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Monday Morning Update 1/7/13

January 5, 2013 News 10 Comments

From Willy Mays Hayes: “Re: Cerner. Our remote-hosted Cerner system just experienced a six-hour downtime that they are attributing to hardware failure in Kansas City. We’re wondering how many other clients were effected.” Unverified, but speak up if your system went down.

From Zorba P: “Re: non-compete agreements. A Wired essay says enlightened companies realize that non-competes hurt the economy.” The article didn’t convince me that companies shouldn’t require employees to sign non-competes, only that allowing employees to freely take their proprietary knowledge to a competitor might increase competition and thus economic output. Maybe it all works out where companies poach each other’s people like a Cold War spy exchange, but the odds of that intellectual property flow being equally balanced among all competitors seem slim and some companies are going to lose. The article tries unconvincingly to make the point that Boston’s Route 128 startup environment lost out to Silicon Valley because California law essentially voids all non-compete agreements, leaving the Massachusetts companies with no-choice lifer employees who stagnated their employers. I might agree with the conclusion that employees should be free to immediately leave and start their own companies since the economy would benefit from having more entrepreneurs and fewer unmotivated corporate clock-punchers, but I’m just not comfortable with the idea that any company with big pockets should be able to steal competitive secrets by simply hiring away insiders.

From The PACS Designer: “Re: Pebble e-paper Smart Watch. Our Travis Good posted in The Year of the Health Gadget about Pebble e-paper Smart Watch, so TPD thought it would be a good addition to the upcoming update of TPD’s List of iPhone Apps. Also found a YouTube preview explaining its use in transferring apps from mobile devices to the wrist watch.” I inadvertently burst out laughing at 0:20 when the company’s “Dream Team” (i.e., stereotypical startup nerds) make a reluctant and un-photogenic appearance, displaying palpable discomfort at being exposed to actual sunlight and fresh air. If your life won’t be complete without a rather ugly but smartphone-connected watch whose least-interesting capability is telling time, you’ll pay around $150 if it ever reaches the market (pre-orders started in May and the company isn’t providing updates), you’ll be buying from a company that failed previously before renaming itself and raising $10 million on Kickstarter, and you’ll be waiting until they find Asian companies willing to build their product cheaply. Not to mention that depending on hard-to-predict fashion acceptance, you’ll either look like the coolest kid around or a clueless idiot flashing a geeky Dick Tracy calculator watch.

1-5-2013 7-27-03 AM

As healthcare IT professionals, we’re even more skeptical than laypeople that providers can keep our medical information secure, with 84 percent of poll respondents saying they lack that confidence. New poll to your right: have you used a patient portal offered by your PCP? I have, and I like it — it’s convenient for making appointments, checking lab results, and pre-paying for a visit and printing a barcoded page that lets me check in at a kiosk instead of waiting in line.

1-5-2013 7-41-43 AM

Welcome to HealthITJobs, sponsoring both HIStalk and HIStalk Connect at the Platinum level. I like the clean look of their site, which has some pretty cool jobs listed. Employers typically need to fill positions in a hurry, and with HealthITJobs.com, positions you post go online immediately. Job hunters can manage the process from their smartphones: checking for openings, receiving real-time alerts when new jobs go up, and even applying for jobs from anywhere. As an employer, I’ve posted hospital IT jobs on some of the big job boards and it’s usually been a disaster, with 95 percent of the applicants having no healthcare experience, no US work credentials, or clearly insufficient capabilities. HealthITJobs focuses on health IT professionals, so you won’t be have Bolivian bricklayers bugging you about your CMIO position. The biggest regret I have about the crappy jobs I’ve held as an employee (thankfully not recently) was that I let inertia keep me from getting serious about moving on. It would have been so easy then and even easier now to find a new gig: register, download the iPhone app, and see what’s out there (hint: it’s a booming industry, so there’s a lot). For employers and recruiters, unfilled positions cost a lot of energy and money, so HealthITJobs is a painless way to post your listings and find that one right person who’s apparently not perusing your listings posted elsewhere. Thanks to HealthITJobs for supporting HIStalk and HIStalk Connect.

1-5-2013 7-43-31 PM

Hackers hit the servers of UNC Lineberger Comprehensive Cancer Center (NC), exposing the information of 3,500 employees and contractors. No patient information was involved. The breach occurred in May, but those affected weren’t notified until after Christmas. University IT employees say their servers are hit with attempted hacks thousands of times every hour.

CMS announces a 90-day extension for meeting Affordable Care Act transaction standards for eligibility and claim status. The reason given: nobody was going to be ready.

1-5-2013 7-44-27 PM

Wolters Kluwer Health completes its acquisition of Health Language, Inc., announced in October.

The fired former president of University of North Texas Health Science Center says he was let go for a variety of not-so-good reasons. One of them was his analysis of an all-campus shared services business center, which he says upset the university’s chancellor because it found that the health science center was paying twice as much as before with reduced quality, including a two-day EMR downtime that affected patients.

1-5-2013 7-33-02 PM

Home medical billing software vendor Brightree LLC acquires CareAnyware of Raleigh, NC, which sells home health and hospice software.

1-5-2013 8-43-06 AM

Reuters covers the recent Critical Care Medicine article in which researchers used plagiarism detection software to determine that most physician progress notes contained at least 20 percent material copied and pasted from elsewhere in the electronic record. I pulled up the original article (thanks to my academic medical center employer for providing remote access to our online journal library) and offer these observations:

  • It was a one-hospital study (MetroHealth Medical Center, Cleveland) of 135 patients admitted to a 14-bed ICU for at least three consecutive days.
  • The EMR system was Epic, which offers built-in functions for copy-paste and copy into a new note.
  • Residents copied more often, but attendings copied more actual text.
  • The threshold for identifying copying was phrases of at least four words and 20 or more total characters that contained at least a 20 percent match.
  • The authors did not interview any of the physicians found to have copied material, did not postulate why they did so, did not ask those involved in care of the identified patients whether the copied material negatively impacted patient care, and drew no conclusions about the potential or actual impact of copying progress note text on patient outcomes.

My conclusion: like many studies that raise a red flag and then run, this one seems to have been thrown together and executed quickly, resulting in a slightly interesting article that has no meaningful conclusion other than that someone with more resources should do a better study. Doctors may well copy progress note material, but that’s not necessarily a bad thing given that EMRs don’t typically offer easy ways to tag highly relevant material from the routine junk that hospital administrators, regulators, and malpractice lawyers require. It should be assumed that bringing material forward has an at least an equal likelihood of being positive for the patient since it might be missed otherwise. And intentional copying is a lot less bothersome than template-generated babble that looks good but says nothing useful.

Everybody wants to armchair quarterback how doctors document. How would you like having a roomful of stern third parties examining every e-mail you write for relevance, insightfulness, originality, and style, looking for opportunities to reduce your pay or sue you? If doctors aren’t complaining about the body of progress notes they work with in caring for their patients (including attendings reviewing the work of residents), then the armchair quarterbacks aren’t likely to find a smoking gun of vast conspiracy or widespread negligence.

If you’re a hospital, set standards on how documentation should be done. Demand that your EMR vendor develop ways to separate the useful from the worthless, and to add logic that considers the age of a documentation element and its graded value from individual providers in predicting its relevance. If you want elegant and thoughtfully composed prose, expect to pay for it in reduced physician productivity. And if you can prove that particular methods or styles of progress notes directly impact patient care, let’s see your data.

I think we can agree that electronic documentation works better in theory than in practice due to poor design and unguided use and therefore could be improved. To that end, I’ll close with a pithy quote from contributor Robert Lafsky, MD: “I’d sure like to see that visiting expert professor try to unravel a difficult case using nothing but the printed output from a typical EMR.”


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

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Currently there are "10 comments" on this Article:

  1. Regarding Non-Competes….I’ve often wondered about the many vendors who insist all new employees sign a stiff non-compete agreement, then sic their lawyers on any who leave and go to a competitor, yet blatantly hire top sales reps or developers from those very competitors. Can you have it both ways?????

  2. Robert Lafsky, MD: “I’d sure like to see that visiting expert professor try to unravel a difficult case using nothing but the printed output from a typical EMR.”

    Not possible. There ain’t no way for an effective clinician to figure out how an illness got to where it is today and what the illness is (diagnosis) when the entirety of the details of care is in random silos, each with its own chronological order. Gee, I wonder how the new HHS and ONC safety program will address this.

  3. Re: the “thrown together” EMR study… even that term is generous. As it stands, it adds to the recent glut of articles blaming physicians first and EMR’s second for the “crime”… the “fraud” (to use CMS’s term) of “cut and paste” and “cloning” of records. (The use of the latter term appeared out of the blue as applied to medical records, in an attempt to sound sinister). The study should focus on the real problem. In reality the villain is not the physician OR the EMR; it is the reimbursement system that pays for repetitive, meaningless verbiage. No one EVER put a social history and family history and a “count the systems ROS” in every note, until Medicare started paying them to do so.
    Have the authors ever heard of a controlled trial? The fact is that many things don’t change from visit to visit. I would bet that if they compared EMR’s to paper records they would find that the latter had a significant amount of “copied” verbiage as well. Less copying with paper? Probably so…but not because of any difference in accuracy; just because the docs didn’t have time to copy it by hand.

  4. I have to assume that your endorsement of a patient portal without a vendor name drop means that your portal vendor isn’t a HIStalk sponsor… Epic’s MyChart?

    [From Mr. H] Being a sponsor has nothing to do with being mentioned. I’ve said before that my PCP has switched to Epic, but not MyChart yet (but coming soon, I would bet). The portal his group uses is homegrown, I suspect, since the practice is university affiliated, but nobody there seemed to know when I asked.

  5. Copy and pasted covered by Reuters: Well then but, the US government wants cookbook uniformity of medical care but does not want uniformity in progress notes.

  6. I think the assumption that non-compete agreements are primarily used to protect industry secrets is incorrect. Preventing employees from pursuing new opportunities in the industry with which they have the most recent and likely the most overall experience has the effect of depressing wages and reducing turnover. This also cuts other employment costs like training expenses. That last point wouldn’t be as significant if the entire industry allowed skilled employees to move between jobs freely as those employees wouldn’t require as much training but this is an example of the tragedy of the anti-commons.

    This is more about restricting labor freedom and keeping labor costs in check than protecting secrets. If wasn’t about that why would employees with very little access to technical and strategic secrets face the same restrictions as the very technical and strategic group? Making it harder for your employees to leave also means you can treat them much worse and for the most part they just have to take it. That said, as much as I dislike non-compete agreements I really hate secret no-hire agreements. The idea that companies like Epic can strong-arm their partners into agreements which restrict where Epic’s employees and people who have never even worked for Epic can work without disclosing to those people that these agreements even exist is disgusting.

    One final note on the matter of secrets, I had a relatively lenient non-compete with Epic dating back many, many years and after I found out that Epic had no interest in holding up their end of that agreement thanks to their secret no-hire setup I would have been tempted to tell Epic’s competitors whatever they wanted to know about Epic for free if they’d asked.

  7. Re: Pebble and Kickstarter – they have provided updates and have done so almost monthly with videos, picture galleries and updates on the process.

    The word in the media is that they haven’t done that. But, I can tell you that as a Kickstarter backer I am excited that they are finally getting closer to final production and shipping. Too many people bashing a start-up and too many “immature” comments from inpatient backers have spread that rumor deep and wide – they were NOT an established company with a final product ready to ship – that’s why they went through Kickstarter.

    It was only $110 for me to back them at the time last spring and I am still glad I did it. I look forward to sporting my Pebble, hopefully at HIMSS in New Orleans. We should know on Wednesday about shipping during their CES live announcement. I also look forward to wearing it while I run with my RunKeeper updates ready for me to see. I also hope it ships with Bluetooth v4 as promised. Maybe Apple will buy them when it finally hits the streets…

    I think they are still ahead of the competitors that have tried to come out before they ship. What I have read about Sony’s so-called Smartwatch is shameful and indicative of where Sony is these days. It does take time and I would rather the shipped version work and have true utility and functionality than just be a piece of dead plastic. Hopefully, the “vaporware” that is/was Pebble will materialize on my wrist one day soon!

  8. @RustBeltFan: Most of the major vendors have non-competes, but understand that people have a right to switch jobs. They generally don’t enforce the non-competes unless there is a contentious departure and some risk of trade secrets being passed to a competitor. Epic is unique in blackballing any and all employees who leave – despite the fact that they purposely hire fresh college grads who are highly unlikely to work at Epic for an entire lifetime.

  9. Re: Non-Compete Agreements
    While non-compete agreements certainly have some basis in the sharing of proprietary information (trade secrets or client based info) many of the companies in our industry simply dont want their employees leaving and becoming their competition. IE: Cerner Analyst leaves a large consulting firm and becomes an Independent Consultant. Also in many of these cases non-compete clauses will not hold up in court and in California they are automatically void due to a California Civil Code from the late 1800’s.

  10. “Everybody wants to armchair quarterback how doctors document. How would you like having a roomful of stern third parties examining every e-mail you write for relevance, insightfulness, originality, and style, looking for opportunities to reduce your pay or sue you? If doctors aren’t complaining about the body of progress notes they work with in caring for their patients (including attendings reviewing the work of residents), then the armchair quarterbacks aren’t likely to find a smoking gun of vast conspiracy or widespread negligence.”

    Already a contender for quote of the year and it’s just the first week of January! Always razor sharp and wonderfully poignant. Thanks again, Mr. H. 🙂

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