Pamela Banchy RN is named CIO of Summa Western Reserve Hospital (OH). She was previously with Summa Health System.

Prognosis HIS names Dustin R. Whisenhunt (TransUnion) as EVP of client solutions.

Death

Cathy Mueller, VP of client experience at Cerner, died Sunday, May 6 after a long battle with cancer. She was 65.

Announcements and Implementations

The Indiana HIE launches SeeMyRadiology.com’s cloud-based imaging platform, giving physicians and hospitals access to shared radiology images.

Columbus Regional Health (IN) will go live on its $15 million Cerner system on June 24.

Sonoma Valley Hospital (CA) will go live on McKesson Paragon on May 22.

M*Modal will interface its computer-assisted coding solution with 3M’s coding and reimbursement system.

McKesson releases a 2012 update to its InterQual clinical criteria tool, adding condition-specific capabilities for managing admissions and length of stay.

Craneware announces GA of enhancements to Insight Medical Necessity, including customize keyword pick lists, commercial payor prior authorization, and expanded reporting capabilities.

Government and Politics

NIST and ONC will host an EHR usability workshop, Creating Usable EHRs: A User-Centered Design Best Practices Workshop, on Tuesday, May 22 in Gaithersburg, MD. Farzad Mostashari MD (ONC) and Jacob Reider MD (ONC) will provide a welcome and overview. Beyond the usability workshops, technical guidance on NIST’s guide for EHR usability will be offered. It’s not a budget-buster: registration is $35 and hotel rooms are $125, provided you get signed up before the 60-attendee registration cutoff is reached. CORRECTION: the afternoon session has two tracks. One is a hands-on session by IDEO, a highly notable design and innovation consultancy whose presence indicates a strong government interest in truly user-centered, out-of-the-box thinking EHR design, which is impressive. That’s the session with the 60-participant limit. The other afternoon track of presentations has no limit on the number of participants, and there’s no registration cutoff.

Innovation and Research

Researchers at University of Arkansas develop the e-bra, wired with sensors that transmit blood pressure, body temperature, respiratory rate, oxygen consumption, and a full EKG via Bluetooth or WiFi. The bra, intended for female athletes, can be programmed to send alerts if it detects abnormalities. The team plans to create a vest version for men.

Other

athenahealth earns the #4 spot on Forbes annual Fast Tech 25 list of “growth kings.” Quality Systems, the parent company of NextGen, was ranked 19th.

KLAS reviews Microsoft Amalga, which it says has limited sales and a 14-point drop in performance scores over the past two years. Half of the interviewed customers said its implementation and maintenance costs were higher than they expected. Others noted that the product is flexible, but complicated.

The Kansas City newspaper profiles Cerner’s Neal Patterson and reveals a few lesser-known facts about his background and personal life, including:

• He and his brothers shared chores growing up on the outhouse-equipped family farm in Oklahoma
• To put himself through college, Patterson and his brothers raised hogs
• He visits a certain “dive bar” a few times a year with friends to discuss politics, business, and family
• Patterson’s wife Jean is battling cancer.

The 2nd International Summit on the Future of Health Privacy will be held June 6-7 at the Georgetown Law Center in Washington, DC. Speakers include Farzad Mostashari MD of ONC, Ross Anderson PhD of the University of Cambridge Computer Laboratory, and Latanya Sweeney PhD of Carnegie Mellon University. It’s sponsored by Patient Privacy Rights.

The wife of Army Chief Nurse Captain Bruce Clark, deployed in Afghanistan, watches her husband die 7,500 miles away during their Skype video chat. She tried frantically for two hours to contact someone in the military to check on him as the video feed continued. The army is investigating, but say they do not suspect foul play.

Memorial Hermann Hospital (TX) will run a Twittercast of a live brain surgery on Wednesday, May 9, with live tweeting and delayed photos and video.

A UK hospital nurse apologizes for the care she gave to a newly admitted 91-year-old patient who later died. Abnormal results from labs drawn immediately after his arrival were posted on the computer and called in by the lab, but the agency nurse did not alert doctors. In addition, the patient was never given the antibiotics that had been ordered. The hospital says it has has increased training, now requires senior employees to sign off on the assessment, has moved patient details from the white board to an electronic system, and has issued a mobile phone to the charge nurse so the lab could make direct contact. The hospital also banned the agency nurse.

In Canada, Hospital for Sick Children rolls out Pain Squad, an iPhone game app it developed that helps children communicate the pain symptoms they’re experiencing. Several TV crime show stars appear on it. I noticed Toronto-born Enrico Colantoni — who I know only as Keith Mars from the excellent Veronica Mars – at the 2:19 mark. The video suggests that the app will be made available (sold, I assume) throughout Canada and the US.

UnitedHealth Group reaches $100 billion in annual sales, buoyed by 71 acquisitions in 12 years.

Sponsor Updates

• Medicomp CEO David Lareau discusses HIEs and the data tsunami they are creating in a guest article.
• OTTR Chronic Care Solutions will participate in next month’s American Transplant Congress convention in Boston.
• PatientKeeper hosts its user group conference this week in Cambridge, MA.
• Shareable Ink partners with Medical Web Technologies to integrate preoperative information collected through Medical Web’s One Medical Passport system with Shareable Ink’s intraoperative solution.
• The County of Fairfax Virginia, a MED3OOO customer, earns recognition from CMS for its 100% accuracy rate in billing of emergency medical services.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

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In Honor of One Very Special Nurse
By Lisa Reichard, RN

Our Heroes

Captain Donna Rowe and fellow servicemen

As nurses, we are called to work in emergency rooms, school-based clinics, homeless shelters, and even war zones. I recently had the distinct honor and privilege to meet and interview Army Captain Donna Rowe, RN, for Nurse’s Week. Donna entered the US Army in 1964 through the Student Nurse Corps Program (ROTC). She was assigned to Vietnam: 3rd Field Hospital-Saigon as the head nurse in the emergency room/triage area from 1968-1969.

“At times, Vietnam War veterans have been portrayed as dropouts or drug addicts,” said Rowe. “This is far from the truth. They were the best our country had to offer.“ She said, “I have to tell you about the men and women I went to war with before I can tell you my story.“

“My generation instilled in us courage, compassion, and patriotism. When we entered the army, we were taught duty, honor, and love of our country. This is what our parents had already taught us – how to be good Americans. Halfway was not acceptable. Contrary to popular belief, most who served in Vietnam –74%, actually – were volunteers, not draftees. I was an ‘old woman’ when I was there at 25 years old. The average age of those who served in Vietnam was 21. The average age of the men there was 18,” said Rowe.

In Washington, DC, there are 58,267 names on the Vietnam Veteran’s Memorial Wall.  Of these, 33,000 belong to service members who were 18 years old.

“Today, the average age of those serving is 26,” Rowe explained. “We were very young men and women sent to war by a country that, when we came home, hated us. This is why not many vets told their stories.”

Donna then began to pull out photos to share from her scrapbook.

“There were 11,000 women who served in Vietnam, 98% of whom were Army nurses,” said Rowe. “We were ER nurses cross-trained in OR and we worked to cover trauma seven days a week, 365 days a year. Nurses saw the worst. Eight were killed in action. For those who served, families suffered, the sacrifice was great, and the transition was tough coming home. We came home one by one to ridicule. Many were not welcomed back as heroes. They called us baby killers.”

Baby Kathleen

Specialist Darrell Warren, Baby Kathleen, Richard Hock, and Captain Donna Rowe

This is the true story about brave American men and a nurse who saved a baby’s life in the middle of a war.

It was May 15, 1969. Rowe had only 30 days left on her tour of duty. The ER area at her hospital was capable of handling 225 casualties at a time, and averaged 700-900 per day during the height of the Tet Offensive.

In a Viet Cong attack on a village that day, everyone was killed except a baby girl who had been found severely wounded in her dead mother’s arms. The mother had died trying to protect her child.

Rowe received a radio message that eight medevac helicopters were on their way to the hospital, each with at least 10 casualties aboard. ER triage priority status went to US servicemen, then US civilians, allied forces, South Vietnamese troops, and then Vietnamese civilians. (Rowe explained they were not allowed to treat civilians because they had their own hospitals.)

“We were in the offensive mode and supplies were short,” said Rowe. “We worked at a school turned into a hospital in the heart of Saigon. I got a radio call from a pilot saying he needed immediate permission to land because he had a critically wounded infant on board. The chopper had already been turned down by other hospitals and ours was its last hope.”

“I knew right from wrong,” she recalled. “I remembered what my mother said to me as I was leaving my hometown of Sterling, MA, to go to war: ‘Always do the right thing, Donna.’ So I turned to my sergeant with the radio and said, ‘Tell him that the Third Field Hospital will receive them.’” She accepted the baby against standing military policy.

“My sergeant then said, ‘You’re going to take some hell for this, Captain.’ I said, ‘What can they do to us? Send us to the front lines of Vietnam? We are already in hell.’”

”Our ambulance met the Dustoff at the helipad. Her dead mother’s arms had to be broken to release the baby from her tightly wrapped, protective arms. The medic rushed the baby into the ER and told me, ‘Dear God, Captain, this baby is dying on us and they killed everybody in her village.’ The North Vietnamese had wiped out the village.”

Rowe continued, “Specialist Richard Hock, one of my best combat-trained medics, took the baby from the ambulance drivers. He immediately realized the baby was in respiratory distress due to bleeding and fragmentation wounds in her chest and abdomen. We got a breathing tube into her with the smallest tube we had in triage, put a manual breathing bag on it, and Richard took over breathing for this little one until we turned her over to the operating room staff several distressing minutes later.”

“The Triage doctor ordered a full-body screen on her, so we rushed the baby to the X-ray room to locate shrapnel to be removed in surgery. On the way from X-ray to the operating room, I saw Father Luke Sullivan, our Catholic Chaplain, and pulled him into the crowd that was half-running down the hospital corridor. Fearing the baby might die at any moment and knowing that if baptized she would have a place to stay, if she recovered, at the Saint Elizabeth Catholic orphanage, I told him ‘Father, come with us. You have to baptize this baby.’”

“Father Sullivan used water from the sink to sprinkle on her tiny forehead and said, ‘I baptize thee …” he looked at me for a name. A name, a name …. I remembered the Irish song my father sang to me while dancing me across the floor as a child, ‘I’ll Take You Home Again, Kathleen,’ so I blurted out quickly, “Name her Kathleen Fields!’ Kathleen from the Irish ballad and Fields because we were at the 3rd Field Hospital.”

“Father Sullivan stated the baptismal rights then looked around the gurney moving by fast, and said, ‘And your Godparents are Specialist Medic Darrel Warren, Specialist Richard Hock, and Captain Donna Rowe.’ The three of us became Godparents that day, joining with a Catholic priest to help with a tiny bit of God’s work while rushing this baby to life-saving surgery.”

“A few days after Kathleen arrived, three soldiers in combat gear came into the hospital. They asked if the hospital had treated a wounded baby and if it had survived. Rowe directed them to Kathleen’s room, where they visited briefly, then headed out. As they passed me, one of the men said, ‘Thank you.’ Those combat troops did something exceptional and wonderful because they could have kept right on walking. They were compassionate and caring. They were Americans."

“After about two weeks,” Rowe explained, “Kathleen was healthy enough to be transferred to St. Elizabeth’s orphanage.” Rowe told the men to scrounge extra food from the hospital mess to take with the baby to the orphanage. An American Naval officer and his wife then adopted Kathleen.

The Need For Technology

“We had no Internet or electronic health records,” Rowe explained. “I truly wish that each soldier would have had a flash drive on them with all of their medical history and information instead of a dog tag. The reality is that a lot of times, the boys did not want to wear the dog tags around their necks. They did not want them clanking when they were walking by in the brush. We would receive the injured with no ID, medical history, or any information. Hand-held devices to enter patient data from multiple locations would have been very helpful in the battlefield environment.”

Today, the Department of Defense and the Department of Veterans Affairs operate the two largest health systems in the United States. They now use integrated, comprehensive clinical application suites that work together to create a longitudinal view of the veteran’s electronic health record. Deployed medical professionals use these on the front lines to streamline medical logistics and enhance situational awareness for tactical forces, as well as promote continuity of care.

Reunion and Update

Specialist Richard Hock, Kathleen Epps (" Baby Kathleen"), and Captain Donna Rowe

After 34 years, Rowe and her colleagues got to hold their "baby" again. Rowe, Hock, and Kathleen were re-united in April 2003 in Fort Sam Houston, TX. Kathleen had been Googling names on her baptismal certificate hoping to find answers. She finally got to meet Rowe and Hock. It was a truly special and emotional reunion for all. “Baby Kathleen” is now Kathleen Epps. She lives in California with her husband and their four beautiful daughters.

Hock, who was a paramedic in Georgia at the time of his reunion with Rowe and Kathleen, remembered the baby as, “A bright spot in a very bad time. She made all the rest of it bearable. She became a beautiful woman with a beautiful family. It is the great American dream all over again."

Kathleen and Specialist Hock, who passed away a year after their reunion, are featured in “The Kathleen Story” segment of the World Film Festival’s award-winning Vietnam War documentary film, In the Shadow of the Blade. Darrell Warren, formerly of Tucson, Arizona, is still living out west. 

Never Forget

Donna received the Vietnam Service Ribbon and Army Commendation Medal. Forty years later, she now travels the country, unpaid, to tell her story. Today, Donna lives with her husband, Colonel (Ret.) Al Rowe, former four-term president of the Georgia Vietnam Veteran’s Alliance. They have two sons. She is a real estate broker in Georgia.

Donna said she would like all to remember that we still have women and men serving in harm’s way – the sons and daughters of the Vietnam vets. “Let’s make sure that these men and women do not come home to a country that hates them or treats them with disrespect of disdain like we had to deal with,” she adds.

Finally, I asked Donna, How we can we show our appreciation for veterans who have served?”

“When you are out and you see a serviceman or service woman in uniform,” she replied, “offer to buy them their meal. Look them in the eye and give them a big thank you for their sacrifice and service to our country.”

Lisa Reichard, RN, BSN is director of business development at Billian’s HealthDATA.

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