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Readers Write 6/8/09

June 8, 2009 Readers Write 12 Comments

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The Problem with Publicly Traded Companies
By Mike Quinto

The problem with publicly traded companies is they serve the spreadsheet, not the customer.

In the last year, I have heard:

  • the VP of implementation of an HIS vendor said that she does not have the personnel to devote to our implementation because she needs to hit a certain metric and this would blow her numbers.
  • a sales VP at a major ambulatory EMR vendor tell me that because of their end of year, they needed me to commit to buying six more licenses (to true up a five-year-old old problem THEY created) within 24 hours or they would “turn us off”.
  • the SVP at a major ERP vendor, admitting that the sales team “made a mistake,” said they can’t fix it because they have to hit a certain profit margin (FYI, your company hitting a certain double-digit growth or profit margin is not a large concern of my non-profit health system struggling to break even — know your audience, people).

Whatever happened to partnerships? It is clear that the ‘partnership’ with the shareholder is far greater than the ‘partnership’ with the client.

I have been fortunate enough to work for privately held software vendors and unfortunate enough to work for publicly traded software vendors. I have worked at a privately held software vendor that was purchased by a publicly traded company. I have seen the difference from both sides. I know that the customer is not at the center of decisions in a publicly traded company; spreadsheets are at the center of decisions.

As a client of both publicly traded and privately held vendors, I am experiencing both sides of the equation. Without question, the privately held vendors make better ‘partners’.

I would not imagine the 14K that caused such a barrier to customer service at a major healthcare ERP vendor is worth the damage it has done to this two million dollar ‘partner’. The 20K that created a competitive environment was not worth putting the client at risk. The confidence lost at the executive level was not worth the implementation team hitting a certain metric for the quarter.

We all have to hit certain metrics. We all have our own challenges. Publicly traded software vendors often keep the short term revenue recognition or expense metric in focus when the big picture should be on customer satisfaction and retention. This quarter’s financial statement will not keep you going in the long run. Your ability to attract and retain happy customers that buy from you again will keep you going.

Mike Quinto is CIO of Appalachian Regional Healthcare System of Boone, NC.

Is Data In Your CDR Accurate? Are You Sure?
By Unfrozen Caveman CIO

I’ve always wondered about the accuracy of the process of duplicating data in ancillary systems, such as a laboratory information system (LIS) or radiology information system (RIS) to a clinical data repository (CDR). The most common process consists of parsing HL-7 messages and storing the data in a CDR. Sounds simple and straightforward. What could go wrong?

It turns out it’s not so simple and things do go wrong:

  1. HL-7 is not simple or straightforward to work with. Parsing data can cause random discrepancies.
  2. Changes, such as revising clinical data, e.g. change a lab value, revising a finalized report, etc., can cause discrepancies.
  3. Software updates in the ancillary system can cause discrepancies between data in the ancillary system and CDR.

My organization is moving away from the CDR-centric framework to a web services framework (aka service-oriented architecture). In this framework, clinical data is not reproduced in a CDR unless absolutely necessary and data is retrieved from ancillary systems using web services when needed. However, for reasons related to response time, we needed to duplicated lab data in a lab data repository outside the LIS.

During this process we discovered that a vendor-supplied CDR and a second, smaller CDR, purchased as a package from a vendor to provide mobile access to clinical data, store lab data that does not match data in the LIS.  These systems are no longer used for clinical operations for reasons unrelated to the discrepancies noted.

As part of our effort to build a lab data store, we also built a program that validates lab data by comparing data in the ancillary system with data in the CDR for a specific date. We are experimenting with the best strategy for running this program. For example, run the program every morning for dates equal to yesterday, last week, and last month.

How significant were the discrepancies? That question misses the point. The question should be what do you do about it? Ignore it and pretend it doesn’t exist? Or have in place a data validation process that identifies, reports, and fixes discrepancies. Did your CDR come with one? If not, what are you going to do about it?

Forget eHealth Ontario
By Justen Deal

Forget eHealth Ontario! Take a look at the federally-sponsored not-for-profit entity, Canada Health Infoway, which actually appears to be accomplishing even less. Plus, because it is not actually part of the federal government, it gets to be much less transparent to boot! 

So far, since 2001, it has received $2.1 billion in funding, including $500 million for 2009 it just got in January.

Their longstanding goal has been to ensure 50% of Canadians are covered by electronic health records by 2010. According to a recent survey by the Commonwealth Fund, only 23% of primary care physicians in Canada are using electronic health records (compared to 28% for the United States). Sounds like they’ve got a long way to go in the next seven months, eh?

That might be why they’re now focusing on a new (and improved!) goal of covering 100% of Canadians by 2016. They estimate more funding will be required…  😉


Justen Deal is venture director at QuarrierWade of Charleston, WV.

NAHAM Report
By John Holton

This is a belated update on the NAHAM (National Association of Healthcare Access Managers) convention a week ago. The most exciting aspect of the convention was the formation of the Healthcare Access Management Coalition which is comprised of NAHAM, hospitals, other healthcare providers and industry vendors.

Everyone acknowledges administrative waste in our healthcare system and yet access to care and the arcane reimbursement environment created by the insurance companies is missing from the current debate. The new coalition is focusing on educating policymakers on the importance of efficient and quality management processes from a patient’s point of entry through the continuum of care. Hopefully through this education, new policies streamlining the administrative end of healthcare will result in more dollars being spent on the actual delivery of patient care.

The goals of the coalition are:

  • Improve access to care and reduce healthcare costs through dynamic healthcare management
  • Ensure healthcare reform includes entry point and patient management processes
  • Educate policymakers about technologies that improve service delivery models
  • Support technology solutions that make healthcare more affordable and efficient

Anyone interested in these topics can get more information by contacting John Richardson, NAHAM Director of Government Relations at (202) 367-1175 or jrichardson@smithbucklin.com.


John Holton is president and CEO of SCI Solutions of Los Gatos, CA.

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Currently there are "12 comments" on this Article:

  1. Mike Quinto nails it regarding publicly traded HIT vendors. In our shop, we have given privately held vendors an edge in this regards (although obviously there are other reasons that need to be taken into account when selecting a vendor).

  2. Wow, Mike Quinto could not be more right. I don’t see how just about ANY service industry can possibly deliver when it’s publicly traded – you either serve the customer or your shareowners. You can’t do both. And customer-based decisions look years down the road – most shareholder decisions look 2Q or less.

    Meanwhile – each one of those vignettes he shared are all too common in this business. Those individuals and their companies should be exposed to the cold, bright light of day.

  3. Re: eHealth Ontario.

    It is a giant debacle “up here.” I read the Toronto Star on the subway every morning and it seems every issue’s political cartoon is about eHealth and the mess we have on our hands. Sadly, since the initiatives started we have had a decrease in wait times for a variety of procedures like joint replacements and CT scans, so I hope the baby doesn’t get thrown out with the bath water on this one. I’m hoping by the time I graduate medical school we’ll have something like athenahealth available in Canada.

    P.S. Nice use of the word “eh,” Justen Deal.

  4. Cassis,

    I wonder how much of the decrease in wait times has been due to eHealth Ontario (and Smart Systems for Health before that) and other provincial electronic health records projects? So much more has been spent on actually increasing staffing, better facilities, and process improvements, and the actual penetration of EHRs has been so minimal, that I would be surprised if it’s anything more than a relatively minor contributor.

    That being said, I think you’re absolutely right that Canada desperately needs athenahealth… The one good thing about the healthcare system in Canada is that once a good idea makes it into one small corner of the system, it can tend to spread very quickly. Once more practitioners and administrators in Canada see the benefits of modern electronic health record systems, I think you’ll see some big changes… Presuming the government doesn’t trample through the HIT marketplace like they are aiming to do in the United States at the moment.

    justen deal

    p.s.: I actually shuttle back and forth between West Virginia and Montréal, so that use of “eh?” wasn’t entirely contrived!

  5. Comment on CDR v. SOA. I think you probably need both if you want to do it right, although each has strengths and weaknesses that depend heavily on the strength of your internal IT group, your vendors, and the funding and support you have. We’ve largely avoided any sort of CDR other than labs at our institution, and went fully SOA. One challenge with this approach is that vendors generally don’t understand SOA or do it very well, and more often than not what you get is a database dump wrapped in XML, if you get anything at all. We had to build much of it ourselves. The other challenge is that without some sort of non-vendor-dependent database of that information, you are forever beholden to that vendor to access your own data. Having a CDR gives you some agility in that respect, although with all the issues raised above. Lastly, for doing data quality reporting and things that cross multiple SOA designs across populations of patients, SOA really isn’t strong, and sometimes can’t do this at all. A CDR can do this much more easily.

    Like I said, though, your mileage may vary. If we can get the money, we’re going to do both for purposes of mitigating the weaknesses of each, but it would be great to have one or the other able to do everything.

  6. Mike Quinto is right on. I worked for a company owned by venture capitalists and they would not even allow you to talk to the client unless it was billable you could not provide good customer service if you wanted too because you got dinged for it by management it became all about the money. I guess they needed those billable hours to pay for all the golf shirts, logo golf balls and trips to the super bowl for the upper management. Its sad because the client and the employee suffer because they both want the same thing a good quality job but are unable to do so because of the contraints that are placed on them by others.

  7. DrM,

    Good feedback. An alternative view is that a CDR does not make a good clinical and financial decision support system. We are building a data store specially designed for translational queries. The advantages are 1) queries run much faster and thus make decision support analysis much more interactive, 2) queries can be run any time and don’t degrade the performance of clinical transaction queries, 3) data integrity issues are little concern as the differences should be “noise” and statistically insignificant, 4) lower cost than a CDR – no need for the high-level of redunancy required of a single-point-of-failure clinical system.

    Good discussion. A key reason I visit HIStalk is to interact with others on the nuts-and-bolts of healthcare IT.

  8. DrM

    My experience is that using web services to get data and using a seperate data store specially designed for clinical and financial decision support has a lower cost and lower total cost of ownership than the CDR model.

    That may sound odd. However, hardware costs of a CDR and redundant hardware AND the cost of maintaining a highly accurate, highly available structured, transactional database are the key drivers to the higher cost of a CDR.

  9. I agree completely on your point of a CDR not being great for translational; most CDRs are designed to do patient-based queries (one pt at a time) and optimized for that purpose, but most reporting is population-based (multiple patients), and those two don’t really mix well. I should have been more specific, we’re actually planning on the population-based data repository, and (second, if we get the funding) a regular CDR for risk mitigation reasons.

    It also makes sense to me that it would be less expensive. Would be a great case study, but hard to find a good place to get the comparative data. A fully operational CDR would cost us about $2M in hw/sw and other things, whereas a database that can run slowly if need be and where big queries are scheduled is <$500k. SOA is pretty capital cheap. Neither of these is brain-cheap, though, and so that cost could go up if you’re supporting both. You shouldn’t be doing both for the same reasons, though, so I’m not sure it would go up by much, you just need extra SOA ppl in addition to DBAs, but probably fewer DBAs.

  10. Very good feedback. I appreciate your comments.

    My experience is SOA has a very low total cost of ownership. They are easy to write and modify. Once written they don’t change unless the ancillary system is upgraded or replaced. We added a developer but he does much more than SOA. In fact, he has trained our want-to-be developers into SOA developers. It is a good path for those with some development experience. Much easier than training them to migrate to OO programming and the MVC framework. MVC is a real challenge for those moving from other frameworks.

    I have a group on LinkedIn called SOA in healthcare IT. Not very active but I’m looking for people with an interest to contribute. Check it out at:


  11. I worked with Mike Q. at the publicly traded company and have also worked at privately held companies. I concur with his thoughts. Publicly traded companies focus so much on the short term earnings targets at the expense of client service. The executive decision making is all about managing quarter to quarter results. I think it would serve the public well to move more towards financial reporting every 6 months for publicly traded companies. It wouldn’t cure everything, but it would hopefully allow management to make better long term decisions and allow them to focus more on service / partnerships.

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