Being John Glaser 1/29/09

The current version of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is part of the larger economic stimulus legislation, will alter the HIT industry and the IT plans of our organizations.

For outpatient electronic health records, the Act puts some non-trivial money on the table. A provider who uses a certified EHR can get a maximum (through Medicare) of:

This totals $41,000. This will clearly increase interest in adoption and could represent a lot of revenue for a provider organization.

To get this money, a provider must demonstrate that they are meaningfully using health information technology. What does "meaningfully" mean?

• Using e-prescribing
• Connecting through HIEs to improve the quality and coordination of care
• Submitting information on clinical quality measures.

While we might be more or less clear about what e-prescribing means, clarification is clearly needed about what we mean by the second and third criteria.

It is anticipated that HHS will spend 2009 providing specifics and clarity about what providers have to do to demonstrate meaningful use. This means that most providers will have one year – 2010 – to finish EHR implementation and put in place the infrastructure, applications, training, etc. needed to get the as much of the incentive money as possible.

This is a tall order. And it means that providers should start moving now (if they aren’t already) even though the dust has yet to settle on the specifics.

John Glaser is vice president and CIO at Partners HealthCare System. He describes himself as an "irregular regular contributor" to HIStalk.

VA Will Pay $20 Million to Settle Stolen Laptop Lawsuits

The Department of Veterans Affairs will pay $20 million to settle a class action lawsuit involving a privacy breach caused by a laptop stolen from a VA employee in 2006, according to a proposed settlement.

The laptop and its external drive contained names, dates of birth, and Social Security number of over 26 million military members and veterans. The equipment, stolen in a routine burglary of a data analyst’s home in Maryland who had taken it home without permission, was recovered by authorities, who concluded that its information had not been accessed.

The settlement will be paid to veterans who can show they were harmed or incurred credit monitoring expenses.

News 1/28/09

From The PACS Designer: "Re: best hospital workplaces. Fortune Magazine has just published its 2009 list of top 100 places to work, which includes 13 hospitals. The highest ranked is Methodist Hospital System (Houston) at #8; followed by #19 – Ohio Health; #45 – King’s Daughters Medical Center (KY); #62 – Griffin Hospital (CT); #63 – Mayo Clinic; #67 – Children’s Healthcare (Atlanta); #68 – Southern Ohio Medical Center; #75 – Atlantic Health (NJ); #76 – Lehigh Valley Hospital and Health Network (PA); #77 – Northwest Community  Hospital (IL); #79 – Baptist Health South Florida; #85 – Arkansas Children’s Hospital; #98 – Vanderbilt University. TPD congratulates those selected as being top notch in their treatment of employees." Link.

From FIT003: "Re: McKesson. They have started laying off staff. Long-term employees are the first to have been laid off. Initial numbers, placed at 50-75 people within the Alpharetta operations." Unverified.

From Songbird: "Re: Perot’s MEDITECH solutions group, formerly JJWILD. Planning a third round layoff this Friday, January 30." Unverified.

From KFC: "Re: Keane Healthcare. About 10% or 30-35 employees from the Keane Healthcare division over the last two weeks. With the sunsetting of the old First Coast Systems patient billing application and the merging of the Unix product, I wonder how this will impact the always-delayed timeline?" Unverified. For all these unverified layoff rumors, by the way, I will run a brief company response if one is provided, whether confirming or denying. That’s fair.

From Ken Kercheval: "Re: physician practice EMRs. It is going to be an interesting year. Lots of companies will go away. Like they say, ‘When the tide goes down, you find out who isn’t wearing a swimsuit’. Indeed."

From Jackie Martling: "Re: sponsor ads. Just a suggestion. The animation is annoying to the point I copy and paste your great content to avoid the distraction. Seems unfair to the non-annoying ads." Noted and dutifully passed along to the sponsors for their future consideration.

HISsies voting will be winding down shortly, so cast your vote now.

Listening: The Gaslight Anthem, a reader suggestion. Good Jersey Shore bowling alley ballads with a soupcon of punk. Should be on an indie film’s soundrack. They’re on Letterman Friday night and touring everywhere.

The Raymond James folks sent over a couple of briefs about the healthcare IT stimulus proposals on the table. They predict that HIT adoption incentives will be around $32 billion over ten years, with the biggest adoption jump happening in 2011-2014 and with the biggest potential beneficiaries being physician practices and hospitals in the 300-499 bed size. They question, as I did yesterday in HIStalk Practice, whether prospects may actually hold off on purchasing clinical systems until the federal involvement shakes out. With that in mind, I’ve put two new polls to your right — one for vendors, one for providers — asking about any purchase delays your employer has been involved with. Your comments are welcome, too, so feel free to e-mail me. The stimulus could actually be detrimental in the short term if potential customers become indecisive.

A Fort Bragg military team is the first to use the AHLTA-Theater battlefield EMR to document patient encounters stateside.

A former Kaiser Permanente employee in Los Angeles kills himself, his wife, and five children ages 8 and under (including two sets of twins), apparently after being fired in a dispute with an administrator. His suicide note claims that the administrator told him on coming to work one day that "you should have blown your brains out." His wife had also previously worked for Kaiser. Update: according to CNN, both parents had been fired from Kaiser for cause.

A reader says Ivo Nelson, formerly of Healthlink/IBM, will launch his new business next week. It’s called Encore Health Resources. The domain is registered to a PR firm’s contact and address.

IBA’s iSoft gets a deal to install its software at 38 Healthscope hospitals in Australia.

New on HIStech Report: an interview with Steve Ura, CTO of MED3OOO, including questions about its InteGreat acquisition.

Capsule (they seem to have dropped the "Technologie" part of their name except when referring to their Paris headquarters) announces the addition of 80 more medical device drivers to its library of 400.

Consumer Watchdog demands that Google "cease a rumored lobbying effort" related to stimulus bill discussions that would allow the company to sell patient information to Google Health advertisers.

Members of Parliament want individual trusts to be able to buy their own systems if NPfIT can’t get its Cerner and iSoft software problems fixed within six months. Also reported: one trust that’s merging with another may be planning to drop Cerner and go with the other hospital’s 20-year-old Atos Origin legacy system. All of this, of course, is a warning to anyone who thinks huge healthcare IT projects can work fine if given the proper money and oversight, neither of which is in short supply in the UK as NPfIT disintegrates.

This may sound off topic, but I’ve been involved with similar solutions that made IT a hero: an Indiana Web 2.0 startup announces that its WiFi digital sign technology has been installed at several hospitals. It’s a terrible press release (as any would be that references rotten teeth) but maybe interesting.

Hospital layoff: Hennepin County Medical Center (MN), 100.

The Wisconsin paper investigates a touchy topic: do hospitals provide enough free care to be worth all the tax breaks they get, especially when governments are strapped?

A rumor site reports that Apple CEO Steve Jobs will undergo surgery at Stanford Hospital, citing as a source "a secondhand account passed along from an employee at Stanford." I’m sure the HIPAA-violating source will provide updates throughout the day if the story is true (he was rumored to have been thinking about a liver transplant).

A phony doctor is arrested at his fake doctor, nurse, and dentist school in India. Graduates of the "Medical Diploma Training Agency" are actively practicing, it’s believed. The doctor was printing his own diplomas, but later outsourced it to a computer company. He was turned in by a night guard who paid for his dentist’s diploma, was told he had to ante up more money, and then was allegedly beaten by the fake doctor for complaining.

Siemens says its healthcare business isn’t so great, but it still sucks less than GE’s.

An Australian hospital is in such dire financial straits that employees, feeling sorry for patients, are spending their own money to buy groceries, bandages, light bulbs, and computer paper.

Venture investing declined in 2008 for the first time since 2003. Green tech companies are hot; software vendors and Web start-ups are ice cold.

Archives of Internal Medicine Article
Clinical Information Technologies and Inpatient Outcomes

"Health info technology saves lives, costs" screams the Yahoo News article. Modern Healthcare fires out an e-mail news blast, claiming that "when computers replace paper, patient mortality rates drop 15% during hospitalization."

The headlines are misleading (as they often are to lure in readers). You need to interpret the article yourself.  It’s available online.

Here’s the conclusion, verbatim from the article: "Hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs."

Sounds promising. Even more so when the article talks about the researcher’s use of a survey tool that actually measures how much technology is being, not just how much has been bought (although that CITAT survey instrument itself isn’t available in this or the predecessor articles that I could find, which is odd since that’s a key part of interpreting the findings).

However, the study had compromises:

• It covered only patients >50 years old and only four medical conditions.
• It randomly surveyed physicians using an AMA file, asking them to respond and to include the hospital in which they provided most of their inpatient care, but it wasn’t clear whether they provided all that much inpatient care at all or whether they were the most prolific doctors at the hospitals being reviewed.
• Since the doctors who responded drove the choice of hospitals, those hospitals studied were not typical: they were much larger and more of them were academic medical centers.
• Outcomes were determined from claims data.
• Some results were predictably erratic, such as the lack of correlation to length of stay and the conclusion that use of electronic notes and records increases the odds of heart failure complication.

Compared to studies that preceded it, this one’s pretty good, but it suffers from Most Wired-like conclusion-leaping (not in the article, but by those who try to turn it into a sound bite). Nothing suggests that technology use caused the improvement, only that it seemed to coincide with it. So, we know what we already knew or presumed: good hospitals are more likely to do many things (including deploy IT) better than bad ones.

Nothing in the article suggests that a given hospital will see its quality improve just because its starts using technology (in fact, that might have been an even more interesting study: take those same hospitals studied, identify those that recently implemented clinical systems, and compare their before-and-after numbers to see if anything changed).

The bottom line: it’s a pretty good study that has encouraging conclusions, even if they are iffy. IT won’t make bad hospitals good, but it can help make good ones a little better if it’s used right and along with other improvement measures. The article does not, however, suggest that IT is the can’t-miss answer to quality and cost problems.

E-mail me.

HERtalk by Inga

Consultants warn that as the economy worsens, more hospitals will lay off employed doctors or slash their pay. The US Department of Labor reports that 107 hospitals had mass layoffs (50+ employees) for the first 11 months of 2008.

Despite all the bad news of layoffs, many believe that healthcare still offers more stability than other sectors. In fact, the US Bureau of Labor Statistic predicts 3 million new wage and salary jobs between 2006 and 2016, more than any other industry. In nursing, older students, men, and second career newcomers are joining the ranks.

In a paper entitled “Hospitals as Hotels,” researchers conclude that amenities such as good food, attentive staff, and pleasant surroundings may play an important role in hospital demand. “From the patient perspective, hospital quality therefore embodies amenities as well as clinical quality. We also find that a one-standard-deviation increase in amenities raises a hospital’s demand by 38.4 percent on average, whereas demand is substantially less responsive to clinical quality as measured by pneumonia mortality.” Sounds like the message is to buy nice furniture instead of improving care if you want to keep the beds full.

Turmoil at Tri-City Medical Center (CA) has employees wondering about the facility’s long-term stability. Last month, a new board majority placed the hospital’s top eight administrators on paid leave and brought in a temporary management team that opponents claim have no hospital experience.

An Ohio man sues a nightclub for $25,000 after a stripper’s shoe flies off during a tricky dance move, chipping a bone in his nose that will require surgery to fix. No word on whether her shoe was damaged, but I say shame on that stripper for risking her shoes.

HealthGrades releases (warning: PDF) its seventh annual Hospital Quality and Clinical Excellence study. Medicare patients treated at top-rated hospitals are 27% less likely to die there, on average, than at other hospitals.

The Association of Academic Health Centers calls for a revision of the HIPAA privacy rule following a study in which HIPAA was found to impede study recruitment and study diversity.

McKesson reports mixed financial results for its fiscal third quarter, losing $20 million because of the $493 million paid to settle AWP price fixing charges. Without that, EPS would have been $1.05 vs. $0.68 last year on slightly higher revenues. Technology Solutions grew but missed expectations due to contract signing delays in hospitals and physician practices. Cost cutting was the key to a pretty good quarter. The company raised its earnings outlook, running the stock up 12% on Tuesday.

MedAvant Healthcare Solutions appoints Troy Burns as CTO. He previously worked at Misys and Payerpath. MedAvant’s president Andrew Lawson is also a former Misys guy.

Philips Healthcare reports 9% sales growth in Q4, driven by sales in imaging systems, healthcare informatics, and customer services. Royal Philips as a whole ended the year with a $1.9 billion loss and will lay off 6,000 employees.

Scott Perra, the new president and CEO of Faxton-St. Luke’s Healthcare and Mohawk Valley Network (NY) claims the implementation of an EMR is his first priority. The health system is about 18 months into installing its $15 million clinical system (I believe Cerner).

In what the company calls a planned transition, Virtual Radiologic Corporation promotes President Rob Kill to CEO. Company co-founder Dr. Sean Casey will remain chairman of the board. The announcement coincides with the release of the company’s Q4 and full-year financials, which include a 24% jump in revenue for the year. Adjusted net income grew from $7.0 million to $9.7 million. The company also just signed its third internal client, this one in Saudi Arabia.

Griffin Hospital (CT) implements the Logical Ink electronic charting system in its new Center for Cancer Care.

Madonna Rehabilitation Hospital (NE) plans to adopt (hopefully they’ve signed a contract) Eclipsys clinical solutions.

The Outpatient Rehabilitation Center of Margaret Mary Community Hospital (IN) implements Chart Links therapy documentation and scheduling system for its 19 physical, occupational, and speech therapists.

PHR vendor MediKeeper announces the appointment of David Ashworth as CEO.

The Queen’s Health System (HI) renews its IT outsourcing contract with ACS. The new contract is valued at $26 million over three years and includes Queen’s Medical Center and its affiliates. ACS has been providing IT services to Queen’s since 2001.

BJC HealthCare (MO) signs a five-year agreement with CareTech Solutions. CareTech will provide BJC and its 11 affiliated hospitals a suite of Web products and services including CareWorks content management system and BoardNet communications portal.

I was amazed to learn there are now over 10,000 applications available for the iPhone. A cool new HIT tool just announced: Safe OR, which includes a 19-item surgical safety checklist A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.

Picis CEO and Vice Chairman Todd Cozzens will chair the Business Office Improvement educational track at TEPR+ next week. I’m envious of anyone who gets to spend a few days in Palm Springs right now. If you’re attending, send us updates and impressions.

Medsphere announces the successful implementation of BCMA at all eight of West Virginia’s state network of acute, psychiatric, and long-term care hospitals.

athenahealth and the Illinois State Medical Society announce an agreement to offer special pricing on athenahealth’s PM solution to its 12,000 members. I also saw that athenahealth hit a 52-week high Monday, following Jonathan Bush’s appearance on CNBC’s “Mad Money” with Jim Kramer.

E-mail Inga.

MD Leader 1/27/09

Ministry Health Care Will Implement CattailsMD

Ministry Health Care has chosen to implement CattailsMD electronic health record. For over 20, Marshfield Clinic has developed a comprehensive electronic health record, now available as a CCHIT-certified ambulatory EHR product known as CattailsMD. The EHR is also available with a data warehouse to actively drive decision support and population management.

Conventional Wisdom

Conventional wisdom speaks against the use of an internally developed product. While conventional wisdom is often used as a rule of thumb, tunnel thinking can limit your options. Every software decision is the result of a complex analysis of objectives, risks, benefits, values, and mitigation strategy. The purpose of this post is not an exhaustive explanation of our decision, but rather a review of several factors influencing our thoughts.

EHRs Are Becoming a Utility

Within a few years, EHRs will be more of a utility than a unique product. Increasing CCHIT certification and government incentives are driving standardization of function. Many organizations are turning to SureScripts to satisfy the CMS E-prescribing incentive. SureScripts standards will be just one of many leading to an ever-increasing identical functioning of EHRs. Simply having an EHR will not lead to process improvement nor increase clinical quality.

EHRs Do Not Improve Quality

Most EHRs have not improved quality of care. Simply automating our traditional process should not be expected to fundamentally improve quality. Improvement occurs when we redesign our care systems and standardize our processes (often enabled by use of an EHR). It is not the EHR that magically improves care; it is the people and processes utilizing the EHR that improves care. If you are both vendor and end user, then you can first vision how care should be provided and then deliver the necessary software to support it.

Marshfield Clinic has effectively demonstrated the value of this approach by achieving improved quality of care resulting in decreased health care costs in an ongoing CMS Demonstration Project.

The Status Quo Will Not Meet Future Needs

Our health care system is broken, we simply are not meeting the prevention, wellness, and primary care needs of our patients. We do not have enough primary clinicians to meet our current needs and we are not producing enough primary clinicians to meet our future needs. In Wisconsin (warning: PDF), the demand for primary care clinicians in the next 10 years is projected to increase by as much as 33% with only a 5% increase in clinicians. We will need to redesign our health care delivery system if we hope to meet future needs.

Our use of CattailsMD maximizes our opportunity to influence the design of an EHR to meet the needs of our patients. Although our vendor is interested in the commercial success of the product, as a provider of health care, their prime objective is the same as ours: caring for patients.

It Is All About the Data

Ministry Health Care and the Marshfield Clinic have a large number of common patients and will share the same EHR. While a shared EHR with a single source of truth for medication lists, allergies, labs, and documents is appealing, the real value is an extensive data warehouse ten years in the making. The data warehouse currently contributes to a number of activities including population management, disease management, maintenance of numerous registries, formal research, and increasingly, decision support.

As our business intelligence tools become more robust, I expect increasing emphasis will be placed on activities such as searching the database for trends of best care, identifying potential drug interactions, post-marketing surveillance of medications, and identifying care opportunities that will improve the health of the communities we serve.

A Decision Without Risk?

Is our decision to use CattailsMD without risk? Nope. But then again, no decision is. During the 20 years I have been interested in health care IT, I have seen numerous vendors (both large and small) come and go. I have also been through the agony of “upgrades” in hardware, operating systems and entire new versions of software forced on us by our vendors.

What has not changed is our need for information to improve health care. We are on the threshold of having EHRs and data warehouses that do not just present information, but actively support the practice of medicine.

A Future Post

Ministry Health Care and the Marshfield Clinic have been actively working to build the infrastructure necessary to support a joint EHR. In a future post, Dr. Carlson (Marshfield’s CIO) and I will discuss some of the issues we have dealt with that will have national significance if government seeks to foster greater sharing of patient data.

While you are waiting for a joint post, please take some time to read Will Weider’s (Ministry’s CIO) advice for President Obama.

Peter Sanderson, MD, MBA is a family physician and Director of Medical Informatics and Operations and Executive Sponsor, EHR Program, at Ministry Health Care. He can be reached at pete.sanderson@ministryhealth.org. He also blogs at MD Leader.

Monday Morning Update 1/26/09

From RSNA Body: "Re: RSNA. Don’t believe this RSNA whitewash about attendance. These were pre-attendance numbers — wait for the audited RFID traffic numbers. I was there and, for the first time, there were hardly any lines for anything. I spoke to cabbies, bus drivers, restaurateurs, vendors, etc. who all reported thin crowds. One cabbie asked me on Wednesday if the radiology show was over because he said the traffic was so light. Several vendors told me that a number of hospital customer contingents had cancelled their RSNA trip or only sent a few rather than the scheduled dozen or so staff. With IT vendor layoffs since November and a worsening economy, I predict a huge decrease in HIMSS attendance." You’re probably right. Conferences, like sports venues, have been known to report big attendance despite obviously empty seats.

From Eclipsys on the Ropes?: "Re: Eclipsys. I understand that McKesson just took another revenue cycle customer away from Eclipsys: ‘Baptist Healthcare System Selects McKesson to Optimize Physician Revenue.’ Can you verify this for your readers?  If so, it seems like Eclipsys is in a certain death spiral. Also, the client that represents 10% of the ECLP revenue is probably North Shore Long Island Jewish since they have both outsourcing and software." I’ll have to call in a lifeline on that because I have no idea. It’s the Baptist group in Kentucky that contracted with McKesson for physician revenue cycle management. I don’t recall hearing anything about Eclipsys there, but it may well be. Update: the group is not an Eclipsys customer, so the reader’s understanding is incorrect (to the other reader who said my facts are incorrect, they aren’t my facts: the blue text is a reader’s question; my answer in black text was "don’t know, never heard of ECLP being there.")

From I’m Just Saying: "Re: Eclipsys. The 10% of revenues client may be Baylor. Also, expect more layoffs this week in Services. One VP resigned in December (J. Bell) and two others were termed last week (B. Pille & D. Tom). J&J could be a good answer."

HIMSS is not too many weeks away. I haven’t come up with any HIStalk-related activities yet since I’ve been swamped, but we’ll have some HIStech Report interviews coming very soon. The conference was awash last year in Fake Ingas, HIStalk shoeshines, badge ribbons, the big bash, and probably stuff I’ve forgotten (like that $1,000 worth of tote bags I bought – is anyone still using theirs or did I waste my money?) I’m open to ideas from vendors on anything that would be cool for readers.

A Georgia family puts everything they own except their house up for auction on eBay to pay the medical bills of their children, a 7-year-old with an autoimmune disease and another with autism.

HHS announces acceptance of HITSP interoperability standards (warning: PDF) that took effect January 16. Complete list here.

Jobs: Sales Account Executive, Northeast, Director of Channel Sales, Epic Clinical Reports Writer, MEDITECH Consultant – Advanced Clinicals. Sign up here for a weekly jobs blast.

Speaking of jobs, several folks at Eclipsys lost theirs this week, which I reported as a rumor on Wednesday. At least 100 have been shown the door, a couple of folks say, and the purge may not be over yet.

And speaking of layoffs, Children’s Hospital of the King’s Daughters (VA) laid off 28 employees on Friday and also cut 90 unfilled positions. It’s also shutting down its child care center. Mike e-mailed about Alegent Health (NE – Immanuel Medical Center pictured above), which laid off seven VPs this week and will eliminate 285 more positions by March. It also forced 20 senior managers to take a 10% pay cut.

And more layoffs: GE Healthcare dumps an unnamed number of employees in Burlington, somewhere between 8 and 39 given their sketchy announced percentage range. The staggering giant has never been forthright about its cutbacks in the old IDX office, probably due more to smothering bureaucracy rather than intentional obfuscation. Kind of like when Jeff Immelt put on his happy face about GE Capital while the rest of the world (me, anyway) proclaimed loudly that the company could not possibly avoid fallout from the financial sector meltdown. Let the record show that Jeff was way wrong: GE’s Q4 numbers announced Friday after the market close showed revenue down 5%, EPS $0.35 vs. $0.66. GE Healthcare’s profits were down 9%. The stock dropped nearly 11% during Friday trading and is down another 11% after hours.

And even more layoffs: NorthShore Skokie Hospital (IL), 150; Frankford Health System (PA), 100; Hamilton Health Sciences (Canada), 250; Irvine Regional Hospital and Medical Center (CA), 510.

Intel’s chairman Craig Barrett will retire in May. He’s been loud about healthcare and technology (I quoted him in July 2007), so maybe we’ve not seen the last of him.

Two PricewaterhouseCoopers executives in India are arrested and charged with conspiracy for the company’s role in signing off as auditor on the books of Satyam Computer Services, whose chairman admitted that $1 billion of claimed cash didn’t exist. I mostly associate PWC with dumb names: its own and the one it announced for its consulting organization in 2002, "Monday," which thankfully never happened because the company sold the whole organization to IBM just five months later.

The State of Massachusetts signed a big mandatory EMR law in August with $25 million a year in funding to get doctors online by 2015. The state cut the budget to $15 million two months later, which everybody agrees is far short of what’s needed to get the job done. Also agreed, judging from the comments, is that not much benefit has been derived so far.

Another victim of Bernie Madoff’s Ponzi scheme: Charleston Area Medical Center (WV), whose foundation lost $800K and the hospital $200K.

McKesson CEO John Hammergren gets his name and picture in The Wall Street Journal, although it’s hardly a flattering mention. The article addresses the methods companies use to calculate executive pension value into a single lump sum payment, with some using an obsolete federal formula that boosts the number as "a sneaky way to give executives larger pay." McKesson tweaked the formula for Hammergren last March, jumping his parting gift’s value to $85 million (everybody’s outraged about healthcare costs, so you might think that would raise an eyebrow or two).

Former QuadraMed CEO Larry English gets a new job as CEO of CIFG Holding, Ltd., a Bermuda-based holding company running a French bond insurer recently bailed out after getting burned on derivatives.

Think we’ve got healthcare challenges? Malawi has 14 million people, of which 1 million are HIV positive, and only 280 doctors. Their answer: treatment protocols managed by non-physicians using touch screen clinical workstations (developed in Ruby on Rails) at the point of care. Scroll down for several YouTube demos. It would never work here, of course, because vendors couldn’t load it down with proprietary bells and whistles to boost the price. Still, you have to like this quote extolling the virtues of designing systems to take the use through a consistent, guided function (which I always argue in saying that charting a med should be as easy as the import wizard in Excel): "If the system is useful, then other people want to use the system. This is a nice problem that gets solved with…training! But soon, the developer notices that users keep using the system in a way that was totally unexpected. Time for another training session… But there is another approach that doesn’t rely on training. They are called constraints … The amount of training required is usually inversely proportional to the number of constraints in the system.."

Two sides of a Connecticut hospital’s proposed health information exchange. Pro: the hospital is raising money for the $8 million project and hopes the federal government will pay for it while it’s slinging money around. Con: the president of the state medical society says the government shouldn’t pay because mandated physician usage would just make the state’s doctor shortage worse because they’d steer clear of Connecticut.

Debbie Turpin, clinical systems manager at Alton Memorial Hospital (IL), is named chief nurse executive.

Odd lawsuit: a mentally disturbed female prisoner is taken by corrections officers to a hospital for psychiatric treatment, where she "went berserk" and bit the nurse’s hand. The officers watched and did nothing, later saying they believed it was outside their jurisdiction. The nurse is suing the city.

E-mail me.

News 1/23/09

From Dr. Yes: “Re: athenahealth. Because of the big deal Athena did today, Jonathan Bush was just on CNBC. He was almost as funny as he was at your HIMSS party. The guy is truly charismatic. I’ll bet the stock goes wild.” The company bagged a big win today, signing University Hospitals of Cleveland (450 doctors) for revenue cycle services. The stock was actually down around 1% today even with the early morning announcement, but the market was down overall.

From Clarence Trauma: “Re: Orlando Health’s Web site. Are women are not adults, or possibly in this politically correct world, are men are no longer referred to as such, but rather addressed merely as Adults? Or, based on the cozy couple next to the Adults button, maybe they’re tapping into the XXX market.” I’m not a fan of the pinkish-red design, I’ll say that. The marketers have been allowed to run amok, obviously, given the biggest headline on the page: Learn About Our New Brand. Your Brand is like your high IQ or dynamite sexual prowess — don’t yap about it constantly; let the few people who care arrive at that conclusion themselves.

From Shawn Spencer: “Re: Tom Skelton. Going to work at MED3OOO, supposedly, maybe to run sales and work up from there. There’s a Pittsburgh connection and some former Misys people at MED3OOO.”

From Songbird: “Re: Hayes Management Consulting. They reportedly laid off consulting staff this week.” We have a contact there since they’re a sponsor (Pete Butler, president), so Inga asked him. “It is always interesting to see how rumors can get blown out of proportion. On January 13th Hayes did make a 7% reduction in force. Some segments of our business are exhibiting significant growth while other segments have slowed due to vendor slowdowns and market conditions. We continue, however, to hire selectively in areas that we have identified as growth areas for Hayes. As the unprecedented economic uncertainty continues to challenge the healthcare industry everyone is being compelled to make adjustments. We consider ourselves fortunate that our adjustments are small relative to those of the industry. We credit this to Hayes’ history of being a well run company that has grown prudently over the years. In 2008 we experienced 15% revenue growth over 2007. We expect our revenues to continue to grow in 2009 including in areas of federal initiatives in Health IT. We remain committed to building long term trusted relationships and we look forward to continuing to serve our clients for many years to come. Honestly Inga, this was a difficult action for us to take and one Hayes has never taken before. We consider all of our employees close members of the Hayes family yet we need to remain good stewards of this company in these challenging economic times. We have a confident outlook for 2009 and continue to experience growth as we kick off this New Year.” Hayes runs a good shop and is #1 in KLAS in overall services, so you can bet it’s not just them. And if you know which areas they pruned back, you’d also know which systems vendors are struggling since it’s a direct relationship.

From Mr. G: “Re: Eclipsys. According to MorningStar analysts, 40% of Eclipsys’ revenues are attributable to the 20 largest clients. One client represents 10% of revenue. Does anyone know who this client is?”  

From Carol Dedmon: “Re: Jeff’s comment. Jeff is a sourpuss – the whole freaking world is celebrating a new beginning and our industry is hopeful of renewed energy and investment. He slaps you down with a ‘mind your knitting’ remark. Jeff left a curt comment on Tuesday’s post saying he was tired of the Obamafest (his word) and that only political pundits should discuss such sensitive topics like the inauguration. I compared Obama’s speech to Jimmy Carter’s, so I figure Jeff was sniping at a brief Inga mention since she’s gushier than me. Well, no hard feelings. At least I found someone even more cynical than me.

From ORISpilot: “Re: Alert. The president of Alert Life Sciences publicly berates the executive sales team from North America for low Q4 sales in front of a large crowd at its annual retreat in Portugal. Staff are being let go.” Unverified. They made a big splash at HIMSS in 2007, but I haven’t heard a word since and had completely forgotten about them. I don’t see anything about US customers on their site, which claims $34 million in 2007 sales but no 2008 number yet. I remember it as being exceedingly cool, but the US is a tough market to crack from Portugal. Or here.

From Spencer Haywood: “Re: HealthVault. I signed up for Microsoft’s HealthVault and starting playing with it. You can enter e-mail addresses to give others access to your records. You can choose spouse, domestic partner, … and pet. Good thing my cat signed up for Gmail last week. Not on the list: provider or physician. Guess my cat needs access to my record more than my doctor.”  

Listening: Fiction Family, brand new duo pop, not my usual cup of tea, but some nice hooks. One guy’s from Switchfoot, the other from Nickel Creek (for bluegrass fans like me). 

Not available in Hallmark stores: e-cards that allow people to anonymously notify sex partners that the sender has a sexually transmitted disease. Noting that gay men often exchange bodily fluids but not e-mail addresses, health departments are also setting up profiles on gay Web sites as an outreach. I don’t know how well it works, but it’s certainly worth trying.

HISsies voting. Be there. Thanks.

You may have noticed that industry news is picking up quite a bit, as is HIStalk readership (keeping me extremely busy). If you don’t get the e-mail updates, you might want to sign up over there to your right. That list is up to over 3,500 confirmed, active subscribers, so everybody will be walking around knowing stuff you don’t if you don’t sign up. It would be cool if we hit the 2 millionth visit by HIMSS, but I’ve counted on my fingers and I don’t think it will quite make it. Still, I’m staggered to have that many folks reading, so thanks much for that. I’m really honored by the number of people who e-mail nice comments and tell me how important HIStalk is to them (Mrs. HIStalk isn’t one of them since she feels she’s been denied my consort, but I’ve tried to explain the whole HIT thing and she just glazes over).

Eclipsys shares hit a five-year low after the company announced low Q4 preliminary earnings yesterday. Shares closed at $8.01, down over 29%, giving ECLP a market cap of just $438 million. I don’t get the primary excuse, that customers planning to go with a traditional license purchase decided to take a subscription license instead and therefore delayed revenue. First, ECLP must be offering bad subscription terms if customers were even considering buying a license instead of stretching out the payments by subscription. Second, the company has always said that the subscription model would provide a nice recurring income stream, which still isn’t clear after all these years. The good news for them is that Cerner doesn’t seem to be making any new sales, but the bad news is … well, Epic’s everywhere you turn, especially when your product line is limited. ECLP has made some nice acquisitions in MediNotes and EPSi, current management is better than the old regime, and the yearly numbers still look good, so here’s my impression: the company needs to fix some problems, but this may just be the first wave of bad news when it comes to the big iron boys whose only customers are cash-strapped hospitals.

Maybe J&J will  buy them. Drug maker Johnson & Johnson is not expecting a great 2009, but is still looking to pick up some acquisitions that have had the wind knocked out of their sales (pun intended) by the recession. The CEO says he’s especially interested in healthcare information technology and wellness and disease companies.

More layoffs at GE’s Burlington office. Songbird had tipped me off that it would happen yesterday and he or she was right.

I heard (indirectly) from a consultant who just lost his ambulatory EHR consulting job after the main vendor his company supports (I won’t name them, but they’re big) had major product issues, causing users to put upgrades on hold, which dropped the demand for consultants. His employer was small, so they didn’t have the resources to cross-train people on products with a higher consultant demand. The person who passed his message along is considering dropping that same vendor’s product and moving to another vendor, possibly eClinicalWorks.

Some Houston fans of open source software in healthcare are holding a July 31 weekend conference, promising good speakers and some cutting edge companies. Only $60 if you sign up stat.

Microsoft was to have laid off 1,400 people Thursday, the first wave of an eventual 5,000 jobs cut in the company’s first-ever layoff. Q2 profits were down by 11% and the company declined to forecast earnings for the rest of 2009. Also announced: travel budgets have been cut, salaries are frozen, and physical expansion of the Redmond campus has been scaled back. Shares were down almost 12% today, dragging the entire market down with them.

Microsoft’s arch-competitor Google did a little better, maybe. The company just announced Q4 numbers: revenue up 18%, but earnings were down 68%, the first time in the company’s history that earnings dropped. It, too, laid off employees, but just 100, and also wrote down most of its $1.5 billion investment in AOL and Clearwire. Cost control was obviously excellent. Shares are up.

A fire broke out at Mount Sinai Medical Center (NY) Thursday, forcing the horizontal evacuation (my HEICS training shines) of 600 patients. Flames were visible from Madison Avenue, but the fire was contained to a mechanical room and was put out with no injuries reported.

Internet inauguration watchers overloaded the network pipes at University of Kansas Hospital (KS), causing patient records to be unavailable for around 30 minutes. An e-mail was sent telling employees to get off, which apparently worked.

TriZetto’s CEO says that government and payers are going down the wrong road with EHRs. “For example, the new Obama administration is promising to spend a good portion of a $50 billion investment with physicians to adopt EHRs and the infrastructure to share them. But, those plans indicate that many in Washington are overlooking a faster, far less costly path to ubiquitous PHRs. Health plan information systems are the single richest repository of comprehensive diagnostic and treatment data and benefits information in the entire U.S. healthcare system. Both government and payers are missing a key opportunity.”

St. Clare’s Health Services (NJ) fires five VPs so the CEO, who’s been there since last May, can bring in his own people. He told employees that operational changes are being considered, but a source tells me that hundreds of employees will be laid off in the next few weeks.

Thanks to Barbara Benson, a reporter for Crain’s Health Pulse and Crain’s New York Business, who e-mailed me to let me know that she had written about NYU’s $186.4 million Epic project. Having run across it while researching the state’s certificate of need records, she checked HIStalk to get some background (it was reported here back in July by Motown HITman and Mad Man). They told her that Eclipsys Sunrise won’t go away, which seems highly unlikely. Here’s what Mad Man said then: “I have heard, from multiple sources, that NYU is moving off of Eclipsys to Epic because Epic provides a comprehensive (i.e., inpatient, ambulatory, physician EMR) solution where Eclipsys XA does not. I find this very interesting since NYU just went live with XA to much hoopla in the trade papers. The system move has caused a lot of chaos in the NYC Eclipsys office.”

John Glaser gets a Wall Street Journal mention in a political story about the economic stimulus. He warns that trying to spend a bunch of federal healthcare IT money too fast may be wasteful and counterproductive, especially if systems are slammed in without regard to the needs and work flow of users. I agree, but Uncle is looking for some fast spending, so here’s a question: if you were doing the disbursing, which projects would you choose that would require hiring lots of people, have good oversight already in place, and are ready to provide near-immediate return on investment?

I think Marshfield Clinic CIO Bob Carlson agrees. In Part II of an excellent interview, he says, “Implementing an EMR can be a very dangerous thing. There are studies that show that given the complexity of healthcare, it’s easy to miss steps in processes and delay important information; in essence, instead of a positive impact on healthcare, if done wrong it may actually be a step backward. That being said, EMR is the first step toward moving healthcare where it needs to go. Once you’re in the electronic format, now you have the ability to take all the tools, the technology, the intelligent assistants, the data mining and trend analysis, and the outcomes and start bringing them to bear where the rubber meet the road – at the point healthcare is being delivered.”

An audit of California’s prison medical system finds that $27 million in technology contracts were issued without legally required competitive bidding. One IT manager was fired in June for being involved, although there was no evidence that the prices were out of line or that employees benefited.

RSNA 2008 did OK considering the economy, with attendance, exhibitors, and exhibit square footage down only in the single digits. Will HIMSS be so lucky, especially since they’re in Chicago for the first time, in April instead of February, and starting on Saturday?

Hospital layoffs: King’s Daughters Medical Center (MS), 21; Memorial Medical Center (PA), 47; Providence Saint Joseph Medical Center (CA), 94; Blue Hill Memorial Hospital (ME), 15; Excela Health (PA), 70; Butler Hospital (PA), 18; Southcoast Hospitals (MA), 12; Grenada Lake Medical Center (MS), 14.

Saint Luke’s Health System (MO) adds ePharmacy to its eICU center, scanning physician paper orders to a remote pharmacist for computer entry, which releases the correct meds from the dispensing cabinets for nurse administration.

Duke University School of Medicine gets a $1.25 million federal grant to develop an infectious diseases ontology for Staph aureus.

Cardinal Health fires an employee for refusing to work Sundays, saying they told him he could take off, but only if he arranged his own coverage. The employee, a minister, is appealing to a higher power – Charlottesville Federal Court, where he’s suing Cardinal for religious discrimination.

E-mail me.

HERtalk by Inga

From Mikey Likes It: “Re: LinkedIn photo. Nice shoes.” So far I have made it a week with my contraband LinkedIn photo. I have the same kind of feeling I did when a bouncer would let me into a bar, even though I was underage. (Geez, I hope my mother isn’t reading this.) I see the HIStalk Fan Club has swelled to 511 members, so we’ve all got to get together sometime.

In case you missed Mr. H’s recent commentary for Inside Healthcare Computing (The Obama-HIStalk Digital Stimulus Grants: Why Letting Me Hand Out the Freshly Printed HIT Cash Makes Sense), he is angling for the chance to hand out $20 billion of economic stimulus money at HIMSS. Personally I think his approach makes as much sense as anything else we have seen recommended so far. Plus it might help boost conference attendance (and thus stimulate the Chicago economy, no doubt), I’m thinking if he gets that gig, I will follow behind him and film the whole thing to post on YouTube.

Just in time to train people to on ways to spend all that economic stimulus money, American Sentinel University (CO) adds a Bachelor of Science degree program in Health Systems Management.

AHRQ releases a series of new reports highlighting the lessons and best practices from the recipients of AHRQ grants. The reports focus on the implementation and use of such technologies as CPOE, EHR, and BCMA.

Minnesota’s attorney general sues Allina Health System for charging illegally high interest rates. The lawsuit contends that Allina charged as much as 18% on unpaid medical bills, which is substantially higher that the 8% cap allowed under the state’s usury laws.

The recession and rising unemployment rates creates unprecedented increases in Medicaid rolls. Many states are seeing 5-10% more Medicaid recipients than a year ago. Growth rates have at least doubled from the previous 12 months.

Earlier this week Mr. H mentioned that Haywood Regional Medical Center (NC) named former EDI and McKesson leader Sheldon Tyndall as interim director of IT. Haywood is bringing on a new CFO, Gene Winters, who has served as CFO HCA, Acadia Healthcare, and Transitional Hospital Corp. Haywood made headlines last year following a temporary loss of Medicare and state certification after inspectors found potentially dangerous problems with medication administration. The story included whistleblowers, lawsuits, and a replaced CEO. Tyndall’s most pressing challenge is to complete the hospital’s EMR implementation.

I must confess that when I heard the names of this new Web site, I immediately envisioned some sort of virtual haircut, or at least someone like Vidal Sassoon administering the latest hairstyling advice. Elsevier announces eClips Consult to help physicians identify and assimilate information from professional medical journals.

Highmark Inc. and Independence Blue Cross announce they are withdrawing their merger applications with the Pennsylvania state insurance department. The companies believed the transaction would not be approved because the state insurance department believed it would adversely impact competition.

Precyse Solutions and Ingalls Memorial Hospital (IL) sign a five-year outsourcing agreement. The $4 million deal includes technologies and services to support Ingalls’ medical transcription functions.

Yalobusha General Hospital (MS) chooses a financial system from Healthcare Management Systems for its 26-bed hospital and two rural health clinics.

Partners HealthCare (MA) selects MDsoft’s MetaVision for acute care and preoperative technology. The system will be used at both Mass General and Brigham and Women’s Hospital.

Oasis Medical Solutions, a UK HIT provider, appoints Chris Spence, formerly with GE Healthcare IDX, as CEO.

Anne Arundel Medical Center (MD) implements VISion: Asset Management by Versus Technology, an RTLS solution the hospital is using for asset tracking.

Edward Hospital (IL) successfully deploys InfoLogix for wireless asset tracking.

Clara Maass Medical Center (NJ) selects Axolotl to support its HIE initiative.

Baptist Healthcare System (KY) signs with McKesson to manage the revenue cycles of its affiliated physicians. The deal includes McKesson’s Revenue Management Solutions group overseeing all facets of the physician billing and collection process. McKesson, by the way, was just named the #1 place to work for Six Sigma professionals.

Nuance Communications appoints a new head of marketing for its India operations.

MEDSEEK announces a new Webinar entitled Hope is Not a Strategy: Neither is Web 2.0 for a Hospital.

E-mail Inga.

Are Portals Becoming Obsolete?
By Robert Connely, Medicity

I wanted to add a comment to the question you raised – are portals becoming obsolete? 

From my perspective, it’s a bit like asking the question “Have mainframe computers become obsolete?” The answer is, of course, that they have not. They have gotten smaller and faster, but they’re still in place, doing their work day-in and day-out. By the same token, portals are not obsolete, they’re just not sufficient by themselves to address all of the information needs of an organization like a hospital in today’s world.

I believe that hospitals need to think more broadly in terms of what I refer to as an “information outreach” strategy. Let me explain.

Today’s CIO is faced with a plethora of requirements that they’re charged with addressing, including:

• Providing remote access to physicians that need data that’s often found in multiple systems
• Exchanging information with an affiliate physician’s EMR
• Participating in the sharing of information in initiatives like HIEs or RHIOs

In these three common examples, there is often a desire to use a single technology to address all of them. This is, of course, nothing new. 

When portals emerged in the late 90s, CIOs would say, “I already have a remote access solution – why use a portal”? The answer was that portals made it simpler for physicians to access a broad range of data from a single, personalized view. As advanced features like electronic signature emerged and physicians could perform useful work remotely, the use of portals expanded.

When new technologies like agent grids evolved to push data to EMRs in the early 00s, CIO’s would say, “I already have a portal – why do I need an exchange solution”? The reality is that if you have an EMR, accessing data from the portal is no longer acceptable. Instead, you want the data pushed to the EMR, where it can be viewed alongside other data on the patient collected by the physician.

In the mid 00s when RHIOs and HIEs emerged, CIOs would either say, “I have an exchange solution, so I don’t need the HIE”, or, “I’m planning to join the HIE, so I don’t need an exchange solution.” As we learn more and more about this emerging world, it is clear that the needs of sharing information in an HIE is quite different that those required to exchange data with an EMR. Considerations like identifier reconciliation, local queuing of information if participating in a federated HIE, and others must be addressed by the chosen technology.

Now add the fact that hospitals serve a large number of physicians who are themselves at various levels of technology use and it becomes clear that there will always be physicians who need to interact with the organization in a variety of ways.

Thinking in terms of an information outreach strategy accepts this condition as a fact that must be dealt with to enable the organization to conduct business. It will likely require an array of technologies to address these varied needs. Because, just as you would never play a round of golf with just a putter, why try to use a single technology to address a wide range of information needs that are substantially different? It will only do one thing well, and everything else poorly. I suggest that instead, we think more like a golfer and have at our disposal a broad array of technology “clubs” to ensure that we have the right one for the shot we need to make.

Using this logic suggests that:

• Portals will continue to be useful in addressing the needs of physicians who either don’t have an EMR or want to access inpatient data that they don’t want in the EMR (physicians often elect to not receive inpatient lab tests in their EMR), or to perform workflow functions like signing off reports that are generated within the hospital.
• EMR exchange solutions must be put in place or risk losing business to another hospital or lab that accepts orders and delivers results electronically to and from the EMR. While it’s true that only 17% or so of physicians use an EMR, these tend to be larger, high revenue-generating practices that few hospitals can afford to lose to the competition.
• As HIEs evolve, the CIO may one day be told that the organization must participate in the initiative, which requires new consideration to what it means to “publish” information to the entity or entities (multi-system organizations often are required to participate with many local HIEs). In this case, portals or EMR exchange strategies are by themselves insufficient, and newer technologies that cache data outside of the internal systems must be put in place, with mechanisms to interact with the HIE core that may or may not include Record Locator Services, Master Patient Indices, and the like.

There may come a time when portals finally do become obsolete (for example, I don’t imagine many hospitals still using analog dial modem banks for remote access), but I can clearly see them continue to play a significant, albeit not an exclusive role, in the hospital’s “bag” for many years to come.

Eclipsys Misses Numbers, CFO Resigns, NYU Chooses Epic

Eclipsys shares are down over 17% in after-hours trading following a disappointing Q4 preliminary earnings report. For the quarter ending December 31, 2008, the company expects flat revenue and GAAP EPS of $0.07 to $0.11 compared to $0.45 a year ago. Revenue for the full year is expected to be up around 8%, with full-year GAAP earnings of $1.82 to $1.86 compared to $0.76 for FY07.

President and CEO R. Andrew Eckert called the quarterly results "disappointing," blaming delayed customer closes, a shift to back-loaded subscription deals, reduced customer utilization of professional services, an increased allowance for doubtful accounts for specific customers, and lower margins on third-party software due to market pricing pressures. "Economic factors are affecting our business, and the business of our clients," said Eckert. "In response to this uncertain environment, we are taking actions to adjust our cost structure and business practices." 

Eckert announced that Robert Colletti, senior vice president, CFO, and treasurer, resigned his position on January 14. David Morgan, VP of finance and assistant treasurer who joined the company in August 2008, will assume those roles in an interim capacity.

Meanwhile, an article published Wednesday reports that NYU Langone Medical Center will purchase a fully integrated clinical and patient financial system from Epic Systems Corp. with a total project cost of $186.4 million. The hospital installed an inpatient system from Eclipsys in 2007, but says it will be enhanced rather than replaced.

Unverified rumors reported to HIStalk today suggest that Eclipsys may reduce professional services headcount and announce the discontinuation of bonuses and merit increases for employees later this week. 

News 1/21/09

From The PACS Designer: "Re: Microsoft Photosynth. TPD has been experimenting with Microsoft’s Photosynth and its 3D capabilities for photo collections. It appears to be a nice way to enhance the photo experience after using your digital camera. It could enhance your photo skill level and at the same change your perspective on creating better photos. Once you download Photosynth, you’ll have to reboot your system to activate the software and also obtain a Windows LiveID before you accessing the application." Link. It takes a bunch of digital pictures and turns them into something like Google Maps Street View, from what I can tell, allowing you to navigate around by clicking arrows (but obviously without a BIG bunch of pictures, you’re just jumping around jarringly). Maybe the technology could be used to create 3D images from plain old X-rays.

From Dillinger: "Re: medical weblog awards. How could Medgadget not even have HIStalk listed as a nominee in the informatics category?" Beats me, but I’ve long ago figured out that blogs giving other blogs awards is nearly always a ploy to get traffic to their OWN blog, hoping nominees will send their readers there to vote. HIStalk has been around since June 2003 with quite a few readers, so I’ll satisfy myself with that accomplishment more than having some other blog declare me a winner.

From Elsie EHR: "Re: TV knee-slappers about Jonathan Bush being the President’s cousin. According to a Chicago Sun-Times article, he and Barack Obama are 11th cousins." Link. The only good thing is that since their last names aren’t the same, it will sail right over the talking heads. That makes two reasons to be grateful that his first cousin has joined the ranks of the unemployed.

From Webbed_feet: "Re: OHSU. Article on the layoffs and IT restructuring." Link. Oregon Health & Science University will eliminate 60 of 400 IT jobs and reclassify another 80, giving employees the pure joy of interviewing against their peers to see who gets to stay on the payroll. The union representing IT (who knew?) claims the university just wants to change the employees from hourly to salary to avoid paying them overtime and differential.

From Microsoft Guy: "Re: dabbling in healthcare. You were puzzled about the value the Senate and NRC place on Microsoft’s input on healthcare IT when we’re ‘dabblers at best’ but then highlight the work we’re doing at MD Anderson a mere half-page later." I don’t know that selling a hospital copies of Visual Studio and Windows 2000 (!) qualifies the company to pontificate to Congress on lifelong wellness, healthcare reimbursement, and appropriate IT investments. All those millions of physicians, informaticists, nurses, management engineers, and healthcare executives out there go unheard so someone who’s never worked in healthcare can advise Congress on healthcare reform? That’s somewhere between arrogant and preposterous. Dabblers like Oracle and Microsoft pop in every now and then as the healthcare market opportunity looks more or less lucrative (see: Healthcare Transaction Base and Amicore, respectively). The rest of us have been here all along.

Obama mentions healthcare IT in his inaugural speech: "We will restore science to its rightful place, and wield technology’s wonders to raise health care’s quality and lower its cost." He gave a stirring, impressive speech (pretty similar to that of Jimmy Carter, in fact, so caveat emptor). The campaign and the fanboy fawning are over, so now he gets judged on actions just like his predecessors. I’m cautiously optimistic so far.

HISsies voting is now open. Thanks to those who nominated the slate you’ll see (some no doubt motivated by the not-so-subtle urging of their employer). Anyway, use your inaugural enthusiasm to get your participative democracy on. The future of The Pie is in your hands.

Jobs: Senior Application Analyst (Sibley Memorial Hospital), Clinical Pharmacist (MedVentive), Chief Applications Officer (Snelling Executive Search), Chief Technology Officer (Snelling Executive Search).

We’re finding a comfortable voice for HIStalk Practice, including regular interviews with private practice physicians and industry experts. We’re up to 300 or so subscribers and a few thousand visits, which isn’t bad for our first couple of weeks. Sign up there for e-mail updates if you follow the EMR market. We’ve already filled our two Founding Sponsor slots there and also added some Platinum ones, so we will announce those shortly. Thanks to everyone supporting us there by reading, commenting, and writing – like the early days of HIStalk, it takes awhile to build up a readership.

Have physician portals become obsolete just as hospitals finally get them up and running? Robert Connely of Novo Innovations (now Medicity) said so when I interviewed him in 2006: "If you’re a doctor with an EMR, you don’t need a portal. In fact, you hate the concept. You want to see the data in your own system … Your physicians are bringing on EMRs and you need another way to get data to them." Stephanie Massengill says pretty much the same thing in a new article: "It seems the time for portals has waned. The marketing value of them is dubious, as the physicians have found that always seeking information is time consuming and, therefore, have stayed away in droves." Not that you need a third opinion, but here’s mine: portals are exactly what you would expect hospitals to have come up with given that they see themselves as center of the data universe, in charge of the conversation with physicians, and pleased to offer a solution that could be checked off as mission accomplished while missing the mark completely when it comes to physician workflow ("if you want to use the data in our systems to help our shared patients, even though it doesn’t benefit you or your practice personally, dial in and look it up yourself, make a copy or manually enter it into your own system, then repeat for each competing hospital in which you practice.") Portals were a good 1.0 stopgap and surely will continue to provide patient value, but for the ever-increasing number of practices with an EMR, better integration tools are available than that busy guy or gal wearing a stethoscope.

Just in: HIMSS announces the winners of its industry service awards. Pat Skarulis of Sloan-Kettering is CIO of the Year, Rosemary Kennedy of Siemens wins the nursing informatics leadership award, and Brian Jacobs of Children’s National is named for physician IT leadership.

Consumers are interested in personal health records … or do actions speak louder than words? A new report (which I’m not about to pay for, so I’m citing only the press release) says that only about a tenth of those people who claim they’re interested are actually using personal health records. Not surprising: if you believe self-reported consumer surveys, Masterpiece Theater is the most popular show on TV instead of innumerable morgue yarns and junk reality TV.

Sheldon Tyndall is named interim IT director at Haywood Medical Center (NC). He used to be at West Georgia and McKesson.

Danbury Hospital announces HealthLink, some kind of RHIO/HIE. Seems like the lawyers should be all over that choice of name since it’s been used about a zillion times.

An interesting article in The New Yorker (thanks to SQL_Goddess for the link) postulates that healthcare reform successfully happened in other countries not because it was rigorously planned, but because it evolved from experience to address current conditions. "Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it … In designing this program, we’ll inevitably want to build on the institutions we already have. That precept sounds as if it would severely limit our choices. But our health-care system has been a hodgepodge for so long that we actually have experience with all kinds of systems. The truth is that American health care has been more flotilla than ship. Our veterans’ health-care system is a program of twelve hundred government-run hospitals and other medical facilities all across the country (just like Britain’s). We could open it up to other people. We could give people a chance to join Medicare, our government insurance program (much like Canada’s). Or we could provide people with coverage through the benefits program that federal workers already have, a system of private-insurance choices (like Switzerland’s)."

So where does this guy fit in when talking healthcare reform? Yelling, bearded, ubiquitous cheeseball infomercial pitchman Billy Mays ("IT’S NEW OXICLEAN DETERGENT — GET ON THE BALL") is hawking health insurance. I’ve seen the commercial dozens of times already, even though I don’t watch much TV. Of course, he doesn’t scream out how much risk you take on when you sign up for "affordable" insurance (its mini-medical plan pays just $100 per day for a hospital stay). You know hospitals and doctors are going to eat the balance when the "insurance" covers next to nothing and the "insured" can’t pay, which is sad because they at least tried to do the right thing instead of just dropping all coverage. As highly recommended as the ultra-annoying Vince the Slap Chop guy ("YOU’RE GONNA LOVE MY NUTS").

Hospital layoffs: Waterbury Hospital (CT), 160; Integris Health (OK), no number given; Inter-Lakes Health (NY), 15.

South Australia’s Department of Health plans to deploy an ERP system covering all of its hospitals.

E-mail me.

HERtalk by Inga

I’ve been glued to the TV all day and have gotten teary a few times. It’s been an extraordinary day. I keep hearing Lee Greenwood singing in my head. It’s great to see so much pride and optimism. Oh, and I loved Aretha’s hat!

The Pennsylvania Medical Society has followed Mr. H’s lead and is now twittering (OK, maybe they didn’t start just because we did, but Mr. H likes to think of himself as a trailblazer), I know there of a number of hospital CIO’s twittering – I wonder if there are any hospital systems?

Canadian EMR vendor MedcomSoft fails to reach an agreement with creditors and files for bankruptcy. The company is now in trusteeship. The press release warns that it contains "forward-looking statements." Hardly.

A hospital-owned clinic in rural Colorado prepares to close its doors, falling victim to difficult financial times.

Nuance Communications continues to bid for Zi Corporation. The current offer was scheduled to expire January 16th, but Nuance as extended it until January 30th. So far, Zi’s stockholders have indicated they aren’t interest in the $.40/share offer. Zi’s stock closed at $.39 on Tuesday.

In Washington, House leaders suggest a December 31, 2009 deadline to complete an initial set of HIT standards. Also under consideration: $65,000 per physician in provider incentives; payments for hospitals that become fully wired; and penalties for not adopting HIT beginning in 2016. Privacy advocates are paying close attention to make sure their concerns are not overlooked.

The majority of Americans don’t consider HIT spending a priority, which may not be a surprise given the turbulent economic times. A recent study by Kaiser Family Foundation and the Harvard School of Public Health finds that 79% of the 1,628 participants want spending for HIT to decrease or stay the same, dead last by far of all the healthcare spending possibilities.

Revenue cycle solutions are all the rage in Michigan, as hospitals attempt to maintain revenues. With rises in unemployment and uncompensated care, hospitals are seeking new tools to update their billing and collection procedures.

Anesthesiologists have a cool new iPhone application available to them. iAnesthesia provides case log tracking, drug calculations, and administration guidelines.

Tomball Regional Medical Center (TX) equips its physicians with real-time patient updates on their mobile devices. The hospital is sending critical patient information to physicians using Clinical Xpert Navigator solution from Thomas Reuters (the former MercuryMD MData solution).

Pathology Service Associates launches a pathology CPT coding services Web site, PathLab Coding Solutions, that will provide responses to coding inquiring and access to automated and online coding resources.

Parkland Health & Hospital System (TX) licenses Lawson Software to automate administrative processes, simplify reporting, and improve data access.

Andrew Bolles joins Zotec Partners as director of business development. Bolles most recently worked as a VP and national sales manager for Dominion Medical Management.

United Regional Health Care System (TX) activates multiple Eclipsys clinical solutions across 35 inpatient units and two locations.

Marion General Hospital (IN) selects MEDSEEK to develop and implement an enterprise-wide healthcare portal.

South Jersey Healthcare (NJ) chooses Sage’s Intergy EHR for its affiliated physicians. The health system will subsidize the cost of the EHR and interfaces to the hospital’s IS/HIE.

Hayes Management Consulting announces that MedicalEdge Healthcare Group is providing MDaudit software for its physician clients.

E-mail Inga.

Ricky Roma Responds

… to comments from his recent guest posting.

A few people asked about the Site Visit problem, especially with respect to compensation. These questions actually highlight the root of the problem. Yes, site visits are lengthy and expensive. Risky? Not so much. 

I completely agree there are plenty of opportunities for sidebars and candid discussion, but these are the customers that the vendor has hand-selected to show off. These are the customers that get things like the best PMs; customized software; direct lines to the vendor’s senior leadership; discounts all over the place; pizzas sent Fridays; paid trips and dinners out with their Inga wannabes at trade shows; and anything else they so desire. These site visit hosts do not generally intend to mislead their wide-eyed visitors — they are just the beneficiaries of a relationship that is rarely repeatable at scale (“at scale” being vendor-speak for “you”).

Are the hosts compensated? Abso-fugly-lutely. Do they get better service than the average bear? Of course they do! That is the very reason why you are being directed there, so you can be guided into thinking ALL of said vendor’s customers live in this state of perpetual bliss. If this utopian state is something that can, in fact, be delivered “at scale,” there is only one way to find out — do your evaluation at scale (“at scale” here being my speak for, well, “at scale”).

The remedy here is to stack up the references. Stay away from the airport and choose quantity over false quality. Use the phone and your Web meeting tool-of-choice. Also, do back channel references — ask one or more of your Good sales people from a different product category if he or she knows any hospitals using Product X and would they facilitate an introduction. The time invested in 5,10, 15 or more calls will pay much greater dividends than getting a fancy trip somewhere.

I would augment this recommendation by having key members of your evaluation team each make calls to their respective counterparts. Find hospitals that are much like yours as possible and avoid the eight-person conference call. Make them one-on-one instead. A direct conversation is much more likely to generate an honest answer than from a crowded conference room. Plus, think of all the new LinkedIn contacts that can be made!    

Make sure your team agrees on a basic set of questions (actual, real, usable functionality; implementation reality; support reality; hidden costs; etc.) so that you can compare notes on the same topics. Also, be sure to ask the classic, "Knowing what you know now, what would you do differently if you came to work for us on this project?” The Dark Side HATES all this and will work hard to discourage this type of enlightened behavior. We want you to follow our script in showing off our wares, not yours!

If you follow this process and have five or more of your team calling at least 5-10 references (more for bigger projects, fewer for smaller), you will have developed a powerful matrix of 25-50-100 or more interviews. This information will serve as a great big spotlight to illuminate the future path you will be headed down with that potential decision. THEN, if you really want to go see this s#@& running somewhere, hop on that airplane and go.

While you are there feeling like a big shot, insist upon dinner with your Good sales person and the company’s CEO (aka, Mr. Discount) and let the negotiations begin …

Being John Glaser 1/20/09

In about a month, it is highly likely that our industry (healthcare information technology) will be very different. In my almost thirty years in this industry, there has never been an industry change of the depth and breadth that we are about to experience.

Last week saw the introduction of the first of the Congressional bills that will cause this change. These bills are part of a broader set of government efforts designed to stimulate the economy out of its distress. The healthcare IT portion of these bills intends to rapidly accelerate the adoption and effective use of information technology in healthcare. The House Ways and Means bill (PDF – go to page 138 and read from there) describes some proposed changes:

• Provision of $40,000 in incentives (beginning in 2011) for physicians to use an EHR
• Creation of HIT Extension Programs that would facilitate regional adoption efforts
• Provision of funds to states to coordinate and promote interoperable EHRs
• Development of education programs to train clinicians in EHR use and increase the number of healthcare IT professionals
• Creation of HIT grant and loan programs
• Acceleration of the construction of the National Health Information Network (NHIN)

All of these changes (and more) are accompanied by the infusion of $20B into the healthcare sector. To put this in perspective, in 2007 the HIT industry in the US was $26B (Gartner).

The “final” form of these changes is not clear. The Ways and Means bill and the Energy and Commerce bill and the Senate bills need to be reconciled. As I write (a snowy Sunday morning in Boston waiting for the NFL playoffs to start) I am sure that a wide range of industry professional associations, lobbying firms, and interested individuals and organizations are plowing through the language to identify improvements, concerns, and sections that need further clarity. Their voices will need to be heard.

And while the legislative process and discussion that arrives at a final bill will be (as it often is) complicated, confusing, and full of ups and downs, we should fully expect that sweeping changes will pass within 30 days.

What should you do about this?

First, to the degree that you have time, you should weigh in on the legislation. Your comments can be sent to your employer (if they are planning to provide feedback to Congress), your elected officials, and/or to industry professional societies (CHIME, HIMSS, AHIMA, AMIA, AHA, etc.) that will be providing feedback.

Second, get ready for an interesting 2009.

John Glaser is vice president and CIO at Partners HealthCare System. He describes himself as an "irregular regular contributor" to HIStalk.

Monday Morning Update 1/19/09

From MM: "Re: home grown systems. Foul! When I read people call software built by healthcare providers as ‘home grown,’ I can feel the hair on the back of my neck rise and my blood pressure go up. In the 1980s, that may have been an accurate statement, i.e. that providers built ‘home grown’ systems, where ‘home grown’ is used as a derogatory statement that refers to software that was developed by a single person using outdated technology with limited testing and no documentation. Today, there are some leading healthcare organizations designing, building, and deploying commercial grade software. With the move towards ‘Agile’ development, one can no longer equate the number of developers with the quality of software. Another point is that the software developed by a healthcare organization is ‘lighter’ and simpler than vendor software because the requirements are lighter." See below for an example of this from MD Anderson, which hardly fits the ‘home grown’ label.

From Salesgal: "Re: EEOC. [EMR vendor] is under investigation by the EEOC for unfair layoff procedures during the June 2008 layoff. All of the complaints are lodged in [sales manager’s] district. Seems he let go pregnant, ill, and staff who were not his groupies and kept his favorites who were not selling. He was ultimately let go, but several reps with solid experience and sales numbers were lost." I’ve omitted the names since I have no official documents to back up the statement. Sounds juicy, though. 

From Rowdy Piper: "Re: layoffs. Orlando Health (formerly Orlando Regional Healthcare System) has ‘reorganized’ positions across the institution by eliminating positions and placing many of those affected employees into other (many times lower paying) jobs. Additionally, they have instituted a system-wide hiring freeze and have started to cut hours for many and even forced time off over the holidays."

From Corndog: "Re: UHIN. Very impressive that Axolotl beat out Medicity right in its own backyard. Intermountain Healthcare has been shrewd in using technology to advance the quality agenda and must have liked what it saw." Maybe, although its big GE partnership doesn’t seem to show infallibility. Still, Axolotl has strung together some pretty good wins recently.

The President-elect is still talking up healthcare IT, this time in a TV interview: ".. in the economic recovery package that we put together, we have a lot of investment in making the health care system more efficient. Those are things that had to be paid for anyway. Just a simple thing like converting from a paper system to electronic medical records for every single person can drastically reduce costs, drastically reduce medical error, make not only health care more affordable, but also improve its quality."

HIMSS Analytics brags (confusingly) that "85 percent of hospitals in the contracting phase of an IT acquisition have signed with a CCHIT Certified vendor since November 2007." There’s no such thing as a certified vendor, only certified products, and even that certification only covers EMRs, not most of the software applications a hospital uses. Does that mean that 85% of hospitals that have bought any IT system in the past year also bought a certified product, or that those who bought a product covered by CCHIT (inpatient or ambulatory EMRs) certification chose the certified one? If they only bought a server (which is an IT acquisition) and no software, how were they counted? Mumbo jumbo aside, it doesn’t really matter — everybody shamed the vendors to lay out the cash to get certified, so it’s not like hospitals have much of a choice other than in office-based EMRs, where they might pick a lesser-known vendor despite dozens of certified ones. It’s not like having certified products available opened the floodgates – they’re buying the same old products that just happen to be certified now. Results, not surprisingly, haven’t changed – just the cost. Products are interoperable, but users aren’t.

And speaking of CCHIT certification, Allscripts Professional earns Ambulatory 08.

UC Irvine Medical Center is proud that its anesthesiologists have stopped falsifying surgical records by filling out forms before the surgery starts as CMS found earlier, now thwarted by its new SIS software the prevents them from doing so.

Former Healthlink VP Ed Kopetsky is named CIO of Lucile Packard Children’s Hospital.

Jonathan Bush and David Brailer were on CNBC. There’s not much new since the TV guys require everything to be simplified so they can understand it, but I bet JB can’t wait until Tuesday when the talking heads will have to drop their "president’s cousin" knee-slappers unless he’s also related to Obama.

Conditions are so bad that Columbia St. Mary’s (WI) intentionally slows down its $417 million new hospital project that’s already almost four years old.

Big layoffs for Wellpoint: the struggling insurer will drop 600 employees and another 900 unfilled positions.

GE Healthcare will lay off in "the low to mid-single digits" as a percentage worldwide.

Hospital layoffs: Tulare District Hospital (CA), no number given; Excela Health (PA), 70; Wellmont Health System and Mountain States Health Alliance, 195; Fox Chase Cancer Center (PA), 80; Montgomery Hospital Medical Center (PA), 17. Brazosport Regional Health System cuts the hours of hourly employees and issues a mandatory 10% pay cut for salaried ones. There are more, too many in fact for me to keep writing about, so suffice it to say that nearly every hospital is freezing discretionary spending, cutting capital budgets, and laying off staff.

West Virginia University Hospitals and its physician group were to have gone live with Wave 2 of their $90 million Epic implementation over the weekend. That’s $18,000 per user or $180K per doctor, just in case you were wondering.

Sen. Chuck Grassley’s investigation turns over another hidden fact: the orthopedics chair at University of Wisconsin-Madison pocketed over $19 million in five years from device maker Medtronic. He claims the money was royalties for patents he holds. So how the heck was he able to keep all that money without the university knowing (that is, unless he was intentionally cutting them out of the deal even though he’s a full-time employee)? He claims he fully disclosed his relationships and never implanted any of the devices in his own patients (so does that mean their care was better or worse?) In fairness to him, the university’s disclosure forms have a top category of "over $20,000," so that’s their fault for not being more specific.

I’m puzzled: why did the National Research Council and then the Senate ask Microsoft (and Intel, for that matter, in NRC’s case) for its opinions on healthcare and technology? Peter Neupert gave the company’s view (warning: PDF) of what the future of healthcare should look like, but everywhere I’ve worked, they just sold expensive, trouble-prone IT plumbing and gave CIOs free trips to Redmond. Of course Microsoft envisions a radically different and technologically future – that’s their only hope for elbowing aside companies like Meditech that have been automating healthcare while Bill Gates and Jerry Seinfeld were still in high school. I’m not saying they shouldn’t have an opinion, only that I don’t get why anyone would give it much value when they’re dabblers at best. At least its rumored layoffs apparently didn’t happen.

Two 19-year-old students develop Refill300, a free e-prescribing and refill site.

AT&T is developing software that will use both WiFi and a low-power technology called Zigbee to send home monitoring information to providers.

Amazon Web Services makes some of its huge public data sets, including genomic and census data, available at no charge for developing cloud applications.

Three UK hospitals are rolling out e-prescribing in what’s called the UK’s biggest eRX project. JAC Computer Services, a subsidiary of Mediware, is providing the application.

E-mail me.

M.D. Anderson’s EMR Project
By Lynn H. Vogel, Ph.D., FHIMSS, FCHIME
Vice President and Chief Information Officer
Associate Professor, Bioinformatics and Computational Biology
The University of Texas M. D. Anderson Cancer Center

I asked Lynn Vogel about the project they’ve been working on at M.D. Anderson. Here is his response.

The January issue of Advance will have some comments on what we are doing with regard to ClinicStation and its SOA architecture, with some observations regarding comparisons with commercial products.

The fundamental problem is that every commercial clinical systems product on the market today relies on a single, physical data repository, generally with HL7 interfaces, and is based on relational data base architectural models that are now close to 20 years old. Outside of healthcare, the IT world has embraced Services Architectural models and is now moving into semantic data models as well. But the cost of a major architecture change is simply prohibitive for commercial healthcare IT vendors. For all the talk about interoperability challenges, not being able to incorporate new data models into our clinical systems environments down the road may be a much larger constraint on improving our nation’s health.

The advent of genomic (or personalized) medicine presents very different types of data from what we have been accustomed to historically. For the most part, clinical data has been viewed as a series of discrete data models — you have a particular laboratory value, or a radiology report, or a graphic from an echocardiogram that you send to a repository via an HL7 message — so incorporating new data of this type into the repository via HL7 has not been a problem. But genomic data models tend to be based more on pattern-matching than discrete data, and products that rely on a single physical data model have real problems integrating these new data types. In addition, the vast volume of genomic data that is now being collected and increasingly available for matching can become unmanageable within a single data model and repository structure.

M. D. Anderson is now working on a parallel product, ResearchStation, also built on the SOA framework, that for the first time promises true integration of research data (e.g., biomarker data) with data from clinical practice. We hope to exploit UDDI capabilities as the actual linkage process between data and services from ClinicStation and ResearchStation. All of this, of course, says nothing about the vocabulary and terminology challenges we face in healthcare, for which is there is simply no comparison in any other industry. This is where semantic models promise to make a significant impact — and major technology vendors such as Oracle are already incorporating such capabilities into their product suites — but these are not even on the radar of the major healthcare IT vendors.

A couple of references with more specifics on what we are doing:

Case study from Microsoft (Word document)
Case study from Avanade, our strategic partner in software architecture and development

Wes Rishel from Gartner included our work as a case study in his presentation a couple of weeks ago at the Gartner Healthcare IT Symposium, so I think the word is getting out about the usefulness of SOA and how it can help us to deal with a number of the data challenges in healthcare.

House Stimulus Bill Draft Calls for $2 Billion for ONCHIT, $18 Billion for CMS P4P Incentives

The discussion draft (warning: PDF) of The American Recovery and Investment Act of 2009 in the House of Representatives contains only $2 billion in new funds specific earmarked for healthcare IT, with that entire amount to be managed by the Office of the National Coordinator. The remainder of the $20 billion figure that was quoted for healthcare IT would  be distributed by CMS as pay-for-performance incentives that have not yet been defined.

ONCHIT’s short-term $2 billion spending would be targeted for nationwide information exchange, healthcare professional training (possibly in informatics, not specifically stated), and grants for hospitals and doctors to acquire CCHIT-certified products.

A report from Piper Jaffray analyst Sean Wieland says that most of the CMS incentive funds will go to hospitals, with the intention of covering 1/3 of the cost of electronic medical records systems, but not prior to purchase.

Meanwhile on the other side of Congress, testimony from yesterday morning’s Senate hearing on Investing in Health IT: A Stimulus for a Healthier America is available online in video and PDF formats. Witness testimony is included from Jack Conchran of The Permanente Foundation, Janet Corrigan of the National Quality Forum, Valerie Melvin of the GAO, Peter Neupert of Microsoft, and Mary Grealy of Health Leadership Council.

News 1/16/09

From Seattle: "Re: HIMSS. At the HIMSS Washington dinner last night, Dave Garets of HIMSS Analytics disclosed that he and others from HIMSS had been working with the Congressional Budget Office on the HIT proposal.They were asked what would it take to get all hospitals to Stage 4. Apparently the proposal includes both inpatient and ambulatory and will be a combination of grants, loans, and Medicare rewards, including up to $1 million in ‘reimbursements’ for systems already implemented. When the speakers panel discussed this, two of the four suggested that this was a lousy idea and seriously questioned why we should be reimbursing anyone. They suggested instead delaying ICD-10 or using the simpler Canadian version or simplifying claims and payments, also focusing on reducing provider time by eight hours a schedule using technology instead of just buying more technology." HIMSS Analytics shows that 95.7% of hospitals haven’t yet made it to Stage 4, which requires all ancillaries to be installed, CDR, controlled medical vocabulary, CDSS for both error checking and clinical protocols, clinical documentation, PACS in all areas, and CPOE (even though you only need one live floor to claim victory). Maybe someone should get the cost and outcomes stats from those who have since I doubt there’s a corresponding improvement. Using that logic, Detroit should be rewarded for buying new robotic welders as a way to create safer and better cars. Why not just pay them for making safer and better cars? Makes sense unless you sell robotic welders.

From Terry Jacks: "Re: Ministry. Is anyone going to point out that this Cattails system that has been recognized recently in the press is not a vendor, has no clients, no implementation staff, no service staff, and no customers other than their own docs? I thought we went away from home grown systems in the 1980s?" I think you may have given Pete inspiration for a future posting. From its data warehouse design above, it’s not exactly a stripped down, spur-of-the-moment system and it’s also CCHIT certified, so I’ll be interested to hear more about what they’ve built.

From Snake Pliskin: "Re: Sutter. The period of time that it has taken Sutter to implement Epic is NOT a reflection of Epic. Sutter is pushing the envelope. When you look at Epic, it’s pretty amazing to realize just what they have accomplished over the course of the past eight or nine years since they entered the inpatient arena. Sutter is a confederation that covers a huge geographical expanse. It’s been about establishing common governance, common processes, achieving consensus, responding to changes in technologies and patient care needs, the desire to improve work flows. I’m going to give Epic and Sutter kudos. Really. It’s a monumental task."

From Seattle: "Re: ICD-10. Compliance deadline extended to October 1, 2013." Link. AHIMA is "applauding" with its imaginary hands, but only for HHS’s approval of ICD-10. It’s not happy about the deadline extension. On the other hand, AHIMA doesn’t sell or use information systems, so that’s easy for them to say (good for coders, too, probably).

From Rommon: "Re: Palmetto Health Baptist Easley. The 50-year-old upstate SC hospital to be spun-off from the largest healthcare system in the state, Palmetto Health, and co-owned by PH and GHS. ‘Not related to the economy.’" Link. 

From RIS Guy: "Re: Agfa. Agfa is, for the second time in four weeks, today going through a US reduction in force of about 60 people. This time, it’s front line sales and service."

From Billy Lyall: "Re: site visits. I have worked for vendors for much of my life and I’m always sensitive to site visits. They’re no easy thing to manage from the vendor perspective. They can be risky — even the best site visit could go downhill quickly. They consume a lot of time for the host. Of course the host is going to get something, maybe some discount on support hours or licensing of new products, but maybe even just special attention from the vendor. But, my impression of the people from the hosting site has always been that they are candid about support issues, implementation hurdles, staffing, and ability to meet end user needs. There’s always the opportunity for sidebar conversations." I enjoyed Ricky Roma’s piece and have asked for more if he’s willing. Inga and I found him by accident and were enthralled by his writing.

From Webbed_Feet: "Re: OHSU. Reorg and layoff alert; Oregon Health & Science University (OHSU) completely re-orgs IT. The final numbers are not published yet, but dozens have been told they will be laid off and will get formal notice on Wednesday. As part of the re-org, the CIO and CHIO formally announce the Clinical Informatics department that encompasses workflow analysis, clinical reporting, HIM nad RN and MD champions for the Epic project." OHSU has been struggling, so it’s probably not too surprising that something had to give.

From Medarling: "Re: Ivo Nelson. I heard interesting comments that Ivo Nelson, former CEO of Healthlink before selling to IBM, may be doing a comeback? Anyone else hearing this?" His LinkedIn profile indicates that he has started a new consulting business in Houston called Ivo Inc., which may or may not be just him puttering around a little. I finally found a personal e-mail address for him and sent an inquiry, but I haven’t heard back.

The House Appropriations Committee released a summary of its stimulus plan Thursday, which includes $20 billion for HIT. It will be interesting to see where the money would go once the details come out. Since Obama wants a quick jolt, the only reasonable way to disburse it would be through organizations that have been efficient and trustworthy in the past. How else, other than parachuting in pallets of cash a la Iraq, could that much money get into play quickly? Who would you trust to dispense it thoughtfully?

David Brailer writes his thoughts on the national health IT agenda, which unfortunately came out about six hours after I sent him a list of interview question and hoped for a response. He says he hoped to let the market drive EMR adoption when he was running ONCHIT, but it didn’t happen, so government incentives are needed. However, he nearly echoes my previous writings, I’m proud to say: "We should not incent physicians and hospitals simply to purchase electronic records. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care." He advocates pay for use. He also points out the obvious need for bunch of clinical informatics people to get all this stuff up and running, which of course is a hundred times harder because every vendor’s system is different and it takes years to really learn each one. He also suggest updating HIPAA and privacy rules, arguing that trusted providers are constrained while companies like Microsoft aren’t because they aren’t providers. Here’s his big pitch: "President-elect Obama should consider one single change that would do more to reshape medicine into an information industry than anything else: have Medicare treat electronic visits as equivalent to in-person visits." Brother Dave, this choirboy hears you loud and clear and says amen, although I might change that last big pitch to: "President-elect Obama should consider one single change that would do more to reshape medicine into an information industry than anything else: put a stop to all the ridiculous documentation requirements for getting providers paid, many of them imposed by Uncle Sam himself through his big payors like Medicare." Imagine how good EMRs would be if all the crap involving billing and malpractice defense could be eliminated and systems redesigned from scratch for the patient’s benefit, not that of the government and the insurance companies. It’s no surprise that the best clinical improvement came from the VA’s VistA – the hardhats didn’t have to program in that 80% of the average hospital system that has nothing to do with patients. Hospitals bought their first computers because of Medicare complexity and that hasn’t changed.

The chair of the House VA committee says he will investigate reported software problems that caused patients to get wrong drug doses and miss treatments. The problems: IVs ran longer than intended and information showed up on the wrong patient. If he finds the perfect information system anywhere in the world in all that investigating, I’d like to hear about it.

Frustrating: I bought those squiggly, energy-efficient Sylvania bulbs from Sam’s that say on the box they’ll last seven years. So far in one bathroom, four of six have burned out in just a handful of months. Ripoff?

John at Chilmark Research weighs in on the Medicity-Novo Innovations merger.

Simon Samaha MD, who we old timers remember as CIO of Cooper University Hospital, is named president and CEO of Summit Medical Group, a 140-physician medical practice in New Jersey.

McKinsey Quarterly noodles on Why Americans Pay more for Health Care. The big reason: outpatient care, which is theoretically cheaper than inpatient care, but only if it replaces it. One culprit CT and MRI scans, which makes it very profitable. Also: "Well-insured patients who bear little, if any, of the cost of their treatment have no incentive to be value-conscious health care consumers. Moreover, even if they wanted to be value conscious, they don’t know enough." Let’s repeat: providers will do whatever they can get paid to do, just like every other profession. It’s not illegal, immoral, or even harmful – it’s just expensive for whomever is picking up the tab (not the patient, in most cases). If you want them to stop, then don’t pay them for doing it.

As Inga mentions below, LinkedIn yanked my photo, a shot of the Unknown Comic. How do they know it wasn’t me wearing a bag? Here’s my thought: I’ll chose an HIStalk reader’s picture and put it on my profile. Then, I’ll see who recognizes them at HIMSS and ask them to report back whether they received any accolades, assaults, or indecent proposals. In fact, I could swap reader pictures once a month so that I am, in fact, an HIT Everyman or Everywoman.

MedAvant, rescued from bankruptcy in September by selling out to Marlin Equity, acquires the Medicare Crossover business of HDM.

The Motion Picture & Television Fund will close its hospital and nursing home in Woodland Hills, CA due to $10 million a year in operating losses, laying off 290 employees.

GE Healthcare announces the merging of its two Milwaukee area divisions, diagnostic systems in Waukesha and clinical systems in Wauwatosa (did they intentionally choose towns with odd yet similar names?) The company boldly claimed it was about growth, no doubt the same reason they’ve been laying employees off and closing plants. It’s also shutting down the GE Healthcare Lunar office in Madison, moving manufacturing to Milwaukee. Despite the oddball name, it makes equipment to measure bone mineral density.

In that vein and locale, Wheaton Franciscan also announces its latest growth strategy: the forced evacuation of another 100 or so employees on top of the 250 positions already eliminated. If you live in Waukesha County, watch out for traffic near the unemployment office.

<shameless self-aggrandizement>A New Zealand integrator working on an RFI there asked me a few weeks back if I would mention their interest in hearing from US software vendors who might participate in a big patient records project. I did and the company says they got more than a dozen inquiries. Also, from a company who ran a text ad like those you see to your right, "We have seen more clicks from your site than any other of our ad locations (Google, Yahoo, etc.). You have a great site and I love reading it every day." </shameless self-aggrandizement>

That’s an HTML joke above, in case you didn’t get it.

Planned business closings and layoffs, courtesy of CoStar Group: Irvine Regional Hospital and Medical Center (CA) was to close Thursday, laying off 510 employees (above). Health Research Association (CA), the clinical trial support organization of USC, will lay off 79 employees on January 30.

Odd lawsuit: the family of a man who died after elective spinal fusion surgery at specialty hospital West Texas Hospital is suing the now-closed facility, claiming its medical staff didn’t recognize his blocked airway complications. His wife repeatedly asked staff for help, the hospital PA covering the ED (!) was paged, nobody thought about establishing an airway, and the wife gave him CPR. The hospital’s action: they called 911.

Jonathan Bush is on CNBC again. He quotes the IOM report and rails against the government gravy train. Worth watching, even if the gaggle of amped up hosts constantly interrupts him at a nearly intolerable volume. "Pay for data, pay for results, and you can’t believe how fast doctors will get out there and get online."

Hospital layoffs: Gaylord Hospital (CT), 11; Wyoming Valley Health Care System (PA), 20; Banner Health (AZ), 334; Mt. Carmel Health System (OH), 300; Rogue Valley Medical Center (OR), 20.

The CEO of Carolinas HealthCare System is doing OK, though, having been paid $3.5 million in 2008. They claim he earned it, which at least is slightly different than the standard excuse of having to pay competitively to attract such notable talent to a non-profit endeavor.

E-mail me.

HERtalk by Inga

From LinkedIn Customer Service: “Re: your profile picture has been removed. The picture is in violation of the LinkedIn Photo Policy because it is not an accurate representation of you.” What? My avatar is absolutely an accurate representation of me (in an optimized, sexier, Barbie-ish sort of way.) Apparently only “photographs” are acceptable. Mr. H is also miffed because his profile picture (a photograph) was also removed. His was the one with the bag over his head, which apparently is one of Mrs. H’s favorites since he likes to wear the bag around the house all the time (I didn’t ask). I just posted a new photo of myself. We’ll see how long before that one is also removed.

I have to say the quality of the writing and commentary from our readers is amazing. In the last week we’ve had some excellent stuff out there, both on HIStalk and HIStalkPractice. Thanks to everyone taking the time to support our sites by providing thought-provoking, smart, and entertaining material. We are always looking for great content, so drop us a note if you have any HIT reflections to share.

Retired Gen. Eric Shinseki, Obama’s pick to head the VA, vows to develop an EHR for active duty personnel and veterans and make business practices as paper-less as possible. Shinseki tells senators during his confirmation hearing that the barriers have not been technical, but rooted in the VA and Defense department’s leadership.

Also on Capitol Hill, NQF CEO and President Janet Corrigan tells a Senate committee that effective use of HIT is essential to improve quality, safety, and affordability.

GE Healthcare confirms its former IDX Systems headquarters in Vermont is cutting staff and other costs. A GE spokesperson would not discuss the number of employees affected.

Hill-Rom Co. also confirms job cuts and operational consolidations. The company plans to cut about 450 positions in the US. Hill-Rom laid off 150 employees at the end of 2008.

If you’ve been affected by all the recent layoffs, perhaps it will make you feel mildly better to know that healthcare workers in other countries are also suffering. Swedish medical officials announces plans to cut 900 jobs (6% of the workforce) in order to reduce costs.

Toronto General Hospital pilots its first surgery checklist, aimed at reducing adverse events.

Here is a new must-have item for fashion-conscious, cold-fingered iPhone users. The thumb and index-fingers on these $40 gloves by North Face are covered with special fabric that includes silver.

Mr. H mentioned an odd lawsuit last week that involved a deaf patient who sued her doctor for failing to provide a sign language interpreter. She ended up winning $400,000. A company called LifeLinks saw the lawsuit as an opportunity to promote its remote translation services, which allow providers to connect with interpreters and sign language specialists via the Web. Providers only pay for the interpreters’ time, which undoubtedly costs far less than $400K.

Medicare beneficiaries in Arizona and Utah test new PHR software that includes two years worth of Medicare claims data. Patients can manually enter additional data. Some additional information can be uploaded electronically. Personally I think I would be more inclined to use an EHR that was pre-populated with at least some data, so this sounds like an interesting pilot.

University Hospitals (OH) launches a new physicians’ portal that combines electronic prescription writing with medication reconciliation.

Blue Shield of California Foundation announces its intent to stop issuing HIT grants, citing more pressing healthcare needs. Last year the foundation issued almost $11 million in HIT grants.

Two Illinois hospitals settle lawsuits alleging they overcharged uninsured patients tens of thousands of dollars. Resurrection Health Care and Advocate Health Care have agreed to recalculate bills and give refunds to needy patients eligible for free or discounted care. In addition, Resurrection will extend a 25% discount to all uninsured patients, regardless of income level.

Anne Arundel Medical Center (MD) implements VISion:Asset Management from Versus Technology to provide real-time tracking services for hospital assets.

Nuance Communications and IBM announce a licensing and technical services agreement to enhance and expand speech solutions, including incorporating IBM technology into Nuance’s speech products. Nuance will also purchase speech-related products from IBM. Nuance also reveals that Warburg Pincus has agreed to purchase $175 million of Nuance common stock. Nuance plans to spend some of the money on merger and acquisition activity. The purchase represents almost 17.4 million shares.

CSC wins a $265 million, 7.5-year contract to replace North Carolina’s Medicaid Management information system.

Polaris Venture Partners acquires a substantial interest in National Electronic Attachment, a provider of secure electronic data for claims attachments.

Telephone equipment maker Nortel Networks files for Chapter 11 bankruptcy protection

CareTech Solutions and EnovateIT team up to create a custom wall station for Crittenton Hospital Medical Center (MI). The e645 Computing Wall Station will be mounted into individual patient rooms for point of care documentation.

The University of Pennsylvania School of Nursing and Eclipsys form an academic partnership that will incorporate Eclipsys technology into the curriculum.

Tawam Hospital in Dubai goes live on Royal Philips’ iSite PACS, the first public hospital in the Middle East to do so. Tawam Hospital is affiliated with Johns Hopkins Medicine International.

E-mail Inga.

Pete Sanderson’s Responses to Comments from Yesterday’s Post

Comment #1
A partner and I are ramping up to start a consulting practice sharing best practices for HIT projects. We are consistently amazed at what a little project management rigor can do to keep the ship on course. Thanks, always interested to hear success stories and lessons learned on HIT projects.

Feel free to share a few of your success stories

Comment #2
I can understand that you don’t want people padding their budget estimates to ensure 100% success, but I also understand why someone might bristle at having their project labeled a failure for completing work too far ahead of schedule or producing something at a lower cost than expected. Much is learned during the course of a project, and it seems like you might inadvertently be disincentiving people from taking advantage of optimization opportunities.

Good point. Every project includes identifying named human resources to accomplish tasks and achieve deliverables. You identify named resources to make sure they are not over allocated.  You seek to avoid asking someone to do 100 hours worth of tasks during a 40-hour work week. As you learn during the course of the project, you produce change requests that either free up resources or seek additional resources for your project. The Project Management Office balances all the change requests from a portfolio of projects trying to balance organizational priorities and resource availability. It can be tricky, but allows the organization to track projects and provide adequate resources where and when needed. An added benefit is the ability to forecast needs and being proactive to meet needs months down the road.

Comment #4
‘Good process and leadership trumps bad software.’ There are some many things wrong with this statement I don’t know where to start. Suffice it to say I completely disagree. Nothing trumps bad software.

With truly bad software, you are correct. The statement should really read, "Good process and leadership trumps marginal software or software that is mislabeled as bad software." How many times have you replaced a product thought of as bad software only to find the problem has not been fixed? We often find our trouble with software is due more to how we have chosen to implement it rather than with the software itself. The point is, business leaders should optimize processes and use of the software before deciding the software is truly bad. Good process and leadership can often improve the use of software mislabeled as bad saving the time and cost of implementing a new product.

E-mail Pete.

MD Leader 1/15/09

Successful Projects

With the use of project management methodology, Ministry Health Care has consistently improved the success rates of IT projects. Any effort installing new software or requiring more than 100 hours of IT time is considered a project. Even using project management, 25% of our closing reports reflect a failed project; one that was not managed to the agreed upon timeline, scope or budget.

Before you start thinking your projects have a better success rate than ours, here is what we define as failures:

• Actual expenses varied by more or less than 10% of budget
• Total project hours varied by more than 10% of planned hours
• Completion date varied by more than 15% of the original completion date
• Two or more material scope changes
• Less than 80% of project objectives attained
• The project’s impact on the organization was not anticipated or was not effectively communicated

Business leaders often bristle at being told their project was a failure because they brought a project in under budget or with fewer project hours than budgeted (the cause of the majority of failed projects). However, we are managing a portfolio of projects limited by resource constraints. If all our projects come in 20% under budget, that means the organization accomplished 20% less than it could have with the same resources.

We also do an additional evaluation at least six months after the closing report evaluating if the project achieved its long-term objectives. Many failed projects are subsequently vindicated. 

I recently completed a Physician Executive MBA ( PEMBA) at the University of Tennessee. My classmates were physician leaders from across the county and numerous foreign countries. Their experience with IT projects was uniformly negative. In general, they thought IT was done to them rather than with them. These leaders reaction to IT should give us all a pause to evaluate our implementation strategy.

Will Weider, our CIO, recently listed Ministry’s "lessons learned" based on 2008 projects:

• Test thoroughly
• Good process and leadership trumps bad software
• Roles should be clearly defined and consistent with our Lean and Six Sigma engagement and acceptance strategy
• Business leaders should fully understand current practice and issues before new software or process change is considered
• Hours are consistently under budget due mostly to the assignment of unnecessary contingency in the project plans.
• Formalize Lean and Six Sigma activities in EHR project plans

We did have one perfect project last year (on time, one budget, satisfying all objectives): a medication reconciliation project at one of our internal medicine offices. This project was not initially supported by our CIO because it was a duplication of effort. We are in the process of implementing CattailsMD electronic health record, but this site will not go live for some time. The CIO correctly pointed out the existing software that was utilized will be replaced by CattailsMD.

The Project Team, comprised of nursing and clinician staff, rightly argued the software was the easy part; the tough part was establishing a standardized process for medication reconciliation. A standard process can be adapted to the future software solution. The team was lead by a Black Belt utilizing lean methodology to map out a future process flow and then used standard change management tools to achieve stakeholder engagement and acceptance. IT and project management played a supportive role. The project was done with the clinicians rather than directed at them.

Our deployment of the EHR will be accomplished with the same techniques used in our medication reconciliation project. Ministry Medical Group will own the implementation assisted by IT and Project Management. While the organization will establish certain high level standards, each practice site will use lean methodology to define its own standardized work flow. A system-wide rollout the EHR software will be accomplished through multiple small work site-centered projects allowing clinicians and staff to improve and own their work flow.

With the new year starting, sit back and evaluate the success of your projects. Share with us your lessons learned, the common characteristics of your successes and how you were able to achieve the acceptance and engagement of your stakeholders. I look forward to hearing from you.

Peter Sanderson, MD, MBA is a family physician and Director of Medical Informatics and Operations and Executive Sponsor, EHR Program, at Ministry Health Care. He can be reached at pete.sanderson@ministryhealth.org. He also blogs at MD Leader.

News 1/14/09

From Fish n’ Chips: "Re: Sutter. oneHITwonder hit the nail on the head. Epic is not going well with Sutter. More delays. 2+ years behind schedule. And money … well, can Sutter print money like the Fed does? They are going to need it."

From SQLImplosion: "Re: Sunquest. As the days go by, more and more Sunquest personnel are being escorted out the door. Not just your every day Joes, but the heart of the former Sunquest team. Tuesday, January 6 saw many employees let go, followed by the former service executive team on Friday the 9th. Now today, Tuesday the 13th, 49 more senior members of staff are gone for about a 20% headcount reduction. The number of years of experience of this staff, well over 600." I’ve contacted the company about the several reports I’ve received in the past few days. They promise a statement here Wednesday. I’m realistic: companies both good and bad are making tough decisions for reasons beyond their control. The first obligation of a business is to survive since it’s not doing the remaining employees any favors to let the entire ship go down together. We’ll hear Sunquest’s side soon, but unlike in giddy times when layoffs were just a convenient way to trim deadwood, I don’t think employers are happy about job cuts this go round. Condolences to those affected in any case.
 
From The PACS Designer: "Re: Cloud 20. Nicholas Carr of the RoughType Blog has a new book out called ‘The Big Switch’. He lists his 20 early cloud computing adopters as the Cloud 20: Adobe, Akamai, Amazon.com, Cisco Systems, Citrix Systems (including XenSource), EMC (including VMware and Mozy), Facebook, Gh.o.st, Google, IBM, Intuit, Metaweb Technologies, Microsoft, Mint, Salesforce.com, Sun Microsystems, 37signals, 3tera, Workday, Zoho." Link.

From Atlas Shrugged: "Re: Akron General. Cutting senior administrators." Link. Out: COO, SVO of marketing, president of the physicians’ group, and the VP of managed care. Layoffs are possible, the hospital says.

From Walnutz: "Re: NJ. Meridian Health buys Bayshore Community Health System and Southern Ocean County Hospital. Also, Bayshore cutting hours in lieu of layoffs. All hearsay from my vantage point, but plausible." Meridian and South Ocean announced exploration of a merger late last week and Meridian had already announced that it was talking merger with Bayshore. Given the desperate hospital situation in NJ, I would be surprised if it doesn’t happen.

From John: "Re: Web 2.0. Web 2.0 and social networking are already playing a role in healthcare. People are helping each other out, providing information and support. It’s happening right now, go and see for oneself. For example, a few quick searches in Facebook finds the group ‘Support the fight against cancer with just a click’ has 1,400,000 members, Autism Awareness has 60,000 members, and ‘Find a Cure For Juvenile Diabetes’ has 27,000 members. Now if by ‘healthcare’ one means ‘the sustainable business model one can come up with to monetize healthcare communities of interests,’ that poses a different question. However, the answer might stem from the large number of folks currently participating in the former notion of ‘healthcare.’" Brilliant and well said. Maybe healthcare as a business has made all of us too cynical about any manifestations of it that don’t come with a big-name CEO or a liquidity event.

Update: I forgot to mention that Medicity and Novo Innovations have formally announced their merger. I’ve thought Novo was one of the coolest companies out there when I interviewed mad scientist Robert Connely in 2006 (one of the most fun ones I’ve done – I need to get him to sit still for a second round). What makes the merger interesting is that Medicity has made great leaps with its technologies and understanding of the RHIO/HIE market and Novo brings its "intelligent agent" technology that provides a more direct connection to physician office EMRs. As my poll and the new report I mention a few paragraphs down indicate, people are beginning to realize that unconnected EMRs are first generation and a some companies (Medicity and RelayHealth come to mind, but there are others) are approaching the EMR benefit model from the other side.

I’m really excited about some upcoming goodies in HIStalk and HIStalkPractice. I always get discouraged through the holidays because the energy (and readership) drops, but it’s going great guns again. We’ve got some super, hand-picked guest authors coming on both sites (and isn’t it cool to see what John Glaser is thinking?) I’m pretty sure Inga and I have never worked harder to get information out there. The bad news is that I’m behind again, so be patient if you’ve e-mailed me. I’m cranky if I don’t sleep and something had to slide a little.

Shares in practice financial management company MedAssets rise 8% after the company reaffirms its 2008 outlook and raises 2009 earnings guidance.

Cerner’s second managed on-site medical clinic opens at Cisco. The article says it was a money-saver at Cerner, which is not surprising if the employee reports I received are accurate (high prices, low coverage). I’d like to think employee satisfaction with the service is important, but in a buyer’s market, it probably isn’t.

Housekeeping: drop your information in the Subscribe to Updates box to your right to get an e-mail blast when I write something new (and do the same on HIStalkPractice if you’re interested since they are separate lists). Right below that is an oh-so-convenient Email This to a Friend button that lets you easily tell people about HIStalk. There’s a search box over there too, which will obediently dig through 5.5 years of HIStalk to find whatever you’re interested in. And, a hideous green Rumor Report button by which you can send confidential stuff my way, even including scandalous attachments.

Listening: The Trash Can Sinatras, lush jangle pop that’s how REM would sound if they were raised in Scotland instead of Georgia.

A report from Booz Allen Hamilton and the Federation of American Hospitals concludes that healthcare IT emphasis needs to be on improving electronic communication among patients and providers rather than getting EMRs installed, with a shift needed way from EMRs as the "big bang" or "magic bullet". Some of its key points:

• Focus on e-prescribing, electronic results, and medical imaging.
• Tie payment to desired outcomes.
• Implement a national health information exchange. The UK already has 90% EMR penetration and a single national broadband network, but they’re still pursuing interoperability as its own separate project.
• Give patients access to their records and a way to communicate with their physicians about them.
• Create a voluntary personal identifier.
• Provide more funding to ONC to go beyond demonstration projects.
• EMRs adoption is poor, but could be improved by generating a "pull" for available electronic data.

I’ve said that here before, of course: PC vendors didn’t have to beg for adoption once the Internet came along. Create valuable content and people will find a way to obtain and use the devices required to access it. This is the second thoughtful report in a handful of days, of course, that questions whether just buying a lot of EMRs will improve healthcare. My theory, for what it’s worth: there will be limited success (defined as improved outcomes) in bringing technology to healthcare IT until everybody realizes that doctors won’t work as typists for free (my previous analogy that everyone wants to consume information, but few want to create it). Drop the guilt-inducing term "EMR/EHR" immediately and focus on deconstructing it into the individual functions that provide value to a given practice. Current technologies can support the market’s demand for functions that are modular, Internet-based, paid for as a service, and in full communication with the outside world, so vendors who don’t want to fight to overpower a generally resistant market will find success in going around that obstacle instead of trying to climb it.

But maybe you already knew that about connectivity is important: the leading vote-getter in the "Spend Obama’s Money" poll to your right is creating a national infrastructure for sharing data (43%), double the percentage who think subsidizing today’s EMRs is the best way to goose HIT.

Interesting: David Bowen, CIO for the Federal Aviation Adminstration and safety whistleblower, came from BCBS of California, Catholic Healthcare West, and Baptist Birmingham.

Caswell Family Medical Center (NC) gets a $99,000 grant to install an EMR.

Hospital layoffs: Westchester Medical Center (NY), 400; Memorial Hospital (PA), 32; Saint Alphonsus Regional Medical Center (ID), 66; Brockton Hospital (MA), 6; Mercy Health Partners (MI), 31; St. John’s Hospital (MO), 19; St. Joseph’s Hospital (WV), 20.

Estonia’s patient portal is delayed. I might be the only one who cares, probably because I’ve been there.

i-Rox, an Israel-based software development company whose employees are all ultra-Orthodox women (thus the name, a play on Internet and Orthodox), is developing a clinical information system for Palestinian Authority hospitals.

An Alaska hospital stops providing birth notices to the local newspaper, even if the parents sign a consent form, fearing abductions.

ED departments and after-hours clinics in Wales will have online access to patient information if the vendor’s final business case is approved.

Health Level 7 releases (warning: PDF) a child health functional profile for EMRs.

Jobs: Cerner Practice Director, McKesson HPP V13, Cloverleaf Integration Consultant.

David Brailer’s Health Evolution Partners announces a partnership called 21CM (21st Century Medicine) that "will identify innovations which change how medicine is practiced." Sounds like he’s found well-known hospital CEOs who are going to give him free investment ideas. Whether they get anything in return isn’t stated.

Intelligent transcription software vendor MD-IT closes $11 million in Series B private equity funding.

CMS tells WellPoint that it won’t allow the insurer to enroll new Medicare drug plan customers because it hasn’t fixed its ongoing computer problems. 

Toronto General Hospital performs a study to find the cause of pseudomonas infection in its ICU that killed 12 people. The answer, published in a journal this month: the sinks. The result: one patient who claims his complications were caused by contracting pseudomonas is suing the hospital for $40 million.

E-mail me.

HERtalk by Inga

From Famous Publisher: “Re: HIStalk. Flattered to hear from the famous Inga! Your site kicks butt. I’ve seldom seen IT folks swarm that way.” Famous Publisher sent me this note after I signed up to follow her on Twitter. Thanks for the nice words. By the way, thanks to all 35 of you following me on Twitter. Since I am the one who encouraged Mr. H to start twittering, it hardly seems fair that he already has 53 followers. Oh well.

Speaking of Twitter, I am following our possible next Surgeon General, who posted the above message Tuesday afternoon. Just think what a fit nation we’d be if Dr. Gupta was at the helm! Kind of inspires me to do some sit-ups tonight.

President-elect Obama taps William Corr as HHS deputy secretary. Corr is a longtime anti-smoking advocate and is currently the executive director at the Campaign for Tobacco-Free Kids.

The healthcare sector gains 30,000 jobs in December, while the nation as a whole loses more than 2 million. About 14,000 of the jobs are in ambulatory care, 12,000 in hospitals, and the rest in long-term and home health care.

Michelle Obama officially resigns as VP for Community and External Affairs at the University of Chicago Medical Center.

I was on the HIMSS site today and noticed there are only 81 days left until the annual conference. There are over 200 educational sessions, which is pretty overwhelming to consider. I would expect Mark Leavitt’s CCHIT Town Hall session to be a big draw. Personally, I might pop into the session called “Change EMR Vendors Midstream? What Were You Thinking?” Harry Lukens of LVHHN is the presenter and he is pretty entertaining. Of course, I’ll probably try to get a peek at Dennis Quaid. I wonder if he’d like an invite to the HIStalk event?

Opus Healthcare announces that its OpusMobility system now runs on the Google G1 phone.

ICA appoints John Tempesco VP of Client Services. Tempesco has been with ICA since February 2008 and previously worked at HealthPort and Companion Technologies.

Former Intel executive Greg Symon joins Red Hat as VP and GM of North American sales. We noticed that former Red Hat VP Dave Nesvisky (who Mr. H interviewed last May) is now EVP at Voxiva.

Memorial Hospital (NJ) signs a six-year agreement with PHNS to provide all the hospital’s IT services.

UHIN (Utah) selects Axolotl’s Elysium Exchange to power its HIE.

Oleen Pinnacle Healthcare Consulting acquires New York IT consulting firm Partners in Health Systems.

The Stratus Avance product wins a InfoWorld Product of the Year award in the category of Best High-Availability Solution for SMBs.

E-mail Inga.

Being John Glaser 1/13/09

The National eHealth Collaborative

In 2004, the Federal Department of Health and Human Services (HHS) established a series of organizations and initiatives in an effort to further the adoption of interoperable electronic health records (EHRs).

The Healthcare Information Technology Standards Panel (HITSP), the Certification Commission for Healthcare Information Technology (CCHIT), and the Office of the National Coordinator for Healthcare Information Technology (ONC) were established. Demonstrations of aspects of a National Health Information Network (NHIN) were conducted, analyses of privacy regulations were undertaken, and assessments of EHR adoption were performed.

Overseeing all of these activities and organizations was a Federal Advisory Committee, the American Health Information Community (AHIC). You can learn more about all of the above at www.hhs.gov/healthit. AHIC was chaired by the Secretary of Health and Human Services and the committee’s membership was composed of individuals from diverse sectors of healthcare and various HHS agencies and Federal departments.

AHIC was set up to transition, at the end of 2008, to a successor organization. During 2008, the Brookings Institution managed an extensive series of meetings and analyses which involved hundreds of individuals from across healthcare, which designed the successor. This successor was to be a public-private organization and continue the work of the AHIC.

The resulting successor organization is the National eHealth Collaborative (NeHC). You can learn more about NeHC at www.nationalehealth.org.

NeHC is focused on advancing the adoption and effective use of interoperable EHRs. To do that, the NeHC will:

• Use Value Cases to define opportunities to establish interoperability standards. The Value Case approach modifies the AHIC Use Case by performing more upfront analyses to ensure that the standards have a compelling value proposition and are likely to be adopted quickly by the market. In addition, the Value Case approach requires greater participation by healthcare organizations and seeks external funding of the work. It is highly likely that the Value Cases will be broader than transaction standards; Value Cases could also be policy and architecture frameworks and best practices. HITSP and CCHIT would continue their respective roles of interoperability specification development and product certification.
• Develop preliminary strategies and approaches for governing the emerging National Health Information Network.
• Identify barriers to the adoption of interoperable EHRs and commission work designed to overcome those barriers. This work might center on financial incentives, privacy approaches and procedures, data use agreements, and implementation practices.

NeHC will focus on “the ground.” In other words, while NeHC will work with government and industry on policy, its core orientation will be practical – how do we help those of us who are trying implement these systems overcome barriers and have a greater likelihood of improving care?

NeHC is a membership organization. Its members are organizations that have an interest in interoperable EHRs. In the next couple of months, information will be made available that outlines the membership application process and dues structure.

You all should check out the NeHC web site for new developments and announcements. You can also contact me (jglaser@partners.org) or Laura Miller, NeHC Interim Executive Director of NeHC (lmiller@ahicsuccessor.org) with questions and comments.

John Glaser is vice president and CIO at Partners HealthCare System. He describes himself as an "irregular regular contributor" to HIStalk.

Bill Stead on the National Research Council’s Report

Full text of the report is available here.

The report calls for a change in approach to health care IT.

This conclusion does not reflect negatively on the sites visited. To the contrary, their pioneering work and suggestions let the committee see the way forward. It does not contradict calls for increased investment in health care IT. Better management and use of information are essential to improving the health care system.

The report suggests that a larger dose of today’s health care IT will result in both improvement and harm. It will cost more and take longer than people expect. Collectively, the result will fall far short of what is needed.

For example, today’s clinical applications tend to be monolithic and complex. Rather than enabling small improvements in practice, the many information system interdependencies actually slow down improvement! Instead, clinical applications should reduce barriers to clinicians and patients doing what is best for care – even if doing what is best requires rapid cycle, iterative change in clinical behaviors and work flows.

A different outcome is possible. We do not need to wait for better IT before we move aggressively forward. However, near-term success will require a fresh approach to managing the investment by health care organizations, our health care IT vendors, and the government.

The report lays out five principles for use of IT to support evolutionary change in health care that are actionable in the near term. With a longer view, it identifies four principles to support revolutionary change and several research challenge problems.

It includes six recommendations directed at the senior management of health care organizations and, through them, to their vendors. Let me highlight a couple.

Organize incentives, roles, workflow process and supporting infrastructure to encourage, support and respond to opportunities for clinical performance gains.

In other words, the IT infrastructure should evolve with the improvement process, not lead it.

For example, if your goal is to reduce medication administration errors, start with incentives and infrastructure for blame-free reporting. Next, identify the situations with a high rate of "wrong patient, wrong dose" errors. Then, target deployment of technology support like bar code medication administration to those situations. Finally, continue to monitor performance, refining the combination of process and technology if needed, or extending to the next highest problem area.

In this way, you guarantee improvement. Use the technology only where needed and correct unintended consequences early.

Balance the institution’s IT portfolio among the four domains of automation, connectivity, decision support, and data mining capabilities.

The majority of today’s health care IT is designed to support automation, with some investment in supporting connectivity and little support of decision making or data mining. Yet the IOM’s vision for 21st century health care expects support for cognitive activities (helping providers and patients think about complex choices as they make decisions) and a learning health care system (mining related bodies of data to recognize and respond to patterns).

These activities are much more about connectivity, decision support, and data mining than about automation. The required shift in focus is large. Technology exists to support movement in these directions, but it is outside the comfort zone of many health care organizations and the established health care IT vendors.

Finally, read the report! It is short. It reflects careful study and review. With complex issues, one sentence may balance another. Hearing one sound bite without the others can mislead.

Health care organizations and health care IT vendors should read section 3 (rebalancing the portfolio), section 4 (principles for success), and section 6.3 (recommendations for health care organizations. They add up to only 12 pages.

In addition, I would point vendors to Appendix C, which summarizes the committee’s observations, the consequences, and opportunities for action, with the latter tagged as short term or research. Check your current offering and product direction against the ones tagged as short term.

William W. Stead, MD is associate vice chancellor for strategy/transformation, director of the Informatics Center (which includes the Department of Biomedical Informatics of the School of Medicine, the Eskind Biomedical Library, and the Center for Better Health), and CIO at Vanderbilt University Medical Center; and chief information architect for Vanderbilt University. He is chair of the Committee on Engaging the Computer Science Research Community in Health Care Informatics, which produced Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions under the auspices of the National Research Council.

Monday Morning Update 1/12/09

From You Missed This: "Re: another e-mail blunder from an HIT CEO." Eclipsys CEO Andy Eckert accidentally copies an equities analyst from Thomas Weisel Partners on what was supposed to be a private e-mail to CFO Bob Colletti and EVP Jay Deady, in which he remarked that a Weisel research note questioning the company’s growth rates, "certainly zeroed in on our organic growth rate." Andy told the analyst that what he was saying is that organic growth is a focus, not admitting that Weisel had uncovered a weakness. Still, the analyst’s generally positive opinion didn’t change.

From oneHITwonder: "Re: Sutter. My father was recently a patient at Sutter General Hospital in Sacramento (he’s home and doing well now). While visiting, I watched a nurse enter his room and pull down a wall-type desk, which revealed a keyboard and monitor. I was very impressed, but the nurse did not use the computer — she just pushed the keyboard out of the way and used the desk for a writing surface. I later asked another nurse if she uses the computer in the room and she said only if all the workstations at the nurses’ station are being used. Another nurse joined in, saying they were put in the room for ‘e-charting’ that never materialized, assuming ‘it must not be going well at other Sutter hospitals’ (I believe the reference here was to Epic). They occasionally look up lab orders, but that is about it. Sutter General uses Eclipsys for CPOE."

From The PACS Designer: "Re: Palm phone. Palm has released its challenge to the iPhone and it created quite a stir at the Consumer Electronics Show. Perhaps there’s a place in healthcare for the new Palm Pre to support user requests to add it to existing systems." Link.

This sounds interesting: Infirmary West (AL) launches an Internet system that lets patients self-register (for a $25 fee) for non-life threatening ED appointments, then come in at the appointed time instead of sitting around watching Judge Judy amidst the mayhem. They take it seriously: if the patient isn’t seen within 15 minutes of their appointed time, their visit is free. The nurse who runs the ED came up with the idea. An employee checks each registration as it comes in to make sure the patient’s condition doesn’t require immediate evaluation. Notice that the registration screen also provides an estimate of when you’ll be seen even before you sign up. The system provider is InQuickER, which runs the same service for several hospitals, but I can’t find out anything about the company.

A reader sent over a local article about December layoffs at North Memorial and Park Nicollet in Minnesota that were to affect over 600 positions.

Medfusion, the Raleigh, NC vendor of consumer-facing technologies for physician practices (like patient messaging, online registration, online payments, etc.) buys the former A4 and Allscripts office building in nearby Cary for $7.25 million, citing strong sales and the need to add up to 50 employees to join the current 70 in 2009.

Tennessee RHIO Shared Health hires Adnane Khalil, formerly of MedAvant, as VP of technology.

I’m doing some tentative experimentation with Twitter, so if you want to follow me, I’ve put an icon over in the right column. You won’t get much except updates when I publish something new, at least until I make it part of my routine. I might use it from HIMSS.

The CFO of Misys PLC resigns "by mutual consent."

Last chance for HISsies nominations. When the voting starts, you’ll say, "Why didn’t that idiot include these obvious nominees?" and I will smugly respond, "Because you and your passive ilk couldn’t be bothered to click a simple link to nominate them." To avoid all that unpleasantness between us, you might as well cast your nominations.

Nobody likes it when welfare recipients complain about the free money they get from the rest of us, so maybe HIMSS should be careful about how it characterizes its EMR Welfare Program. In Modern Healthcare, its director of congressional affairs is quoted as saying, "Our minimum is $25 billion."

I’ve never heard of Leap of Faith Technologies of Crystal Lake, IL, but the eHealth technology vendor is looking for testers for its "virtual pillbox" for smart phones. The eMedmobile application extracts information "smart labels" on pharmacy containers to issue medication reminders and to notify someone if the patient misses doses. Grants to help cover its development cost came from NIH, the National Cancer Institute, and the National Institute on Aging. Check out the demo – it’s cooler than it sounds. 

Interesting: medical students at University of Washington practice surgical technique in a mocked-up OR that includes a computerized patient. What’s different is that they’re also using simulations like these for nurses, dentists, and pharmacists and will combine the programs to teach the professionals communicate better, not just to practice their technique. A good line from the executive director of UW’s Institute for Simulation and Interprofessional Studies on the traditional surgeon’s training of learning on live patients: "I’d rather be able to tell some surgical resident, after 25 unsuccessful tries on a simulated patient, that maybe he ought to consider going into pathology.” UW is is also trying to get Microsoft to adapt the Xbox to allow training students at remote locations, but apparently hasn’t had much luck.

Reports suggest that troubled Satyam Computer Services is looking for a buyer. The CEO was arrested and the board dissolved this week after admitting that revenue was overstated and $1 billion of cash assets did not exist. Law firms are lining up to get a shot at the lawsuit coming against auditors PricewaterhouseCoopers, about which one big equity firm’s head said, "If you’re an auditing company and your client says they have $1 billion in cash, you do check with the bank." The company’s interim CEO was formerly president of its commercial and healthcare businesses.

Cardinal Health cuts its fiscal year outlook, citing hospital cutbacks in capital spending.

I’m guessing Bush and Obama don’t agree on much (thank goodness), but here’s one goal both think is important: having electronic health records for all Americans by 2014 (and that you can deficit-spend your way out of a depression, apparently). In a speech Thursday, Obama said the government will make "immediate investments" on IT, which will not only save money, but "reduce the deadly but preventable medical errors that pervade our health-care system." With that in mind, Gerson Lehrman Group predicts a 14.1% annual growth in the EMR market, although they oddly list Google and Microsoft as big potential winners (and also GE and Siemens, whose products I sure wouldn’t want my taxpayer dollars to fund if it’s innovation that’s needed). It’s funny that the Republican pushed free open source solutions like VistA, while the Democrat seems to be in favor of just buying commercial products with federal money. You’d think it would be the other way around, although not when the goal is just to spend a bunch of government money.

With that in mind, new poll to your right: where should the billions be spent?

Hospital layoffs: Good Samaritan (NE), 32; St. Francis (NE), 22; Blue Hill Memorial Hospital (ME), no number given; University of Chicago Medical Center (IL), up to 1,000; St. John’s Regional Medical Center (CA), 33; Los Robles Hospital & Medical Center (CA), 8; Ventura County Medical Center (CA), 30; Central Kansas Medical Center (KS), 50; Carson Tahoe Regional Healthcare (NV), 30; Erlanger Medical Center (TN), 80. Tenet Healthcare announces cuts in vacation time, sick time, and 401k contributions for its 50,000 employees. CGH Medical Center (IL) shuts down its free nurse hotline that gets over 550 calls a week.

West Penn Hospital says it fixed a patient-reported problem in which its online bill payment application that allowed users to see information about other patients. The hospital blamed a billing partner, but didn’t explain why the patient e-mailed the hospital twice and didn’t get a response until she called the local TV station.

More on the National Research Council’s Report on Healthcare IT

I worked late Friday night to get a summary of the report out because I think it’s important. I’m already getting some thoughts back from folks in the industry, so I think we’ll have a good dialog about what it means.

Much of what I’ve written in the past aligns with what the report says. In 2005, I cited an excellent report from The Advisory Board Company as the basis for an editorial on the shortcomings of clinical systems like CPOE, which the report said fails to improve practitioner performance 87% of the time. I said, "Several years after the IOM report that supposedly opened our eyes, clinical systems really haven’t delivered on the expectations. They haven’t made us much better … Everyone is buying and implementing and improving, but the patient doesn’t seem to get much benefit from all this clinical system churning. We’re still plagued with poor integration, sloppily designed bolt-ons to old products, and outdated architecture. We’re also not good at changing business processes on the provider side, so let’s take a few lumps along with our vendors. We’re equally guilty."

The logical question people might ask themselves: I agree with the report to some extent, so what happens next? Will the conclusions cause years of sustained activity and industry self-reflection like IOM’s "To Err is Human"? Some thoughts:

• Who’s going to pay for all this clinical and IT improvement?
• Is the IOM’s vision of patient care a reality or a pipe dream? Will hospitals commit to it? If not, there’s no reason to build automation that won’t be used – we already have that problem.
• Show the numbers that justify the cost. Did UPMC’s cost or outcomes improve after they spent tons on IT? Are they better than less-automated facilities? So far, the link between IT investment and excellence (of any kind) seems iffy, especially when held to the standard that IT caused the improvement, not just co-existed with it.
• The report suggests that a complete shift in systems development, implementation, and use is needed. So how do you put that into play, especially in a competitive IT market where vendors can’t just scrap what they have and start over? And in a competitive provider market that’s struggling with low margins and entrenched inefficiency?
• Were conservative CIOs part of the problem, happy to ditch best-of-breed systems in order to gain integrated mediocrity that’s easier to support? And is that still necessary with more modern integration technologies? All of those systems were designed even before the Internet caught on.
• Maybe the next step would be to create specific standards from those goals that could be used to assess specific systems and their use. I’ve often said that a big problem with clinical systems is "having them" vs. "using them to improve care."
• The challenge will be the lack of standards in hospitals, even the lack of repeatable processes within a given hospital. Hospitals are notoriously unwilling or unable to get employees and physicians to follow even obviously important rules (like "wash your hands"). Systems are hard to support and enhance because hospitals resist change, forcing vendors to build in an infinite number of configuration options.
• The committee intends to follow this report with others, although in the case of "To Err is Human," most of the reaction came from the shock and public shame of the first one (Googling "98,000 medical errors" gives 83,000 hits).
• It will be interesting to see how HIMSS reacts. My first thought was that it would rush out a vindictive, clearly vendor-serving defense like it did with Ross Koppel’s articles, where he studied the unintended consequences of a clinical system implementation that actually increased patient harm, and HIMSS took offense. I think they’re smarter now, though, and will simply suggest more research while staying the course, i.e. still insist that the government should subsidize the purchase of today’s EMR systems, which is diametrically opposite to what the report concludes. HIMSS sees itself as the voice of healthcare IT, so it will surely recommend actions in which it (and organizations it influences) will be a prominent player.
• With that in mind, the last organization that I would want at the table when discussing healthcare IT changes is HIMSS. No offense to them, but their world is high-paying vendor members and flashy exhibit halls, not upsetting the gravy train. The approaches IOM says are wrong are the ones HIMSS pushed us into: RHIOs, CPOE, and "clinical transformation" that rarely had any impact.
• Nothing in the report should be interpreted as blaming vendors for anything. It merely says, "We’re here and we need to change direction to go to there." The job of vendors is to sell what customers will buy, so I take the conclusions as more of a criticism of providers who not only don’t demand systems that might work differently, they don’t even use the ones they have optimally. Providers should be setting the vision, not vendors, but have shown a remarkable inability to do so. Still, current products were based on old paradigms and old technologies, so it’s a good time for vendors to take stock.
• Despite the long list of problems in the report, it should be noticed that some hospitals have had success (quiet or otherwise) using off-the-shelf systems. I see it like this: today’s systems have taken us about as far as they can, hopefully providing value and benefit along with way. Now we’re ready to envision the second generation of systems (I’m arguing that we’re still in the first generation, but you may disagree), assuming that providers are simultaneously ready to embrace the changes that these new systems will support.
• Software vendors and hospitals dedicate a huge chunk of resources to billing and malpractice avoidance. If you want to reform healthcare and healthcare IT, simplify payment and free up all those people working on billing and  other administrivia to do something that actually benefits patients.
• If you want to know what a given person or organization will excel at, look at what they’re paid to do. If you want someone to change their behaviors, make sure you’re rewarding the behaviors you want. If you’re paying someone to paint your house, don’t base their pay on what they spend for paint.
• The bottom line: the goal is measurable quality improvement and reduced cost, not conspicuous consumption of IT. If you pay people to deliver better and cheaper outcomes, they’ll figure out what tools they need.

E-mail me.