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Readers Write 8/15/12

August 15, 2012 Readers Write 14 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Note: the views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

A Letter from Michael Stearns, MD

8-15-2012 6-22-58 PM

As many of you know, I was until recently the president and CEO of e-MDs, Inc. an ambulatory EHR vendor. I joined e-MDs in 2006 as their CMO and was promoted to president and then president and CEO in 2007 and 2008. Through 2011, my tenure at e-MDs was marked by significant increases in revenue.

On July 2, 2012, I was abruptly removed from my position with e-MDs for reasons undisclosed, other than a vague inference to company policy violations. e-MDs has refused several requests to disclose the details of these alleged infractions or the names of those involved, making it impossible to respond or to provide essential information that would allow me to clear my name. 

Unfortunately, e-MDs took the unusual step of publishing a press release that contained information based on false allegations that have not been subject to basic tenets of due process. The rationale for taking such action is difficult to discern. Regardless, I will be relentless in my pursuit of the facts. I remain confident that information will eventually emerge that will exonerate me completely. 

Due to a very unfortunate situation that occurred while I was a Navy medical officer roughly two decades ago, I have learned to be particularly sensitive to my conduct in the workplace. In summary, I found myself caught up in the fallout from the Tailhook scandal of 1991 that resulted in hundreds of naval officers having their careers damaged or destroyed, as detailed in this Duke Law Journal article.

Staffing shortages in the Navy resulted in a lack of available female chaperones, and female patients made a number of complaints. One of my patients, a female seeking disability for unexplained loss of genito-rectal sensation, bladder dysfunction, and lower extremity weakness, complained that my examinations had been overly detailed on two separate occasions. An investigation of my conduct with female patients over a four-year period led to two other complaints emerging, but the overwhelming majority of patients reported that I was “one of the most caring and thorough physicians they had ever known.” 

During the investigation, a number of facts emerged that shed doubt on the validity of the claims made by these individuals. Given the post-Tailhook atmosphere, there was a great deal of pressure on the commanding officer not to demonstrate leniency in any matter of this nature. I was given the option of either fighting the allegations in court or submitting my resignation in lieu of charges. However, under a subsequent threat of media attention, they reneged on the resignation offer and filed indecent assault changes.

My military counsel, after a cursory fact-finding effort, informed me that given the hysterical climate created by Tailhook — regardless of my guilt or innocence — I would be found guilty and could spend up to 15 years in prison. I was told my only realistic option was to accept a time-sensitive plea offer that reduced the charges to the misdemeanor equivalents of simple assault and battery. In return, I would also be found formally not guilty of the indecent assault charges, including any reference to inappropriate sexual touching. I was also informed by my attorney that the plea bargain would not result in a loss of my medical license, based on direct communication she had with the Maryland Board of Physician Quality Assurance (MBPQA).

A MBPQA review body recommended that my license be suspended for six months and the suspension stayed. However, after a protracted and acrimonious process, the MBPQA removed my license to practice medicine for a minimum of one year. Perhaps most disappointing to me, especially in light of the fallout from the Tailhook scandal, was that, despite my pleadings, the MBPQA did not perform an independent investigation that would have revealed a number of exculpatory findings of fact. Making matters worse, the published MBPQA order contains false information that has never been corrected. I was found formally not guilty of indecent assault and all language to that effect was removed from the guilty pleas. Despite this, the MBPQA order states that my guilty pleas arose from inappropriate sexual touching, something for which I was actually found innocent.  

My former employer, to their credit, conducted their own independent investigation in 2010 to address the facts surrounding the MBPQA orders. e-MDs went so far as to speak with a physician who served alongside me in the Navy and who corroborated the information I provided to them. They concluded that the process had been unfair and biased and published their findings on their website for over a year. HIStalk republished their findings in this article

Due to the age of information and easy availability of this erroneous MBPQA order, a number of individuals have drawn incorrect conclusions regarding the facts and actual findings of law based on the MBPQA orders. I appreciate HIStalk giving me the opportunity to address this in a public forum and I am hopeful that the MBPQA successor, the Maryland Medical Board, will correct the errors in these documents.

While always conducting myself in a respectful way, I have learned to be cautious and somewhat guarded in my professional interactions over the 18 years that have passed since this situation arose. Thus, I was stunned to hear of the vague allegations brought forth by e-MDs. 

During my leadership, e-MDs was increasingly seen as a company willing to contribute substantially to core informatics efforts driving advances in healthcare and clinical research. In addition to running a company that saw a roughly 15-20% annual increase in revenue during my tenure, I represented e-MDs on multiple boards and played a direct role in informatics, policy, standards, interoperability, genomics, coding, patient safety, patient privacy, compliance, and educational efforts related to HIT initiatives; gave over 100 educations presentations; provided five testimonies to various work groups of the ONC; and was invited to a private White House town hall meeting on HIT in June of this year.

It is disheartening to believe that a company to which I dedicated more than five years to would publish something so vague as to invite innuendo and speculation. The unusual step e-MDs took in publishing conclusions based on a hastily conducted and inexplicably incomplete fact-finding process was highly unfortunate and damaging to my reputation. Knowing that inaction in the face of defamation can cause long-term damage, I have no other choice than to provide corrections through public forums while I work diligently to clear my name.

Michael Stearns, MD.

Response from e-MDs

e-MDs, Inc. removed all the material and information that comprised the web posting “The Truth About Michael Q. Stearns” that had been posted in March of 2010, and this removal occurred immediately following the action taken on July 2, 2012 by e-MDs that completely terminated its affiliation with Michael Q. Stearns.

Both e-MDs, Inc., and Dr. David Winn, each formally retract that entire prior posting statement and want to be very clear that statement should not be relied upon as the current position of e-MDs, Inc. or of Dr. David Winn.

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August 15, 2012 Readers Write 14 Comments

HIStalk Advisory Panel: IT and Patient Outcomes 8/15/12

August 15, 2012 Advisory Panel 2 Comments

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a provider organization (hospital, practice, etc.), you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This month’s question: Why has healthcare IT not uniformly improved patient outcomes?

Vendors and Products Don’t Align with Clinical Needs

  • Doctors don’t see technology as an ally in helping them take care of patients. Please see the article recently published on Medscape. The default mode of healthcare practice in the US is to practice defensive medicine (defense against lawsuits). Examples like those given in the article above don’t raise a healthcare provider’s confidence in technology. Notice how the article specifically gives the example of vendor contracts that say if something goes wrong using our technology, it’s not our fault.
  • We have focused on a computer fixing a workflow problem while at the same time becoming more dependent on computers to tell staff what to do.
  • With few exceptions, the vendor community supports our efforts to enhance and embellish the product with each deployment. In some cases, neither the vendor nor the client has an incentive to collaborate with other vendors, or other clients, to ensure that every deployment of IT is better than the previous one. This is getting better, but we still have much to do in this regard.
  • Some outcomes take a long time to improve, longer than the HC IT has been in use. Some HC IT focuses too much on documentation without a balanced approach to deriving outcomes information let alone being integrated into the care process sufficiently to affect outcomes.
  • The answer is in part within the question: IT implementation has not really been uniform across the care spectrum. As most realize, systems are often if not usually built from a developer / programmer standpoint, reaching out to address a problem rather than starting with a problem (or "job to be done") and working back to develop the necessary system to perform that job. This has lead to numerous issues of usability, human-computer interface problems. More importantly, and more fundamentally, many systems simply aren’t designed to improve patient outcomes. They’re built from the start to support billing, financial management, documentation, etc. As a corollary to the above, rarely is the clinical environment placed at the center of the system. This is evident in the approach vendors generally take with deals: focus on administrative and IT needs (decision-makers) with lesser attention devoted towards those who both use and see the actual patient effects.
  • The Jurassic Park line, “Just because we could does not mean we should"says it all. Not every EMR or HIT app needs to be adopted or will prove to be of value. Not all of them are created equal. In many instances, it has been the technology that drove the cost with very little benefit.
  • Clinical decision support that follows the rights (right clinician, right intervention, right time, right level of alert logic, right ease of use ) is almost non-existent, except for the simplest medication alerts. Apologies to Jerry Osheroff, I don’t think he gets this quite right. Until the biggest EHR players improve their CDS functionality, and there are good guidelines for turning structured knowledge into CDS, I don’t think we will get very far. We will, but I am waiting for the ability to use a general purpose programming language on data in the EHR to create new levels of CDS that are actionable. Further, I bet not much of this happens locally until the EHR players are forced to have some "skin in the game", some liability for the CDS that is already baked into their model install. It is just silly that each of 5,000 hospital CDS committees have to decide whether an aspirin after an MI is a good thing, or whether you ought to check a cholesterol every couple of years on a statin.
  • There are many factors that contribute to uniformly improving patient outcomes. But one issue that is still a work in progress is developing and deploying a system to provide the right information to the right people in the right place at the right time. Integrating data on previous care that a patient receives from their primary care physician during regular clinic appointments, with emergency encounters, possible inpatient episodes, care provided at an ambulatory care organization, etc. pose a unique challenge to collect all of these disparate encounters and the data generated. While EHR systems bring together some of these important data elements, there are still gaps (for example — data on an emergency room visit while a patient is out-of-state on vacation). Additionally, even if data is integrated together, all of these indicators and data points need to be filtered and targeted to improve upon a specific outcome (e.g. reducing the likelihood of myocardial infarction readmission). Recommendations on improving outcome and supporting information need to be concisely delivered to the proper places when care is provided, to the physician when a patient presents at the emergency room with chest pain to the care coordinator prior to discharge.
  • While there has been considerable time spent integrating healthcare IT into related systems of care, there needs to be a more systematic approach, time and resources spent integrating into the process of care – specifically clinician workflow so the tools are optimized.

Usability/Integration Issues

  • I think Dr. Rick’s excellent articles have shed light on the usability issues of EHRs. He mentioned some data on how short-lived human working memory is. EHRs can take 5-10 seconds to respond to every mouse click.  These long delay times make it difficult to keep a coherent stream of thought going when documenting, especially when providers get interrupted (appropriately) by office staff who need something or the other. In the end, what gets produced are long canned narratives about generic patients. When the note is read a few days later by the provider or someone else, they see a generic note that tells them little about the patient. Our EHR would take 45 seconds to a minute to open a chart in the mornings. By the late afternoon, it was five minutes to open a chart. That’s typically caused by memory leaks. We (a medical clinic) had to call a technology firm that says its been in business for 20 years to tell them they had memory leaks! Now all charts take about 45 seconds to open.
  • The main problem is usability, which involves both design and implementation. Many HIT systems are simply not designed well. They are often trying to "replicate the current way of doing things" with the idea that this will improve adoption. However, it turns out that computers are lousy at being paper, and so can never match up. However, computers are really good at being computers, and so the best HIT software takes advantage of the unique properties (e.g. complex data analysis, data visualization) and enables a better experience. Additionally, good design should start with observing the real needs of the end user (not just listening to what a user thinks they need), and most importantly should involve an iterative process which acknowledges that the programmer and physician should work closely for months to fine tune a system. However, the second problem may be even more worrisome. The same EMR system can be implemented in so many ways that the results can range dramatically. A recent editorial talked about how EMRs cost a lot, and slow down doctors, and introduce new errors, and are thus not ready for prime time. But the fact is that while this is a reasonable conclusion based on many experiences, it is a short-sighted view of the potential of what can happen when a good EMR is implemented well. I think the best use of an EMR is to allow for automation and delegation of various parts of the workflow to empower a team to do more care and to do it consistently – thus resulting in both higher quality outcomes as well as less work for physicians.
  • Technology in and of itself is useless and even detrimental unless built and used correctly. In order to have a positive patient outcome, in my mind, a technology theoretically should be easy to use, be actually useful (for the user or the patient), and have minimal negative impact (on workflow or patient care). A breakdown of any single one can result in a subpar result. Patient outcomes may not have improved universally because current healthcare initiatives don’t necessarily encourage focus on all items. Also things like “usability” can be oftentimes extremely difficult to create.
  • The hodgepodge of company acquisitions that has created a market where products have never been integrated. One of the reasons Allscripts is collapsing is because of an inability to integrate Eclipsys products. I find it hard to believe that companies that size, with the resources they have, can’t integrate two products. Clinicians have to sign onto several products multiple times a day to get information they need. It is guaranteed that in such a system there will be conflicting data in different databases increasing the risk of patient harm. Maybe this makes systems like Epic better, but that also stifles innovation. EHRs aren’t going to improve with markets dominated by companies like Epic as is being demonstrated everyday right now.
  • Too many disparate systems that don’t talk to one another. Even with HL7 messages, there is still a lot of variance. All it takes is sending something in the wrong HL7 field to cause a problem.

It’s the User, Not Just the Technology

  • A dependency on the skill and performance of the user related to the IT solution in question. The use of the word "uniformly" makes me consider that every user will create a different outcome. As an example, an electronic health record relies on inputs from various sources in order to aggregate the patient history and then present a user with information to make decisions. The term "decision support" is bandied about with great import these days but as the term implies the tool is there to simply support the clinician’s capability to make a decision. Almost all technology is just that, a support system to assist the clinician or user. The same can be said of a technology such as the Da Vinci Robotic Surgical System. In the hands of a great surgeon, the outcomes can be outstanding. In the hands of a first year surgical resident, the outcomes probably will not be the same.
  • That is like asking why the carpenter’s apprentice who was recently trained on how to use a hammer, router, etc. (insert your specialized tool or technique of choice) hasn’t improved his/her ability to create beautifully crafted cabinets or furniture. It takes time to become competent, proficient, and then the master of skills with the usage of newly introduced and evolving tools. This describes skills improvement for the individual. To obtain uniformly improved skills and thereby products / outcomes, it takes even more time to build an organization or industry of skill masters. Our digital society that expects instant gratification and results has forgotten that it takes time and commitment to master skills and provide high quality products and services. This obviously is an oversimplification, but I think an appropriate analogy to the usage of a healthcare IT to improve outcomes.
  • While this question is understandable given all of the federal government’s promises and expectations of what HIT will do to improve patient outcomes, the question reveals a lack of understanding of what IT in general can and cannot do. Healthcare IT (and in fact any IT investment) on its own can do nothing; it is only when used in conjunction with improved workflow and processes that patient outcomes can be improved. That is what we should be measuring. There is a reason why IT is called an “enabler”, and a “complementary” technology (like electricity). On its own, IT (like electricity!) has no value, and therefore won’t (can’t) improve anything. It has to be used in conjunction with changes in workflows and processes in order to improve outcomes.
  • The effective deployment of technology has a number of requirements, of which the actual technology may be the smallest piece of the puzzle. At the end of the day, improved patient outcomes are a combination of provider decisions and judgment, patient compliance, adequate monitoring of efficacy of treatments and the use of technology to support all of those. The last item on that list is dependent upon the provider learning and adopting the technology to its full (not necessarily fullest) capabilities. Any one of these factors has the potential to derail the process, so if we don’t look at the process holistically, we shouldn’t expect uniform improvement.
  • Lack of leadership on the provider side and lack of appreciation and understanding of HIT on the hospital executive side (one executive in charge of 11 hospitals did not know who Todd Park is).
  • Ultimately it is not HIT by itself that will change outcomes, but what people do with it and how providers use it. Even HIT left unchecked can be harmful. I made more mistakes with electronic prescribing than I ever made on paper. I do not believe that we should stay on paper at all, but until we are all connected out there on the Medical Internet and the information flows freely, we will not reap the benefits of technology. One article in the Economist called "When the carpet calls the doctor" failed to explain how a device attached to the carpet that sends a signal to the doctor when the patient is about to fall is going to prevent that fall. Is the doctor or nurse supposed to get in the car or fly to the rescue? How about the apps that would monitor the patient’s weight or glucose — what will one do if the patient will not use it? Who is going to sit in a tower 24/7 to monitor all this and who pays for it? Not much is being said about that. As excited as I am about HIT, I do realize that our bigger-than-life expectations may not be materialized — not soon enough, anyway. Hope this helps, as it is written in between rounds at three hospitals, two of which are still on paper.
  • Because IT alone won’t accomplish anything.  If you take a bad process and simply duplicate it with IT solutions, you still have a bad process.
  • I would be mildly surprised if it had. In my view, outcomes will improve with decreased variability (with the most likely shapes of the outcome curve you can prove this mathematically) and clinical decision support. Theoretically, EHRs reduce variability with templates and order sets, but I have seen few real world examples of templates standardizing care, except in very limited areas, like DVT prophy. Clinicians still go off and do their own thing after the initial orders are in, and the templated H+P is done.

Variations in Implementation

  • Probably the top reasons would include: variability in the technology itself, variability with the implementation, and variability of the adoption/use of the technology by the end users. All of those areas of variability exist at every hospital (even those within larger health systems who attempt to "standardize" their efforts). It should surprise no one, then, that "Healthcare IT" does not have uniform results. A poor implementation of even a very good technology solution will not have the same results as a good implementation. Similarly, poor adoption will not yield results from the effort to implement the technology (or may yield negative results directly due to the hybrid environment created by poor adoption where some are using and others not using the technology). Additionally, any negative outcome will be blamed on the new technology being implemented even if something else is actually to blame. However, I would posit that a good implementation with good adoption and engaged end-users with even a mediocre technology solution has the potential of generating positive results for patients.
  • There is nothing uniform about the way we deploy healthcare IT solutions. We are often inwardly focused and insular as we define, design, and deploy the solutions that we must implement. We are often working very hard to leverage the technology we have acquired so that we can make the best use of scarce resources. We seldom take the time to measure our own local progress. We surely struggle to make time to share lessons learned with others. Our local efforts often limit the extent of our reach, while also limiting our ability to measure what impact we may have had.
  • Just because your facility has implemented an EMR system, regardless of how mature the model is, it doesn’t mean the facility is using that technology to improve outcomes. Case in point: our facility is in the last stages of an EMR implementation. We are incorporating what our clinical team believes is industry best practices and evidenced based care i.e. Elsevier and Zynx, and we are going to reduce the variation in care that not only drives cost up but produces varying outcomes. We went on a site visit to a hospital who has already implemented this system but are using terrible practices. That is not the fist place we went where we saw this. It takes real leadership to stand up and say we are going to do it a specific way that uses evidenced based/best practice care. The IT systems can readily support an organization who is trying to do this with real time clinical behavior reporting. This will start to drive outcomes.
  • Healthcare IT has not been uniformly distributed. The inequity among hospitals will be even deeper. Hospitals that are EMRAM level 6 or 7 and hospitals in rural areas that could benefit the most from health IT but cannot afford it.
  • Lack of consistent adoption. Lack of understanding on how some technology can impact outcomes. Lack of discipline in organizations to use what they have. Poor BI use that would help isolate areas of improvement.

Lack of IT Support

  • The CIO/IT Director doesn’t always get it. If we don’t understand the business of our organization, there is no way that we will provide the tools necessary to analyze / improve our business. A good example is that of business intelligence. My organization doesn’t think it is necessary or quite frankly, even understands what it is. I know that we have to have better analysis, and that in order to do that, I have to provide the appropriate tools. If I wait till the organization gets behind BI, it won’t happen for another 2-3 years and then it will be too late. I’ve searched out a solution that makes sense in our environment and began the implementation 12 months ago. The next step is to push it out to the organization and educate the management team on its value.

Meaningful Use has Distracted Clinicians and Vendors

  • The emphasis on Meaningful Use metrics over the past years has led to a significant percentage of adopters to be focused almost exclusively on meeting those criteria that would allow for bonus attainment. These tools have the possibility to bring focus to a singular patient’s health issues and treating that patient as a unique individual with unique needs. This can be done efficiently and effectively when the clinician is able to utilize the tool as they see fit. Instead the clinicians become distracted by unnecessary hurdles mandated by someone sitting on Capitol Hill. The emphasis on evidence-based medicine and population health also distracts somewhat from the unique physician / patient experience by moving the focus up a layer or two from the primary interaction. Eric Topol has written a great deal about this.

The Healthcare Business Model Stands in the Way

  • Our supply driven healthcare system and culture that needs to change. For-profit HIT, hospitals, and so on that has made us pursue the highly profitable but not always the most cost effective or valuable course of action.The only one whom I saw commenting on that was Peter Orszag, who said that it will be difficult to reconcile years of marketing in healthcare and direct-to-consumer advertising with customer satisfaction and reducing costs. We want to retire on 401(k) plans that invest heavily on healthcare companies and we want them to be profitable, but squirm when it comes to paying for it and attempting to cut cost. We cannot have it both ways.

Benefits Will Be Realized Only when Quality can be Measured

  • Most providers / clinical entities are still trying to get past the data entry hurdles. Not yet at a point where most are focused on measuring quality. No defined quality standards that most agree on. Multiple groups with multiple standards, and these are not aligned with EMR companies.
  • There is nothing stable about the environment into which we are implementing systems. The regulatory climate, the scientific environment, and the relentless pursuit of discovery creates a dynamic setting into which we are deploying systems. Collectively, this often prevents us  from thoughtfully, comprehensively, and accurately measuring the impact of our implementations. So to some degree, we don’t really know if we are making a difference. We don’t always measure the things that matter, and sometimes we aren’t certain of the aggregate benefit of our collective actions.
  • Healthcare IT has not uniformly improved patient outcomes because we have few clinicians with sufficient vision and understanding of the potential that can, in turn, influence the change. The CIO/Clinical IT employees cannot produce the level of influence needed and it will take a lot longer to move from a world of data collection to a world of data analysis. In addition, we still take too much of an individualistic approach to patient treatment. Evidence-based medicine has not been accepted in any of the organizations with which I’ve been affiliated.
  • There have not been enough in-roads in the establishment of systems where data has been uniformly stored and then shared. Taking those outcomes and running them through statistical engines is the holy grail to improve outcomes. It takes time to build the foundation to support this future endeavor.
  • Patient outcomes have not been well defined and continue to elude us. A patient who does well after open heart surgery may do so because he has a supportive family as opposed to one who lives alone. HIT cannot alter that; it can only help measure it.
  • Our litigation-crazy society has made it almost impossible to share and be transparent about mistakes and medical errors,HIT induced or not.
  • I do not believe we learned any lessons yet. Someone should interview those hospitals that spent in the $100 million range IT budgets or the ones that made mistakes so we can all be enlightened.
  • The most obvious answer is that healthcare IT has been used in different ways, and to different degrees, from one provider to another and from one department to another. Now that healthcare IT is becoming more broadly adopted, and as advanced analytics are developed to empower caregivers more, patient outcomes are expected to improve. Any discussion of outcomes should recognize its limitations. For example, some medical conditions lend themselves to objective measurements of improvement, while others don’t. Despite the extreme complexity of healthcare, there’s a natural desire to measure the end result, the output of the process, in objective and simple terms. Did the patient get better? If so, how much? Did the patient population get healthier? If so, how much? But not every patient with the same diagnosis(es) will get better in the same way. Can an objective measurement adequately convey the difference? Some patients won’t get better at all. For a terminal patient released to hospice, for example, shouldn’t we instead be asking whether the patient and loved ones feel they were treated with respect, dignity, and compassion? For them, that is an outcome. Acute care hospitals should follow the lead of the subacute sector, which focuses heavily on such measurements. For non-terminal cases – those that indeed may be expected to get better – were they and their loved ones kept informed throughout the stay, or did they feel frustrated by a disjointed, piecemeal system of specialists, which mostly kept them in the dark? Were they informed and guided through decisions? These considerations should be incorporated into any meaningful discussion of "outcomes."
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August 15, 2012 Advisory Panel 2 Comments

News 8/15/12

August 14, 2012 News 9 Comments

Top News

8-14-2012 9-23-52 PM

SAIC completes its acquisition of maxIT Healthcare, making SAIC’s Health Solutions Business Unit the nation’s largest commercial consulting practice in EHR implementation and optimization.

Reader Comments

From Neal Patterson’s Evil Twin: “Re: new research group survey of hospital CIOs. It compares the cost of a major EHR upgrade to the original contract price: Epic (40-49%), Cerner (30-35%), Allscripts / Eclipsys (20-22%), and McKesson Paragon (10-13%). Epic had the lowest cost for minor upgrades at 1%. Amazingly, the CIOs surveyed seem to have been caught off guard – they didn’t develop an adequate total cost of ownership model.” Unverified, since the company producing the report requires registering to get a copy of it and I refuse to do that on principle. I agree that Epic, often bought recently at the height of organizational optimism and as a knee-jerk reaction to previous experience with unresponsive vendors, is going to be a big budget problem for a lot of hospitals that will never realize the ROI. I don’t know of any examples where IT on its own has ever changed the trajectory of an organization – it usually just accelerates it slightly. If your organization has always sucked at management, planning, and delivering quality care efficiently, it’s probably not lack of Epic that caused that situation nor implementation of Epic that will fix it for you. Like all non-profits, hospitals change only to threats to their existence.

8-14-2012 6-39-47 PM

From Don: “Re: E.J. Noble Hospital hiring a CFO to improve their financial software. They are CPSI even though the CFO’s relevant experience was with Meditech.” Trying to confirm which system a given hospital is using is almost impossible. I always Google and try to find a couple of items that seem to confirm and none that contradict (announcements, posted jobs, physician newsletters, etc.) but I always say it “appears” they’re using the system since you never know what’s changed. In the case of E.J. Noble, I turned up one Meditech user list that included them (perhaps that site incorrectly assumed that they are the same facility as Noble Hospital, a Meditech hospital in Massachusetts) and, most convincingly, E.J. Noble Hospital’s employment application specifically asks whether the applicant has Meditech experience, which is not a common question for non-Meditech sites. I assume the reader is correct, but I can’t prove that, either.

8-14-2012 9-37-07 PM

From Dell Encore: “Re: Encore Health Resources. In serious negotiations to be acquired by Dell.” I asked EHR CEO Dana Sellers, who says she hadn’t heard the rumor and says the company isn’t for sale. I believe her since she’s always been a straight shooter, but I should mention that when I ask CEOs about acquisition rumors, I get one of three possible outcomes: (a) they don’t respond, which leads me to assume the rumor is true and I’ll run it as an unverified; (b) they tell me the rumor isn’t true, although in at least two cases CEOs who I would consider to be friends of HIStalk flatly denied a reader’s rumor that turned out to be deadly accurate all along shortly thereafter, which I don’t really consider to be uncool since they can’t have me blasting it everywhere right in the middle of their negotiations; or (c) the CEO tells me off the record that the rumor is true, but implores me to hold off mentioning it until the announcement, which I usually do (sometimes they offer me an exclusive story or interview in return). Occasionally I get briefed even before anything is announced, allowing me in several cases to conduct an interview and have it ready to blast out the second the news hits the wire. The best ever was when a CEO arranged to call my house one evening to tell me that the company was going to be acquired for huge money by a publicly traded company, which was fun because, (a) he treated me like a real journalist, trusting me not to do something stupid like leak the news or trade the stock of the company that was involved, and (b) it was priceless when Mrs. HIStalk asked me who I was talking to and I casually mentioned that a CEO just wanted to chat with me about selling his company for a few hundred mil the next day. For at least 30 seconds, I felt like more of a big shot than just some hospital guy and spare bedroom blogger, but then I had to get back to work.

From Horshack’s Laugh: “Re: predictive analytics solutions. Lots of vendors and providers are talking about the need for them without offering a standard definition of what they are or aren’t. Have you looked into who might be the reportedly top 5-10 vendors? Thanks much … love your stuff.” My stuff loves you right back. I’ll defer to readers on the question since I know better than to opine in the presence of experts.

8-14-2012 9-50-30 PM

From Dr. Nancy: “Re: article in The Atlantic. It’s old, but worth reading if you haven’t seen it. You are the best.” The perspective of the 2007 article by Shannon Brownlee (Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer) is interesting and timely: do we have too many rather than too few doctors? It says that the usual arguments that aging Baby Boomers will increase demand just as aging doctors retire, causing a decline in patient outcomes, just might be wrong, quoting a physician researcher who said, “If we sent 30% of the doctors in this country to Africa, we might raise the level of health on both continents.” The article observes that docs congregate where business is good (bigger population, more insured patients) and generate their own demand by ordering more stuff for patients, but outcomes aren’t any better in those doctor-rich areas like Manhattan and Los Angeles. Doctor-patient ratios at academic medical centers are 2-3 times higher at UCLA and NYU than Mayo and Duke with no better results, it says, possibly because all those docs need to justify their existence, like by ordering unnecessary tests and not communicating with the hordes of competing specialists roaming the halls.

Acquisitions, Funding, Business, and Stock

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Emdeon posts a loss of $35.4 million for Q2 compared to a net income of $9.2 million a year ago, attributing the red ink to the costs of its acquisition last year by Blackstone. Revenue was up 4.4% to $294.5 million.

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HIM consulting firm TrustHCS acquires Legacy Coding LLC, a clinical coding and auditing form.

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Health accelerator Healthbox starts its three-month Cambridge, MA program today, with 10 companies getting office space, mentoring, and $50K in seed capital in return for a 7% stake. I got distracted (and annoyed) by the write-up of Bon ‘App, which says its nutritional app has “simplistic language.” As Inigo Montoya says, “You keep using that word. I do not think it means what you think it means” (either that or its app is one to avoid).


Texas Health Resources selects Medicity’s HIE solutions to power information exchange among its facilities and physicians.

Winkler County Memorial Hospital (TX) will implement financial solutions from Prognosis HIS.

The George Washington University and the National Institute of Child Health and Human Development will use PeriGen’s PeriCALM Patterns alerting system for maternal in a research project involving the use of intrapartum fetal heart rate monitoring to predict neonatal outcomes.


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Former Siemens Healthcare President and CEO Eric R. Reinhardt joins the board of Varian Medical Systems.

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Seattle Children’s Hospital promotes Wes Wright from VP/CTO to SVP/CIO.

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Beacon Partners promotes Kimberly Post from controller to CFO.

Announcements and Implementations

Harris Corporation will expand Florida’s HIE secure messaging service to 11,000 physician offices that use Care360 solutions from Quest Diagnostics.

Regional Medical Center at Memphis completes implementation of the Siemens perioperative management solution by SIS, which will interoperate with Soarian.

The Kansas HIN and ICA announce that Via Christi Health Systems and HCA Wesley have successfully transferred data into the KHIN production environment.

MEDSEEK will incorporate GetWellNetwork’s GetWell@Home into its patient portal.

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University of Michigan Health system goes live this week on Epic’s MyChart patient portal. The article in the Ann Arbor paper also mentions that hospital executives attribute part of its fiscal year loss, announced in June, to the cost of implementing Epic.

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Health Care DataWorks announces Value-based Purchasing, which tracks the 20 CMS VBP quality outcomes measures that affect hospital payments starting in October.

Government and Politics

Innovate Primary Senior Care (IL), Treasure Coast Healthcare (FL), and Virginia Commonwealth University Health System and the Medical College of Virginia Hospitals and Physicians (VA) join 16 independent practices in CMS’s Independence at Home Demonstration.

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You might think the VA is paperless given the high marks its VistA system receives. Not so, as a VA OIG inspector knows after writing up its Winston-Salem, NC office for piling 37,000 claims folders on top of file cabinets, to the point that the sixth floor office’s floor was sagging and in danger of collapsing. The VA cleaned up the area and will spend $400K for a filing system to be located in the basement.

Innovation and Research

8-14-2012 6-31-50 PM

A group of 14 organizations in 10 European countries begins trials of the DebugIT antibiotic decision support system they developed, which applies statistical methods to their collective susceptibility information to recommend optimal antibiotic therapy to clinicians.


The Kansas HIE board postpones voting on the proposal to dissolve the organization and instead forms a committee to analyze the proposal and return with a recommendation for the board’s September 12 meeting.

Greg Reed, CEO of the embattled eHealth Ontario, declines his $81,250 performance bonus for the second year in a row. The Ontario government is facing a $15 billion deficit and wants all public sector workers to take a two-year wage freeze.

The Surgeons of Lake County (IL) announces that an unauthorized user hacked into its computer system, encrypted the server, and demanded money in exchange for the password to regain access the EMR and corporate e-mail files. The practice refused to pay the ransom and instead turned off the server and contacted law enforcement. It’s unclear whether the practice had a backup, but the server remains unplugged. The practice believes the intent of the authorized access was to extort money rather than obtain patient information.

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Ed Marx has an article called “CEOs, CIOs must look to IT for success” in Modern Healthcare (registration required).  

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The Siemens folks at their user meeting sent this photo of John Glaser with Cal Ripken, Jr., who looks disturbingly like Uncle Fester in this shot.

Speaking of Baltimore, HL7 is holding its annual meeting there September 9-14. A reader invites you to attend a session on standards-based approaches for PACS-EHR integration, which will focus on DICOM and IHE workflow profiles. That session is September 13 from 11:00 a.m. to 3:30 p.m. at the Hyatt Regency Baltimore at the Inner Harbor. I would almost make the trip just as an excuse to revisit one of my all-time favorite restaurants, the brilliant Woodberry Kitchen.

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Weird News Andy captions this article as “Say What?” but stop reading now if you’re one of those people that worries about bugs crawling on (or in) you while you sleep (or whether China has a HIPAA policy). Doctors at a hospital in China, examining a woman complaining about itching in her head, find and remove a spider that had burrowed into her ear five days earlier, easily discernible in the creepy photo above.

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Speaking of HIPAA, the firefighter’s unions in Las Vegas, trying to convince insolvent cities to stop considering outsourcing non-emergency calls to private ambulance services, may have inadvertently violated HIPAA privacy laws by posting a list of private ambulance calls that took longer than their 12-minute contractual maximum. The list contained home addresses and reason for the call, which included such items as suicide attempts and drug overdoses. The image above blurs those reasons, but the one on Latefor911.com didn’t.

A New York Times article covers the huge profits being made by HCA and the mind-boggling money that private equity firms like KKR and Bain are making in orchestrating its complex financial transactions. How HCA does it: aggressive billing of private insurance, creative use of the coding system, turning non-emergent patients away from its EDs, and cutting clinical staff. On the other hand, the company at least pays taxes, unlike its non-taxpaying counterparts sometimes use those same tactics to boost their bottom lines. All of this was inevitable when the decision was made, going back to the early days of Medicare and Hill-Burton if not earlier, that hospitals should be run as businesses rather than as charities or religious outreaches. The new rules said you had to make money but weren’t specific about the limits of how you could do that beyond your organizational conscience.

Union representatives in Contra Costa County, CA say correctional system nurses filed 142 complaints about its new $45 million Epic system in July, claiming that they are Epic’s detention facility guinea pig. A nurse says super-users told management about the problems and warned that the two-hour training sessions weren’t adequate since the training system wasn’t fully set up. “What nurses want is for the Epic program to go away until it’s fixed,” she says.

A cardiac perfusionist sues Mount Sinai Hospital (NY) and her former boss for creating a hostile work environment, claiming everybody knew that he regularly watched porn on his smartphone while working cases in the OR.

Sponsor Updates

  • Forbes includes Greenway Medical Technologies as one of its five favorite growth stocks.
  • Like Kareo on Facebook by August 17 for a chance to win a Kindle.
  • St. Joseph Health (CA,TX, NM) adds additional revenue cycle technology solutions from MedAssets.
  • Simonmed Imaging will deploy Merge’s radiology and interoperability solutions across its 50+ sites.
  • A Vitera Healthcare Solutions study finds that 91% of doctors want a mobile EHR solution, yet only 6% connect to an EHR through a mobile device.
  • Allscripts says it will debut new mobility functions and integration between acute and ambulatory settings at this week’s ACE 2012 in Chicago. Wednesday’s opening address is available on the website.

Report from the Allscripts Client Experience – Day One
By Bill Rieger, CIO, Flagler Hospital

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Today was a pre-conference workshop day. As CIO, I attended the executive session, which started off with Glen talking about transformation and change in a session titled, "It’s not about IT."  

He talked about the open approach Allscripts has, both from a philosophy and a technical perspective. He talked about Allscripts’ CLEAR values: Client experience (client always first); Leadership (inspire, innovate, grow);  Extraordinary people (learn, grow); Aspire (think different, think big); and Results (say, do).  

Kevin Larson from ONC spoke next and really didn’t enlighten us with any more information than we already had about MU and ONC initiatives. He brought up the concept of semantic interoperability (I saw a bunch of folks looking it up on their phones, me included!) and it became a buzzword that I heard multiple times throughout the day.

There was a panel discussion where LIJ, Brown and Toland, and Jefferson Medical college talked about accountable care and the iterations each organization has engaged in. Maureen Kahn, CEO of Blessing Hospital in Quincy, IL told a great community story and how the successful implementation of ADX 1.5 has impacted their organization.

Finally before lunch, Cliff Meltzer, VP of development at Allscripts, talked about what has been delivered since last year’s ACE conference: automated testing features, a client advisory group, and an early adopter program. He talked about the performance improvement with MSSQL2012 and how in 6.0 the whole environment can be virtualized. One of the things I liked that he talked about was end user performance monitoring.  I believe that the hourglass is the enemy of adoption, so I was glad to hear that they were focusing on that a bit.  

After lunch there were breakout / roundtable sessions that I found to be very valuable. I attended two of them. One discussed linking outcomes to income and heard several stories about using data to improve physician behavior leading to additional revenue. The other one was related to HIE, and dbMotion was there. There were some roundtable discussions that showed me that we are all not on the same page when it comes to simply defining what HIE is and what are the problems they are suppose to solve. Interesting, but frustrating.  

Finally, Thomas Atchison spoke. It was very entertaining, and I walked away with two thoughts. One is that in the absence of information, the void is always filled with negativity. The other is that words lie, behaviors never lie. Two things for me to chew on there. Looking forward to tomorrow when the regular conference begins.


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

More news: HIStalk Practice, HIStalk Mobile.

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August 14, 2012 News 9 Comments

EHR Design Talk with Dr. Rick 8/13/12

August 13, 2012 Rick Weinhaus 11 Comments

Fitts’ Law and the Small Distant Target

“. . . the importance of having a fast, highly interactive interface cannot be emphasized enough. If a navigation technique is slow, then the cognitive costs can be much greater than just the amount of time lost, because an entire train of thought can become disrupted by the loss of contents of both visual and non-visual working memories." — Colin Ware, Information Visualization: Perception for Design

Paul Fitts was the pioneering human factors engineer whose work in the 1940s and 50s is largely responsible for the aircraft cockpit designs used today. His life’s work was focused on designing tools that support human movement, perception, and cognition.

In 1954, he published a mathematical formula based on his experimental data that does an extremely good job of predicting how long it takes to move a pointer (such as a finger or pencil tip) to a target, depending on the target’s size and its distance from the starting point.

Fitts’ Law has turned out to be remarkably robust, applicable to most tasks that rely on eye-hand coordination to make rapid aimed movements. Although digital computers as we know them did not exist when Fitts published his formula, since then his law has been used to evaluate and compare a wide range of computer input devices as well as competing graphical user interface (GUI) designs. In fact, research based on Fitts’ Law by Stuart Card and colleagues at the Palo Alto Research Center (PARC) in the 1970s was a major factor in Xerox’s decision to develop the mouse as its preferred input device.

As you would expect, Fitts found that it takes longer to move a pointer to a smaller target or a more distant one. The interesting thing is that the relationship is not linear.

If a target is small, a small increase in its size results in a large reduction in the amount of time needed to reach it with the pointer. Similarly, if a target is already close to the pointer, a small further decrease in its distance results in a large reduction in the amount of time required to reach it.

Conversely, if a target is already reasonably large or distant, a small increase in its size or small decrease in its distance has much less effect.

What is Fitts’ Law telling us? Why isn’t the relationship linear? Are the two tasks fundamentally the same or are they different, requiring different visual, motor, and cognitive strategies?

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Perhaps the best way to get a feel for this aspect of Fitts’ Law is to try it yourself. If you have two minutes to spare, click on the link below for an online demo. You will see two vertical bars, one blue and one green. The green one is the target. Your goal is to use your cursor to move to and click on the green bar, accurately and rapidly, each time it changes position.

As you go through the demo, imagine that the bars represent navigation tabs or buttons in an EHR program. In other words, imagine that your real goal is to view EHR data displayed on several screens—clicking on the green target is just the means to navigate to those screens.

You will see some text displaying a decreasing count: hits remaining — XX. Keep track of this hit count while moving to and clicking on the green target. This task will have to stand in for the more challenging one of remembering what was on your last EHR screen (see my post on limited working memory).

When you finish, you can ignore the next screen, which displays your mean time, some graphs, and a button to advance to a second version of the demo.

Here’s the link to the online demonstration of Fitts’ Law.

What did you find?

You probably found that if the green target was sufficiently wide and close to the cursor, you could hit it in a single "ballistic" movement. In other words, with a ballistic movement, once your visual system processes your starting position and the target location, other parts of your brain calculate the trajectory and send a single burst of motor signals to your hand and wrist. The movement itself is carried out in a single step without the need for iterative recalibration or subsequent motor signals.

Your brain used the same strategy as the one used for ballistic missiles. The missile is simply aimed and launched, with no in-flight corrective signals from the control center.

Conversely, you probably found that if the green target was narrow and far from the cursor, you couldn’t use a ballistic strategy. After initiating the movement, most likely you had to switch your gaze to the cursor, calibrate its new screen location in relation to the target, calculate a modified trajectory, send an updated set of motor signals to your hand, and so forth in iterative loops, until reaching the target.

These two strategies are fundamentally different. Not only does the ballistic movement take less time, it requires much less cognitive effort. In fact, if the target is large and close enough to your cursor, you can make a ballistic hand movement using your peripheral visual field while keeping your gaze and attention on the screen content.

These differences between ballistic movements and those requiring iterative feedback may explain the non-linear nature of Fitts’ Law.

As I discussed in a previous post, the rapid "saccadic" eye movements we use to redirect our gaze are the benchmark against which all other navigation techniques should be measured. Not surprisingly, these saccadic eye movements, lasting about a tenth of a second, are ballistic. Once the brain has made the decision to redirect gaze, it calculates a trajectory and sends a burst of neural signals causing our eye muscles to turn the eyes to the new target and simultaneously preparing our visual processing system to expect input from that new location.

It makes sense that saccadic eye movements are ballistic. We want to turn our eyes to the new fixation point as quickly and effortlessly as possible. In fact, we take in no visual information whatsoever during the saccade itself. We only acquire visual information between saccades, when our gaze is fixed on an item of interest.

From an evolutionary standpoint, it would appear that saccadic eye movement, being more rapid and efficient than iterative strategies, was selected as our primary means of navigating visual space. If we want our digital input devices and interactive designs to approach the efficiency of saccadic eye movement, we should create user interfaces that facilitate ballistic strategies.

Returning to the vendor’s design presented in my last post, the "maximize" buttons, shown below outlined with red circles, are both tiny and distant:

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There is no way we can move the cursor from one maximize button to another (except for the adjacent ones) using a ballistic strategy, whereas the design below, using a separate navigation map, supports such a strategy:

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Of course, all design choices require trade-offs. The second design requires a major compromise. By requiring a separate navigation map, it adds another level of complexity to the user interface.

It’s not usually the case that one high-level design is good and another isn’t. Most high-level designs have their advantages. But if you are going to stick with the vendor’s design, at least use the entire area of the title bars as the targets. If you are going to use a separate navigation map, make the panes large and close enough for a ballistic strategy to work.

To be clear, the problem is not the extra second or so that it takes to acquire a small, distant target. It’s that poor designs cause the user to break concentration and use working memory for non-medical tasks. An unnecessarily difficult navigation operation can disrupt the train of thought needed to apply good medical judgment to an individual patient.

Quite simply, when designing EHR interfaces, many choices are not a question of preference or aesthetics. We are hard wired so that certain tasks are simply easier than others. Our EHR design choices need to be informed by an understanding of these human factors.

Next post:

A Single-Screen Design

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

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August 13, 2012 Rick Weinhaus 11 Comments

Monday Morning Update 8/13/12

August 11, 2012 News 8 Comments

From The PACS Designer: “Re: big data mining. One of the challenges facing healthcare is how to collect, manage, and view data that can improve outcomes. Some interest is brewing in the open source community to help with the challenge. An open source solution drawing this interest is Hortonworks with Apache Hadoop 1.0. While it’s still relatively new, the chances of HortonWorks being production ready in the next year or two are high, and it could show up in healthcare settings in several years.” The post also quoted EMC’s CTO, who listed some healthcare big data opportunities: (a) always-on end user query capability for all data sources; (b) data collection from real-time medical instrumentation; (c) in-memory capabilities for fast decision-making in the ED; and (d) real-time health scoring as is done in ICUs. Above is a nicely done overview of the Hortonworks Data Platform that should get tech geeks salivating.

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From A Curious Reader: “Re: Meditech’s KLAS numbers. The 16 customer losses in 2011 are from the C/S platform, while the 14 are from Magic. The C/S losses are a mix of v.5.x and v.6. KLAS issued an trend alert in July reporting that 35% of over 50 hospital respondents said they wouldn’t buy v.6 again because of product immaturity and usability issues. Of the non-IT respondents, more than half said they wouldn’t buy it again. According to a CIO quoted, ‘Some of the applications have been developed in the new v.6 language and some applications are in the old NPR language. Because of that, the new v.6 platform requires a million connections, and from a management and monitoring standpoint, the transfer of data is very complicated.’” Just to address the counterpoints: (a) Meditech has a ton of hospital customers, so their percentage loss is probably tiny; (b) Magic is ancient and upgrading is almost like a re-install, so it’s not surprising that those clients would explore and sometimes choose alternatives; (c) Meditech hospitals tend to be small and thus more likely to be acquired and subjected to a forced system replacement, assuming those are counted by KLAS as “losses” (which would likewise give Epic an inflated count of wins.) The customer comments about v.6 are indeed troubling, however.

Listening: First Aid Kit, a pair of amazing sisters from Sweden who covered a Fleet Foxes tune with their camcorder running in a Swedish forest when they were 17 and 14, making them a modest YouTube sensation. That was five years ago and they’re still putting out mature, bittersweet harmonies that could be pegged somewhere between indie pop and American country-folk. They use talent, not studio tricks – check out this rather stunning video that was shot as they sing and play memorably while walking down a public street in Paris right before their show, with cars and people milling around them. They’re doing several US dates in September and October.

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Two-thirds of us would be disappointed if we went straight from a routine doctor’s appointment to the hospital, which would have no record of our just-concluded ambulatory visit. New poll to your right: how has Meditech’s market position changed in the past year?

As I was creating the poll, I struggle as I always do with whether I should write Meditech (my usual) or MEDITECH (like everybody else does). It struck me that I should check the “AP Stylebook” (the Bible of news writing) that’s two feet from my chair, which says all-capital company names aren’t used unless the letters are individually pronounced. It’s OK for IBM or GE, but not Nasdaq or Meditech. That leaves me puzzled about HIMSS (Himss?) since it’s always sounded out. I also learned that characters are not used in a company name (so it’s MModal, not M*Modal), periods go outside parentheses unless what’s inside is a full sentence (so it’s outside this set), and the first word of a sentence is always capitalized no matter what (so it’s Athenahealth, not athenahealth, if it’s the first word of the sentence).

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Speaking of MModal, the company agrees to release the projections its financial advisors used to determine that JP Morgan’s $1.1. billion buyout offer was fair. The disclosure is one of the terms in a settlement agreement the company reached with shareholders who felt the offer price was too low, representing just an 8.3% premium over current market share price and 18% less than a competing bid from Nuance that MModal’s directors rejected. Meanwhile, the company reports Q2 results: revenue up 7%, adjusted EPS $0.21 vs. $0.31, missing expectations on both but maybe backing up the board’s arguments that the buyout price is fair.

Bond ratings company Fitch warns bond investors that HITECH payments can hide the “otherwise anemic revenue growth” of hospitals given that it’s a one-shot payment that doesn’t even cover the IT costs required to earn it in many cases. They also say that the need to implement IT is helping drive hospital consolidation.

Presidential candidate Mitt Romney names Rep. Paul Ryan (R-WI) as his running mate. Ryan’s healthcare IT connections: (a) he wants to overhaul Medicare and Medicaid, saying the country can’t afford the cost; (b)  he was #1 on the “100 Most Influential People in Healthcare” for 2011; (c) he co-sponsored a bill in 2008 that would have established independent health record trusts that would allow consumers to manage their own health records, force EMR vendors to link to those trusts, and split the proceeds from de-identified data sales between the patient and the trust to fund the operation; and (d) he and four other Wisconsin politicians tried to influence the VA and DoD to buy systems from home-state vendor Epic instead of writing their own. My favorite trivia items about him: he was voted prom king and “Biggest Brown-Noser” as a high school senior and he worked a college summer job at Oscar Mayer and was allowed to drive the Wienermobile once (both irrelevant factoids courtesy of warring Wikipedia edits by fans and foes).

Allscripts chooses Symedical Server from Clinical Architecture to address clinical terminology requirements for its entire product line.

E.J. Noble Hospital (NY) hires a new CFO mostly for his IT experience, saying an unnamed system it installed in 2010 works OK for patient care, but isn’t user-friendly for the finance people. That system would be Meditech, according to noted healthcare IT expert Mr. Google. UPDATE: they aren’t Meditech, even though their job application asks about Meditech experience. Folks are suggesting they are using CPSI.

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St. Luke’s Hospital (NC) goes live on McKesson Paragon after what it said was a 3,000-man-hour, $2.5 million project.

General Dynamics is awarded a five-year, $20.6 million contract to connect the Indian Health Service’s EMR system (an offshoot of the VA’s VistA called RPMS) to the Nationwide Health Information Network.

Former Awarepoint CEO Jason Howe is named president and CEO of Vaporstream, which offers a secure digital messaging channel for executive communication that prevents legal discovery.

Personal health records systems haven’t done much of anything, but that doesn’t keep everybody and his brother from cranking out low-rent versions sold cheap on the Internet or burned onto flash drives. Here’s a new $35 one from from “a local Mom” that runs on your PC and requires printing out your manually entered information in advance. The local mom even made a TV commercial. I couldn’t find a screen shot or example of the printed report anywhere. At least the local mom identifies herself as “Owner/Founder” on the site, unlike most spare bedroom part-time moguls who grandly label themselves as CEO like that’s going to fool someone into thinking they’re running multinational conglomerate.

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This story about over-capacity Yale-New Haven Hospital buying the money-losing Hospital of Saint Raphael, also in New Haven, CT, illustrates how political the hospital business is. The YNHH people had to brief city aldermen whose constituents have been pestering them about their fear of losing their jobs or benefits. YNHH said only one group would definitely lose their jobs: the estimated 60 people on HSR’s payroll that Yale had previously fired, raising the ire of one alderwoman who said, “Just because Yale fired them they can’t work? You’re not willing to give them a second chance?” YNHH was also questioned about whether it would dismantle the Teamsters union at HSR; it said it wouldn’t. Maybe it’s no mystery why HSR needs a bailout given that it hires previously fired employees, has to deal with the Teamsters, and pays so much that employees are afraid of a gravy train derailment after being taken over by a university, a group collectively known (as are hospitals) for overpaying masses of marginally competent people who will never be fired or demoted for anything short of a felony committed on company time. Hospitals are like NASA: the science is sometimes questionable, the lack of value is inarguable, but nobody can touch them because they create a lot of jobs and political allies.

Bizarre: a new mom who agreed to appear in an instructional video for breastfeeding is horrified when Googling her own name to find a slew of porn links and explicit YouTube videos. The video company said it’s not their fault that somebody spliced the breastfeeding scenes into a porn video featuring graphic footage of someone who resembles the woman performing acts much less innocent than breastfeeding, but they don’t deny that the video displays the woman’s full name on the screen. She’s suing, of course.

Weird News Andy finds the story of this former law student inspiring (“Tough as Nails,” he labels it). Experts can’t figure out her skin disease, in which fingernails are growing out of hair follicles all over her body. She was referred to Johns Hopkins, where she’s racked up $500,000 in medical bills that her insurance won’t pay because it’s an out-of-state provider. She takes 25 medicines, of which insurance pays for five.

Vince responded to a reader’s request to have all of his HIS-tory episodes available in one place. All 50+ of them have been loaded to his company’s site, where I intended to take a quick look but got wrapped up in reviewing them all over again. This week’s edition is an introduction to the series, why he’s doing it, some folks he fondly remembers, and a plea for material for future episodes from those who lived the HIS-tory he writes about.

Sponsor Updates
  • Certify Data Systems, which offers the HealthDock intelligent interoperability appliance, is named as a "Major Player” in HIE technology.
  • A White Plume blog post observes that physicians seem to prefer to code E/M visits manually even though most EHRs can do it automatically.
  • A HealthCare Anytime fact sheet describes its patient portal, which offers online bill pay, appointment requests, refills, messaging, and a PHR.
  • Henry Elliott & Company’s hot position openings include Cache’ developers, MUMPS programmers, and several other technical jobs.
  • Eastern Health goes live with the disease screening solution of NexJ Systems, which offers next-generation customer relationship management systems for healthcare.
  • Besler Consulting provides an overview of CMS’s Hospital Readmission Reduction Program.
  • Southern Oregon Orthopedics (OR) chooses SRS after de-installing its legacy EHR product that it says had tedious drop-downs, wasn’t meeting transcription needs, and wasn’t getting them to Meaningful use.
  • Shareable Ink customer Sheridan Healthcare (FL) describes its use of the company’s “digital pen and paper” system.
  • Current opportunities at Executive Search Recruiting include consulting VP, IS director, consulting partner, and certified consultants for Meditech and Epic.
  • API Healthcare offers a free August 14 Webinar called “Will You Ever Love Your Patient Classification System? Embracing PCS with Evidence and Persistence.”
  • Health Data Specialists, which offers consulting services for Cerner, Epic, Meditech, and Siemens, will exhibit at Siemens Innovations this week in Baltimore.
  • TrustHCS, which offers coding, compliance, and ICD-10 solutions, will speak about ICD-10 readiness at the AHIMA convention October 1-3 in Chicago.
  • OTTR Chronic Care Solutions will host its user conference September 17-19 in Omaha. The $485 registration fee includes 2 1/2 days of discussions, Q&A sessions, networking, lunch, and a half day of small group workshop training.

The “Future” is Now “Today!”
By Dr. Gregg

There’s a true labor of love that I do each year for the American Academy of Pediatrics – National Conference & Exhibition (AAP-NCE) which used to be called the Pediatric Office of the Future. This non-profit event began as a demonstration of how technology could improve a pediatrician’s office practice. It now showcases technology in all areas of practice – office-based, hospital-based, and mobile / social / telemedicine. It has grown from just seven sponsors and a 900-square-foot booth in 2007 to more than 30 sponsors in a 4,500-square-foot space last year.

It’s a huge volunteer effort. We work hard every year to give our attendees greater informative value and our exhibitors greater ROI. Big changes this year include:

  • No more “sponsors.” Every vendor in our exhibit is a true “exhibitor” who gets better signage, sales conversations, and individual lead capture for a single exhibitor fee.
  • The event itself is now an exhibitor, allowing us to offer short and sweet exhibit hall-style educational offerings as long as we clearly label them as non-CME.
  • We (COCIT — Council On Clinical Information Technology, which runs the event) control the marketing. If we can fund it, we can do it.

We’ve rebranded the exhibit as the “Pediatric Office of Today!” to make it clear that what we are showcasing are tools that can help today instead of in the future.

The non-CME educational offerings will build on last year’s Tech Talk Theater, adding the TIP Stop Video Booth (“How do you put “Technology In Pediatrics?”) and a Meet The Experts area where, during the MTE sessions, attendees can chat one on one with pediatric informaticists, telemedicine pros, REC reps, MU and ePrescribing experts, and even high-level ONC folks. (there’s a rumor that “The Farzad” might drop by.)

The media area of our new site will contain an ongoing record of these sessions, along with audio and video recordings from past years and professional video from this year. It will become our virtual pediatric tech library.

The Pediatric Office of Today! is all about having some fun as we promote advanced technology for delivering better pediatric care, improving bottom lines, and enhancing life and work styles. As the pediatric HIT market’s potential is just starting to take off, it’s exciting to help it take wing. To all our volunteers, AAP support staff, and each and every vendor who has helped or will help support our project: thanks for helping turn the “Future” into “Today!”

(And a special thanks to Mr. H for graciously letting me share the word here about my little pet project.)

8-11-2012 2-37-50 PM

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of Today! exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

E-mail Mr. H.

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August 11, 2012 News 8 Comments

News 8/10/12

August 9, 2012 News 8 Comments

Top News

8-9-2012 9-21-00 PM

Allscripts reports Q2 results: revenue up 4%, EPS $0.04 vs. $0.08 (adjusted: $0.16 vs. $0.22), falling short of analyst estimates on earnings. The company raised earnings expectations for 2012 and says it will borrow money to buy back its own stock, sending shares up 18% on Thursday. Puzzling given the current lackluster results right there in black and white, but perhaps this was a relief rally since no new bombs went off like last quarter and pessimism was already built into the share price. Some highlights from the conference call:

  • Two new Sunrise clients signed on in the quarter, one of them in the UK.
  • The company says it continues to “make progress enhancing the performance and integration of our portfolio."
  • Sunrise Financial Manager is entering early adopter phase and is scheduled for general availability in Q4.
  • The company admits that upgrades have been spotty as some clients "experienced challenges."
  • Allscripts expects 4,000 attendees to attend the Allscripts Client Experience in Chicago next week.
  • The company says it expects to win more hospital business in the next year since unnamed competitors have "started to step away."
  • Glenn Tullman admits that some prospects were holding back in case more corporate surprises surfaced or the company turned in a disastrous quarter, but says "the selling environment is going to come back."
  • MyWay sales were announced as flat, with more of its users moving to Professional.
  • Allscripts Professional will have an iPad version released at ACE.
  • Glen Tullman describes Sunrise as "affordable, easy to install, and open."
  • Glen Tullman: "The open message is starting to resonate … paying these astronomical amounts to installed a closed system doesn’t make sense for the future … they simply can’t afford it anyway … healthcare is going to get squeezed … we’re in talking to a lot of customers, including some customers who are saying, hey, we have this big system that’s from a well-known brand and we can’t afford it anymore, so how can you help us take down our cost.."
  • More Glen Tullman: "And relative to population — health and population management, Humedica is our partner there. As full disclosure, we have an ownership stake in Humedica, that they’re known as industry leader in the space and we’re strengthening both our marketing and sales efforts, but we are also strengthening the integration between the products."
  • On the relationship with clinical research organization Quintiles: "But as we talked about creating a partnership to improve research, that benefits the clients, it benefits the patients and it benefits pharma "

Reader Comments

From Black Box CIO: “Re: HIPAA and business associates. We are working with a company on development work and they refuse to sign a BA agreement, even though they have access to patient information. They are not permanently storing information, but are running scripts, pulling and manipulating data, viewing data, and printing out data. Our risk director, attorney, and I think they are wrong and need to sign the BAA. Do you or your readers have an opinion?” Per HHS, if you’re disclosing protected health information to that company, you need to get a signed business associate agreement to protect yourself unless the company’s people are under your direct control (i.e., working at your site under supervision just like your own employee would) and their service doesn’t involve treatment, payment, or operations. The primary question is whether the company really needs live patient data to do their work – if they do because of your setup, then they need to sign a BAA even if it’s not their fault that you don’t have good test data (I bet if you told their competitor they could have the job if they sign a BAA, they’d jump all over it.) Obviously it’s in the company’s best interest to convince you to let them slide, but HHS is clear on the issue:

The mere selling or providing of software to a covered entity does not give rise to a business associate relationship if the vendor does not have access to the protected health information of the covered entity. If the vendor does need access to the protected health information of the covered entity in order to provide its service, the vendor would be a business associate of the covered entity. For example, a software company that hosts the software containing patient information on its own server or accesses patient information when troubleshooting the software function, is a business associate of a covered entity. In these examples, a covered entity would be required to enter into a business associate agreement before allowing the software company access to protected health information.

From Digital Bean Counter: “Re: personnel updates. Michael Streetman has joined WellStar as VP of IT. His LinkedIn profile does not yet show the update. I am fairly certain Michael is Jeff Buda’s replacement (Jeff left for Floyd Medical Center, as you reported).” Unverified.

From Love is a Drug: “Re: HIMSS. Continues to demonstrate a complete lack of leveraging basic online business and IT practices. First it was the horrible, long post-conference survey, and now this week it tested a listserv in production, filling by inbox with a dozen garbage messages. They’re not moderating the comments on their mHIMSS site, allowing search engine manipulators to post spam. The industry is lost if this is our leader.” I see they’ve added CAPTCHA spam protection to their commenting function and have removed the garbage comments that were posted earlier.

From Chester the Investor: “Re: technologies. Speech recognition came out of nowhere after many years of dormancy to suddenly be the hottest thing in the sector, as just about all the players were acquired over a short period. Is there a similar technology that will follow that trajectory?” Real-time location systems.

From Pilsner Paul: “Re: surveys. How can vendors influence surveys conducted by reputable survey firms? You say they do, but I don’t see how.” The best way of all is the method drug companies have been using for years to get positive research articles published: commission a bunch of them, then toss all the ones whose findings don’t match your marketing plan. Nobody knows that the one good research paper represents 50 that failed to prove anything positive and therefore never saw the light of day (note to self: why doesn’t FDA require all research to be registered with them in advance as with hospital IRBs so we see all the results, not just the favorable ones that get published?)

From Hurry & Wait LLC: “Re: Meaningful Use. I’m hearing that OMB now has the final rules from ONC/CMS. However, it may take until the fall of 2012 (think turkey and stuffing) for the final rules to be published. With that comes the requirement that the MU2 attestation period will be 90 days in Year 1.”

HIStalk Announcements and Requests

inga_small If work, vacation, or Olympics TV viewing got in the way of reading HIStalk Practice this week, here are some highlights: a UC Medical School physician says EMRs are expensive, take time to implement, and decrease office efficiency. CareCloud adds a VP of product management. AAFP supports new measures to reduce prescription drug abuse. Better economic conditions and new insurance plans that support preventative care services helped drive clinician visit volume up 5% in Q2. The ever irreverent Joel Diamond considers the meaning of “ACO.” Kyle Swarts of Culbert Healthcare Solutions tackles business intelligence and the need to create a body of knowledge. My fragile self-esteem gets a boost each time a new subscriber takes the required two seconds to sign up for e-mail updates, so thanks for taking the time to boost my mental health. Thanks for reading.

8-9-2012 7-03-41 PM

Thanks to the folks at Vitera Healthcare, sponsoring both HIStalk and HIStalk Practice at the Platinum level. I figured we’d made them mad since they previously sponsored awhile back, but apparently their was some mixup that they’ve fixed by rejoining the fold of happy sponsors. They’re talking about the newly released Vitera Intergy v8.00 if you’d like to click on over to reassure them that they made the right decision. Thanks to Vitera.

This is the point where I cheerfully warn anyone who doesn’t already know (noobs) that I’m always behind, so set your expectations appropriately for me to respond to e-mails. Picture your own full-time job, then another 4-5 hours of heads-down focus when you get home, plus all weekend — that’s pretty much my life right there. My “sent” folder has 25,000 e-mails, so that gives you an idea of how long it takes to work my way through my inbox, which usually has hundred of e-mails crying for attention. I try to catch up over the weekend, so wait until Monday at least before resending, which just makes the situation worse. After nine years of writing HIStalk, I’m cured of the shame of not always being able to keep all the plates spinning in the air at once, so now I just say that’s the way it is.

I know how to keep women happy and dewy-eyed satisfied, at least if the ladies in question are Inga and Dr. Jayne, who will reward your skilled electronic touch (male or female) with a rapt, smoldering gaze of longing and maybe even a more intimate connection if you play your cards right. Here’s the move: (a) sign up for spam-proof e-mail updates; (b) arrange to have your paths cross by surreptitiously seeking them out on the usual social not-working sites (Facebook, LinkedIn, Twitter) and connecting with them; (c) influence them through their friends by reviewing those shimmering sponsor ads to your left and possibly perusing the surprisingly robust Resource Center that has cool, searchable sponsor information and maybe even some videos and stuff; (d) stand out in their crowd of smitten admirers by sending news, rumors, guest articles, and anything else that demonstrates your wit, wisdom, and charisma since everybody likes someone who can make them laugh or feel special; and (e) feel free to tell everyone you know about your shared experience — the ladies have enough reader love to go around. We appreciate your attention in whatever form it takes and we reciprocate whenever we can.

Acquisitions, Funding, Business, and Stock

8-9-2012 5-51-26 PM

Shares of Accretive Health fell more than 14% Wednesday after the company reported earnings that missed expectations and lowered its revenue forecast. Shares are down 41% since April 24, the day the Minnesota attorney general accused the company of using overly aggressive hospital collection tactics. The company tried to put some positive spin on the glum report by announcing that it has signed a five-year contract extension worth up to $1.7 billion with its largest customer, which to the slight detriment of the big news, happens to be partial owner Ascension Health.

Meditech files its 10-Q for the most recent quarter. Revenue was up 9%, net income increased by about the same percentage.


8-9-2012 6-06-33 PM

University Hospitals (OH) names John Foley (West Penn Allegheny Health System) as CIO.

8-9-2012 6-07-43 PM

NaviNet appoints Frank Ingari as CEO, succeeding Bradley J. Waugh. He was previously CEO of Essence Healthcare, a sister company of Lumeris Corporation, which acquired NaviNet earlier this year.

8-9-2012 6-48-09 PM 8-9-2012 6-47-30 PM

Cloud computing vendor ClearDATA Networks hires Ralph Reyes (an early partner in KLAS) and Jonathan Russell (HMS) as sales VPs.

8-9-2012 7-34-22 PM

CareCloud names Edwin Miller (Cardinal Health) as VP of product management.

8-9-2012 8-31-45 PM

Old news, but I missed the announcement if there was one: Jacque Dailey, formerly CIO of UPMC’s Children’s Hospital of Pittsburgh, is now CIO at Highmark.

Announcements and Implementations

Regional Medical Center at Memphis (TN) completes its six-month implementation of perioperative and anesthesiology systems from Surgical Information Systems.

8-9-2012 6-44-09 PM

The local paper in Cranston, RI profiles the use of GetWellNetwork by an 11-year-old boy whose rare skin disease requires frequent hospitalizations and surgeries. His condition precludes the use of his hands, so he has learned to use Facebook, control on-screen entertainment functions, and peruse medical education content by using his feet on the touch screen (he says he got a ton of Facebook Likes when he explained how he was posting.) If you watched the video I posted a couple of weeks back from the GetWellNetwork user conference in Orlando, you saw him (Antonio Torres) speaking to the group.

Grand Itasca Clinic & Hospital (MN) goes live next week on Epic (or EPIC, as they apparently can’t resist shout it out proudly), provided by Allina.

The Phoenix business paper covers the work of Dignity Health and the Arizona State Physicians Association to create an accountable care organization with Vanguard Health Systems, which will allow independent physicians access to an HIE powered by Siemens MobileMD.

Government and Politics

CMS releases details on the Medicare EHR Incentive Program 2012 Reporting Pilot for eligible hospitals and CAHs.


The Geisinger-led Keystone Beacon Community (PA) will use Caradigm’s data-sharing technology to allow skilled nursing facilities to contribute their patient data to the HIE, even if the facilities do not have an EHR. The Caradigm “MDS to CCD Transformer” converts the minimum data sets (MDS) used by nursing homes into Continuity of Care Documents.

Columbus Regional Hospital (IN) blames its new EHR for temporarily doubling its average ED wait time to nearly five hours. Two months after the go-live, the average wait is still more than three hours, worse than before. The system vendor isn’t mentioned, but they were a Meditech site at one time.

A federal judge approves a whistleblower lawsuit against Florida Hospital Orlando and several other Adventist Health System hospitals in Central Florida. A former billing employee says the hospitals overbilled the federal government tens of millions of dollars in false or padded medical claims. The attorney for the plaintiffs says damages could exceed $100 million, barely containing his excitement over his mentally tabulated percentage.

8-9-2012 6-27-52 PM

CapSite’s 2012 US Medical Device Integration study finds that nearly two-thirds of 400+ bed hospitals recently bought such technology, with many of them implementing it right now. Cerner and Capsule were the most common vendors, with Capsule easily leading the pack in the 400+ bed range. iSirona is getting an equal number of looks from those considering vendors. The primary reasons for implementing medical device integration was to improve outcomes and efficiency. Of those big hospitals that haven’t bought yet, an amazing 82% say they’re planning to, most of them within two years.

8-9-2012 6-58-06 PM

A new KLAS report on hospital clinical system finds that when it comes to new wins, it’s pretty much all Epic with a bit of Cerner thrown in and everybody else eating their dust. There’s not even a clear-cut third-place winner for reasons spelled out in frank detail (remember, these are customers talking, not self-proclaimed experts.) Epic sold 54 hospitals of 200+ beds in 2011 and lost none. Biggest losers were GE Healthcare, McKesson Horizon, and Meditech (who lost more current product users than legacy product users.) Thanks to the folks at KLAS for allowing us to excerpt their report. Definitely worth a read if only to hear the customer-provided counterpoint to what some glass-half-full vendor CEOs are saying.

A federal monitoring team hits Parkland Hospital (TX) with scathing criticism about poor management and a quality culture that allowed patient-harming errors (and deaths) to occur. One bright spot: the report said Parkland was doing a pretty good job in enhancing its clinical systems (in other words, Epic is the best thing happening there, according to the report.)

A Reuters article frets that Obamacare will make it easier to identify and deport illegal aliens who seek medical care since they’ll be the only people left without an insurance card.

8-9-2012 6-30-04 PM 

The teenager accused of impersonating a PA at Osceola Regional Medical Center (FL) and performing CPR on one patient, blames hospital personnel for giving him the wrong ID card. He says it was the hospital’s “stupid” mistake and that whoever made the error should be fired “because apparently they are too ignorant to have that position.”

8-9-2012 9-04-08 PM

Strange: in England, an NHS hospital ED doctor who took a six-month paid sick leave for stress and then worked at other hospitals goes on trial for defrauding her primary employer of almost $50,000. She was turned in by her former boss (also her married former lover) after boasting of her “megabucks” and “stupid amount of dosh” on Twitter, catching the attention of the former boss’s wife. The doctor said she worked the extra shifts to keep her clinical skills current.

Sponsor Updates

  • Medicomp Systems announces its MEDCIN U conference October 14-16 in Reston, VA.
  • dbMotion and Allscripts host a free webinar September 18 on preparing for accountable care within the workflow.
  • Imprivata announces details of its HealthCon 2012 user conference November 6-8 in Boston.
  • Alere Health and AT&T partner to deliver DiabetesManager,  a mobile health solution powered by WellDoc for type 2 diabetes management.
  • Jay Savaiano of CommVault authors an article on big data in healthcare.

EPtalk by Dr. Jayne


It’s not just for pharmaceutical companies any more. ONC uses direct-to-consumer marketing to explain “how widespread adoption of electronic health records and other health information technology is giving our health care system a 21st century upgrade.” The animated video from ONC’s new Office of Consumer eHealth aims to “spark conversation” between patients and providers about leveraging technology. The opening slide shows various caregivers, including ‘my doctor’ and ‘my gynecologist.’ (last time I checked, gynecologists were doctors, too.) Some of the other graphics are downright goofy: a stereotyped female nurse in old-school whites and a cap and a hipster pharmacist who needs a shave.

All the health IT in the world can’t fix the fundamental problems: many people eat too much, don’t exercise enough, and indulge in habits with negative consequences. A Centers for Disease Control report published Tuesday corroborates this. The study was designed to assess the prevalence of walking, which was defined as “at least one bout of 10 minutes or more in the preceding 7 days” which is really quite minimal. Not surprisingly, one out of three US adults reports no aerobic exercise during leisure time and less than half report levels of activity meeting current guidelines.


In trying to convince patients of the importance of exercise as “medicine,” I started recommending the Presidential Active Lifestyle Award challenge program. Anyone age six or older can sign up for the six-week program and jump start their exercise plans. As an added bonus, those of us who weren’t proficient at the flexed arm hang or the shuttle run in middle school have another chance to earn a cool patch with the Presidential seal. The downside: the website is a little glitchy and they don’t have a mobile app. Perhaps the folks at ONC could help out.

I came across this publication in the AHIMA library: Ensuring Data Integrity in Health Information Exchange. It offers a good, high-level overview for anyone starting involvement with HIE. They address governance up front, which is unfortunately something quite a few HIEs fail to do effectively. This should be required reading for all tech people working on HIE projects so that they understand the big picture.


Thanks to Twitter to alerting me to this piece by Atul Gawande talking about how restaurant chains control quality, cost, and innovation. He wonders if health care can learn from the Cheesecake Factory. I found the discussion of “guest forecasting” and restaurant analytics fascinating and agree with Gawande’s premise. We need to be using aggressive analytics throughout healthcare and enable highly functional teams throughout the patient care space. He also talks about his mother’s knee replacement experience, which is timely for those of us with parents in the Medicare set.

Have an idea how long you have to spend on the treadmill to neutralize a piece of cheesecake? E-mail me.



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

More news: HIStalk Practice, HIStalk Mobile.

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August 9, 2012 News 8 Comments

News 8/8/12

August 7, 2012 News 10 Comments

Top News

8-7-2012 6-49-05 PM

The board of the Kansas HIE, having found few takers for its fee-based services, meets this week to decide whether to dissolve itself and turn its operation over to the state, hoping to reduce its $400,000 in annual operating costs. Taxpayers would be on the hook to cover the remaining half of its costs. Former Kansas Governor Kathleen Sebelius, now HHS secretary, convened the commission that recommended creating KHIE by executive order in 2010, which makes it questionable as to whether the group has the legal authority to simply disband itself. KHIE funded its operations with a $9 million federal grant and has $5.5 million left.

Reader Comments

8-7-2012 7-52-59 PM

From InTheKnow: “Re: Alere. Just closed a deal to acquire DiagnosisOne.” Verified, but not announced as far as I can tell. Alere (the former Inverness Medical Innovations, which acquired interoperability vendor Wellogic last year ) offers diagnostic and health management  technologies and programs, while DiagnosisOne sells tools for order sets, decision support, analytics, and public health surveillance. DiagnosisOne is backed by Edison Ventures, which is how I verified the rumor after digging around forever – the acquisition was buried on one of the pop-up pages on their site.

8-7-2012 8-36-33 PM

From Justa CIO: “Re: Indiana University Health. Announced that Bill McConnell, Jr. started this week as CIO, replacing Chris Van Pelt, who has left the organization.” Verified. Bill has updated his LinkedIn profile showing that he started this month. He was previously CEO of FlowCo, which makes a stent-related medical device.

From Jeremy: “Re: 3D printed medicine. How would people feel about their EHRs printing the medicine ad hoc?” A research paper speculates that a 3D printer could be loaded with pre-filled, drug-containing vessels, allowing medications to be “printed” on demand.

8-7-2012 8-14-47 PM

From Rick Starkey: “Re: JAMA article. Very entertaining.” Indeed it is. John Lennon’s Elbow, by Robert H. Hirschtick MD from Northwestern University’s Feinberg School of Medicine, is funny as it criticizes EMR documentation with Beatles references (I won’t give away its conclusion, which yielded the title.) A snip:

I once asked an intern why his successively longer daily progress notes retained old or irrelevant test results. His response was revealing: “This way, my final progress note is also the discharge summary.” This Twelve Days of Christmas approach—building a final supernote by successive daily addition—yields a discharge summary that is long, thorough, and unreadable. Unreadability is a problem only if readability is a goal. But these notes are not constructed to be read. They are constructed to warehouse data. All the key information is contained within but as hard to find as a radial pulse beneath multiple color-coded wristbands.

From Consultant: “Re: Providence Health Systems. They are slowing down their Epic implementation, one of the largest in the US to learn from initial go-lives.” Unverified. The $750 million implementation was announced in 2010 and the first go-live was originally planned for 2012, with a 30-month completion timetable.

HIStalk Announcements and Requests

8-7-2012 6-23-51 PM

inga_small My top Olympics’ observation of the day: water polo players rock. Twenty-eight minutes of treading water and swimming and throwing a ball? The athleticism of it has almost inspired me to jump off the couch and go for a run. And speaking of runners, how about Felix Sanchez, the 35-year-old from the Dominican Republic who won the men’s 400m hurdles? Way to beat the youngsters. And speaking of youngsters, I am adding Uruguayan footballer Edinson Roberto Cavani Gómez to my Hot Olympian list.

Acquisitions, Funding, Business, and Stock

8-7-2012 8-38-03 PM

HCA reports Q2 results: revenue up 12% to $8.1 billion, EPS $0.85 vs. $0.43. The company reaffirms 2012 guidance, including estimated EHR incentive income of $325-$350 million and EHR expenses of $90-$115 million. The company also announced that it was notified this week that the Justice Department wants to see records from its heart procedures at certain hospitals. A New York Times report suggested that they performed unnecessary procedures to boost revenue in preparation for HCA’s 2011 IPO.

8-7-2012 8-39-16 PM

Mediware  will acquire the assets of Strategic Healthcare Group, an Indianapolis-based provider of blood management consulting.

8-7-2012 8-50-51 PM

Nuance announces Q3 numbers: revenue up 31%, EPS $0.25 vs. $0.13.

Staffing company Cross Country Healthcare swings to a Q2 loss due to a delay in an unnamed large EMR project for which it provides staffing.

It’s not healthcare related, but it’s a cautionary tale about letting computers do too much thinking (or maybe to do more testing before a rollout.) Stock trading firm Knight Capital, which single-handedly caused wild swings in stock market share prices last week when its newly installed high-speed trading software sent incorrect orders to brokerage houses over a 45-minute period, nearly goes out of business when the SEC holds it accountable for the $440 million in erroneous trades its software caused, four times the company’s profits last year.


Orlando Health (FL) selects onFocus epm software for enterprise performance management.

Muenster Memorial Hospital (TX), United Hospital District (MN), and Rothman Specialty Hospital (PA) sign with Park Place International for its OpSus|Live cloud-based hosting solution utilizing Meditech-certified servers and storage.

8-7-2012 8-42-59 PM

Poudre Valley Hospital (CO) selects ProVation Medical Software for gastroenterology procedure documentation and coding in its GI labs.

Windsor Health Plan will deploy MedHOK’s care, quality, and compliance platform that includes NCQA certified software for HEDIS, pay for performance, and disease management performance measures..

8-7-2012 8-41-41 PM

Anderson Hospital (IL) selects M*Modal Fluency Direct for use with Meditech in the hospital and NextGen in its physician offices.

Allied Services (PA) signs a contract to implement Cerner Millennium. It offers rehab, vocational, home care, and residential services.

Announcements and Implementations

South Lyon Medical Center (CA) goes live on CPSI’s EHR.

8-7-2012 8-44-24 PM

Powell Valley Healthcare (WY) goes live on NextGen’s Inpatient EHR.

Orion Health is named a reseller and services provider for Caradigm’s Amalga platform and Vergence SSO software in the Asia Pacific region.

McKesson announces McKesson Cardiology Inventory and McKesson Surgical Manager Point-of-Use Integration Module which allows a clinician’s single barcode scan to document, charge, and reorder items.

8-7-2012 7-35-20 PM

Chicago Mayor Rahm Emanuel proclaims October 30 – November 7 to be Informatics Week (plus a couple of days, apparently), a “city-wide celebration” of biomedical and health informatics that will precede the AMIA meeting there.

The VA begins its RTLS implementation at seven VA VISN 11 medical centers in Indiana, Illinois, and Michigan. HP is managing the project, which involves several brands of sensors providing real-time information to its Intelligent InSites RTLS software to track equipment and supplies, monitor temperatures, and trigger workflows. The $543 million project will eventually cover 152 medical centers.

8-7-2012 8-26-39 PM

Hospitals in Franciscan Alliance Northern Indiana Region go live on Epic, right on time from their project plan.

Zynx Health announces Version 3.0 of its AuthorSpace clinical decision support authoring tool.

Katalus announces an EHR Total Cost of Ownership model that will be offered as a cloud-based solution.

Government and Politics

The Substance Abuse and Mental Health Services Administration awards $4 million in grants to six organizations for HIT tools to expand access to substance abuse treatment in underserved areas.

Innovation and Research

Researchers from NorthShore University HealthSystem (IL) find that the increased use of EHRs by hospitals and health systems could help physicians make more exact, real-time decisions when prescribing antibiotics.


Health engagement management provider Eliza Corporation receives a notice of allowance from the patent office for its Complex Acoustic Resonance Speech Analysis System, which provides conversational, high-performance speech recognition.


8-7-2012 8-46-13 PM

Hospital officials at Olympic Medical Center (WA) tell commissioners that their ongoing transition from Meditech to Epic will cost about $6 million, with ERP software from Infor/Lawson running an additional $1 million.  

8-7-2012 9-31-46 PM

A blog post from John Glaser of Siemens Healthcare compares his selection to throw out the first pitch at a baseball game to the impending accountability of healthcare IT to improve care (in neither case would you want to pull a Baba Booey in front of a crowd.)

8-7-2012 6-57-07 PM

HHS records show that the medical records of 21 million patients have been exposed by breaches since September 2009, with six organizations reporting incidents that affected more than a million people. Leading the pack is the federal government itself, whose Department of Defense / TRICARE (specifically, federal contractor SAIC) lost backup tapes during shipping in September 2011 that contained information on 4.9 million individuals.

ONC’s Office of Consumer eHealth puts out a video pitching EHRs to consumers.  

8-7-2012 7-08-31 PM

If you’re an Epic competitor, there’s not much good news in the KLAS Mid-Term Performance Review from June that a reader just sent my way. Unless you sell anesthesia information systems, anyway.

8-7-2012 8-47-43 PM

A pharmacy technician at University of Miami who “seemed to live beyond his means” in paying $56,000 in cash for a BMW is suspected of stealing $14 million in drugs from the cancer center pharmacy over a three-year period. The university’s CFO admits that the pharmacy had no inventory controls at all in place. The technician was caught pocketing drugs on surveillance cameras, but his lawyer says that while he did steal some drugs, it could have been anyone who nabbed the $14 million worth since anybody could just grab what they wanted. He was caught when the pharmacy buyer noticed discrepancies in the quantities on hand of the drug Neulasta, which she then inventoried manually since the new inventory software “was not the most trustworthy.”

Seattle Children’s Hospital, trying to cheer up a 16-year-old cancer patient who has been hospitalized in isolation for months and missing her cat Merry, crowdsources through Facebook to collect 3,000 cat photos to project in a “virtual feline cocoon” they built for her. Her response: “You guys remind me that there is so much good in the world, and its just makes me feel so much better, and connected. I can’t tell you how it feels sometimes, feeling disconnected and cut off from the world, and then with something like cat pictures bringing me back.”

Sponsor Updates

  • GetWellNetwork launches a video on the future of patient engagement using interactive patient care solutions.
  • Billian’s HealthDATA recognizes five hospitals to watch on Twitter.
  • e-MDs hosts a webinar featuring Jen Brull MD, FAAP and her practice’s use of social media to build community and engagement with patients.
  • GE Healthcare releases details of its Centricity Perinatal National Users Group conference in October.
  • OTTR Chronic Care Solutions will participate in next week’s NATCO Conference in DC.
  • Forrester Research names Covisint a cloud identity and access management leader in its Enterprise Cloud Identity and Access Management report.
  • A Surgical Information Systems survey indicates that drivers for implementing perioperative IT include facilitating improvements in OR efficiency, the quality of patient care, and reduction of documentation errors. 
  • Howard County Medical Center (NE) selects BridgeHead Software’s healthcare data management solution as its backup and archival system.
  • Cumberland Consulting Group promotes Mark Riley to principal.
  • T-System hosts a free webinar on proper documentation of E&M services to optimize reimbursement.


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

More news: HIStalk Practice, HIStalk Mobile.

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August 7, 2012 News 10 Comments

HIStalk Interviews Simon Arkell, Two-Time Olympian and CEO of Predixion Software

August 6, 2012 Interviews 3 Comments

Simon Arkell is CEO of Predixion Software of San Juan Capistrano, CA. He represented Australia as a pole vaulter at the 1992 Summer Olympics in Barcelona, Spain and at the 1996 Summer Olympics in Atlanta, GA.

8-5-2012 12-26-27 PM

Tell me about yourself and the company.

Predixion Software is a three-year old company. We formed it back in 2009  in order to leverage what we thought was a big opportunity in the business intelligence market. That was this space of predictive analytics, which has historically been technology that is only attainable to the very most-trained data scientists and PhDs with very expensive and complex toolsets. We thought that there would be a great opportunity to take that and break down those barriers to predictive analytics and make it more available to many more people. At a very high level, that’s been our vision since Day One.

I’ve been involved in enterprise software for most of my career. I was a co-founder of a number of companies and have raised money from venture capitalists. I’ve even gone over to the dark side and done investment banking and private equity for a little while in order to really learn the business. Each time I came back to an operational role, where I just believe that this particular opportunity was the best I’d seen in my career.

The reason for that is that my co-founder and our chairman Stuart Frost had sold his company, which was in the data warehousing space, to Microsoft very successfully. It was his idea to identify predictive analytics as this hot space. The more research I did, the more I realized that we were in a position to not only create a game-changing technology, but also to leverage the success that Stuart had had a DATAllegro with the investor base.

At the same time as starting the company, we were introduced to a gentleman over at Microsoft named Jamie MacLennan, who, long story short, came across and became our founding CTO. Jamie had a vision for many years as head of data mining and predictive analytics over at Microsoft to do exactly the same thing, and that was to bring predictive analytics to the masses and to make it more available.

With that technical firepower in place up in Redmond, we now have a development office in Redmond, and have had since Day One. Our engineering team is effectively the former data mining team or predictive analytics team from Microsoft. With that story, we were able to be very successful in raising venture capital. We have a very large strategic partner — who is also an investor — that we don’t name, along with three other venture capital firms: Palomar Ventures, Miramar Ventures, and DFJ Frontier. We’re getting ready for our next round of investment.

We’ve been very successful in the healthcare space over the last year and a half. That happens to be an industry with a lot of issues and problems that are a great fit for predictive analytics technology. We’re well on our way with a great team in place and getting some really nice early success in healthcare.


What kind of healthcare problems can predictive analytics solve and what kind of data is needed to be able to start using it?

We have seen many problems in healthcare that are a perfect fit for predictive analytics. The low-hanging fruit, and the one that everyone’s talking about right now due to CMS mandates that are coming down and penalties that commence in October, is around preventable readmissions. We call them predictable readmissions.

Effectively, you can get ahead of a problem by predicting an outcome and preventing its outcome. We have nice tagline that says, “You cannot prevent what you cannot predict.” In the case of readmissions, we’re able to assign a risk of readmission to a patient when they admit into the hospital the first time. That admission or readmission probability improves in accuracy throughout the length of stay. At the point of discharge, the hospital is allowed to actually now have very stratified and targeted intervention based on the risk profile of the patient.

Being able to assign a risk profile to a specific patient when they admit the first time is something that’s a game-changing solution. We’re able to apply that concept to many different applications, like predicting hospital-acquired sepsis, predicting the length of stay, predicting which outpatients are likely to become inpatients, and the list just goes on and on. We think that being able to predict a particular outcome is what the industry needs. Customers are absolutely responding in a big way.


How customizable is the prediction algorithm based on what information a given institution has available, based its choice of electronic medical record or whether it’s doing physician documentation electronically?

Very. Everyone wants to build a Lamborghini, but we find that even if you’re not 100% data-ready and have the perfect electronic setup as a provider, you’re able to benefit from this technology. A common term in the predictive analytics industry is that, “lift is lift.” Meaning that if you can get some improvement through machine learning over and above just a human guess, then there’s a return on investment. Over time, if you bring more systems online, that can become more and more effective.

We’re seeing very, very accurate models. It’s fairly easy to determine the accuracy of a model because you just apply it to historical data and see how accurate it was in actually predicting what actually did happen. We’re seeing very accurate models, which are measured in terms of what’s called a c statistic. We have the highest in the industry, because we apply our models and our algorithms to the electronic data – whether it’s clinical data, claims data, etc. – at the hospital level.

We do not rely on a national algorithm, because no two regions and demographics are the same. You may have a hospital in Minnesota in the middle of winter, which would have an entirely different reason for readmissions than potentially one in Florida. By being local, being agile, being easy-to-use and adapt, we’re seeing a lot of uptake from our customers right now.


A few companies did a primitive version of this back into the 1990s, use technology such as neural networks to try to make patient predictions. They really didn’t get very far. Was the problem that their information wasn’t good enough, their algorithms weren’t good enough, or that hospitals weren’t ready to do anything with the information that they were getting?

I think it’s probably all of the above. Obviously there are some hospitals that are now electronically equipped and jumping on board all of the various government initiatives to bring them up to an acceptable level. The algorithms are much more accurate. We’ve got significant domain experience now in applying our algorithms or our technology to this problem set. We’re finding that the accuracy of our models is just as high amongst just about every one of the providers that we’ve used this with.

The other thing that’s much, much different is how you get the regular information worker in a provider network to actually access this information and respond to it. Having someone with a PhD in a white coat in a back room somewhere crank on these models and algorithms in order to get information is one thing, but how do you actually get that out into the hands of a nurse who can do something about it?

We’ve solved that with what we call the last mile of analytics. Two of our customers, just in the last couple of weeks, decided to move forward with our predictive readmissions portal. It’s an HTML5 thin client portal that can be accessed on any workstation or at a nurses’ station or in a hospital room, or even on a iPad or iPhone. It will give the nurse or the case manager a list of the patients that are currently under their care and are inpatients and their risk of readmission.

What we’re working on now with our customers is being able to respond according to a risk strata of the patient. Now all of a sudden your patient population of inpatients has a very low, a low, a medium, or a high risk of readmission. The intervention at discharge can be very different now for the first time. Instead of applying very limited resources to all patients that you discharge because you were using just guesswork as to who might be at the highest risk, we’re now able to create an intervention strategy for the very high-risk patients and medium-risk patients and then intervene on them.

Intervention to a high-risk patient may mean deciding whether to send them to a home healthcare facility or sending a nurse out every second day and then having someone call every day to make sure the patient’s taking their meds. You would therefore be able to put less attention to a very low-risk patient. You can become much more efficacious or accurate in how you intervene with the patients in order to reduce your readmissions rates.

The same concept applies with regard to targeted intervention for hospital-acquired sepsis, fall risk, etc. We’re seeing  a lot of new thoughts and excitement come out of our customers who now are able to do something for the first time that they previously didn’t think was possible. It’s having all sorts of ramifications with regard to brainstorming new ideas and applications and solutions.


That’s maybe the big difference from the 1990s. The idea then was to redesign a process, like using different drugs or creating different care plans, rather than intervening on individual patients, plus there was no economic incentive since hospitals got paid for readmissions anyway. Even though the technology may have been similar in a primitive way, it was a different climate.

Exactly. You know better than anyone as we move from fee-for-service to a wellness-based industry, getting ahead of the problem and actually being able to do something about it before it happens is everything.

The ramifications in the UK are even greater. One of our prospects who is about to move forward with our predictive readmission solution received a very significant fine just last month. It was over a half million dollars, just for having readmission rates at an unacceptable level. So you’re starting to see massive payback from putting in a solution that can solve this problem for you.

And you’re right, retrospective reporting is really what business intelligence has always been up until now. We’re in the business of putting prospective information into these reports so that you can get ahead of the problem and prevent it before it happens. Again, that’s not new; there are great companies out there like SAS and SPSS, which is now IBM, who have these very specialized workbenches. But again, you’re not putting the end results in the hands of a nurse or practitioner who can do something about the output; you’re relegating it to a back room with some guy with a white coat.


Kaiser Permanente is probably the most advanced user of healthcare data in the country and they’re your customer. How are they using your product?

They’re fairly private in how they announce their utilization of our technology and any other, but I will say that they’re being very aggressive with some of the stuff we’ve already talked about.


You made two trips to the Olympics as a participant. What would you say were the best and worst memories?

Good question, because everyone always talks about kind of the excitement and the best parts of it. I have learned a lesson since competing in the Olympics. Enjoying the journey is something to be embraced. I do that now in my career and in my life as much as I can.

The best part by far was living a dream and having it turn into a reality. From the age of 11, all I ever wanted to do was compete in the Olympics. The problem when I was 11 was that I wasn’t very good at anything, so I had to find my way. When I discovered pole vaulting, I absolutely fell in love with it, but realized I wasn’t very good at that, either. But my best friend was very good at it, so we kept getting invited back, and 20 years later, I got to compete.

It was a long, long journey, and one where the biggest lesson for me was that hard work and persistence absolutely pay off. I really was so excited to be walking into the opening ceremonies and marching in the Parade of Nations for the first time in Barcelona, which I then did again four years later in Atlanta. I’d say the worst part, though, was not performing to the extent that I was capable of and being too attached to a specific outcome as opposed to really just embracing and enjoying every second of it.


I would think it must be unusual for Olympians who have focused much of their lives on a single sport to suddenly do a 180 and go out and establish themselves in the world of business, especially a technology-related business. How did you get from one to the other?

The concept of risk is not one that I’m unfamiliar with. When you’re an athlete, especially an individual athlete, it’s all about risk and reward, and the risks that you take and the things that you put on hold in life.

I found that having come from Australia and being so focused on my athletics and getting to the Olympics that my friends were all getting very established in their careers, and becoming more and more senior. I continued to get educated along the way, but I started a couple of companies while I was still competing just to make sure I could get my business chops going. I knew that’s what I wanted to do.

I always felt after I retired from athletics that I had some catch-up to do, and the way to catch up was to start a company and make that highly successful, as opposed to going the common route, which is to and work for IBM or one of the big boys and work my way up. It turned into an entrepreneurial catch-up situation. I’ve been addicted to the high-risk start up environment every since.


I assume you’re watching the Olympics now. Thinking back to when you were a participant, what do you think has changed?

I think it’s much easier for the athletes to get into a whole world of trouble these days because of the advent of Twitter and Facebook. You see it time and time again. Australians were banned for posting photographs of themselves holding guns on Facebook. A triple-jumper from Greece was sent home because she made a racist comment on Twitter. You just see so much more at risk. You’re in even more of a fishbowl now as an athlete than back before social networking. 

I  see that as a big difference, but I still believe in the Olympic philosophy and competing. Competing is a great honor, and something that for me I’ll never forget.

8-5-2012 1-31-31 PM

8-5-2012 1-22-10 PM

We’re having a lot of fun at the office right now because everyone’s keeping up with the Olympics.  Our partner account manager, Tom Hoff, I’d known from the Olympic movement. He was a member of the US volleyball team in Beijing. He was the captain and they won the gold medal, so, we use and abuse that fact and have him show up at trade shows with his gold medal. Today we’ve brought our marching uniforms in and we’re going to be taking photographs. I’ve got my opening ceremony uniform and my competition uniform and he brought his in as well, along with his gold medal, so we’re going to take some photographs and have fun with it.


Send me the pictures when you’re finished. Any concluding thoughts?

Predixion Software is in the business that is solving such massive problems for the industry. We really believe that we can save lives. Everyone here is just so focused on execution and being successful, because we truly believe that our technology can save lives and really help an industry that needs help. We’re really excited to be in the game and to be going for it.

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August 6, 2012 Interviews 3 Comments

News 8/3/12

August 2, 2012 News 7 Comments

Top News

Even though the Stage 2 MU final rule has yet to be published, the HIT Policy Committee MU Workgroup releases its preliminary draft recommendations for Stage 3 MU. Among them:

  • Threshold requirements are higher in several areas, including the percentage of EP prescriptions sent electronically (50%), percentage of hospital discharge medications sent electronically (30%), percentage of lab results that must be stored in the EHR as structured data (80%), and percentage of patients using secure messaging communications with providers (15%).
  • More clinical support interventions are required (15 related to five or more clinical quality measures).
  • New EHR certification standards, including requirements that EHRs maintain up-to-date and accurate problem and medication lists.
  • Increased emphasis on patient and family engagement, including requirements to provide patients an option to submit data online and to offer additional patient education material in languages other than English.
  • Expanded requirements to improve care coordination and population and patient health.

Reader Comments

8-2-2012 10-40-06 PM

From Hilltopper: “Re: AHA Solutions endorsement. Two years we (naively) responded to an AHA RFP to become an endorsed solution provider for a specific category of consulting services. We were down-selected, went to Chicago for a presentation, and were eventually named their vendor of choice for the prescribed consulting services. We then found out they wanted way in excess of six figures for their endorsement (advertising, promotion over a three-year period) and a percentage of new business, we declined. What a waste of time, and it was not disclosed earlier in the process.”

From Benny Hanna: “Re: MUMPS. It’s ugly and I despise it, but like XML, DB2, or NoSQL, it works. If you index properly (or at all) and your storage is fast, the database will perform. The biggest news around MUMPS was your item about Dell/Epic to allow virtualization of their servers, both application and database. Now you can throw a whole farm of processing and storage power behind that old flat file database.”

From Lovelietuva: “Re: Adventist Health System vs. Moleski. The pre-trial hearing is October 8, 2012 at the Orange County Courthouse in Orlando. AHS is the Goliath that owns the Orange County justices.” This is the “Death by Deletion” former Adventist Health System risk manager and whistleblower who claims she was ordered to deleted electronic patient information to cover up errors and who also says AHS’s Cerner system caused incidents of patient harm. She should definitely press for a change of venue.

From BlueDog: “Re: Community Health Systems contractors. The rumor is true, although the number seems high. I know that they sacked roughly 80 contractors working on Allscripts Enterprise EHR projects and scaled back a lot on Allscripts and athenaclinicals implementations. All eyes within CHS IT are on an Oklahoma City Allscripts Enterprise EHR implementation that begins in five days.” Unverified.

HIStalk Announcements and Requests

8-2-2012 3-32-29 PM

inga_small I’ve been struggling with badminton today. I admit there probably has been a time or two I intentionally threw a gutter ball while bowling in order to commence happy hour, and I do recall a certain strip poker game in college. But intentionally losing at the Olympics makes no sense to me. Maybe my real issue is that I dislike badminton since it conjures images of sixth grade PE and those horrible one-piece uniforms we had to wear. Speaking of images, if you haven’t seen one of US rower (and Wilhelmina model) Giuseppe Lanzone, he’s worth a Google.

inga_small HIStalk Practice highlights from the last week: as mentioned below, a few observations  from the just announced Stage 3 MU draft recommendations. Medicare and Medicaid issue $6 billion in MU payments through the end of June. Dr. Gregg whines about his unread EMR prose. My thoughts on why some crunching of MU attestation numbers may be meaningless. The ONC says the TOC is higher for a SaaS EHR than an in-office solution. I’ll keep it simple this week: go to HIStalk Practice, read good stuff, and sign up for e-mail updates. Thanks for reading.

Listening: new Rush, thanks to reader Mark, who tipped me off that Amazon is running it as a $0.99 full-album download.

Acquisitions, Funding, Business, and Stock

8-2-2012 10-31-30 PM

Visage Imaging signs a definitive agreement completing the sale of its Amira Division to Visualization Sciences Group for $15 million.

8-2-2012 10-32-02 PM

Quality Systems, Inc. continues its public spat with big shareholder and director Ahmed Hussein, who has nominated his own slate of directors to be considered at the upcoming shareholder meeting. Management says he’s trying to take the company over without paying a premium via a proxy fight and hasn’t made a convincing case that his nominees would enhance shareholder value, also calling out the company’s historically successful (until recently) share value growth, its sales opportunities, and its opportunity to focus on revenue cycle management. They also say Hussein has violated the company’s insider trader policy by pledging all of his company shares as collateral for margin accounts, requiring him to liquidate 2.24% of the company’s shares and further driving share price down. They also comment that his track record in creating value for his other businesses is poor. His press release says as a board member, he’s never heard anything about the strategies the company says they’ll follow and that his gripes aren’t with management, but rather with the current board.

8-2-2012 10-32-44 PM

MedAssets reports Q2 results: revenue up 11%, adjusted EPS $0.28 vs. $0.23, beating consensus estimates of $0.22. Shares jumped 20% Thursday on the news.

8-2-2012 10-33-12 PM

Vocera reports Q2 numbers: revenue up 30%, non-GAAP EPS of $0.09 vs. $0.00, beating expectations of $0.01 and raising guidance. 


The Purdue REC will use SA Ignite’s MU Assistant for client MU reporting.

Franciscan Alliance chooses Merge Healthcare’s iConnect Access to image-enable its EMR.


8-2-2012 3-38-15 PM 8-2-2012 3-38-42 PM 8-2-2012 3-39-11 PM

AirStrip Technologies hires Lori Jones (McKesson) as chief commercialization officer, Matthew Patterson MD (McKinsey) as SVP of business transformation, and Rudy Watkins (GE Healthcare) as SVP of business development.

8-2-2012 4-18-51 PM

NexJ Systems appoints former SAP North America president Robert Courteau to its board.

8-2-2012 4-27-31 PM

Cumberland Consulting Group promotes Amy Meiners from principal to partner.

8-2-2012 5-10-22 PM

Kelley Schudy, group SVP at Allscripts, announces that he’s leaving the company.

8-2-2012 9-51-57 PM

Baptist Memorial Health Care (TN) promotes chief nursing officer Beverly Jordan to VP/chief clinical transformation officer, leading its Epic implementation.

Precsyse appoints former IDX CEO James H. Crook, Jr. to its advisory council.

Announcements and Implementations

St. Francis Medical Center (CA) goes live with electronic medical records from QuadraMed, including medical device integration using iSirona.

Government and Politics

Medicare’s fraud unit opens a $3.6 million command center in Baltimore that includes a giant video screen that two Republican Senators are labeling a boondoggle, saying that the fraud unit is not implementing common sense recommendations in claiming that they are understaffed. The unit’s computer system went live last summer, but by Christmas had only stopped one suspicious payment totaling $7,600.


Providers are concerned about vendor training and readiness for hybrid OR suites when selecting interventional systems, according to KLAS. Toshiba earned top scores for overall satisfaction, though Siemens had the greatest market penetration.

8-2-2012 10-35-18 PM

About 50 unionized transcriptionists at The Ottawa Hospital (CN) complain about losing their jobs to Dragon Voice Dictation, trying to get doctors on their side by sending them a Christmas card saying they were being let go and including an instruction book for Dragon. According to the union’s spokesperson, “Not only was technological change implemented without any canvassing of staff, but an interesting fact is that at the end of a transcription, the voice recognition software adds a disclaimer stating that the document ‘may contain errors.’ There has got to be a better solution, especially when it comes to patients’ health.”

Olympus, fresh off accounting fraud problems, informs the Department of Justice that its physician training program in Brazil may have violated the Foreign Corrupt Practices Act. The company says that DOJ was already asking questions, potentially indicating that Olympus and perhaps other companies were being investigated following DOJ’s multi-million settlements with Biomet and Smith & Nephew over bribing foreign doctors to use their medical devices.

8-2-2012 9-41-28 PM

The TV program “In Focus with Martin Sheen’” will cover electronic medical records in a series of reports. The show doesn’t say it’s a paid infomercial that runs between PBS programs, but it seems like that might be the case.

8-2-2012 10-37-36 PM

In Canada, patients at St. Joseph’s General Hospital have been without TV since mid-May after Healthcare Resource Group shut down its prototype touchpad-driven bedside entertainment system. The company restructured and found that its server licenses from Microsoft, Adobe, and Dell had been illegally registered under the name of their former CTO. The hospital says HRG missed their final deadline to sort out their problems and will be replaced.

8-2-2012 10-03-19 PM

Strange: a blind Native American man files suit against a hospital, several doctors, and others, claiming he’s the victim of a racial hate crime because his non-blind friends are telling him that scars from his emergency stomach surgery kind of look like the letters KKK.

Also odd: the family of a deceased man files a $2 million lawsuit against a New York medical school, claiming the school humiliated them by declining to accept the man’s donated body as a medical cadaver because he was too heavy.

Sponsor Updates

  • TELUS Health Solutions and Sun Life launch an eClaims solutions for extended healthcare providers in Atlantic Canada.
  • BridgeHead Software and the European Centre of Expertise for the Health Care Industry EEIG partner to provide a cloud-based archiving solution for European hospitals.
  • Lippincott Williams & Wilkins, part of Wolters Kluwer Health, launches an EHR learning tool to prepare nurses for new practice requirements.
  • GE Healthcare IT reports that its customers have received more than $100 million in MU incentive payments since the program’s inception.
  • CommVault and Fujitsu expand their partnership to offer an integrated solution with Fujitsu’s ETERNUS DX storage arrays powered by CommVault Simpana 9 software.
  • Kareo CEO Dan Rodrigues advises physicians on the use of technology to thrive in business.

EPtalk by Dr. Jayne


HIMSS issues its call for proposals for the HIT X.0: Beyond the Edge “conference within a conference” at HIMSS13. No, that’s not a mistake in the link – it’s a HIMSS12 link. If they can get their act together, they will accept proposals from August 1-31. I’m pretty burned out on HIMSS between the annoying mailbox clutter and the feeling that they’re not really doing anything new or different these days. But I am looking forward to getting my New Orleans on, whether I actually attend the meeting or not.

Northwestern Memorial Hospital’s Home Hospice office was burgled last week, resulting in the theft of laptops and tablets. Supposedly their security controls were suspended because they were receiving upgrades. They are offering credit monitoring services to affected patients. Luckily the authorities do not suspect that PHI was specifically a target of the theft. That’s a good thing, because I can’t imagine anything more pathetic someone preying on hospice patients.

In a reminder that they’re not just a software company, McKesson is ordered to pay $151 million in a legal settlement involving related to Medicaid drug price inflation. Although New York State Attorney General Eric Schneiderman issued a statement that, “This settlement holds McKesson accountable for attempting to make millions of dollars in illegal profits,” the company denies price manipulation or illegal activity.


News outlets continue to report that there will not be enough physicians to meet the country’s health care needs in coming decades. I don’t disagree, yet I don’t see people dangling money in front of me to convince me to return to traditional primary care practice. I’m not hopeful for the next generation, either. A high school student I have been mentoring decided that he wouldn’t be meeting with me any longer because he had decided on a new career path. His choice: game warden.

I’m a sucker for technology stories of all kinds, so I was interested to hear today about a Dark Matter detector in a former gold mine in South Dakota. Here’s to unlocking more mysteries of the universe right in our back yard.

No, it’s not Las Vegas: Cerner partners with the town of Nevada, Missouri (pronounced Ne-VAY-da) to reduce costs and improve care. The project will involve health education via the local school district, construction of sidewalks and bike lanes, and digitizing health records at Nevada Regional Medical Center.

As the world comes together at the Olympic Games, I am reminded of the vast disparities still present in world healthcare with two sad stories from Uganda. Ebola virus is causing an outbreak of hemorrhagic fever, and this is on top of a mysterious illness called nodding syndrome that has killed more than 300 children and neurologically devastated more than 3,000. Even with all the negative things about our healthcare system, we should be reminded of how lucky we really are.



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

More news: HIStalk Practice, HIStalk Mobile.

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August 2, 2012 News 7 Comments

News 8/1/12

July 31, 2012 News 15 Comments

Top News

7-31-2012 9-55-13 PM

Accretive Health will pay $2.5 million to settle charges by Minnesota’s attorney general’s office over its aggressive patient collection tactics in hospitals (including those of Fairview Health Services) and lax security controls involving a stolen PHI-containing laptop. The company will cease all business operations in Minnesota, is banned from returning for the next two years, and can re-enter the state within the following four years only with the attorney general’s approval. Accretive is also required to return all patient information to the hospitals that provided it. The attorney general says she will turn over the patient affidavits her office collected to CMS, suggesting that Accretive’s hospital clients may have violated EMTALA laws that require them to treat emergency patients before trying to collect payment. The $2.5 million settlement will be added to a fund to compensate patients. Chicago Mayor Rahm Emanuel, who had previously inserted himself into the proceedings by trying to use his Democratic Party influence to get AG Lori Swanson to back off, declined to answer questions about his involvement.

Reader Comments

From Yesterdays: “Re: Community Health Systems. Contractor friends tell me they were part of the nearly 600 IT contractors laid off by CHS recently.” Unverified. I didn’t bother trying to confirm since I recently e-mailed someone at the for-profit hospital operator about a rumor that they were switching EMRs, but didn’t hear back.

7-31-2012 6-44-11 PM

From Wildcat Well: “Re: Practice Fusion. They have discontinued their affiliate program, which pays websites to promote signups for their ‘free’ EHR.” Unverified. They’re still taking signups on their Web page from what I can tell.

From Carolyn: “Re: National HIT Week. Are you involved in any of the activities?” No. To be honest, I’ve hated that concept from the day HIMSS started pitching the idea that provider IT people should stand shoulder to shoulder with their vendor brethren in trying to persuade politicians to throw taxpayer money at products sold by the vendor members of HIMSS (or as HIMSS nobly rephrases it, “public and private healthcare constituents will work in partnership to educate industry and policy stakeholders on the value of health IT for the US healthcare system.”) I don’t blame vendors for trying to influence the DC crew, but I am totally mystified how hospitals can justify spending the time and money required to send their IT people traipsing around Capitol Hill for the benefit of for-profit companies.

7-31-2012 9-57-01 PM

From Safety Paradocs: “Re: Wyckoff Heights. Wired for safety ‘well before ARRA’ as reported by the newsroom of Meditech, yet the young patient was not safe. How can we prevent such striking deaths?” Wyckoff Heights Medical Center in New York, which The New York Times politely calls “one of the most troubled hospitals in the city” because of mismanagement and its hiring of political cronies, admits a 22-year-old student who had consumed a diet drug and beer while pulling an all-nighter for her college Latin course. The hospital gives her IV lorazepam, ties her arms to her bed, and makes no notations in her chart (all documentation was on paper) that anyone was checking on her. Nobody notifies her family. She dies. A few weeks ago, the hospital’s own 83-year-old former chairman, who had been forced to resign and was then admitted for fainting spells, was found in his hospital room with a broken neck. Despite its problems (check out its reviews on Yelp), the hospital earned HIMSS EMRAM Stage 6 and $4.9 million in federal taxpayer dollars for its Meditech MAGIC implementation. To be fair, the incident occurred in 2007, which I assume was long before all of its EMR accomplishments. My takeaways are as follows: (a) while it’s true that better hospitals use more technology, it’s also true that technology didn’t make them substantially better – its use is correlated, but not causative, and plenty of crappy hospitals are using cool systems; (b) all the IT systems in the world won’t help if you have unskilled or uncaring caregivers, so choose your hospital based on quality and reputation, not what they’re packing down in the data center; (c) never, ever go to a hospital for anything serious without having an intelligent and alert advocate sitting by you at close to around the clock as possible, because having worked in several hospitals for most of my adult life, I can say that every one of them screwed up regularly due to inattentive or poorly trained staff, overworked doctors, unwashed hands, failure to notice when patients start to slip, overly aggressive treatment just because it’s possible, and lack of care coordination by all the one-trick specialists running around treating their particular body part of interest. Bring along a friend or family member to check your meds, personally challenge each major decision to make sure it’s based on conviction and science rather than lack of objection, and ask nurses whether your doctor and treatment plan are any good because they know but won’t say unless you press them. I think most hospital employees would agree that you need a wingman.

7-31-2012 10-00-14 PM

From Westie: “Re: cancer patient whose costs exceeded insurance cap. Wins a victory via Twitter.” Treatment of a 31-year-old’s colon cancer exceeds the lifetime dollar limit of his Aetna student insurance plan, leaving him with no insurance. He gets into a Twitter debate with Aetna CEO Mark Bertolini, who decides to cover the $118K in bills the patient racked up before was able to sign up for a different insurance plan. The tweets are fascinating as observers jumped on Aetna, blaming the company for selling insurance with low caps, questioning what would have happened had the patient not drummed up his own social network, ridiculing the CEO’s $10.6 million salary, and questioning how the Affordable Care Act will or won’t help. I’m glad he’s getting help, but we’re back to the original issue that patients can easily run up more expenses than the insurance they voluntarily signed up for will cover, and unlike every other kind of insurance, everybody expects someone else to pay without objection even though they met their legal obligation. I’d be interested to see who charged what of the $118K University of Arizona Cancer Center bill since those folks aren’t sharing Aetna’s financial sacrifice on the patient’s behalf as far as I know.

7-31-2012 10-01-30 PM

From Frank Fontana: “Re: paid endorsement programs such as those from AHA Solutions and the HFMA Peer Review Program. What do readers think about those programs?” I said years ago that they were pay-to-play, but they do still require products to be vetted, leaving me neutral on their value (I don’t see the benefit, but if they help connect vendors with prospects, then I see no harm.) Your opinions, please.

From EMR User: “Re: downtime penalty terms in contracts. We negotiated that any issue that we deem adversely affects our access or system usability allows us to subtract 5% of our monthly fee. We can do this daily up to five times per month.” I’ve said it before, but maybe it bears repeating. List the top handful of items that would be worst-case to you once you’re live on a vendor’s system (downtime, vendor acquisition, hardware failure, lack of acceptable implementation people, poor support) and insist on a penalty if any of them occur. Or, if you’re a glass-half-full type, reduce your fixed payment amount and offer a bonus if none of the events happen (same result, but it sounds nicer.) That makes sure your vendor has a vested interest in not allowing your worst dreams to come true, and at least if they do, you get the slight satisfaction that you’re getting paid for your trouble.

From Laboratorian: “Re: Epic. Could you opine to the extent to which MUMPS is constraining the growth of Epic? Everyone suggests this is a limiting factor, but so far it hasn’t been. How and when would they hit the proverbial wall?” It’s armchair quarterbacks, not customers, that keep trying to create a non-existent Epic Achilles’ heel out of MUMPS and Cache’. Most of that hot air comes from competitors Epic is killing, self-proclaimed experts who’ve never worked a day in IT or in a hospital, and cool technology fanboys who can’t stand the idea that Epic doesn’t care what they think. Despite the use of some ancient underpinnings, Epic’s product is apparently almost infinitely scalable, it does everything customers need it to do, and it works reliably. Nobody cares what it’s written in except their programmers – customers just want solutions, and the decision-makers when Epic is purchased are usually end users and operational executives, not IT geeks who salivate over source code. The only walls Epic could hit would be if InterSystems decided to go out of business (that’s not happening – they were absolutely printing money even before all those thousands of new Epic Cache’ user licenses dropped into their lap); if InterSystems decides to get greedy and either raise their Cache’ licensing fees or stop developing it (doubtful); or if Epic can’t get programmers willing to learn MUMPS (which has never been a problem because they do all of their training in-house and new UW psychology grads aren’t exactly swimming in job offers from Microsoft or Cisco). Anyone who claims Epic is about to hit the technical wall is just trying to plant fear, uncertainty, and doubt in the market. If there’s an Epic wall to be hit, it will be high costs that hospitals can no longer afford with reduced reimbursement, lack of ability to scale as it tries to extend its dominance outside of the US, some kind of meltdown like Judy stepping down and creating a vacuum of power, or perhaps some major and heretofore unfelt shift toward open systems that would put its rather closed model at risk. You’ll know that’s happening when you see the KLAS scores move from green to yellow. The only opinions that count are those expressed by customers with their dollars.

From Infrastructure Manager: “Re: downtime. I used to work with McKesson Horizon Clinicals, which didn’t have a great downtime report system. We scripted a routine that generated a PDF on a different server than Horizon and also copied it to a few PCs. It’s not a fast system to begin with, and you can’t help but feel the system drag when running those reports every hour, even with a huge Oracle server farm run by skilled DBAs. Also, the database design is poor and the tables are not indexed properly – you’ll see 4000 IOPS on a table/storage location and wonder that the hell is going on. If you’re hosted, who cares? Chew up those servers in a data center you don’t run and hope they’ve scaled to the appropriate size. If you aren’t hosted, take these reports very seriously.”

HIStalk Announcements and Requests

7-31-2012 9-34-41 PM

inga_small Unlike the curmudgeon Mr. H, I have watched a good deal of the Olympics. Who knew team handball was even a sport, much less an Olympic one? Yep, that’s what’s on at 5:00 a.m. on Sunday (don’t ask why I was up so early.) Go Iceland, by the way. So far my biggest complaint is that the men beach volleyball players don’t wear uniforms that are nearly as hot as the women’s. Thank goodness for men’s synchronized diving, however. I have decided that someone ingenious needs to develop an app that blocks all spoilers on Twitter and Facebook so that I will be totally surprised when Michael Phelps becomes the most decorated Olympian of all time (thanks all you expats in England who just had to share the news on Facebook.) Finally, good thing Rio is only one hour ahead of Eastern time so we’ll all see more live coverage in 2016.

7-31-2012 10-03-51 PM

Just  to prove to Inga that I’m not totally Olympics ignorant even though I haven’t watched the tape-delayed spectacle, here’s an interesting fact: the 300 hospitals beds used in the producer’s opening ceremonies tribute to NHS will be donated to hospitals in Tunisia.

Listening: reader-recommended Son Volt, music for driving or moping in smoky bars. Born of the remnants of 1990s minor stars Uncle Tupelo, somewhere between alt-country and roots rock. REM meets Neil Young.

Acquisitions, Funding, Business, and Stock

7-31-2012 10-04-53 PM

CommVault beats Wall Street expectations with its Q1 performance: net income of $10.1 million ($0.21/share) compared to $3.1 million last year on revenues of $111.3 million, up from $91.5 million.

7-31-2012 10-05-36 PM

Merge Healthcare announces Q2 numbers: revenue up 13%, adjusted EPS $.02 vs. $0.06, beating earnings estimates by a penny.


7-31-2012 10-08-02 PM

The Canadian Centre for Addiction and Mental Health selects Cerner Millennium as its clinical information system.

North Carolina HIE expands its relationship with Orion Health with the implementation of the company’s Health Direct Secure Messaging. The HIE went live in April 2012 and 70 providers have signed up, with the next phase being rollout of Orion’s EMR Lite. NC Direct is free for NC HIE participants and $100 per year per mailbox otherwise.

St. Louis-based Mercy chooses Humedica MinedShare as the Epic-integrated clinical intelligence solution it will use to manage population health for its 31 hospitals and 200 hospitals.


7-31-2012 5-41-41 PM

Lifespan (RI) names Eric Alper MD (UMass) as information systems medical director, charged with overseeing the development and implementation of clinical applications for the health system.

7-31-2012 5-44-37 PM

Amanda LeBlanc (Encore Health Resources) joins CTG Health Solutions as managing director of marketing and communications.

Announcements and Implementations

7-31-2012 10-09-46 PM

Yavapai Regional Medical Center (AZ) implements Cerner.

Christus St. Vincent Regional Medical Center (NM) goes live on the second phase of its Cerner implementation with the addition of CPOE and documentation for physicians, nurses, and ancillary care providers.

The VA system in western New York announces its participation in the HEALTHeLINK HIE as part of the VA’s Virtual Lifetime Electronic Record Health Communities Program.

Vocera announces the availability of its B3000 Communication system in France and introduces the Vocera Secure Messaging application for tracking messaging communications.

7-31-2012 10-10-57 PM

Jacksonville Medical Center (AL) goes live on CPSI.

E-prescribing system vendor NewCrop will incorporate interactive drug services from PDR Network into its platform, allowing its users to receive updated drug information, safety alerts, and regulatory and liability messages at the point of prescribing.

Caradigm (the GE-Microsoft joint venture) announces GA of Vergence 5, the latest release of its single sign-on and context management platform for healthcare.

Iowa Medicaid says its integrity program saved the state $30 million in its second year of operation, bringing the total to more than $50 million. Optum administers the program that analyzes provider claims for overcharges due to upcoding, unnoticed private insurance coverage, fraud, and simple math errors in bills.


The FDA clears Proteus Digital Health’s ingestible sensor, which works with a companion wearable patch and mobile app to monitor medication adherence.

7-31-2012 10-15-08 PM

The DoD and VA release PE (for prolonged exposure) Coach, a free smart phone app to assist service members and veterans with PTSD.


Minnesota achieves the highest rate of e-prescribing use in 2011, with 61% of prescribers routing prescriptions electronically. Massachusetts and New Hampshire had the highest physician adoption rate at 86%.

The New Orleans paper reveals that two-thirds of the full-time physicians working in Louisiana state prisons have been disciplined by the state medical board for issues that include pedophilia, substance abuse, and dealing methamphetamines.

7-31-2012 9-43-15 PM

Hartford Hospital (CT) and a home care group announce that information about 10,000 patients was contained on a laptop stolen from an employee of Greenplum, a “big data analytics” vendor and division of EMC that was doing readmission analysis for the organizations. The laptop was not encrypted.

I’m always skeptical of the Meaningful Use attestation numbers, so here’s an example that Meditech sent over in response to some of our recent posts. Inga’s analysis of numbers provided by CMS showed Meditech with around 120 hospital customers attested through May 2012. Meditech’s official number is 431, and even if mega-customer HCA is counted as only one hospital, they’re still at 271. That would place Meditech at #1, far above CMS’s #1 Epic, except that maybe CMS has their numbers wrong, too. I personally don’t think the number of attesting customers means much and this makes me even less interested in the vendor totals.

Physicians and experts testify to a House subcommittee that small practices are dropping like flies, with physicians moving to employed positions because of declining payments and increased reporting requirements. An orthopedist said his group shut down and took hospital jobs after spending $500K on an EMR hoping to reduce cost and improve quality, but the initial savings were eaten up by increased IT labor costs, upgrade fees, and the work required to document Meaningful Use.

Weird News Andy dubs New York Mayor Michael Bloomberg as “Dr. Bloomberg” after his push for hospitals to discourage new mothers from using canned baby formula instead of breast-feeding. WNA adds that he assumes the newborns won’t be allowed to have 32 ounce Big Gulps, either.

Sponsor Updates

  • Wolters Kluwers executive board member Jack Lynch discusses the emergence of “compliance clouds” during the company’s Half Year Media Roundtable meeting in Amsterdam.
  • Informatica gains partner support for its latest release of Informatica Cloud.
  • Impact Advisors earns the highest ranking in KLAS’s HIE consulting report, specifically identified as the only fully rated vendor providing HIE advisory and technical work.
  • DrFirst Chief Strategy and Privacy Officer Thomas Sullivan testifies at an ONC hearing on identity-proofing solutions for the electronic prescribing of controlled substances.
  • HIStalk sponsors earning a spot on Modern Healthcare’s Best Places to Work in Healthcare in 2012 include Aspen Advisors, DIVURGENT, Encore Health Resources, ESD, Hayes Management Group, Iatric Systems, Impact Advisors, Imprivata, Intellect Resources, Intelligent InSites, maxIT Healthcare, Santa Rosa Consulting, and The Advisory Board Company.
  • Allscripts, Beacon Partners, Cumberland Consulting Group, ESD, Merge Healthcare, and The Advisory Board Company receive the Healthcare’s Hottest companies designation by Modern Healthcare.
  • eClinicalWorks and Intelligent Medical Objects host webinars to introduce eCW IMO Problem IT Smart Search for ICD-10 coding.
  • United Hospital System of Kenosha (WI) renews its licensing agreement for Streamline Health’s Enterprise Content Management Solution.
  • MED3OOO customer Family Healthcare Network (CA) receives over $500,000 in EHR incentive payments.


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

More news: HIStalk Practice, HIStalk Mobile.

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July 31, 2012 News 15 Comments

Curbside Consult with Dr. Jayne 7/30/12

July 30, 2012 Dr. Jayne 1 Comment

This is the final piece in my series about vendors using physicians and other clinical experts in design, implementation, and support. I heard back from a few individual physicians working for vendors who asked not to be named. I’ve paraphrased their responses as well to give them a little more anonymity.

Miriam works for a top-tier ambulatory vendor. Although she does primarily go-live support and physician-to-physician training, she also works with content designers on specific specialty-related projects. Although there are a large number of physicians in her company, she thinks that the physicians are underutilized in the development process.

I would like to be involved more upstream in the development cycle. Since we’re in the field so much, we know better than the development teams as far as how the users work.

She notes a high degree of physician turnover due to the 75% travel schedule her company requires.

Jae is an internal medicine physician working as a consulting firm subcontractor. Although he would like to work for the vendor directly, he previously worked for a client and an anti-poaching agreement prevents him from being hired. He was involved in what sounds like a fairly messy practice breakup and the remaining partners would not give him a release, so he’s spending a year in what he calls “independent contractor limbo.” Although he does the same type of work as other physicians employed by the EHR vendor, his services are passed through the consulting firm to avoid actual employment.

I do a lot of liaison work with sales prospects, especially sales demos since I still do some locum work and can say I am a practicing physician. I can also technically say I’m not on the company payroll, although I’m not crazy about how the sales team sometimes plays that. The contractor thing isn’t all bad, though. I probably make about the same salary as the employed physicians once you figure the difference in hourly wage vs. paying for my own benefits, but I probably have a lot more control over my schedule this way. I don’t think I have as much influence in development, though.

There’s more to his very interesting story, and I must say I admire the vendor’s way of intentionally working around their no-hire agreement. Given the recent reader comments about a certain vendor’s no-hire agreements, it’s interesting to see it work the other way.

I’ve been saving this early submission for a strong finish. Dr. Ryan Secan of HIStalk sponsor MedAptus sent information about his work as chief medical officer, including an action photo.

I share many of your concerns about medical software, as I’ve often noted that the applications I’ve needed to use don’t seem to have had any input at all from a practicing clinician and are not designed with my workflow in mind. This is why I joined up with MedAptus last year. It was chance to help create software for physicians from the point of view of a practicing clinician. While my role at MedAptus includes participation in the sales process and acting as a liaison with client physicians, I also have an integral role in the design process. I understand physician needs for clean, simple, and intuitive interfaces that facilitate their work rather than hamper it. At MedAptus, we believe that our software should fit itself into physician workflow rather than forcing physicians to change their workflow to match the software. This has been particularly important as we prepare for ICD-10 implementation and the sheer volume of codes threatens to overwhelm the provider. Leveraging my clinical experience has allowed us to continue to put out a product that remains easy for clinicians to use despite the increasing complexities of medical billing and coding.


The above photo is me with James Scott, who is the vice president of engineering at MedAptus. James and I meet regularly to discuss feature enhancements, usability design, and navigation. This was taken during a meeting in which we were reviewing changes to the physician interface of our professional charge capture application to support end-user ICD-10 code searching and selection.

There were a few respondents who said they were going to obtain permission to send something but then never got back with me, so I assume the marketing and communications gatekeepers were not big fans of the idea. Or maybe, like my experience last week, they were pulled to work a double shift at the hospital. If they ever make it through the PR gauntlet, I’ll be happy to run their pieces.


E-mail Dr. Jayne.

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July 30, 2012 Dr. Jayne 1 Comment

Monday Morning Update 7/30/12

July 28, 2012 News 27 Comments

7-28-2012 9-23-13 AM

From Meaningful Juice: “Re: GAO report from last week. Of 4,855 eligible hospitals, 776 were awarded eligible $$$ juice for 2011. Phew – my tax dollars are not being wasted!” Among the GAO’s recommendations was that CMS needs to beef up its scrutiny of whether providers really were eligible to get their payouts.

7-28-2012 3-12-03 PM

From Dave: “Re: Michael Stearns, before being fired as e-MDs CEO. See this document.” This is old news that has been mentioned here before. The Maryland State Board of Physician Quality Assurance suspended the medical license of Dr. Stearns in 1997 after he pleaded guilty to four counts of assault and battery in a US Navy court-martial case in which four female patients claimed “inappropriate sexual touching” during his examinations of them. David Winn, who as e-MDS board chair fired and replaced Stearns as CEO on July 2, defended him in this 2011 write-up, saying that Stearns was never convicted of a felony and was perhaps misled by poor legal counsel in a Tailhook-sensitive environment and inconsistent behavior by the Maryland board after the fact. Mike Stearns says he will address this and other issues in an HIStalk Readers Write article in a couple of days. He hasn’t said that he’s suing his former employer even though he claims the allegations behind his termination are meritless, but one might assume that’s his only remaining option. I’ve heard from several folks who extolled the character and capabilities of both Dr. Stearns and Dr. Winn, so hopefully they will avoid the public debate, reach some kind of agreement, and move on without further embarrassment.

From Happily Hosted I Hope: “Re: host environment performance. Do any of your readers have language around system performance and high availability in a hosted environment that they could share? We’re going to be installing an EMR through a hosting arrangement with a local hospital and I’m looking for advice.” Given the high-profile downtimes that have come up recently, I think it’s a great topic to address. If you’ve put terms and conditions into a contract with an EMR hosting provider and would care to share details, please send them my way. I won’t mention either client or vendor and will strip out anything identifiable, so your non-disclosure terms are safe.

7-28-2012 2-09-17 PM

From EHR Warrior: “Re: NextEHR. Looks like it’s finally dead as the company that bought the intellectual property changed its name to iPenMD.”

From ITKnowsTheScoop: “Re: [vendor name omitted.] Under FDA review regarding surgery and anesthesia solutions. They had to remove or reclassify features, which halted sales for four months.” Unverified, so I’ve omitted the company’s name.

From IT Director: “Re: Cerner. I have an unfortunate trove of horrid experiences related to extended planned or unplanned service interruptions, some of them due to a shoddy corporate implementation of Cerner Millennium. Our implementation spanned time zones, so we had a six-hour downtime twice a year when Daylight Saving Time changed. We has spectacular outages where the entire hospital system went dark with no local backup whatsoever. The corporate implementation was insistent on a paperless workflow, so we weren’t even allowed to print periodic paper backup copies of order synopses or MAR summaries. During our first major downtime, a little girl was left in writhing pain for most of the night because the house officer didn’t know the timing and dose of her pain meds. This downtime was rumored to have been caused by a profound error in hardware sizing, but poor database design didn’t scale well even with additional hardware. I don’t blame Cerner as their staff were truly engaged and helpful, but rather a centrally managed health system corporate mentality of arrogance and ignorance that discounted the local reality and specialized workflows. Perhaps the morale of the story is simply that any given implementation is only as good as its implementation team. If they’re evil, then the implementation will be similarly evil. In some ways, Cerner as much as a victim as the hospitals of setting poor implementation leadership.” Your experience matches mine. Unless every vendor’s implementation has been a disaster, it can’t be their fault alone (i.e., one successful comparable client means the stuff basically works). The main problems usually involve: (a) lack of customer technical and implementation resources; (b) poorly developed, self-deceiving project budgets that don’t support enough headcount, training, and hardware to get the job done right; (c) letting IT run the project instead of getting users involved, which is especially problematic if the corporate IT people are clueless; (d) unreasonable and inflexible timelines as everybody wants to see something light quickly up after spending millions; and (e) expecting that just implementing new software means clearing away all the bad decisions (and indecisions) of the past and forcing a fresh corporate agenda on users and physicians, with the vendor being the convenient whipping boy for any complaints about ambitious and sometimes oppressive changes that the culture just can’t support. I might also mention sloppy contracting on the client’s side, since I’ve seen hundreds of contracts and am often amazed that the interests of the vendor weren’t legally aligned with those of their customer via a few standard terms and conditions.

From Commando: “Re: Cerner. Cerner has two electronic downtime solutions for remote hosted clients. The read-only methodology referred to requires the user to be able to log into the system back in KC, which wouldn’t be possible with the DNS servers out of business. There is another level of downtime service – something I guess his/her organization decided not to purchase. That next level dumps patient information to local computers (at our hospitals, at least one on each floor) at regularly scheduled intervals. i.e. updated every 5 minutes. That way, even if all connection with KC is lost, staff has information (including meds, labs and more) locally on each floor which is accurate up to the time of the last update. Finally, since this outage was due to a DNS problem, anyone logged into the system at the time it went down was able to stay logged in. This allowed many floors to continue to access the production system even while most of the terminals couldn’t connect.” Assuming this is an accurate description of the available options with Cerner hosting, it might be a good time to check out the local caching option. That would be protection against even internal network problems, which in a lot of hospitals is not uncommon. I recall that Kaiser uses that with good success for its Epic/HealthConnect system that’s deployed regionally. You could probably create a poor man’s solution by running specific reports (MAR, active orders, recent lab results, etc.) to a PDF file and dropping them in specific folder locations on a frequent schedule, like maybe once an hour.

7-28-2012 4-50-48 PM

From West Coast: “Re: John Muir Health. Hires a CIO.” The internal memo sent my way indicates that Jim Wesley has been announced as SVP/CIO of John Muir Health. He was most recently a consultant, but has healthcare CIO experience. John Muir’s hot button is getting Epic up and running.

From Maryann: “Re: Epic. I work directly for a hospital that is implementing several Epic modules over the next 5-7 years. I have two Epic certifications. I applied to several consulting companies and each one told me that they couldn’t hire me if my hospital was in the middle of an Epic implementation because of an agreement with Epic. Is this legal? How long to I have to wait if I leave my hospital before a consulting company will hire me?” Welcome to the murky world of Epic non-competes and recruitment restrictions. Epic controls your opportunities with potential employers via separate agreements and/or implied punishment for poaching Epic-certified people. Is their practice legal and binding? Almost certainly not, but you’d need a lot of lawyer money to find out, and by the time you got a ruling, you could have just sat out your time as an untouchable by working in a non-Epic role somewhere (I think it’s a two-year timeout, but it may just be a year … I seem to remember there was discussion about changing it.) Epic’s practices are designed specifically to thwart exactly what you want to do – use your short-term Epic experience and certification to bail out on your employer and cash in with a consulting firm. Even if you had the financial resources and extended timeline needed to mount a legal challenge, there’s still no guarantee that you’ll get hired, because legal or not, nobody wants to cross Judy for fear of choking their own particular gold egg-laying goose. Not to add more rain on your parade, I’m not sure you can even easily move to another Epic hospital, but I’ll let those who have first-hand experience explain how all of this works.

From The PACS Designer: “Re: waterproof accessories. If you want to limit infection from entry devices, there’s now a solution from Seal Shield. They feature waterproof keyboards and other computer input devices that are easily washable and ready for reuse, thus reducing the spread of infections that could come from multiple users of those devices.” I’ll say this – they make a fantastic commercial. You can waterproof your iPad for $30 or your iPhone for $20.

7-28-2012 3-53-48 PM

Welcome to new HIStalk Platinum Sponsor M*Modal. The company’s cloud-based Speech Understanding solutions that are used by 2,400 customers include Fluency (converts physician’s narrative into electronic documentation that can be integrated into workflows, in effect speech-enabling EHRs); Catalyst (retrieving information from unstructured encounter documentation, with the first in a series of tailored versions being Quality and Radiology); and SpeechQ (dictation capture for radiology). The company also offers transcription services via its 10,000 transcriptionists (it’s the largest in the US) as well as coding services for clients struggling with Discharged Not Final Billed accounts and the possibility of negative audit findings. We know from recent headlines that M*Modal is a very successful company since arguments have been made that JP Morgan is getting too good of a deal in acquiring it for $1.1 billion, so that’s a nice debate to be having. Thanks to M*Modal for supporting my work.



Here’s an M*Modal video I found on YouTube.

Listening: new from Citizen Cope, which is primarily singer-songwriter Clarence Greenwood. A uniquely American mix of soul, blues, and roots music. Eric Clapton is a fan.

TPD has updated his list of iPhone apps.

I have zero interest in the sprawling commercial spectacle of the Olympics for a variety of reasons (athletes itching to bag endorsement deals the day the flame and their short-lived fame are simultaneously extinguished, smug US cheerleading, glorification of photogenic participants and sports to the exclusion of most of the others, participation of state-sponsored and chemically altered participants and richly compensated professionals like LeBron James that make a joke of the phony, feel-good “amateur” aspect) so I won’t have anything to add to the already smothering media coverage that I won’t be following (except for articles involving widespread Olympic Village debauchery.) Inga bah-humbugged me and says she’ll pipe in with anything HIT-related (like the frequent GE commercials she’s already mentioned to me), so we’ll count on her to make it interesting.

Speaking of Inga’s Olympics chime-in, she sent this newspaper article criticizing the UK’s NHS promoting itself to a worldwide audience just after several high-profile incidents of patient harm that occurred under its supervision:

Sitting in a home somewhere while fireworks lit up the Olympics opening ceremony would have been the family of Kane Gorny. They watched their cherished teenage son die of thirst at the hands of incompetent doctors and nurses … The letters ‘NHS’ dazzled in bright red like some triumphant advert. All around these pranced self-indulgent nurses who had volunteered to take a few days off to be part of the ceremony … That such a politically divisive subject was included at all is utterly shocking. Not least because it glossed over the cracks in a system that is creaking at its seems crying out for urgent reform.

And speaking of NHS, it apologizes to the family of a 76-year-old hospitalized cardiac patient who died right after her son discovered three workers drilling holes in the ceiling above her head to install a patient entertainment system.

7-28-2012 9-01-39 AM

Readers say the future of public HIEs is bright, at least if you count dying a screaming death in a giant nuclear fireball of failure as bright. New poll to your right: in which HIT-related company would you invest $100K today? (assuming you have to choose one).

7-28-2012 5-02-52 PM

Defense Secretary Leon Panetta disappoints a House committee by advising them that integration of the respective electronic medical records systems of the DoD and VA (AHLTA and VistA) won’t be finished until at least 2017, and he didn’t even sound confident about that date. VA Secretary Eric Shinseki observed that simply reaching DoD-VA consensus on a open architecture system was quite an accomplishment given previous discussions with “a proprietary contractor.” Rep. Bill Johnson (R-OH) wasn’t happy with that answer: “I understand that you can’t account for the last 10 years, Mr. Secretary. And I understand that you’ve got two bureaucracies that don’t necessarily like to be told what to do and (don’t) get along all the time. But I will submit to you that another five years is unacceptable (and) ought to be unacceptable to you.”

HIE Networks and Hillsborough County Medical Association (FL) announce their collaboration to deploy a county HIE. HIE Networks operates the Florida Health Data Network.

Some quotes I highlighted from the McKesson earnings call:

  • The clinical conversions — when we talked about our Horizon to Paragon strategy, we talked about the fact that we believe it is a viable solution for our customers, and that over time they need to evaluate that as an alternative because of its more tightly integrated infrastructure and its lower cost of operations … we’ve seen many of our Horizon base evaluate the products. We’ve seen some of that base already contract to move to Paragon, and some already have moved because of whatever remaining development is necessary and Paragon was not of import to those customers. Others have said, you know what, we’re going to go, but we want you to build out another module or we’re going to go after we get our Meaningful Use dollars settled.
  • We are really pleased with our position in RelayHealth. I have to admit that the e-prescribing portion of the market’s transition is not a particular profit driver for us. We’re in that transaction both in our electronic medical record businesses as well as in Relay. But that’s not really where the opportunity lies. The opportunity lies in the continued build out of our financial systems.
  • And if it’s a surprise to anyone that clinical buying is beginning to wane, they must not be deep in the industry. We believe that our customers have largely made their clinical decisions … We’re in the implementation phase now. Actually if you look at our results under the cover, you actually will see that our hospital buyers are beginning to come back to purchasing other solutions beyond clinicals. And I think those companies that don’t have a portfolio beyond clinicals are probably feeling the effect of a pipeline that is probably headed in a different direction.

Some quotes I highlighted from the Cerner earnings call:

  • While there is one competitor that remains a challenge, our competitive position against them continues to strengthen. At the same time, their weaknesses are becoming more known in the marketplace. As we’ve discussed, our significant improvements to our physician solutions and the workflow is neutralizing one of the primary areas they used to compete. And we believe the capabilities we are rolling out in Millenium+ and PowerChart+Touch surpass their capabilities. In addition, our investments in our operability, data analytics and population health management are becoming an increasingly important differentiator against them as their platforms make interoperability and data analytics very challenging. We also believe they will face an inevitable upgrade from their MUMPS-based platform that is needed to catch up in these areas, and this will be very disruptive and expensive.
  • Currently, approximately 45% of our core hospital clients have attested for Stage 1 Meaningful Use, and we expect approximately 85% of them to have attested for Stage 1 by the end of the year.
  • As background, our experience with data and analytics dates back to 1996 when we started Health Facts, which is a research database that now has over 150 million patient encounters and nearly 2 billion lab results. While in the past this data has largely been used to support pharma and biotech research, our server map organization is now using it along with published evidence to accelerate the development of predictive clinical agents.
  • But we clearly have a significant amount of cash on the balance sheet. We think we are in a situation in kind of part of the market that there could be some interesting opportunities for us to deploy that cash in a way that could be — either supportive of Millennium, get us more quickly into some of the new businesses that we’re looking at. I think, relative to the existing traditional HIT market, the window is getting very close to being closed for that being interesting to us. So I think the status of many of those competitors are a little bit on the downhill side of the hill.
  • I think probably the one country that’s got a lot of demand is going to really be — just a funding issue — is the UK. As more and more of those trusts are becoming foundation trusts, which means they control their capital outlet — outlay as opposed to the government putting the dollars out there, we think that’s going to turn into a more normalized US- type market where each trust is going to go out to the market and look to acquire technology. In 2015, the current NHS contracts expire. So almost all of those trusts are going to be looking in the market in some form or fashion, probably depending on their access to capital.
  • The RFP volume, I’d attribute a lot to the failures of many of our competitors to be ready for the changing landscape. And so they’re in the midst of either — they’ve done acquisitions and they’re trying to put things together, they’re trying to move to new platforms, they’re sunsetting existing platforms, they are on old technology. And those types of things, as people look to what the future is, they know that they have to have data liquidity, their systems have to be interoperable, and they’re going to need that data no matter where the person is in the entire care cycle, inclusive of the home … the recognition that Cerner can do that work, that their current providers can’t do that work.

Vince’s HIS-tory continues with the story of Keane and its Threshold product that could run on any hardware vendor’s UNIX platform.

E-mail Mr. H.

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July 28, 2012 News 27 Comments

Time Capsule: Google Health: Does Anyone Still Care?

July 27, 2012 Time Capsule 1 Comment

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 September 2007.

Google Health: Does Anyone Still Care?
By Mr. HIStalk


I like just about everything about Google. I like its products, its offbeat style, its innovative products, and it’s "we’re really just geeks like you" winking acknowledgment of its own cool technology.

Notice I said I like "just about" everything Google. What I’m sick of hearing about is Google Health, whatever it is (if it’s anything at all).

Everybody’s atwitter because the company’s health guy, Adam Bosworth, either quit or got fired last week. Google kept it mighty quiet, not admitting it until a blogger ran the story from a tip. The acknowledgment was terse, so you might well figure that he either got canned or went off to start a competitive business.

Google’s entire health output so far is, well, zero. The company hasn’t even announced anything. Googlers don’t show up at conferences, don’t write white papers, and don’t dazzle us with their usual brilliance. Maybe the company got embarrassed and cleaned house.

Of course, most Googlers are engineers. They are a great asset in solving purely technical problems, like writing search algorithms. Could it be that they’re ill equipped to understand the rat’s nest that is US healthcare, much less do anything to improve it, or even more importantly to shareholders, profit from it?

Everybody assumes Google’s healthcare people have been sequestered while creating a world-beater personal health record. I wasn’t so sure since it seemed like an odd business for them (and everybody else) to be in. Leaked screen shots of a cheesy (not sparsely elegant) prototype weren’t encouraging. This is the best that a $164 billion market cap company could come up with? It looked like one of those "$40 on a USB stick" spare bedroom programmer products that are giving the PHR genre a bad name.

It wouldn’t surprise me a bit to see the company get back to what it knows best: advertising. Google doesn’t know EMRs, PHRs, or HISs, but it knows how to jam context-sensitive ads in your face and get you to click on them. Why would Google want to get into the ugly Vietnam of clinical systems and low-rent PHRs when it could simply find new places to serve up more of those ads that effortlessly bring in billions? Like in front of doctors who have already amply proven to be influenced by obnoxious drug company advertising, for example.

You’ve seen the faltering first steps of ad-powered physician systems, healthcare social networks, and online references. The approaches have been amateurish, but I guarantee somebody will figure out that the real money will be made by giving drug and medical device companies access to prescribers at the point of decision-making. Pay-per-click gets much more valuable when presented in context to free EMR content and patient-specific information. Say, do you really want to order Drug A? Why not try Drug B instead, especially since this patient has renal problems and we’re offering a special price? Click here for our convincing medical references. In fact, we’ll buy your whole office lunch if you’ll just click OK instead of Cancel.

Many big company toes have been dipped into the healthcare waters over the years. Most got drawn back quickly, burned by an industry in which even deeply experienced organizations often fail. Fresh healthcare ideas are a dime a dozen, but the bigger the company, the more ludicrous the results have been.

At this point, I’m past whatever interest I had in Google’s healthcare efforts. They’ve had plenty of time to dazzle me. I don’t care any more. Just stick those AdSense ads in clinical software and let’s move on.

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July 27, 2012 Time Capsule 1 Comment

HIStalk Interviews Linda Peitzman MD, Wolters Kluwer Health

July 27, 2012 Interviews 1 Comment

Linda Peitzman MD is chief medical informatics officer of Wolters Kluwer Health.

7-27-2012 5-25-45 PM

Tell me about your job and the company.

Wolters Kluwer is a large company that started as publishing of information. It now creates software and information to help with workflow and decision support in the verticals of tax accounting, legal, and health to help the professionals in those areas with their decisions and information needs. 

I’m with the healthcare division. I’m a physician who worked for a long time as a full-time practicing clinician trying to figure out ways to solve problems and make things go better and help the systems that I was using.

I got myself involved in the IT side way back and started working with ProVation Medical. I came into Wolters Kluwer through the acquisition of ProVation Medical. Since that time, I have been working with the health division and spending most of my time with the Clinical Solutions Group at Wolters Kluwer Health, which provides workflow software, information, and decision support at the point of care for healthcare professionals.


You’ve worked a lot with order sets, which early on were just collections of commonly used paper orders that somebody keyed in to a CPOE system. What’s the state of the art in the use of order sets today and what’s coming in the future?

That’s a big question. There are a lot of things going on with order sets, for many reasons. There’s a lot of regulatory and other pressure to implement CPOE systems, so there’s a lot of work effort being focused on order sets.

As you say, they’ve been around for a long time because they help doctors with time and efficiency, and they’ve been around in paper form. But one of the big problems has always been once you get all those orders set out there, how do you maintain them? How do you make sure they are evidence based? How do you make sure they’re driving the right behavior in terms of quality patient care?

Some of the things that are going on right now with order sets include the use of tools to help with all of those things. To help with the complex governance process in your organization, to go through all of the review, the review of the evidence, the review of the order sets, the agreement upon what should be done at that hospital and in that organization, making sure it’s consistent with the hospital’s formulary and the types of tests and drugs they think should be ordered for that condition. Then I’m making sure that gets into the CPOE system and is used by the clinicians at the point of care.

All of that depends upon the processes and tools that an organization has and the culture that an organization has. A lot of it depends upon the capabilities as well of the CPOE system that the hospital happens to use.


It seems like hospitals generally struggle with the whole idea of evidence-based process, like formularies or trying to consolidate their medical devices into the most cost-effective ones. Everybody likes the concept of evidence-based order sets, but hospitals don’t seem to be ready for them yet. Do you think that’s the case?

I don’t know that that’s the case. I think that most hospitals really want to use evidence-based medicine. It’s just complicated to maintain that, to know exactly what’s going on in the literature, to make sure that you keep everything current. I think it’s also complicated sometimes in the culture of an organization to go through the process of review by all the people that need to do that and then get it done in a timely fashion. 

There’s a lot of tools out there to help organizations with that now. I think that some of the regulatory and payment pressures are focusing hospitals in certain areas and certain medical conditions, to make sure they are doing certain things for that care of patients that are consistent with evidence as well.

I think that just about every hospital is focused on evidenced-based medicine, particularly with order sets, at least in some areas. That’s why they’re doing what they’re doing – to provide the best care they can for their patients.


Efforts are being made to put clinical content in the clinical workflows, such as with the Infobutton standard. What changes do you think we’ll see in the next few years to make clinical content more available when it’s needed and to make it more specific to the clinical situation at hand?

I think there are a lot of things happening. A lot of groups that are working on experimenting with getting the right information at the right time. Alerts are popping up all the time when you’ve seen it a hundred times has really been discouraging for some clinicians. They haven’t really done as much as people thought initially they might do.

There are other things that have really been successful, like some things in the background in terms of drug information and drug interactions. drug dosage, and getting the right medications dispensed. Some things have been really successful. I think the work continues to try to figure out how you get the right nugget of information into the clinician’s hand at the time that they are thinking about it and deciding what to do. 

There are a lot of forms of clinical decision support. One of them is an order set. Having the right order set when you’re admitting the patient and you have to be using an order set anyway. Having the right information there that really takes you through the workflow and helps you make the right decisions that’s helpful. Having really smart rules and alerts than can be configured to provide benefit, but not get in a clinician’s way. 

That’s a real hard nut to crack, but a lot of people are working on it. Even having smart documentation, when you’re documenting something and going to the next step of deciding what the next thing to do is, being able to walk you on the right path.

There’s a lot of work going on. The technology is starting to evolve to allow some of that. If an EMR now has the capability of sending out to a clinical decision support system information about the patient that is very specific, then the information sent back can be much more specific and can be more focused right on what the clinician might want to know instead of  having more broad-based alert that might be more of an annoyance than a help. As those things continue to evolve and more and more EMR systems have those capabilities, I think organizations like Wolters Kluwer and others can help provide more focused information right at the right time into that workflow.

We have a group called the Innovation Lab. It’s partnering with several organizations looking at just that. How can we get clinical information right at the right point of care into the workflow of a clinician when they have to be ordering or when they are opening a problem, a record of a patient if that patient isn’t on a critical medication that is called for by virtue of the fact that they have these six conditions and they’re already on these other two drugs? Can there be a really smart alert that says hey, have you thought about this, and maybe a link to the supporting evidence to show the clinician? 

There’s a lot of work going on. I don’t think anyone has solved the problem completely by any means, but it’s really exciting to think that we could help clinicians make decisions at the right time in the point of care.


Going back maybe 20 years ago, you had publishers of journals you put on your shelf, but early electronic order entry systems that didn’t look at clinical content at all. Those systems were happy to just get an order entered and routed correctly. Is there still a lot of work to be done to take all that information that’s in almost limitless supply in research and publications and turn it into something that can be used at the bedside?

I think it’s an almost impossible task for an organization like a healthcare provider organization by themselves to accomplish that. Clinical information is said to be doubling every three to five years, and unfortunately my brain isn’t growing at that rate — just the task of managing all that and sorting through the literature. 

Part of our organization has a group of clinicians on the UpToDate team does that for their product, sorting through hundreds of the journals every month to try to identify the real changes in practice. By partnering with organizations where we can separate the wheat from the chaff and provide the real nuggets of clinical information as to what might really matter in terms of changing practice and then do work to try to figure out how to get that information into the hands of the clinician at the right time in the point of care, it can really help.

There’s so much going on and so many things published to be able to identify, first of all, what has changed? What really matters to my practice or the practice at the hospital? And now that we know that, where are the order sets that matter? How do I update them? Where are all the education pieces that I need for the physician? How are the patient education materials and how do I update them? As we were talking about before, I think maintenance of evidence-based practice is the big thing we need to solve. I think there’s a lot of people working on tools to help organizations with that.


The company’s doing some work to support Meaningful Use requirements. Can you describe that?

Meaningful Use requirements include quite a few different things. In this first phase, you need to be able to be report on certain measures. That requires certain systems in place that you have purchased, and you have to show that you’re using them in a meaningful way. We have a wide variety of products, including one that is a documentation product that helps to document and report some of those measures. In a broader sense, all of our products and other organizations’ products that are working in clinical decision support are trying to help support hospitals in the work they’re doing. 

One of the things that they’re really focused on right now is Meaningful Use and core measures. In all of our product lines from our order sets to our other types of clinical decision support, we try to point out the areas that matter for those things. For instance, in our order sets, we have quality indicators with each order set that show what the CMS measures are or Joint Commission or other kinds of areas that would matter for regulatory organizations for this particular order set or this particular condition. We try to help tie the works that hospitals are doing for things like Meaningful Use into other product lines. 

We are trying to assist organizations with implementation of CPOE systems, which is one of the things that they are working on doing towards that goal by providing the tools to help them come to consensus with their order sets, release their order sets, and then also provide some integration into their CPOE system so they can go live with CPOE and meet their measures of providing orders in the CPOE environment for things like Meaningful Use.


You mentioned that you were involved with ProVation before it was acquired. That’s a product that basically owns the gastroenterology market, a very specialized product. Will the idea of having specific documentation products for specialties continue or will the market push specialists toward standard products whose weaknesses they’ll have to live with?

We started in GI, in gastroenterology, but ProVation MD expands many other specialties for documentation. We have products in cardiology, cath lab, echo, nuclear, and surgical areas such as general surgery, plastic, ENT, eye, OB/GYN, and a variety of other surgical sub-specialties, orthopedics, and pulmonology as well. We span most clinical procedural specialties with ProVation MD.  That’s used in a variety of specialty areas to allow people to document and report on procedures in those areas, including in the cath lab, echo, cardiac, etc.

However, in a more general way, I would say that there are pressures on both sides. There are pressures to try to get one system to do as much as you can, because if you are working on the IT side of a hospital, you don’t want to have thousands and thousands of systems that you have to maintain and integrate and update and keep current with each other.

On the other hand, I think it’s becoming more and more clear that standard EMRs are not going to be the providers of everything for a hospital IT environment in terms of particularly current information and content and sometimes even very specific workflows for clinicians. I do think that there will be partnerships with the EMR systems that are the systems in place that are storing that patient record and information and workflow software providers that can join together to meet the needs of the various clinicians in the various workflows they need to complete.

However, the problem has been integration and ability to pass information back and forth. Also ease of use, in terms of having a provider needing to go from one system to the other. There’s a lot of pressure now on trying to make sure that there’s adequate integration involved and that an end user does not have to know that they’re in one system vs. the other – they can just do their work and then all the information can go to the right system and go to the EMR to be stored and viewed as the patient’s record. I think there’s a lot of work going on there. 

I do not believe that any one system is going to solve all the needs, for many reasons. One is because there is just huge tasks involved with understanding which workflow involves different clinicians and managing all that clinical information that’s happening in all of those clinical specialty areas.


That acquisition of ProVation is interesting, but I’m not sure most people realize how long the list of other Wolters Kluwer acquisitions is. There was also UpToDate, Lexi-Comp, Pharmacy One Source, and even a joint venture in China. What’s the company’s strategy?


The ones you mentioned are all within the Clinical Solutions business unit of Wolters Kluwer Health. That’s the group that is working at the point of care to provide workflow software and content solutions for clinical decision support for healthcare professionals.

We have a variety of products, from providing the answers to the clinicians with a product like UpToDate, providing tools to manage order sets like the Provation Order Sets product, and clinical documentation with ProVation MD. With the acquisition of Pharmacy One Source, also are working in the areas of the workflow of the clinical pharmacist and in surveillance. We now have tools available to help hospitals with real-time surveillance, looking for patients that might have indications that they need something done. For instance, watching for earlier signs of sepsis to make sure that the hospital can intervene in appropriate time and help provide morbidity and mortality associated with that. Many other things as well, including antimicrobial stewardship. 

We also have a lot of drug information products. Lexi-Comp, Facts & Comparisons, and the database of Medi-Span, which does alerts and reminders and drug-drug interactions, etc. for drugs used in the clinical setting. Each of those products represents a form of clinical decision support and help to the hospital environment.

But what we are really working on is looking across them and trying to find ways to do two things at a very high level. One is to integrate those products together in ways that are helpful to our customers that have more than one of them. UpToDate information is embedded inside of order sets, and if you have both products, there are ease of use issues across order sets and UpToDate that help the clinicians and helped the hospitals. We do that with many of our products. We try to integrate, so we have UpToDate patient educational materials inside of ProVation MD and other things such as that.

At the second level, what we’re working on trying to do is to really look at the problems, the current problems that our hospital and clinical customers are having, and say what can we do, not just with one individual product, but maybe with pieces of products and with our expertise from those product lines to bring them together in a new way to try to solve those problems? 

As I mentioned earlier, we have a group called the Innovation Lab at Clinical Solutions that has a steering team that represents the clinicians and informaticists and technical folks across all of those products that we just mentioned. We are a partner with hospital systems to try to solve very specific problems and are taking to the pieces of both content and technology to try to come to bear on problems that hospitals are having in new ways. 

We are working now in the area of mobile devices to help with early detection of sepsis. We are looking at providing, as I said earlier, ways to get nuggets of clinical decision support into a clinician’s hand at the right time and the workflow, which will be in EMR setting, through APIs and other things. We’re really excited about that and have quite a few hospital partners that are working with us to try to solve some of their problems in that way.


The old Internet saying was that “content is king.” Does the content piece get enough recognition when people talk about EMRs and Meaningful Use and how these products will actually deliver the benefit they’re supposed to?


People that are focused on one side or the other tend to have less of an understanding of the technical versus the content side. I believe it’s both. If you don’t have the right content and have the capabilities of understanding all of the changes in clinical practice and sorting through all the literature and making sure you keep your order sets current with evidence-based medicine, then you’re not doing your patients or your organization a service.

On the other hand, if you don’t have am EMR or a CPOE system that allows ease of use for the physician to be able to order something, or even has capabilities of being able to override things and be able to say why and track why are certain things were not ordered, you really can’t provide the best care. You also can’t measure what you’re doing well enough to be able to go back and improve it in a continuous improvement cycle. 

Content is king, because without the content, without knowing what you should do for patients, it’s hard to do it. On the other hand, if you don’t have systems and a workflow on place that makes that easy to use for a clinician and then can track what’s actually been done so you can improve it, then it’s also a really next to impossible as well. Both things have to continue to improve, and the ability to manage the content and get it into the workflow of the technologies is what really it has to happen. There are a lot of things being done towards that goal now, but there’s a lot of work that remains to be done.


Do you have any concluding thoughts?

It’s a really exciting time right now in healthcare IT for many reasons. It’s also a very frustrating time for people on the front lines in healthcare IT. There are so many pressures both currently and coming down the pipe, from switching from ICD-9 to ICD-10 and Meaningful Use and core measures and value- based purchasing and ACO pressures. Trying to manage all that and figure out what to do first and how to best accomplish it and still have systems that are maintainable and manageable in your hospitals is a really overwhelming task. 

There are tons of opportunities. There are tons of ways we can help make things more efficient and improve patient care. There’s just so much going on right now that sometimes it can be a little overwhelming. That gives organizations like mine an opportunity to try to identify what those top priorities are for our customers and try to help solve them in a variety of innovative and unique ways.

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July 27, 2012 Interviews 1 Comment

News 7/27/12

July 26, 2012 News 9 Comments

Top News

7-26-2012 9-40-39 PM

Quality Systems Inc. (NextGen) reports Q2 numbers: revenue up 18%, EPS $0.26 vs. $0.32. The company also eliminates future guidance, apparently burned in this case by impending deals that didn’t close by the expected dates. CEO Steven Plochocki blames the drop in net income on fewer higher-margin software system sales. Shares dropped 33% (Nasdaq’s biggest percentage loser of the day) on the news to their lowest price since November 2008, dropping the company’s market cap to under $1 billion. In the conference call, President Scott Decker said the loss of long-term client HMA was caused by HMA’s lack of resources to roll out its product, and said HMA won’t replace NextGen completely but that HMA wasn’t contributing all that much revenue anyway. The company says it will move more work to India to reduce costs. It also predicts that Meaningful Use Stage 2 and ICD-10 will take out a bunch of its competitors. When asked about pressure on hospital-owned practices to move to competitive products, Scott Decker said he wasn’t worried about Cerner, Siemens, or Meditech, but Epic is “a challenge for us like it is for everybody in the market” that “causes a little bit of pain.” Above is a one-year share price chart, with QSII in blue and the S&P 500 in red.

Reader Comments

7-26-2012 6-56-59 PM

From Winning: “Re: Microsoft. It will sign now business associate agreements with partners for Azure storage and core services (their cloud offering). That means Microsoft will shoulder some of the burden of ensuring HITECH and HIPAA compliance in the cloud. Hosting costs are high for a startup like us since HIPAA requires the database to be logically separated from the Web server, meaning we need at least two servers. That’s not cheap with .NET/MS SQL. The value proposition from a major player like MS Azure is pretty high. I wonder if we’ll see more of this from other vendors?” I appreciate that update. I would have put in a little plug for Winning’s company to return the favor, but I was running too late to ask if that was OK. The topic might make a good Readers Write if he’s inclined to write one. That’s a nice move by Microsoft.

7-26-2012 7-44-44 PM

From Jonathan Grau: “Re: AMIA 2012 Annual Symposium. We’re in Chicago this year from November 3-7.” Jonathan, VP of corporate relations and development for AMIA, keeps me in the loop about their activities. I couldn’t help but notice that five of the seven conference sponsors are also HIStalk sponsors (CAP, FDB, IMO, Philips, and nVoq).

7-26-2012 8-04-07 PM

From IT Director: “Re: Cerner downtime. Just so you know, it lasted about six hours … and you didn’t hear it from me.” According to the purported Cerner communication attached, a Cerner network administrator received an error when trying to update DNS records via the management console, so he or she made the change manually and inadvertently deleted a DNS zone while doing so, an unfortunate change that was then replicated to all servers. Anything using that zone was instantly hosed, and the tools needed to fix the problem were also not available because of the error. They had to restore the file from backup and replicate it manually to all the controllers.

From Doc Down: “Re: Cerner downtime. I’m a doc at a Cerner remote hosted site. We got our first e-mail about a ‘performance problem’ at 12:45 p.m. and the downtime was resolved at 5:35 p.m. In between, we got an e-mail that referred to some sort of DNS issue, but it was a bit confusing to understand what actually transpired. We got one message saying it should be fixed by 4 p.m. then another saying it would be fixed by 5 p.m. We have the read-only product for use during downtimes, but that couldn’t be accessed either. We recently moved our inpatient physician documentation to electronic, so reverting to paper with no access to anything recent was a nightmare. Don’t know anything that could have been done any differently on the hospital end, but it would be nice if Cerner would be transparent and describe to organizations and interested users what really happened as it doesn’t inspire much confidence. Unanticipated things do happen, but I’ve personally been unimpressed by the software or support. Though I have met a few topnotch Cerner folks, most seem fixated on selling us new modules, consulting and programming devices, etc.” Downtime is going to happen despite best intentions and known ramifications, but I’d be concerned that the read-only option, which exists solely for that eventuality, didn’t work.

HIStalk Announcements and Requests

inga_small This week’s HIStalk Practice includes a statement from former e-MDs CEO Michael Stearns regarding his recent firing. Epic, Allscripts, and eClinicalWorks lead other vendors in the number of ambulatory EHR attestations. ONC says the total cost of ownership of an in-house hosted EMR is less that the SaaS option. A Florida ACO uses Craigslist to recruit physicians and offers up to $100,000 a year in shared savings. Julie McGovern of Practice Wise points out a few considerations for practices moving their applications to the cloud. When you pop over to HIStalk Practice, click on an ad or two because you might find a sponsor offering a solution that will make your world better. And sign up for the e-mail updates because it could be the only way I know you care. Thanks for reading.

On the Jobs Board: Manager Systems Development, Database Administrator, Services Implementation Project Manager.

The HIStalk vital signs consist of measurements that you can actually influence: number of readers, number of e-mail subscribers, and the vitality of reader interaction in the form of comments and news tips. That means that you get to control our electronic destiny, which makes you a pretty powerful force with which to reckon (cue some tears-inducing Sarah McLachlan heartfelt warbling to move you to action). Actions that will stave off our eventual demise include (a) signing up for my spam-free e-mail updates, so you’ll be the first to know when I dig up some incredibly juicy industry gossip or random sophomoric humor that I can’t resist sharing; (b) electronically mate with Inga, Dr. Jayne, and me on Facebook, LinkedIn, and all that truck; (c) peruse the fun Resource Center, where you can search and navigate through a bevy of benevolent sponsors who crave your electronic attentions just as much as I do; (d) use the Consulting RFI Blaster to … well, that one’s pretty self-explanatory; (e) get off your figurative couch and out here on the healthcare front lines with us and participate with your comments, insight, or anonymous tips (e-mail works, but so does the nauseatingly green Rumor Report button glaring spitefully from the right side of the page); and (f) play a few rounds of Sponsor Roulette, scrolling the page and randomly clicking the ads to your left to see where you land, assured that it will be among friends since only the cool companies sponsor HIStalk instead of the boring alternatives. Inga, Dr. Jayne, Sara McLachlan, and I appreciate your participation in our continued non-flatlining. Every day we wake up and the page is still displaying is a good day.

Speaking of the three of us working in healthcare day jobs, Dr. Jayne’s healing talents were required for an encore shift in her local hospital’s ED, meaning she didn’t have time to contribute this time around. I suppose saving lives and all that stuff is a good enough excuse to let her slide this time.

Acquisitions, Funding, Business, and Stock

7-26-2012 6-06-14 PM

Compuware releases Q1 numbers: revenue down 2%, EPS $0.05 vs. $0.08, beating consensus earnings expectations of $0.04. Revenue for the company’s Covisint business unit grew 27% to $21 million.

7-26-2012 6-07-17 PM

McKesson announces Q1 numbers: revenue up 3%, adjusted EPS $1.55 vs. $1.27, beating expectations of $1.49. Revenue in Technology Solutions was up 4%, with adjusted operating profit of $109 million.

7-26-2012 6-24-27 PM

Clinithink secures multi-million dollar investments from Finance Wales and existing investors to fund ongoing technology development and establish the company’s US operation.

7-26-2012 6-25-15 PM

Cerner reports Q2 numbers: revenue up 22%, adjusted earnings $0.59 vs. $0.44.

7-26-2012 9-21-03 PM

CPSI announces Q2 results: revenue down 6%, EPS $0.75 vs. $0.72.

7-26-2012 6-26-51 PM

Facebook’s first earnings report wasn’t so hot, with revenue increasing 32% to meet expectations, but growth was the slowest in 18 months and the company doesn’t appear to be monetizing heavily increasing mobile usage very well. Shares dropped 9% Thursday and are down another 11% in after-hours trading Thursday evening. In the mean time, shares in Facebook-dependent game maker Zynga (FarmVille) continue their toilet orbit after a bleak Q2 earnings report, knocking another 40% off the share price and dragging shares down to 70% less than their December IPO price to the embarrassment of idiotic stock pickers who somehow thought Zynga had a real, sustainable business instead of a hyper-annoying fad with a low barrier to entry.

The CEO of HealthStream says the education and HR technology company may move into related healthcare business such as long-term and behavioral care.


7-26-2012 9-45-17 PM

Cedars-Sinai Health System (CA) chooses Health Care DataWorks to provide a clinical data warehouse and analytics solution.

The Commonwealth of Virginia’s Department of Medical Assistance Services awards HMS a contract to provide a customized Medicaid fraud and abuse detection system.

Norton Healthcare (KY) contracts with CSI Healthcare IT to provide 100 resources for the second wave of its Epic activation.


7-26-2012 6-29-04 PM

Healthcare analytics company ArborMetrix appoints former Covisint VP Brett Furst as CEO.

7-26-2012 6-33-44 PM

The Commonwealth Fund, a private healthcare-focused foundation and think tank, names former National Coordinator David Blumenthal MD its next president, effective January 1, 2013. He is chairman of the organization’s Commission on a High Performance Health System. Blumenthal will replace Karen Davis, who announced previously announced plans to step down at the end of the year.

7-26-2012 7-26-35 PM

Luther Nussbaum, retired chairman and CEO of the former First Consulting Group, is elected to the board of consulting firm MedSys Group.

Healthcare billing and payment systems vendor Zepherella names David Bond (A4 Health Systems, Allscripts) as EVP of sales and marketing.

Announcements and Implementations

St. Francis Medical Center (CA) and O’Connor Hospital (CA) go live on iSirona’s device integration solution that connects medical devices to their QuadraMed EMR.

7-26-2012 6-43-06 PM

Transitional care provider Remington Medical Resorts (TX) goes live on HealthMEDX Vision at all of its Texas facilities, including rolling out a paperless environment that allows physicians to work from iPhones or iPads.

7-26-2012 7-07-51 PM

The new Palomar Medical Center (CA) will open next month, a 288-bed, $956 million “hospital of the future” that has been under construction since December 2007. Space was pre-built to allow expansion to twice the number of beds if needed.

In Australia, New South Wales completes the initial phase of the rollout of TeraMedica’s Evercore imaging exchange in 12 hospitals.

Government and Politics

HIMSS proposes language for inclusion in the Democratic and Republican National Committee party platforms in support of HIT to improve healthcare efficiency, quality, and outcomes:

“In order to improve the quality of healthcare for all Americans while reducing costs, the Party will continue its strong support for the rapid, nationwide adoption of Health Information Technology including electronic health records and secure health information exchange capabilities.”


The Ventura County Board of Supervisors (CA) approves an additional $5.75 million for its $41 million Cerner EHR implementation, which is scheduled to be operational at two county hospitals by July 2013

Compared to physicians, physician assistants, APRNs, and RNs spend more time online for professional purposes, use smartphones more during patient consults, and more frequently access pharma or biotech Websites.

A Milwaukee newspaper article notes that Wisconsin hospitals are charging victims of sexual assault up to $1,200 for the cost of collecting evidence to identify and prosecute their attacker. Sometimes insurance pays, sometimes the hospital knows to bill the government fund that was set up to cover the cost, but in some cases the patient ends up getting stuck with the bill.

A Harvard health economist says that 90% of the country’s economic growth over the past 10 years got sucked up by increased healthcare spending, but the CEO of Marshfield Clinic says at least some parts of the Affordable Care Act (though he declined to guess which ones, but IT is mentioned) will eventually slow the increase. As I always say, everybody’s for reducing excess costs as long as they don’t personally have to take a pay cut.

Weird News Andy found this story, in which Mayo Clinic apparently fired a pediatrician who wrote a Arabic blog post advocating female circumcision. Mayo says female genital mutilation not only has no medical justification and thus can’t be performed in its facilities, but is also considered a felony-level child abuse crime in the US.

The University of Missouri School of Medicine will use a $13.3 million HHS grant to create electronic dashboards that will allow physicians to get a quick read on how individual patients or groups of patients with a single condition are being managed. The project has been christened LIGHT2.

Kiplinger’s Personal Finance ranks Madison, WI as the best city for young adults, with UW-Madison and Epic helping push it to the top. Rounding out the Top 5 were Austin, Boston, Washington DC, and Denver.

It really bugs me when PR-seeking hospitals decide to magnanimously waive their bloated, cost-shifted charges for high-profile victims. Three Colorado hospitals say they won’t charge victims of the Dark Knight shootings, some of whom had no medical insurance, for their care. I’m all for generosity, but I like it better then it’s less self-serving and selective. I’d rather they take it out of their executive salaries instead of just pushing the cost onto those who have insurance and less-publicized medical problems. Everybody struggles to pay for their healthcare, and fuzzy accounting like this isn’t helping.

In Canada, Eastern Health fires a nurse for inappropriately accessing and sharing the records of 122 patients. She’s the fifth employee the hospital has terminated for privacy violations so far this year.

Some bored newspaper folks apparently decide to check whether former HHS Secretary (and former lobbyist and current Senate candidate) Tommy Thompson ever had a VeriChip implanted in his arm as he said he would in 2005 when he joined that company’s board. Answer: no. His reason: hospitals didn’t buy the technology to read the chips, so the company tanked. He sure was pitching it hard on Squawk Box back in the day, but he’s a politician after all.

Sponsor Updates

7-26-2012 7-38-14 PM

  • Software Testing Solutions will have an active presence at the Sunquest User Group conference August 6-10 in Scottsdale, AZ. STS will demo Version 4 of its Test Manager product; CEO Jennifer Lyle (above as your HIStalkapalooza co-host in Las Vegas) will conduct an automated testing cost justification session on August 8; and the company will offer its popular Breakfast with the Puppies event on Thursday to collect donations (which the company will match) for Home Fur Good, a Scottsdale-based no-kill shelter.
  • Santa Rosa Consulting is named to Modern Healthcare’s Best Places to Work in Healthcare for 2012.
  • Trustwave and Microsoft partner to support additional Web server platforms, including Microsoft’s Internet Information Services and Nginx.
  • Certify Data Systems earnsMajor Player distinction in IDC Health Insights’ HIE vendor assessments report.
  • Consulting firm ESD (your gracious HIStalkapalooza sponsor last time) earns a Healthcare’s Hottest award recognizing fast-growing established healthcare companies. ESD also was named by Modern Healthcare as one of the Best Places to Work in Healthcare for 2012, the second year in a row.
  • Prognosis participates in this week’s Texas Healthcare Trustees Annual Conference in San Antonio.
  • NextGate’s continued growth requires a second move into larger space in Monrovia, PA.
  • The Huntzinger Management Group reports significant growth in 2012 as it helps organizations address regulatory compliance issues, changing reimbursement models, and IT demands.
  • MedAssets heads to San Antonio next month for the AHRMM 12th Annual Conference..
  • Wellcentive introduces Provider Benchmarking capabilities within its Advance Outcomes Manager solution.
  • Macadamian CEO Frederic Boulanger is selected as a Quebec finalist for Ernst & Young’s 2012 Entrepreneur of the Year in the Technology and Communications category.
  • FTI Consulting signs a five-year licensing agreement with Streamline Health for its OpportunityAnyWare business analytics and patient financial services solutions.
  • NextGen Healthcare selects Health Language to provide standardized terminologies within its ambulatory product suite.
  • Culbert Healthcare Solutions publishes a white paper on centralizing patient access and revenue cycle functions.


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

More news: HIStalk Practice, HIStalk Mobile.

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July 26, 2012 News 9 Comments

News 7/25/12

July 24, 2012 News 8 Comments

Top News

Cerner had an apparently significant disruption of its remote hosting service on Monday, leading to extended downtime for clients all over the country (and possibly outside of the country as well, according to some reports.) Information is hard to come by, so feel free to leave your comments if your organization was affected. Would you do anything differently next time in terms of preparation or downtime procedure?

Reader Comments

7-24-2012 6-29-36 PM

From Mr. Allscripts: “Re: Surescripts outage. I have more info.” Mr. A included a document suggesting that the Surescripts network had connectivity problems over about an hour last Thursday, during which time prescription routing and medication history transactions may have failed.

From Kaplan: “Re: Cerner. Remote hosting is down – it’s all over Twitter.” Apparently true, but I got just one reply to my Twitter inquiry of affected users for more information. Judging from the timing of some of the tweets, it looks like it was down for at least four hours. You can imagine the disruption of having your entire hospital go offline at once without warning, but at least it’s someone else’s problem as the IT folks sit and wait along with their users. I’d want an explanation, of course, and hopefully those affected were smart enough to have put a downtime penalty clause in their agreements.

From Mister X: “Re: Cerner downtime. Communication was an issue during the downtime as Cerner’s support sites was down as well. Cerner unable to give an ETA on when systems would be back up. Some sites were given word of possible times, but other sites were left in the dark with no direction. Some sites only knew they were back up when staff started logging back into systems. Issue appears to have something to do with DNS entries being deleted across RHO network  and possible Active Directory corruption. Outage was across all North America clients as well as some international clients.” I’ve lived through a lot of downtime it’s the same story as in this case. You don’t know when the systems will come back up until right before they do in most cases – 90% of the time required is diagnosis, not treatment. Users always want to know “how much longer” and you as the IT organization hate to tell them, “Beats me” even though that’s usually the case. Not to mention that when resources are stretched trying to get the problem fixed, there’s nobody sitting around to shoot the breeze with users wondering how it’s going (the user-to-geek ratio is about 1,000 to one, and you haven’t lived until you kill your pager battery within about 15 minutes with the constant pages demanding an individual briefing on what’s going on.)  And I can also say from experience that the worst problem isn’t server or power failure since those systems are backed up – it’s something like this, where Active Directory gets trashed, your name server dies, or you lose IP connectivity inside your data center. It takes forever to diagnose and fix.

From HERSS: “Re: mHealth Summit. I got an e-mail from HIMSS saying a certain company ‘will make their first appearance at the 2012 mHealth Summit as a Platinum sponsor and as such will have a significant role in the summit program and a key presence on the exhibit floor.’ I head to read twice to make sure this wasn’t from the basement sweatshop World Healthcare Congress sales reps and their over-the-top spamming. HIMSS has dropped to a new and very disturbing low. I would never have come out and said that a vendor will play a significant role in the program – that hardly inspires me to spend my hard-earned money for a conference pass. ‘A key presence on the exhibit hall floor’ means the vendor paid their prostitution dues to the pimp and are being properly rewarded for it.” Most of the HIMSS e-mails I get these days are just another form of vendor spam, pitching products, Webinars, or urging political action to interfere with the free market in healthcare IT. To be honest, I’ve twit filtered them into oblivion. When HIMSS speaks, it’s like a bad ventriloquist act – it’s easy to spot the arm up their backside. I really think they mean well and they have some honorable and dedicated people working there, but like a politician pandering to special interests, they lost their connection to the average provider once the dollar signs filled their eyes.

7-24-2012 7-17-42 PM

From Colorado Health Exec: “Re: Aurora shootings. While I was not involved, I want to extend my thanks to the healthcare professionals that did a great job in the early hours of Friday morning.  There were many heroes that day, from people in the theater, to the police, firefighters, and last but not least the nurses and doctors that treated the patients injured and consoled families trying to make sense of a senseless act. My thoughts and prayers go out to the victims and their families. Say what you want about the politics of healthcare these days, but professionals like these are the reason I am proud to be in healthcare.”  The above is from Denver Broncos tight end Jacob Tamme, who continues to tweet about being moved by his ongoing visits to Swedish Medical Center to visit with hospitalized survivors.

HIStalk Announcements and Requests

7-24-2012 7-28-08 PM

Welcome to new HIStalk Gold Sponsor CIC Advisory. Their tagline is “trusted informatics experts” and you probably really would trust them – the principals are Cynthia Davis, RN, FACHE (who’s been a CIO and has led several EHR/clinical transformation projects) and Marcy Stoots, MS, RN-BC (who has an interesting history of being an ICU nurse, wrote her master’s paper on data mining, is finishing a DNP in informatics, and led the EHR implementation at BayCare and other places). They’ve also just co-authored a HIMSS book called A Guide to EHR Adoption: Implementation Through Organizational Transformation. Testimonials are here. I was impressed that both ladies are members of the HIStalk Fan Club on LinkedIn, which always scores points with me. If you need help with EHR projects, informatics issues, Meaningful Use, business intelligence, or strategic planning, Cynthia and Marcy would be happy to speak to you. Thanks to CIC Advisory for supporting HIStalk.

It’s not quite as pervasive as squeezing “sort of” into every sentence, but what’s with everybody suddenly leading off a thought with the word “so” like they’re telling a story in a bar? You ask someone when they’ll finished a particular task and you get, “So we’re working on the documentation …” I’m also noticing that the young folks (who raise their inflection to a painfully high pitch at the end of every sentence as though they’re asking a question even when they aren’t) are also prone to sticking a confusing “no” in front of their “yeah” when excited. Example: “I just heard this great new band …” and they burst in with, “No – yeah, they were dope.” Curious.

I was thinking about the “deceased” flag in everybody’s EMR system after reading a story about a dead patient receiving an appointment in the mail in the UK. I assume that field populated only if the patient dies while admitted and someone keys in the discharge disposition. For research and population management purposes, it would be nice to know whether the patient is actually still alive, not just whether they went home that way last time from your own facility. If there was a national patient identifier, state and national death records could update everybody’s system. Seems pretty basic if we’re really going to try to account for patients between episodes. Or maybe somebody’s already doing this. Seems pretty basic: “Is this patient still alive?” “All I know is that he was the last time he came to the office.” Small-town doctors used to peruse the newspaper obituaries to send condolences and archive charts when appropriate.

Acquisitions, Funding, Business, and Stock

The senior management team of Quality Systems (NextGen) sends shareholders a letter voicing their strong support for the QSI board nominees. This move follows actions by dissident director and board member Ahmed Hussein, who is attempting to gain control of the board by nominating his own director candidates. The letter urges shareholders to support the QSI board nominees at next month’s annual meeting.

7-24-2012 9-44-49 PM

The FTC grants early termination of the waiting period for the acquisition of M*Modal by One Equity Partners, clearing the way for the deal to close.

7-24-2012 9-45-52 PM

HealthStream announces Q2 numbers, which were in line with estimates: revenues up 23% to $25.8 million; net income up 33% to $2.4 million.

7-24-2012 9-45-23 PM

Philips reports Q2 numbers, with earnings beating expectations and healthcare leading the way with a 7% jump in sales.

Apple misses Q2 expectations, turning in its second quarterly miss in year and setting lower guidance for the next quarter. iPhone sales were way down, which could be attributed to the lack of the iPhone 5 rollout, a struggling world economy, or impatient users moving to hotter new phones like the Samsung Galaxy S3.


Providence Health & Services will deploy Nuance’s Dragon Medical 360 voice recognition technology across its 250 clinics and 27 hospitals, integrating it with Epic for the health system’s 8,000 clinicians.

Centura Health (CO) selects the Explorys platform and Enterprise Performance Management applications for their ACO and PCMH initiatives.

Jordan Hospital (MA) selects dbMotion’s interoperability platform to connect multiple acute and ambulatory HIT systems throughout its local medical community.

7-24-2012 9-48-28 PM

Pomona Valley Hospital Medical Center (CA) selects ProVation Order Sets.


7-24-2012 6-17-46 PM

The Missouri Health Connection names Mary Kasal (Cornerstone Advisors) president and CEO of its statewide health information network.

7-24-2012 6-19-38 PM

HIT Application Solutions hires Richard Crook (onFocus Healthcare) as VP of consulting services.

7-24-2012 6-20-11 PM

Rodney M. Hamilton, MD (PointClear Solutions) joins ICA as its CMIO.

7-24-2012 7-10-05 PM

Floyd Medical Center (GA) names Jeffrey D. Buda (WellStar) as CIO.

Announcements and Implementations

The SE Michigan HIE announces that it has completed all milestones to provide its e-disability claim filing service to the Social Security Administration, which will accelerate the processing of disability claims from 457 days by paper to six hours electronically.

Canada’s Eastern Health goes live with NexJ’s Disease Screening solution for its Colorectal Screening Information and Reporting System project.

7-24-2012 6-36-48 PM

Military robot maker iRobot, worried about losing profits due to reduced military spending, decides the time is right to jump into the healthcare market with a new product in a partnership with InTouch Health. iRobot, which also makes the Roomba room vacuum cleaner, says the head of its new robot head is a moveable monitor that can be controlled, allowing the remote physician to look around the room. It comes with a stethoscope that it doesn’t know how to use, which makes it very doctor-like if you’re talking about psychiatrists, dermatologists, and physician executives who haven’t actually listened to anybody’s chest since residency, but who strut around in a white coat and draped stethoscope so they look more doctorly.

7-24-2012 8-25-32 PM

The chief administrative officer of Northwest Imaging (MT) develops a shift-budding app that he plans to complete and commercialize.

Cleveland Clinic and The Ohio State University announce a partnership to commercialize products that include medical software.


7-24-2012 7-04-49 PM

HELO announces its new TabletStrap PRO, a rotating leather hand strap for 10-inch tablets. Looks pretty cool for $60. Holding the iPad is awkward for me, especially when walking and poking at it, and this looks like it would be more comfortable and secure.


7-24-2012 7-57-49 AM

inga_small A reader last week asked if we were aware of updated MU attestation data by vendor. As it turns out, CMS published new information last week that includes details through the end of May. I used Excel to play with the numbers a bit, but a more robust reporting tool would probably be more efficient. EHRs by Epic, CPSI, Cerner, and Meditech were the most widely used products by attesting hospitals, which really isn’t much of a surprise. If you are interested in ambulatory EHRs, I created a similar chart on HIStalk Practice showing EP attestations by vendor, with Epic, Allscripts, and eClinicalWorks leading the pack.

Cerner partners with the city of Nevada, MO to focus on creating a culture of health in the community through education, incentives, infrastructure, and partnership with local employers and community organizations. Cerner will also deploy its CommunityWorks critical access clinical suite at Nevada Regional Medical Center.

7-24-2012 8-47-44 PM

AHRQ issues an RFI pertaining to quality measures enabled by healthcare IT.

Sponsor Updates

7-24-2012 9-51-08 PM

  • Stockell Healthcare Insight client Cooper Green Mercy Hospital earns $2.1 million for meeting Alabama State Medicaid’s EHR adoption, implementation, and use requirements.
  • A Calgary newspaper highlights TELUS Health and its remote patient monitoring tools.
  • MED3OOO’s chief medical executive, Paul McLeod, MD tackles the question of bundled payments in the company’s July newsletter.
  • Orion Health HIE is named to the Leader category in IDC’s MarketScape Vendor Assessment report.
  • Holon Solutions will install its CollaborNet interoperability solution at George Tech’s Interoperability and Integration Innovation Lab.
  • Aspen Advisors produces a white paper on assisting Frederick Regional Health System (MD) develop a business intelligence strategy.
  • Hayes Management Consulting offers a free white paper on patient portal design and implementation.
  • Over the last 15 months, Emdeon has boosted its employee count by 300 as a result of acquisitions and organic growth.
  • Informatica Corporation joins the Google Cloud Platform Partner Program as a Technology Partner.


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

More news: HIStalk Practice, HIStalk Mobile.

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July 24, 2012 News 8 Comments

EHR Design Talk with Dr. Rick 7/23/12

July 23, 2012 Rick Weinhaus 7 Comments

Pane Management — Part 2

The human visual system evolved over tens of millions of years to help our ancestors keep track of and interact with real objects in the physical world. To the extent that an EHR user interface design can harness our finely honed visual-spatial capabilities, using it will be intuitive and nearly effortless, even though the "space" we are navigating is that of data and the "objects" we are manipulating are abstract concepts.

Unless acted upon, objects in our physical world don’t move around, get larger or smaller, or change their orientation in relation to other objects. The human visual system "understands" these properties of the physical world. We are very good at constructing mental maps of what we see and using those maps to keep track of how objects are organized in space.

Unfortunately, graphical user interface (GUI) designs are not bound by the laws of physics and the constraints of the physical world. When we manipulate one object on the screen, other screen objects, for no apparent reason, can disappear and suddenly re-appear in different locations or radically change their shape and orientation.

While we might enjoy an altered set of physical rules as part of the challenge of playing a video game, it would be disconcerting, to say the least, to encounter such behavior in an EHR user interface.

Consider the EHR design below, by a well-known healthcare software toolkit developer.


Above is the physician’s home screen for a particular patient. Six panes are used to display six categories of patient data — Most Recent Activities, Medications, Patient Charts, Risks, Lifestyle, and Current Care. For clarity, I have enlarged the font size and drawn red boxes around the title bar of each pane.

Each pane is assigned to a particular location on the screen. One at a time, each pane can be expanded and then contracted by using the mouse cursor to click on the "maximize" button at the far right of its title bar (see Risks pane above).

So far so good. But look at what happens to the other panes below when I do expand one pane, such as the Risks pane (purple arrow). For clarity, I have significantly shortened the horizontal span of the screen in the next two figures:


When I expand the Risks pane, all the other panes close so that just their title bars are displayed. Worse, they all change their position, size, and orientation. The Most Recent Activities pane (red arrow) and the Medications and Patient Charts panes (blue arrows) are now oriented vertically along the far left of the screen. The Most Recent Activities pane is twice the width of the others.

The Lifestyle and Current Care panes (yellow arrows) maintain their horizontal orientation and relative position, but have been shifted to the bottom of the screen and stretch along its entire extent.

If I need to expand another pane, such as the Medications pane (indicated by the blue arrow below), all the other panes again change their position, size, and orientation:


With the Medications pane expanded, the Most Recent Activities pane (red arrow) is now oriented horizontally instead of vertically and extends along the entire top of the screen.

The Patient Charts pane (bottom blue arrow) keeps its vertical orientation, but now is displayed on the right side of screen, elongated to span the entire screen height. The Lifestyle and Current Care panes (yellow arrows) change from horizontal to vertical orientation as does the contracted Risks pane (purple arrow). In addition, the Lifestyle pane has been stretched vertically.

In fact, whenever any pane is expanded, the other, non-expanded panes somewhat arbitrarily change their position, size, and orientation in this way. This is a poor mapping. It doesn’t correspond to our mental model of the physical world. It doesn’t take advantage of our highly evolved ability to organize objects in visual space.

Instead of the design above, why not use a small overview map for orientation and navigation, as in the figure below?


This is a more natural mapping. The positions of the six panes in this small overview map correspond to those of the home screen (first figure) and those positions remain constant regardless of which pane is expanded. Furthermore, this overview map (overlaid below, for comparison, in the lower right corner of the expanded Risks pane) takes up less than 3% of the screen area, whereas the vendor’s design (outlined by the yellow border below) uses almost 20%:


It’s not that physicians and other users can’t work with problematic EHR interfaces such as this one. Humans are remarkably adaptable and flexible, but it requires cognitive effort. It’s not just the extra second or so that it takes to find a pane in its new location. That’s the least of it.

The real problem is that, unlike computers, humans have extremely limited working memory. Having to deal with the shifting location, size, and orientation of data objects is disorienting.

Whenever we use a slot in our visual working memory for these kinds of tasks, we can no longer use that slot for clinically relevant information. It’s easy to underestimate how much this kind of EHR interface can interfere with our ability to make sense of complex patient data in the clinical setting.

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

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July 23, 2012 Rick Weinhaus 7 Comments

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