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Monday Morning Update 5/26/14

May 24, 2014 News 13 Comments

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Cerner CEO Neal Patterson tells shareholders that the company is transitioning from a healthcare IT company to a healthcare company, echoing sentiments expressed in the company’s most recent earnings call. Cerner executives say the company will dominate areas that include aggregating information across providers, reducing healthcare costs, improving outcomes, and providing consulting services related to population health management.

Reader Comments

From Katherine Kroessler, MD: “Re: EMRs and Meaningful Use. The burden is overwhelming for small practices. More physicians will become employees and use systems where someone else crunches the numbers. My small practice’s EMR is fine for MU, but it has increased our overhead and staffing and thus has decreased physician income. We have some electronic lab/DI data and others come on paper. Docs fax paper referrals and we fax back paper consults because our systems don’t talk to each other. Information gets put in folders to be scanned and has to be tracked down when the patient is in the room. However, if you are in a large contained system, all of that works seamlessly. The government should have created an incentive for IT vendors to use the same interface requirements so their systems could talk to each other. Doctors are being reduced to clerks and spend more of their valuable time clicking boxes and coding unless they are part of a large infrastructure that automates that for you. I just hope that new doctors will know how to think about patients and not just how to copy and paste notes. Listening to our patients is our most important skill because, at least in neurology, 90 percent of the time the diagnosis comes from the history. Doctors will become employees of large systems and their thought processes and workups will be governed by those systems. Let’s hope the systems get it right because the MDs phasing out of medicine will all be Medicare patients soon enough.”

HIStalk Announcements and Requests


Eighty percent of respondents think ONC should certify EHRs only if they offer external program access (APIs) for interoperability. New poll to your right: is the Meaningful Use Stage 2 slowdown good or bad?

Announcements and Implementations


KLAS announces that it is developing a myKLAS mobile app.


Epic is named the #5 best company for employee pay and benefits in a Glassdoor review of employee surveys. It’s probably the one company on the list whose name the average American wouldn’t recognize.

Government and Politics

The White House says HHS has passed a cybersecurity assessment that was required by a presidential order, saying its voluntary efforts are sufficient to address cyber risk.

Oregon Governor John Kitzhaber said he fired the director of Oregon Health Authority in March effective immediately over the Cover Oregon health insurance exchange debacle that will end up costing nearly $300 million, but the local paper discovers that he’s still on full-time status and getting paid $14,425 per month, at least until July when his vacation pay runs out. Federal investigators issued several subpoenas last week to people at both the health authority and the insurance exchange, apparent interested in finding out whether state officials lied to CMS about the project’s status to get more federal money.  

CMS announces the second round winners of its Health Care Innovation Awards. Among them: $15.9 million to the American College of Cardiology Foundation for  the SMARTcare provider feedback and decision support tools for reduction of inappropriate procedures; $7 million to the Association of American Medical Colleges for an electronic consult and referral model in five academic medical centers; and $10 million to UCSF for a monitoring system for dementia patients.


Sam Foote, MD, the retired Phoenix VA doctor who turned wait list whistleblower, says in a New York Times opinion piece that he doesn’t think the current VA investigation will be effective because it’s being performed by Veterans Integrated Service Network office workers who will just ask employees a few questions, while he would rather see an anonymous electronic provider survey. He also says the VA’s VistA system is excellent and second to none in transferring information from one VA facility to another. He concludes by saying that any negative findings will be pushed back because it’s an election year.

Innovation and Research

Researchers at Stanford University develop an externally rechargeable embedded implant it calls an “electroceutical” that may be able to cure specific medical conditions using radio energy.



The CEO of Athens Regional Health System (GA) resigns after problems with its Cerner implementation. A dozen doctors sent a letter to administration complaining about lost orders, medication errors, ED patients leaving AMA after long waits, and an inpatient who wasn’t seen for five days. They also complain that the implementation timeline is too aggressive and the users aren’t ready. The doctors claim that Cerner problems have caused several doctors to drop their hospital privileges and others to send patients to a competing hospital. The health systems foundation VP said in a letter to donors and volunteers, “The last three weeks have been very challenging for our physicians, nurses, and staff … parts of the system are working well while others are not.”


HIMSS congratulates some new EMRAM Stage 6 organizations.

Medical educators say that doctors are losing the ability to diagnose based on a physical examination, instead relying on sophisticated tests. One says he has seen cases where “technology, unguided by bedside skills, took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon and often a lawyer. Sometimes even an undertaker.” Medical schools are going back to basics, teaching students, for example, to use a stethoscope instead of an EKG. A former NEJM editor weighs in after his experience as a patient at Mass General: “Doctors now spend more time with their computers than at the bedside,” with electronic medical records containing only short descriptions of how he felt and looked, but with “copious reports of the data from tests and monitoring devices” that generated few documented conversations. A professor and doctor tells the story of a resident desperately clicking through a febrile patient’s EHR looking for a cause when a short walk to the patient’s room would have made it obvious that his IV site was inflamed. Another says foreign doctors are more competent clinically than their American counterparts because they are either trained to rely less on technology or don’t have much of it available.

Someone asked me the other day if Vanderbilt was still using WizOrder. I assume so, even though McKesson’s commercialized version of it under the Horizon nameplate is being put slowly out to pasture.  Apparently this physician informaticist was impressed.


The Houma, LA paper profiles Objective Medical Systems, started by a group of cardiologists to create a specialty-specific EHR. It captures the output from medical devices, presents a combined view of test information, and can recommend research papers relevant to the patient’s condition.

Weird News Andy says we should fight illness with fist-bumps instead of handshakes according to a JAMA article that urges creating “handshake-free zones” to reduce the spread of pathogens. The article says shaking someone’s hand could eventually become as much of a social taboo as smoking.

5-25-2013 9-20-46 PM
Photo: Pete Marovich/EPA

Monday is Memorial Day, set aside to honor the one million US Armed Forces members who died while serving. Thanks to them, you are free to decide that you won’t fly the flag, visit a military cemetery, or think about those who made the ultimate sacrifice on your behalf. That’s not to say it wouldn’t be nice for you to do those things voluntarily on Monday. 

Book Report
Where Does It Hurt?


Where Does It Hurt? is an entertaining, punchy potpourri of ideas, just what you would expect from athenahealth’s Jonathan Bush and his professional co-author. The book is breezy and fun, with self-effacing humor and first-person stories about Bush’s experience with the healthcare system as a paramedic, a failed consultant, a failed birthing center operator, and now the successful co-founder of a pretty big back-office services and software provider.

Bush works his readers into righteous indignation by pointing out the fairly obvious things that are wrong with our broken and massively expensive healthcare system. Most of his anecdotal everyman ire is aimed at hospitals, which should be interesting since their fat and happy leadership (in his mind) are the prospects that will drive athenahealth’s planned growth into health systems. (He probably shouldn’t hand out copies of the book as part of the company’s pitch to hospital prospects.) 

Where Does It Hurt? delivers on its title, with nicely summarized and fun-to-read examples the maddeningly illogical healthcare system. Consumers rather than healthcare insiders are the target audience for the recitation of issues covered in far more specific and analytical detail elsewhere. As you would expect, Bush travels in circles different from the rest of us, so when he wants to learn something (and share it with readers), he has access to the CEOs and politicians who will tell him first hand.

Where it fails to deliver is on its subtitle: “An Entrepreneur’s Guide to Fixing Health Care.” The book is long on criticizing the system in its 241 pages, but short on offering new ideas about how fix it. He doesn’t fall short on “the vision thing,” but perhaps he could have been more prescriptive, especially given the barriers of government meddling, the political power of organizations profiting handsomely from the status quo, and the disconnect between those receiving services and those who pay for them, all of which have sucked the energy out of most of the good ideas that have floated around.

Early on, Bush declares that “healthcare is the new oil” in urging entrepreneurs to create profitable businesses that target monolithic, protective hospitals and the massive chunk of healthcare spending they consume. He provides fascinating examples such as Steward Health Care and Florida Woman Care, relayed mostly as conversations between himself and the CEO of those companies, and how they found easily picked low-hanging fruit in the inefficiency of their lumbering big-hospital competitors that weren’t adding much value in providing routine services.  He suggests that the idea of the Affordable Care Act had promise, but most of what it could have accomplished was neutered by special interest lobbyists into being little more than insurance for a lot more people instead of really reforming anything.

The “what should we do about it” message isn’t as clearly presented. After reading the book, I went back through it twice (it’s not all that big) to manually pick out what seem to be its main suggestions since it’s a bit all over the place.

  • The industry should train lower-level people to perform routine tasks, just like the military does in turning an 18-year-old with poor academic achievement into a weapons operator by breaking everything down into simple steps. He wondered in his New Orleans EMT days why there weren’t a swarm of $9 per hour EMTs like himself providing services in the community rather than just hauling patients with routine problems to the ED (in the cab-u-lance, as he refers to it.) He sees retail clinics as a model that works for up to 70 percent of the patients who would otherwise be sitting in the expensive ED’s waiting room.
  • Hospitals, especially academic medical centers, should transform into focused factories that offer fixed-priced services for specific, complex treatments in which they have developed notable expertise, leaving routine services to less-expensive providers. Hospitals fund their high-overhead operations by drastically marking up basic tests and procedures without adding any value and that money could be better spent elsewhere.
  • Big hospitals should overcome their geographic constraints by employing telemedicine and providing air transportation for patients who need their specific treatments.
  • Community hospitals shouldn’t get a free pass to make a lot of money just because they erect impressive buildings, staff EDs, hire a lot of people, and instill community pride. He says they should be reconfigured into providing emergency and high-acuity services and be paid accordingly since inpatient bed demand is already dropping significantly. He observes that hospitals are fighting to keep control of their fiefdoms, buying each other and medical practices to snuff out potential competitors that might undercut them in bidding for insurance company contracts.
  • State-specific limitations on provider licensing and insurance sales should be eliminated, as should artificial provider limits such as certificates of need.
  • Doctors should realize the power they have and band together rather than selling their practices to hospitals.
  • The government should loosen up anti-kickback laws so that providers can pay each other for information, such as contributing data. (Bush adds an interesting note that doctors selling their practices to hospitals is the ultimate kickback given the increase in business hospitals get from their referrals.)
  • The government should eliminate the requirement that only providers can run ACOs, opening up the market to entrepreneurs.
  • Insurance companies should offer tailored packages instead of the one-size-fits-all type. They should also offer barebones plans for those who don’t need extensive coverage.
  • The government should encourage new entrepreneurial insurance companies by backing their risk as it does mortgages through Fannie Mae.
  • Patients should be financially engaged in the healthcare decisions they make, should learn from each other, and should demand data.
  • Providers should manage populations and offer health management rather than just healthcare services, such as coaching, classes, and exercise.
  • Epic is part of the problem because it was designed to do what big academic medical centers want – protect their near-monopolies. Its high price ensures that most independent practices can’t afford it, giving Epic’s big customers the leverage to tell those practices to use their Epic system (at a discount) or risk being left out, giving those hospitals more control of the market and the data needed to protect it.
  • Entrepreneurs shouldn’t try to sell software to those big hospitals because the changes they will demand will reflect their inefficiency, turning the entrepreneur’s fresh approach into the same old systems everybody else is selling.
  • Data is the key to figuring out which treatments are effective.

I enjoyed the book and recommend it for those not expecting magic answers. It contains a lot more observations of problems than solutions, and healthcare insiders won’t learn very much from the admittedly interesting presentation of what’s wrong with healthcare. If I got my $11.99 worth (Kindle edition) it would probably be because it’s entertaining to hear Bush’s take on what those of us in healthcare see every day as being part of that expensive system that needs to be overhauled. You can hear a lot of Jonathan Bush’s ideas for free by watching business TV shows, so there’s no reason to sit impatiently waiting for the sequel.


Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis, Lorre.

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Currently there are "13 comments" on this Article:

  1. Where Does it Hurt?
    As you point out JB comes down hard on Epic. But consider this, in one chapter he goes on about how his cousin George and his minions almost killed Ahtenahealth just as he was getting it off the ground. The Bush administration was the real initiator of the ACO movement, and subsequently Obama just pushed it even more. I give him credit for not leaning on his cousin George and asking for special favors, but if you think it through and ask why should that be such a threat to Athena you will realize two things.

    First, Athena from the start focused on doc offices. Given the massive ARRA changes that was a strategic mistake, and he’s had to play catch-up since. I very much doubt that Judy had a direct link to George.

    Second anyone that has worked in the health care more than a year knows that if you design new software that helps providers address regulations, those very regs could change on a dime. So to anticipate and counter such a change you better have a solid understanding of the health care world and incorporate a very flexible design. His statement that the change in regs almost killed Athena tells me they did not have either. Epic as far back as 1995 anticipated that someday the wall between docs and hospitals would fall and Epic paid for being ahead of the curve in its early years.

    I get the feeling that his lack of broad health care experience is the root cause of many problems for Athena. And how come in all those many recommendations none pertains to Athena?
    My recommendation is he stop wasting time on rants, books and PR thrusts and better spend it on improving his product. I guess Athena’s strategy now is if you can’t deliver what the market needs, tell the market to change!

  2. Re: Athens Regional Medical Cerner Install and CEO Resignation. It is inexcusable for a failed implementation of Cerner. There is plenty of support from within Cerner and industry consultants to create a plan of success and manage to execution. I commend the CEO for taking responsibility; however, in this case the CNO and CIO should step down. They are both equally complicit in the failure of the install.

  3. I am simply amazed at Katherine Kroessler’s comments at the start of this update. I work for one of a dozen vendors that provide services that allow systems to talk to each other and there are standards that have been developed and are being implemented at thousands of practices around the US that utilize these standards and take advantage of the ability to exchange CCDA’s, Summary’s of Care, provide electronic referral capabilities and use tools like HISP’s, XDR Direct and other protocols to make everthing this physician does not seem to know exits, improve practice workflow, lower costs and improve the quality of care provided to patients. If physicians are not willing to take the time to investigate, understand and deploy these products they should hire people that can help them with it. They will save money in the long run.

  4. The HIT Vendor misses the whole point: all those “solutions” come… at what cost?!… are doctors to be blamed for wanting to take some money home at the end of the day and not just pay an army of consultants when the reimbursements are lower then ever? and for who ? the patients are yet to benefit from it yet we provide an army of people with employement. ACO for who does not know stands for ” awsome consulting opportunities”!!!!

  5. “The government should have created an incentive for IT vendors to use the same interface requirements so their systems could talk to each other”.

    It’s called HL7. Did you buy or still use a piece of crap that doesn’t use HL7? However, even between HL7 there can be inconsistancies between concepts- patient centric versus visit centric vs account centric.

    Or perhaps you’re unfamiliar with controlled vocabularies or category choices that need to be interpreted between systems.

  6. The Cerner implementation problems at Athens should come as no surprise, considering the complaints from users in the UK who complained at the Milton Keynes, that the Cerner system was “not fit for purpose”.

    If the company is now focusing its efforts on being a Big Data vendor, has its support for the devices it deployed been depreciated?

    Why would the CEO resign for such a trivial matter?

  7. Re: Sam Foote, MD whistleblower, defending VISTA: The electronic libraries of medical records, especially imaging and lab test results, has always been thought to be benevolent. What Sam states is true, but he aggregates the CPOE and CDS components with the library.

    The safety issues and impediments to efficient and timely care, arise from CPOE and CDS systems.

    I ask: if the VA electronic record system is excellent, why were the doctors so slow in seeing their patients? That question is being avoided by the press and the Congress.

    It is not the electronic library that slows them down. It is the poorly usable CPOE system and never ending pages of CDS guidance, that is meaningfully useless that reduces efficiency by 30%-40%.

    Thank you for all you do, Mr. H, and happy Memorial Day to the troops and veterans waiting for care.

  8. Mr H, I appreciate how you go out of your way to recognize veterans. There is a sad opinion piece in today’s NYT that shows how much needs to be done at the VA before it gives all of them the level of care they deserve.

  9. @ Keith McItkin, PhD — Cerner, somewhat distinctly from Epic, gives you enough rope to either create beautiful macrame or to hang an entire institution. There is nothing inherently wrong with Cerner. There are, as Mr H has noted himself, many, many sites where Cerner is installed well. Some sites have chosen to create terrible workflows, poor ordersets, and duplicative data storage. That is not Cerner’s fault. Sure, Cerner as a company and Cerner as software are not perfect. But if you show them that their software is flawed then they add that change request to their list and they’ll get it fixed if it involves patient safety or something reasonably critical.

  10. First off, the majority of EHRs in the market still do not interoperate and no, HL7 doesn’t get you there today and Direct is nothing more than secure email sending flat files – I’d hardly call that interoperable. Also, just how many ambulatory EHRs now installed can actually consume and parse a CCD or CCDA – exceedingly few.

    Secondly, Bush may want to stop talking to CEOs and start talking to those on the frontline re his comments about Steward Health Care here in New England. Organization is struggling in the market.

  11. Re the resignation of CEO for Athens Regional for the EHR deployment that created the dozen doctors to send a complaint letter to administration – was this an “act of courage”? Could the resignation be viewed as an example of a leader taking personal risks for the greater good [ensuring that physicians were not disenfranchised from the system]? It would be interesting to understand more details as a case study for the industry. It also begs the question, are those CEOs who are not closely tied to IT initiatives at risk? As technology takes greater importance in the healthcare landscape, will we see see all C-suite executives more engaged with CIOs?

  12. to PD: I do encourage you and the bulk of the C-Level (no, not the band) who have not already read Barbara Kellerman’s the The End of Leadership to do so, it is excellent and may give insight into the leader/follower struggle that you might be alluding too?

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