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Readers Write 9/23/09

September 23, 2009 Readers Write 11 Comments

Thoughts on the Proposed Acquisition of Perot Systems by Dell
By Ralph P. Fargnoli, Jr.


The Dell acquisition of Perot means that Dell wants to be taken seriously in the HIT market, providing PCs, servers, and strategic outsourcing and consulting services to the HIT industry and beyond. As others before them, they are interested in their piece of the $2 trillion market. With Perot, they have a name recognition factor going for them.

With Dell focused on services with the Perot acquisition, they need to keep the Perot management that understands the HIT market. If they are not successful holding onto the people that made the Perot acquisition attractive, some of their HIT verticals will disappear from the market. Perot is the recognized player in HIT services, not Dell.  

This will also drive competition for the benefit of the HIT market, as HP and IBM also have a recognized HIT services group. Overall, it can be a win for Dell and the HIT market as there are more choices for HIT adoption along the technology vertical.

As it relates to the consulting business, we believe it is a positive because over the long term, the acquisition removes a layer of competition due to strategic focus and revenue needs of public companies. We saw this with the acquisitions made by ACS, IBM, CSC, and others. The billion-dollar players cannot meet Wall Street expectations being everything to everyone. That opens the gate for Beacon Partners to grow.

Ralph P. Fargnoli, Jr. is the president and CEO of Beacon Partners, Weymouth, MA.

Order Set Software: Clinician-Focused Design is Key to Adoption
By Stephen Claypool, MD


Few physicians will argue that standardized order sets are valuable tools. Paper versions have been around for decades and typically enjoy high adoption rates because they are easy to use and don’t disrupt the clinical workflow. But they are also time-consuming to create, nearly impossible to keep current and cannot be altered when a patient’s needs fall outside the norm.

For these reasons — and because they are key requirement for HITECH funds — more hospitals are seeking to automate the development and use of order sets. Unfortunately, many are discovering that their physicians are far less receptive to electronic order sets than they were to their paper-based counterparts.

The problem is that too many order set applications are designed by engineers with little or no understanding of actual clinical workflows. They work, but not in a way that actually drives efficiencies for physicians.

To avoid adoption problems, it is important to evaluate the software through the eyes of the clinicians who will be using it. Starting with the basics, any order set application should include:

  • A large selection of prebuilt, yet customizable, order sets based on nationally recognized best practices
  • Templates for creating new order sets
  • Links to trusted medical content
  • Robust authoring and editing tools
  • Ability to track reviewer comments and version changes
  • Easy integration with any EMR/CPOE system
  • User-friendly navigation requiring little training to achieve proficiency

Beyond the basics, order set software must offer features and functionality that enhance — rather than complicate — authoring and use at the point of care. For example, applications with a sizeable library of orderable items will eliminate the need for manual re-entry. Software with an underlying structure that is data vs. text-based will streamline mapping and simplify integration into EMRs or CPOE.

The solution should also deliver intuitive clinical decision support during authoring and at the point of care. “Intuitive” is key, as it avoids alert fatigue by taking each order in context and delivering only meaningful alerts or recommendations.

Formatting is also important. Like their paper-based counterparts, electronic order sets should be easy to read and make clinical sense. The trouble is that many applications are too rigidly constructed, which can hamper treatment of conditions (e.g. meningitis) that fall outside routine protocols. Yes, the elements of the order set must be mapped to specific orderable items, but an appropriate level of flexibility must be built in to allow for necessary alterations to the sequence in which individual orders are issued.

On the back end, maintenance is the greatest long term challenge facilities face with evidence-based order sets. Look for an application that automates medical content monitoring and delivers alerts when new evidence or guidelines are available.

Creation happens once and maintenance is forever. Thus, a powerful maintenance component must be considered alongside the format, functionality and the intuitive nature of order set solutions.

Stephen Claypool, MD is a practicing physician and vice president of clinical development and informatics-clinical solutions with Wolters Kluwer Health.

Healthcare Clearinghouses and the 80/20 Rule
By Nick Revak

The Pareto Principle, also know as the 80/20 rule, states that, for many events, roughly 80% of the effects come from 20% of the effort.

Variations of this principle can be applied to a wide range of situations, including healthcare EDI transactions. That is, 80% of a provider’s EDI transactions will be exchanged with 20% of its payers.

Here’s another one. In software development, 80% of results are achieved with the first 20% of effort.

Providers would do well to heed the 80/20 rule when considering their EDI transaction strategy. Providers should consider building their own connections to their top 3-4 payers (Care/Caid/Blue) and leave the rest to a clearinghouse. This will result in the provider saving 80% of the transactions fees while leaving 80% of the effort to the clearinghouse.

Nick Revak was a senior developer with Healthcare Data Exchange (HDX) for many years and is currently an independent consultant/contract programmer on assignment to Stanford University Medical Center.

Healthcare Litigation Reform Versus Pay for Performance
By Greg Park

Defensive Medicine is a significant factor in healthcare costs. In fact, studies by The Harvard School of Public Health found that eight percent of healthcare spending is directly related to physicians ordering tests, procedures, and scheduling visits primarily to reduce malpractice exposure. These numbers are nearly twenty years old, but logic tells us they have compounded since the study was first published.

Three out of four physicians recommend some form of malpractice reform. And why not? Fees for malpractice insurance have skyrocketed to a point where many physicians simply pack their bags for less risky waters. Worse than that, medical students understand these conditions and are opting more for specialization and research rather than direct patient care. 

But is the issue really that physicians are so worried about being sued that they over analyze? Or is the problem of over-analysis a symptom of the volume-based practices that exist today?  Isn’t it much easier to diagnose an unknown medical condition with a sledgehammer of tests when your daily office queue exceeds forty patients? Aren’t we as a nation rewarding this behavior by continuing our payment methods that reward tests, but turn a blind eye to results?

No, malpractice reform is either another distraction or a means to treat the symptom rather than the disease. 

Let’s dig further into this issue and support those who are promoting evidence-based medicine and the financial rewarding of physicians with positive outcomes that follow established medical pathways. Agree that there will be those clinical situations that exist outside the norm, or where the chance of positive outcomes will be slim. These are high-risk situations that need to be examined differently, but whatever we do we do not want to create disincentives for care.

There are deeper issues than malpractice reform, single-payer systems, and public options that are not the focus of our public debate. We need to discuss how physicians can spend quality time with patients while maintaining their practices. We need to discuss how to grow the ever-shrinking demographic of general physicians while giving them the time to review a deluge of medical information published daily. 

Perhaps we even need to discuss why medicine must be a for-profit industry. Economists will tell you that competition and the pursuit of wealth creates strong markets, but do we really want our healthcare professionals wondering how to squeeze profits from the system? I believe that those driven to the industry are motivated beyond personal profit and are focused on providing care. Quality care.

I know many of you are debating these topics in your think tanks, ivory towers, and specialized committees, but this is pure Latin to a majority of Americans. The general debate going on now is distraction which prevents us from considering how the fundamental beliefs of our system must radically change.

Greg Park is national account and product manager at DB Technology.

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Currently there are "11 comments" on this Article:

  1. Re: Greg Park’s comments – Bravo! I couldn’t agree more. This is a message that needs to be heard by the White House and our elected officials.

  2. I concur with Ralph’s view of Perot Systems acquisition by Dell. Having worked with Dell over ten years ago to bring a Windows based Cardiology PACS (CPACS) to the marketplace with pre-installed software along with a fibre channel storage solution, I know they’re going to bring some exciting solutions to the healthcare space through partnerships that include Perot and other suppliers. This total solution effort will save institutions from the startup problems that normally come with new equipment installations, and improve the chances for smoother interfacing with legacy systems.

  3. I believe Mr. Revak’s opionion might be prudent for limited connecitons for a single state, otherwise it is a nigtmare to keep up with the “standards” of each state’s version of the standard. HIPAA still has done little that I can see in paperwork reduction or a unified front.

    PS: Mr. Revak is an independent contractor, probably getting some free adverstising here, drumming up business.

  4. I really like Greg’s comments, well thought out. But as a nation are we making a mountain out of a mole hill in terms of what changes are being discussed in healthcare reform.

    How come nobody is talking about how we are going to prevent people from going to the doctor or popping pills.

    We can reform payments to doctors, we can reform malpractice, we can even reform HIT all day long, but in reality are we really doing anything of value.

    Why are we not talking about getting healthier as a nation? Where is the war on ASTHMA or the war on HFC syrup?

    Maybe I am viewing it wrong but instead of aruging how much the doctor should get paid, wouldn’t the more effective cost cutting model be, how do we prevent little jonnie or little suzie from even getting sick or developing a chronic condition?

  5. S. Claypool generates a valid point. Order sets are good for an assembly line, like making cars.

    Each person is different. Thus preordained order sets in the majority of clinical situations put the recipient patient at risk.

    Mindless medical care is dangerous.

  6. I presume Nick writes based on his expertise with a clearinghouse (HDX). If a hospital can maintain 20 different ADT interfaces (which also vary from one vendor to another), they can maintain 3-4 ANSI X12 transactions. I’ve been surprised how dependent hospitals have remained on clearinghouses for so long and how little value clearinghouses have added over the years. I don’t think maintaining direct connections would be money well-spent for all hospitals, but for large ones, particularly those spending $10K a month in transaction fees for Medicaid eligibility alone, they could easily justify a direct-connect. There are big hospitals that have been paying HDX $0.40 a transaction for Medicaid eligibility for 10-12 years — as many as 25,000-50,000 tx per month for Medicaid alone. Cha-ching!

  7. Sam you are correct.

    We speak of cutting healthcare expenses by simplifying payments.

    We speak of reducing the likelihood of litigation.

    We speak of shifting money from payers to consumers’ pockets.

    Yet we gorge unhealthy foods, drink a six and smoke a pack a day (well…not me of course).

    Hey this is your right as an American! I don’t begrudge anyone from these activities, but where is the personal responsibility? The statistics are staggering when you account for how much lifestyle choices account for our total healthcare expenses.

    Is it possible to change these habits? Maybe, but it’s going to take time, and until that time let’s make it better where we can.

  8. Greg Park’s comments point out the weakness in P4P: physicians will be incentivized to drop patients who do not acheive the expected benchmarks. On the other hand, insurers are proposing to charge higher premiums to members who fail to comply with treatment plans. As the relative of a person who was dropped by their medical provider because the hemoglobion A1c was consistently too high, I frankly would support the second option as more fair and certainly more likely to result in long-term behavior change.

  9. In response to B. Harrell’s comments:

    I think we’re agreeing on my basic point. That being that a provider could consider creating and maintaining direct connections to a few payers. At the same time, I certainly agree with you that trying to stay abreast of variations across a wide payer base could quickly get out of hand.

    As for trying to get free advertising and drum up new business, I can see why you might think that. But if I were trying to drum up new business, first thing I would do is register as a job seeker on the Healthcare Central job site. I haven’t done that. Fact is that after 40 years in the healthcare IT business, I’m supposed to be easing into retirement. Someday … 🙂


  10. Oh…but wait a minute, we can’t do that if the insurer can’t deny coverage for a pre existing condidtion…so,
    keep smoking, drinking, eating junk food, be a couch potato…

    It’s you right as an American!

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