HIStalk Advisory Panel: Best Ways for Vendors to Engage Hospital Leadership 7/18/12

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news development and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a provider organization (hospital, practice, etc.), you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This report involves these questions, submitted by a vendor CEO. What are the most effective ways you learn about products and companies? What advice would you give that CEO about using his salespeople and other resources effectively to explore areas of mutual interest with hospital IT decision-makers?

What are the most effective ways you learn about products and companies?

• HIStalk for one. HIMSS is another.
• HIMSS national and local chapter meetings. Peer suggestions. Company website review. Google searches. Healthcare system / physician leader blogs. If I am still interested in learning more, then, and only then will I contact the vendor.
• #1 HIStalk (kudos to you and your team – indispensable!) #2 HIMSS and other more specialized expos. #3 Occasionally through listservs and other blogs I follow.
• Internet research if I am looking for a particular service or product. Trade shows if I am interested in what’s new on the market.
• I read a lot. As problems arise or as I see something that piques my interest, I will contact a local partner to see how we get more info. White papers are a good thing and healthcare-specific press is good, too.
• HIStalk, of course! Really, nice capsule summaries from blogs are more effective than glossy brochures, webinars, or other such efforts to snag my time.
• CHIME’S CIO Fall Forum offers vendor access to many CIOs and other key resources through their program to engage through small groups forums. These sessions often are around how to market a new or different service or how to package a product. They are also good lead generation tools. Similarly, regional HIMSS and similar meetings, relationships with other vendors to offer a solution to a problem that crosses disciplines, can be effective. Sales cold calls either in person or by telemarketing are at best an irritation and at worst a total turn-off. E-mail is little better. I do look at sponsorship of HIStalk as a positive. The absolute best is a CIO acquaintance testimonial.
• This is tough. There is so much noise you have to figure out a way to rise above it. A box in the mail always attracts my attention – I know it’s shallow, but it works. I get 100 junk e-mails (that get through my filters) every day — e-mail doesn’t work any more.
• Honestly, I find out about companies through your blog. Not through the ads, but through the notice of implementation. I’m a buyer rather than a shopper, so I’m more likely to look at a product that has mentioned several times. Also, I don’t go looking for something until I need it – again, a buyer mentality rather than that of a shopper.
• From my staff. Vendors often want to get right to the CIO or the CEO, but mostly we block these cold calls. Get someone on my staff excited about something and they can get to me.
• Several recommendations. First, ensure you take time to learn about the provider organization… key clinical / business challenges as well as the current landscape of IT priorities. Nothing more annoying than a vendor who shows up and asks, “What are your challenges?” Second, ensure proposed / new product / service has a fit – innovative ideas that create real value for patients, offer a true opportunity to enhance operating margin. We’ve heard the other  pitches before and are overwhelmed with folks offering EMR skills, offering to “outsource” our data center or application teams. Nothing new there. We want to hear the new, innovative ideas, and don’t be shy about telling us where in the development cycle something is. If it’s new and we’d be the first to implement, just let us know upfront that you’re proposing more of a partnership. 
• I pay attention to CHIME and HIMSS updates. I read all updates from Advisory Board and Healthcare IT News. The problem comes when I need a specific solution and have nowhere to turn. I know it is out there somewhere, but where? It is kind of like the red car syndrome — when you buy a red car, you suddenly see them everywhere. When I need a solution, all of a sudden I pay attention to the direct mail campaigns that bombard me. Most of the time they are irritating and quickly discarded, but always at least looked at from a cursory perspective.
• Beside HIStalk? Word of mouth, other CMIOs.
• CHIME sessions, introductory 1:1 meetings, regional seminars.
• By researching on my own, speaking with peers, or working with my colleagues. Have to start with a business issue or need realized throughout the organization first.
• Whatever they do, don’t cold call me. Trade shows are not bad as long as there is an introductory e-mail or mail piece sent ahead of time. I also like the vendor speed dating events, as I can learn more in 15 minutes of focused time with a company than any other way (effectively).
• Often word of mouth from colleagues. Occasionally at a show like HIMSS. I do like HIStalk’s interviews and reviews on HIStalk Mobile because they seem to be more candor than fluff.
• Websites such as HIStalk, Information Management Direct, Data Governance Institute, etc. White papers, with real case scenarios not fluff, distributed via websites.
• I learn from reading blogs like HIStalk and in talking to friends at other practices (most of those opinions are very negative).
• Throwaway magazines. Word of mouth from other CMIOs. News articles. Meetings (e.g., AMDIS). This is obviously not a great system, but it’s true.
• Trade shows and conferences. The exhibit floor is a great resource, as are the networking events. 
• Reading stories about their success. Conferences.

What advice would you give that CEO about using his salespeople and other resources effectively to explore areas of mutual interest with hospital IT decision-makers?

• We have a local HIMSS meeting once a month that is always looking for a sponsor. A local EMR user group is always looking for a sponsor also. Another way is to figure out a way to get to the IT staff and have them sell it to the boss. Instead of trying to get on that CIO calendar or get through that CMIO door, network until you find the lead tech or application person and sell them first. The "C" folks have people beating down their doors and free lunches galore. A little attention to the folks in the trenches can go a long ways.
• I have to go back to HIMSS and other ways of getting in the door without taking time out of their busy schedule. It is not easy and it is getting harder, so you have to be open to thinking outside the box. A "lunch for the IT staff" like the clinicians get every day. How about free education combined with selling?
• Get to the point. What exactly does your system do and how does it avoid my pain? And Dear Lord, skip the buzzwords of industry-leading, complete platform solution, etc. I can’t tell you how many product descriptions I’ve read in entirety and still had no
  idea what they did. Videos take too much time – don’t bother. The message has to be something that can be delivered in a quickie pitch, single e-mail, single web page, etc. Provide more info if desired, but any extra required steps puts off that many more execs. Possibly ask for a simple e-mail address but not much more.
• First, understand our business and local relationships. Second, DO NOT cold call or e-mail requesting to introduce yourself. I rarely read or listen to the entire message and immediately delete. I do not have time to participate in “fishing expeditions.” Third, get involved with local tertiary organizations (sponsorships) and events. You first have to establish a relationship, then understand us before we will then seek to understand you or your company.
• Fairly simple: ask what problems they want to solve. Don’t offer a solution and try to find a problem it can solve. Be prepared to not see an immediate ROI or anything and at the same time be ready to experiment with a few new areas where you might not see the payoff.
• As someone in the same shoes as this CEO (i.e., a vendor), we’ve been lucky in that we can typically get in the door for a brief conversation based on our benefits of revenue enhancement and similar “hot button” issues that are top of mind for them. That said, given they are incredibly busy and operate at broader stroke level, once you’re in, your team will need to deliver your message very clearly and succinctly in a way that they can grasp the concept and benefits quickly and basically make the decision your solution is worth pursuing or at least exploring further to get it to the next step or person who’ll dive deeper. We’ve been very successful with this model.  a. Internet research if I am looking for a particular service or product. Trade shows if I am interested in what’s new on the market.
• I could write a book on this topic. It’s more about what not to do. Here are a few suggestions. (a) Respect the CIO’s time. Whether its voicemail or e-mail, get to the point quickly and tell me how you are going to solve my problems and intrigue me enough to contact you. Of course to do that you need to know something about my organization, so do your homework on me and my organization before contacting. If you can find out what keeps me up at night and provide a solution, I’m all in. We constantly live in fear of something. Find out what that is or convince me I should be afraid. (b) Find someone who knows me. You’ll have a better chance if a trusted colleague introduces you. (c) Do not sell to users or go over the CIO’s head. Most CIOs have big egos, so this is a non-starter and will only tick them off. (d) Try starting lower down in the IS organization. Most CIOs will listen if a subordinate leader feels that CIO should meet a particular vendor. (e) Offer a free trial or some sort of risk-sharing proposal. If I know you are offering to put skin in the game, I am more likely to listen.
• I know I don’t meet with new vendors often. I don’t listen to cold call voice mails and don’t really read spam e-mail. It has to be through a mutual contact or something I am looking for if I am going to talk to a new vendor. The best way in is through partners or resellers. All IT departments have them and they work closely with the management team. That is the best inroad to the department. Local HIMSS groups or industry groups like that would be a great way in also.
• The cold call approach will not work. The cold e-mail approach won’t either. Finding a method that can present a forum for general questions, before any specifics are identified for commonalities, is most productive, and lets me weed out those with whom I can find no area(s) worth pursuing.
• No hard sell. Solve a problem for me and be respectful of my time and the organization’s limited resources.
• From a vendor perspective, direct access to the C-suite is difficult. In many cases when you do get access, you have a very small window of time to make an impression. If that C-level doesn’t have what you are pitching on her radar at that particular moment, your chances of progress are greatly diminished. What I have always tried to do, and coach our sales people to do, is become part of the community in which we sell. Participate (not just join) in organizations that support the local medical delivery area. Attend meetings and offer to speak about subjects (not a sales pitch) that interest the participants. Help make connections with other executives. Get to know the executives and let them get to know you as a person who is helpful and a thought leader. Once something appears on their radar that you can help with, the chances are pretty good they will remember you and reach out. It sounds like a really slow way to build a pipeline, but that is not the point. Opportunities happen every day, and if you are connected, you will find them by being a known quantity. Executives in any market leverage their network of contacts and associates to get things done when they need it. Healthcare is no different. The best sales people I know are those that build the best relationships. Nobody really sells ice to Eskimos.
• We almost all participate in some kind of association. HIMSS is obviously the big one, but there are local organizations that offer more meaningful networking opportunities. This is where the vendor needs to hire experienced people. They already have the relationships established.
• Offer white papers and case studies. Please don’t call me or send me e-mail because I will just delete it. Don’t call, because I won’t call you back. Partnering with a customer to present a Webex of a business problem that they solved together is appealing.
• Google. So much about our organization is in the public domain. Look at a map—see what hospitals are close to us and then investigate what they are doing. Chance are good that we know and care about our competitors.
• Set up a focused briefing with multiple decision-makers in the room. Nothing is going to happen without CIO insight, consent, alignment. We have found, however that briefing sessions, if well-coordinated and with the right IT and clinical resources in the room, are a good use of time. Education for the provider team plus exposure to the right audience for the vendor. In a large provider organization, what’s not effective is having lots of one-off conversations with local hospital folks. Understand the provider’s governance and decision-making process.
• Make the investment to attend conferences. At these small conferences (IHT2 ,for example, in Fort Lauderdale a few weeks ago) I spoke to every vendor there. It was a good event.
• I would see it as an iterative process. You get one customer, give them a good deal, use their story (and people) to get the next, larger, bigger name customer, and repeat. Write articles for blogs, "throwaway" journals, newsletters. If your niche is small, a well-titled article in a throwaway will catch my eye. I can delete about 100 unsolicited e-mails a minute and my secretary doesn’t take cold calls. It would be sneaky, but you could get your first CMIO (your first customer) to go to the appropriate meetings and shill.
• The least-effective way is the cold call—can’t delete those fast enough. HIMSS has lost its charm for me, so a booth in the nether regions of the exhibit hall is not a good use of limited funds IMHO. A short, well-written e-mail that clearly identifies the problem the vendor is seeking to solve with a link to a web site/demo video is often an effective first encounter. An article in one of the trades can be a good route too. Obviously, the best answer is to network and know the potential customer’s situation and needs. AKA, targeted marketing.
• Work with someone in the industry such as an ex-CIO who can open doors for 1:1 intro meetings or small group events in local markets with a select group of CIOs to discuss the product offering in an intimate, non-high pressure environment.
• It is not easy for salespeople to reach me – that is by design. I get more cold calls than I can care to listen to and delete voicemails as soon as I realize it’s an unsolicited call. As much as it can be irritating to me and the rest of the IS department, it’s best for vendors to connect with the business units that may benefit from their offering. I look at the IT role as one of guidance and support. We can run a project, crunch numbers, negotiate contracts, evaluate technology, etc. We aren’t the ones to evaluate the true business need, but we can lead our internal customers through the process of evaluation.
• There needs to be a compelling reason for me to become educated on the product and to see if it fits a need that we have. Sales is tough. Getting in front of a CIO is tougher. And going around IT to get the message out if it is a tech play is the kiss of death. Companies have to be patient, too. Just because you have the greatest thing since single malt scotch does not mean we are ready to consider it.
• Every CMIO and CIO these days is totally deluged with requests from all kinds of vendors, large and small. It’s overwhelming, and almost impossible to determine who is selling a useful product. To be honest, I rarely make time for salespeople any more. I’m more likely to talk to a company CMO or clinical resource if they reach out to me.
• We are busy and don’t have time for drop-in or sales calls. Sending information i.e. white papers is an easy way to generate interest. Have one or two current users present when you attend or present product at local / state / national meetings- they can give real life examples of why the product is good.
• Cold calls are never good – best to leverage if some kind of relationship to the company already exists or leverage a conference where leaders are there to be looking at other vendors and technologies. Larger health systems are increasingly placing emphasis on ‘vendor management’ departments within IT and working through this groups can be useful since they are usually involved in determining partner vendors and vendor selection processes.
• Acknowledge to me that you understand that I’m busy and that I may already have the equivalent of what you are selling (at least I think so). Offer to look at what I already have to see if there’s ways that you can help me. If no, say so, retreat and fight another day. Don’t ask the CMIO about things that are the CIO’s realm and vice versa – nothing I hate more than when a vendor has talked to my CIO about systems that impact clinicians without talking to me first or talking with us together. If you’re talking to a CMIO or CIO in a hospital system, don’t go directly to the docs or to individual hospitals – that’s a real no-no.
• My number one rule is that all messaging from sales to CXO level needs to be focused on the business issues of the CXO and their organization in their market. Not focused on me, the vendor, my cool product, my cool customer base, my cool technology. Cut out all the buzz talk, marketing speak, tech speak, and really study the provider and their town. Who are their competitors? What is their market share? What are their financials like? What do their physician customers and patient customers think of them?They need to open their conversations with a provocative message that shows they have done their homework and know the business. Let that conversation flow until the customer says, “Hey, can you help me with that issue?” Salespeople need to be customer experts, not product experts.
• This is an interesting question in that the answer has changed drastically in the last five years. It used to be easier to engage with management, no matter how busy, because it could be done after hours – dinner, a sporting event, drinks. Now, however, more and more facilities have purchasing guidelines in place that prevent employees from taking anything from vendors, including meals. This means that all meetings have to take place during already jam-packed days, resulting in fewer opportunities to build relationships. It has become more of a 15-minute elevator speech opportunity rather than a relationship-building opportunity. Because of that, an effective plan seems to be: e-mail contact, phone contact, correspondence through e-mail with questions and answers, in-person meeting, follow-up information through e-mail and calls. Much less personal, but still effective.
• His salespeople better know his clients really well.

SAIC To Acquire maxIT Healthcare for $473 Million

SAIC has announced that it will acquire maxIT Healthcare in a $473 million all-cash transaction. SAIC says it will combine maxIT, which is the largest private, independent healthcare IT consulting company in the US, with its previous healthcare IT acquisition Vitalize Consulting Solutions to create the country’s largest EHR consulting practice.

SAIC had previously announced its interest in expanding its EHR implementation and integration services to offset declining federal government revenue.

maxIT Healthcare’s 1,300 employees will join SAIC’s Health Solutions Business Unit. The acquisition is expected to close in August.

News 7/18/12

Top News

Shareholder materials from Quality Systems, Inc. (NextGen) indicate that “dissident shareholder and current Board member” Ahmed Hussein has launched his fourth attempt to gain control of the company by nominating his own slate of director candidates. In announcing his action, he said, “I am confident in the potential of Quality Systems, but a hand-picked board is allowing the non-executive chairman to be declared an independent director and act in an inappropriate executive capacity.” Most interesting is that one of his director candidates is Pat Cline, the former Quality Systems president and chief strategy officer who retired in 2011.

Reader Comments

From HIT Guy: “Re: shifting capacity in the Madison market. I know there is some behind-the-scenes software that looks for doctors making referrals out.” Insurance company Physicians Plus says it will save $30 million per year in moving services from UW Hospital to Meriter.

From Stephen Yoder: “Re: prescription drug abuse. Do you think efforts like this will help?” Any solution that involves restricting the supply and not the demand is doomed to fail – all that does is raise prices and thus profits for those selling drugs. Much of the country has been blasted out of its mind since the 1970s when Valium and Librium became the mother’s little helper of choice. Drug companies have convinced patients and doctors that everything from difficulty sleeping to minor pain requires immediate pharmacologic intervention, and you don’t hear patients complaining about popping pills. Even if you completely shut off the flow of illegal drugs, you’d still have millions of people altering their consciousness with legal ones. I don’t know the answer since routine drug use no longer carries much of a stigma when everybody’s grandma is doing it.

From Doc Martin:“Re: Martin Memorial in Florida. I’ve heard their Epic installation is not going well. Supposed to cost $80 million and now north of $100 million and still climbing. The stuff is not working well and their A/R and billings are a mess.” That’s not the case, VP/CIO Ed Collins says. They hit a few snags early, but are now meeting their budgeted revenue and A/R targets. The $80 million number was spread out over 10 years and they are pretty sure they’ll meet or beat that number. Martin successfully attested for MU Stage 1 for Medicaid and Medicare last week.

From HITEsq: “Re: McKesson lawsuit. A small Texas practice is suing McKesson for a failed EMR install. It’s not clear what happened, but there are complaints about failing to transfer patient histories, a weird HIPAA violation, and the price of hardware. They’re seeking less than $100K in damages.” It’s something about copying records from one practice to another when the former office neighbors went their separate ways, but only for patients that were moving to the new practice. The new practice’s doctor says McKesson couldn’t copy just the specific records, so they copied everything. We haven’t heard McKesson’s side of the story, but it sounds like the doc should have done more due diligence, as evidenced by complaining the lawsuit that the contract required the practice to buy the “severely overpriced” hardware from McKesson. I would hope the parties will settle instead of making their lawyers rich.

From A CEO: “Re: ambulatory healthcare IT market. Lots of rip and replace. Significant teasers from investment bankers on EHR deals. Practices that sold their souls to hospitals are getting a peek at reality.”

HIStalk Announcements and Requests

Today’s post may be a bit less comprehensive and more likely than usual to contain grammar or spelling errors. I missed work today (which almost never happens) with a temperature of 101.5 and I’m feeling less than stellar, but I’ll do what I can despite fuzzy cognition and sweat dripping onto my keyboard.

Here’s a brief Listening, involving the singer-songwriter genre, which I usually detest because I don’t like warbled twee love songs. My one and only exception: John Dawson Read, who had a modest hit or two in the 1970s and then disappeared from the music industry. I first heard this song, which he wrote about his friend Tommy Davidson (not the guy from In Living Color) going blind from muscular dystrophy, many years ago on late-night radio when it was already old, and I never forgot it despite only one listen. I just happened to run across it on YouTube this week. Pure genius. He’s even making new music after a three-decade break.

Welcome to Wellcentive, joining HIStalk as a Gold Sponsor. The Roswell, GA-based company offers solutions for population management, care management, Patient-Centered Medical Home, and accountable care. Consider its Advance Outcomes Manager, an open, cloud-based data aggregation platform that provides analytics, risk modeling, and a clinical rules engine for management population health and quality (here’s a case study from Lakeshore Health Network). Clinical decision support capabilities include care gap alerts, medication reconciliation, patient report cards, and secure messaging. It’s pretty cool that the company announced its sponsorship, although making me blush by calling HIStalk a “thought leader” (although maybe it’s my pyrexia that’s causing the blushing.) Thanks to Wellcentive for supporting HIStalk.

My predictable YouTube foray turned up this recent video on Wellcentive’s Advance Outcomes Manager, which explains it in two minutes.

Acquisitions, Funding, Business, and Stock

Zebra Technologies acquires LaserBand LLC, a maker of patient ID wristbands.

Internet-based transcription provider iMedX completes the acquisition of the medical transcription assets of Electronic Medical Transcription Services (eMTS).

Sales

Epic Medical Center (OK) selects RazonInsights’ ONE solution for inpatient clinicals, financials, and ambulatory practice management.

Hacienda HealthCare (AZ) purchases Healthland Centriq EHR for its 15-bed hospital and long-term care facility.

Pacific Health Corporation (CA), Physicians for Healthy Hospitals (CA), and Optim Healthcare (GA) select McKesson’s Paragon HIS.

People

The SSI Group announces the retirement of Bobby Smith, its founder, CEO, and president. VP/CFO James M. Lyons will replace him.

Former Vitera SVP Lee Horner joins Eliza Corporation as SVP of sales for the company’s health engagement management segment.

EnovateIT appoints Mike Wilson (Compuware) as its chief strategy officer.

Huron Consulting Group promotes Hazel Seabrook to lead the company’s clinical operations solution within Huron’s healthcare practice.

Maxim Healthcare Services appoints Andrew Friedell (Medco Health Solutions) as VP of government affairs.

Announcements and Implementations

The Hawaii Island Beacon Community announces the expansion of its Alere Wellogic HIE following a successful pilot at North Hawaii Community Hospital.

Hunterdon HealthCare Partners establishes an ACO with Aetna using Medicity’s HIE technology.

ADP AdvancedMD deploys its 2012 Summer release, which includes an iPad app, new ICD-10 tools, and workflow improvements for pediatrics.

ICA announces the launch of Kansas Health Information Network’s direct messaging capabilities.

NCHICA and Oak Grove Technologies create a mobile app of the HITECH Act Breach Notification Risk Assessement Tool. Its $1.99 on iTunes.

Amcom Software releases Version 5.0 of its critical test results solution, which it recently acquired from IMCO Technologies. It has earned FDA’s 510(k) clearance as a Class II medical device.

Botsford Hospital (MI) joins the Michigan Health Connect HIE.

Orlando Health’s neurologists use Polycom’s RealPresence to assess and treat stroke patients from their tablets. The health system will expand its use of the technology to trauma collaboration.

Aprima announces an app to provide mobile EHR access on iPhone or Android devices.

Other

The CDC finds that 55% of US doctors use some type of EHR, with 85% of them reporting being either somewhat or very satisfied with its day-to-day operations.

Weird News Andy says this is what happens when the government runs healthcare. In the UK, NHS addresses budget cuts by suggesting that all provider contracts be redrafted, to include pay cuts, elimination of overtime and holiday pay, and reduced vacation. If they don’t like it, they’ll be let go.

Two UK hospitals say that problems with their Cerner Millennium implementation caused appointments to be cancelled or were mailed to patients with incorrect dates, requiring the spending of $7 million to fix the problems. However, an independent review says the hospitals themselves were the problem – they didn’t have enough skilled employees, training was inadequate, they let IT run the project instead of operational leadership, and the trust ignored outside advice and declined to follow its own governance processes.

Sponsor Updates

• Allscripts VP of Strategic Initiatives Rich Elmore provides details of his one-year leave of absence serving as ONC coordinator for Query Health.
• MedHOK achieves 2012 Disease Management performance measures certification for its 360Care software.
• University of Louisville Hospital is using Access Intelligent Forms Suite to import electronic documents into Siemens Soarian without manual indexing.
• Beacon Partners offers a hospital roundtable discussion white paper on ICD-10.
• Surgical Information Systems releases the results of its survey showing that surgeons view technology as a tool to reduce errors and improve quality of care.
• eClinicalWorks, Allscripts, GE, NextGen, and Greenway are named among the top nine EHR vendors the Office of Inspector General in a report on the progress of EHR implementations.
• Alfa Insurance selects Kony Solutions to launch its Alfa2Go mobile app.
• Streamline Health Solutions and nTelagent enter into a joint marketing agreement to support revenue cycle improvements and patient access.
• INHS announces that 16 of its clients have been named “Most Wired” hospitals for 2012.
• Cloud-MD contracts with DrFirst to integrate DrFirst’s e-prescribing capabilities into Cloud-MD’s PM/EHR.
• Iatric Systems highlights how its PtAccess solution enabled Griffin Hospital (CT) to successfully meet Meaningful User criteria.
• Digital Prospectors Corp receives three awards in the Top 2012 Businesses of New Hampshire.
• Macadamian’s Director of Research Lorraine Chapman presents best practices at the 9th Annual Healthcare Unbound Conference in San Francisco this week.
• Culbert Healthcare Solutions promotes Tom Gantzer and Jason Drusak to managers of Epic Consulting Services.
• An AT&T-sponsored physician practice technology survey finds that 37% of practices have fully implemented an EHR. Expense continues to be the top reason practices say they’ve not done so.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 7/16/12

Last month, I threw out a challenge for vendors to brag about their use of physicians and other clinical experts in design, implementation, and support. I’m a bit surprised that certain vendors were so quiet. I know of at least a handful that have large physician teams in addition to significant numbers of other clinical professionals, but I didn’t hear a peep out of them.

I offered priority placement to companies with witty submissions and was not disappointed. The grand prize goes to this one. While I must keep them anonymous, their piece left me grinning like a Cheshire cat. I’ll let them speak up and claim it if they decide to get approval from The Powers to make a public statement:

As the IS department of a multi-specialty group practice, we are bucking the trend of buying vendor software and living with the consequences. Instead, we develop the majority of our clinical software in-house, which provides tremendous advantage and incentive. We eat our breakfast 300 yards from 4,000 medical staff who are trained to kill us, so don’t think for one second we can code with apathy, charge for upgrades, and not be nervous.

When you develop software for an aggregate group of faceless customers, you come to work with a different perspective than when you develop software for the physicians that will sign off on IS raises. The age-old question posed by efficiency expert Bob Slydell, “What would you say you do around here?” to engage physicians in software design is tackled next.

Last year, IS made the organizational transformation from Waterfall to Agile development. To better facilitate and support active provider involvement, we implemented new technologies and architectural platforms, remodeled our workspace, and completely changed the way we work with operations (including providers and support staff.) We created transparency in everything we do and greatly enhanced our channels of communication, transforming from a culture of “Us vs. Them” (operations vs. IS) to a culture of “We” collaboration and teamwork. (we habitually hold hands and break into stirring renditions of Kumbaya!)

Our providers now work closely with us throughout all stages of development, often meeting one or more times per week and are also readily available via e-mail – both our product owners (the providers ultimately responsible for driving the solution) as well as other members of the workgroups created to support the product owners. These cross-functional workgroups are composed of other providers along with members of various operational departments, including care coordinators, administrators, patient financial services, HIM, support staff, ancillary departments, and more. (we even include fictional characters to keep the meetings lively.)

As we develop working prototypes, we regularly engage willing providers, residents, and support staff in focus groups and usability testing in our state of the art usability lab (the unwilling are goaded by inviting them to the same lab under false pretense of providing pizza and light snacks.) In addition, our user experience design research team comes in to give a green light to the product or send it back for more iterations. (reminds me a lot of French class, Fait Encore!)

Requirements workshops, interviews, surveys, and design workshops are yet other methods we utilize to give our providers a voice in our projects. They, in turn, provide a plethora of much appreciated input.

Happily serving our providers so we can still afford to eat,

The IS Department

It’s hard to top that, so I’m going to leave this team standing on the first-place podium. More to come in next week’s Curbside Consult.

E-mail Dr. Jayne.

Monday Morning Update 7/16/12

From The PACS Designer: “Re: Bromium Microvisor. An interesting concept is forming at Bromium in the development of a micro-web browser within your main web browser. The Bromium Microvisor encapsulates e-mails, PDFs, and other documents within a micro-visor so that malware can’t infect your operating system. When you delete an e-mail or other document, the malware is deleted as well, and your operating system is protected. This concept may be a solution to consider for healthcare institutions who have to daily deal with numerous mobile devices.” Bromium is a lightweight and transparent hardware-based utility that limits what a launched malware application can do, isolating it so it can’t infect anything outside of its own assigned micro-virtual machine even if the malware penetrates company e-mail or secured sites. A standard laptop can run hundreds of simultaneous micro-VMs, each of which run in their own little world without running a separate instance of the operating system. It would be great for bring-your-own-device security, but only if your own mobile device runs Windows on an Intel processor (not likely) since that’s all Bromium supports at the moment.

From The Borg: “Re: resistance is futile, you will be assimilated – signed, Epic. This may have always been out there, but in the 2012 release, they have renamed ‘Now Showing’ as Epic Earth.”

From DBD: “Re: video. See Death by Deletion.” I think I’ve mentioned this before since it’s an old story. Whistleblower and risk manager Patricia Moleski claims her former employer, Adventist Health System, manipulated electronic patient information for various reasons to protect itself against liability. She also claims that a bug in AHS’s Cerner system caused patient injury and death. She says she was then fired, legally bullied, and intimidated by gunshots to her house and the burning of her car. That’s her side of the story, which I would be cautious about taking at face value without hearing the other side. She’s not mentioned on the Web very much, other than by sites catering to workers’ rights and those who claim the Adventist faith is a cult, so I don’t know what happened with her claimed involvement as an informant with the FBI, which she says was investigating her charges. This incident is a couple of years old, so you would think it would have been resolved one way or another by now.

Listening: new from Marina and the Diamonds, which is really just quirky Welsh-born singer-songwriter Marina Diamandis and her backing band. She’s intentionally playing the character of a witty, cynical, and insightful pop star with an American celebrity attitude, fronting music that ranges from faux bubblegum to 80s New Wave. Good for fans of Florence + The Machine, although the less-concepty first album (The Family Jewels) is probably a better starting point.

Go after insurance companies if you want to control healthcare costs, said respondents to my most recent poll (though they are also suspicious of malpractice attorneys). New poll to your right: will telehealth improve healthcare quality and/or reduce costs? Before complaining that I should have included 20 other answer choices (as a few folks always do when faced with the polarizing characteristics of questions with a Boolean answer choice), note that you are not only permitted but actually encouraged to add a comment after you have been forced under duress to choose one answer or the other. That’s where you may opine more extensively than your allotted one click allows.

Thanks to new HIStalk Platinum Sponsor CommVault, whose Simpana solution allows its health system clients to protect, manage, and access their organizational information. Hospitals use Simpana’s single console to manage all of their enterprise information: application data, messaging, files, and databases, from laptops to the cloud. Simpana bundles backup, archiving, and reporting into a single platform. The company is partnering with EMR and PACS vendors to simplify healthcare data management, ensuring security and compliance, managing data growth, cutting storage costs by up to 50%, and supporting the establishment of a common set of data and information management policies. Data growth has messed up the backup and restore capabilities of many organizations, motivating 16,000 users to save time and money by leaving NetBackup, Networker, and TSM behind and moving to Simpana (CommVault has conversion tools). If you run legacy backup software, CommVault suggests that you ask these five questions before renewing your maintenance agreement. Thanks to CommVault for supporting HIStalk.

 
I headed over to YouTube to look for a CommVault Simpana overview, so here’s a webcast that explains it. I also found this Gartner video that includes an interview with CommVault customer Sharp HealthCare, as VP Teri Moraga talks about the health system’s storage needs and solutions at around the 6:30 mark (and why they switched to Simpana at around 9:15).

Dr. Jayne has previously pontificated on both the zombie apocalypse and smartphone addiction, so I thought of her when I saw this.

The Florida National Guard hosts representatives from five Caribbean islands to discuss the military’s use of electronic medical records.

Penn State Hershey Medical Center names Rod Dykehouse (ProHealth, UCLA – left) as CIO. Former CIO Tom Abendroth MD (right) will become the hospital’s first chief of medical informatics, leading efforts to use its EMR to improve care and research.

Former Mediware COO John Damgaard is named president of nursing home software vendor MDI Achieve.

Huntington Memorial Hospital (CA) chooses Infor’s Lawson solutions for financial management, supply chain, and analytics.

Representatives of a local hospital district in Minnesota are “reeling” after the breakdown of talks with executives of Essentia Health, which leases the 25-bed critical access hospital. Hospital board members complained that Essentia isn’t investing in Essentia Health – Sandstone and gave notice that the board was cancelling Essentia’s lease that expires in August. Essentia then fired the top two hospital executives and said it would exercise its option to buy the hospital outright. The two main issues are hospital oversight and the EMR system used by the hospital, which they want to keep instead of replacing it with Essentia’s system (which I believe is Epic.)

The San Francisco business paper mentions that Washington Hospital Healthcare System (CA) is halfway through its $86 million Epic implementation.

The Joint Commission revises its standards pertaining to the use of scribes in hospitals, adding Physician Assistant as a professional for which scribes may perform EMR documentation under their supervision (along with physicians and advanced practice nurses.) TJC also specifically said that scribes should not enter orders directly into CPOE systems.

A BMJ article says the British government is premature in advocating the widespread use of telehealth as a way to cut cost and improve care, claiming that preliminary findings are inconclusive. One of the authors says her own hospital trust has looked at everything that might reduce hospital admissions and none of the potential solutions, including telehealth, has reduced the rate of increase. A previous study by the same trust concluded that increased efficiencies in discharging patients may have simply opened up more beds for doctors to fill, allowing them to admit more patients. I noted, however, that despite the imposing BMJ (the former British Medical Journal) on the article and a list of academic-looking citations, this particular article is a feature written by a freelance journalist. The same issue has several articles on telemedicine, though.

I’ve reported this previously: FDA launched electronic surveillance of its own scientists, intercepting the e-mails of those on its “enemies list” who criticized the agency. The FDA’s document imaging subcontractor botched the project by inadvertently posting the intercepted documents to the Internet, allowing anyone (including The New York Times) to read e-mails that had been sent to members of Congress and even the President. The scientists found out and are suing. Senator Chuck Grassley, upset that e-mails of one of his employees turned up in the surveillance database, called FDA “the Gestapo.” FDA used parental monitoring software sold commercially for $99.95 to spy on its scientists, who they suspected of leaking confidential vendor information about medical imaging equipment which they believe exposes patients to excessive radiation.

A Mississippi oncologist, her office manager, and her billing clerk plead guilty to overbilling Medicare and Medicaid by $15 million for cancer drugs. Prosecutors say the cancer clinic administered drugs while the doctor was overseas and also reused needles and diluted chemo drugs. The clinic was shut down and $6 million was seized from the doctor, but she has been held without bond because she has plenty of money left and is considered a flight risk to head back to her native India.

An editorial in The Australian says the government’s Model Healthcare Community Roadshow is guilty of misleading advertising in pitching that country’s $1 billion personally controlled e-health record (PCEHR). The critique says PCEHR may contain a few physician-uploaded medical summaries, but there’s no way for hospitals, EDs, specialists, or pharmacies to add information, and any updating that occurs is not real time. The road show truck shows diagnostic images even though PCEHR can’t accept images yet. The article concludes that as a voluntary system, doctors have already said they won’t rely on its information for making treatment decisions.

A Weird News Andy find: a California urgent care doctor suspected of writing prescriptions for cash examines an undercover officer, studying the x-ray the patient brought in and helpfully pointing out the bones causing the pain for which the doctor recommended “Roxicodone? Or oxycodone? Or whatever you want.” His diagnostic acumen might be questionable, however, given that he missed the fact that the patient had a tail, according to the x-ray (which was actually of a German shepherd and was clearly labeled as coming from an animal hospital). The doctor, who was previously convicted of taking kickbacks for Medicare home health referrals, was arrested for improper prescribing.

Vince ties up loose ends on HMS, including taking an interesting peek into what systems the under-100 bed hospitals use and what they cost. For the next HIS-tory, Vince will start a series on Keane. He’s looking for help from anyone with details about the companies Keane acquired over the years — Source Data Systems, Infostat, PHS Patcom, CHC, or Pentamation / Ferranti. If you can help out with fun anecdotes or yellowing documents, e-mail Vince. He is always effusive with his thanks and generous with his acknowledgments.

E-mail Mr. H.

HIStalk Advisory Panel: When to Join an HIE 7/16/12

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news development and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a provider organization (hospital, practice, etc.), you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This report involves a question submitted by a health system’s VP of physician systems. When is the right time for a provider to participate in a new HIE initiative: when it first launches, when it reaches financial stability, or when physicians and/or patients demand participation?

At Launch

• Probably upon launch or shortly thereafter. It could easily become chicken-and-egg and never reach the latter two without significant participation at the onset. If there’s never critical mass, financial stability and public awareness will likely never happen.
• If everyone waits until the HIE reaches financial stability, very few will get off the ground. It is important to support these as soon as they are available IF they can show a reasonable path to sustainability (if they can’t they shouldn’t be supported.) Limited term funding guarantees, a fair sharing of costs among providers, hospitals, and insurers (the major beneficiaries) should all be considered.
• Our hospitals is an HIE founding member, but our providers derive almost zero benefit from it. There are a number of reasons for this, but workflow is probably the most important. So, any advice I have about when to engage providers in an HIE must be taken with a very large grain of salt—it could reasonably be argued that I don’t know what I’m talking about. That said, I would say when it is first launched. If you wait until it is financially stable, it may fail because you are waiting.
• Excellent question, and one that we’re wrestling with as a nascent HIE is forming on our doorstep. Our health system has chosen to be a charter member (long before financial stability or patient and physician demand) in order to ensure this thing evolves in a way that matches our business interests. However, having previously been involved with a failed statewide HIE, I know all this effort may come to nothing.
• When it first launches, especially if vendor has a significant share of the market.
• Having been involved back in the early 2000s when we called them RHIOs and everyone loved  the idea but didn’t participate, I would say that getting in early and driving the direction and focus is better than jumping in late and playing catch-up. I think an early aggressive stance is better than sitting on the sidelines. I understand that there are cost issues to play in an HIE, but I would rather try and make the rules than have to follow the rules built by others.
• I believe that getting in at the ground level, when it first launches, is important. The provider will have some voice in necessary changes, will probably get in for a lower cost, and will not have to wait in line down the road when everyone jumps on the bandwagon.
• The right time is at the beginning so they can be involved in functionality and governance. But the more pragmatic time is when there is a definite need and business model to support it.

When Other Providers are Jumping On

• You definitely don’t want to be in early. Too many bugs and no real benefit because there are no other providers to collaborate with within the system. You also don’t want to be last in. There is too much risk of losing patients to providers who offer the service from an HIE with a patient portal. As an MD, I would start publicizing that I will be joining and when patient demand reaches a level that ensures interest and benefit start the process.
• For most providers, the right time is when the local hospitals start using the HIE. The real benefit for the independent providers is to exchange data with hospitals. Unless there are hospitals signed up, it does not make much sense to invest time and money into this fairly resource-intensive process. Alternatively, there are several incentives (state or federal outside of MU) that help the providers sign up to HIE. Independent providers should seriously consider joining the HIE if one of the financial incentives is strong enough.
• When the health system the provider affiliates or partners with is actively engaged – makes the individual provider’s efforts more worthwhile and helps to ensure that patient information useful to the provider is going to be available via the HIE.                          

When the HIE Achieves Financial Stability

• When it reaches financial stability. We have three that we could hitch our wagon to, but two of them probably cannot sustain their current financial model. I’m glad that we waited a year before making a decision. Our physicians and patients are still not demanding it, but it’s the right thing to do. If we wait for them, it might not happen for another three years.
• We have providers who fall into each of these categories. However, in the spirit of what is best for the patient regarding continuity of care and cost reduction, I would argue that once an HIE is established (assuming early adopters have technically proved it out) and sustainable, that would be the best time. Once patients start demanding, you are already behind the curve and have suffered from a customer service perspective.
• After it reaches financial stability, but before physicians and patients demand participation. In that window, you should move when you are almost but not completely comfortable that it will be *the* platform.

When Benefits Are Compelling

• Only when the benefit outweighs the risk. Only when the information offered by the HIE is worth something to your clinicians. We have yet to reach that point.
• When the participant (physician, nurse, care coordinator, etc.) feels that there is something useful being offered by the HIE, they will join. There must be utility in the service or potential participants won’t be bothered. What is utility? The answer depends on the person offering and receiving the information. Some physicians may want a simple hospital discharge or something as detailed as a complete CCD. Some may find a PDF that can be attached to the patient record useful; others may find utility only in data being stored in fields within their EHR. I just sat in a think tank meeting yesterday (my friends would find irony in that statement!) where a similar topic was discussed for hours among various stakeholders with no clear consensus. All that being said, sustainability is also a concern. Maybe some participants will operate under the “I’ll take what I can get while I can get it” mode, but many others will be more cautious and wait to see if this new service will be around for the long haul. In a pay-to-play model, I would imagine that participants would become hyper-sensitive to both of these points.
• I’m not sure there’s a magic answer here. The right time should be when any benefit can be realized for providers and/or patients. Ideally, you want a guarantee that an HIE will be financially stable and provide some benefit to the community. However, if someone doesn’t take risks to be the first, then you don’t make progress.  My experience to date is as follows:  our state HIE has wonderful presentations on their technology architecture, but no answer to how they will sustain the solution once the grant dollars dry up. It’s hard to create executive support for any initiative if you can’t tell them how much it’s going to cost. Creating a regional HIE would be an alternative solution, but the competitive environment between the practices and hospitals in the area may make this a pipe dream. Instead we have one-off integration attempts between select hospitals and practices. I think it’s a shame for the patient – most families will end up having their data compartmentalized throughout the community, and if MU Stage 2 continues with the proposed rule, patients will have to utilize multiple portals to gain access to their information. This is not progress.

When Physicians or Patients Express Interest

• I would say when physicians and/or patients are interested. HIEs are fee based, so value needs to be identified before committing. Stage 2 MU has some specific criteria regarding electronic exchange, so timing could be a moot point.
• Generally I would say when others demand your participation, but that is not what we are doing. We got involved right at the beginning, assisted with vendor selection etc. It is more expensive to be involved at the beginning, but you can impact the direction more that way. If you miss the beginning and have no input, then wait until physicians demand it. All of these are being funded on the backs of hospitals, so spend only when you need to.
• This question sounds like it comes from someone at a large organization. From the small practice perspective, not many providers really think about this. Most providers in private practice probably don’t know what HIE stands for. We have 10 providers (doctors and physician assistants). Of them, I know of one who might know what an HIE is. If the demand comes from providers, it will start at large organizations like Kaiser and hospital systems and then spread to communities. 

Depends on the Organization or Area

• There is no right answer here:  much like any other “bleeding edge” vs. mainstream vs. laggard discussion, jumping in too early can have more pain (growing pains, financial pains, failure) it also can be a marketing tool for patient engagement and connectivity. What is the value of that? Clearly, it depends on the locale, competition, etc. Understanding the dynamics of the local market and needs is more important, and having realistic expectations for all is a necessity.
• I think this depends on the size of your organization. Larger institutions are typically the earlier adopters and have the resources to get the HIE launched. Smaller institutions will join as it becomes more stable.
• The timing decision to participate in a new HIE depends on the culture of the provider organization. There are the early adopter benefits of participating at the beginning. You may be viewed as a thought leader and innovator. Additionally, your organization may shift faster to leverage and benefit from the exchange. There may also be early adopter risks of sharing without clear guidelines for exchange participants. Organizational support tends to be key regarding timing along the HIE maturity curve.
• It depends upon your broader competitive and clinical integration strategy. The more strategic, get in early. The less strategic, fit it in when you can, if it makes sense at all to do.
• This is really a chicken and egg question. If a provider does not start early, then the chance of the HIE being sustainable — and more importantly, set up in the best interest of all stakeholders — is greatly reduced. However, if the ante to be at the table early is too risky for an organization, then they should stay on the sidelines until the HIE is proven functional and sustainable. The issue across the country, of course, is one of sustainability… and politics.  In our state, an insurer/provider conglomerate tried to convince the state to run on their infrastructure. It took great effort to derail that thought (imagine you are a provider and the insurer side of this company has a deep dive or this kind of data to potentially use against you in contract negotiations) AND as soon as a new direction was set, the state then pushed the provider consortium aside for another politically-driven organization. At that point, the providers exited.
• HIE participation depends on multiple aspects, and requires frank assessment of both the HIE and the participating provider. If the HIE is inadequately funded, its leadership does not have a proven track record, and questions arise about its stability, then a provider organization should not devote resources to what may turn out to be a failing proposition. The converse is also true: if the participating provider is inadequately funded and dealing with its own internal problems (either staffing or trying to meet government and more pressing internal organizational goals,) then it should not try to devote scarce resources even if the HIE is a stellar player. The character and experience of the participating provider also should determine time of enrollment: if the provider is tech-savvy, at the forefront of the implementation curve, and has both time and resources to deal with startup issues, then they should be a first-launch participant. However, if the provider expects smooth sailing or a plug-and-play experience, then waiting for maturity of the HIE is in order. Looking back on historical ease of implementation and rollout of EMR to individual physicians may provide a template for which providers should go up first on an HIE and which should wait.
• Depends upon (a) the provider’s tolerance for ambiguity and willingness to shape the HIE. If high, get involved when it first launches and be among the first to participate. You can always use it as a marketing tool with your patients to show how advanced you are. If low, wait until there is demand. If you wait until it reaches financial stability, you’ll grow old and die first in most cases. (b) the cost of participation. There will be limited value at first, sort of like those who had the first telephones when their neighbors didn’t , but there may be discounts (temporary or permanent) that could be negotiated for early participation.

Dr. Sam 7/13/12

MEMS and the Patient – Computer Real-Time Interface

We are an industry of fads and trends. As a close consultant friend of mine often says, our industry spends hundreds of millions of dollars annually trying to differentiate between the two. "Futurists" tell us what is happening next – or sometimes what is happening after what is happening next – a relatively safe place from which to operate since by the time whatever happens after what happened next happens, it is too late to get your money back.

I’d like to discuss an essential technology with unlimited application to healthcare technology and quality care that has been quietly happening while everything else that is happening next has been happening – almost completely under the healthcare IT industry radar.

Have you ever wondered how your cell phone or iPad display knows how to orient itself depending on the position in which you are holding your phone? How your digital camera remains stable enough to take a perfect picture even though you know you moved a little bit when you pressed the shutter button or icon? How the compass application on your cell phone knows the direction you are pointing the phone? Or how your Wii game reproduces the tennis stroke, golf stroke, or punch that you deliver with the handset swinging in midair with just the right direction and intensity?

Just a few decades ago, we marveled that entire computer circuits could be on a single chip the size of the head of a pin. Today, micro-machines are created and produced on silicon chips that fit easily on chips of the same size. Almost any machine that you can imagine – with actual moving parts – can now be embedded in microchips. That includes (but is no means limited to) gyroscopes, radios, sensors (pressure, radiation, stress), transmitters, levers, hinges, gears, chain assemblies, micron-sized motors, tweezers, pumps, separators, injectors, needles, scalpels, propellers, turbines, mirrors, …. and on and on. The Industrial Age is being reborn on a microscale and even a nanoscale level. The science of MEMS – Micro-Electrical-Mechanical Systems – is well underway and has been for more than a decade.

That positional sensor that rotates your cell phone display is a microscopic acceleration detector. Micro gyroscopes keep your camera steady. MEMS sensors keep choice lists and drop-down menus scrolling on device screens when you speed up your touch movements. Combinations of such devices tell your Wii machine if you just threw a jab or an uppercut and how hard you punched. Within a few months of the tsunami disaster in Japan, micro-radiation detectors were available within cell phone circuitry to serve as alerts to radiation exposure.

On the nano scale, sensors based on silicon chips use electron spin instead of charge to store information using nanoscale layers of magnetic film with thickness measured in atomic levels.

The implications for medicine and healthcare are both endless and mind-boggling. Embedded microchips are currently capable of measuring and transmitting real-time blood pressure and glucose levels in a linear timeline. Hearing aids are likely to be replaced by self-adjusting artificial cochleas. There is active development of artificial implantable retinas. Cardiovascular stunts are being designed to measure and transmit blood flow and therefore the integrity, patency, and efficiency of the stent (cheaper and more accurate than CT scanning). Embeddable microchips can perform and transmit lab analysis studies and even do DNA analysis. Micro pressure sensors can transmit intra-arterial pressure in abdominal aortic aneurysms. Pressure sensors in contact lenses and even embedded in the iris can transmit intraocular pressure measurements for real-time monitoring of glaucoma treatment.

As we struggle to implement electronic health records to maximize real-time documentation, order entry, lab reporting, and data sharing, an entire science is developing that is capable of delivering direct exchange of digital information. Not between external devices, but directly from within the bodies of our patients.

Imagine how this capability might eventually impact health information exchanges, data collection, outcomes monitoring and adherence to protocols, developing personal health records, and the concept of the Medical Home.

The trends of today may well fade to fads that have been eclipsed by science that has outpaced them.

The MEMS industry itself is no fad. In 2001 it was a $215 million industry. According to IHS iSuppli‘s market intelligence, MEMS revenue will grow at an enviable 9.7% CAGR (compound annual growth rate), from $7.9 billion in 2011 to $12.5 billion in 2016. This compares to only 4.5% for the overall semiconductor industry. In term of units, shipments of MEMS sensors and actuators will more than double, from 5.4 billion in 2011 to 13.7 billion devices in 2016—a 20.7% CAGR.

An entire renovation and revolution in how we diagnose, treat, measure, and monitor is soon to envelop us.

Gentlemen, start your nano-engines.

Sam Bierstock MD, BSEE is the founder of Champions in Healthcare, a widely published author and popular featured speaker on issues at the forefront of the healthcare industry, and the founder of Medical MEMS, a healthcare MEMS technology consulting group.

Time Capsule: The HIT "Trendulum" Starts its Swing

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in August 2007.

The HIT "Trendulum" Starts its Swing
By Mr. HIStalk

Anyone who’s worked in healthcare IT for a long time knows about the often-mentioned pendulum (or "trendulum", as I call it). It swings one way, reaches its maximum travel, and then starts its swing back in the other direction. Some examples have been:

• PC desktop vs. thin client
• Midrange/mainframe vs. PC
• Own vs. lease
• Build vs. buy
• Outsource vs. bring it back in-house

I’m not sure why there’s a pendulum. Probably because providers are limited in capital, project resources, and institutional focus, thereby making it impossible to get IT projects done until the need for them reaches a crisis level.

Four or five years ago, the pendulum finally swung back on clinical applications after a long absence. The formerly hot enterprise resource planning, budgeting, and financial systems cooled off in favor of patient care systems.

Magazines started fawning over CPOE and forming RHIOs for clinical data sharing. Maybe it really was a trend, or maybe reporters just got tired of writing about administrative systems. Toss in some eager consultants and feel-good politicians and suddenly the only systems that mattered were clinical.

It’s hard to accurately detect the pendulum’s slow reversal, but it looks to me like it’s almost ready to head back the other way. Maybe it wasn’t permanently lodged on the clinical side after all.

The reason is disillusionment. CPOE got sold, but not used. Clinical decision support systems haven’t yet yielded the expected results on clinical outcomes. Small-practice doctors have steered a wide berth around electronic medical records systems. RHIOs met the technical challenges, but not the business ones.

In the mean time, payments (or "reimbursements" for those too polite to say the word) have been stagnant or declining. Costs are up (including IT costs ratcheted up by all that clinical systems activity). No margin, no mission. Before you know it, customers will again be clamoring for those formerly unsexy systems that handle purchasing, collections, and contracting.

Wall Street and the private equity companies apparently see it coming. Indian firms are snapping up healthcare billing and collections companies. MedAssets and athenahealth are going public with an attractive value proposition: those who use their systems, unlike clinical systems, get to take home more money. Wal-Mart is putting its healthcare IT clout into RFID tracking, not patient care software.

That "equal but opposite" reaction was inevitable. Care redesign hasn’t paid off yet, so it’s time to go back to wringing inefficiencies out of the system. Everybody’s best hope for doing that will rest with IT systems, just like it did for outcomes improvement.

That’s not necessarily a bad thing. Once one fire has been brought under control, it’s time to turn the hoses on the other ones. Everyone gripes about healthcare costs even while providers swear they’re not making money, so something has to give.

The great thing about predicting a trend is that you can be vague on the timeline and you’ll eventually be right. So, here’s my prediction: it won’t be long before the industry will be buzzing about administrative systems again.

News 7/13/12

Top News

University of Virginia settles its $47 million breach of contract lawsuit against GE Healthcare over what it claims was a botched IDX implementation going back to 1999 (the suit wasn’t filed until 2009.) UVA wanted a refund of the $20 million it paid IDX (later acquired by GE Healthcare), but GE said UVA violated the contract by neglecting its own responsibilities related to project staffing and workflow analysis. UVA signed an Epic contract, then terminated its agreement with GEHC. Terms of the settlement were not disclosed.

Reader Comments

From HITEsq: “Re: Allscripts and Cerner. Both sued by RLIS for patent infringement. Based solely on the complaint, it appears that RLIS tried its hand at the EMR industry in the late 1990s and failed.” I’ve never heard of the company, but they did file the lawsuits.

From Lindy: “Re: MD Anderson. They got tired of trying to build their own EMR over the past eight years when everyone around them is up on Epic or Cerner. Their new president probably forced a fresh look at the huge costs and minimal results from their internal software development effort.” Unverified, and I assume speculative based on the wording provided. If it’s true, I would add one comment – the vendor pickings were slim back when MDA first started developing ClinicStation. Then-CIO Lynn Vogel wrote on HIStalk about their development work in January 2009.

From Newport: “Re: Capsule. Acquired by JMI Equity. The press release makes it sound like this was simply an investment, but it is an outright acquisition of 100% of the shares.” Capsule announces a strategic investment from JMI Equity and the appointment of Gene Cattarina as CEO, replacing Arnaud Houette (who will remain on the company’s board). Cattarina’s background includes executive roles at Impulse Monitoring, Lynx Medical, E&C Medical Intelligence, Landacorp, Medicode, and TDS Healthcare Systems. Some of JMI’s other healthcare IT holdings are Navicure (revenue cycle management),  Courion (identity management), and PointClickCare (EHR for long-term care.)

From Ross: “Re: reading suggestions. I’m a relative newcomer to HIStalk and to the industry in general. I’m interested in reading suggestions to deepen my understanding of the field. I’d love to know what readers are reading, even if it’s not about healthcare.” Leave a comment if you’d care to pass along suggestions to Ross.

HIStalk Announcements and Requests

I’m back from vacation, sort of. Even though I posted several times that Inga and I would be out this week in a rare but unavoidable simultaneous absence, a few folks kept e-mailing the same requests every day, apparently either unwilling to believe that we aren’t hard wired to e-mail 24×7 or thinking that a lack of immediate action on our part meant we were being unresponsive and thus in need of a more forceful request (I really dislike that about post-iPhone electronic communication – expectations for e-mail are what they used to be for instant messaging, where a delay of more than a few hours is perceived as being irresponsible.) I figured I might as well forget the rest of vacation, come home early, and get back to work. I was annoyed enough that I cancelled a new sponsor who was e-mailing me daily wanting one thing or another immediately, even though I replied every time that I was on vacation and would get to it when I got back. For everybody else, I will most likely spend the weekend catching up before going back to work at the hospital on Monday. At least I got to take a short break, working only a few hours early in the week while enjoying time away with Mrs. HIStalk.

Sales

Parkland Hospital (TX) selects M*Modal Fluency for Coding(TM) in preparation for ICD-10.

Memphis Obstetrics & Gynecological Association (TN) chooses MED3OOO’s InteGreat EHR for its 24 providers.

South Hills Radiology Associates (PA) will implement McKesson Revenue Management Solutions for its 13-physician practice.

Jacobs Engineering Group announces a $20 billion contract award it won to provide a variety of IT support services to NIH and other federal agencies.

Announcements and Implementations

INTEGRIS Health (OK) deploys Amalga from Caradigm.

Quintiles and Allscripts partner to develop solutions improving processes for clinical and post-approval drug research.

Ten-bed Guadalupe County Hospital (NM) goes live on Medsphere OpenVista.

Other

Here’s the latest cartoon from Imprivata.

KLAS announces a new enterprise imaging report, finding that the top two strategies are vendor-neutral archive and PACS enterprise archive solutions. Those surveyed mentioned GE and Philips most often as strategic enterprise imaging partners, while Agfa and Merge are mentioned most often for the VNA-centric strategy.

CSC begins laying off employees involved with the failed NPfIT project in the UK.

The local TV station covers the $70 million implementation of Epic (which they inexplicably spell EPIC) at Lee Memorial Health System (FL). It’s the typical TV piece, light on research and heavy on anecdotal chat, but aimed appropriately for laypeople with marginal interest.

FDA’s Jeffrey Shuren MD, JD, in an NPR interview, says some apps that behave as medical devices (like those that turn a smartphone into an EKG machine) need FDA’s review before marketing, but the agency has no interest in overseeing apps related to lifestyle, wellness, and management of personal medical conditions.

Weird News Andy finds this news cool, but scary (and asks, “First Amendment, anybody?”) The Department of Homeland Security has developed a laser-based scanner that can analyze people at the molecular level from up to 164 feet away, detecting everything from illegal substances to high adrenaline levels. It’s the last paragraph of the article that gets WNA’s attention: “Although the technology could be used by ‘Big Brother,’ Genia Photonics states that the device could be far more beneficial being used for medical purposes to check for cancer in real time, lipids detection, and patient monitoring.”

Sponsor Updates

• Imprivata receives a patent for its “biometric authentication for remote initiation of actions and services.”
• TeleTracking announces enhancements to its capacity management software to help hospitals manage length of stay and increased transfer center volume.
• AlliedHIE (PA) and ICA announce the go-live of Allied-DIRECT allowing AlliedHIE to recruit providers to join the statewide DIRECT grant program established by PA eHealth Collaborative.
• The Salvation Army and MedAssets partner to provide healthier choices in food and nutritional items at a better cost through MedAssets buying contracts.
• OTTR will host a July 18 webinar demonstrating its soon-to-be released OTTR Mobile.
• Merge Healthcare will offer OrthoPACS, its new image management and digital templating solution for orthopedics, as a subscription model.
• A military-specific version of the Vocera Communications System earns the Department of Defense’s Joint Interoperability Test Command certification.

EPtalk by Dr. Jayne

NCQA offers a seminar on facilitating PCMH recognition. It will be held on August 21 and 22, with a session on PCMH Best Practices and Lessons Learned to follow. I guess that’s like a stiff drink with a chaser. I’m not sure I could handle three full days of PCMH, especially with the steep price.

The Institute of Medicine reports that as baby boomers age, the nation is unprepared to deliver mental health services to that population. I would argue that based on the decline of primary care and the challenges of Meaningful Use as well as the continued problem with Medicare payments, we’re pretty much going to be unprepared to deliver a lot more services than just mental health.

Wisconsin-based Asthmapolis receives FDA approval for its asthma inhaler sensor. The prescription device captures timestamp data on asthma attacks and transmits it to the company. Patients can use mobile and web software to track asthma symptoms and triggers. Additional features include text messaging for medication reminders.

IT staffers beware: a recent study links sitting more than three hours each day to a shorter life span. I wonder if they controlled for various different types of sitting? I think sitting in meetings viewing endless badly-done PowerPoint presentations will take much more off one’s life expectancy than sitting on the beach with an umbrella-bearing cocktail.

Hallucinogenic club drug ketamine (known as Special K) is being tested as a potential treatment for depression. Ketamine is used as a horse tranquilizer and as a sedative for pediatric patients. In adults, it can give them disturbing hallucinations. One scientist comments, “If not used carefully, we could end up curing depression with schizophrenia.” Anyone want to volunteer for that clinical trial?

According to a recent report, fear of errors in computer-aided E&M coding may lead physicians to code visits manually. The CEO of the American Medical Association is pushing for testing of coding recommendations during EHR certification. How about this: we convince CMS to institute a fair system for compensating physicians instead of giving them games to play with two different coding schemes and a nauseating array of arcane rules and aggressive auditors.

I appreciate the number of readers who were able to identify the photo of Harney Peak (also known as Black Elk Peak or Saint Elmo Peak) and especially those readers who didn’t cheat and load the link associated with the photo. The structure in question is a fire lookout tower – correctly identified by several other readers even if they didn’t know the specific location. Two readers tried to identify it as a fire tower near El Centro, CA which tells me there must be one pretty similar. Another thought it looked like an 18th century European signal tower, and having seen a few of those, I tend to agree. Our winner is Richard S., who gets the bragging rights.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Mobile.

News 7/11/12

Inga and I are on a short break for another couple of days, so I’ll keep my posts brief (and rather Spartan) so that Mrs. HIStalk doesn’t feel neglected on vacation. If I’ve missed anything important, let me know.

From UK Lurker: “Re: Epic. As Epic projects get going in the UK, is there any indication of how UK customers will be handling their project team staffing? Are they using US-based consultants who have experience with Epic? UK firms that know the NHS?"

The CEO of Baptist Memorial Health Care (TN) says he is “thrilled” to announce that the organization has signed with Epic. We reported the rumor from Jog that Epic would replace McKesson Horizon there on July 6.

Kevin Shimamato is named interim CEO of Tulare Regional Medical Center (CA). He was previously CIO at Sierra View District Hospital and says it’s a trend that hospitals are hiring CEOs with a technology background. He applied for the job through his consulting company. 

MyHealthDIRECT names board member Tom Cox (Healthways) as CEO. He replaces founder Jay Mason, who will remain with the company and continue serving on its board.

University of Virginia and GE Healthcare head off to court this week over what UVA says is the failure of the former IDX to meet hospital information system implementation milestones going back to 1999. GE Healthcare bought IDX in 2006, the hospital says GEHC didn’t resolve the issues, and it’s suing for $30 million after already moving to replace IDX with Epic. GEHC says UVA didn’t make an effort to fix its own project and still owes it money. 

Weird News Andy is glad to see that these nurse assistants have been banned from healthcare. While working on contract for the Virginia Veterans Care Center, they took four wedding rings from elderly veterans suffering from dementia and other chronic conditions, pawning them immediately for a total of $405 (their appraised value was over $4,000.) The first was found guilty, but says she took only two of the rings and claims she didn’t remove them forcibly, although at least one of the victims had bruised fingers. She could be sentenced to up to 120 years in prison. Her partner in crime (check out her photo above – would you voluntarily choose her as your caregiver?) will be tried later this month.

Sponsor Updates

• University Physicians (CO) will deploy GE’s Centricity Business solution across its hospitals and physician practices.
• Legacy Health (OR) selects ProVation Medical software by Wolters Kluwer Health for its GI lab documentation and coding at five hospitals.
• Hartford Healthcare Corporation realizes $15.3 million in financial improvements within a year of selecting MedAsets revenue cycle solutions.
• DrFirst launches an e-prescribing task force to assist New York physicians in meeting the requirements of i-STOP.
• Southwest Community Health Center (CT), an FQHC, will deploy NextGen EHR, PM and Electronic Dental Record across its 12 locations.
• InMedica, a division of IMS Research, names Merge Healthcare as the #1 vendor neutral archive provider in its recent market study.
• OrthoKC (KS) selects SRS EHR for its 10 providers.
• e-MDs congratulates its client, Princeton Healthcare Affiliated Physicians, for the successful MU attestation of all 21 eligible providers.
• Optum launches coding technology to facilitate and accelerate hospitals transitioning to ICD-10.
• NextGate highlights two wins by its partners, Orion Health and Covisint, using its EMPI and provider registry.
• New York City Health & Hospitals Corporation attests to Stage 1 MU in all 11 hospitals and met interoperability requirements by exchanging data with New York’s RHIOs using QuadraMed solutions.
• James Backstrom MD of Foundation Radiology Group and Robin Brand of The Advisory Board Company will present strategies to increase imaging referrals during a free webinar July 19.
• Memphis Obstetrics & Gynecological Association (TN) selects MED3OOO’s InteGreat EHR for its 24 providers.
• MEDSEEK partners with BrightWhistle to resell its social patient acquisition solutions.

E-mail Mr. H.

Curbside Consult with Dr. Jayne 7/9/12

I wasn’t surprised at all when I read this article about a San Diego Padres fan being struck in the chest by a foul ball. Although neighboring fans moved out of the way, the injured spectator was trying to update Facebook and didn’t notice the ball speeding to his section. Studies have demonstrated increases in injuries to pedestrians who text and we all know the hazards of texting while driving. This is another example that smart phones may really be making us dumb.

For many of us, technology has been integrated into various facets of our lives longer than it has been playing a role in healthcare. Because of it, some of us are losing essential skills. Now that GPS navigation is widely available in vehicles and on phones, people seem less likely to know how to read a map or use a road atlas. On family vacations when I was a kid, I looked forward to driving across the state line so we could stop at the visitor’s center and pick up a map. We always had a stack of maps from various states in the glove compartment which were great to look at while on long trips.

Vacations were about getting away from day-to-day activities rather than letting work stress follow us everywhere we went. We didn’t feel obligated to tell the world every little thing we did or broadcast pictures of our food using the internet. If we needed to contact someone, we had to find a pay phone. (Remember pay phones? My buddy Skeptical Scalpel does in this funny blog posting.)

Technology can be great – it’s definitely safer to have a cell phone in case of emergency than to have to walk down the road to find a pay phone which may or may not be in working condition. It’s reassuring to have allergy and interaction alerts in my electronic medical record rather than relying on memory (as if one could actually know every interaction out there – cytochrome P450 haunts my dreams.) But does relying on the system hamper our desire to actually learn and retain the information?

I thought I’d be immune to it by now, but as a primary care doc, I’m still amazed at people’s dependence on technology. The other day, I walked into an exam room where a patient was scheduled for a gynecological exam. I generally run on time and actually had to wait a minute after I knocked because the patient was still changing out of her clothes. I could barely make it into the room because the patient had rearranged the chairs to allow her phone charger to reach the outlet. She also unplugged the exam table, making it impossible for me to perform her exam without plugging it (and the lamp) back in. She was already texting by the time I entered the room and I had to ask her to put the phone down so we could conduct the visit.

I see countless parents who can’t put their phones down long enough to talk to me about their children. What message do they think they’re sending? Unfortunately, the kids develop the idea that what’s on the screen in the virtual world must certainly be more interesting than the real world. They think it’s normal to be connected to the office 24×7. When we’re rounding in the hospital and we’re focused on our phones rather than interacting with nursing staff and the care team, it’s no different. Conversely, trying to interact with members of the team while they’re texting or taking personal calls isn’t a good thing, either.

At a local youth camp where I volunteer, we have detailed emergency preparedness plans and the staff monitors conditions so that we’re ready for severe weather. Nevertheless, parents are still glued to their phones watching weather radar in case it might rain rather than seeing their kids do fun things like archery and horseback riding. I watched one mom tell her son that he needed to get back in line to do archery again so she could take a picture because she missed him doing it the first time. Why did she miss it? She was on Facebook posting pictures from the morning’s activities.

With obesity and lifestyle-related diseases on the rise, it’s even more important for each of us to put down the technology for some part of the day. Try driving without the GPS and actually take in your surroundings. Or, get outdoors and let your brain recharge or give your body some needed activity. Reclaim your critical thinking skills and your sense of wonder rather than letting technology define your world.

Can you name the location pictured above (courtesy of Jake DeGroot) or do you know its purpose? Email me.

E-mail Dr. Jayne.

Monday Morning Update 7/9/12

From Gob Bluth II: “Re: Health Information Partnership for Tennessee (HIP TN). HIP RIP. Another HIE bites the dust.” Verified. Gob forwarded the e-mail that went out to stakeholders on Friday, along with a copy of the official announcement that will be released Monday. The three-year-old state network says officials decided to pursue a simpler strategy of using the DIRECT system as a HIP replacement. HIP TN chose Optum’s Elysium Exchange (the former Axolotl) in October 2010 and now it’s going to the Greek mythology version of Elysium, the afterlife of the chosen.

From Data Birth: “Re: Consumer Reports hospital safety rankings. I’ll wager the reason the data were inconsistent or missing is because hospitals don’t want this particular information to reach the eye of regulators or the public. You would think this would be available through Joint Commission inspections.” In my experience, the Joint is good for two things: (a) reacting to headlines by setting big-picture goals and ever-moving standards that never result in hospitals getting punished, and (b) clearing the hallways of carts and getting storage boxes away from the fire sprinklers, which happens only when their inspectors are on site. Hospitals in the past have been given a clean bill of health by Joint Commission, only to be threatened with shutdown immediately afterwards by inspectors from the state or CMS over egregious patient safety problems. I’m not casting implications on the Joint’s motivations since I’d much rather have them than not, but they’re making nice coin by not only selling inspections but also the tools and services that help hospitals pass them, and sometimes I think they struggle with the balance of being both a regulator and a vendor (like other similar organizations.) I think they see their role as more consultative than punitive, while sometimes the latter seems more appropriate.

From Max Payne UK: “Re: NHS and Epic. Epic doesn’t have a UK localised product and Cerner is installed in several Trusts. Reportedly, Cerner was cheaper than Epic. So how did Epic wind up being the winner? What consulting company or consultant advised the Trust on this decision?” Hospitals often choose Epic for non-financial reasons: perceived honesty, a near-perfect track record of going live on time, general polish on issues like training and documentation, and lack of Wall Street pressure that could shift their focus quarter by quarter. Not to mention that the big price tags mentioned for Epic projects are all-inclusive of even internal labor, which other vendors don’t include to the later discomfort of their customer. If you’ve seen the actual contracts (and I have), Epic isn’t always more expensive than arguably inferior alternatives. With regard to localization, they have over 5,000 employees and have learned from the mistakes made by others, so the have a leg up on the pioneers before them who crawled back with arrows in their backs. You bring up a good point – do organizations buy Epic because consultants recommend it, or do consultants even get involved with Epic decisions? And as one last thought, Epic (and Meditech) are big enough to command UK attention, but emerged unsullied by the NPfIT meltdown since they weren’t players, so that’s a plus for them. I would hope that those who made the Epic decision talked to the Cerner-using trusts first.

From Konrad: “Re: job stress. I often wonder if part of the fear of EMR and Obamacare is tracking of stressful of employers, like cancer centers. One place I worked actually did that for employees.” The former CEO of France Telecom is released on bail after being questioned by government officials about the suicide of more than 30 company employees in the two years just before he quit. He says the suicide rate was similar to that of non-employees and blames pressure brought on by the economy and the company’s minority shareholder (the French government), but did say he wishes he had paid attention to the warnings of doctors that the company’s massive layoffs and unreasonable performance targets were causing employee health issues.

From BitesTheDust: “Re: John Muir. Epic must have gotten another major McKesson account – this time John Muir in California. Looks like the CIO (Eric Saff) is already gone too as an executive firm looks for his replacement and prefers Epic experience.” They chose Epic awhile back, I think. I had run a rumor here (without naming the hospital) that Epic had originally declined to work with John Muir over some perceived conflict with its IT department and told the hospital’s board as such. I think this may happen more often that we know – the Epic train rolls right over the CIO during selection or implementation when Epic’s way isn’t warmly embraced by IT.

From HR Guy: “Re: stack ranking of employees. Epic does stack ranking as well, with about the same results, combined with the slow hire/quick fire mentality it’s been pretty deadly.” An article about Microsoft’s lack of agility and its fall from swaggering innovator to bean-counting market follower blames stack ranking, the practice that requires a fixed percentage of employees to be identified as great, adequate, or poor, with the great getting promotions and the poor getting shown the door. It concludes, based on Microsoft employee interviews, that everybody spent more time stabbing each others’ backs and sucking up to those who might review them instead of worrying about how Apple was beating them like a drum. Steve Ballmer gets a lot of the blame (honestly, what does Microsoft see in that guy that nobody else does?) but the damage was well underway when Bill Gates was still running the show. A former marketing manager concludes, “I see Microsoft as technology’s answer to Sears. In the 40s, 50s, and 60s, Sears had it nailed. It was top-notch, but now it’s just a barren wasteland. And that’s Microsoft. The company just isn’t cool any more.” Epic does apparently follow the same practice of quickly categorizing employees based on feedback from managers and co-workers who may barely even know them. I like the practice in theory, but as in most aspects of life and business, execution is everything.  

Welcome to new HIStalk Platinum sponsor Visage Imaging. The San Diego company is a global provider of enterprise and advanced visualization solutions that make slow, trickily deployed client-server and Web-based PACS approaches obsolete. No more reconstructions at the modality console while the radiologist twiddles his or her thumbs waiting on digital mammography or PET/CT — Visage 7 makes even the largest multi-slice datasets completely navigable in seconds via an intelligent thin-client viewer displaying server-rendered 2D, 3D, 4D, and advanced visualization imagery on a single desktop (in plain language, huge images don’t need to be pushed painfully and slowly from the hospital data center to the radiologist’s workstation – the server does the work and interpretation gets underway faster no matter where the radiologist is sitting.) Its platform enables enterprise viewing and interpretation and image enablement of EMRs, VNAs, HIEs, and RIS/PACS. You can use it on smart phones and even on Macs. Thanks to Visage Imaging for supporting HIStalk.

I headed over to YouTube to see if Visage Imaging had anything there, and lo and behold, here’s a brand new video on Visage 7 that includes some cool product video (though being a non-radiologist, anything with lots of movement and color seems cool to me).

Clearing out my “Listening” box for now: Phideaux, interesting “psychedelic progressive gothic rock” led by TV soap opera director Phideaux Xavier. Think Jethro Tull, Kansas, and Renaissance rolled into a more modern package with bigger production. It’s really good, especially coming from a guy who directs General Hospital as his day job. I’m playing it loud enough for Mrs. HIStalk to ask me what I’m listening to, though her tone suggests an interest that doesn’t necessarily involve my loading it to her Nano.

Inga and I are coincidentally both traveling this week (not together, just to be clear) so we may be occasionally tardy in our responses and terse in our writing as we take rare simultaneous vacations. Let me know if anything really important comes up this week that I might otherwise miss since I’m hoping to spend a few more hours than usual not working.

Thanks to the following sponsors, new and renewing, that supported HIStalk, HIStalk Mobile, and HIStalk Practice in June. Click a logo for more information as you ponder with me the illogicality of respected, successful companies backing a shoot-from-the-lip journalistic ne’er-do-well who nonetheless appreciates their support in forms that often extend beyond financial to personal. There hasn’t been a day in the nine years I’ve been writing HIStalk that I didn’t marvel at how cool it is to live my Mr. H alter ego even though it’s purely imaginary.

PPACA pretty much splits us as taxpayers, but we apparently like it fine as healthcare IT people. New poll to your right: which group would you target first to reduce healthcare costs? Obviously it’s a simplistic question with limited answer choices, so the poll accepts comments for your further elucidation.

A Physician’s First Watch poll on the Affordable Care Act drew similar results, with 65% of respondents (presumably mostly doctors) saying they like the Supreme Court’s decision (which presumably means they like PPACA).

CapSite releases its 2012 Laboratory Information Systems study. By the numbers, the dominant vendors are Meditech, Cerner, and Sunquest, and 81% of respondents say they won’t be replacing their system within two years. I like reading CapSite’s reports because they’re formatted as PowerPoints saved as PDFs and they get right to the point with charts. I had forgotten until I read the graphic above that Allscripts offers a LIS, which I assume is the former Sysware that it acquired in 2006. I also noticed that Epic’s Beaker is moving up the LIS ladder even though it’s not quite there yet, but probably will be by the time its newly implementing customers are ready to take another look at lab systems.

For the stats-obsessed among us (not me, but maybe Inga, and surely that one person who always e-mails me to ask), June’s readership numbers were really good given the annual summer slowdown: 102,849 visits and 191,515 page views, up a bunch from last year.

Weird News Andy finds the comments left on the Physicians’ Declaration of Independence interesting.

Here’s why e-MDs CEO Michael Stearns is  no longer with the company, as explained to its customers via e-mail. Grizzled Veteran provided that rumor last week. Founder and board chair David Winn has replaced Stearns as CEO.

This might be the first time that a hospital is acquired primarily for the value of its expected Meaningful Use payout. Cookeville Regional Medical Center (TN) will hold back $700K of its $6.7 million acquisition price for Cumberland River Hospital until that hospital gets its $4 million in Meaningful Use money. CRMC’s CEO said, “Part of the viability of this acquisition is the fact the Meaningful Use dollars are tied to it. That’s why it’s vital to have those dollars. That’s why we were adamant to have a hold-back of $700,000 so that we wouldn’t close the deal and they would stop working if they have a chunk of money held out there to comply with the purchase."

Vince continues his HIS-tory this week with HMS, having connected with co-founder Tom Givens to get a first-hand account of those heady days. I suspect many of you who are enjoying Vince’s series lived the experience first-hand in some of the 1970s-80s companies he has mentioned (and those he’ll be mentioning down the road). If so, Vince could use your old pictures and papers for future installments, but most of all, your anecdotes of what it was like back in the day.

E-mail Mr. H.

HITlaw 7/6/12

Practice Fracture and EMR Rights

Physician groups are signing up for EMR technology in a rush in order to meet eligibility deadlines for reimbursement under the HITECH Act. Unfortunately one of the key considerations in the process, the license agreement, is too often seen as a “last step” on the checklist. As I have urged in previous papers and postings, this should not be the case, as many items are overlooked in the push to acquire an EMR, implement, go live, and finally attest to Meaningful Use.

One important issue that is left unaddressed in the supermajority of licenses is transfer rights in the event of a practice split.

By split I do not mean the situation where a physician leaves a practice and the practice remains intact, because in those cases the license stays with the practice. No issue there. The departing doc takes nothing away in terms of license rights.

But when a practice splits and dissolves, what happens with the EMR license? How is data divided and protected? Who is responsible to the vendor for the security and confidentiality of the EMR system?

When licensing EMR technology (or any other type), the practice should negotiate terms for the perhaps unlikely but still possible situation of the practice breakup. The first request to the vendor should be an accommodation permitting the transfer of the license to multiple successor entities in the event of a breakup. Note that this will rarely, if ever, be without additional cost to the subsets of physicians, and many vendors have minimum provider thresholds, all of which is fair. If a vendor does not market customarily below a certain provider level, there is a reason, which is in most cases ongoing cost. They have determined the minimum sustainable level at which a product can be licensed, enhanced, and supported.

That said, the key issue here is the right to split the license should the need arise. No vendor wants to lose a client, and if the vendor can accommodate a license split, they actually increase their client base and revenue stream.

Next on the priority list would be some recognition by the vendor that in the event of a non-subscription-based license split, some accommodation will be made in terms of original license fee investment. (Quick sidebar – I exclude subscription-based systems because there is no upfront, perpetual license fee – it is simply pay as you go.)

With regard to non-subscription license fees, providers should not expect a known, predetermined allowance, as there are too many factors involved. For example, a five-provider license could be split into subsets of providers in 120 different ways, if my math skills are still up to par (5 factorial, or 5 x 4 x 3 x 2 x 1). Now do the math for a 10-provider license and you will be amazed at the number of combinations. Further, if the license is more than five or seven years old, the practice has in all likelihood taken a full depreciation on the initial investment and should keep this in mind.

I suggest that the most you could reasonably request is a statement that the vendor will make an accommodation of some type with regard to license fees, perhaps on a prorated basis allowing for depreciation and subject to the vendor’s minimum provider level. Prior implementation costs and support fees are clearly not eligible, as those services were provided and paid for. However, there may be a savings to be realized if minimal implementation and training are required by the new practices due to the familiarity with the incumbent vendor’s system. There is real incentive to the vendor to move from a single customer to multiple customers, with no sales effort, minimal implementation effort, and increased revenues, both one-time and recurring. The flip side is the customer should not expect to split a single license into multiple licenses and systems with no corresponding increase in fees, especially support fees.

Although not a pleasant topic, the practice breakup is a possibility, and having a pathway for continued use of the subject technology is important. If done up front, it means one less (or smaller) headache should the breakup occur.

Another very important issue is the data in the EMR. If a practice breaks up, what happens with the data? The first issue here is to determine what happens between the physicians with regard to their respective patients’ data. Consider record retention periods and ongoing access to records by patients or former patients. These are not issues for the vendor, and the best time for the practice to address these issues is when the EMR (or other) technology is acquired.

The associated request to the vendor should be a “transition services” accommodation. This should include the willingness to export or convert data to another vendor’s system should the practice at some point move to a different technology, obviously at a cost. Next you should discuss and investigate (before signing), the ramifications of splitting data into subsets, even if to populate new systems from the same incumbent vendor, and address those as well. Find out before implementation if there are any issues to consider regarding how the EMR or associated database should be structured.

Finally, when the practice breakup occurs, what happens with the original EMR system? The customer practice has obligations to the vendor. These must be carefully considered and fully performed. From the vendor’s point of view, it does not really matter which entity (original or successor) is responsible, but that there is an accountable entity involved. This may not be necessary if the original system is split and licensed anew to subsets of the practice, with the eventual result that there is no “old system.” However, too many times I have assisted vendor clients in situations where the provider customer expects new systems to be created with credit(s) or allowance(s) given for the original system, but then also expects to keep the original system alive and well and running in order to access historical data.

It doesn’t work that way, especially if the original practice is dissolved. The vendor needs protection. Providers should recognize that if you “want it both ways” you should expect to pay full price for the new systems, which is entirely fair. I have used the example many times that you cannot purchase a new car at a price based on trading in your old car, and then decide to keep the old car with no corresponding increase in price for the new car. Note there is also the reasonable middle ground where the old system may be accessed and “wound down,” with corresponding support fees, for a limited period of time after which the system goes away and the customer certifies this to the vendor.

When practices do not work out details ahead of time as to license and data ownership rights, the vendor gets drawn into the fray. As far as the vendor is concerned, the original licensee — the practice itself — is the holder of the license and the owner (as between vendor and customer that is) of the associated data. If you find yourself in this situation as a provider customer, develop a few options that might work between practice members and then approach the vendor.

Just keep in mind that no vendor wants to be asked to decide issues that are properly between practice members. If your EMR license agreement does not contain language permitting a partial license transfer for the benefit of practice members in the event of a practice split, you can imagine what might result. Some members might want to continue using the system and consider the license “theirs”. Others might seek to block that effort. Both might go to the vendor and ask for a ruling. For the benefit of all, I will repeat once again, address these issues up front at acquisition time.

In summary, practice groups should plan ahead when signing for new technology. Negotiate license transfer rights. Expect to pay something, but know you have established a transfer pathway. Determine between practice members what happens with the practice data if the practice breaks up. Discuss this with the vendor, address conversion of data in the license, and investigate database configuration options for implementation time. Do all this at the time the technology is acquired.

Time spent addressing important license issues at the acquisition stage helps avoid future problems, whether between practice members or the practice and the vendor.

William O’Toole is the founder of O’Toole Law Group of Duxbury, MA. You may contact him at wfo@otoolelawgroup.com and follow him on Twitter @OTooleLawHIT.

Time Capsule: Software: No, You May NOT Have It Your Way

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in August 2007.

Software: No, You May NOT Have It Your Way
By Mr. HIStalk

Healthcare IT is a lot more like McDonald’s than Burger King. When it comes to software, you may NOT have it your way.

Here’s a classic example. Well-intentioned clinical software sends alerts to doctors or pharmacists that a certain drug is eliminated by the kidney. Therefore, it nags incessantly, making sure you’re amply warned to reconsider the dose you’re ordering. Sometimes the warning is too stupid to even realize that the patient’s kidneys are normal – it just fires indiscriminately any time that drug is ordered.

That’s not terrible for inexperienced residents, but it’s darned annoying for specialists who spend their entire working lives dealing with patients and drugs like this. "I’m a nephrologist and this system thinks it knows more than me? Hah."

So, one might innocently ask, why must the computer treat all users as infuriatingly equal? Would it not make sense to allow those warnings to be selectively turned off for qualified users? Or, maybe clinical systems should work like some PC applications, where there’s a "basic" mode with limited available options and an "advanced" mode that opens up all kinds of cool but dangerous capabilities once you’ve proven your capability, kind of like a learner’s permit.

Much of the software in use today was built with the mainframe paradigm, i.e. users are stupid and programmers need to spank them if they dare make a mistake. Programmers usually have a deeply held contempt for non-geeky users. If the technology existed, they’d send 110 volts through the keyboards of imperfect users in some kind of Skinner-inspired operant conditioning experiment. I’ve been a programmer and we always dreamed longingly about this ("So he enters medical record number where it says visit number, and — ZAP! Read the screen next time, loser.")

PC and Web software has, in the mean time, progressed into this century. Amazon knows who you are, makes recommendations, lets you easily find your previous orders, and offers you deals on stuff it knows you’ll like. iGoogle lets you build your own home page and use your choice of hundreds of widgets that can do everything from showing your inbox to displaying the latest headlines from The Onion. When you want to do stuff in Windows, you can choose a friendly, step-by-step wizard instead of an imposing screen full of impending, cryptic warnings.

It’s no wonder that doctors and nurses are disappointed by the multi-million dollar systems we make them use. They’ve used the cool PC stuff. Using healthcare software is like waiting in the driver’s license line: everyone is treated contemptuously equal.

Here’s how it should work. The kidney expert gets a basic warning about a certain drug’s dosing in renal failure. A button should be right there that says, "Don’t show me these kinds of messages again." Just like Word’s spell checker, in other words. The doctor is a big boy or girl and can choose for themselves what’s useful and what’s not. Just because the computer has the capability to issue warnings doesn’t mean it should. You trust users to deliver care, so trust them to ignore unhelpful information.

Technically, this is not hard. Neither is personalization that allows users to customize menus, create their own subset of commonly used items, or create an inbox of the kinds of new information they’d like to see about their patients.

It’s no wonder that clinical users just can’t warm up to a computer system as a trusted ally when it often behaves like electronic idiot savant happy to fire off ignored and unwanted information to those who resent it.

News 7/6/12

Top News

Consumer Reports rates hospitals on safety in the August issue just published, with a surprising number of the big names omitted from the top. The safest hospital in the country, says CR, is Billings Clinic (MT) with a score of 72 on a 100-point scale. The worst is Sacred Heart Hospital of Chicago, which racked up a 16. At the bottom of their respective states: Central Florida Regional Hospital (FL), South Fulton Medical Center (GA), Wake Forest Baptist Medical Center (NC), Medical Center of Lewisville (TX), and Clinch Valley Medical Center (VA). However,they could only review 18% of US hospitals because of missing or inconsistent information (there’s another IT challenge if you’re up for one). Criteria were infections, readmissions, communication, CT scanning, complications, and mortality. You can bet that hospital marketing people are spinning the numbers even as we speak given that even the top-rated hospitals still scored low.

Reader Comments

From Grizzled Veteran: “Re: e-MDs. Word on the street is that President and CEO Michael Stearns is no longer with the company. He’s no longer listed on their management page.” Unverified, but his bio has indeed been expunged.

From Jog: “Re: Baptist Memorial Memphis. A buddy told me they’re leaving McKesson for Epic.” Unverified.

HIStalk Announcements and Requests

The latest goodies from HIStalk Practice: attorney Jessica Shenfeld discusses four questions every physician in private practice should ask themselves. Hayes Management Consulting’s Rob Drewniak provides advice for practices to improve internal security and protect against security and privacy threats. Lawmakers introduce legislation that would allow behavioral health providers to participate in the MU program. AMA recommendations for practices weighing HIE options. If you are are not a regular HIStalk Practice reader, what are you waiting for? And if you are, thanks for reading.

I replaced HIStalk Mobile’s comment function with a version that improves readability, allows logging in with Facebook credentials, supports easy subscribing to comment updates, and allows easy sharing of comments with social networking sites. It has other functions that I’ve turned off for now, but look it over on this post and let me know if you think I should install it on HIStalk as well. Try posting a comment, but just remember it’s like HIStalk in that incessant spamming from overseas has forced me to approve each comment, so you may not see yours immediately.

Listening: Black Bonzo, Swedish rockers that sometimes sound like 1970s hard-rocking but musically precise prog bands like Uriah Heep, Deep Purple, and Kansas with a bit of Anglagard mixed in. They’re sporting big Mellotron and Hammond organ sounds, always a plus in my book. And if you’re looking for something laid back and different but still proggy, try fellow Swedes Moon Safari.

Sales

Oak and Main Surgical Center (NJ) selects SourceMedical’s Vision OnDemand for EHR and billing.

Gilbert Hospital and Florence Hospital at Anthem (AZ) choose the Healthcare Management Systems EHR.

People

Mobile health development tools vendor Diversinet names Bret W. Jorgensen (MDVIP) chairman of the board to succeed Albert Wahbe, who is retiring as chairman but keeping his board seat.

Other

Doctors at Australia’s Gold Coast Health say their new clinical system is “totally inadequate and dangerous” because of log-in problems, delays in finding records, and lost information. A hospital spokesperson admits that the system is “very bare-bones” and “does some things particularly poorly,” but they don’t have the money to fix the problems. The hospital’s rollout was part of a $200 million Cerner project by Queensland Health, which was accused of fast-tracking its Cerner selection by intentionally wording its proposal to exclude other vendors. 

Also in Australia, a Canberra Hospital executive admits that the hospital changed dozens of ED records each day to make their publicly reported ED wait time stats look better. Auditors also found that the user accounts under which the records were altered were generic and had weak passwords that had never been changed. The auditors also noted that the iSoft system has a “feature” of not recording previous values when information is changed, making audit logs nearly worthless had the hospital checked them (which they hadn’t.)

And in yet another Australia story, the government admits that its recently launched $480 million personally controlled health record system can’t accept patient names with hyphens, requiring online registration to be taken down right after go-live. Accenture gets the black eye, not only for that, but also because the system was hacked during development because of what the government says was sloppy Accenture security practices. Other reports suggest that Accenture completed only 40% of the agreed-on work by go-live. The president of the Australian Medical Association summarized the system’s launch as “throwing a paper plane out the window at Cape Canaveral.”

A newspaper in M*Modal’s home state of Tennessee questions why the company wants to sell itself for what some analysts are calling a too-low price of $1.1 billion, saying it’s worth at least $300 million more than that and that it would be better off pursuing its growth with a financial partner rather than a new owner. Several law firms are threatening to file the usual shareholder class action lawsuits that claim the company didn’t hold out for maximal shareholder return.

In Canada, Hotel-Dieu Grace Hospital rolls out a bed control smartphone app that displays available beds, expected discharges, and the length of time ED patients have waited for a bed.

Greenville County, SC pilots software in a program to triage low-acuity 911 calls to a nurse to determine if emergency response is warranted. The chief medical officer of Greenville Hospital System says that 5% of patients use 50% of the system’s ED resources, with 61 patients accounting for 1,000 visits in one year (with one patient racking up 100) and most of them weren’t really emergencies. They cite figures saying that connecting patients to a medical home, managing their care, and helping them with transportation and prescription costs reduced the ED visits by 26% and patient days by 55%. The county says 20% of the 911 calls it gets are for non-emergency situations, but it is still required to send an ambulance at a trip cost of $280. The software they’re using isn’t named, but is used nationally in the UK.

Methodist Dallas Medical Center (TX) suspends its kidney and pancreas donor program after transplanting a donated kidney into a patient who wasn’t next in line on the recipient list. The hospital blames human error – the donor ID number wasn’t matched to the recipient.

UnitedHealthcare launches its Blue Button program, which like the original VA program will allow its 26 million insurance enrollees to view, print, and download their health information by mid-2013.

Access to medical care isn’t a problem for some: the governor of Iowa is hospitalized “out of an overabundance of caution” after choking on a carrot and vomiting it up during a ceremony.

Only in America: a New Jersey woman hit in the face by a baseball at a Little League game two years ago says the 11-year-old catcher did it intentionally when he overthrew the pitcher he was warming up in the bullpen. She’s suing him for medical costs plus pain and suffering, plus her husband has added his own damages of loss of her apparently valuable consort to raise their demand to $500K. The boy’s parents, both Little League volunteers, say they’d like to beat the charges in court, but it would cost thousands of dollars and require the young players to take the stand. The Little League national organization has refused to get involved.

Sponsor Updates

• Sunquest Information Systems hosts its annual users group conference August 6-10 in Phoenix.
• ZirMed earns full EHNAC HNAP certification.
• CSI Healthcare IT spotlights its 2011 sales leader, Bryan Richardson.
• NextGen’s parent company Quality Systems Inc. wins two Gold Stevie Awards in the 10th Annual American Business Awards.
• CPU Medical Management Systems, a division of MED3OOO, releases Version 7.01 of its MED/FM practice management and billing software.
• Consultant Cynthia Castro discusses the ease of the 5010 conversion process using Kareo’s software.
• NextGate posts a fun story highlighting the travel adventures and challenges of two of its engineers implementing NextGate EMPI in Spain. 
• Lancet joins the Informatica INFORM Channel Partner Program.
• nVoq director Derek Plansky discusses the advantages of using speech recognition with CPOE.

EPtalk by Dr. Jayne

The AMA reports that through efforts to process health insurance claims more effectively, more than $8 billion has been put back into the US healthcare system. I’m not sure where the savings has gone. The report mentions that physicians had to spend more time on prior authorizations, adding $728 million in “unnecessary administrative costs and countless hassles.” I’m betting that much of the savings went into for-profit coffers.

No surprise: a study published last month found no association between patient satisfaction and a practice’s adoption of patient-centered medical home processes. A researcher states, “It may lead to better care for the patient, but some of these things maybe turn these places into factories.” Based on anecdotal evidence from the Medicare beneficiaries in my family, I don’t disagree. Team care results in less face time with their physicians. Even though patients get better diabetic care, they don’t perceive it as having as much value as chatting directly with their physicians (even about subjects unrelated to their care).

A bill recently passed in the Pennsylvania Senate moves the Keystone State closer to its first statewide health information exchange. Governor Tom Corbett plans to sign it, setting up the Pennsylvania eHealth Partnership Authority to oversee its development. The goal is a decentralized system to connect regional private HIEs currently under construction.

Citrix offers a video promoting the ability for physicians to always be accessible “whether it’s in the middle of the night or on their day off.” Grammar issues aside, I’m not in favor of the idea that physicians need to be accessible 24×7. I see too many burned out docs on a daily basis. New technologies allow them to access charts from everywhere, making them reluctant to sign out to covering partners. Allowing people time to unplug and participate in self-care activities is essential to promoting healthy caregivers. I know the kind of decisions I make when I receive a phone call at 2 a.m. while I’m on vacation, and they’re generally not at the level I want to deliver where patients are concerned.

For ambulatory EHR developers: a recent study finds that more than 25% of American teens have sent nude photos of themselves electronically. The authors suggest that physicians who care for teens ask them about sexting practices. It’s time to think about adding some new questions to those well-child visit templates, I suppose.

Quote of the day: “Harassment is supposed to be sexy. You’re not even doing it right.” Thanks to one of my favorite consultants, I was recently introduced to Better Off Ted. For those of you who haven’t seen it, the plot revolves around the R&D department of a soulless conglomerate. In some ways it reminds me of our industry. Episodes are 21 minutes long, which is just the right length to take a break but not feel like you’re idly wasting time.

Thanks again to all the readers who sent birthday wishes on Facebook, Twitter, and e-mail. It was nice to receive them throughout the day and they helped mitigate any dread of being a year older. I’m pretty sure being a CMIO ages one more rapidly than other careers. However, I’m content knowing that with age comes wisdom (or at least the sense of having been there and done that, and knowing how much heartburn a new project will bring when you see it coming 50 yards away).

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Interviews Ralph Fargnoli, CEO, Beacon Partners

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

Tell me about yourself and the company.

I started my healthcare career in a health system in Rhode Island that was an early adaptor of technology. I started working at IDS up on Commonwealth Avenue in Boston in 1983. That really put me into the forefront of healthcare systems, working for Paul Egerman. I worked at IDS, which changed their name to IDX, until 1988. 

I was managing many implementations. What I saw in the management of those implementations was that they were hiring consultants. The consultants were at the time, I think, Big 8 or Big 10. I felt that I had some things to offer the other side of the table, and instead of working on the vendor side, working on the consulting side. 

I left IDX and started Beacon Partners in 1989. The goal was to provide healthcare professionals with experienced healthcare professionals who understood their business, who understood the technology and how it would impact their business. From there, Beacon has grown substantially from a small company focused mainly on IDX to 300 employees, with service lines of the major vendors including IDX, Epic, Meditech, and Siemens.

We’ve been shifting our business to be more strategic in nature over the last three years. We are focusing more on strategic planning, working with many organizations about aligning physicians, changing over legacy systems, ICD-10, security, and so forth. The business model has changed from just providing implementation and project management services into strategic areas.

Beacon Partners is a national firm. We have clients from Hawaii to Puerto Rico – actually to Ireland — and of course, in Canada. We have a Canadian practice with clients in most of the provinces except Quebec. 

The growth has been exciting. It has been fueled by technology, but also all the opportunities with regard to the regulatory and compliance issues that are either being mandated or pushed into the provider world by the federal or the state government. We’ve put together a good senior leadership team, and you’ll see announcements about new people who are joining the company. 

It’s an exciting time to be in this business. We look for another five to 10 years of growth and opportunity for everyone in the company.

Do your customers care about innovation and competitive advantage when they’re choosing systems vendors? Or are they just trying to make modest process changes and measure those in hopes of learning from the data what they should do next?

My perception is that customers are trying to find some type of innovation, something that will help their patients and their provision of medical services and in getting to data to help them with patient care. But it looks like to me it’s unknown whether that will be the ultimate outcome of all these major investments that are going on right now.

We see a lot of demand for vendor software, but what I also see is that it seems to be a market play. Let’s get as much software in as we can, then we’ll go back and optimize it and see what kind of data we want to get out of our system. So to me, it’s more of a technology push. 

I think we also see that in the studies that are being done, physicians are not really bought into all this technology. They feel it’s interfering, or that it’s not the right software for them to practice medicine so far. 

I think that the innovation of how to use data to enhance patient care will be over the next three to five years, versus what we see going on right now, which is basically just a technology replacement and adaption.

Have you seen examples where someone truly got a lot better clinically or operationally by just installing something?

I can say that in some of our clients, we have seen that they’re starting to use the data in their research or they’re trying to understand patient access and looking at opportunities for more advanced service lines for patient care. We’re starting to look at that. I also see data analysis for cost controls and understanding what their true costs are.

I think we all know about the Kaisers of the world and Mayo Clinics and Cleveland Clinics. They seem to be at the forefront. I think many organizations need to understand how they’ve turned their technology investments to a competitive advantage, because I see many of our clients still at that phase where they’re trying to get the systems installed and have some type of realization on those investments.

Their model is different than 99% of what goes on in hospitals and they can afford technologies that nobody else can. Can what we learn from them be plugged into the average 200-bed community hospital?

That’s going to be very difficult. Kaiser is a not-for-profit, but it’s a well-run business corporation that provides medical services. The 200-bed  community hospital is not there. They’re not business people. They’re not driving it towards running it like business. I think they’re caught up with the patient care aspect of it and the patient services, which is their mission, but they truly need to take a step back and say, “That’s our mission, but how do we do this in the best way to maximize these investments, to get realization of these costs so we can contain them for the future of our mission?”

I think many organizations look at it independently. I look at it that we have technology, we have patient care, we have our physicians. If you look at some of these organizations and the way they’re integrated in their communication of technology and how we’re going to use it, it seems to me very siloed. They’re not there yet.

Will reimbursement and policy changes, along with the difficulty in delivering technology, do the same as it did for the solo independent physician practice, to the point that it will no longer be practical to run a 100-bed unaffiliated community hospital?

I do think that most, if not all, of the community hospitals will eventually have to align. It’s interesting here in Massachusetts. We have a very good community hospital, South Shore Hospital, that is now aligning itself with Partners HealthCare System. It has been a strongly-willed independent, but they need access to specialty care to drive their competitive nature. They’re aligning themselves with Partners because they need the dollars for the specialty care. They also want a more competitive edge against other community hospitals that are also forming their own smaller systems. You see the physicians not only aligning, but actually becoming employed by these hospitals.

I see a trend where you’ll have a network of the smaller community hospitals, but they will try to maintain their independence like South Shore. South Shore Hospital is going maintain their independence to some degree and the physicians will become employed, but I think they all have to be at some point integrated to maximize technology investments, to maximize data exchange, and to control their costs. They all realize that with all the specialties out there now and new technologies for medicine, they all can’t afford it. They all can’t just be independent in that degree and make those investments, so they have to leverage each other at what they’re good at. I think that will evolve over the next couple of years.

Meaningful Use has been good for the healthcare IT business. Do you think it’s been good for providers and patients?

I’m not sure how much patients know about Meaningful Use in the sense of technology adaption. I think providers look at it with some degree of angst, especially some of our senior providers. There seem to be mandates and a lot of push, that Meaningful Use dollars to grab the incentives and avoid the penalties. From an organizational standpoint, it helps with the investment. Of course it doesn’t pay – I  would be surprised if it paid for 25% or 30% of the total cost of the investment.

Some providers are definitely excited about the adaption, but I think some of them are finding hurdles to it. Now they have to change their work flows. It’s not necessarily the way they’ve practice medicine for years. What we see out there is a lot of hesitancy, a lot of training and educational issues.

On the patient side, we see some questions about, “Why is he staring at his computer? Why is he typing and not paying attention?”

We have many of these physician rollouts going on. The word from the consultants is that patients seems to be curious about the technology and there is a learning for physicians to try to balance the patient attention versus getting the information into their system. It’s definitely going to be a learning curve for both the patient and the provider and how to interact with each other in the technology.

Until the patient sees the benefit for being at home and being able to access portions of their medical record to see their lab results — that’s happening today, but as more and more get that access, we’ll see a better response to it all around. I think even the physicians eventually will see that this is a good use of technology so they don’t have to make phone calls and push out letters and so forth.

A lot of the attention of the providers is being directed toward Meaningful Use and implementing the systems required to get the financial carrot. When do you see that tapering off, and then what’s the next hot issue waiting in the wings?

I think Meaningful Use will start to end probably around the 2016 timeframe, but I think the technology adaption will be around for at least five to 10 years. I look at what we see as some deficiencies in technology out there. There’s just so much to be done that the market, from a technology adaption standpoint, could go on for the next five to 10 years. Meaningful Use, because of the timeframe that the government has put in place — there’s a great push to avoid the penalties. When we get to the penalty side — like anything else that happens in healthcare and with the government — they could say, “We’re not going to penalize you. We’ll push it out for another year.” 

What also is driving our business and others like us is the changeover in ICD-10. That’s going to be a major project for many organizations. I believe that most of them are not prepared to take this on. They’re not thinking about how it impacts their downstream revenue when this happens. 

We also have security of patient information as we pass data from organization to organization through HIEs. That’s something that we see as a business driver also, because there’s a lot of questions out there. How do protect the PHI? As you probably see, we’re not very good at it yet. We seem to have PHI on laptops and USB drives. We have basic password issues. 

Business intelligence and understanding data from all these investments that we’re making is going to be a large business driver for us and others the next five years.

Any concluding thoughts?

We seem to be spending an awful lot of money adapting technology. Organizations that are no more than maybe five miles apart are spending $75-$100 million to adapt similar technology as a competitor down the street. At some point, some of these boards that approve these projects are going to be asking “We spent this money. Are we getting the ROI and meeting the expectations from these big investments?” Many of these boards are approving these large implementations and procurements of these systems, but not really understanding the magnitude of what it takes to get this done.

As we progress over the next couple of years, this is going to be a business driver. We see it as an opportunity, if you have the right people, to help these organizations be successful. I also believe that someone needs to take a step back and look at this and say, “Do we have the people? Where are we going to get the resources?” 

I think that they’ll be questioning whether these investments are paying off. Also, whether they can use the data they have collected to improve and enhance patient care.

Over the next three to five years, those questions will be asked. It will be interesting to see what those answers come out to be. I’d still question many of these organizations spending these dollars very independently from each other. Why not together?

News 7/4/12

Top News

Speech recognition vendor M*Modal will be acquired by the private equity arm of JP Morgan Chase for $1.1 billion in cash, representing an 8.3% premium over Monday’s closing share price. Philips owned a 70% share of MedQuist until 2008, when it sold its shares to CBay for $200 million. The resulting MedQuist Holdings then acquired bankrupt transcription vendor Spheris in 2010, acquired M*Modal in July 2011 for $130 million, and then took that company’s name in January 2012.

Reader Comments

From HISEsq: “Re: Cerner. Sued for patent infringement by a patent troll named CeeColor, whose only claim to fame seems to be suing HIT and security companies.” CeeColor’s intellectual property, like that of other patent trolls, is vaguely described. In their case, it’s a proximity-based computer security system. I mentioned in March that the same company sued Imprivata claiming similar infringement. Googling their name turns up nothing but lawsuit filings, so one might logically assume all they have is a patent bought elsewhere and a lawyer with lots of free time available to hound companies into paying them “licensing fees.”

From Reppin’: “Re: GSK. You should run the GSK Las Vegas sales kickoff video if you can find it. That’s what’s wrong with healthcare. The big boys scream to government, ‘Get off our backs, we can regulate ourselves.’ They can’t, and a $3 billion fine is nothing to them. Executives should have been fired. They aren’t alone: Abbott, Pfizer, etc.” Drug maker GlaxoSmithKline will pay $3 billion for promoting two of its popular drugs for unapproved uses and for hiding safety information about a third drug. Its marketing tactics included sending doctors on pheasant hunting trips to Europe and paying them for speaking. GSK pushed doctors to prescribe Paxil for depression in children even though the drug was not approved by the FDA for patients under 18. GSK says it has learned its lesson, which would be remarkable given the very long list of similar problems the company has bought its way out of over years (overbilling Medicaid, charging third-world countries high prices for AIDS drugs, adulterating drugs, dodging US taxes, and hiding drug side effects.) Company profits dropped in the most recent quarter to a “disappointing” $2.1 billion, so the “huge” fine amounts to around 18 weeks’ of profit. Maybe that’s the lesson they’ve learned – settlement payouts for arguably criminal wrongdoing are just a marketing cost. If it were me, I’d go after the docs who were willing to place their patients in danger for perks – publishing their names publicly should have been a condition of the settlement. We know drug companies often lean toward scumbaggery given ample opportunity, but they didn’t take the Hippocratic Oath and represent themselves as the patient’s advocate while pimping out their prescription pads.

From Luis: “Re: GSK. Cleveland Clinic is mentioned. Did they find the drug problems with data mining out of Epic?” The original journal article was published by Steven Nissen MD, chairman of cardiovascular medicine at Cleveland Clinic and drug company critic. He did the legwork proving that Vioxx and Avandia cause problems, leading to an FDA crackdown on their use. Above is an interview in which he talks about healthcare reform and how Cleveland Clinic is different. They went live on Epic on the ambulatory side in 2000, so they may well have dug into their own data to link drugs to patient harm. Even if they didn’t, many health systems will be able to do that going forward – all they need is enough patients to make a valid sample size.

From GreenGiant: “Re: Valley Medical Center, Renton, WA. Live on Epic ambulatory on July 2.” I apparently missed the link on their main page. Its board voted in December 2010 to move from McKesson to Epic.

From HIT Guy: “Re: fat-producing foods. The Supreme Court talks about broccoli, healthcare firms punish obese workers, and Vince Ciotti talks about making certain foods expensive. Science is now saying that diets that were previously thought good for you aren’t, and the early studies were good examples of how not to do a study.” A New York Times article talks up a theory that I believe in firmly: weight isn’t as simple as calories in minus calories out, with a new study finding that it’s more about the carbs consumed than the calories. My theory is that weight problems are due to fat storage and insulin regulation (i.e., the hypoglycemic index), not just taking in more calories than are burned off. I also believe that not all exercise is created equal, and pure cardio is good but building muscle is better. You can run your butt off on the treadmill for an hour and only burn the equivalent of a candy bar, so that’s not going to work for most folks unless their body composition changes.

From James: “Re: healthcare system repair. Taiwan was a free market system like ours and became one of the best by going with a single payer, which gets the full pool of money for both healthy and sick patients, can’t cherry pick the young and healthy, negotiates prices with providers and manufacturers, and makes judgments for what to reimburse. Private payers still have a crucial role for all the stuff that the main payer doesn’t cover, like physical therapy, allied health, home care, etc.” I’m frustrated enough with the current non-system here that this alternative is sounding attractive.

From Tom: “Re: healthcare system repair. If I could change one thing, it would be to eliminate employer-based health insurance, a remnant of the World War II era. Individuals buying insurance directly from payers improves continuity of care, removes a major employer cost, incents individuals to manage their health, and reinforces the need for interoperability. It would open the floodgates on HIT innovation and use of tools such as mHealth and PHRs.” I’m becoming cynical that any solution that involves insurance is doomed. Not only because insurance companies will always find ways to make a profit from healthcare, but because healthcare insurance covers more than just catastrophic situations. Homeowner’s insurance is relatively inexpensive because you collect significant amounts only if you suffer major damage, which nobody in their right mind wants, so if we all pay a little everybody is spared from losing their home due to a tornado or fire. Imagine the cost of homeowner’s insurance if it covered every possible problem with appliances, appearance, and the lawn and business were created around collecting inflated payments for providing those services. Not only would policies be priced out of reach, services would become so expensive that you’d have to have insurance to afford them, causing prices to just keep going up to everybody’s benefit except the person needing the service. I’d like to see the concept of healthcare separated completely from the requirement of buying a third-party company’s actuarial bet that you’ll consume less of it than they charge you.

From SW: “Re: ACA. Stan Hupfeld, former president and CEO of Integris Health, wrote an excellent book summarizing the Affordable Care Act, why solutions for other countries won’t or can’t apply here, and how neither party serves us well.”

From CIO: “Re: ROI due diligence on clinical systems. My organization is spending many dozens of millions to install inpatient clinicals. We paid attention to ROI, but it was not the driving factor, and actually I am grateful for that. Proving out a hard ROI is not only a challenge, but I think it diverts attention from the real reasons an organization may want to pursue a new system. Our organization changed our IT strategy after years of integration issues from a ‘best of breed’ to ‘integrated clinical system.’ We did this prior to the guarantee of Meaningful Use funding because we felt it was the right direction for our organization and patient safety. As a part of our new system installations, we resolved a number clinical and IT data exchange issues that have improved patient safety measurably. One small example relates to interface issues with messages erroring out, requiring manual work to resolve the specific problem. On occasion this included patient allergies and other vital data. And for those of you in the industry, you know all the other examples of data exchange challenges that also impacted best of breed approaches. We could have put a price on risk / actual claims / patient harm for this and related issues, but we kept on focus on the improvements we wanted and not the dollars. And frankly with all the other challenges pressing down on hospitals, I take some pride in knowing that we have a safer environment with our new system than our prior ones. This approach may not stand up to real accounting scrutiny, but I think the real question is, ‘Are patients materially safer?’ For us, the answer is yes.” 

From Bruce Brandes: “Re: Pliny’s question about FDA regulatory oversight of mobile apps. What Pliny is describing is a clinical decision support system. FDA considers these to be at least Class 1 medical devices per their mobile medical app guidance. Where the data is processed is not important. If the input and display take place on a device, whether it’s a mobile app, web page, terminal application, hardware/software product, then the device is a medical device and subject to regulatory oversight. The determination of whether the device is considered Class 1 or 2 depends on the risk to the patient attributed to a misdiagnosis or delay in treatment. From a regulatory standpoint, class 1 and class 2 devices require the company establish and maintain the same quality management system and design and servicing controls. The only difference is Class 2 devices require premarket approval by FDA, Class 1 devices do not.” Bruce is EVP and chief strategy officer of AirStrip Technologies, which has a lot of experience working within FDA guidelines. I’ve always assumed that most of the healthcare apps out there weren’t created with the FDA in mind, but maybe I’m wrong. Feel free to chime in.

Acquisitions, Funding, Business, and Stock

HealthStream acquires Decision Critical, an Austin, TX-based provider of learning and competency management products for acute care hospitals, for $4.3 million.

Dell will purchase IT management software provider Quest Software for $2.4 billion.

Microsoft announces a $6.2 billion write-down of the $6.3 billion in cash it paid to buy online advertising company aQuantive in May 2007.

Announcements and Implementations

Catskill Regional Medical Center (NY) goes live on Epic in its two hospitals of 235 and 25 beds.

Grand Itasca Clinic and Hospital (MN) announces a partnership with Allina Health System to install Excellian, Allina’s version of Epic. Allina will provide implementation assistance and support.

The local paper highlights the T-System and NextGen implementation of White Mountain Regional Medical Center (AZ).

David Runt, CIO of Contra Costa Health Services (CA), tells me that they went live on Epic (called ccLink at their place) on July 1 enterprise-wide (hospital, clinics, and health plan.) I notice from David’s LinkedIn profile that he spent 22 years as a medical service corps officer in the US Air Force Medical Service, so I’ll throw out an Independence Day nod to David and his fellow veterans for their service.

In the UK, Cerner complains to Cambridge University Hospitals Foundation Trust that its EHR bidding process was a sham and it had already chosen Epic without regard to submitted prices. The trust says it followed the rules when it picked Epic in April.

Oracle announces its Health Sciences Network for developing and conducting clinical trials, working with Aurora Health Care and UPMC to create a cloud-based system to manage de-identified patient information from member providers. Aurora was a key player, providing its patient information in hopes of improving its work in several hundred research studies. Expected challenges include the possible unwillingness of academic medical centers to participate, the difficulty in combining information from a variety of proprietary EHR data formats, and the storage required to eventually add genomic information.

Caradigm, the Microsoft-GE Healthcare joint venture, announces that the number of active users of its identity and access management solutions (Vergence, expreSSO, and Way2Care) has increased by 50% in the past 18 months.

Government and Politics

A proposed California bill would change the Confidentiality of Medical Information Act, which allows patients to sue healthcare providers for up to $1,000 per breached medical record. AB 439 would eliminate damage awards for first offenses and in some cases for repeat offenses if the provider notifies patients whose records were exposed and takes preventive action. The bill’s sponsor is McKesson.

Innovation and Research

The for-profit technology subsidiary of Palomar Health Foundation, which operates Palomar Pomerado Health (CA), announces that AirStrip Technologies has acquired exclusive rights to its MIAA mobile EMR viewer application. I first wrote about it in February 2011 when Cisco was helping pay for its development.

DataMotion files a provisional patent for a Direct Project-based secure e-mail messaging system for patients and providers.

Other

A London Daily Mail article covers Epic Systems. It’s loaded with snark and off-topic rants, but says that not only will Epic sign a $16 million, two-trust contract, but will soon take on another two hospitals in England and most likely bag more as each trust makes their own decisions and sees the value of using Epic as a data-sharing replacement for the failed NPfIT. It describes Judy Faulkner as “a 68-year-old Harley-Davidson-riding friend of President Barack Obama” who lives in a “nice, but not palatial” house. The paper tried to pry information from someone who answered the phone at Epic and was told, “Your messages have been passed on, and if we want to get back to you, we will.” It speculates that the massive Verona campus expansion was spurred by the likelihood of Epic’s expansion in England.

Another Epic article, this one from Wisconsin, describes the company’s construction boom, with its reporters counting 12 construction cranes hovering overhead. The company expected to hire 300 more employees in June and 1,000 more for the year, bringing its total to over 6,000 (and another 750 expected next year). The Farm Campus will add another 1,000 offices, underground parking for 1,000 cars, and the 11,000-seat auditorium that looks like a UFO crashed and buried itself into cow field. The article says the new construction on the 811-acre campus is valued at around $400 million, with 1,300 construction workers on site making it the biggest construction job in the Midwest.

Orthopedic surgeon Larry Bone MD (I’m not making that up) finishes up basic training and is shipping off to Afghanistan for a three-month tour of duty as a battlefield trauma surgeon. He’s 64. The head of orthopedic surgery at the University of Buffalo wants to give back for the treatment his son received after an IED explosion in Iraq six years ago.

A JAMIA article evaluates CPOE orders that are cancelled and then immediately re-entered on a different patient, concluding that over 5,000 orders per year are being entered on the wrong patient. The proposed solution: make physicians enter the patient ID twice before allowing order entry.

In England, a 22-year-old teaching hospital cancer patient becomes delirious from dehydration and missed meds, finally dialing the equivalent of 911 to say he’s thirsty and nobody will give him water. Nurses send police away when they arrive, but the patient dies shortly afterward. His mother, who says her son was restrained, sedated, and ignored in his room the night before he died, said a nurse asked afterward, “Can I bag him up?”

Sponsor Updates

• Bottomline Technologies offers webinars on payments and cash management.
• RelayHealth shares details of its role in preparing for ICD-10.
• Liaison Healthcare Informatics will provide awareness activities in support of National Health IT Week September 10-15. Liason is also sponsoring NCHICA’s quarterly roundtable meetings for CIOs and CMOs/CMIOs.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Mobile.