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Morning Headlines 4/8/14

April 7, 2014 Headlines No Comments

10 years after the revolution

Modern Healthcare recounts the history of the ONC and the impact each of the previous four national coordinators has had on shaping US health IT policy.

Proposed Risk-Based Regulatory Framework and Strategy for Health Information Technology Report; Notice to Public of Availability of the Report and Web Site Location; Request for Comments

The FDA begins accepting public comments on the FDASIA Health IT Report. The comment period ends July 7, 2014.

Kaiser Permanente Northern California Department of Research to notify participants of potential breach

Kaiser Permanente notifies 5,100 patients of a data breach that potentially exposed full names, age, gender, address, race, medical record number, and lab results. The breach, Kaisers fourth, stems from a malware-infected server that was being used to store research data.

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April 7, 2014 Headlines No Comments

Curbside Consult with Dr. Jayne 4/7/14

April 7, 2014 Dr. Jayne 3 Comments

I renewed my battle today with Big University Medical Center in trying to get my information corrected on its patient portal. Unfortunately, my efforts were derailed by a much more sinister problem – basic office chaos.

Luckily I’m a nice, stable patient so I only have to visit Big University’s outpatient clinic once a year. They run chronically late. I’ve learned to always schedule the first appointment of the morning so I can have a chance to make it to my own office before noon. I make sure to arrive on time if not early because they tend to triple (if not quadruple) book appointments and I want to be the first of the cohort to be roomed. I also bring plenty of reading material so I don’t go out of my mind when I inevitably end up waiting.

I shared the elevator with a member of the office staff who was reviewing a printed patient appointment schedule (including names, appointment reasons, and dates of birth.) I’m not sure why anyone would need to take home a printed schedule since they have a big-time EHR system with remote access and plenty of redundancy and they definitely shouldn’t have been reviewing it openly in the elevator.

I hit the floor 15 minutes early (as instructed by my appointment reminder that came through the patient portal) only to find the doors locked and six patients standing in the hallway. The weather was decent, so bad roads or traffic weren’t a viable excuse. They finally opened the doors just a few minutes before my appointment time and all the patients hustled to the check-in desk.

Since the office doesn’t use sign-in sheets (purportedly for HIPAA purposes) they told everyone to sit down and they would call us up in appointment order. Most of the patients were retirees and began grumbling. While we were waiting, we were treated (via the open floor plan check-in desk) to one of the receptionists chatting about some birthday party she was invited to.

By now, it was past the first appointment time and we got to watch her start up her computer, stow her personal items, then walk away. 

My process improvement brain had engaged. I decided to do an impromptu time and motion study. She was gone four minutes and came back with an open cup of coffee. I know there are no OSHA requirements about coffee at a desk, but there ought to be some rules about open liquids and eating around computers. Not to mention that slurping coffee in front of patients is unprofessional. 

The first receptionist had checked in two patients and had called me up before the second one was ready to start working. The receptionist apologized about my wait. I mentioned that their reminders tell everyone to come early. She said she knew it was a problem and they’ve asked to have the message modified several times because they don’t open early. They didn’t have a printed patient information form to verify, but rather read all our demographics aloud and asked for verbal verification.

I felt bad asking her about my patient portal problem and spared her the long story. I simply asked if they had a help desk number I could try before I left the office since all the demographics are correct at the practices where I’m seen but are wrong on the portal. The only advice she could offer was to try the help feature from within the portal.

By this time, they had four patients checked in. It was 15 minutes after the first appointment time (assuming I was actually in the first slot as I had requested) and not a single patient had been called back by the clinical staff.

I was placed in an exam room with the door left open. While waiting for the patient care technician to start my visit, I was treated to conversations about other patients coming later in the day, various people walking back and forth chatting about their weekend activities, and a physician who normally doesn’t work at the satellite location who didn’t know what exam rooms he should work from or who his assistant would be. Not exactly a vote of confidence for patient privacy or engagement.

Last year my physician had used a scribe to document my visit in the EHR. I figured at least once they would try to blame the EHR for the delays. As they started my visit, I realized they wouldn’t be scapegoating the EHR – the office had gone back to paper. The tech started documenting my visit on a photocopied paper template. She did reference the electronic allergies documented in the EHR and re-documented them on paper, so score one for patient safety. She also reviewed the previous note input by the scribe as well as a “backup” paper note that apparently was documented during my last visit.

I let her know I wanted to talk about a new concern that popped up in the three months I waited for my appointment. She responded by letting me know my physician was no longer caring for “routine follow up” patients and I would have to find a new doctor if the new concern didn’t turn out to be anything serious. I’ve already been handed off multiple times within this practice, so I’m no stranger to starting over, but I thought the timing was poor.

I finally saw the physician 45 minutes after my scheduled appointment. She remembered that I’m a member of the community teaching faculty for Big University and offered to keep me as a patient even though my new concern turned out to be nothing. I should probably feel grateful to not have to change physicians again, but I think I’m going to anyway. Their office is a mess and I get aggravated every time I go. Simple things like a) cutting the personal chatter while there are multiple patients waiting; b) being vigilant about behavior when the practice has an open floor plan; and c) manifesting obvious “hustle” when you know you’re late opening would go a long way towards reducing that aggravation.

Now they’re not using EHR any more, so my data isn’t available to share with other physicians. There’s not an advantage of staying there vs. finding a physician at one of the other institutions in town. If my records are going to be in silos, it doesn’t really matter if the silos are 20 miles apart or right next door. The clinic always posts a loss and blames it on the number of Medicaid and charity patients they see, but after several years of this routine, I’m fairly convinced that poor management has as much to do with it as patient mix.

I’ve never received a patient satisfaction survey from this location, but hope I get one today. I’ve got some choice recommendations to share with them, although I don’t think it will make much of a difference. It doesn’t matter how much we spend on IT or whether the systems have outstanding usability if we can’t get back to the basics and actually manage our offices, whether they’re academic clinics, private practices, or hospital outpatient departments.

Making sure that IT functions support our mission by synchronizing automated reminder messages with actual office practice, having help desk support for patient-facing systems, and ensuring staff come in early enough to turn their computers on before they start assisting patients are a must as well. There are numerous stressors on all our healthcare systems and personnel. We have to come up with ways to fix them.

Have any creative ideas? Email me.

Email Dr. Jayne.

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April 7, 2014 Dr. Jayne 3 Comments

HIStalk Interviews C.T. Lin, MD, CMIO, University of Colorado Health

April 7, 2014 Interviews 1 Comment

C. T. Lin, MD, FACP is CMIO at University of Colorado Health.



Tell me about yourself and the health system.

My title is chief medical information officer of UC Health. We were just University of Colorado Hospital and now we are now a five-hospital partnership.

That role allows me to continue to practice medicine, both inpatient and outpatient. It’s about 20 percent of my job to see patients in general and internal medicine. Then 80 percent of my job is overseeing the deployment of our electronic health record, the physician-computer interface, and the information flow through the organization.


Is it important that you continue to see patients to be successful in the other 80 percent of your job?

Yes, both for my own sanity and a reality check. Because I feel like if I stop seeing patients, I become more of a suit and less of a healthcare provider. Also because, as one of my colleagues said,  you have to eat your own dog food sometimes. I find that to be a helpful grounding. I also enjoy seeing patients. So for several reasons, I think it’s important for me to continue.


You’ve used the terms “secretive” and “paternalistic” about hospitals sharing patient information with the patients themselves. Is that a challenge in most places and is it changing?

Yes and yes. It’s a challenge in many places. I’ve been talking about opening up the patient’s chart for both online communication as well as release of test results — and soon, opening up their progress notes — for over a decade. We started working on this in 2002.

Even now — perhaps a little bit less so than back then — there’s a lot of resistance from physicians, from administrators, to thinking that, “Why would we? This is doctor’s work. This is not patient information. It’s too hard to explain. it’s going to increase our workload.” There’s lot of potential fears, and unfortunately, there’s very little research data.

It’s a little better. We’re helping to contribute to the data. But a lot of it’s theoretical fear with no grounding in the research data or real-life experience.


There’s not a lot of pressure being brought on hospitals and doctors to force the issue. Are there any signs of a growing movement that will increase expectations?

I agree that there’s not a lot of pressure. There’s not a lot of organized patient pressure, aside from the Society for Participatory Medicine. You probably have interviewed Danny Sands or he’s been a contributor before. I really like what that group is doing. In fact, we’ve published in their journal as well, in terms of our views on trying to be more transparent.

But aside from groups like that, which are applying some pressure, hospitals do not feel a lot of direct pressure from their individual patients. Meaningful Use has helped with that in terms of saying that certain fraction of your patients need to receive and be able to download and transmit their own patient information. But that’s viewed as a government regulation, not as the right thing to do just yet. So unfortunately, that’s the case.


Describe how the My Health Connection portal supports how patients want the healthcare system to work.

Patients want to be treated with respect. They want doctors to be responsive to them. They want to have convenience of accessing advice. 

We make it so hard for them. We say that our office hours are from here to here. You can then talk to an on-call person, who may or may not know you. We put high school graduates on the phones so that when patients have symptoms, you have to struggle through the first line of defense with the front desk staff. If you’re lucky, maybe you get the triage nurse. And boy, it’s all nearly unheard of that you actually get to talk to the doctor on the telephone.

Part of that is intentional, because we think that doctors are overworked, and part of it is old structure. Allowing us to have online transactions allows patients to bypass all of that. They can get directly to medical knowledge. They can get directly to opinions from others. They can get directly to other patients’ experience, as well as get directly to their doctor.

This improves patient satisfaction, but threatens the hierarchy of the doctor being in the center of the spider web. Sometimes they’re not any more. Sometimes they’re not up on the latest research on Familial Mediterranean Fever, whereas the patient spent 12 hours reading on the latest thing. The hierarchy is being overturned. Physicians who are not ready for this change are being very much threatened by it.


Is today’s practice of medicine configured correctly for the expectations of population health management, where instead of seeing patients sitting in front of you, you are managing patients who may not have reached out to you at all?

Boy, that’s an hour’s conversation. Yes, I think that medicine is not configured appropriately for the coming pressure of population health management. 

We have several big things standing in our way. One is the payment structure, which we still are in for the most part fee-for-service. That’s beginning to change and it is changing in the right direction. In some ways, it’s back to the future where we had capitated care and you were paid per-member, per-month. You could be motivated to say, for my 2,500 patients in my panel, it’s more efficient for me to make phone calls. In some cases, my staff to make phone calls, in some cases, me to do online conversations. Then restrict in-person visits to my sickest, most complex patients.

If we were paid for that sort of model, which I think is coming, then online transactions will become a much more attractive option for physicians, who currently look at online transactions as stealing from my mouth because I don’t get to bill for that work at this point.


Will motivation change in the right direction under a risk-based or value-based model?

I hope so. Certain organizations have tried this a couple of times before with variable success. I don’t have a crystal ball, but I’m hopeful that payment reform will push us much more towards online or creative ways of not forcing patients to come see us in clinic.


All of us in healthcare are patients ourselves at one time or another and we’re usually just as unhappy as everyone else with the result. Do you hear a lot of those stories?

Yes, but unfortunately less so from the decision makers in the organization. Does that make sense? I mean, you hear it in meetings occasionally, “Hey, I was really frustrated when my mother, XYZ.” But the folks who really need to internalize that need to be the C-suite folks who need to say, you know, this is so important to us that we need to move forward.

We had a CEO, this was a couple of CEOs ago, who really championed and passed for us. He had a saying: “We should not make any changes in our systems unless a patient feels a beneficial impact.” I thought that was a brilliant way of taking a filter towards all of the activities at the hospital and the clinics.


Is the health system using patient input for more substantial decision-making in areas that would have been strictly in the medical domain before?

Yes, we’re starting to. We formed a patient and family-centered care group. It’s a 30-member panel of former and current patients who meet monthly. We frequently take topics to them.

For example, when we have concerns or complaints from patients about, “You released this test result too soon,” or, “How come you wait a whole week to give me this test result? I think you need to change that,” it’s no longer a C.T. plus a couple of physician champions making a decision. We take that to the PFCC group and we say, “One of your patient colleagues says this. What do you guys think?” Then they give us feedback on that sort of thing. Increasingly, we’re trying to insert one of the PFCC representatives into many of our committees for hospital decision making in general, but that’s a slow process.

I borrowed John Halamka and CareGroup’s rules on release of test results to patients. To this day, when I go to the Epic meetings and formerly Allscripts meetings and talk about our policy on test results release, people are aghast that we are this aggressive. I think the rules are to release all blood tests with no delay, with the exception of HIV and genetics testing. Then we release all plain film results with no delay. In fact, patients see it the same time as the doctor does, with only a seven-day delay on CAT scans, MRIs, and PET scans, and then a 14-day delay in pathology. That served us well since 2009, so it’s been five years now.

Then we’re moving towards OpenNotes. We were invited to be part of the Open Notes project back in 2011, but it turns out that was the year that we were deploying Epic and ripping everything out from underneath all the doctors’ feet. We did not have an appetite to do that. But we’re looking to get primary care into OpenNotes by summer of this year.


Is the primary patient benefit of giving patients access to their results that they can be relieved at getting a normal result, or do they have other reactions?

What we’re seeing from patients is, “Why is there any delay? This is about me. This is not for you to sit on and think about for a week or two. I want to know for myself. And if I have a question, I have Google and millions of hits and pages I can read about, so that by the time I have an interaction with my doctor, I can have an intelligent question.” That was perhaps the biggest push from our patients who value the immediate release.

Secondarily, we insist that our physicians also send an interpretation message along, but we ask patients their forgiveness that it could take up to two business days for our doctors to comment on the test result. Commonly, they’ll get their lipid panel, and then two days later, their doctor will say, “This looks pretty good and here’s what I would recommend next.” 

In fact, one of my patients said, “What I really like about your system is that not only is it on my portal, but my portal’s mobile on my phone. It’s like having my doctor in my pocket. It’s really a very positive loop.” 

The other thing that patients tell us is, “When you show this to us this transparently, it means you have nothing to hide. I don’t often look at my test results in real time, but the fact that I get a ding and know that it’s on its way and you’re not hiding anything from me really increases my trust in the organization.”


It has always puzzled me that for inpatients, there’s no patient equivalent of the medication administration record or a daily itinerary. We make the patients sit there in a box and either come to them or wheel them out when we want something. Do you see any pressure to make them feel more in charge during their admission?

Absolutely. In fact, I think it was Tom Delbanco who wrote a nice opinion piece challenging physicians on the inpatient side that just because the paradigm is that we never share anything with a patient, is that truly the best care? He challenges us, and I agree, that having the patient look over their med list allows them to get more educated; allowing a family member to look it over as well. It’s another set of eyes for safety. 

We are striving to move in that direction. The challenge is, even we don’t know sometimes what’s happening with the patient that day. The primary care team comes by and says, we consulted GI, we think you might need an endoscopy. A few hours later, the GI team comes by. They have to decide whether endoscopy is the right thing to do for this patient and whether or not to bump someone else off the schedule so that this patient gets the endoscopy. The plans may change three or four times during the day. 

Being able to show that to the patient in a way that’s comprehensible. The patient wakes up in the morning and says, where’s my schedule that says my endoscopy is at two? Well, five times during the day that schedule plan will have changed. Is that worse or better for the patient to see that you’re on the schedule, you’re not on the schedule, you’re at the end of the day, you’re at 2:00. No, you’re off the schedule again. “What are you guys doing? Are you not talking to each other? This is crazy.” 

We have some practical things we have to solve in order to be able to present something to the patient that makes sense and that doesn’t increase anxiety.


Is the system so illogical that to expose any of it to a patient can do nothing but harm?

I don’t necessarily agree with it, but it’s not a straightforward, obvious answer of, “Let’s just open the kimono, it’ll be great.” That’s not true.

At the same time — I know I’m talking out of both sides of my mouth — I want to push hard for transparency. But you have to leaven that with some realistic expectation that it appears to be chaotic unless you are very familiar with how a hospital works. The first time you see it, you’re like, “What the heck is going on here?”

Releasing test results on the inpatients is something else that we have written about. But if you go to JOPM, the Journal of Participatory Medicine, we wrote a two-page editorial or case study about a patient who we had signed up through My Doctor’s Office and clinic when they were a transplant candidate. This patient underwent a transplant and went into the ICU. When he was unconscious, his wife was using his portal to access inpatient test results because we did not filter them out. 

As a consequence, the patient was telling the nurse, “Hey, that potassium result is back, how come you’re not doing anything about it?” We had an emergency call from that nurse to our office saying, “I didn’t realize that patients could get their own test results. This is a terrible idea. You need to turn this off. You are ruining my ability to care for this patient.” 

That alarmed us. We did not make a change, but we went to investigate. The next nurse on shift, said, “This is the best thing ever. I finally have a way to engage the patient and the family in a way that I could never do before. I could ask them, you know, if you would just let me know when you see that test result — I’m looking as well, but when you see that blood gas come back and I haven’t seen it yet, feel free to give me a buzz. I can come over and we can have a talk about what we’re doing and why.” 

We have completely divergent ICU opinions about whether this is a good idea for test results release on the inpatient. We think fundamentally it’s the right thing, but we have to retrain our nurses and our physicians and our staff, to be able to accommodate that sort of conversation, because in many cases we’re not ready for it.


What technology possibilities have the most promise to improve patient engagement in the next three to five years?

Three to five years is a long horizon. Three to five years ago, there was no such thing as an iPhone. 

We’re completely upside down, and I think mobile has really moved along a great way. It would be neat to have patients be able to gather virtual teams to care for them. Moving into the future, personalized medicine is a big catch phrase, but means different things to different people. In some cases, it means being able to use my genetics and customize a treatment for me. That’s been well written about.

What’s been a little bit less written about is personalized medicine, where for a patient can aggregate a group of experts that he wishes to put together, not necessarily what the physician wants to put together, and be able to have a multi-disciplinary conversation. I’m not exactly sure what form that takes, but you could have a primary care-internal medicine input, you could have a cardiology input, you could have a pulmonary input and some way — whether it’s asynchronous or synchronous conversation — get your experts to communicate together about your care.

That would be an astounding way of moving forward using transparent records and transparent communication as a foundation. I’m not quite sure exactly what that looks like yet.


Do you have any final thoughts?

I wear a couple of hats in addition to my CMIO hat. One of them is on physician-patient communication. I teach a workshop at University of Colorado to our medical students and our residents called “Difficult Physician-Patient Relationships.” There are communication tools that we teach that, unfortunately, many of my colleagues don’t regularly use. What’s worse is that when we move to electronic tools like personal health records and electronic health records, we know that emotional connections between patients and physicians are 60 percent body language and 30 percent tone of voice and pace of speaking. It’s only about 10 percent the actual words that you use.

When you strip away 90 percent of a connection between a physician and patient and leave the words behind, it’s proportionally more difficult to establish a good relationship. I’m not sure many people are looking at that unintended consequence as we’re moving to virtual communication and virtual relationships. There’s probably a need for explicit retraining of physicians to handle an altered relationship in order to continue to derive the most value from it going forward.

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April 7, 2014 Interviews 1 Comment

Morning Headlines 4/7/14

April 6, 2014 Headlines No Comments

IMS Health raises $1.3B in 2014′s second-biggest IPO

IMS Health completes its IPO, selling 65 million shares at $20 and raising $1.3 billion for the company. Stock prices closed at $23 Friday, up 15 percent, at the end of its first day of trading.

5 Things About States With Problem-Plagued Health Exchanges

Oregon, Maryland, Massachusetts, Nevada, and Hawaii are named as having the worst health insurance exchange marketplaces in the country.

Oversold Conditions For Athenahealth

In trading on Friday, analysts watching key financial indicators warned that Athenahealth’s stock had entered into oversold territory. The stock closed down 11 percent by the end of trading Friday.

Beebe rolls out $33 million electronic records system

Beebe Healthcare (DE) goes live on its $33 million Cerner system, concluding a nine-month implementation and a two-year vendor selection process.

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April 6, 2014 Headlines No Comments

Monday Morning Update 4/7/14

April 5, 2014 News 4 Comments

Top News


Thoughts on the months-late FDASIA report (based on an earlier work group report) that proposes minimal FDA oversight of healthcare information technology:

  • Vendors should be breathing a sigh of relief. The report contains nothing new and in fact takes FDA further away from having health IT responsibilities.
  • The report proposes that IT vendors continue to be self-regulated without FDA’s involvement, turfing any new responsibilities to ONC rather than FDA.
  • The report is intended to stimulate discussion about what other parties might do. FDA’s only to-do is to “actively engage stakeholders” to implement the framework the report proposes. In other words, the report doesn’t impose responsibilities on anyone.
  • The report seems uncomfortable addressing the issue that an IT system may or may not be safe depending on how its users implement and maintain it, which is a clear distinction compared to single-purpose medical devices approved for use in specific ways. That may have been the overriding factor – vendors could product a perfectly safe IT system that is rendered unsafe by how a customer does with it.
  • Products will be regulated only if they post significant risk to patient safety. FDA does not propose regulating anything it isn’t already regulating. If it’s not a medical device, FDA won’t regulate it. The FDA’s definition is above, although it is more appropriate for distinguishing a medical device from a drug than for determining whether a given information technology is a medical device.
  • The report proposes grouping products into three categories, but that’s irrelevant from a regulatory standpoint since the medical device category would continue to be the only one regulated.
  • FDA’s recent Class 1 recall of an anesthesia information system that displayed the wrong patient information seems at odds with the draft, which says that FDA will focus only on the medical device portion of such a system.
  • It’s still user beware when it comes to clinical decision support systems, order entry, and results reporting since FDA proposes no change in their current unregulated state.
  • The report suggests that ONC create a Health IT Safety Center in collaboration with FDA, FCC, and AHRQ, which in effect puts IT patient safety under ONC’s purview rather than FDA’s.
  • The report says that while ONC’s certification program addresses only EHRs, it has the authority to certify other health IT systems. That’s an interesting observation given that “certification” as it exists today only affects providers interested in collecting government handouts, but the implication seems to be that such certification should address all vendors and users. 
  • Better interoperability standards and testing criteria are needed, the report says.
  • The report urges adoption of practices for healthcare IT implementation that address installation, customization, training, contracting, and downtime, suggesting the use of ONC’s SAFER Guides as a starting point.
  • The report proposes that vendors and products undergo “conformity assessment” that could include product certification, testing, inspection, or vendor attestations. It suggests private industry conformity assessments except in situations where patient safety is critical, in which case government assessments would be appropriate. It mentions NIST’s usability standards.
  • The report notes that vendor contract terms and customer fear of liability impede the free flow of information.
  • The report agrees with IOM in suggesting that vendors be required to list products that include any degree of patient risk with ONC. That’s a new suggestion, that ONC require software vendors to register products that meet specific criteria.
  • The report has a 90-day comment period, although I could find no stated process for submitting comments.

The FDASIA’s original work group whose recommendations from last summer were incorporated into this report contained an industry-friendly mix of members. By my count, 15 of the 30 members represent vendors or investors, six come from government or associations, four are academics, three are providers, one is from a testing organization, and one is a consumer.

Reader Comments


From Jack: “Re: John Muir Health. It has been a long time coming, but we’ve arrived: our state-of-the-art electronic health record (EHR) and revenue cycle system are now live within John Muir Health! With today’s go-live, all of our hospitals, outpatient clinics, Home Health, John Muir Medical Group practices and several IPA practices are on our single, integrated EHR, as are our patients’ health records. This is great news for John Muir Health, and even better news for the patients and communities we serve. With the entire health system up and running on Epic, all patients will benefit from improved service and care coordination.”

HIStalk Announcements and Requests


Only 12 percent of respondents say they’ve benefitted as a patient from an HIE. New poll to your right: what force is to blame for the delay in ICD-10 enforcement? Clicking a radio button alone doesn’t provide much insight, which is why it would be swell if you’d click the “Comments” link at the bottom of the poll after voting to explain your position.

Thanks to the following sponsors, new and renewing, that recently supported HIStalk, HIStalk Practice, and HIStalk Connect. Click a logo for more information.


Listening: San Diego-based No Knife, apparently defunct since 2003 other than a few reunion shows. The were kind of emo-indie with quite a bit of complexity. Also: the re-formed and touring Zombies, with Rod Argent and Colin Blunstone (both 68 years old) sounding amazing on new stuff as well as “Time of the Season,” “She’s Not There” and Argent’s “Hold Your Head Up.”


I added my Twitter support to the Thunderclap project of OpenNotes. As a patient, I should able to see the notes providers have made about me. The fact that this is a controversial issue tells you how paternalistic and patient-unfriendly healthcare is.

The Twitter word that signals someone is about to do some stealth bragging: “honored” (us when humbly but firmly announcing their recent success in being published, featured as a speaker, or given a high-visibility role.)

Upcoming Webinars

April 9 (Wednesday) 1:00 p.m. ET. Think Beyond EDW: Using Your Data to Transform, Part 1 – Avoiding Analysis Paralysis. Sponsored by Premier. Presenters: Kristy Drollinger, senior director of population health analytics, Fairview Health Services; J.D. Whitlock, corporate director of clinical and business intelligence, Catholic Health Partners; Sean Cassidy, general manager of information technology services emerging business unit, Premier, Inc. Are you ready to invest in an integrated data platform? Do you have a strategy to make the information accessible and actionable? How will enterprise data warehousing transform care delivery? There’s more to data analytics than simply deploying an EDW. Learn what goes into becoming an information-driven enterprise in the first webinar in this series.

April 16 (Wednesday) 11:00 a.m. ET. Panel Discussion: Documents, EMRs, and Healthcare Processes. Sponsored by Levi, Ray & Shoup. Presenters: Charles Harris, senior technical lead, Duke University Health System; Ron Peel, technical advisor, LRS; and John Howerter, SVP of enterprise output management, LRS. IT department in hospitals implementing EMRs often overlook the role of document-driven workflows. Prescriptions, specimen labels, and discharge orders, and other critical documents must be reliably delivered with minimal impact on IT and clinical staff. This panel discussion will discuss the evolving use of documents in the “paperless/less-paper” environment.

Acquisitions, Funding, Business, and Stock


Interesting points on the big IPO of IMS Health. The company was taken private a few years ago and its three main private equity investors (who bought in for $5.2 billion) will nearly triple their money by taking it public again. As often happens when the private money guys take control, IMS has loaded itself with debt along the way, jumping from $1.3 billion in debt before they got involved to a current $4.9 billion. It will use the IPO proceeds to pay the debt down to $3.95 billion. Annual revenue is $2.5 billion.


Shares of athenahealth plunged 11 percent on Friday, with shares dropping 28 percent in the past month.


Etransmedia Technology licenses its Connect2Care patient engagement platform to Merge Healthcare.



Gary Lakin (Microsoft) is named CEO of Australia-based oncology vendor charmhealth.

Announcements and Implementations


Scanadu starts distributing its wildly hyped $199 tricorder-type diagnostic to its Indiegogo backers, but has to stop when it finds a several problems, including algorithm errors, incorrect temperature readouts, and breakdown of the machinery that creates the device’s case. The Scanadu Scout can’t be sold until approved by FDA, so the backers had to sign up as study participants. With those kinds of problems, it’s a long shot that FDA will ever approve the device.

Government and Politics 

US CTO Todd Park has been minimally visible since the rollout fiasco and the ensuing Congressional subpoena, but he shared celebratory champagne with contractor QSSI early Tuesday morning after the site exceeded its goal of enrolling 7 million people.

The Wall Street Journal recaps the five states with the most problem-plagued health insurance exchanges, all covered here previously: (1) Oregon (still not working); (2) Maryland (dumping its dysfunctional system and moving to the one Connecticut developed); (3) Massachusetts (still not working); (4) Nevada (carriers are being sent incorrect information); and (5) Hawaii (not being used because state law already required employers to provide insurance).

Influential House lawmakers continued Thursday to press the Department of Defense and VA for failing to create a single EHR that would follow service members during and after their service. According to Rep. Rodney Frelinghuysen (R-NJ), who chairs the committee that funds the DoD, “It’s enormously frustrating. It makes us angry. … This is way beyond the claims backup VA has. It’s pretty damn important.” Rep. Pete Vicslosky (D-IN) added, “We fought a world war in four years. We’re talking interoperability of electronic medical records from 2008 to 2017, and I’m appalled.” The DoD’s assistant secretary of defense for health affairs says the current approach is to allow the two separate systems to talk to each other, which is says has been a problem nationally and why DoD wants to buy its own commercial product for $11 billion instead of using the VA’s VistA for free.


The State of Connecticut says that Windows XP, which finally goes off support Tuesday after Microsoft replaced it in 2008, still runs 20 percent of its computers, including all of the Department of Corrections and 43 laboratory instruments. The state is planning to pay Microsoft $250,000 to continue receiving Windows XP security patches, which may or may not keep it safe from potential HIPAA violations for running an unsupported and potentially compromised operating system. According to Microsoft, “Businesses that are governed by regulatory obligations such as HIPAA may find that they are no longer able to satisfy compliance requirements.” Another report finds that 77 percent of British companies still run XP and only a third of those surveyed plan to upgrade.


The Missouri House sends a bill to the Senate entitled the “Second Amendment Preservation Act” that would make it illegal for a healthcare professional to use an EMR that requires information about a patient’s access to firearms.

Innovation and Research

Maybe we really do need Amazon to get into healthcare. Check out its new Dash device that allows easy ordering through its AmazonFresh grocery delivery program (only available in Southern California, San Francisco, and Seattle for now.)


Billionaire AOL founder Steve Case decides on a whim to invest $100,000 each in all 10 startup teams pitching at the inaugural Google for Entrepreneurs Day. Among the companies funded is Nashville-based InvisionHeart, a Vanderbilt spinoff that is developing technology that converts EKGs to digital form for sharing in the cloud.



The local paper covers the $33 million Cerner go-live at Beebe Medical Center (DE), featuring CMIO Jeff Hawtof, MD.

The two HIEs located in Columbia, MO (Missouri Health Connection and Tiger Institute Health Alliance) say they may talk about sharing information despite disagreements that arose when Missouri Health Connection demanded that Tiger Institute pay it. The current setup means that two Columbia hospitals could be close together but unable to share information because each participates in a different HIE.


Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre.

More news: HIStalk Practice, HIStalk Connect.


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April 5, 2014 News 4 Comments

Time Capsule: Can’t We All Just Get Along? Why IT and Clinical Jobs are Different

April 4, 2014 Time Capsule 5 Comments

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 April 2010.

Can’t We All Just Get Along? Why IT and Clinical Jobs are Different
By Mr. HIStalk


I worked several years in hospitals before I went over to the IT dark side, spending time in both frontline patient care and operational management. It’s a lot different than working in IT. For those who’ve spent their entire healthcare careers sitting at a desk in front of a monitor, I thought I’d point out some of those differences as I see them.

The most dramatic difference is the timeline. IT people are the Pentagon generals fretting over long-term plans and organizational structure. Clinicians are the ground troops who are under siege by an enemy of superior number, hoping only to survive until the end of their shifts. Picture the soldiers in “Platoon” sitting in on a Pentagon press briefing — that’s how IT project meetings go down when clinicians are invited. Fragging is inevitable.

The biggest divide between IT people and patient care employees is that those people on the front lines don’t get to eat lunch out. Ask a surgery nurse about good restaurants and they’ll only know about close-by Chinese buffets willing to box up group order takeout clamshell boxes for 20 co-workers. Meanwhile, the IT people know all the fancy places with great appetizers and patio dining, although they don’t always know the prices since vendors often pick up the tab and even drive (anyone who knows anything about hospital parking will see the value in being picked up and dropped off curbside).

Team relationships are different for the front-liners. Clinical job skills are theoretically interchangeable, so the biggest difference between one nurse and another doing similar work is their attitude and work ethic. They don’t get to coast because they’re the only Oracle DBA or the last surviving in-house COBOL programmer. Out on the floors, nothing matters except what you got done during your last shift and how well you supported those around you. 

In my experience, IT’ers stab each other in the back a lot more. It’s an organizational behaviorist’s dream to put a bunch of Type A IT management people in a conference room and watch them skillfully undercut each other, lobby for suck-up points with the ranking person in the room, and dodge ugly assignments, all without being obvious.

Non-IT’ers are not nearly as subtle in the art of war. If they get mad, there will definitely be shouting, scowling, and storming out of the room. Their blow-ups are more spectacular, but are over almost immediately and everybody makes up, most likely with immediate hugs all around and a cake brought from home the next day (frontline workers eat on the job a lot). Come to think of it, that matches the timeline above — IT people are playing an intricate, involved chess game while the frontline workers go right for the boxing gloves.

Clinical people are blunt compared to their reserved and polished IT counterparts. If an application sucks, they’ll tell the CIO directly. They don’t mind ripping the "helpless” desk in front of the people who manage it or to complain that all the IT’ers are fast asleep in their beds when the network crashes at 2 a.m. Out on the floors, communication is urgent and potentially life-saving, so the ability to be soothing and politically correct is not valued. IT skin toughens a little after dealing with crusty night shift nurses who call people by their last names or that 25-year OR veteran who can make cardiac surgeons cry. You might as well expect eye-rolling and watch-glancing if you drag out a 45-minute PowerPoint that’s more propaganda than useful information.

Floor people don’t know or care about C-level management. To 90 percent of hospital employees, "management" means a nurse manager, supervisor, or ancillary department manager, not the $500K suits sitting in the really nice offices. They have probably never seen a hospital office that had good furniture, secretaries, and carpet on the floor. They also question (probably rightfully so) whether those suits really understand what it’s like to actually deliver the services that hospitals are paid to deliver. To the frontline worker (and, truth be told, probably to patients as well), nobody is vital to the mission if they aren’t working weekends and holidays. That’s why IT executives make a big show out of bringing in donuts at 6 a.m. during go-lives.

The biggest dividing line is salary, of course. IT pays better than actually delivering patient care, so IT is always stealing clinicians away from the bedside. That doesn’t win friends and influence people.

I can’t say one job is better than the other. Working on the floor is great because you can go home on time tired, but knowing exactly what you accomplished and you get to start over the next day with a clean slate. IT is a slog because it’s just the same old thing day after day, with little feeling of progress or individual accomplishment.

All things considered, though, I’d take the higher salary. Plus, eating lunch out whenever you want is undeniably cool.

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April 4, 2014 Time Capsule 5 Comments

HIStalk Interviews Robert Kahn, MD, Faculty Lead for Population Health, Cincinnati Children’s Hospital

April 4, 2014 Interviews 1 Comment

Robert Kahn, MD, MPH is professor of pediatrics, associate director of the Division of General and Community Pediatrics, and faculty lead for population health at Cincinnati Children’s Hospital of Cincinnati, OH.


Tell me about yourself and the program.

I’m a professor of pediatrics at University of Cincinnati and the Cincinnati Children’s Hospital. I’m a general pediatrician, but also with a degree in public health. 

My interests have always been with the broader circles of influence on kids. Not just are they getting the right shots and the right medicine, but obviously kids live in families, families live in communities, and there are a whole lot of other influences that determine how well a child is doing and how they are in their development. 

To that end, in 2010 the hospital developed four county-wide health goals around asthma, injury, infant mortality, and obesity. Because of my interests, they asked me to help co-lead that effort, thinking how does a quaternary care hospital begin to engage more deeply in achieving population health goals? That’s the background to some of these projects that then involve through electronic health record and helping bridge between what a physician would normally do in a day-to-day clinic filled with patients to begin thinking about community and population health.


Can you give a brief background on population health management, particularly that involving the public health issues in children that you mentioned?

Population health management refers typically in two different ways. One is, how is my total panel of patients doing? How can I get a high-level overview of everyone I’ve seen? How are all my patients with obesity or with asthma doing? How should I shift my overall care and allocation of resources?

What we’re doing here in addition to that is thinking, what about all the children we’re not seeing who have asthma? How should we think differently about improving their outcomes, even if they aren’t going to walk in our door? For us in Hamilton County in southwest Ohio, with 180,000 kids zero to 17, we wanted to begin a journey to say, what would it take to improve the health of all kids?

I would say we’re very early in that effort. We started in just a couple of neighborhoods to think about population health outcomes for that neighborhood. For example, in the city of Norwood, which is nested within Cincinnati, we know there are about 800 households with children under four. We wanted to think about what would it take to reduce injuries in homes with those kids. Our head of trauma surgery, who typically spends all his time in the operating room or in the emergency room helping these kids, has helped lead a team to think in a population way about injuries in the city of Norwood.


Do you feel vindicated in a way that you were early on in something that now everyone wants to figure out?

[Laughs] I’m not sure I feel vindicated. I’m excited that more and more people are interested. I’m really excited to think that maybe payment mechanisms and healthcare reform will start bringing financial incentives to do the prevention-oriented work that could help out in the community.


You mentioned that some of your work involves targeting neighborhoods and subsections of neighborhoods. Describe how you use geocoding.

There’s two ways we’ve used geocoding. We use electronic health records and part of that is geocoding. One is around clinical care and one is around population health management. 

In clinical care, we’ve used the electronic health record to help drive key questions about these other influences. We have one of the largest training programs for pediatricians in the country. If we set in front of them a series of questions in electronic health record about the quality of the housing, what school does the child go to and how are they doing there, are they able to make ends meet, what we can do is drive the discussion to these determinants that are outside of the typical exam room or outside of the typical physiology of an individual child. That then leads everyone to say, hey, where does this child live? What is his address? What other resources in the neighborhood we can get to the child? That’s at the clinical level.

At the population health management level, what we can do is take every single asthma admission in the past year. We know the minute they register. We have their address. We can then link that address to a latitude and a longitude, or what people typically call geocoding. We can say hey, that means they live in this census tract or this neighborhood. Then you can begin to look for patterns of where the asthma is particularly high, or patterns of where the injury or prematurity is high. 

The minute you put a dot on a map, it shifts the center of gravity away from just in the exam room in that moment to, my goodness, I didn’t realize I had 15 kids admitted from a 10-block radius, or a 20-block radius. What’s going on there that might lead to such high admissions rates for asthma or a high emergency room visits for injury? Now we’ve gotten to the point where literally on a monthly basis we can chart injury rates, prematurity rates, and asthma admission rates from each of the 70 to 80 neighborhoods in Hamilton County.


How do you draw a box around how far you can go being a hospital-based project? Do you put people on the street or link up with social agencies?

That’s a fantastic, very insightful question. People are really excited about it, but the right question is, where does our mission end and another person’s mission or another organization’s mission start?

This is a frontier time. On the journey, we’re out there trying to figure out what is it we can do, and then how do we catalyze new relationships, new missions, shared missions. 

As an example, I do not see my job as improving housing for children, even if they have asthma. I see my job is to know that mold, cockroaches, water damage, or a negligent landlord are important in exacerbating this child’s asthma. But then I really need to find the agency in the community that has a mission to improve that housing. So to me, it’s about building new partnerships. Staying true to my mission about improving health and delivering healthcare, but doing it in a way that engages other people with complementary missions. 

We work very closely with the Legal Aid Society of Greater Cincinnati. One of the great cases we had is a child with asthma, middle of the summer. The mother came to the doctor with the child. The doctor said, tell me about the child’s housing. The mother said, well, I’ve wanted to put an air conditioner in, it’s 100 degrees outside in Cincinnati in mid-summer, but the landlord told me I’d be evicted if I put an air conditioner in my apartment. It turned out we had had three other cases with the exact same story in the past week, all with different doctors. Because of our relationship with Legal Aid, they asked the really simple question I don’t need to ask, which is, who’s this landlord?

It turned out this landlord owned 19 buildings and was in foreclosure doing no upkeep on any of these buildings. Almost 700 units were going into disrepair. Legal Aid took it on, developed tenant associations, started to work with Fannie Mae and the property management, and ended up with hundreds of thousands of dollars in repairs and new roofs on these buildings. 

To me, the boxes fit together neatly. We did our job about saying this isn’t just about the kid’s lungs, it’s about where he’s living. They took it on to improve the conditions in where they’re living. But it was only because we had tracking systems through the electronic health record to know who these kids were and what their addresses were that then Legal Aid could go ahead and really understand what the pattern of the housing was and what the problem was.


What struck me as admirable in your model is that the hospital didn’t have any way to make money from this and hospitals a lot of times are guided by where the revenue comes from. How do you think hospitals can create a business case for these kinds of public health projects?

Luckily I’m in a place where very senior leadership at the very top has supported this notion and the board itself had endorsed these community-based goals. As our CEO says, our mission is to improve health, not to improve healthcare, or to simply deliver healthcare. It’s to improve health. If this is what it takes, this is what we need to do.

In an era of accountable care organizations in which there would be a global annual payment or a per-member, per-month payment to keep a child healthy, certainly then there’s a financial incentive to move out into the community and figure it out. Then every emergency room visit or an ICU admission for asthma becomes a loss. In that scenario, really beginning to go to the next step where you would say, what would it take? Would it take community health workers on the ground? Would it take hiring paralegals, or simply contracting with these other types of organization that could be effective in the community?

We also have a great collaboration with the Cincinnati public school nurses, who are really trying to think, how do we work hand in glove to help manage these kids? Again, to the extent there’s a huge financial incentive on a per-member, per-month basis to prevent illness, it becomes more and more feasible and desirable to build these relationships.


Where do you see information technology fitting in?

I’d say our approach has been relatively rudimentary. We work off the back end of our electronic health records system. There is a huge challenge because the school system or the pharmacies or the Legal Aid Society all have different technologies. It is not seamless right now and I’m sure it will take a while for it to be seamless, to figure out, how do we have shared responsibility for the patient? How do we share consents and get through some of the privacy issues? How can we track over time? 

My sense is, I haven’t seen that kind of technology developed, certainly between hospitals. There’s a lot more health information exchanges that work between hospitals. There’s a few folks, I think Nemours in Delaware, who have figured out how to get electronic health record look capability to the school nurses. But I think we’re a long way from true interoperability between everyone who might be touching a child or a family in terms of health.

I sometimes compare it to FedEx. If we were FedEx, I would know exactly when the patient showed up at the pharmacy, what time they checked in at school, how the lungs were doing there, and when they were going to come back to me. That level of tracking and monitoring to help the family with the family’s permission would be great to try to get to in the future.


Have you seen tools or thought about tools that would help what you’d like to do?

I’d like to say yes. [laughs] I’m intrigued by some of the new self-monitoring biosensors that are linked to, say, phones and then back to management software. Propeller Health is one example of a company that’s trying to think, how do you move the information from where the family is, where the child is, and bring it back to a central management point? That notion is a pretty huge advance. 

It’s still a long way off from saying, I’m co-managing these patients with the pharmacy, with the school nurse, with the community development corporation who’s thinking about green space in parks for the kids. We’re moving in the right direction, but there’s a lot of integration and a lot of issues to overcome. With the geocoding software, we’ve only scratched the surface, and even that’s not something hospitals typically use in their health analytics.


How would the average academic medical center or their physician practice organization create a model similar to yours?

I would think a health analytics group five years now, whether they’re working in a hospital or they’re working in an accountable care organization infrastructure, would have a geospatial group working with them. With that, they would be understanding where their patients live, what are the key local and regional determinants of health in that region, and then beginning to deploy healthcare resources differently. Being able to almost predict when there would be problems. Even knowing pollution and pollen patterns might be the kind of information that could be brought in, and then more anticipatorily, trying to get medicine out to the community if they know there’s going to be a surge in asthma morbidity.


Will be hard to get hospitals to do more public health outreach work instead of comfortably treating people who show up within their four walls with a complaint?

It’s going to take some time. It’s out of the comfort zone of where most hospitals are right now. Schools of public health and public health departments around the country could help healthcare a lot in trying to move the ball further faster. But I think until there’s a real financial incentive where there’s a big loss involved unless we’re preventing illness, it will be relatively slow-going.

The other caveat would be until we truly demonstrate a significant return on investment by thinking this way, it may also keep the work moving slowly. That’s our goal — to demonstrate we can actually reduce morbidity and cost by developing this kind of a platform.


Is there existing literature of where that’s been done, or are you finding that what you’re doing so far is promising?

We’re working really hard right now thinking about how to prevent prematurity with this kind of an approach. Every time a baby is born at 24 weeks gestation, it’s a $300,000 to $500,000  immediate cost and probably millions over their lifetime. If we can use a place-based strategy to prevent prematurity, we’ll have a much better argument for deploying the resources necessary, like community health workers, to get the job done.

There are various models of community health workers or home remediation, but I don’t think there’s been an integrated set of interventions put together that would really make the argument at the level of a hospital or an insurance company to push this strategy.


Do you have any final thoughts?

I’m excited to keep trying to push the boundaries. I see the electronic health record and geocoding is a way to break down the walls. 

I would just add, I have found tremendous, capable, and highly interested partners in the community who are really excited to have these kinds of partnerships, whether it’s the school nurses or the pharmacies or even Legal Aid. We’re now 10 percent of all Legal Aid’s cases in southwest Ohio because of this progress. It’s almost always a win- win-win — a win for the hospital, a win for the organization, and then a win for families that we can break down these barriers using electronic records and geocoding.

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April 4, 2014 Interviews 1 Comment

Morning Headlines 4/4/14

April 3, 2014 Headlines No Comments

Proposed health IT strategy aims to promote innovation, protect patients, and avoid regulatory duplication

HHS publishes the long-awaited health IT regulatory framework proposal. The report suggests that health IT products be separated into three risk-based categories, with the FDA regulating only the category that includes software with medical device-related health IT functions, such as bedside monitor alarms and radiation treatment software. The FDA would not regulate EHRs or systems that provide medication management, provider order entry, clinical results review, and clinical decision support.

GE Healthcare to Acquire Analytics Solutions Provider CHCA, Further Advancing Industrial Internet Mission

GE acquires Canada-based CHCA Computer Systems, which offers the Opera Surgical Management System.

M*Modal Reaches Agreement On Financial Restructuring Plan

MModal announces that it has reached an agreement on the terms of a financial restructuring plan that will reduce its debt by than 55 percent, or $350 million, and lead to a conclusion of its debt-restructuring plan within the next 120 days.

CRMC implements new electronic medical records system

25-bed Cherokee Regional Medical Center goes live on its $2 million Epic install across the hospital, with all outpatient clinics coming on board later this year.

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April 3, 2014 Headlines No Comments

News 4/4/14

April 3, 2014 News 3 Comments

Top News


HHS releases a draft report from its FDASIA work group that includes a proposed strategy and recommendations for an HIT framework for maintaining appropriate patient protections and avoiding regulatory duplication. It reaffirms FDA’s position that its regulation is appropriate only for medical devices and not clinical software (including clinical decision support tools.) The report ponders the question of how a conformity assessment program (product testing, certification, and accreditation) might work and whether the government should play a role. It also recommends creating the Health IT Safety Center, seeking input on how it should be operated to share incidents, lessons learned, and user experience, also suggesting that third-party tests or reviews might play a role. The report describes three categories of health IT products:

  • Products for admin HIT functions, such as software for billing, scheduling, and claims management  that pose little patient risk. No FDA regulation is proposed.
  • Clinical software for health information and data management, medication management, physician order entry, electronic access to clinical results, and most clinical decision support software. No FDA regulation is proposed.
  • Products with medical device functionality, such as computer-aided detection software, software for beside monitor alarms, and radiation treatment software. FDA would continue to regulate products falling into this category.

Reader Comments

From Harry-O: “Re: NTT Data-supported Indy car. I’m pleased that we are no longer a client. While I understand that vendors need to market their products, those of us in the trenches are struggling to survive and pay their (for the most part) exorbitant support fees. Wouldn’t it be nice if they could find a way to market and reduce costs at the same time? What a waste, paid for by a hospital near you.”

inga_small From Perky: “Re: ICD-10 delay. Does anyone have an inkling as to how things are going to proceed with such things as CQM reports and MU 2 demonstration/certification with the delay of the ICD-10?  As I try to think this through, my head sort of explodes. If they are going to continue to require ICD-10 codes for the CQM, PCMH, and MU 2 reports, then how are the codes going to get entered if we are not using them for billing? If they decide to stick with the ICD-9 for CQM, PCMH, and MU 2 reports, what happens with the certification process? If we are not allowed to use ICD-10 until after October 1, 2015, what happens with all of the products that are already certified to use ICD-10? Are they expected to rewrite their reports using ICD-9? Do they then need to go through the certification process again?” Unfortunately Perky just hits the tip of the iceberg with his list of questions and CMS may not have enough disk storage to adequately address all the new FAQs. CMS has been been oddly silent on the whole issue all week, suggesting that  no one at the agency saw the delay coming. One of the first steps towards clarity will be the issuance of a final rule for the new ICD-10 deadline. If anyone wants to stab at Perky’s questions, please share.

HIStalk Announcements and Requests

8 million

Assuming this isn’t your first time reading HIStalk, you contributed to the 8 million visit milestone. Thanks.

inga_small A few highlights from HIStalk Practice this week include: AMA remains tight-lipped about the ICD-10 delay. Physicians in academic settings report higher compensation when more time is spent seeing patients versus performing research. Specialists who are late in adopting EHRs may struggle to meet Stage 2 patient portal requirements. European Union GPs report that interoperability issues, a lack of regulatory framework, and inadequate resources are the biggest barriers to adopting ehealth tools. The GAO recommends CMS expand its benchmarks for assessing Medicare physicians. Dr. Gregg contends that HIT’s next big role is to motivate change in consumers that will drive transformation in providers. Thanks for reading.

This week on HIStalk Connect: IBM partners with the New York Genome Center to research genetics-driven brain cancer treatments with Watson. Rock Health’s digital health funding report recaps a record-breaking $700 million in funding in Q1, its strongest investment quarter to date. Airstrip acquires San Diego, CA-based Sense4Baby, a startup from the West Health Institute that markets wireless fetal monitors.

Upcoming Webinars

April 9 (Wednesday) 1:00 p.m. ET. Think Beyond EDW: Using Your Data to Transform, Part 1 – Avoiding Analysis Paralysis. Sponsored by Premier. Presenters: Kristy Drollinger, senior director of population health analytics, Fairview Health Services; J.D. Whitlock, corporate director of clinical and business intelligence, Catholic Health Partners; Sean Cassidy, general manager of information technology services emerging business unit, Premier, Inc. Are you ready to invest in an integrated data platform? Do you have a strategy to make the information accessible and actionable? How will enterprise data warehousing transform care delivery? There’s more to data analytics than simply deploying an EDW. Learn what goes into becoming an information-driven enterprise in the first webinar in this series.

April 16 (Wednesday) 11:00 a.m. ET. Panel Discussion: Documents, EMRs, and Healthcare Processes. Sponsored by Levi, Ray & Shoup. Presenters: Charles Harris, senior technical lead, Duke University Health System; Ron Peel, technical advisor, LRS; and John Howerter, SVP of enterprise output management, LRS. IT department in hospitals implementing EMRs often overlook the role of document-driven workflows. Prescriptions, specimen labels, and discharge orders, and other critical documents must be reliably delivered with minimal impact on IT and clinical staff. This panel discussion will discuss the evolving use of documents in the “paperless/less-paper” environment.

Acquisitions, Funding, Business, and Stock


GE Healthcare will acquire CHCA Computer Systems, the Canada-based developer of the Opera software application for OR management and analytics, of which GEHC Is a distributor.


MModal reaches an agreement with the majority of its bankruptcy creditors to cut its debt by over 55 percent, which is about $350 million. Investor’s Chair sitter Ben Rooks provides some financial perspective about the company in answering a reader’s question in his “Health IT from the Investor’s Chair”.


IMS Health Holdings, which sells de-identified patient prescription information, goes public in an IPO that values the company at over $6 billion.


Practice software vendor edgeMED acquires revenue cycle management company Physician’s Billing Alternative.

ZirMed acquires the payment processing, patient eligibility, and patient estimation business owned by TransEngen.


Pharmacy automation vendor Aesynt, which operated as McKesson Automation until its November acquisition by Francisco Partners, acquires Italy-based pharmacy IV technology vendor Health Robotics.

4-3-2014 1-28-54 PM

TreeHouse Health makes a six-figure cash investment in LogicStream, a provider of clinical decision support tools.


A healthcare quality collaborative headed by San Jose Clinic (TX) selects CompuGroup Medical’s CGM Enterprise suite for community health practice management.

Memorial Health Care System (TN) and St. Vincent Health System (AR) select MedAptus Professional Charge Capture for automated coding and billing.

Visiting Nurse Service of New York chooses Crescendo from Delta Health Technologies for homecare business management.

VNA of Albany and Visiting Nurses Home Care (NY) choose Homecare Homebase.


Oconee Medical Center (SC) adopts PeraHealth’s PeraTrend platform as its real-time clinical decision support tool.

The Center for Diagnostic Imaging (NJ) will implement Healthec’s HIE platform.

Craneware signs multi-year contracts with two unnamed hospitals in the Eastern US for about $6.9 million.


4-1-2014 7-09-34 AM

PatientSafe Solutions names Cheryl D. Parker chief nursing informatics officer.


Nextech appoints Ron Kozlin (Pilgrim Software) CFO.

4-2-2014 4-50-14 PM

CareCloud names Lee Horner (Eliza Corporation) chief sales officer.

4-3-2014 1-39-53 PM

Baylor Scott & White Health appoints 11 new members to its senior leadership team, including Matthew Chambers (Scott & White Healthcare) as CIO.

4-3-2014 1-48-52 PM

Aaron Karjala, CIO of the troubled Cover Oregon online marketplace, becomes the fourth top manager to resign his post.

Announcements and Implementations

Cherokee Regional Medical Center (IA) goes live on its $2 million Epic system.

4-3-2014 8-29-21 AM 

Qatar’s Al Khor Hospital and Al Daayan Health Centre go live on Cerner.


Hudson Valley Hospital Center launches its MyHVHC patient portal.

Emory Healthcare and Grady Health System join the Georgia HIN.

The Spanish Catholic Center (DC) implements Forward Health Group’s PopulationManager and The Guideline Advantage. 

Government and Politics

4-3-2014 6-39-02 AM

CMS issues a Daily Digest Bulletin that summarizes the newly passed Protecting Access to Medicare Act of 2014, Noticeably absent is any mention of the ICD-10 delay. The Bulletin notes that “more information about other provisions will be forthcoming.”

Innovation and Research

The New York eHealth Collaborative and the Partnership Fund for NYC call for applications for the second class of the New York Digital Health Accelerator, a program that will give up to 10 early- and growth-stage companies $100,000 each to advance their digital health technology efforts.

Children’s Memorial Hermann Hospital (TX) offers patients a chance to virtually visit the Houston Zoo, located across the street from the hospital, from their hospital beds using Google Glass.


4-2-2014 7-16-11 PM

inga_small I suppose this constitutes a bad day at the office, at least if you are the tree trimmer who is recovering after the chainsaw he was operating kicked back into his neck.

The local paper covers the plight of a 25-bed critical access hospital in Arkansas, whose February computer fees of $63,000 contributed to a loss of $142,000. Administrators expect a $1.2 million EHR incentive check in May, but those funds will be used to pay off  EHR vendor Healthland, which did not require the hospital to pay until it received its MU check.

Mercy Technology Services, the information backbone of the Mercy healthcare system, will market its services to other Epic users as the first provider accredited in the Epic Connect program.


A KLAS report on ICD-10 consulting services (with the unfortunately timed subtitle “Who Can Help in the Eleventh Hour”) ranks The Advisory Board highest for overall ICD-10 consulting performance, followed by Aspen Advisors. Optum and 3M earned the highest scores for on-site training.

The majority of health organizations participating in a HIMSS Analytics survey report having a formalized EHR governance structure in place with a structure that involves a cross-functional, multi-disciplinary advisory board or committee. The biggest EHR governance challenges are physician engagement and adoption.

Sponsor Updates

  • 3M completes its acquisition of Treo Solutions, a provider of data analytics and business intelligence to providers and payers.
  • Analyst firm IDC names Covisint a “major player” in worldwide federated identity management and single sign-on.
  • Medworxx Solutions and Leidos Health will offer providers help with patient flow performance and analytics.
  • Allscripts recognizes its customer Citrus Valley Health Partners (CA) for being one of the first organizations in the country to meet the 2014 MU Stage 2 requirement for electronic transitions of care, which it accomplished using Allscripts dbMotion.
  • Wellcentive will demonstrate is population health management platform at this week’s AMGA meeting in Grapevine, TX.
  • Biztech profiles ICSA Labs and its work certifying security products.
  • The Health Catalyst team explains how population health management solutions lead to overall better health care.
  • MedAssets president and CEO John Bardis headlines the SEMDA 2014 Conference as the Gala speaker May 7-8 in Atlanta.
  • A local paper interviews Summit Healthcare founder and CEO Ted Rossi, who shares details of the company’s history and growth.
  • A KLAS report on HIEs finds that 100 percent of InterSystems HealthShare customers have made HealthShare part of their long-term plans and say they would purchase HealthShare again.
  • Craneware conducts its annual Executive Industry Leadership Survey to measure revenue integrity priorities.
  • ADP AdvancedMD, Intelligent Medical Objects , The SSI Group and NextGen issue statements following the passage of the ICD-10 delay legislation.
  • Kit Check adds Medi-span integration to its Trusted Pharmacist Medication Checks software.

EPtalk by Dr. Jayne


I seem to be rounding up lots of federal issues this week. Monday opened with an extremely heated discussion involving a hospital laboratory director, our medical group operations VP, and me. To make a long story short, one of our hospitals is refusing to play nicely in bringing a bidirectional interface live for our employed physicians. Although many of our physicians use a large national reference laboratory (mostly due to payer requirements) we have a handful of physicians who are being held captive because they are located in the hospital medical office building. The terms of their lease prohibit external vendors from picking up samples at the office after hours, which basically locks them out of the market. Since the practice specializes in OB/GYN and has a high volume of office-collected specimens, they’re stuck using the hospital’s lab and pathology services.

Although the hospital initially agreed to a bidirectional interface so the practice could meet its requirements for both structured data and CPOE, it is now balking under the excuse that a bi-directional interface isn’t “required” for Meaningful Use. They want the practice to figure out some way to create magic with electronic ordering that prints to paper requisitions and an unsolicited results interface. The orders can’t match up automatically, which makes a mess of all the numerators and denominators unless staff manually matches the results. I explained to the lab director in my best primary care voice that a bi-directional interface isn’t entirely about MU, but rather actually has a great deal to do with patient safety.

He didn’t seem to care that it would help close the loop on orders, making sure results were received and catching misses through electronic reporting. He actually suggested providers should use an accordion file and duplicate copies of the requisition. What century is this person living in? I understand competing priorities and limited budgets, but these are our employed physicians that we placed in the hospital building in good faith.

I thought at one point I was going to have to perform a stroke assessment on the operations VP. He made some threats about calling the hospital CEO to discuss breaking the lease and the lab guy still didn’t flinch. It was brinksmanship like I haven’t seen in a long time. I know the hospital CEO well and would love to be a fly on the wall when he calls the lab director and tells him to get it in gear. The bigger picture includes hundreds of newborn deliveries and even more GYN surgeries. Given the practice’s revenue boost to the hospital, I would bet money that the lab director will be singing a different tune by next week.

I’ve also been wrangling entirely too many consultants and administrators regarding the now-approved ICD-10 delay. We’re breathing a sigh of relief on the inpatient side because our hospital vendor still hasn’t delivered decent software. On the ambulatory side, I’m just aggravated, though. Our vendor worked extremely hard to deliver solid product and we’re upgrading very soon. I think of all the “real” enhancements they could have done to the software with the development dollars that they pumped into getting ICD-10 ready and out to the client base with ample time for everyone to upgrade.

Speaking of the legislation, did anyone read the whole thing? I did read the “Protecting Access to Medicare Act of 2014” and there were a couple of other gems that snuck in under the cover of the SGR patch. I love the fact that the Government Printing Office uses an old-school type face for the header on legislation. Check out Section 111, which gives hospitals some relief from the so-called “two-midnight rule” through March 2015. Of course “evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider” can trigger an audit regardless.

Sections 205 and 206 include abstinence education and funding for the PREP personal responsibility education program. I know there are some sassy seniors out there, but I fail to see how throwing this in with the “Protecting Access to Medicare Act” makes logical sense. They should have called it the “Protecting Medicare, Serving Special Interests, and Tidying Up Odds and Ends Act.”

Fifteen million dollars for pediatric quality measures is in section 210. One of my favorite add-ons is section 216, “Improving Medicare policies for clinical diagnostic laboratory tests.” It requires laboratories to report their private payer contractual rates and test volumes to assist in establishing Medicare rates. So much for a free market (although we knew that was long gone with Medicare already.)

Another favorite (which I almost missed because of the mind-numbing and sleep-inducing effects of federal legislation) is section 218, which promotes evidence-based care by requiring physicians to use clinical decision support before they order certain radiology imaging studies. CDS modules can be part of certified EHR technology or independent. Eventually outlier physicians will require prior authorization before they can order studies. Just when you thought it was safe to go back into the water after MU2, there are more sharks circling. I hope the EHR vendors can code fast enough to keep them at bay.

The ICD-10 delay is in section 212, if anyone is interested. I gave up after page 31. A reader gave me my laugh of the day about the delay:

Dear Dr. Jayne,

I have three young boys and one of them is always winding up in the ER. This year alone we’ve already had boy vs. coffee table, boy vs. Evel Knievel bicycle jump, and boy vs. monkey bars. Every time our insurance pends the claim and sends me a letter asking for verification that the injury was not work-related or due to a motor vehicle accident. I wish they could figure out that if the boys are 4, 7, and 10 they’re probably not on the job. A quick skim of the ER note would give them the rest of the information. I was looking forward to ICD-10 because maybe the more specific codes would give the insurance company what it wanted in the first place. I guess I’ll have to wait another year to find out. Hopefully we’ll be less accident prone by then.

Those descriptions remind me of Struck by Orca and I’m thinking maybe a companion volume is in order. What’s your reaction to the ICD-10 delay? Email me.


Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre.

More news: HIStalk Practice, HIStalk Connect.


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April 3, 2014 News 3 Comments

Health IT from the Investor’s Chair 4/3/14

M*Modal from $1.1 billion to Chapter 11 – What Were They Thinking?

"Mr H, can you get Ben Rooks to opine on how smart Wall Street types could pay $1B for a $450M transcription company? Greater fool theory or something sinister?"

Sitting here in the Investor’s Chair, few things make me happier than a thoughtful question. I’m wondering what sinister theory you have in mind (and I’d love to hear it), but my view is emphatically one of the Greater Fool Theory. To support my thesis, let’s enter Mr. Peabody’s WABAC Machine and take a look at the events as they unfolded.

Long-time industry watchers will recall MedQuist (the predecessor company) from the 90s, when its growth was in large part driven by acquiring various transcription companies. As so often happened, earnings were ultimately missed, shareholder lawsuits appeared, and in this case, allegations of fraud emerged based on how MedQuist had been calculating its transcription billing rates. The company emerged from that peccadillo with a new management team. and one assumes, a new outlook on life.

Flash forward to July, 2011, when MedQuist acquired cloud-based natural language processing company, M*Modal (the * is presumably silent) for the fairly princely sum of $130 million in cash and stock. Princely in that it was over five times M*Modal’s run rate revenues, and the multiples of last 12 months revenues paid for medical transcription or HCIT companies were (using data from M*Modal’s later Fairness Opinion) 1.7x and 2.2x respectively. Hmm, interesting choice [valuation].

Back into the WABAC and skip forward to January 2012. Our next noteworthy event was six months later, when the company renamed itself M*Modal, according to its then CEO, “Illustrating our progression from a services-focused business to a provider of technology-enabled services and commercialized proprietary technology solutions.” Corporate brand identity is not part of the Investor’s Chair purview in this instance, but it seemed (even at the time) analogous to buying new carpeting and updating the landscaping prior to putting one’s house on the market.

In actuality, SEC filings show that even in October 2011, One Equity Partners had begun discussions with M*Modal’s management about acquiring the business in a Take-Private Transaction. Readers can review my previous post on how these work here.

Meanwhile, over the next few months, the company was approached by a number of other financial sponsors and a competitor referred to in the proxy as “Party A” (which I would guess was Nuance.) M*Modal went on to retain an investment banker, and by March, 19 private equity firms were invited to participate in the auction, of which 16 signed non-disclosure agreements.

As an aside, the value of NDAs is suspect at best, because over the next 10 days, representatives of five additional financial sponsors, having learned of the process from “unidentified sources,” separately contacted the Company’s financial advisors to indicate their interest in participating in the process and were subsequently invited to participate (because in auctions, the more, the merrier – as long as they can write checks — is usually a good rule). Bids were due April 26 and seven PE firms submitted.

Well, one would think that if financial buyers are attractive, strategic buyers should be more so, because they can bring various cost and revenue synergies to bear. That being the case, the bankers contacted five unnamed strategic players in late May, of which three immediately said, “Thanks, but no thanks” and two others said, “Sure, send us some materials.” Tellingly, neither of those submitted a bid.

Hindsight is generally pretty close to perfect, but this to me is the clearest evidence of the Greater Fool Theory in action. ST Advisors has on several occasions advised private equity investors on potential acquisitions. One of our questions to them invariably is, “OK, if you win this auction, you’ve just outbid all the strategic buyers. What will be different when you try to sell in a few years?” One can only wonder what One Equity’s thesis was. From the outside looking in, it appears to be a case of investors with little to no HCIT market insight believing their financial engineering skills could offset the risk of catching the falling knife that is transcription.

Over the course of the next few weeks as due diligence continued, some of the potential financial buyers notified the bankers that “they were withdrawing from the process, citing concerns about the ongoing profitability of the Company’s core transcription business, the nascent stage of the Company’s emerging healthcare technology business, and execution risks involved in the Company transitioning to a high-growth healthcare technology business.” Again, with the benefit of hindsight, good choice.

Party A was brought back in, but due to various concerns — especially relating to potential anti-trust issues — ultimately did not win the auction, leaving One Equity and M*Modal to announce on July 2 that it was acquiring M*Modal for $1.1 billion (a 19 percent premium over 180-day trading average and an 8.3 percent premium over the prior day’s close.)

Wow. $1.1 billion (2.4x LTM revenues) for a transcription vendor, albeit one with some spiffy speech rec, though Nuance certainly seemed to have that as well. Readers of this blog (or anyone not living under a rock) should realize that the ARRA-driven growth in EMR adoption is (very) likely to shrink demand for transcription. Based on the market dynamics, transcription pricing has been declining for several years. And other methods of data capture are becoming both more prevalent and easier to use. And other NLP vendors (Coderyte and A-Life Medical) were out there, again, wow. Over a billion seems like a lot here.

But did One Equity really spend over a billion dollars? Well, they did and they didn’t. Recall that the “L” in LBO stands for leveraged. A quick perusal of the data suggests that of the money paid:

  • $425 million was a term loan due in 2019
  • $250 million was a corporate bond due in 2020
  • $75 million was the company’s line of credit

leaving about 25 percent (or $250 million) in cash paid by One Equity and its investors. This left the rest to be borrowed from a syndicate of banks and investors (Fidelity was the largest debt holder, by the way).

Because there was a public market for these corporate bonds, we can track investor sentiment over the subsequent months. The bonds issued that summer at par value (meaning, you pay $100 for the bond for which the company has committed to pay you the $100 back, along with the agreed-upon interest). Shortly after Labor Day, approximately 90 days after the transaction was announced, the bloom began coming off the rose as the bonds started trading in the resale market at the mid-80s, showing that investors were beginning to get a tad skittish about the relative safety of this investment.

The bonds seemed to stabilize for some time, though in April 2013 the debt ratings were downgraded by Moody’s to “Outlook Negative.” Perhaps as a result, in June 2013, a new chairman and CEO were announced – Graham King and Duncan James, respectively – two industry executives with strong pedigrees and track records of creating shareholder value (disclosure: Duncan was QuadraMed’s CEO when it was a client of ST Advisors).

Despite this change, bond investors apparently continued to have misgivings, because by October 29, 2013, the bonds were trading at $60. A month later, they dropped from $58 to $45, indicating investors thought there was little likelihood the company would deliver on its financial commitments. On January 14, 2014, the bonds were trading at $37, and on March 20 of this year, in announcing its bankruptcy filing, M*Modal’s CEO made the understatement of the year (this being the biggest healthcare-related bankruptcy filing of the year so far): “When M*Modal was taken private in 2012, the acquisition was financed with a capital structure aligned with a specific set of assumptions that are no longer relevant.”

It’s hard to point the finger at anything sinister. I’m not privy to One Equity’s Investment Committee’s report or findings, but it definitely appears to be one of two components.

First, there’s sum-of-the-parts: (1) transcription – admittedly not a great business (and, in fact, worse than expected), but one generating cash, which can both cover some debt and fund some development; (2) technology (aka the original M*Modal), whose voice recognition and NLP solutions could be used for things such as data analytics, coding (hello ICD-10) and other sexier (read: high growth / margin / high multiple) businesses.

These two issues, together with a healthy (or perhaps unhealthy) dose of the aforementioned Greater Fool Theory likely drove the valuation discussion. In addition, its competitor Nuance was performing well, the company had a fairly attractive client base, and the new investors ultimately brought in a very talented CEO in Duncan James.

Still, weighing the fundamentals, it’s hard to imagine why One Equity thought this was a company worth over $1 billion or that it could support the debt service that a billion-dollar valuation required. As a result, their equity has likely been wiped out and the debt holders have been both crammed down and converted to a new equity.

This likely raises a follow-up question. Hey Ben, if the original M*Modal business was the gem here, why didn’t a PE firm just buy that? Recall that M*Modal at the time was a technology vendor with less than $25 million in revenues. That’s just not the kind of business that a PE firm can acquire as a platform acquisition, as it can neither be leveraged nor can it be big enough to generate the associated fees that drive the PE business model.

On the subject of transcription in general, I’ll close with a quote from arguably the world’s best (and wittiest) investor, Warren Buffett:

“Should you find yourself in a chronically leaking boat, energy devoted to changing vessels is likely to be more productive than energy devoted to patching leaks.”

Thanks again for your questions and keep them coming!


Ben Rooks spent a decade as an equity analyst and six years as an investment banker, where he worked on transactions such as this. Five years ago he formed ST Advisors to work with companies on issues that don’t solely involve transactions. He lives in San Francisco and absolutely loves e-mail.

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April 3, 2014 Investor's Chair 5 Comments

Morning Headlines 4/3/14

April 2, 2014 Headlines 2 Comments

ICD-10 delay puts pressure on CMS for answers

Attention shifts to CMS for new guidance now that Congress has prohibited the October 2014 mandatory transition to ICD-10.

MMRGlobal 2014 "This Is Our Year" Letter to Shareholders

MMRGlobal sends a letter to its shareholders titled "This Is Our Year" in which the company boasts that because of Meaningful Use, the patient portal business is “the right business, at the right time”. The letter goes on to acknowledge that it prepared for Meaningful Use by investing millions of dollars in patents, intellectual property rights, and technology.

Veterans Affairs cut claims backlog by 44 percent since last year’s high

Since March 2013, the Department of Veterans Affairs has cut its backlog of pending benefits claims by 44 percent and shortened the average wait time for decisions from 282 days to 119. However, during that same timeframe independent audits turned up errors in 55 percent of the VA’s decisions. Appeals cases are up 50 percent.

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April 2, 2014 Headlines 2 Comments

Readers Write: Advanced Interoperability: Leveraging Technology to Improve Patient Lives and Provider Workflows

April 2, 2014 Readers Write 1 Comment

Advanced Interoperability: Leveraging Technology to Improve Patient Lives and Provider Workflows
By Justin Dearborn


There’s an increasing need for all of healthcare to be integrated in its approach to accessing, sharing, and storing information. It’s not just patients who could stand to benefit from more advanced interoperability. It’s also healthcare providers who want to meet legislative requirements such as Meaningful Use Stage 2 and Stage 3, as well as reduce costs and improve care quality.

Consider what typically happens in today’s medical imaging environment—often partway between a traditional manual environment and a fully interoperable one—when a patient presents to his primary care physician (PCP) complaining of shoulder pain, for example:

After receiving a comprehensive clinical exam, a patient named Dave heads home with a hand-scribbled order for a shoulder MRI. Before the exam can take place, however, the imaging center must get the order pre-certified by Dave’s health insurer. After receiving the insurer’s faxed approval days later, the imaging center schedules the patient for his exam. Days after that, the radiologist faxes his report to the PCP, who then calls Dave to set another appointment to discuss his torn rotator cuff. Once the decision to seek surgical treatment is made, Dave is asked to bring a CD of his radiology images to the orthopedic specialist.

If this process sounds cumbersome, time consuming, and inefficient, that’s because it is. It’s also the rule with respect to today’s medical imaging processes.

While it’s true that anywhere between 10 to 20 percent of imaging orders issued today are processed electronically, that still means the vast majority are processed manually via paper and/or fax. According to the Centers for the Disease Controls and Prevention (CDC), approximately 12 percent of all PCP visits alone result in a referral for diagnostic imaging—some 44 million imaging exams each year—which equates to a lot of wasted time and paper, not to mention money.

The payer-approval process only adds to that burden. Roughly 122 million imaging exams are processed manually by radiology benefits management companies each year, at a cost of about $75 per exam. That adds up to nearly $8 billion of waste a year.

So the question is this: What would happen in an environment of advanced interoperability, where existing electronic health records (EHR) and other technologies are fully leveraged? Take Dave’s scenario again:

After receiving a comprehensive clinical exam, Dave’s PCP electronically orders a shoulder MRI and schedules an imaging appointment for later in the day. Before the exam takes place, the imaging center receives electronic pre-certification. Once the MRI is complete, the PCP automatically is alerted that an image-enabled report is available. Before he leaves his office for the evening, the PCP calls Dave to discuss his torn rotator cuff and to electronically refer him to an orthopedic specialist who already has secure automated access to the image-enabled radiology report.

As this simple scenario illustrates, the entire patient-imaging process can be streamlined by enabling five key services: 1) electronic referrals and ordering; 2) automated pre-certification and approval using clinical decision support; 3) electronic patient navigation and scheduling; 4) image-enabled reporting; and 5) analytics.

Such advanced interoperability provides Dave, his PCP, and his orthopedic specialist with near-instantaneous exam ordering, approval, and scheduling. Ease of access to reports, results, and images is dramatically increased.

By creatively leveraging EHRs and other technologies, healthcare organizations can maximize their interoperability with internal and external providers. All these services, moreover, can be provided without costly point-to-point HL7 interfaces.

With payment reform, it is clear that the days of disjointed, manual image processing are numbered. Indeed, advanced interoperability like that described here not only addresses the challenges that impact physicians, but also pays handsome dividends for patient care.

Justin Dearborn is CEO of Merge Healthcare of Chicago, IL

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April 2, 2014 Readers Write 1 Comment

Readers Write: Competing for Talent in Healthcare IT – Remember, Candidates are Interviewing You, Too

April 2, 2014 Readers Write No Comments

Competing for Talent in Healthcare IT – Remember, Candidates are Interviewing You Too
By Mike Silverstein


The healthcare IT market is as hot and competitive as ever and the battle for the industry’s top talent is on. If your firm has gone through any recent hiring waves, I probably don’t have to tell you that the buyer’s market of 2008-2012 is over. Strong candidates, regardless of specialty, who have good work records, great performance reviews, and above-average soft skills are being flooded with lucrative and enticing opportunities as soon as they dip their toe in the market.

These concrete, actionable items can help win over a candidate who is evaluating offers from multiple firms.

Tighten Up the Recruitment Process

Companies are making decisions and hiring faster than I have experienced in the past five years. In order to be competitive, make sure your process is swift and efficient and that the proper decision makers are involved. Nothing kills the chances of landing a great candidate faster than not being able to schedule something on a hiring manager’s calendar for a delayed period of time. Talent is the lifeblood of an organization. Make sure managers block off the appropriate time on their calendars so they do not become the bottleneck that kills the process.

Also, make sure there is a good rhythm between calls with the candidate. If the last phone interview was two weeks ago, don’t expect the candidate to be as excited about your job as they were 12 hours after their initial call.

Make Sure Messaging is Consistent

Nothing spooks a candidate more than hearing different things about a position from different people. Make sure everyone involved in the recruitment process understands the reason you are hiring for the position, who it reports to, what the expectations are, what the time frame is, and what is expected from this individual. If anyone is going to bring up the compensation associated with the position, make sure it’s consistent with what your HR team and your recruiter is saying.

Present the Company in the Best Light

From a convenient travel itinerary (even if it costs a few extra bucks) to having a “Welcome Joe Smith” sign on the door, it is important to pay attention to the details. Have a well-organized itinerary of meetings with the hiring team. Schedule a meeting with those same executives within 48 hours to make a go/no-go decision. 

Be to produce a succinct written offer within 24 hours after that decision, including a comprehensive benefits summary, explanation of compensation including (competitive) salary, bonus, and equity. Include a breakdown of how to earn 100 percent of the bonus.

Virtually none of this advice will cost you any more money. It is all about making the candidate recruitment experience more attractive and enjoyable. 

Mike Silverstein is partner and director of healthcare IT of DIrect Consulting Associates of Solon, OH.

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April 2, 2014 Readers Write No Comments

Readers Write: Below the Waterline: Is Your Network Population-Health Ready?

April 2, 2014 Readers Write No Comments

Below the Waterline: Is Your Network Population-Health Ready?
By Nancy Ham

4-2-2014 3-42-44 PM

Historically, health information exchange (HIE) implied the tactical, the plumbing and pipes that enable movement of health-related information among organizations according to national standards. Today an HIE network is a strategic asset vital to population health management.

Health organizations must supply more than bricks and mortar as our industry moves from what was once a conceptual model of healthcare to reality. They must provide a network solution for powering appropriate population health management capabilities.

HIE capabilities are evolving. Existing competencies are being coupled with workflow and care management processes, essential for analyzing and managing populations of patients − a shift from the traditional retrospective version of care to real-time, preventive care. Today’s care management needs to be informed and powered by high-quality, real-time discrete data from myriad sources across the continuum of care.

To affect population health, the entire healthcare ecosystem from acute to ambulatory to long-term and beyond needs to be connected, moving beyond the traditional reach and capabilities that current health information exchanges offer.

We’re all familiar with the phrase “the tip of the iceberg.” The tip of the iceberg is visible. It glints and shines. This iceberg principle applies nicely to many population health management solutions with flashy dashboards and snazzy visualization methods. They look really good on the surface, but what is imperative is what lies beneath the waterline. Is the foundation − the data asset from which the analysis is conducted − a solid one?

Before adding population health visualizations, ensure that your foundation is complete. Ask yourself:

  • Are your patient records correctly and accurately matched?
  • Do you have a sophisticated privacy and security infrastructure?
  • Do you have pointers established to access clinical data regardless of where it exists?
  • Can you manage granular patient consent?
  • Do you have a sophisticated mechanism for driving role-based access, including new network participants such as payers?
  • Is your solution able to scale to bring more and more participants into your network?
  • Does your system represent the entire healthcare community across care settings?
  • Are your referrals managed and communicated among providers?
  • Do you have alerts to notify providers when a patient experiences a health event so they can make informed and timely decisions for that patient’s care?
  • Are your EHR interfaces bi-directional?
  • Do you have patient engagement tools such as patient portals and personal health information?
  • Can you aggregate claims and billing data in conjunction with clinical data?
  • Are you using data standardization methods to furnish mineable data?
  • Can you share patient care plans?

Your HIE should do all of this. Your HIE partner should have a track record of linking hospitals with the entire community of providers.

When you have a sophisticated HIE network to enable clinicians to manage their patient population, you have a scalable foundation for improving the quality and cost of care. The foundation is key. From there you can snap on population health analytics solutions, whether from your HIE vendor or from one or more third-party vendors. Now you have evolved your HIE to a strategic network, curating the data flowing through the network to provide contextual, real-time information that engages both clinicians and patients.

Nancy Ham is CEO of Medicity of Salt Lake City, UT.

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April 2, 2014 Readers Write No Comments

CIO Unplugged 4/2/14

April 2, 2014 Ed Marx No Comments

The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.

Accelerating Workplace Relationships

I inherited the party bug from my parents. I recall that during their parties, Mom and Dad would march us seven kids in to play our instruments and sing. I think we each earned a quarter in exchange for those performances. Not bad for a non-union, late-60s era gig, I suppose.


My parents had many guests over between parties as well. Sometimes my dad’s co-workers, other times just small socials and mixers made up of Mom’s and Dad’s extensive friend network. We had no dull moments growing up!

When an HIStalk reader asked me to comment on how to accelerate work relationships and break down silos, partying was the first thing that came to mind. I’ve carried this tradition into work and home. While Julie is more into hospitality as I am into entertainment, parties and fun times with friends reside in our blood. Hardly a weekend night passes where we are not out dancing or hosting some sort of get-together.


Clearly, there are many techniques to building work relationships. Since you can download a book and get routine ideas, I will focus on methods less talked about yet in my wheelhouse, because I love to party. Yes, I party with my work peers and subordinates. I can hear the naysayers and I respect you. I can assure you from personal experience over the years, partying has made a positive difference in business outcomes as well as employee engagement. Plus, it’s fun. Life is too short to work with dull people!

Here are some ideas. I’d love to hear yours. Please comment below so we can all benefit. Not all will be applicable, but we won’t know if something works unless we try it. Be brave!

  • Monthly after-work socials. Who: managers and above. One Thursday per month, we hit a city (rotate) in our sprawling metroplex and get to know one another in a relaxed setting. Typically, we visit 2-3 venues and the first round is on me. Everyone knows the rules. People are responsible for their behavior during this voluntary social and getting wasted is discouraged. We are so hurried at the office that there’s little time for informal chitchat; this relaxed venue allows for real engagement.
  • Annual cheese, wine, and chocolate party. Who: directors and their significant others. Dress code: a step above casual. We’ve hosted six of these parties at our home. This fellowship has a two objectives, one social and one training. Some of our directors have officer-level career ambitions. This offers exposure to a new culture and a safe environment in which to practice new skills.
  • Annual Christmas party (non-office setting). Who: direct reports with their families. We host this event in our home as a gift to those who serve me directly. December is way too busy, so we schedule this for the first weekend in January. Our white elephant gift exchange has produced some interesting and memorable … stuff.
  • Annual leaders’ family barbeque and swim. We rotate the location of this summertime event at one of our director’s homes. Kids and significant others are the focus. We eat lots of food and chill while the kids—and a few brave adults—frolic in the pool. You want to engage your team? Engage their kids!
  • Sports (all unofficial due to liability.) Soccer teams, Ironman triathlon teams, mountain climbing teams, etc. Not everyone participates, of course. These are simply additional examples of outside-the-office party opportunities. After every adventure race, we have a line for our guest shower before the celebrations begin.
  • Manager and director thank you party. We did our first one of these in January. A gift from Julie and me, it is an opportunity to say thank you to my entire leadership team and their significant others. Email is OK and I love thank you cards, but having everyone over and showering them with love is yet another way to engage at a deep level. My success is largely attributable to their leadership so we are quick to have everyone over and splurge.
  • Special events. As needed. Last year, we won the Davies Award, so we hosted a professionally catered dinner for everyone who made this happen (including significant others.) Additionally, we invited the president of the EHR software company we used to come reinforce the magnitude of the achievement.
  • Personal parties. We have several parties throughout the year and we often include many from work (peers, staff, etc.). These include birthday parties, game nights, and theme parties. We have “The Great Gatsby” coming up next week. I suspect that 25 percent of our guests at personal parties are from the workplace.
  • Recognition events. Directors have access to our home to use as a party venue for their teams. Some of them use our home for team-building events, some use it for parties, and others for special recognition for projects well done. While many of the examples above stress managers and directors, over 50 percent of my entire department has been to my home at least once for some sort of party.
  • Exercise parties. Yes, my entire staff is invited to any of my daily workouts! Sometimes I will hold “office hours” in our treadmill or spin-cycle conference rooms. For some reason, these seem to be the least popular of all the parties …
  • Dallas City Lights. This monthly event involves friends in all of my circles, but again includes about 25 percent from the workplace. I choose a different location each month and we all meet up. February we went country and March we hit the Glass Cactus, where part of the dance floor was reserved for our group. We danced to ‘70s music until they turned the lights off at 2 a.m. In May we hit an infamous ‘80s-only venue. Dancing takes center stage at many of these gatherings.
  • Other peoples’ parties. I accept most the invitations I receive.


Many traditionalists suggest maintaining a big border between work and play. Leaders should not engage or otherwise be transparent with the teams they lead. I disagree. I found great success by being transparent and opening up my heart and home to those I lead.

Together, we have accomplished tremendous things, and I attribute a large part of this because of the level of engagement we have achieved. We know one another deeply. We know spouses. We know children. We know our joys and our hurts. When we know deeply, we care deeply. When one of us is injured or needs help, my joy is seeing many rush to walk with them, even carry them if needed. I’m thankful for the times they carried me.

And yes, when our kids were younger, we marched them out to entertain our guests. There was Brandon the Magician and Tali the singer. Memories!

Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.

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Morning Headlines 4/2/14

April 1, 2014 Headlines No Comments

Securities and Exchange Commission: Form S-1, Imprivata, Inc.

Imprivata files paperwork for a $115 million IPO. The company’s revenue has increased by 30 percent in each of the last two years, but it booked a net loss of $5.5 million at the close of 2013.

Selected Defense Programs Need to Implement Key Acquisition Practices

A GAO report finds that the Department of Defense is not accurately calculating future costs for its information systems projects, with 11 of the 13 programs inspected missing their long-term cost targets. One program, an in-country EHR called the the Theatre Medical Information Program, was originally budgeted to cost only $67 million, but has already ballooned to $1.6 billion.

“Litigious nature” of software vendors preventing unbiased reviews of healthcare software

In England, hospitals trying to collect and publish unbiased EHR reviews are being pressured to stop by EHR vendors. One hospital executive explains, "We would like to see something like… but our pockets are not deep enough to confront the legal departments of the suppliers."

Doctors prescribe scribes

Brigham and Women’s Hospital will expand the use of scribes across its facilities to help doctors manage EHR-related data entry. Scribes join physicians during patient exams and take real-time electronic notes while the doctor and patient talk.

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News 4/2/14

April 1, 2014 News 7 Comments

Top News


Implementation of ICD-10 will be delayed until at least October 1, 2015 (it’s up to HHS to set the exact date, apparently) as the Senate approves (64 to 35, with 60 votes required) a hastily assembled bill intended to once again delay the SGR-mandated 24 percent physician pay cut for another year, the 17th time it has been delayed rather than repealed and replaced. Nobody claims to know how the one-sentence ICD-10 language ended up in the otherwise unrelated bill. Sen. Jeff Sessions (R-AL) declares that the “doc fix” violates the just-passed Bipartisan Budget Act since there’s no money to pay for it. The patches have cost taxpayers an estimated $150 billion. The President signed the bill Tuesday. Several organizations expressed disappointment that ICD-10 was delayed and the AMA says it is “deeply disappointed” that the Senate kicked the can down the road again rather than repealing SGR instead of addressing Medicare physician payment reform. HIMSS didn’t announce a position on the delay, but CHIME said it wasn’t happy about the industry’s wasted efforts and the unknown aspects of the delay. A few sages predicted this could happen: the HHS big wheels declaring at the HIMSS conference that ICD-10 would not be delayed further are civil servants, not legislation-making members of Congress.

Reader Comments


From Minnesotan at Heart: “Re: Mayo Clinic in MN, AZ, and FL. Looks like they are looking at Epic and Cerner from this article in the employee newsletter.” According to the March 28 newsletter, Mayo will implement a single-instance EMR at all campuses and has narrowed the field to Cerner and Epic for demos.


From Vince Ciotti: “Re: Indy Car Grand Prix in St. Petersburg, FL. I took this picture of the NTT DATA car.” Many readers would have been jealous of the obviously great weather in Florida had spring not finally kicked off in some places.


From Todd Hatton: “Re: Saint Luke’s Health System. We have gone live on Epic inpatient clinical applications on March 28 at our seven metropolitan hospitals in a big-bang fashion. Applications implemented are ClinDoc, Stork, Rover, Haiku, Cantu, Orders, ASAP, Willow, Radiant, OpTime / Anesthesia. SLHS implemented on the Linux database platform. New wrap-around applications are Perceptive Software integrated document imaging, Nuance eScription partial dictation integration, Perigen fetal strip integration, and iSirona medical device integration for anesthesia, ventilators, and bedside monitors in ED, surgery, ICU, and NICU. Things are going well.” Congratulations to the Kansas City area SLHS, where Todd is associate CIO and is no doubt proud of the team that made it happen. A seven-hospital big bang Epic go-live is quite an accomplishment.


From Plausibility: “Re: Meditech. We are looking a vendor-agnostic solution that pulls contextual information from the patient’s record. I am concerned that Meditech will block access to its data. Has anyone used a solution like this without having Meditech block the information or have advice on encouraging them not to?”


From The PACS Designer: “Re: iPhone 6. Rumor has it there will be two designs, a 4.7-inch phone and a 5.7-inch phablet.”

HIStalk Announcements and Requests


Welcome to new HIStalk Platinum Sponsor Navicure. The Duluth, GA-based company offers worry-free clearinghouse and payment solutions built for physician practices, supporting expanding health systems by accelerating and protecting practice cash flow, decreasing A/R days, providing enhanced eligibility verification, improving staff productivity, and giving patients tools to manage online statements and payments. The company serves over 50,000 providers, offering them a “3-Ring Policy” guaranteeing that support calls will be answered within three rings. Thanks to Navicure for supporting HIStalk.

I found this YouTube video overview of Navicure. 

image image

I sent $50 Amazon gift cards to three randomly chosen readers who responded to my annual survey, but Lorre noticed that two other readers had written in that if they happened to win (they didn’t), they wanted their prize donated to my favorite charity, DonorsChoose. I was touched, so this is for you, Andrew Gelman of PDR Network and Pam Landis of Carolinas HealthCare. I funded an amazing DonorsChoose project with your $100. I found a grant program underwritten by Autodesk that helps pay most of the cost for certain classroom equipment, and your $100 bought – you won’t believe it – a $2,669 MakerBot 3D printer, supplies, and support package for Mr. Fraustro’s architecture, engineering, and construction classes at high-poverty John A. Rowland High School in Rowland Heights, CA.

Upcoming Webinars

April 2 (Wednesday) 1:00 p.m. ET. A Landmark 12-Point Review of Population Health Management Companies. Sponsored by Health Catalyst. Presenter: Dale Sanders, SVP, Health Catalyst. Learn the 12 criteria that a health system should use to evaluate population health vendors and to plot its internal strategy, then see the results of grading seven top PHM vendors against these criteria. No single vendor can meet all PHM needs. The most important of the 12 criteria over the next three years will be precise patient registries, patient-provider attribution, and precise numerators in patient registries.

April 9 (Wednesday) 1:00 p.m. ET. Think Beyond EDW: Using Your Data to Transform, Part 1 – Avoiding Analysis Paralysis. Sponsored by Premier. Presenters: Kristy Drollinger, senior director of population health analytics, Fairview Health Services; J.D. Whitlock, corporate director of clinical and business intelligence, Catholic Health Partners; Sean Cassidy, general manager of information technology services emerging business unit, Premier, Inc. Are you ready to invest in an integrated data platform? Do you have a strategy to make the information accessible and actionable? How will enterprise data warehousing transform care delivery? There’s more to data analytics than simply deploying an EDW. Learn what goes into becoming an information-driven enterprise in the first webinar in this series.

April 16 (Wednesday) 11:00 a.m. ET. Panel Discussion: Documents, EMRs, and Healthcare Processes. Sponsored by Levi, Ray & Shoup. Presenters: Charles Harris, senior technical lead, Duke University Health System; Ron Peel, technical advisor, LRS; and John Howerter, SVP of enterprise output management, LRS. IT department in hospitals implementing EMRs often overlook the role of document-driven workflows. Prescriptions, specimen labels, and discharge orders, and other critical documents must be reliably delivered with minimal impact on IT and clinical staff. This panel discussion will discuss the evolving use of documents in the “paperless/less-paper” environment.

Acquisitions, Funding, Business, and Stock


Imprivata files for a $115 million IPO, planning to list its shares on the NYSE. According to the SEC filing, the company lost $5.5 million on revenue of $71 million for the year ended December 31, 2013, with 83 percent of its revenue driven by the OneSign single sign-on product that has 2.6 million licensed healthcare users and another 740,000 outside of healthcare. The S-1 registration statement also notes that the company uses a development firm in Ukraine with obvious exposure as Russia threatens. The fine print notes that BIDMC CIO John Halamka was given options worth $140,700 as a company director.



Florida Hospital Memorial Medical Center (FL) chooses Authentidate’s InscrybeMD telehealth solution to manage chronic disease patients in a partnership with Bethune-Cookman University.

ViaQuest’s Clinical Services Division (OH) will use Netsmart CareManager for its planned Health Home.

Ministry Health Care (WI) selects Besler Consulting to assist in the identification of Medicare Transfer DRG underpayments.



Patty Griffin Kellicker (Humedica) joins Hayes management Consulting as VP of marketing and communications.

Announcements and Implementations

St. Francis Hospital’s (CT) use of ReadyDock’s storage, charging, and disinfecting system for mobile devices gets coverage on the local TV station.


Brigham and Women’s Hospital (MA) will expand its use of scribes to operate its EMR, at least until that system is replaced. According to CMIO for Health Innovation and Integration Adam Landman, MD, MS, MIS, MHS, “It lets me sit next to the patient and focus 100 percent of my attention on the patient. There are a few patients who don’t want the scribe involved in their care, and then I ask the scribe to leave.”


TigerText says it will cover up to $1 million in fines if its customers are charged with violating HIPAA secure messaging requirements.

Government and Politics


A GAO audit finds that Department of Defense is lousy at estimating long-term system costs, with its TMIP-J battlefield EHR (which includes the frontline portions of the AHLTA, CHCS, and DMLSS systems) being by far the most wildly underestimated. DoD estimated its cost at $68 million in 2002, but they’ve spent $1.58 billion on it so far.


Indiana’s professional licensing agency asks the state’s ethics commission to review a Board of Pharmacy decision that allows Walgreens pharmacists to use workstations that aren’t located behind counters in its “Well Experience” program. The pharmacy board’s president at the time the request was approved was a Walgreens manager. Consumer groups expressed concerns that pharmacists might leave the area and expose confidential computer or label information to customers.



Retired Akron, OH cardiologist Terry Gordon, who advocated placing automated external defibrillators in public areas, is working on a scavenger hunt-type game app that would encourage high school students to locate and report the AED locations to a central database so emergency responders can direct 911 callers to them in a cardiac emergency.



In New Brunswick, the government’s $16,000 subsidy of the $24,000 Velante EMR sold by a for-profit venture of the New Brunswick Medical Society ended Monday. Expected physician enrollment was running well behind expectations through the end of February. The medical society partnered with a vendor who then contracted out system development to a New Zealand company.


Epic offers its usual April 1 merriment, declaring that it will immediately discontinue Meaningful Use support to allow clients to claim Stage 2 hardship exemptions, KLAS realizing that it has always spelled CLASS incorrectly, and Epic funding research into how to pronounce the name of its business intelligence suite Cogito but advising to just call it “ree-POR-ting” for now.


A new JAMA-published study finds that 19 of the 50 largest drug companies have at least one academic medical center leader on their boards, paying them an average of $313,000.

The chairman of an England-based CMIO-type organization says his organization can’t say anything negative about their software systems because vendors will sue them. “Our pockets are not deep enough to confront the legal departments of the suppliers,” he says, suggesting that instead trusts contact each other before buying.  

Weird News Andy titles this story “To Make You Feel Better.” Hearing-impaired California consumers who called the listed 800 number to receive help signing up for health insurance are surprised to hear, “Welcome to America’s hottest talk line.” The site’s incorrectly listed number was for a sex chat line. A Covered California spokesperson denied that its site listed the wrong number despite the local TV station’s screenshot clearly showing it. A Sacramento newspaper had made the same mistake previously, running a number that was one digit off and sending prospective subscribers to the same service.

Sponsor Updates

  • Brad Levin, GM of Visage Imaging, contributes an post titled “The Time is Now for Deconstructed PACS.”
  • SyTrue is selected to present at the Healthcare Documentation Integrity Conference in Las Vegas, NV July 23-26, offering “Your ‘Hitchhiker’s Guide’ to Medicine’s ‘Tower of Babel.’”
  • PerfectServe discusses clinician exhaustion and offers three steps to eliminate the problem.
  • Harris Corporation’s FusionFX Patient Portal earns 2014 Edition Modular Ambulatory and Inpatient Certification from ICSA Labs.
  • Health Care Software posts its event calendar through October.
  • ESD celebrates 24 years in healthcare IT.
  • Etransmedia Technology’s Direct Care Coordinator receives ONC-ACB certification.
  • DrFirst and Insight Software partner to offer e-prescribing to eye care providers.
  • First Databank will summarize research findings on drug pricing benchmarks at two pharmaceutical conferences in April and May.
  • WebInterstate Inc partners with Liaison Healthcare to integrate its MediMatrix mobile imaging solution to multiple EMRs.
  • MedAssets continues to support clients in preparation of ICD-10, saying the transition is “when” rather than “if.”
  • Deloitte Analytics senior advisor Tom Davenport expounds on the findings of the strategic planning required for big data to be of use.
  • Wellcentive will demonstrate its population health management platform during the AMGA conference in Dallas, TX April 3-5.
  • Perceptive Software creates a blog to recap Inspire 2014 in Las Vegas April 4-9.


Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre.

More news: HIStalk Practice, HIStalk Connect.


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Reader Comments

  • Whimps: It's not a courageous article. It's a biased article in the "Open Health News". That's like taking a comparison docu...
  • Keith McItkin, PhD.: Are not the scribes defeating the original purpose of CPOE and EHR, which was to avoid non physicians from performing th...
  • David: Doesn't this go to show that Meaningful Use was needed to cause change in the EHR world? I'm not an expert, but this so...
  • Mobile Man: Very, very interesting! Thank you both. And, I must say - I love the "final thoughts". Many/Most don't end with an ...
  • IntriguedByVistA: the link ...

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