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Monday Morning Update 3/10/08

March 8, 2008 News 6 Comments

From Katie Jane: "Re: specialty hospitals. Congress wants to create a bill making insurers equalize physical and mental health benefits, which will in turn increase some government health programs. Since the bill will effectively ban specialty hospitals, they go ahead and assume those hospitals cause higher healthcare costs and the ‘savings’ of closing them will pay for the budget gap. Insanity." Link. Here’s a snip: "Big hospitals say specialty hospitals drive up costs because the doctors who own facilities have an incentive to over treat patients with expensive procedures. Specialty hospital proponents disagree. They counter that if smaller facilities were banned patients would be forced to go to big hospitals, which they say deliver lower-quality and thus costlier care."

From Lazlo Hollyfeld: "Re: EMR. This was reported today in regards to the pending Medicare physician payments cuts (10.6% as of July 1, another 5.4% on of January 1). ‘MGMA members reported that they will suffer further operational damage as a result of payment instability and the projected double-digit reductions to Medicare physician payments … More than two-thirds of respondents described how they will sacrifice or postpone information technology (IT) and equipment investments.’ While it is highly unlikely that these cuts will actually be enacted, even a portion of these cuts could pose a huge problem for the ambulatory HIT market in ’09 and beyond. Arguably the most important thing looming over the market right now." 

From Bignurse: "Re: EMR. I took my family member to a new specialist, where he was handed six sheets of paper and asked to hand-write his demographics, medical conditions, allergies, and medications. Funny, he had just written all of the same information on paper earlier this week in the previous doctor’s office who referred him! Imagine my surprise when I learned that the specialist has one of the top-name, expensive EMRs (overkill in a single-physician office?), but after three years, the patient history is still on paper. In fact, the entire time I was there, the doctor never turned the EMR monitor on. What’s wrong with this picture? It will never get better until patients like my relative walk into a doctor’s office and refuse to fill out another paper form!" Want to bet that it was a hospital that provided that expensive and unused EMR? That Mass BCBS article that Inga quoted says it all: doctors don’t get much EMR benefit, so requiring EMR use for bonus programs doesn’t make sense. You can’t make a small business buy software that doesn’t pay its way no matter how much society might benefit. It would be great if paint stores recorded your custom colors on an electronic personal profile that was shared among them all, allowing you to stroll into any Home Depot or Sherwin Williams and have your records immediately available, but that’s not happening for exactly the same reasons. Unless enough customers demand it, of course.

From TenaciousD: "Re: Stanford and Legacy. I heard that the Epic Stanford project is running at $180M for total costs. I also heard that Epic is telling potential clients (specifically an academic in the northeast) that Stanford is their beta for anesthesia. I will be curious how the implementation delays will affect Epic delivering anesthesia. Regarding Legacy, the article said that they expect Epic to cost about $10M over the next 3-4 years. That is the biggest Bull SH**. I know for a fact they told the CIO straight up it would cost $200M to replace Cerner and implement across all facilities." I wondered if Epic would bother with a $10 million deal. Wouldn’t it be great, knowing that software has zero incremental cost for a new customer,to still turn your nose up at a customer who only has $10 million to spend?

From Janie Lane: "Re: Midland Memorial’s EMR Stage 6. Somebody needs to talk about this when talking about the Epics of the world, where customers drop $10 to $50 million when OpenVista could do the job at a fraction of the price. If there were enough folks who lined up behind VistA to move it forward as a true open source project, it would be the default system of choice." Note the list of 11 Stage 6 hospitals and the conspicuous absence of nearly all of those big-spending hospitals. All the poster children academic medical centers haven’t made the cut, but 74-bed Citizens Memorial Hospital and Denni McColm have. We’re worshiping the wrong HIT role models. It’s kind of like translational medicine — choose a vendor for results achieved, not far-reaching vision. If you’re a CIO, you’ll be long fired before that vision ever ships.

From Bodie: "Re: Park Nicollet. They’re going from GE to Epic. It will take place over a couple of years, but it’s a done deal. They are running LastWord. Perhaps they figured they might as well take the pain once rather than moving to Centricity."

From Inside Outsider: "Did you catch any of the news following Apple’s announcement of their Software Development Kit for the iPhone yesterday? Looks like they’re going to release a really slick SDK that is easy to use and allows for rapid development. One of the companies that received the SDK early was Epocrates, which created a drug lookup app using the SDK and SQLite. They created it in less than 2 weeks. It will be  interesting to see if the medical industry jumps on this new platform." I’m betting yes. Never underestimate Apple’s ability to create an entirely new market by doing the opposite of what most tech companies do: giving geeky stuff mass appeal and style while hiding the nuts and bolts. I wish they’d build clinical systems. Mark it down: iPhone apps will be everywhere at HIMSS09. Here’s a link to the Epocrates story.

From Jack Ripper: "Re: your 2/18 mention of MagicJack. Perhaps you should refrain from endorsing products. I purchased it and still haven’t seen it and there is no support information." I wouldn’t say I endorsed the VoIP phone gadget (since I haven’t used it)  but I did say it looked cool. I’d give it a little more time, then contact your credit card company and dispute the charge. I’ve gotten my money back every time I’ve done that. And if you ever receive it, it just won a PC Magazine Editor’s Choice award, so I wasn’t the only one that liked it. 

From Steve-O: "Re: Brailer. Believe me, he’s smug every single day."

From CPR CIA: "Re: QuadraMed. Signed Quadramed as a sponsor, huh? I hope that you stay as open / honest about the state of CPR going forward as you were before taking their cash." No problem there. I liked CPR the last time I saw it years ago, but it was a train wreck even before Misys got its fumbling fingers on it. The years of neglect haven’t been kind, so let’s hope QD is up to the challenge. It does have superb user design and strong physician support. QuadraMed at least got it off its oddball database and onto Cache’. The offshoring decision is a gamble, but QuadraMed has some urgency in getting the job done and throwing low-cost Indians into the fray may provide the troop surge needed to make CPR sellable. Upgrading Affinity users is important, but if CPR’s big academic medical center users feel neglected, they’ll bail, so QuadraMed will need to develop an ivory tower worship competency to mollify them. As everyone knows, the biggest pain-in-the-ass IT customers are (1) academic medical centers, followed by (2) children’s hospitals, both for the same reason: they are irrationally convinced that their bizarrely inefficient and sometimes safety-endangering practices are better than everyone else’s. So, you have to hack your application to shut them up even though every other customer uses it just fine.

From Kate Bradley: "Re: consultants. Quite a few consultants read HIStalk. Would you consider running a survey of them to see what it’s like working for their current or previous employers? It’s sometimes tough to find out the nitty gritty from people already working there." I’m a sucker for taking on more work when it sounds fun. If you’re a consultant, please take my two-minute survey about your current and previous employers and I’ll e-mail you the survey results.

We spring forward tonight. Good luck to you IT folks on call.

Kleiner Perkins Caulfield & Byers creates the $100 million iFund to invest in companies developing high-impact ideas for Apple’s iPhone and iPod touch. Apple will be involved as well.

Cerner says KLAS has ranked Millennium as #1 in overall value proposition scores for CPOE and #1 in "deep" physician CPOE usage. Also from KLAS: 100% of Cerner’s remote hosting clients recommend that option.

Jobs: Senior PR Account Executive, Siemens Soarian Consultant, Network Analyst, Senior Business Analyst.

Privacy warrior Deborah Peel has an opinion letter in the Atlanta newspaper. Excerpts: "Most Americans think HIPAA protects their health data. Wrong. Those Americans should read the fine print issued earlier in this decade by rule makers who, reversing the intent of Congress, eliminated the right of patient consent over how their data is used for treatment, payment or health care operations … The foremost beneficiaries of widespread availability of health data will not be patients. It will be employers who will use that data in helping to determine hiring. It may be credit firms. It will be the data-mining firms that will use that data to push their wares on consumers." What I would do if I were her: hire a researcher to reference the source of every claim she makes. She’s a doc appealing to a medical and technical audience, so it would be nice to see the same factual rigor that you might expect in a journal article. The ‘can you prove that?’ questions are distracting from her message.

Article tidbit: MD Anderson used iRise visualization software to design its homegrown EMR, claiming it cut development time by half.

E-mail me.

Inga’s Update

Go-live for Cerner Millennium at Barts and the London NHS Trust is rumored to be pushed back again due to supposedly outstanding issues with the software. The trust has been testing the product since August 2007.

The Greater Rochester RHIO launches online sharing services enabling medical offices to access patients’ lab reports, radiology results, and medication history. Patients can’t view their own information (yet?) but can request an audit to see who has accessed their record.

From Political Pundit: "Re: Beacon Survey. I like it. Execs are torn over whether to vote for the person who will subsidize their field of industry or the person who will exchange fewer personal liberties for the soup kitchen of the welfare state. Maybe the question should have been: which candidate do you think will bully for the most taxpayer dollars to be thrown at HIT projects?"

Check out Neil Versel’s podcast interview with Jonathan Bush. I found it both informative and fun. I love how Jonathan rambles back and forth between the serious and the insane. He also mentions Mr. H and me at the start, which of course made me smile.

E-mail Inga.

Shahid Shah on Using Virtual Machines for Easy Open Source Deployment

Shahid Shad is the CEO of Netspective and writes The Healthcare IT Guy.

The open source movement in healthcare technology is growing by leaps and bounds from where it was only five years ago. However, open source software is often difficult to install and get up running, so "trying it out" is not so trivial. I know many CIOs and senior executives who would love to try out open source, but the knowledge required causes IT staff to push back. Most open source software today needs web servers, application servers, database servers, etc. all working in tandem, just to conduct a trial. On the commercial side, things are a little better, but still complicated.

Given how hard it is to install open source solutions, I strongly suggest that the use of virtual machine software like VMware, which is now free for many licensing options, would make it significantly easier for customers to try out software. Other options like Microsoft’s Virtual PC 2007, which is also free, might also be beneficial.

A virtual machine (VM) engine is a piece of software technology that dates back from the mainframe era. It basically allows multiple logical operating systems (a "virtual machine") to operate on a single physical machine. Assuming you have enough memory and processor power, you could have a Linux or Windows "host computer" that would allow multiple Windows 95, 98, NT, XP, Linux, etc "client virtual machines" to run as separate windows at the same time. On my workstation, I often run several virtual machines at the same time. The technology is stable, almost ubiquitous, and very slick.

For almost a decade, I’ve been advising my clients, most of which develop software for a living, to use virtual machines to help improve quality, test multiple operating systems on a single machine, produce "snapshots" of an operating environment for installations and training, and many other uses. I also started suggesting as early as a few years ago that software vendors should create a "virtual machine image" of a system that has their software, database, network, etc. all pre-installed and pre-configured.

VMware has a free version that can take a machine image and launch it on any modern computer. This bundling of an operating system with a pre-configured, special-purpose application is called a "virtual appliance". Cute name, but virtual appliances take literally minutes to run (it usually takes longer to download them than to actually run them). In a virtual appliance, there’s no installation step. You just turn it on and you’re ready to run the software immediately.

For Windows-based offerings, there might be licensing issues from Microsoft (a vendor can’t just create a virtual machine client image with Windows without licensing it appropriately). However, for any software that runs on Linux, that’s not a problem – just bundle the operating system fully configured to run your software along with whatever else is needed and give your customer a "single click" launch and test capability.

The folks from Medsphere, VISTA, ClearHealth, and other open source groups should take this advice. The virtual machine client model forgiving a trial version would change the trial deployment model dramatically and give you leg up on your competition. You could offer a "five minute" install regardless of how complex your software is.

There are already hundreds of other virtual appliances out there in the broad non-healthcare market. It’s time for the healthcare IT sector to create its own virtual appliances to ease the management and maintenance burden on already tired staff.

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Currently there are "6 comments" on this Article:

  1. Re: MagicJack – I had seen the commercials and after seeing the mention here decided to go for it. Got mine in 2-3 days. Works flawlessly when on a wired connection but a little choppy when on wireless (a la my hotel at HIMSS a “very Good” connection on an 11Mbps line). Cool features including an Outlook plug-in to dial directly from Contacts. You get full-duplex voice quality as the one physical USB device uses two logical USB ports. Also – don’t need a phone as you can use a headset or simply your PC speakers and mic. Voicemail is nice too as you get an instant e-mail when someone leaves you a message. As for support, it’s true – there isn’t much (I’m thinking the entire operation is an unshaven guy sitting in front of a PC amidst empty pizza boxes and Mountain Dew cans who answers the door only for when UPS picks up the shipments) – but my install problem was fixed with their java-based MagicFix routine, and a subsequent question was answered promptly, courteously and accurately by their LiveChat tech support (the guy with the pizza boxes?).

  2. Re: TenaciousD: “Re: Stanford and Legacy – Wrong on the Anesthesia count. They’ll be early but others are already live on early release components. Never heard an Epic person say Stanford is their beta for anything. They don’t do it that way in general.

    Re: Legacy, you might want to think about project cost v. vendor costs. Epic typically doesn’t cost as much as what most people think. They just have that funny midwestern thing going where they actually try to estimate the whole project cost correctly and stick to their budgets. I’d guess the 10M number is what Epic is charging for their part of the whole thing. The rest is just the cost of doing a very large and comprehensive project.

    Maybe TenaciousD would rather people just didn’t do anything and stuck with paper.

  3. Re: Insider – The confusion between what Epic costs, and what the project costs may also be due to the fact that other vendors have whole consulting organizations within their companies, and so a large part of the total project cost also goes to the vendor. It is indeed gross misinformation for Mr. Histalk to imply that Epic wouldn’t bother for a 10 million deal…

  4. Want to bet that it was a hospital that provided that expensive and unused EMR? That Mass BCBS article that Inga quoted says it all: doctors don’t get much EMR benefit, so requiring EMR use for bonus programs doesn’t make sense. You can’t make a small business buy software that doesn’t pay its way no matter how much society might benefit. It would be great if paint stores recorded your custom colors on an electronic personal profile that was shared among them all, allowing you to stroll into any Home Depot or Sherwin Williams and have your records immediately available, but that’s not happening for exactly the same reasons. Unless enough customers demand it, of course.


    Here is another slant on this discussion. What if BCBS of Mass is actually seeing that the amount of documentation provide by an office EMR is allowing doctors to bill them for much higher paymnets. In the past physicians and thier office staff did not have the elctronic back-up for higher coded claims. Now with EMR documentation there is no way to refute these claims and pay a lower amount.

  5. The Mass BCBS article and the other CPOE spin is at times fascinating and other times horrific to follow. I find the irony of those hailing BCBS as a hero for forking over 50 mil for a study to announce oops nah lets not do that EMR stuff now. I don’t know about you but if I were a subscriber I’d want to know what is being done to lower my rates. The spin and obvious connected parties on this subject in itself should be a study. – perhaps another insurance company could write a check on that one.

    Mass Collaborative seems to want to take over where the Leap Frog group failed to thrive – capitalizing on the ignorance of the big picture and still no one says the Monarch has no clothes. The everyday Joe has no clue that CPOE does not mean your complete clinical documentation, not just meds ordered. No discussion on JCAHO Core Measure, zero on evidence based medicine. Uhm where is the study on Adverse Drug Events with those items?

    I don’t now about you but if I am in the hospital I am less worried about a docs signature than someone hanging someone else’s meds on my IV poll or not scanning my wrist band (if I’m given one with a bar code) to ensure I am who the system says I am. This is not to say CPOE has zero merit – however its a placebo for more significant issues that await attention and education.

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