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Monday Morning Update 8/16/10

8-14-2010 8-31-00 PM

From Delgado: “Re: contracts. I thought you might want to check out a contract between an HIE and its EMR vendor participants. Some doozies: the price is fixed for all EMR vendors with no deviation and the vendor can’t charge for support for the first five years.” I was amused that this particular HIE requires that any communication to it be sent by both snail mail and fax. Maybe HIEs don’t really buy into the whole idea of electronic communication of important information.

From Nuther1BitesDaDust: “Re: MedeAnalytics. If Ralph Keiser is in as SVP, then Sandy Cugliotta must be out. When will they stop shooting the sales leader messengers? The stuff is losing in the market.” Unverified. Both still list the company as their current employer.

Listening: Sister 7, reader-recommended, female-led funk or rock or something (whatever it is, I like it). I can’t figure out if the Austin band is still active.

8-14-2010 5-05-21 PM

The magazines try to convince everybody that Most Wired matters. It doesn’t, according to the 82% of industry expert readers who said on my poll that it’s irrelevant to their choice of hospital (if HIT experts don’t care about a hospital’s HIT, who should?). New poll to your right, because I’ve run a similar one before and I know people get stirred up about it: what educational level should a hospital CIO have achieved? The poll accepts comments, so feel free to argue your position while expressing it.

I interviewed Debby Madeira, a nurse manager at Huntington Memorial Hospital (CA) about mobile devices on HIStalk Mobile. I don’t get the chance to interview front-line people all that often, so I would welcome more opportunities.

Verified: Ben Clark, SVP of client support for Allscripts, is leaving. He’ll be replaced by his Eclipsys counterpart, Cos Battinelli.

8-14-2010 8-33-45 PM

The Milwaukee paper does a nice piece on API Healthcare’s success following its acquisition by Francisco Partners and its appointment of J.P. Fingado as CEO.

Response to Ed Marx’s post on multitasking was overwhelming, with over 100 folks requesting a copy of his personal strategic plan. Inga and I e-mailed out a bunch of copies until Ed offered to let me make it available for anyone to download here (he felt sorry for us having to send individual copies). Note: browser quirks sometimes cause it to download as a .zip file (at least on my PC), so just rename it back to .docx so Word can open it.

Weird News Andy won’t refuse this story: paper medical records from four Massachusetts hospitals, including pathology reports, are found in a public dump. The hospitals said the former owner of a billing service used by their pathologists told them he dumped the records when he sold the company in June. I think he’ll probably regret that decision.

Shareholders of Eclipsys and Allscripts approve the acquisition of the former by the latter.

A reader sent over a copy of the McKinsey article that says hospitals will need to spend $80-100K per bed to meet HITECH requirements (with HITECH money offsetting only a small percentage of that), but will save $25-44K per bed per year as a result. Unfortunately, the article was light on detail, making any kind of critique impossible.

8-14-2010 8-08-58 PM

UK hospitals are using a not-for-profit social networking site for patients to post updates about the condition of patients. Patients can post messages or use instant messaging. NHS says the service doesn’t cost them anything to use, plus it saves nurses time since family members don’t have to call them for updates. Brilliant. I’d be selling ads, though.

Big contractor CSC says it will sue if NHS cancels NPfIT as it’s threatening to do.

E-mail me.

Epic Staffing Guide

A reader sent over a copy of the staffing guide that Epic provides to its customers. I thought it was interesting, first and foremost in that Epic is so specific in its implementation plan that it sends customers an 18-page document on how staff their part of the project.

Epic emphasizes that many hospitals can staff their projects internally, choosing people who know the organization. However, they emphasize choosing the best and brightest, not those with time to spare. Epic advocates the same approach it takes in its own hiring: don’t worry about relevant experience, choose people with the right traits, qualities, and skills, they say.

The guide suggests hiring recent college graduates for analyst roles. Ability is more important than experience, it says. That includes reviewing a candidate’s college GPA and standardized test scores.

I bet many readers were taught by their HR departments to do behavioral interviewing, i.e. “Tell me about a time when you …” Epic says that’s crap, suggesting instead that candidates be given scenarios and asked how they would respond. They also say that interviews are not predictive of work quality since some people just interview well.

Don’t just hire the agreeable candidate, the guide says, since it may take someone annoying to push a project along or to ask the hard but important questions that all the suck-ups will avoid.

Epic likes giving candidates tests, particularly those of the logic variety.

Given my dismal experience with clueless hospital HR departments (was that redundant?), I love this guide.

Editorial Critique

Chris Lehmann, editor in chief of the online-only Applied Clinical Informatics, asked me to discuss this editorial from the current issue. It’s called Electronic Health Records – Beyond Meaningful Use, written by Asif Ahmad, soon-to-be outgoing CIO at Duke University Health System (he’s leaving for US Oncology next month). Some of its points:

It conclusion, as I inferred it, is that instead of rushing to buy and implement new EHR products simply to qualify for HITECH payments, hospitals should use and improve what they have to meet their local needs.

My first reaction was that the editorial states the obvious. However, I’m reconsidering since cooler heads need to prevail during the EHR gold rush that’s consuming the energies and budgets of many hospitals, many or most of which are likely to be disappointed by the result.

Contrary to popular perception, HITECH does not require providers to buy new systems. They’ll get paid for results, not rebated for newly incurred IT capital expense. As long as their existing system is certified, the rest is based on how they use it. It’s not a vendor problem.

For some providers, their HITECH checks will be pure gravy. They’ll just use their existing systems better and earn a check without spending any new capital dollars.

For other providers, disappointment lurks. Just buying a new system doesn’t get you anything. Writing a big vendor check won’t automatically trigger even bigger government checks. HITECH money must be earned the hard way — by creating change.

I’ve been involved in a few hospital EHR selections and implementations. It takes quite a while to do them wrong and even longer to do them right. I would bet most of the Johnny-come-latelys won’t be ready by 2012 even if their vendors are. And I can only hope they don’t harm patients in their frenzied attempts to take the HITECH checkered flag.

Asif’s third point is easy to gloss over. Everybody talks about analytics, so it’s easy to miss his point: EHRs are massively complex living and breathing packages of processes that coalesce around business and clinical rules that are almost always poorly defined and documented. EHR customers cause many more EHR failures than EHR vendors. These aren’t set-it-and-forget-it systems that can be checked off as completed once the switch is thrown and the IT people are sent away to work on other stuff.

Asif doesn’t offer examples of analytics, but here are some I came up with. How has CPOE changed ordering and utilization patterns? How quickly can be be used to correct clinical problems, such as inappropriate drug utilization or lack of documentation needed for research or reimbursement? How quickly can CPOE and decision support changed clinical practice based on new findings, such as new dosing algorithms or promising adjustments in how diabetic patients are managed? How often do providers heed guidance offered in order entry and documentation? How have clinical system changes impacted length of stay, cost per DRG, and outcomes? What information is available to analyze outcomes by provider, by treatment, or by predisposing factors? What can be done to standardize practice by the use of order sets and predefined pathways? How can clinical systems support applied research, such as the effect of rotating antibiotics on a given service or the use of new medical devices in selected patient populations?

One of the most disgraceful aspects of US healthcare is also one of the least noticed: it takes decades before doctors actually use in practice the mountains of available (and expensive) research that could improve lives. Unless someone or something pushes them forcefully, doctors keep practicing like they did straight out of residency (that’s not opinion, that’s fact). The best way to get their attention is to pay them to do it a certain way. The second best way is to push them electronically by making it convenient for them to do the right thing.

Asif’s last point is also easy to gloss over as fluff, but it’s not. Let me paraphrase to make his point more clear: hospitals are lazy, incompetent, or both if they can’t think of anything better to do with their expensive new EHRs than punch an MU checklist and bank their stimulus check. I believe that’s Asif’s challenge to hospitals: do something with your EHR that benefits patients and not just your CFO.

Those with hospital experience know how big IT projects progress: (a) internal interest turns into impatience after the fun parts of the project, like site visits and system selection, are over; (b) once the hard work begins, the vendor and product chosen are almost always maligned as deceitful, undesirable, and unresponsive; (c) going live is such a drawn-out process that the project team is disbanded immediately afterward to catch up on deferred work; and (d) nobody goes back to measure before-and-after performance and push the organization to keep using, improving, and learning (often because that wasn’t budgeted upfront).

The five points he lists as the role of the EHR are nearly universally applicable. Even if they aren’t, every hospital should make their own list: what exactly do you hope to accomplish with this software other than to make people use it in some unspecified way? What are your success criteria and how will you measure them in a way that’s specific to patients? Is the organization capable of mandating change?

Practice makes perfect in almost everything, including EHR usage. Nobody get it right at go-live. Docs scream, nurses roll their eyes, and the IT people cast downward glances at their shoes even more often than usual. When the first batter doesn’t knock one out of the park, the crowd streams for the exits.

None of that makes any sense whatsoever. Quality improvement is, by definition, continuous. Usually it happens without anyone even noticing until some obscure quality geek armed with Excel e-mails out a graph that startles everyone: holy crap, we actually changed something for the better. The overriding question should always be: are we delivering better patient care today than we were yesterday?

Uncle Sam, Asif, and your vendor can tell you how to Meaningfully Use your EHR. They can’t tell you how to use it meaningfully. There’s a difference. Each hospital must choose its own goals and the methods by which it will achieve them. MU is the least common denominator, the gentleman’s C that causes no shame, but earns little respect. What hospitals do beyond being minimally compliant with the MU checklist is meaningful. That’s the part that will make all those taxpayer billions worth it.