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February 9, 2011 Readers Write 5 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Comments on the PCAST Report
By HITworker

You don’t have to look very far to see evidence of just how much this PCAST report is a sophisticated marketing piece for Microsoft’s ailing Health Solutions Group.

The committee co-chair (note – not just a member, a full co-chair so presumably he had a lot of control over input and direction) is Craig Mundie. The Health Solutions Group was set up by Craig Mundie and the Peter Neupert, who leads the Health Solutions Group and reports to Craig.

Listed under expert input at appendix A are a list of 47 ‘experts’ who contributed to the report. Thirteen of those experts are from vendor companies, the rest coming predominantly from federal departments and health providers. Of the 13 experts, three of them are from Microsoft including:

  • Craig Feied – Microsoft Health Solutions Group’s chief strategy officer, who joined Microsoft after selling the Azyxxi product he built to Microsoft, which later became Amalga UIS (which just happens to be a clinical data aggregation technology – so favored in the PCAST report).
  • Sean Nolan – Microsoft Health Solutions Group’s chief architect, who admits to having no experience in health IT before he led the development team that designed Microsoft HealthVault (which is a personal health record, also so favored in PCAST).
  • Peter Cullen – Microsoft’s chief privacy officer, who has a significant role around advocating in relation to Microsoft’s approach to privacy in cloud computing,  (the third and final favored technology in PCAST).

Then of course, there’s Craig Mundie.

I got to looking into this after reading a blog posting on John Halamka’s blog (Life as a Healthcare CIO), where Sean Nolan of Microsoft illustrated how he believed Microsoft had all the answers for a Universal Exchange Language for health using their products Amalga and HealthVault. This was only a couple of weeks after the PCAST report was published in which he was a named ‘expert’.

So curious, I dove a little deeper into the other 10 ‘experts’ and found that seven of them work for three companies (Ingenix, athena, Sage, and Medicity) who all have partnership relationships with Microsoft.

Now I’m not opposed at all to vendors contributing to these kinds of reports – industry often has expertise and insight that is not readily available within government — but something didn’t seem right. These just aren’t the companies that would leap to mind at all when I think of the leading vendors in health IT with the most expertise and insights to contribute. Something’s amiss.

We’re being asked to believe a committee chaired by someone who runs Microsoft Health Solutions group, independently and without bias sought input from experts, and that three of the 11 experts from industry consulted just happened to work for the chair of the committee within Microsoft. And that these three had direct responsibility for products that just happened to address the three key technologies called out as enablers of the PCAST recommendations. Furthermore, seven of the other industry contributors work for companies that are Microsoft partners.

Something is most definitely wrong with this picture.

Bill Bria for ONC
By Ann Farrell

Note from Mr. H: industry long-timer and consultant Ann Farrell is mounting a campaign to have Bill Bria, MD (CMIO of Shriners Hospitals for Children) considered for David Blumenthal’s replacement at ONC. Her reasons: he’s an industry thought leader, he is regarded for his work with AMDIS, he is not self-promoting, and he recognizes the value of informatics in areas other than those involving physicians. Ann believes that his appointment would unit the industry and signal an HHS commitment to patient-centric, benefits-driven, interdisciplinary, and workflow-friendly technology strategies. Her letter is below.

2-9-2011 4-43-21 PM


I am a career-long champion of EMRs as end-user at first US commercial implementation, EHR vendor VP and now Principal of Strategic HIT consulting firm. The news of Dr. Blumenthal’s departure while not totally surprising is nonetheless of concern with now third hand off of leadership in high impact initiative that is advantaged by continuity.  Nevertheless, this is an opportunity to look carefully at the character, characteristics and capabilities of the new leader so we can align the next set of challenges to the appropriate candidate and perhaps overcome flaws with current approach.

We recognize value of the next leader having directly supported ONC in HITECH initiatives. We also appreciate value of someone who has successfully supported change management with “hands on” experience in implementing EHRs in several diverse organizations who’ve achieved goals of HITECH in real world settings. The person ideally would be universally respected by vendors, hospitals, colleagues and the market – without political baggage and not part of “old boy network”.

In this regard, we think Dr. Bill Bria would make an exceptional candidate. His knowledge, passion and track record well position him for success. Perhaps most importantly, Dr. Bria recognizes that healthcare does not equal “MDs“ alone but requires a care team who execute MD orders as well as plans of care that together drive efficiencies and outcomes.  All caregivers contribute to EHRs and patient care. Till this time, a clear MD-centric bias is reflected in Meaningful Use content, phasing of criteria and messaging.  Ironically, this approach has had unexpected negative consequence for MDs as well as the program.

Dr. Bria has played a critical role in the “visioning” and design of several lead EMR/EHRs since the early days and played key leadership roles at diverse prestigious healthcare organizations and AMDIS. Bill is a hero to those of us who worked with him.  Dr. Blumenthal’s departure provides a chance to “reboot” HITECH – Dr. Bria could bring a new more realistic and a-political, patient-centric, interdisciplinary approach needed to optimize this once on a lifetime opportunity for HIT.  


Ann Farrell
Principal, Farrell Associates
San Francisco , CA 94114

Five Things Hospitals Should Know About Backing Up Virtual Machines
By Charles Mallio

2-9-2011 6-18-11 PM

As more hospitals introduce virtualization to their data centers, they must incorporate virtual machines (VMs) into their backup and recovery strategies. How is backing up VMs in a hospital environment different? There are five things that hospitals should think about as they incorporate VMs into their overall DR program.

  1. Don’t assume agentless backup. One of the most common misconceptions about VMs is that you will be able to perform backups on any machine without an agent. VMware does help in this regard, but it is often the case that you will need a backup client – virtual or physical – especially when you consider how you are going to recover applications.
  2. VMware doesn’t reduce the importance of good DR planning. For example, virtualizing your server environment does not negate the need to fully optimize your backup routines. In every hospital, approximately 20% of data is dynamic (i.e. current, active content that is highly likely to be accessed and or changed), which should be given the highest priority in your DR cycle. Yet, around 80% of a hospital’s data is static (such as DICOM images from PACS, which will never change and are highly unlikely to be recalled again). Whether this static data is in a physical or VM is irrelevant – the fact is, if you don’t move it out of the primary backup stream, you will end up making unnecessary copies of copies, place a considerable, additional burden on your infrastructure and dramatically delay your backup processes.
  3. VM sprawl will require more thorough DR planning. As VMs multiply within the data center, each hospital must align each VM with their overall DR strategy and assign policies for restoring mission-critical applications and data so that business continuity criteria are met.
  4. VMware has produced some new features in vSphere, but these do not provide a DR silver bullet. vStorage APIs for Data Protection (VADP) offers great new facilities, such as changed Block Tracking, that may be applied in a VMware environment to enhance data protection and disaster recovery. These tools are ideal when protecting file and print servers, but you should always ensure they offer adequate facilities to RECOVER applications in your environment.
  5. Choose backup hardware that meets your business needs. Although migrating from physical to VMs will bring new economies to the data center, it does not mean that you are restricted to disk-based backup. VMs can just as easily be protected on more affordable, portable tape media. Hospitals should choose the backup media that best meet their budgets and business processes.

Charles Mallio is vice president of product strategy and business development at BridgeHead Software.


Capitalizing on PQRI’s Financial and Quality Improvement Learning Opportunities
By John Nelson

It is not often that the Centers for Medicare and Medicaid Services (CMS) offers an initiative or mandate that allows doctors to receive extra money, deliver better care, and attract and retain patients without inflicting enormous pain and extra work on a practice. However, after a false start, CMS’s Physician Quality Reporting Initiative (PQRI) has become such a program, enabling us to easily collect a bonus while positioning us to learn what we need to do to further enhance quality and prepare for an era where payments will be based on outcomes rather than visit or procedure volume.

This was not always the case. When the program began in 2007, the Heart Center of North Texas, a nine-doctor cardiology practice in Fort Worth, Texas, found that collecting and reporting PQRI quality measures was so burdensome and expensive that we did not want any part of the program. But we changed our minds in 2009 after CMS, acting on physician complaints and feedback, not only made it easier for doctors to participate in the program but also enabled them to report quality measures through registries.

Another reason we participated in PQRI is that the Texas Medical Association offered a coupon covering nearly the entire cost of the fee we had to pay CMS to register our participating physicians.

It took a clerk only a month to collect the information from our electronic health record and clinicians, which she then forwarded to our registry. Her effort had no impact on clinician workflow but had a huge impact on our bottom line: CMS paid us $87,000 for the 2009 reporting year.

Collecting data for 2010 turned out to be even easier than in 2009 in part because CMS changed the definition of consecutively seen patients. Now, the reporting physician did not have to see 30 patients consecutively which allowed them to go back and gather the data. This plus the fact that we stand to receive another substantial bonus led us to participate in PQRI again. We urge our colleagues follow our example, as they still have plenty of time to meet the March 15, 2011 deadline for the 2010 reporting period.

Another reason to file for 2010 PQRI incentives is that the bonus will be at its highest level. CMS will reduce the 2 percent bonus to 1 percent in 2011. From 2012 through 2014, the bonus will drop to 0.5 percent. In 2015, the carrot changes to a stick: reimbursement for non-participating physicians will drop by 1.5 percent and by 2 percent in 2016. Why pass up the bonus when it’s so easy to participate now?

Additionally, we believe PRQI enables us to identify areas where we are strong and where we can improve, giving us a head-start on accountable care, bundled payment, pay-for-performance and other care models that CMS and other insurers are rolling out. It is my job to ensure my group is clinically, financially and administratively efficient. The bonus, information and electronic reporting help me achieve these goals.

John Nelson is practice administrator of Heart Center of North Texas, a nine-physician cardiology practice in Fort Worth, Texas.

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Currently there are "5 comments" on this Article:

  1. Hmmm, While Dr. Bria might be an excellent candidate to replace Dr. Blumenthal at the ONC, whether he is interested in a GS-15 job is not exactly certain. I think the top of the pay scale for GS-15 is $155,000. He might already be doing a little better than that at Shriner’s. Still, if that makes sense to him it makes sense to me, as if that matters.

  2. The PCAST report was quite disappointing. It completely glosses over the difficult issue of clinical semantics of the data and the difficulty of harmonization of meaning, while focusing only on transport and formatting, which are simple (and solved) problems. Just making EHR’s XML-aware isn’t going to move interoperability of clinical data forward much.

  3. William Bra is a HIMSS member and has been a HIMSS presenter and contributor to HIMSS work groups, and has contributed to HIMSS bioks and other publications.

    Bria is a technocrat. Come on now, just put H. Stephen Lieber in the White House. LIEber seems to dictate everything for the HIT industry now, why not shoot for the top! David Roberts, HIMSS VP, can be Lieber’s HHS Sectetary, instead of running for Congress again.

  4. Agree with Ken, but PCAST was more than disappointing, it is an example of where neither political party (R or D) is immune from bias and infiltration. Anyone who doesn’t understand the level of Microsoft’s involvement with White House staff like Aneesh and Vivek is simply being naive.

    And if you haven’t figured out yet why Glen Tullman get’s to cherry pick any panelist or testifying role in congress or ONC hearing then you simply don’t know how Chicago politics work.

    This is wrong and a glaring example of runaway government.

    You can certainly make many friends by handing out cash. Many of those friends will likely be nice to you after your tenure of handing out cash in government comes to an end.

    We have to be aware and thoughtful about what is really going on. We’ve given ONC control, and with influence of the WH, they are overseeing a massive hand out program.

    Certainly many are executing their roles with good intentions, but to assume all our is again naive.

  5. Peter,
    Googling doesn’t count as “insight” – Bill lives his mantra “clinical informatics starts with clinical” – he’s the ANTI-TECHNOCRAT.

    ONC/HIMSS instantiated bias in MU criteria. CPOE for med orders FIRST before an eMar is great example of “rookie mistake”.

    What drove this decision?

    1) Workflow? = Does NOT SUPPORT MD WF

    MDs review meds GIVEN (not ordered) and patient response in critical decisions in high risk meds (e.g. heparin, insulin). eMar should be on line with other CDS data and accessible to MDs doing CPOE. Did ONC envision MDs chasing paper MAR? if remote, calling RNs? worse yet, shooting from the hip, hoping for the best?

    2) Patient safety? eMar reduces more errors than CPOE

    RNs and MDs err in similar numbers, 50% of MD errors caught by RX or RN – 98% of RN errors reach patient.

    3) Adoption? In EHR “lessons learned” since Batelle Study (1970s). EVERY credible analysis stresses RN role as largest HCP and EHR user group – pre-populating record with assessment data, helping stabilize the system, then cajoling MDs to come on board. RNs can’t overcome a bad EHR but ease the transition.

    Did ONC consider lessons learned? MD WF? Patient safety? Adoption drivers? Apparently not. Was it informatics exercise for academics or a “pecking order”? Clearly not a proven strategy.

    Final straw inspiring “Bill campaign”…

    4) Stage 2/3 preliminary criteria – worse case

    ONC calls eMar a”recording” – an “indication of COMPLETION OF MD ORDER”! We learned long ago MDs (98%) have NO IDEA what happens once they hit the send key – does ONC think orders deliver care that generates outcomes?

    Med admin process requires RN critical thinking prior to “recording” – just like safe med decisions require thinking (and data) prior to CPOE. Med admin as “MD order completion” is system, not process think. Patient centric, team approach fundamental for US healthcare reform (ACOs) is missing in ONC culture, thus in MU.

    Do leaders work in a vacuum, and all contributing members of HIMSS are evil by association? Agree, technocracy is endemic and why we’re where we are. HITECH is off the ground but needs a course correction. That’s only possible with leadership by a widely respected EHR veteran/change agent with 21st Century thinking. .

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