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Monday Morning Update 11/23/09

November 21, 2009 News 16 Comments


From The PACS Designer: “Re: Google’s Chromium OS. Google has just announced the Chromium OS, an open source project. Since it is a completely Web-based open source development application, it brings with it some interesting possibilities for developers and eventually users. The Chrome OS browser will still be used to access all of the Chromium OS applications that evolve from development efforts, and some of the new features will eliminate the need for a hard drive since solid state memory will take its place. Chromium OS Security is a new approach to address security flaws.” Video overview here. I’m buying the concept because the Chrome browser is shockingly faster than FireFox (and less surprisingly, IE) when it comes to running complex Web apps. I’ve moved to it almost completely, even though it has some annoying deficiencies (no Google toolbar and no drop-down history).


From Dr. Pepper: “Re: Flash animation in ads. It’s causing me difficulties in scrolling and appreciating the content of your Web site. Can you limit this or allow us to turn it off?” There are many ways, but here’s the easiest one: click the View/Print Text Only link at the bottom of a posting to bring up a nicely formatted, paper-sized Web page with a Print option. Even then, it would be great if you take an occasional look and/or click on the sponsor ads since they make the wheels go ‘round and often have interesting information to share (nearly all the sponsors are big fans of HIStalk beyond just running ads).

From Bernie Tupperman: “Re: Kaiser. US News & World Report named KP Medicare Advantage in Colorado as the best in the country for Medicare, with all the rest of the KP plans except one near the top of their markets.” I don’t have any first-hand experience with Kaiser, but the pitch from George Halvorsen’s  internal e-mail that Bernie forwarded is certainly compelling, not to mention big on IT:

When you are a KP Medicare Advantage member and have coordinated care, fully linked caregivers, prescriptions and tests done onsite in convenient proximity to the rest of our care team and then leave our coverage and have to go out into the wilderness of solo, unconnected, unlinked, uncoordinated doctors — and when your new doctors don’t even know what prescriptions other doctors have written or what tests your other doctors have taken — and when you can’t schedule an appointment electronically or order your refill prescriptions electronically or even send e-mails to your doctor — those patients feel like they have fallen into a time warp into a very primitive world.

From Cam Winston: “Re: Pennsylvania HIE. I’ve heard Medicity has been chosen as the vendor in a $10 million deal.” I’ve seen that mentioned, but not officially. I’m sure Medicity won’t issue a press release until the contract is signed. Obviously that’s a big win for them if so. That led me to think how long it’s been since they started sponsoring HIStalk and I think it was in 2003, the year I started writing it. I don’t know where the time has gone. Including this year — can it really be just three months or so until HIMSS?

I’ve been slightly involved in some software usability projects over the years, so I enjoyed these clips (above) of real-life user frustration with healthcare software. They’re from Healthcare Human Factors, based in University Health Network, Canada’s largest teaching hospital. Thanks to JustAThought for sending over the link.


The Harvard people who published the study (warning: PDF) saying EMRs don’t improve quality or save money don’t exactly come across as impartial academics in an interview with HealthLeaders Media. Some quotes: “The idea from this administration that we’re going to pay for health reform out of savings from electronic medical records is baseless propaganda … What kind of an idiot hospital administrator would buy a system that will actually decrease what you can bill to payers? These systems help them extract more money.”

Speaking of those Harvard authors, nobody seems to have noticed that they wrote Bleeding the Patient: The Consequences of Corporate Healthcare and seem to have a socialist bent (“only when the U.S. has a party of labor will we have a national health program … it’s going to take a broad strengthening of the left.”). They also founded Physicians for a National Health Program, which advocates single-payer national health insurance, so they have an agenda that goes beyond IT. They also advocate open source over vendor systems: “We should really think about whether we want to continue to use our public funds to promote private, entrepreneurial HIT systems that have a business orientation, or if we should use those funds for further development of less expensive, open-source HIT systems designed specifically to enhance the quality of patient care, just as the VA health system has done.” Not to quibble, but the VA didn’t get VistA for free — it spent what must have been millions if not billions to develop it, and unlike vendor system development, taxpayers footed the bill. Even though the authors seem to have strong opinions that bled over into what was supposed to be a research article, I can’t say I disagree with most of what they say.

Meanwhile, here’s how the authors did the research for their article. They matched up self-reported levels of hospital automation from HIMSS Analytics with Medicare Cost Reports and Dartmouth Health Atlas data over a four-year period, looking for a correlation between degree of computer use (calculated from the authors’ own formula), cost, and quality. They not only didn’t find any, but even the Most Wired hospitals showed no clear advantage. There are lots of limitations in their method (using Medicare cost data, using the limited quality measures in Dartmouth to extrapolate overall quality, and having incomplete data for some of the years). Do their conclusions hold water? Maybe in aggregate.

Here’s the same observation I always make when the Most Wired people use similar number-crunching to try to convince you that IT improves costs and outcomes — correlation is not causation. Also, the conclusion isn’t that IT isn’t worth it, only that they could not prove that it was from their approach. Still, I’ll go with their general conclusion since I’ve been saying it for years — if there was one rock-solid case study of a hospital that reduced cost or improving quality solely because of IT, that hospital’s competitors would be out of business, their IT vendors would own the market, and we wouldn’t be stuck with the unsatisfying conclusion that it’s not what you buy, but how you use it (actually, Kaiser may be that one rock-solid case study now that I think about it). Still, prospects who think they’ll be a notably positive exception keep the HIMSS exhibit hall full.


HIMSS paying people to watch EMR demos is a bad idea, 79% of you said. New poll to your right: studies are showing that EMRs haven’t done much to improve quality or reduce costs, so who’s to blame for that?

A Mayo Clinical family medicine clinic in Arizona notifies patients that it’s dropping Medicare because it doesn’t pay enough to cover the clinic’s costs. Patients will be fully responsible for a $250 annual administrative fee, office visit fees ranging from $175 to $400 each, and a physical, with the grand total estimated at $1,500 per year.

Some interesting quotes from jurors on Charlie McCall’s trial. Referring to Al Bergonzi: “We just thought he was a thug in a suit”. Of Charlie’s legal dream team: “They were a little more theatrical … It goes to show spending millions of dollars on your defense is not necessarily effective.”

Three Denver area provider groups (Children’s Kaiser, and Exempla) go live on their HIE.

Listening: 30 Seconds to Mars, a reader recommendation. Sounds good – hard progressive with a little grunge DNA in there.


Shaun Priest, a vendor VP (I’m not sure if I’m supposed to mention the company’s name), has a novel available on Amazon called Decisions that involves an HIT sales guy fighting his demons.

HIMSS isn’t the only big trade show bailing on Chicago because of cost. The CEO of the huge plastic industry trade show, which is leaving Chicago for Orlando after 40 years, blames the work habits of union workers rather their reputation for being nasty. “We heard over and over again that the electricians were nice, but they dragged their tails. Jobs that should take two hours, they dragged out to five or six.” The president of the Chicago Federation of Labor said it was a wake-up call, but the electrician’s union boss wasn’t so humble: “I think HIMSS would have left anyway. They took a parting shot when they pointed at electricians.”

Odd, but possibly effective: a British dancer with epilepsy plans to induce an on-stage epileptic seizure to raise awareness of the condition.

MedAptus announces that its system for capturing professional charges is available for BlackBerry smartphones and coming next year for the iPhone.

Tampa General Hospital, like everybody else, signs with Epic in a $90 million project. It was just announced, but rumor reporter Jerry Seinfeld told you about it here on November 6.

The CSI Companies, the Jacksonville, FL-based staffing company that Grady Hospital (GA) chose for its Epic implementation, says business is up 40% over the past four years to $21 million, mostly because of healthcare IT. It says EMR implementations typically require 20-40 employees for 2-4 years.

Odd lawsuit: a man whose ear was torn off by his son’s dog is transported to the hospital by New York City paramedics who brought the ear along on ice. The hospital said the ear was contaminated, so the paramedics tossed it in the trash. He’s suing the city for being deprived of treatment, so the city is suing the hospital for telling the paramedics to throw it away. And in Florida, a woman who claims her emphysema was caused by smoking is awarded $300 million in her lawsuit against Philip Morrris, claiming the company is responsible for her addiction.

Mr. HIStalk’s 10 Ways to Get Off on the Wrong Foot as a New Hospital IT Executive

  1. Convene endless department meetings under the naive assumption that all problems, from understaffing to poor system architecture, are due to insufficient employee communication.
  2. Insist on extensive cross-training and information-sharing, thereby alienating the experts who deliver most of the results, but who don’t like working in teams.
  3. Mandate the use of overlapping software applications that require employees to record time and write status reports in multiple locations.
  4. Fill leadership positions with people from your previous employer, communicating a clear message of distrust for the department that just hired you.
  5. Spend time behind closed doors working on org charts, having meetings with high-level peers, and plotting strategy, all without ever getting to know the employees who have to actually do the work being planned.
  6. Repeatedly state that you wouldn’t have been brought in from outside if things were going all that well, so obviously past accomplishments were bogus and everything must be immediately changed to the exact structure, policies, and practices of wherever you came from.
  7. Compare the software applications in use with those great ones where you came from, implying that you’ll displace the existing ones at the first opportunity even though you know nothing about them.
  8. Consider group consensus to be equal at best to your own anecdotal experience.
  9. Convince the executives to increase IT funding as part of the job offer, then take personal credit for the resulting technology improvements even though they could have been achieved at any time had the money been freed up.
  10. Repeatedly remind low-level employees that, unlike them, you get a reserved parking spot, a sweet office, and bonuses.

E-mail me.

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Currently there are "16 comments" on this Article:

  1. The three Denver area organizations that recently went live with an “HIE” all use Epic. Their HIE software is Epic’s product, Care Everywhere.

  2. Three Denver area provider groups (Children’s Kaiser, and Exempla) go live on their HIE.

    I couldn’t tell, do they all have Epic as a foundation?

  3. “Also, the conclusion isn’t that IT isn’t worth it, only that they could not prove that it was from their approach.”

    Himmelstein et al. did write: “CONCLUSION: As currently implemented, hospital computing might modestly improve process measures of quality but does not reduce administrative or overall costs.”

    Note the “as implemented” phrase.

    A similar conclusion was reached in “Electronic Health Record Use and the Quality of Ambulatory Care in the United States. Arch Intern Med. 2007;167:1400-1405” by Linder et al. of Harvard and Stanford. I don’t know their spot on the political spectrum…but…

    The authors examined electronic health records use throughout the U.S. and the association of EHR use with 17 basic quality indicators. They concluded that “as implemented, EHRs were not associated with better quality ambulatory care.”

    To medical informaticists, the key phrase that explains these findings is “as implemented”, to which I would also add “as designed”, i.e., badly.

    — SS

  4. Mr. HISTalk – I didn’t know you had a crystal ball that gazes into my organization. OK, so not each one of the top 10 items were an exact match, but we’re batting better than .500!

  5. Silverstein has it right pointing out “as implemented”. I remember my first HIMSS’s awards event just a couple of shorts years ago when one of the CIOs receiving an award stated when addressing lessons learned: “I wish we would have thought more about process workflow before installing the system instead of mapping existing processes to the new software.” About fell out of my chair in disbelief. If a major mfg CIO had said something like that 10yrs ago they would have been shown the door.

    Is it any wonder that the healthcare industry sector can not demonstrate ROI/quality improvements?

  6. Mr. H said:”The Harvard people who published the study (warning: PDF) saying EMRs don’t improve quality or save money don’t exactly come across as impartial academics…” Really?
    What about the “educational” programs and publications sponsored and offered by the “not for profit” HIMSS and its well to do leadership who “educates” Congress to spend $ billions on devices that have now been shown to lack efficacy?

    Mr. Histalk, I detect a defensivesness in your prose.

  7. Saturday’s New York Times cover story talks about how Grady is insolvent, run by taxpayer dollars…and sad tale of not being able to provide life-saving care to patients as a result of these fiscal problems. Incidentally I read on your blog that they purchased EPIC and understand that system to be the most expensive EHR on the planet. As a taxpayer and US citizen, I must question whether this decision was prudent? Were there no other EHR’s that could do the job at a lower cost at Grady?

    We often talk about executive salaries when analyzing “wasteful spending”…..

  8. Re: EMRs don’t improve quality –

    Rather, the study showed you don’t *need* an EMR to meet quality guidelines. You can get very good compliance with guideline measures from manual checklists and processes that ensure the use of those checklists (e.g., a squad of nurses assigned to read through patient charts and follow up on compliance).

    The real question on the benefit of EHRs is whether it makes quality guideline compliance easier in terms of personnel and task time.

  9. I am not surprised by the comments about the Chicago unions. I have been at conferences in Chicago where they did behave as described. I am not, however, persuaded that other venues can do better.

    My advice: Bring along an extremely attractive young lady to speak to the electricians. When they slow down, have her ask sweetly if they could speed things up. I think that would help. (Yeah. I know its sexist. The young woman we had do this thought it was pretty funny, too.)

  10. EMR vs. IDN EMR or Integrated Care Team EMR – and what the gov’t and institutions should be demanding from their HCIT and HIE

    Obvious as this is, we should evaluate the efficacy and value of an EMR (most HCIT) by it’s use case in different care settings:

    > An EMR that is one of many disparate systems across distributed and complex networks (e.g. one that enables a single patient’s caregiver network) – the typical use case for most EMR implementations


    > An EMR in an integrated delivery network or an integrated care team – Kaiser, the VA, the national healthcare system of Sweden, etc.

    Halvorsen’s comments point to real gains being shown for KP’s multi-billion dollar Epic investment as the core tool of their IDN. (I’m a KP member – not Medicare just yet – but I agree with his assessment about time warps and primitive worlds of un-integrated healthcare settings). A comparable level ($Bs) invested in EMRs across dozens even hundreds of “un-integrated” institutions capable of caring for a population like KP’s (8MM people?) will not yield the same results. Not even close. You’d have a billion dollars in application integration professional services and I still wouldn’t know my medication history – and I don’t have any age-related dementia yet.

    But this level of investment is happening. $X00MM here, $Y00MM there – I read it every other day on this site and others. And for what: operational efficiency INSIDE of these orgs?

    Furthermore, government spending that perpetuates the HCIT status quo (investment in disparate systems across distributed networks with odd secret hand-shakes and misleading membership tattoos) will not make our healthcare system better or cheaper. Government should be looking to disrupt the status quo in this case.

    Institutions should be demanding EMRs, HCIT and HIE that is truly interoperable and clears the path to better care and better outcomes via better data: rational methods for publishing and consuming external data and information services; enabling mash-ups and mass collaboration; and, leveraging web services, SOA, SaaS, IaaS, PaaS, etc. If our patients, payers, providers and government aren’t integrated, at least our systems might be. They are or will be in the “government option” of most other nations that are making better technology investments in care and costs.

  11. As a former Kaiser employee, (Northern California, Epic Ambulatory) I had Kaiser coverage. While I had some serious problems with the massive amount of irresponsible spending I saw as an employee and the strange pick of terrible, terrible managers (alongside some really great ones) I must say that the health coverage I had as a Kaiser member was the best I have ever had. I now work for a different health organization and the benefits dont hold a candle to what I had at Kaiser in terms of affordability and coverage. Also Kaiser’s integration of Epic with their legacy systems was incredible. The information was always at my doctors fingertips. Kudos to Kaiser for a great Epic implementation!

  12. 11th Way:
    There is never a good reason to emerge from the secluded privacy and comfort of your office suite for useless mingling with the rank and file. Ever.

  13. !!!!They not only didn’t find any, but even the Most Wired hospitals showed no clear advantage. There are lots of limitations in their method (using Medicare cost data, using the limited quality measures in Dartmouth to extrapolate overall quality, and having incomplete data for some of the years). Do their conclusions hold water? Maybe in aggregate.!!!!!

    Himmelstein et al are to be commended and not depreciated for their research. The HIT kool aiders on this site will do all to attack the person and the work. The numbers do not lie.

    Those who have been forced to use the care disrupting equipment are not at all surprised.

    Efficacy proven NOT and safety NOT proven.

    Lawyers, are you getting it?

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Reader Comments

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