Readers Write 12/11/08

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Low Cost IT Hospital Improvement Project
By Downin Katmandu, CIO

Our Information Services Department is working with our hospital’s Infection Control (IC) Department to create a system that sends a real-time, proactive notification of patients that present at hospital with chief complaints that might trigger operational or policy processes.

Due to the nature of our data collection process, specific diagnosis codes are rarely available during the admission/registration process. That being the case, we use the chief complaint as our primary data field for attempting to notify the IC department of patients that might benefit from more timely intervention by the IC staff.

The basis of our pilot study is to evaluate appropriate HL7 records and segments for keywords (keyphrases) defined by the IC department. If we find one of these words/phrases we will:

1. Send the IC department an email containing a message that does not contain patient identifiable information (PHI, re: HIPAA), but it will contain the chief compliant. The IC department can use this field to prioritize their processes.
2. Send a more descriptive file to a secure folder on the network
3. The file we send will contain the following fields:

Patient Information

Message Information: A04
Patient MRN                 
Patient Account Number        
Patient Name                
Patient DOB                
Patient Sex                 

Admission Information

Admit Source                
Chief Complaint       
Admit Date Time       
Admitting Doctor      
Attending Doctor      
Current Location            
Patient Class               

A04: Patient Registration
A01: Patient Admission

The file naming convention that we are using to store the detailed reports is Lastname-AccountNumber-ccyymmdd-hhmmss.txt.

This same system is used by the Admitting Department to receive real-time notification of incomplete registrations. Our hospital information system does not require a chief complaint during admission and registration processes, but our hospital policy states that it must be entered. We use this system to help audit compliance.

Software: MIRTH Interface Engine (www.mirthproject.org – Open Source)
Hardware: Low end PC or server
HL7 Feed: Clone from ADT Feed from HIS to Laboratory System

Keyword examples: influenza, tuberculosis, lice, pertussis, diarrhea, chlamydia, strep, pinworms, measles, blood in sputum, bloody sputum.

You Can’t Give It Away
By Catherine Huddle, VP Market Development, Sevocity

While the Big Three automakers extend their tin cups on Capitol Hill, we hear that at least one of the first four communities designated by HHS to receive Electronic Health Record (EHR) funding, Louisiana, submitted only half the applications of the 100 available $58,000 grants. So, you can’t even give EHR away?

I believe that part of the problem is that most physicians didn’t know about or understand the HHS program. Our company saw the first four community initiatives as an opportunity to get in front of physicians at the most opportune time. We sent multiple mailers and made calls to hundreds of physicians in the first four communities. What we learned:

• Mail that is not payment- or insurance-related may be ignored or lost. Less than 5% of our mail was returned, but over 80% of practice managers said they never received our mailing or couldn’t find it.
• Nearly all the office managers and physicians we talked to were unaware of the HHS program. Those who had heard about it were confused and didn’t understand the difference between the EHR program and the national HHS ePrescribing initiative.
• Trying to explain the available funding and the timing was difficult. If you review HHS’s Web site, this problem is clear — the process to obtain the funding is long and convoluted and the dollars to be expected is difficult to predict.
• Physicians do not believe they will see any material funding from HHS.

So, if physicians had a clear program that helped them fund purchase of an EHR would it make a difference? I think the answer is yes — sometimes.

Just like a tax incentive encourages a would-be home owner to become a home buyer, I believe that clear, timely payments for EHR adoption would incent the physicians interested in EHR to go ahead buy EHR. Funding is such a clear motivator for the group already interested that I think it helps explain why our company is achieving record sales in a very weak economy.

The new customers I talk with tell me they purchased after months or years of looking because our solution is CCHIT-certified/complete, but only requires a small down payment and ongoing monthly payments. Their risk is minimized because their personal investment is minimized.

While there is a segment of physicians that is already motivated to buy EHR and will do so with some clear achievable financial assistance, I believe there is another segment that wouldn’t implement EHR if you gave it to them – right now. This is the segment that is downright terrified of implementing EHR. They have read and heard the horror stories of six-figure EHRs that sit unused. They are concerned the EHR will slow them down, knowing their productivity is the lifeblood of their income.

As EHRs evolve, physicians experience the benefits, and EHR vendors improve, I believe this will gradually change. As vendors, it is up to us to make this happen. We must listen to our potential customers and design affordable and easy-to-use systems.

Low Cost IT Hospital Improvement Project
By Julie

Having worked in healthcare for 20+ years in both the hospital and vendor settings, I see many opportunities for low cost IT projects. Many in the hospital setting are not utilizing the power of the Intranet to provide Web-based access to policy and procedure manuals, the automation of manual calculations (e.g. heparin protocols), and the use of paging/text messaging. Many other types of info (links to emedicine, Medline, etc) could be of great help if provided at the clinicians desktop in an easy to use format.

CEO-Express provides a desktop application that I’ve used for years both personally and in business. The generic MD-Express has potential as well, if taken private label and customized. I have no financial ties to the company, but have found it extremely useful.

Access to well-written, searchable policies and procedures is critical, with staff members (both nursing and ancillary) frequently being forced to float due to variations in patient populations and workloads. Also, with the diversity among providers today, communication can be hampered by regional and international accents and dialects. Text-based paging/messaging can be a non-obtrusive method of improving communication.

Having worked for Cerner and seeing real and planned “bleeding edge” technology only to return to a severely challenged community hospital has been extremely frustrating. Financial limitations and the staff’s lack of exposure to or fear of even 20th century technology are disturbing. And to think this organization is not that physically distant from both Partners and BIDMC is amazing! While expert rules firing off text messages to communicate critical values to providers is technology available to some, there have to be workarounds for financially challenged organizations.

Some things to think about: while most people choose a hospital perceived or documented to be the best, most progressive, well-staffed, or well-funded, the reality is that if you or a loved one is involved in an accident or suddenly falls ill, you may not have the choice of where you go for care. The nearest hospital becomes your best or only chance for survival. If that hospital is severely challenged in any way, you or your loved one may not make it. Transport to another hospital depends upon the patient’s stability. For those without the clinical knowledge and understanding to evaluate the limitations of a facility and where the best care would be for a particular condition, you are at the mercy of whoever is providing care.

Readers Write 12/4/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice – we’ll substitute a phony one unless you ask specifically to be named). Submissions are subject to approval and become the property of HIStalk.

Low Cost IT Hospital Improvement Project
By Leonard Kravitz, Informatics Director

We gave Blackberrys to all members our interdisciplinary ICU  team — physicians, nurses, social work, pharmacy, dietician, etc. It was a total of 39 devices. Most staff sign up for a device when they start their shift, although some have their own device (like the ICU director and physicians). These are text-only, no voice.

They provided a huge improvement in communication efficiency. There was no more wasted time trying to find the physician or nursing trying to find pharmacy about a missing med. The bottom line is faster, more efficient care for patients and reduced errors.

The total cost is around $17K. The only reason it is that much is because we are running the devices over a cell network. We will be moving to VoIP over Wi-Fi in the next year and costs should fall to $5K/year.

What is good about this is that it’s technology that works and makes a big difference. Text-only is not disruptive, it has a time-stamped, legible message, it can be sent to many people at once, and the pagers can receive alerts from our clinical system.

The key to success is giving devices to everyone on the team, which increases the value of the network.

Low Cost IT Hospital Improvement Project
By Larry Spannel, Hospital CIO

We discovered a significant opportunity to improve customer service for our nursing and clinical staff. Like everyone else, if a problem occurred with their computer equipment, the nursing staff was expected to call the Help Desk and arrange for service. We found that this rarely happened.

When a nurse or physician had a problem with a workstation, they would leave it and find one that worked. They never had time to call and report the broken device. It was not unusual for a nursing unit to have a large number of its workstations out of service before IT was aware of the problem. In our heavily automated clinical environment, this was a real concern.

We asked our Help Desk and Field Services staff to think of a better way to ensure that all of our nursing unit workstations were available all of the time. They developed an equipment rounding plan where our field services techs visit every nursing station, every weekday. The techs inspect every workstation and printer, and fix any problems they find.

We piloted the rounding program for a couple of weeks to see if it would be effective. We were amazed at the reception we received from the clinical staff. They loved the fact that they did not have to worry about equipment availability anymore, and that they were no longer tied up making calls to the Help Desk. Where once our clinicians had a very low regard for IT support, the techs are now welcomed and appreciated for their work.

The program was so successful that we quickly implemented it for our emergency department and all of our nursing units. The program is cited as an example of excellent customer service throughout the hospital. It was a zero-cost change since we rearranged the work of our existing staff to do the rounding.

The Impact of Technology on Diabetes
By Marc Winchester, President
Digital Healthcare Inc.

Diabetes is a pervasive chronic disease that affects the coronary, neurological, renal and vision systems of over 22 million Americans with an additional 50 million termed as "pre-diabetic". If left untreated, it will remain the leading cause of lower limb amputations, end stage kidney failure, and blindness in the working age population. In terms of economic impact, the disease has no equal. Conservative estimates indicate that the annual cost of diabetes is now well over $100 million.

Technology has a critical part to play in the assessment of risk, diagnosis, treatment, and management of the disease. In order to manage the condition, technology needs to be pervasive across the care continuum.  

It may surprise some to learn that diabetes can be prevented and, in the early stages, it can be reversed. This requires lifestyle change and increased awareness among the high risk population group. The role of technology in the first instance is one of supporting public health communications. Patients need to have access to simple risk calculators that can predict early onset; Personal Health records need to be easy to use and easily accessible. However, it is important to realize that those at most risk tend to also be the most technology-averse. Until this issue is addressed, technology won’t have an impact on the care process until after a patient’s initial diagnosis.

When a patient presents to the primary care physician with diabetic symptoms, a series of tests is performed to confirm diagnosis. Most medical record systems are more than capable of storing the information. However medical record systems must identify those at risk through general health, genetic, and lifestyle data. A real advantage would be a system that assesses risk and red flags patients before they have full-blown diabetes.

As the disease progresses, physicians are left with a series of options to arrest its progress through pharmacological intervention, lifestyle advice, and ultimately, referral to secondary specialists, such as endocrinologists or ophthalmologists. Efficient referrals must aim to manage the patient through a defined "care pathway," but patients rarely comply with such instructions. Technology should integrate contact management systems to ensure that patients are "nagged" by whatever means to follow up on their prescribed care plan.

In order for technology to have a real impact on chronic conditions, it must integrate diverse components into a workflow similar to that used in manufacturing processes. At Digital Healthcare, we have found the way to achieve this is to place detection technology in the primary care setting and have an automated pathway send high resolution images and data to a clinical specialist. The specialist systematically assesses the risk and recommends the next treatment option, which is also defined in the pathway. So far, we have saved the sight of thousands of people around the world using this approach.

Until we see the convergence of technology with public health policy, evidence-based medicine, and uniform reimbursement strategies, simple disconnects will continue to contribute to many more deaths and the continuing rise in health insurance premiums.

Clinical Software Review -  Microsoft CUI – Secondary Care
By The PACS Designer

The Microsoft Common User Interface has been released for review and user input based on Microsoft’s Silverlight platform.  We will be reviewing Secondary Care for Brian Johnson.

To proceed with this lesson you need to have Microsoft’s Silverlight platform installed on your system.

We are going to launch the Patient Journey Demonstration. Once you are on the Patient Journey Demonstration page, you are going to be navigating to the Secondary Care section, so click the "Launch Button" under "Secondary Care". Follow the steps below to learn the best method for navigating:

1. Brian Johnson has been sent to the ECG Laboratory for a stress test. Brian is in Exercise Test Room One. While waiting for a message to appear on your screen, click "Molecule triggers allergy attack" in the "Health News box" to view the article, then close it. When the message pops up for viewing his test results, click the "View LIVE ECG" button in the message.
2. Next, you will see Brian’s ECG images. The message requested that you look at V4, V5, and V6. Click the down arrow to the right of "Select a lead" then click "V4" to view the ECG image.
3. Next, click the "white box" below "V4" to view "V5". Then click "white box" again below "V5" to view "V6". When done, click "V6" to return to all ECG images.
4. At the left under "Chest Pain Clinic" click Brian Johnson’s "View Results" to see the data.
5. Move your pointer over "Stage 4" that is on your extreme left and click the "Red Box" in the upper right corner to expand it. Next, move your pointer up to the numbers " 0 thru S" in the upper right of the screen and click the second "Red 4".  Again, click the small "Red Box" to expand it and when done viewing it click again to return.
6. Next, click "Known Allergies" to see Brian’s allergies. When you are done, click the "Up Arrow" to the right to close.
7. Click "Search Care Pathway Library" in the lower right hand corner, then click "Angiogram/Angioplasty" to see other aspects of Brian’s health record.
8. At the bottom of the screen, click "Review results" in box marked "Angiogram" to see Brian’s angiogram. Click the "Play Button" to run the viewer. Next, on the left side of screen under "Select Run," click the down arrow and then click "LAO 30 Cranial 26" to view the 3D image, then use your pointer to move the 3D to the left and right for slower viewing.
9. For the last step in this review, click the "Show Guide" in the upper right corner to view all the capabilities of the online viewer. The "Show Guide" can be accessed for each viewing screen for more information by clicking "1. Registrar landing page" through "5. Angiogram" for this Microsoft CUI. Close "Show Guide" when done.

This completes the third and last review of the Microsoft Common User Interface (previous lessons are here and here). Please let us know your feelings about this new concept from Microsoft.

Readers Write 11/19/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk.

IT Projects Resulting in Savings (for $25,000 or Less)
By Southeast CIO

These are based on my personal (15 years) experience in hospital IT. Some of these may be a little dated.

Medicaid Eligibility Double Check Before Aged Receivables Go to Bad Debt Agency
Annual Savings: $50,000

Hospital sometimes help patients apply for Medicaid, usually after the patient receives treatment. The patient is usually placed into some type of Medicaid-applied status. When the application is approved or denied, the status is changed. Sometimes all that works and sometimes it does not. We created a batch process that identified any self pay/indigent patient/guarantor ready for bad debt and applied that information against the Medicaid Eligibility source/TPA. Even in these HIPAA-friendly days, a second check will find an organization money.

Resigned/Terminated Employee Automatic Dis-enrollment from Benefit Plans
Annual Savings: $20,000

The base HR package didn’t automatically term benefits. HR had to dis-enroll employees manually from programs. Sometimes that would not happen in a timely manner or a step was missed. The option is to either buy an expense add-on module or script the series of key strokes. Scripting can resolve this problem, eliminating part of an FTE and saving benefit dollars.

Intranet Application That Assigns Registrars To Patients/Rooms, Reduces Overtime
Annual Savings: $15,000

Some hospitals provide bedside registration, especially for maternity wards. Registrars were constantly on the phone or going back to the main office for their next assignment. We created a basic application for the Intranet that could be updated showing next assignment. Registrars could access that from their mobile laptops on carts and indicate when done. Overtime went down, registration productivity went up. We also used instant messaging for these employees (policy was no IM at that organization).

Fax Server to Retain Surgical Case Documents Faxed To/From Physician Offices
Annual Savings: $50,000

Faxing with MDs office always has its challenges. On occasion, surgical cases are delayed, increasing overtime and frustrating many involved. A fax server that retains inbound and outbound faxes eliminates a lot of headaches.

Microsoft License Discounts for Educational Organizations – Teaching Hospitals
Annual Savings: $12,000

Microsoft provides discounts for educational organizations. A 400-bed hospital usually provides some type of education to residents, etc. Even if it is on a small scale, it will sometimes help qualify.

Reduction in Hospital Bill (claim) Hold from 5 to 4 days
Annual Savings: $35,000

Most HIS systems are set to hold charges for X days after patient discharge. The point is to enable all charges to be entered, scrubbed, then dropped on a claim. When most HIS systems go in, to be careful, bill holds are sometimes set high. With good charging processes and focus, you can reduce these days. Interest earned on one day of charges billed and paid one day earlier adds up.

Small Revenue-Enhancing Projects: The Rule of the Year for 2009-2010
By AgedObserver

You’ve preached for a long time that our industry, in many cases, has adopted technology for the sake of technology, without examining the fundamental reasons of “why” and “what benefit” (CPOE is the best example). There have been countless multi-million dollar projects in the last 10 years where the end result has been average technology, combined with poor execution, resulting in lousy adoption and no demonstrable ROI. 

Instead of accelerating the entity, the attempted technology has slowed the organization’s progress, and in the hindsight of today’s economic environment, has placed provider organizations at risk because hundreds of millions of dollars poorly invested has escaped from their bank accounts.

Jim Collins identified some key aspects of how leading organizations use technology as an accelerator, thereby “avoiding fads and bandwagons yet becoming pioneers in the application of carefully selected technologies.”  Clayton Christensen talks about innovation needs, not for the sake of innovation, but to move the business forward in a steady, directed fashion.

In today’s environment, where capital for large technology projects is very scarce, it’s important that every project be aimed at providing additional revenue to the organization for work already being done, i.e., if you’re leaving money on the table because you don’t have the right technology (square peg/round hole or one-size-fits-all) and you can get a vendor to guarantee financial improvement, you have a winning solution. Large projects don’t work today because the manpower and up-front costs lead to extended (if any) return on investment for the purchaser.  

Small, focused, revenue-enhancing projects should be (my prediction is they will be) the rule-of-the-year for 2009/2010. The tie between the clinical activities and revenue is obvious, but so many technologies put a 10-foot wall between the two, or try to solve only one part of the two sided-puzzle, and hence don’t resolve true issues and put more money into provider’s hands.

The Future of Primary Care
By TornMD

The NEJM just had a roundtable on saving primary care, with big names in the field talking about the usual things: medical home, changing reimbursement, etc. Personally, I don’t see how anything but a drastic increase in salary will attract people to the field. I’m also not sure those are the people you want as your doctor.

Even though most EMR systems are targeted to internists, more technology is not going to change the everyday workings of a primary care provider. I did an informatics fellowship, so I’ve never practiced more than three sessions per week, always in an academic setting (with two sessions of supervising residents). Though I’ve found my patient care sessions very rewarding, there’s no way I could have managed a full week of it. Primary care is just not that intellectually satisfying.

As our department chair told us when I was finishing residency (2001), there’s no future in primary care. PAs and NPs can handle 95% of the cases we see (as evidenced by the excellent PAs I work with in our walk-in clinic). I often feel that dealing with lower back pain, URIs, and diabetes management is a waste of an MD.

The reward I get from primary care is probably what most people in private practice find the most frustrating. Being in an academic setting without productivity constraints, I have (a lot of ) time to spend with patients. The whole medical home concept — case management, explaining lab results, dealing with specialists — is a lot of what I do (especially since I speak Spanish and may be one of the only providers who can talk to patients without a translator). It’s also a lot of what patients appreciate. I often feel much more like a psychologist than a doctor; however, I don’t need an MD to do what the patients appreciate most –  listen.

There will always (I hope) be people who go into medicine because of the rewards of patient interaction, but the current system makes that less and less viable. Because of the lack of intellectual challenge in primary care, I believe the only way to attract the “best” is to couple it with research or teaching and to work where patients really need you. I was miserable during my private practice sessions when I saw well-insured patients for yearly checkups, STDs, or blackberry thumb. When I see Medicaid, non-English speaking patients for diabetes control or atypical chest pain, however, I feel that I’m actually contributing and fulfilling my role as a physician. Unfortunately, a Medicaid-focused private practice is not really financially sustainable.

Readers Write 11/13/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk.

Report from AMIA 2008
By Grant Ritter 

As a (now part-time) academic, I love coming to AMIA to see what kind of blue-sky thinking is going on in all those NLM-funded labs. As I’ve attended more conferences, however, I find that I enjoy the panels more than the paper sessions.

Dr. David Eddy of Archimedes gave a great keynote about the development of his system. I then went to the public policy session where Dr. David Blumenthal, an Obama advisor, gave his opinion of what will go on in the new administration. Unfortunately, because of his position, he couldn’t give much detail, but there is hope that the $50 billion promised for HIT will somehow survive.

I had another meeting on Monday, so I was sorry I missed “Movie Magic in the Clinic — Computer-Generated Characters for Automated Health Counseling” from Northeastern, along with other sessions on virtual worlds-virtual patients. There was a lot going on during the session about promoting informatics as a recognized profession, with board certification, etc.

Also, several panels on the AHIC successor, whose business model I still don’t understand (in whose interest is it to pay dues?)

The AMIA exhibit hall is little league compared to HIMSS, certainly tailored to the mainly academic audience — NLM, ISO press, Elsevier, training programs … In other words, no booth babes or free cappuccinos.

There were several Web 2.0-themed sessions, from decision support to PatientsLikeMe to one of the top student papers, “A Scientific Collaboration Tool Built on the Facebook Platform”.

Dan Masys’s year in review was probably, as always, the best-attended session (his slides are available on the Vanderbilt Web site). Afterward was a great session on informatics and entrepreneurship.

My favorite speaker of the conference was Craig Feied, founder of Azyxxi (now Amalga) and 13 other companies. The panel also had Michael Kaufman, formerly of Eclipsys. Great for academics to hear from real business people, especially when Mr. Kaufman started talking about EBIDTA. The panel also included some businesses that failed, so great lessons on both sides.A good panel on medical homes Wednesday morning as well.

Above all, the best part about AMIA is being able to go up to people like David Bates and hear what they have to say about your (or their own) ideas. I’m not sure how much interest there would be for someone actually running a clinical information system, but hopefully it provided some glimpses of the future of HIT.

Report from World of Health IT
By Maurice Ganier

 
I spoke at the World of Health IT last week. It was a real treat being at an HIT conference with only 2,000 attendees (“only” when compared with HIMSS 28,000) and where the focus was truly on the education sessions, most of which were very good. It was also enlightening to see how far behind we are here in the US compared to other countries with socialized medicine. Even just referring to what we call patients, as “citizens” brings home the point that they have a vested interest in caring for their populations.

Aside from the fact that Panasonic debuted their new mobile clinical assistant device to go head-to-head with the Motion C5 – and directly across the aisle from Motion’s booth, no less – the absolutely coolest thing in the hall was a booth run by the Danish government showing off their IT Experimentarium. It is a “dummy” hospital, complete with nursing unit and patient rooms equipped with all types of equipment, in which all health IT applications are designed, put through their paces to ensure that they address workflow adequately and optimally, and then used for training.

Better than the popular “conference room pilots” that we are accustomed to using, the “patients” (either real people being instructed by a doc behind the curtains through an earpiece, or a dummy with a built-in speaker through which the doc speaks) are able to convey real-life scenarios to the clinicians providing care either through a script or by incorporating “curve balls” to truly test the limits. There is a good video available all about it at www.regionh.dk/itx (scroll down to access the English-language version).

Clinical Software Review – Microsoft CUI
By The PACS Designer

The Microsoft Common User Interface has been released for review and user input based on Microsoft’s Silverlight platform. We did a review of the "Microsoft CUI Introduction" previously, so now we are going to follow the path for finding a patient.

To proceed with this lesson, you need to have Microsoft’s Silverlight platform installed on your system. Get the download here.

After logging off and relaunching your system, you can go to the Microsoft CUI by clicking this link.

We are going to launch the "Patient Journey Demonstration". Once you are on the Patient Journey Demonstration page, you are going to be navigating to the Primary Care section first, so click the "Launch Button" under "Primary Care".  Follow the steps below to learn the best method for navigating:

We want to find a patient in the Microsoft CUI named Brian Johnson so we can see the details on his condition for his next appointment.

1. The first step is to look for Brian Johnson’s name in Dr. Oliver Cox’s schedule on the "GP landing page".
2. Dr. Cox has an 8:50 appointment with Brian and wants to review his medical history. To view it, double click Brian’s name on the appointment schedule for Dr. Cox and you’ll see the many aspects of his medical record.
3. Under "Most Recent Activities," click the clear box in the upper right hand corner to expand the record. Since Brian’s hypertension is now accompanied by chest pain, you want to next click the box for Dr. Christina Lee in the lower right hand corner. You will see that Dr. Paul Dunton, a cardiologist, is covering for Dr. Lee since there is a Green Bullet before his name. Click the Green Bullet for contact options and click desired method to launch Outlet Express 6 if you wanted to communicate with him. Click box in upper right hand corner to return to previous screen.
4. Next, click the clear box in "Patient Charts" to expand Bryan’s charts for hypertension. Click the different chart descriptions to see their data points. When finished, move the mouse pointer to 2. Patient Record under Scenes at top of screen to return to previous screen.
5. For the balance of this exercise, navigate to the other aspects of this record to view their details.

This completes this view session for Silverlight and the Microsoft CUI.  TPD will be doing Secondary Care next.

Readers Write 10/29/08

CCS HIT Fall Report
By Pedro Borbon

The Fall CCS HIT summit had its ups and downs. I was surprised at how small it was. Apparently last year there were four times more people, but this year there were probably <50 attendees.

The first day’s content was average, but there were two very impressive speakers. John Geade, the CIO at El Centro Regional Medical Center who has done a great job integrating various HIT systems in his hospital and also installing an EMR in his ER, and Gay Madden, CIO of Florida Hospice of the Suncoast, which appears to have a much more advanced HIT system than many academic centers. Mark Probst of Intermountain Healthcare gave a good keynote, but pretty generic.

I think the problem with these types of presentations for us who are so steeped in the HIT world is that it’s hard to find anything really "new".

The small size made networking easier, especially on the second day, when there was a superior panel on PHRs: Missy Krasner (Google), Philip Marshall (WebMD), and Sanjay Gupta (Dossia).

Naomi Fried, VP of Innovation and Advanced Technology at Kaiser Permanente, has what seems to be a dream job (and who also seems like she would be a great HIStalk interview), and spoke about KP’s telehealth projects. There was also a good payer panel, with Charles Kennedy (Wellpoint), Julie Klapstein (Availity), and David Lanksy (Pacific Business Group on Health).

Dr. Lansky told us that he offered free trips to the Health 2.0 conference to every employer who makes up his group and not one of them took him up on the offer …

I don’t think I’ll be back, but maybe the spring summit will be better attended. Can’t tell if it was the content or the economy. Sofitel LA is a great hotel!

The Cloud Computing Phenomenon
By The PACS Designer

Cloud computing is the phenomenon that is sweeping through the vendor community lately. Some commentators are saying it is a fad that will pass, while others are forecasting a much wider cloud computing community.

TPD has been using clouds to describe design work for several decades, so the concept is far from being new. What is new is the movement of the cloud description from the development side to the public side. In the design workspace, clouds are used to describe future development features, and also the type of outside services that may be employed in the design.

Amazon thought that bringing cloud computing to its customers would expand its product offerings and also help retain existing customers for many years to come. So far, it appears to be working as planned even though there have been some service outages, but with any new service offering there are bound to be some bumps in the road that come up unexpectedly.

Hyperic, the company that designed the "CloudStatus" web site, fully understands the cloud computing concept and has formed their business plans around the aspects of IT services described as clouds. The concept does have some compelling ideas, which include lowering the costs of software support, using proven concepts others are using, and creating the opportunity to simplify the interfaces by eliminating custom interfaces and the costs associated with their design.

Hyperic had this to say about cloud computing: "Cloud computing is a system of technologies and services that have commoditized (sic) IT to make it more readily consumable, scalable, and cost-effective for everyone. It has leveraged the innovation and expertise of Internet giants like Amazon and Google, and is making it accessible to anyone with the next big idea. It removes the investment in physical and human resources to scale up a business. It affords more folks to try their ideas and vet its worth in the market. It also affords these same businesses to scale out as quickly as their business demands. Cloud computing, same as open source, is a way to package products and services to ease adoption so everyone benefits."

In summary, you can expect cloud computing, as a term used to describe outside services, to be around for many decades to come. It will provide a more robust platform for future designs as we move forward toward a more connected world environment.

Response to "Hallway Medicine"
By The Alchemist

Who would have ever “thunk” that Hallway Medicine is safe and good for the economy by simply moving patients to corridors while waiting for a room as a way to unclutter ERs? Just peruse this screen shot for the top 20 countries from the WHO Report Annex Table 1: Health System Attainment and Performance Ranked by Eight Measures (click to enlarge).

Anyone would agree that the U.S. is the leading country for health expenditures and proudly number one for the Responsiveness Level for Attainment of Goals. I knew that Management by Objectives would prove successful:

The reader can formulate their selective opinions on what are important metrics to define the U.S. Health System. Hint: The Middle East is not too impressed with U.S. ranking in Health Systems around the world but they will buy our products.

Readers Write 10/23/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk.

Personal Health Records are Durable Medical Equipment
By Manfred Sternberg, J.D.
Presiding Officer, Board of Directors, Texas Health Services Authority

There is little debate that knowledge and information have always been among a physician’s best clinical tools. Consistent with this fact, information technology (IT) should be viewed by the healthcare industry as a medical device. With the advent of evidence-based medicine coupled with advances of IT, we are in many ways on the brink of a golden age of medicine.

In the relatively near future, information supporting evidence based medicine will translate from bench to bedside at speeds never before witnessed. We will have more accurate information to treat health issues more appropriately, based on the data, than ever before.

Admittedly, IT is in many ways a crude medical device, but that is today. Many of the now traditional medical devices that were introduced into the healthcare market throughout history started off as crude devices; think about surgical tools.

Like other medical devices, this device is certain to evolve with use, experience, and continued development and innovation. Many predict that the use of this IT device by healthcare professionals will become the standard of practice, like scrubbing in before surgery. The legitimate debate generally centers on how and when.

As with other changes in medicine, the adoption of this new tool will be an evolution. It will not happen by just flipping a switch at the end of any given year, it will evolve. Consumers and their physicians must participate in this evolution for it to ultimately be successful. The consumer’s best platform to effectively and economically engage with the industry is a standardized personal heath record (PHR).

What is a PHR?

A PHR is an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

PHRs may also include information that is entered by consumers themselves, as well as data from other sources such as pharmacies, labs, and care providers. PHRs enable individual patients and their designated caregivers to view and manage health information and play a greater role in their own health care. PHRs are distinct from electronic health records, which providers use to store and manage detailed clinical information.

The Benefits of using a PHR

There is consensus among stakeholders that the widespread adoption of health information technology will lead to safer, more effective healthcare. Experts believe adoption of technology will reduce preventable errors, such as medication errors, increase compliance with recommended treatments, improve treatment for people with chronic disease, and contribute to lower health care costs.

Ultimately, this new tool will allow physicians to benefit from improved information about each patient, and consumers and doctors can share that information to make the best decisions concerning their healthcare. Better data (e.g. timely, personalized clinical and billing data) provides better results whether in the hands of a physician, patient, health coach, or measurement program Additionally, care coordination from a process management perspective is critical to improved results

Consumer Empowerment

Consumers have great interest in the subject of healthcare. It is the most searched subject on the Internet, yet the long predicted wave of consumer empowerment in healthcare has yet to arrive.

Consumers, as well as the business community, are generally unaware of the healthcare cost and quality issues and interoperability issues. Nor do they recognize that they have a new, long anticipated, role as purchasers seeking value in the healthcare delivery system. They tolerate the existence of numerous inefficiencies and cost in the healthcare sector far more than in any other market, because of and in spite of its relative importance and their inability to judge value.

Today, the consumer is unable to identify value without information on cost and quality. Quality cannot be identified without measurement and it cannot be compared without standardization.

Since the mass adoption of the Internet, the benefits of IT have embedded themselves into society as one of the most powerful tools that consumers have ever had. Endless information is now available in everyone’s home. Society has embraced this new found consumer tool, but comprehensive personal clinical information has not digitally made its way into the consumer’s hands. To some degree it is not readily recommended or available, yet.

How does a consumer get educated about their new role in their own health and their interaction with the healthcare delivery system? Who do they trust to guide them? Consumers trust their physicians far more than any other group in the Healthcare system. They certainly value their doctor’s advice, even if they don’t follow it all of the time.

Today, the consumer is effectively, unwittingly waiting on their physicians to recommend this new medical device for their health. Therefore, engagement of the physician is the key to fostering consumer empowerment.

What is Durable Medical Equipment (DME)?

There is no single authority, such as a federal agency that confers the official status of DME on any device or product. A fairly comprehensive definition of Durable Medical Equipment as contained in a Texas Group Policy is as follows:

Durable Medical Equipment is defined as being equipment that:

• can withstand repeated use; and
• is primarily and customarily used to serve a medical purpose; and
• is generally not useful to a person who is not sick or injured, or used by other family members; and
• is appropriate for home use; and
• improves bodily function caused by sickness or injury, or further prevents deterioration of the medical condition; and
• is prescribed by a physician.

A consumer’s PHR fits the definition as follows:

Durable Medical Equipment means

equipment : Noun. An instrumentality needed for an undertaking or to perform a service.

that:

• can withstand repeated use. A PHR easily withstands repeated use.
• is primarily and customarily used to serve a medical purpose. A PHR contains a consumer’s relevant medical information so many medical decisions can be made based on the contents of the record.
• is generally not useful to a person who is not sick or injured, or used by other family members. A PHR is not useful to anyone in the consumer’s family but the consumer and only the consumer can use it to track and support her health or coordinate her care when she is ill
• is appropriate for home use. A PHR is appropriate for home use or anyplace a consumer has a connection to the Internet.
• improves bodily function caused by sickness or injury, or further prevents deterioration of the medical condition. According to the trade association that represents insurance plans and the executives of most plans, there is consensus among stakeholders that the widespread adoption of health information technology will lead to safer, more effective health care. Experts believe adoption of technology will reduce preventable errors, such as medication errors, increase compliance with recommended treatments, improve treatment for people with chronic disease, and contribute to lower health care costs.

and is prescribed by a Physician; Can physicians professionally make this recommendation to their patients? It depends on whether they can professionally agree with the statement that “a PHR is a medical device that in certain cases can benefit their patient’s ongoing health or illness.”

If physicians prescribe a PHR for their patients, and the Payers collectively agree to pay the costs, the standard of practice in a community will change. Physicians will create a new business model in order to pay for their EMR system, and the power of a new medical device can be leveraged for the benefit of the consumer.

The PHR information must be stored in a secure way with patient privacy a cornerstone of the repository. Physicians must play a role in the central repository of this clinical information in terms of governance and oversight with appropriate financial compensation for their participation.

If every physician in Harris County, Texas prescribes a PHR for every patient that could benefit from such a device, it will be a catalyst for the creation of a clinical information database that would be owned and controlled by doctors and their patients.

The opportunity for today’s leaders is to take steps to enable our community to appropriately leverage the power and value of the data. To be sure, this is not as much a technology problem as it is a sociology issue. The first step is for the Industry is to acknowledge IT for what it is, a medical device.

Readers Write 10/16/08

Thanks to all who participated in the live chat with Glen Tullman of Allscripts on Wednesday evening. It’s pretty cool that a CEO went on live with a blog and its readers (recall, too, that Glen was typing his own responses in real time!) Glen passed along a message to everyone that he was happy with the chance to connect. If you missed it, you can scroll through the transcript here.

From the Floor of the American Academy of Pediatrics Convention
By Willis Jackson

I’m tired and burned out, but here is the news from the floor of the AAP show from a veteran booth slut.

The traffic was not bad, as attendance was up this year. The Hynes Convention center is a bit awkward (multiple floors, each floor is "split" in the middle), but most vendors we spoke to thought it went well. The last few years, the AAP floor has not been strong.

The sharks are in the water. About 15-20 EHR/PM vendors who haven’t set foot near a pediatric show in the last five years are suddenly in the house. Some claim pediatric customization, but that just means growth charts and some templates they got from a practice. Why now? We all think that it’s the CCHIT money … the Feds, et al, have thrown the chum over the back of the boat and the sharks are circling. Meanwhile, the AAP’s COCIT committee can’t must enough $$ to get a decent program and none of these companies can be bothered to help underwrite them.

The Allscripts booth did not have a corrective sticker slapped over the logo on Monday morning. They also didn’t have many people stopping by, either. Misys, I believe, may be the only mainline EHR/PM vendor who WASN’T at this show.

Word on the street, and I heard this from more than a dozen folks, is that Office Practicum is "the only pediatric EHR to consider" right now. Personally, I have to concur. They have leapfrogged everyone, including (and especially) eCW, NextGen, etc. Every person spoke to who attended the EHR showdown said that OP crushed it, though one person gave a half nod to iMedica, if I remember correctly.

The GE booth was big, quite sparse, and usually empty as well. The sales people were on their phones rather than attending to customers. We presume they were checking the Dow.

A small group of well-known pediatricians is focusing on creating a centralized, Web-services driven clinical data repository for things like pediatric dosing, immunization algorithms, etc. Ultimately, it looks like the goal would be to pass the ownership of this desperately needed material to the AAP. If you don’t get it, imagine a quarterly HL7 download from the AAP against which all of your pediatric norms, etc., could be compared. Right now, it’s a mess. I’m hoping it works.

The nagging flies throughout the conference were the folks from Phreesia (phreesia.com – like "Frees Ya!" – get it? – they say it has to do with a flower, I don’t buy it). It’s the "Patient Check-In Company." They have a Tang-orange tablet (with a mag strip reader) that walks patients through the standard questionnaire process on the tablet. Your standard patient kiosk concept, except that it prints the report and the entire thing is ad-supported. Client after client, potential and otherwise, stopped by and said, "You have to go work with those guys. That thing is so cool!" So, we stopped by. And, no, they don’t interface with any EHRs or PMs yet. It prints the report. From their FAQ: "Q: How does Phreesia work with EMRs?  A: Phreesia is compatible with EMRs." By this standard, so are paper charts. And the mag strip – which would be really really cool for collecting co-pays and reading insurance cards – doesn’t work yet either. Yet again, a vendor has chosen to take the pharma+ money up front  rather than build a good product to interface with others. Wasn’t that the PCN model, almost 20 years ago?

Clinical Software Review -  Microsoft CUI – Introduction
By The PACS Designer

The Microsoft Common User Interface has been released for review and user input based on Microsoft’s Silverlight platform. This Microsoft CUI introduction requires you to download and install Silverlight 2 Beta 2 on your system. Once you download it,  reboot your system and launch the application to see how the Microsoft CUI works in daily practice. Here us the download link.

After logging off and relaunching your system, open the Microsoft CUI by clicking this link.

We are going to launch the "Patient Journey Demonstrator".  Once you are on the Patient Journey Demonstrator page, you are going to be navigating the "Explore UI" section first, so click the "Launch Button" under "Administration". Follow the steps below to learn the best method for navigating:

1. You will notice four physicians have their day’s schedule posted. The "Red Bullet" before Dr. Cox’s name indicates he is busy. Click the bullet to see the contacting options that are available to reach him.
2. Next, move your cursor over Dr. Cox’s box and drag it to the right and place it over Dr. Yu’s box. You’ll notice that the two doctors with green bullets are now first and second in the order of physicians. The "Green Bullet" means they can accept new patients in their daily schedule.
3. Dr. Cox has called to say he can’t see Hao Chen at 8:10, so drag Hao Chen to Dr. Gibbons at 8:10 so he can see the same doctor as his father, John Chen.
4. Click the "Clear Box" in the upper right hand section for Dr. Gibbons to see his entire schedule for the day. Also note that the other three doctors are on the right and can be clicked to see their daily schedules.
5. As the last step for this lesson, navigate by clicking the "Clear Box" of the other boxes so you can see the information they contain.

This ends the first lesson, come back to HIStalk to get the next lesson when it is posted. TPD will be doing a review of "Find a patient" next.

Rumor has it that Cerner’s Neal Patterson is trotting out his old "shot heard ’round the world" e-mail. You know, the pizza-and-parking lot one that sarcastically referred to EMPLOYEES instead of the HR-friendly “associates” because everybody was goofing off (I always write it as ASSociates because it sounds exactly what you’d expect dopey HR types to sit around dreaming up from their happy little floating HR cloud).

Somebody sent his internal-only e-mail to the press back in 2001, while the stench of dot-com smoke was still hanging heavy. Investors were spooked. Shares dropped fast and hard. Neal lost millions overnight while everybody was enjoying a good laugh at his "ready, fire, aim" approach.

Neal got the last laugh. Cerner headcount, profits, and his bankroll are immeasurably larger than they were back in 2001. And in a “goes around, comes around” kind of nostalgia, he’s supposedly proudly brandishing the famous e-mail to employees again, a shot across the bow as a reminder that he wasn’t kidding then and he isn’t now.

Here are some often overlooked facts about the original e-mail. Neal was griping about employees who were working less than 40 hours a week, which is an entirely reasonable bone to pick. He scolded his managers, not the slackers themselves, following the chain of command. It was a raw message intended for (and sent only to) the management team.

This is about as direct as you can get: "I think this parental type action SUCKS … what you are doing, as managers … makes me SICK … the majority of the KC based associates are hard working, committed to Cerner success and committed to transforming health care … this is a management problem, not an EMPLOYEE problem."

It wasn’t personal. It wasn’t even unreasonable (although the 60+ workweeks described are a bit much).

Neal isn’t some emotionless Wall Street hack brought in to push paper. He’s the founder, the owner, and the undisputed boss. When Cerner got too big for him to impose his will directly, he followed the chain of command in telling management to fix the problems he was seeing. Management by nastygram. That’s his right.

Everybody had great fun complaining and commiserating. Some EMPLOYEES left. Those with less backbone or fewer career options just kept whining safely out of Neal’s earshot while turning in fictitious timesheets.

Maybe one benefit of today’s economic meltdown is Depression-era common sense. Nobody promises lifetime employment. Nobody said work is always fun and fulfilling. Nobody promised that the boss might not occasionally behave like a horse’s ass in expressing disappointment in individual or group performance.

Employees with guts or valued skills don’t stick around to whine – they just move on. That’s how you hurt an unjust company (if there is such a thing) or an insufferable boss: you leave them, forcing them to forge on with a workforce of scared and compliant underperformers who have nowhere else to go. If the company thrives, you were wrong. If the company tanks, you were right.

Whether Neal is indeed rattling his e-mail saber again is irrelevant. The feel-good era of "associates" is over, if it was ever anything more than an illusion to start with. When jobs are hard to find, lots of people would love to have yours. Those would-be EMPLOYEES might even work harder, cheaper, or with less complaining. People tend to do that when they’re broke. That’s not to say that any particular company will start treating employees badly, but those who do will find it easier to keep them.

In that regard, Neal’s e-mail wasn’t the ranting of a tyrannical CEO. He was, as he often is, simply ahead of his time.

Readers Write 10/1/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk.

A Summary of Reader Predictions of How Economic Issues Will Affect Healthcare

Employment

• White collar markets (including healthcare) will be flooded with hard working but ethically questionable employees displaced by the dismantling of the financial industry
• HIT employment will drop slightly, but will increase in 2010-11
• A big jump in unemployment will occur if the credit market seizes up
• Consultants will do well because big system vendors will minimize headcount to keep P/E ratio looking good
• Process redesign work increases as hospitals have to live off their own revenues instead of bond money
• Sales reps will turn over because it will be hard to make the numbers and sales costs are easy to cut fast
• Hospitals will reduce headcount before they reduce payments to vendors
• Vendors will cut projects that haven’t gained market traction and those teams will be cut

Hospital Spending

• No change
• Slowdown in big capital projects due to funding problems
• Ambulatory surgery center niche market dries up
• Projects will shift from clinical improvements to operational improvements
• Emphasis will be on throughput, staffing ratios, and cash flow
• Projects that result in more referrals, lab orders, and radiology orders in the IDN’s big hospital will get focus

Physician EMRs

• Physicians will buy only when affiliated hospitals insist
• Downward pricing pressure
• More interest in e-prescribing and disease registries, which cost little and provide benefits like CMS incentives
• Less interest in EMR adoption because primary care providers will be squeezed even more
• Physicians and physician groups will face tight credit and postpone big outlays

Healthcare Reform

• Consumer-driven healthcare dies when consumers lose what little clout they had
• Healthcare reform is moved back at least five years
• High deductible health plans will increase, forcing employees to shop on price or defer treatment
• Population health will decline as patients can’t afford chronic care
• Employees will underfund health savings accounts
• Emergent care will increase
• Providers able to communicate value and patient relationships will compete for the fewer patients with enough healthcare savings account funds to afford care
• Uninsured patients will rise in number
• Only private pay will flourish
• Patients will go overseas because of bad press about US healthcare
• Providers will need to collect for the care they deliver since self-pay will increase due to uninsured patients and higher deductibles
• Hospitals will struggle with how aggressive they should be in collecting payment and will be challenged on pricing

Provider IT Investments

• A shift to those providing quick financial wins, probably at the expense of clinical and patient-centered systems
• HIT will be pressed to prove the value of technology
• Hospital EMR projects will be scaled back or not purchased because of long-term expense
• No change in the short term because budget cycle is already underway
• IT departments need to educate the executive team about their focus and value
• Hospitals will scrutinize capital outlays more carefully since some will face liquidity crises because of their investments are in securities
• Solutions with quick ROI and a cost that is not prohibitive will get purchased

Vendors

• Consolidation due to credit constriction
• Niche startups encouraged, other new entrants discouraged
• R&D will be hard to fund for new companies trying to develop products with long cycles
• Sales will keep dipping
• Reductions in training and travel budgets, hiring freezes, salary freezes
• Less presence at conferences
• Foreign investment increases
• Non-real estate investment companies will still look for companies at $20 million, but smaller will be too risky and not worth the trouble
• Companies themselves will postpone IPOs, but mergers and acquisitions will pick up in hopes of finding synergies and cost savings
• Increased push to outsource
• Healthcare won’t be recession-proof this time
• Small companies with an undifferentiated product will die more quickly
• If the economic crisis lasts 2-3 years, mid-tier companies will be squeezed for operating capital and will be acquired
• Large vendors will weather the storm if they monitor expenses
• Middle tier companies will suffer, but more innovative companies will appear in 2-5 years
• Lag of new technology development will create cheaper and better solutions in 4-10 years
• Sales cycles will extend and some purchase decisions that are close to signing will be cancelled or postponed indefinitely
• Small vendors will face more financial scrutiny from customers who fear being left holding the bag
• Well capitalized vendors may use the uncertainty to push clients into term licenses or subscription models, which are less attractive than license payments, but require less cash and provide more flexibility
• Minimal change in M&A activity because vendors will seek exits, but downward valuations will convince them to wait out the storm

Readers Write 9/24/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk.

Why Sarah Palin is Relevant to HIT
By Wilma Pearl Mankiller

I found it amusing that so many people took Inga’s comments about Sarah Palin and bangs and Botox and turned it into something political. I agree with the readers who think HIStalk isn’t the right forum for politics. We get plenty of that from every cable news channel every night.

That being said, the Sarah Palin story is relevant to our little healthcare technology world. There are some excellent women leaders in our industry, but men far outnumber the women in the top spots. With Palin, we see a working mom who has a realistic chance to be the #2 “guy” in the country. This makes her story relevant, interesting, and inspiring for those of us who have struggled to advance our careers while also balancing our family lives.

Years ago, when I was first newly pregnant, I went to dinner with my husband, a male co-worker, and the co-worker’s high-level executive wife. All but my husband worked for HIT vendors. At that dinner, I recall the wife warning me that no matter how much my husband claimed he was going to help carry the weight, some things would always fall to the wife/mother. At that time, I was young and naive and didn’t fully comprehend what she was telling me. All I really understood was that she and her husband had successfully raised three great kids and she managed to rise through the professional ranks at the same time. I aspired to be like her.

Fast-forward a few years. I supposed I can say that for the most part I achieved what I had hoped for: kids, a nice house, enough money, and some time as an executive. I suppose some would say I had it all. Perhaps I did. But the reality is that getting it “all” can include a few things you never expected or wanted, such as:

• Tears, while sitting in the parking lot of my son’s daycare the first time I dropped him off.
• The discomfort and inconvenience of expressing milk in airplane bathrooms and rental cars.
• Resentment, from both men and women who felt it was unfair that they had to pick up the slack for me while I was getting paid time off just to hang out with a baby.
• Frustration and guilt, for cancelling product demonstrations because I had a sick child at home who needed me.
• Ambivalence, when removing my name from promotion consideration after learning I was (unexpectedly) pregnant again.
• More ambivalence when I asked for lesser job with lesser pay so I would no longer have to travel.
• Guilt and self doubt when others questioned (judged?) my career advancement decisions and my commitment to being a mom (and for some reason, the highly paid men with stay-at-home wives were the worst because they never seemed to understand that not every husband is the family’s major breadwinner).

Obviously and unfortunately, my frustrations weren’t unique to HIT. In fact, the same challenges exist in just about every industry, which is probably why there are only eight women CEOs running Fortune 500 companies. If you are a woman who chooses a career AND motherhood, you face challenges that only other working moms appreciate. The role models in our hospitals and companies are few and far between. While we can all name a few women that have shattered the glass ceiling, these leaders are the exceptions.

So, here we have Sarah Palin, a real mom who is potentially the country’s next VP. She got where she is by some combination of brains, ambitions, timing, good looks, and luck. We can appreciate that she has to take a baby on the campaign bus. Her kids aren’t perfect. She has critics who think she should be staying home with the kids. Unlike Condoleezza Rice or Janet Reno, she has a family. And if she can succeed, then it gives the rest of us hope that maybe more of us will have a chance to run a hospital/IT department/software company one day.

That’s how Sarah Palin is relevant to HIT.

Observations from the Epic User’s Group Meeting
By SNL

Epic is an engaging, dynamic company. They definitely put on a good show. But the smart observer can figure out their MO.

When Epic wants to build a new software tool or enhance an old one, they put a couple of recent college grads on the project. After "research", and whatever that involves and an hour or two of client Webex’s, they release the upgrade. If QA is done, it’s by other non-clinical people.

When a client complains, especially a doc, they shower them with attention, phone calls, a trip to Madison. "We want to work with you and hear your feedback." Then, after a number of back and forths, all volunteer time on the doc’s part, the module is improved. This can take years.

Meantime, no one really asks "Why didn’t you do a better job building the thing before you released it?" Anyone who does and doesn’t volunteer to pitch in is not a "team player".

Who loses in this game? The doctor/nurse/lab tech, and then the patient, who suffers through the risk of alpha software.

Who wins? Epic, who doesn’t seem to ever pay a dime for this expert help. Kaiser Permanente seems to be learning this the hard way.

Do other companies play this game? Has anyone ever been a paid expert for Epic design? Does Boeing design airplanes this way?

From the Mailbag

Got questions for Mr. H or Inga? E-mail them over!

Dear Inga,

Did you see where one of the AAFP directors suggested EMR vendors are part of a big Ponzi scheme and the only ones making money are the vendors? What do you think? – Carlo P.

Dear Carlo,

Dr. L. Gordon Moore is the doctor who apparently doesn’t like EMR vendors. What Dr. Moore said supposedly said was, “Beware of the monolithic, expensive IT vendor, because there are always things they don’t do well. The whole thing can be a Ponzi scheme. The only ones making money from most of these products are the vendors selling them.”

First of all, is there something about making a profit that should make a vendor ashamed? Of course EMR vendors are trying to make a profit. Making a profit is a good thing because it means your vendor is more likely to stay in business to support you and continue developing the products.

So, was Dr. Moore suggesting his EMR did not help his practice become more profitable? Is that why Dr. Moore bought an EMR??? In my experience, the physicians who utilize EMR most successfully are those who initially went into the project looking to improve patient care (by making information more readily available, records more complete, reminders automated, etc.) EMRs can definitely increase efficiencies, which might make the practice more money. Of course some vendors and solutions are better than others and there are always things a particular vendor doesn’t do well as another. This is true with both the monolithic and expensive vendors and the nimble and inexpensive start-ups.

Bottom line, Carlo, I don’t think Dr. Moore is the kind of guy I’d have fun chatting up at a cocktail party.

Dear Mr. H,

I saw a reader comment in an earlier Readers Write about the problem with meetings. What is your take on them? – Lorena

Dear Lorena,

I detest meetings. Really. They are like gases – they expand to fit whatever space and time is allotted to them, yet nothing ever results except a vow to hold even more meetings to which even more people are invited. I don’t like attending them and I don’t like conducting them. I will do anything, including faking an emergency page or coughing spell, to escape back out into the sweet, cool air of freedom.

The really bad ones are when the suit-du-jour is running a meeting of the worker bees. Everybody’s jockeying for the boss’s love and admiration, so it will take twice as long as usual to achieve nothing. When a boss is present (hint: they’re the ones with the suits who came late and are furiously keying BlackBerry e-mails instead of listening to people who actually showed up in person) they will pretend to be fully engaged by randomly spouting out one of these non sequiturs:

• Make sure you document that
• Let’s put that in the parking lot
• How about a bio break?
• Schedule another meeting with (cast of thousands)
• E-mail me the details
• Give me a completion date
• Send me a list of the risks involved
• I need to review that before you send it out

Notice how none of these items really adds any value except to support the illusion that the boss is vital to the outcome?

Some people are meant to conduct valiant battles on a field of laptops, armed with minimal knowledge and maximal need to prove it. Others just get the job done instead of yammering about it.

Dear Inga,

What kind of sales tricks should doctors look out for when considering the purchase of a PM/EMR system? – Suspicious Doc

Dear Suspicious Doc,

Are you buddies with Dr. Moore, by chance? Since when did EMR vendors get put in the same category as used car salesmen? Although I do recall hearing about this sales guy who used to “hide” a second PC and switch box underneath the table during a demo. At just the right moment, he would switch from the computer running the PM software to the one running the EMR. He was such a pro at it that prospects never realized the two products were in no way integrated. He was smooth.

Anyway, I think one thing important to understand is if the software version you are reviewing is actual live and in production. If it is a pre-release version, that is ok, but it’s important to understand whether or not the version you are looking at is fully tested and the one you will be getting. Also, definitely talk to other practices and ask them about implementation, support, and whether or not the software works as advertised. If you believe a particular function is critical for your operations, make sure you talk to at least one practice (anywhere, any specialty) that uses that feature.

Finally, assume that in most cases that whatever price you are presented initially can be negotiated. It’s likely that the vendor is more concerned with the total contract amount than individual line items. If they throw in a PC or an extra day of training, understand the value of the item so you can access if it represents 1% or 10% of the total deal. If you are offered a lease option, keep in mind the sales rep (and maybe the company) receives some sort of commission for the lease, so they may be willing to give you a little bit better deal on the total price. Also, lease rates can usually be negotiated if your credit is good.

Dear Inga,

I know a female sales rep who slept with a hospital IT person and her company’s product was chosen. Is that common? – Ms. Kitty

Dear Ms. Kitty,

That is a one of the oldest sales tricks ever (check out the Old Testament). Seriously, I guess I am just naïve enough to believe that women (or men!) don’t give up their bodies to win business. I bet what happened with your female sales friend is that she just happened to find true love with that IT person and her product just happened to be the best solution.

Dear Inga,

I loved your avatar! I was in love with your mind before, but now that I realize you must also be beautiful I’m beginning to think we might be made for each other. By the way, are you getting all sorts of cyberspace love letters from wacky IT nerds? – Obsessed Fan

Dear Obsessed Fan,

Um, you are the first. (that was a pretty creepy e-mail.)

Readers Write 9/10/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk.

A Physician’s Experience with Kaiser’s Epic/HealthConnect Rollout
By Bernie Tupperman, MD

I am a Kaiser physician in Northern California and a user of HealthConnect (Kaiser’s implementation of Epic) for inpatient and outpatient records. Our medical center has used Epic’s outpatient software since early 2005. We recently went live with the inpatient EMR and operating room software. I read the HIStalk reports about Stanford’s physicians supposedly rebelling after their Epic rollout. I wanted to tell you informally about our experience.

Eight of our medical centers are live for inpatients in Northern California. Each rollout has been smoother and smoother. It takes proper preparation, the right education, and peer group help.

Preparation for an Epic inpatient implementation starts years in advance. In Northern California, central planning and coordination of support, educational web-based training, and training of regional physician and specialty staff is coordinated from a central headquarters in Emeryville, CA.

Each hospital is linked to Kaiser’s data centers across the country. Implementation of computer layout and wireless PC cart connections starts 18-24 months in advance: networks, computers, UPS power in closets, design of networks (vendors), review of construction and facilities, switches and access points… and testing.

Epic inpatient software is purchased off-the-shelf (inpatient, CPOE, Operating Room, Reports), but national and regional builds are created with the help of regional specialty groups and domain groups. A domain group is a local committee of multidisciplinary users who work in a specific area of the hospital, such as pharmacy, inpatient nursing, periop, etc. They make local policies, identify and solve problems, and develop workflows for their area.

The Epic inpatient modules were first rolled out in one medical center, where problems were ironed out and methods of implementation were tried out. Epic programmers worked with local physicians and team leads to troubleshoot the deployment and create training materials and customized "navigators" to guide physicians, nursing, and ancillary staff into a logical workflow, helping to smooth the interaction between Epic and the human users. Total time to troubleshoot was about a year and a half.

Things have worked so well that the pace of installation and rollout will be increased from one medical center every three months to one every month.

Medical centers going live on inpatient are required to already be live on the Epic outpatient EMR, preferably with several years’ of physician and staff experience. The inpatient and outpatient modules are similar in function and appearance, so that makes training easier.

Probably the most important resource Kaiser has developed to improve physician and nurse acceptance and training is the creation of Physician Clinical Experts (PCEs) and nursing Faculty Clinical Experts (FCEs). These are self-selected or nominated physician or nursing IT champions who are given time off for additional orientation in the inpatient modules and are given early access to training environments for practice. They are given the opportunity to attend a medical center go-live and are allowed to assist other staff in this time period. They get experience helping others use the software while being assisted by regional physician and nursing leads. The new physician follows an experienced physician and learns basic troubleshooting techniques and how to solve the most common problems.

Experienced specialty physicians who have regional support and appointments develop departmental connections with IT departmental champions and mentor them in preparing their department.These are frequently leaders who emerged from the early go-live department centers.

Four to five months before go-live, groups of physicians are begun on early adopter programs, allowing them to use limited inpatient charting tools. Web-based training is the primary method of instruction, but the physicians are free to use "sandbox" Web sites to get some familiarity with the system.

Early adopters primarily use Epic inpatient charting with special limited navigators, but orders are not placed at this time or accepted since there is no one to acknowledge them. Since these inpatient charts are still primarily paper, all notes written in the inpatient modules still have to be printed and placed in the chart. However, physicians have access to problem lists and special smart abbreviations to create history and physical exams, operative notes, discharge summaries, and, most importantly, complete patient discharge instructions that fulfill all regulatory requirements. Familiarity with the electronic charting and navigator use simplifies the steep learning curve and makes the conversion to the full inpatient modules easier.

Two to three months before a medical center go-live, all inpatient specialties are asked to take Web-based training covering the basic functionality of the inpatient Epic modules. This includes inpatient specialty physicians, nursing, pharmacy, ADT, interventional radiologists, and other inpatient support staff (clerical, respiratory services, physical therapy, discharge planning, and utilization services).

Three to four weeks before go-live, training starts in earnest. Groups of physicians work in a training environment in a computer lab, overseen by an instructor who runs through basic functionality using a pre-determined script. Most classes are small and supported with written customized manuals, additional computer support staff, and a physician IT champion or clinical expert with inpatient software experience. Questions that cannot be answered are logged and answers are provided afterwards.

Teams of physicians and nurses are recruited from other medical centers to support a go-live. In addition to the Regional teams of leaders who have responsibility for the go-live, local teams are formed from admitting, pharmacy, nursing, radiology, dietary, biomedical engineering, IT, and programmer technical support. A reporting bridge is set up for reporting trouble; programmers are available 24 hours a day to test and fix software. A quality hub is set up for monitoring of all aspects of charting and ordering and all activity is monitored, including medication administration, discharge instructions, orders needing co-signing, pended notes and orders, prescriptions, discharge summaries, history/physicals, and more.

On go-live day, chart cutover begins early in the morning. Groups of staff from specialties and departments meet in conference rooms and receive their assignments, process, and schedules for the day. Between 15 and 30 teams of physicians and nurses are dispatched to every ward and await the signal to begin reviewing each chart and entering the patient’s paper orders into the electronic medical record. Cutover does not begin until the pharmacy, X-ray, and lab are ready to receive orders and process them.

Once the go-ahead is received, all orders are carefully scrutinized by physicians and entered into the electronic medical record. The chart is passed to one of several nurses on the team to enter the nursing flowsheets. The orders and flowsheets are verified with the patient’s nurse to be sure that everything is correct. Finally, the chart is sealed with a distinctive rubber band and marked with a red sticker confirming that the chart is now in HealthConnect.

It is not usually necessary to enter the medications during cutover since pharmacy has already entered these. Only nursing care orders, diet, code status, and ancillary staff consultations such as respiratory therapy, physical therapy, or nursing care consults are entered, simplifying the conversion. The charts are converted and sealed one by one until the last chart is done. The unit is then marked as being on HealthConnect.

Some teams move to other wards to continue the cutover, while some remain on the unit to offer post-live support and to assist the staff with their charting and workflows, which had previously only been practiced on the training environment. Certain key members of the staff on the nursing unit coordinate the flow of charts and make sure that new orders are not entered in the paper chart or paper notes are written after the chart is sealed.

During the go-live, emergencies always occur that require urgent surgical care. All staff are told that patient care comes first. Charting and orders in the EMR can be done later. A periop PCE (Physician Clinical Expert) is available at all times to assist physicians with the workflows and can be summoned by a simple phone call. PCE and FCE (nursing) support continues for three weeks after the go-live, 24 hours a day. After that, there is local trained software support staff for several more weeks. Telephone support is available through a local hotline and night support through a regional toll-free number. That continues indefinitely.

What have we learned?

First of all, the EMR absolutely does not change our business. We always focus and take care of the patient first. When you actually look at what we did before and how we do things now, the basic workflow, orders, and actions are the same as the paper chart. The difference is that the computer is much more specific about what goes where. It presents the same activities in a new manner that tends to trip people up or makes them feel like they are learning to practice medicine all over again.

There are inefficiencies and inconveniences and a lot of learning how to do things at first. With familiarity, improvements are evident within days. Those more than make up for the steep learning curve.

We stress to the staff that it is OK to make mistakes in learning the new workflow, telling them to do their best, focus on the patient, ask for help (since there is plenty of nursing, administrative, and physician support there in the first few weeks), keep their sense of humor, and give others the benefit of the doubt. We have found that encouraging the staff to stay in the workflows that were developed for them (navigators) and to keep documentation simple and concise helps all learn and become comfortable.

What about emergencies where there is not time to document? This actually happens. If we have time, we document the minimum, make the phone calls, take care of the patient, and document later. In a surgical emergency, patients can be brought from the ER to the OR with minimal documentation and can be taken care of in the usual fashion, with documentation following later. In these situations, even paper documentation is appropriate in the Epic workflow.

What about physicians who resist or are angry and "act out," or refuse to cooperate? There will always be these types of physicians, but their numbers are fairly small, perhaps two percent or less. With time, they can be usually brought around once the software nuances become more apparent and the advantages of an EMR are clearer. Peer pressure helps, too. Their complaints are listened to, acknowledged, and sympathized with, but they are reminded that there is no perfect medical record system.

What about physicians who cannot appear to "keep up" or fall behind? A few physicians, even in the paper record, fail to keep up or do sub-standard charting. The EMR makes their work or deficiencies easier to track and monitor. The most difficult decision that the local medical center leadership has to make is what to do about these deficiencies.

I am a strong advocate about why we are going to an electronic medical record. With the paper chart, only one person can work in it or review it at a time. If the chart is moved off the ward to another part of the hospital, no one has access to it. You can’t find it. If you want to write an order, you have to find the chart. If you write a brief operative note but the note is torn out and lost, then the note is lost for good. If you put a form in the chart that is accidentally removed, it is gone. If the binder comes loose and all the notes and charting falls on the floor, someone has to pick it up and put it together again. If you want to write an order but you are not physically present in front of the chart, you have to call and wait for a nurse and give a verbal order. If you want to see how the patient is doing, you have to call the nurse to get a report or go up and see the patient and look at the chart. If you want to review the orders to see what the patient is getting or what labs are ordered, you have to walk up to the floor and look at the chart. If a consultant is writing a consult in the chart, then you have to wait until they are done before you can review the chart. If the nurse is charting and you want to see the chart, then she has to stop what she is doing and give you the chart.

With the electronic medical record, at every day and at every moment, I can see and review the active medications and care orders and make corrections. It is a tremendous patient safety feature. I can communicate securely to the nurse and my associates using the medical record. Computerized physician ordering can help enforce national guidelines for antibiotics, deep vein thrombosis prophylaxis, and accidental ordering of medications to which the patient is allergic. Both medications and the patient are bar-coded, so deviations or overrides in medicine administration can be tracked and active interventions carried out.

I think you get the idea.

From the Mailbag 

To have your question answered by Mr. H or Inga in From the Mailbag, just e-mail (note: if this is a medical emergency, please log off and dial 911).

Not long ago, Mr. H sent me the link to a certain Dr. V, aka Dr. Venus Nicolino. Dr. V is a psychologist who, according to Mr. H, is a “hottie” (he liked the clunky glasses just waiting to come off and the bedroom hair). He even suggested we might want to consult with her next time we had a neurotic poster or the like.

Since I wasn’t about to be displaced for a moment by someone named Venus, I volunteered to go through my recent e-mails and provide my own expert opinions on some of the more worldly matters that readers have brought to my attention. And to make me feel better about not having a smoldering head shot like Dr. V, Mr. H sprang for an artist-rendered picture (no kidding) that, while possibly a bit customer-flattering like all commissioned portraits, was actually drawn using real photos of me as a model. So, this is me as a Barbie doll.

Dear Inga,

I am totally with you on the fist bump thing. It’s just not me and not very professional. However, what do you do when one of your male co-workers presents his fist for bumping? There is a part of me that wants to be one of the guys and I really don’t want to come off as a wet hen. Signed, Handshake Gal.

Dear Handshake Gal,

I appreciate your desire to fit in with the guys. Guy co-workers can make the job fun and it usually is a good career move to get along with any of your fellow employees. So, the interesting thing about men in the workplace is that many aren’t much different than the guys you went to school with in 7th grade.

Remember the guys that would hit you because they liked you? It didn’t really make sense that they were smacking you, but in truth the guys just didn’t know how else to act around you. Many guys still haven’t got the whole woman thing figured out, especially those in the workplace. They don’t know if they should treat you as one of the guys (e.g., giving you the fist-bump) or as a delicate flower (like they do with their wives and girlfriends.)

The key to guys is you have to tell them what to do (this is a universal truth, by the way.) Unlike females, men don’t get offended if you tell them something plainly and don’t spend a week analyzing the situation to death.

So, next time you get a fist and you rather have a handshake, simply explain you aren’t a fist-bump kind of woman. Or, perhaps make him feel special and tell him nothing makes your day more than feeling the palm of a man’s hand. Trust me, this method works particularly well.

Dear Inga,

I’ve been thinking about that study you mentioned about the presence of a particular genetic variant that makes some men more prone to unfaithfulness. I think some men certainly seem to have trouble staying faithful no matter the circumstances. I found myself wondering what percentage of those men with high levels of the hormone were still prone to stray if the sex life at home was fulfilling and frequent. Can you tell I’m divorced? Signed, Manly Man.

Dear Manly Man,

There is no doubt that some men are simply pigs. However, those that choose to act like pigs should be aware that the female pig goes into heat only once every three weeks. I suspect everyone would be happier if people didn’t act like pigs.

Dear Inga,

I don’t know if you pay much attention to politics, but don’t you think it is pretty cool that there is a female on the presidential ticket? And she is attractive, smart, AND well-spoken. Even if one doesn’t agree with her politics it’s a great step for women! OK, so between us girls, what do you think of her hairstyle? Signed, Hear Me Roar.

Dear Hear Me Roar,

I have to admit I was pleasantly surprised by Palin. Even if her ticket doesn’t win, I suspect we will see more of her in the future.

Regarding the hair, I suspect it’s the bangs that you find troublesome. If that is the issue, I bet you are under the age of 40. You see, when you get to be a certain age, your choices are bangs or Botox to cover unsightly forehead wrinkles. I’m not loving the bangs either, but governors with five kids simply don’t have time for Botox.

Readers Write 9/3/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk. Thanks for your thoughts!

Lab Integration: Feds Mandate HITSP
By Product Management Guru

I probably won’t be the only one to point this out, but Interoperability Spec #1 from the federal HIT standards group is lab. This standard is ‘recognized’ by the government, meaning the Fed won’t purchase a product for lab EHR unless it complies. Of course, the standards are complex and most don’t mandate compliance. But, Fed now does.

The purpose of this Interoperability Specification is to describe the top-level specification for the HITSP EHR Use Case. This Use Case comprises two scenarios that describe the entities and interactions that would be needed to implement an electronic EHR or other clinical data system with a laboratory interface. The goals supported by this Interoperability Specification are stated in the EHR Use Case:

• Transmission of complete, preliminary, final and updated laboratory results to the EHR system (local or remote) of the ordering clinician
• Transmission of complete, preliminary, final and updated laboratory result (or notification of laboratory result) to the EHR system (local or remote) or other clinical data system of designated providers of care (with respect to a specific patient)

Many labs don’t care about the Fed and meeting the recognized standard. Or, the existing healthcare standards have plenty of gray areas to squeeze into. I think a lot of people do support the standards like HL7, ANSI, etc., but while the standards provide help for transport and app layers, they often leave mismatched coded values and other vagueness.

So, the two sides still need to spend a lot of time talking about what they place in the transactions. Plenty of people say that some vendor-specific format is less work then figuring out a standard. This seems to be the history of healthcare integration.

HITSP, specifically for the federal use cases identified by the Office of the National Coordinator, is trying to complete the picture by stating ‘use this spec’ as well as ‘use it like this.’ As a major purchaser, the Fed will influence vendor decisions. Early adopters are emerging already.

I noticed John Halamka coincidentally writes about lab values in his blog today (he is also chairman of HITSP). I’ve heard Dr. Halamka talk about how standards have knocked integration projects from $100K-200K to $10K-20K. HITSP is trying to knock them down to $1K-2K (paraphrasing – he may use different numbers). In the interest of disclosure, I have been volunteering time (or my company’s time) on some HITSP committees.

Lab Integration: Labs are Blocking the Plan
By Lab Dude

I think the labs agree this needs to happen, but just don’t want to invest in it. It is very painful to get a lab interface up and running. Each lab has multiple regions that act differently, have their own compendiums, etc. Because there is no standard test code, all the codes are proprietary. Testing is required for each and every one.

The EHRVA had a lab summit meeting in July and brought together the major players in lab (reference labs, EHR vendors, American College of Pathologists, HL-7, CCHIT, etc.) The goal was to create a three-year plan for faster adoption. We decided to create a use case to send to ONC, spent around six calls on it, then wrote it. All along, the labs were involved.

Recently a lobbyist for the labs sent a letter claiming the jointly developed use case goes too far and the labs can’t possibly do it. So, it looks like the labs are banding together to block the plan. It’s very frustrating. How are we going to get better?

Lab Integration: ELINCS Initiative
By e-Practice Management Chief

With respect to your request for comments about lab standards, there actually has been a great deal of work done in recent years in an attempt to establish a standard. While the HL-7 specifications are typically used for results communications, the individual lab providers themselves have different terminologies/codification of results within that specification. The ELINCS initiative attempts to set this straight by:

1. Establishing a more standard construct for the HL-7 specification so that there is less variance in where different pieces of data are placed (e.g. last and first names which are critical for matching). HL-7 adopted the standard in 2006.
2. Using LOINC codes as a standardized nomenclature for observations/results instead of "local" codes designed by different Lab Information System (LIS) providers, which result in variances between systems for the same concept.

One of the barriers right now is a normal one for our industry: the existence of entrenched systems which would be very costly to change. Since there are many regions with just one or two dominant lab players who control their local markets, there isn’t a great deal of momentum to make the changes happen very fast. However, the ELINCS standard definitely has traction with major players such as the Markle Foundation, CMS, HL-7, etc. and it is also the standard for results for CCHIT certification which is obviously a major force.

The California HealthCare Foundation has managed this work, including pilots. Sujansky & Associates was contracted for technical consulting and other management. They have also provided an excellent and free testing tool (EDGE) which we use whenever we have to interface to a new LIS and do testing of those third party results files. Most of the time we seem to get cooperation, but there are some cases where a particular system and its technicians are not familiar with the standard and have problems with making changes.

This link provides good information about ELINCS.

With respect to the ordering process, there is enormous variation with very few true bi-directional interfaces available. Some clearinghouse operations are attempting to act as middlemen, but it is very challenging. Most of the demonstrations still show a manual entry process at the clinic side because they are not used to getting true orders which are typically expressed by doctors using billing terminologies (CPT).

We find that most labs are stuck on legacy systems and held hostage to the LIS vendor’s willingness to make changes. We don’t require that they meet the specs 100%, but we do refer them to ELINCS as optimal specs. Our interface developers think that maybe half of the vendors actually go to the ELINCS site to at least look at the specs. Because changes may have to be made anyway, labs have to invest some time and money changing their format, to some degree. This is also a reason why some entities like hospitals often contract to third parties like Iatric. They can keep their existing system and have the middleware keep up with other changes.

Lab Integration: Nobody Dislikes Standards
By Bob Nadler

You asked, "Are lab standards an issue one of the various work groups is addressing? Are the labs on board?"

When you say lab, what you’re really talking about is the large number of medical devices commonly found in both hospitals and private practice offices. As you note, the need for interfaces to these devices is so the data they generate can be associated with the proper patient record in the EMR. This not only allows a physician to have a more complete picture of the patients’ status, but the efficiency of the entire clinical staff is vastly improved when they don’t have to gather all of this information from multiple sources.

The answer to your second question is yes: many labs — medical device companies — are actively in involved in the development of interoperability standards. The EMR companies are also major participants. There are two fundamental problems with standards, though:

• A standard is always a compromise
• A standard is always evolving

By their very design, the use of a standard will require the implementer to jump though at least a few hoops (some of which may be on fire). Also, the device-to-EMR interface you complete today will probably not work for the same device and EMR in a year from now. One or both will be implementing the next-generation standard by then.

Nobody dislikes standards. Interoperability is usually good for business. There are two primary reasons why a company might not embrace communications standards:

1. The compromise may be too costly, either from a performance or resources point of view, so a company will just do it their own way.
2. You build a propriety system in order to explicitly lock out other players. This is a tactic used by large companies that provide end-to-end systems.

The standards problem is not just a healthcare interoperability issue. The IT within every industry struggles with this. The complexity of healthcare IT and its multi-faceted evolutionary path has just exacerbated the situation.

So, the answer is that everyone is working very hard to resolve these tough interoperability issues. Unfortunately, the nature of beast is such that it’s going to take a long time for the solutions to become satisfactory.

Lab Integration: The Thorny Problem of Semantic Interoperability
By Huckleberry

I work with hospitals sending data to physicians’ ambulatory EMRs. I had to say "thank goodness I’m not alone" when reading your comments.

I’ve been to many conferences (TEPR, HIMSS, World Health Congress, etc.), and nobody seems to be able to tackle the thorny problem of semantic interoperability. Everyone can speak HL7, but that’s only half the problem. There are so many different entities that need to agree on what each of those data elements MUST ACTUALLY MEAN that I’m not sure we’ll ever see a solution.

I heard one speaker say something like, "We can send a man to the moon, but we can’t exchange healthcare data." His point was that it might take that type of governmental effort (and mandate) to make this happen. I cringe thinking about it based on what’s happened so far on the governmental front with the NHIN, CCHIT, etc., but he may be right.

Something hilarious. Check the box at the top of the Wikipedia definition of semantic interoperabilty. Well, that’s it in a nutshell, isn’t it?!

Open Software Review -  Aurora by Adaptive Path
By The PACS Designer

Aurora is a concept video presenting one possible future user experience for the Web, created by Adaptive Path as part of the Mozilla Labs concept browser series. Aurora explores new ways people could interact with the Web in the future based on projected technological trends and real-world scenarios.

Through the development and release of Aurora, Adaptive Path, a research and development practice, will contribute its design expertise to support Mozilla’s efforts to inspire and engage a global community in an open design process to spur improvements.

The increasing ubiquity and importance of the web browser made it an excellent candidate for an R&D project. Mozilla Labs and its efforts to scale its open design process offered Adaptive Path an opportunity to contribute to the community and help Mozilla reach out to designers as well as developers. Adaptive Path’s emphasis on collaboration and openness was a good match for the culture and values of the Mozilla community.

The key components of Aurora are:

1. Natural interaction: Spatial, visual, and physical engagement with the Web
2. Continuity: Seamless, consistent Web and browser experience across devices
3. Multi-user applications: The Web as a space for collaboration, sharing, and remixing
4. Context awareness: Products that know where you are and what you’re doing, both physically and virtually

There’s a video of the Aurora solution.

While Aurora is possibly a Web 3.0 solution, it is a good example of what developers are focusing on to make the web experience more interactive and informative.

Readers Write 8/27/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk. Thanks for your thoughts!

CCHIT, The 800-Pound Gorilla
By Jim Tate, EMR Advocate

Yes, it’s true. There is a monster in the jungle and he is devouring all that is creative and laying waste to the brilliant small companies trying to lead the way in HIT development. Only the giant dinosaurs will be left the divide up the swamp once the blood bath is over. We are doomed, the sky is falling, and the Mayan prophecies of the end of the world are coming true.

That seems to be the belief of those who rant and rave against the presence of the CCHIT.

I beg to differ. I remember all too well when there were NO STANDARDS. I remember physicians being completely at the mercy of salesmen with slick demos (now they are at least somewhat less subject to the snake oil speech). I remember the industry making minimal progress on interoperability until it became a standard. I remember when there was no forward pathway that gave any indication of where EHR development was headed.

Say what you will about the CCHIT. I have found it to be an extremely transparent organization that is helping level the playing field and make it safer for clinicians to take the plunge into electronic records. In my experience, the staff at CCHIT has been incredibly responsive and helpful providing answers and directing me to clarifying resources. They set the standard on credibility. Certainly more open, helpful, and responsive than any major EHR vendor I have every contacted for support.

So there it is. You can throw stones if you wish, but you ignore them at your own risk. The CCHIT is here and is becoming ingrained in the road that lies before us. As Dylan said, “You don’t need a weatherman to know which way the wind blows."

ICD-10 Risk Assessment
By Art Vandelay

Discussion around this topic will benefit us all.

With the changes to the ICD-10 coding scheme, I have classified our systems into four categories – highest risk, moderate risk, low risk and no-risk.

I determined the categories by considering a few areas of risk: (1) the perceived impact to their applications’ architectures; (2) perceived capability of the vendor to handle these types of changes based on past experience with HIPAA and Y2K; (3) the vendor’s ability to share a plan for ICD-10 (few have been thinking ahead); (4) the vendor’s use of ICD-9 in application and interface logic, such as order checking rules and code-to-procedure checking rules); and (5) the use of discrete ICD-9 or groups of ICD-9s to drive key reports.

After considering the areas of risk, our main ancillaries (pharmacy, surgery, pathology, radiology) and revenue cycle add-on products are in the highest-risk category. Also in the category is our EHR. This was only due to the decision rules around the EHR and the way the department-focused portions of the EHR are used. It could be much worse here if we were using more reporting or decision rules. The revenue cycle add-on products are the most troubling. These include claims scrubbing, coding rules, and charge edits.

In the moderate risk category are our revenue cycle, scheduling, medical records, and decision support products. The revenue cycle vendor has a decent plan in place.

The low-risk category includes many of the biomedical and patient education applications. These applications do not have much logic associated with a diagnosis. They also do not send interpreted data outside of the system. Some raw data without diagnoses is sent.

The no-risk category includes our enterprise resource planning (ERP) systems and document imaging system.

ICD-10 also enables the HIPAA-compliant claim attachments. We have not performed this risk analysis, but believe our EHR product will help. My fingers are crossed.

Because of this change, the independent physicians may start to approach the hospitals for some EHR-Practice Management system donations under the Stark and Anti-kickback law changes. This will place the hospitals in the unenviable position of thinking about themselves and their projects versus keeping the physicians happy. It could also impact the forms, order sets, and other data to be built in these applications because there are more possibilities to consider.

We have added ICD-10 contract language to our list of the usual items we negotiate with both our systems and medical devices. This mirrors our HIPAA and Y2K language.

Soarian Financials
By Clinton Judd

Last week, Otis Day clarified his positive comments regarding Soarian development to say he meant Soarian Clinicals, not Soarian Financials (SF). He went on to say, "I do agree that Siemens is looking to improve short-term and milk INVISION. And why should Siemens care, or the customer, for that matter? If the customer is happy (and paying their invoices), where’s the problem? Does Mr. Judd suggest this is a negative situation?"

Soarian Cynic answered this in Monday’s HIStalk by detailing how his hospital has waited six years for SF and they were recently told to wait at least two more (and asked to extend INVISION for at least five more, just in case). This is two years before SF is ready for them to start implementing. Hospitals have been hurt by the delay. They have been sold on the functionality to come in SF and, as a result, accepted that INVISION would stop being enhanced (not sunsetted, but few significant enhancements in years). 

If hospitals had known in 2005 that they wouldn’t have an integrated contracted management system or an integrated EMPI until 2012, they may well have solved their revenue cycle challenges with Eclipsys’ Sunrise Financials (formerly SDK) or they might have invested in bolt-ons to INVISION to get them the process improvements they sought. Waiting for Soarian Financials has frozen some hospitals with respect to patient access and revenue cycle improvements at a time when they desperately need to improve and be efficient. CIOs (particularly ex-CIOs) have been hurt by the Soarian delays, too.

Despite still collecting high-margin INVISION fees, Siemens has been hurt, too. For example, Monday’s HIStalk mentioned Oregon Health Sciences’ (OHSU) implementation of Epic to replace A2K and LCR (A2K is OHSU’s name for INVISION). Siemens lost a very big customer there to Epic. Soarian simply wasn’t ready to compete with Epic and a number of other very large accounts nationwide have or will make the same decision to stop waiting and go with Epic. Similarly, I have heard (second-hand) that MedSeries4 has lost a number of customers to Meditech in recent years. Perhaps Soarian would have helped there too.

The difficulty with Soarian Financials isn’t because there aren’t a whole lot of good people trying hard. Siemens has invested a ton in this effort (I think SMS started the effort in 1998). The challenge is that Siemens is replacing INVISION.

INVISION certainly has its weaknesses and shortcomings, but customers have done a lot with it. It is surprisingly flexible and open to integration, if you have the skilled resources. This flexibility will make (has made) it very hard to replace. It’s the hospital’s billing system, so any replacement has to do everything INVISION does plus more. SF not only has to be a super, everything-to-everyone solution, but it effectively has to be backward-compatible too. 

Oh, and it needs to keep up with the market too. Ten years ago, it didn’t need a patient portal for billing and self-scheduling, but it needs one now. Five years ago, it didn’t need registrar score cards; it needs them now. Three years ago, it didn’t need a patient payment estimator, but it needs one now. These are all bolt-ons Siemens’ customers keeping connecting to INVISION and now want in SF or require SF to integrate to. 

The goal line for Soarian Financials keeps moving back. I don’t envy SMS/Siemens for having to create a replacement to INVISION. 

Siemens has done much better with Soarian Clinicals, as Otis Day commented on. Soarian Scheduling is more like SF; at least one regional medical center de-installed Soarian Scheduling after just months of use for scheduling radiology.

When Soarian Financials is finally ready (however ‘ready’ is defined), the next challenge for Siemens and its customers will be the conversion process. Implementing SF is a massive, long project — a 24-month effort? It is supposed to replace the entire revenue cycle, soup to nuts. Everything. Siemens probably still has 400-500 hospitals using INVISION. How many can they convert/implement a year? If they can do 50 a year (one a week), they’ll need 8-10 years. That’s IF they could do 50 a year. If anyone has heard Siemens’ answer to this conversion/implementation effort, I’d be interested in what they think they can do.

So, Soarian Cynic, if I were your hospital’s CFO, I’d either sign up for five more years of INVISION (maybe get a better price for seven years) and beef up your bolt-ons (there are great solutions available to enhance your access/revenue cycle processes).

Readers Write 8/20/08

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. Use your real or phony name (your choice). Submissions are subject to approval and become the property of HIStalk. Thanks for your thoughts!

Software as a Service
By John Holton, President and CEO, SCI Solutions

 

Software as a Service (SaaS) emerged with a new technology delivery (ASP) and a new business model (subscription) a little more than eight years ago. Since this time, SaaS has evolved from simple collaborative applications, such as e-mail aimed at small to medium businesses, to enterprise-wide systems (manufacturing, HR) utilized by Fortune 100 companies. A recent study by Goldman Sachs of more than 100 of large enterprises (including a number of prominent health systems) indicates that 55% of these companies currently utilize SaaS services for some of their IT needs.

One statistic highlights how far along the adoption curve SaaS has traveled: 10% of the companies currently have more than 25% of their applications being delivered via the SaaS model. A Saugatuck Technology survey reported that by 2012, "at least 40% of the mid to large companies will seriously evaluate SaaS-based ‘core’ financial systems of record.” In other words, they will rely on SaaS vendors for one of their most important IT applications.

Another area receiving increased attention is SaaS-supplied core IT infrastructure applications for a variety of system management services for desktop computers, servers, and mobile devices. SaaS is quickly moving from the confines of small business to being purveyors of mission-critical services to the enterprise.

Initially, large enterprises employing SaaS solutions were concerned with service levels, such as up-time reliability and software response time. Today, those concerns have been assuaged, with the SaaS vendors now focusing on interoperability with legacy on-premise software and compliance with the strict identity and access management requirements of large corporations (e.g. HIPAA). Enterprises moving forward with SaaS applications have benefited in a number of ways.

First, since SaaS vendors take responsibility for all aspects of software delivery, many IT departments have leveraged their internal resources by assigning increasingly more projects to SaaS vendors.

Second, because the SaaS vendors know their software intimately, installation and training is much faster with fewer problems than on-premise applications. Upgrades and services packs are installed almost immediately after general availability without being reliant on customer IT resources.

Third, since the business model is subscription-based without large upfront fees, capital can be utilized for other projects. The SaaS return on investment is almost immediate after go-live since the client receives benefits but has little capital invested.

Large corporations have had to adapt to SaaS realities that are different from their traditional on-premise experience. These adaptations include (a) limited control over the delivery of mission-critical applications; (b) less customization of software than they have had in the past;  (c) more vendor due diligence required before selection to insure compliance.

To continue their success, SaaS vendors will have to address enterprise expectations of customization, integration, and workflow. In addition to these challenges, unseating legacy vendor “stickiness” may prove difficult.

To date, successful SaaS companies began with the SaaS model and have not evolved from the traditional on-premise model. Traditional on-premise vendors have had difficulty with the SaaS model and its emphasis on rapid sales, installation, and training and software enhancement.

Saugatuck Technology predicts that by 2012, 50% of the SaaS companies will be pure plays and 50% will be today’s major players who started with traditional on-premise models (Microsoft, Oracle, SAP) that have re-positioned their businesses. This means major on-premise vendors will buy their way into the SaaS world. Expect significant consolidation within the current SaaS vendor community over the next several years.

Eight years after in inception, SaaS is a major component of successful IT management and a significant part of an enterprise’s cloud computing strategy (IT utilizing the Internet).

Siemens Layoffs
By Clinton Judd

Otis Day is wrong. The Soarian development layoffs are not because Soarian Financials is ready and stable. The truth is that Siemens is having trouble converting even single-hospital INVISION sites to Soarian, let alone multi-hospital or academic sites.

For example, Medicorp Health System has pushed their go-live back for at least the second time, for a total 11-month delay. The implementation will be about 27 months long if they hit their new go-live date.

My opinion, and this last comment is just an opinion, is that Siemens is looking to improve short-term results and continue to milk the INVISION product line, even if it means that Soarian development and adoption will slow. I don’t think Siemens really cares whether the sites use INVISION or Soarian — they basically get paid the same regardless (except for the one-time implementation and conversion fees).  If I were a Soarian customer, I’d be concerned.

The Problem with Meetings
By Richard Hell

Here is my thunk-the-head insight from attending hundreds of meetings.

The problem with meetings starts with the invitation list. You and everybody else looks to see who else will be there and how they rank among their fellow attendees. One of two strategies is chosen: either dominate the meeting because you’re the big dog or use the opportunity to impress everyone with the details they missed or the insight that only you could bring to the table. You were invited, so show you earned your chair. 

The only value managers can add is to question those who know their stuff, often without zero preparation. The engine that powers overheated gum-flapping is vast experience and intuition, not quiet diligence. It’s mental combat and it’s personal.

First meeting: horror of horrors, you’re not as uniquely brilliant as you thought. All the good ideas and smart conclusions have been taken by the other attendees. How dare they steal your brilliance? Now you have to challenge their thoughts as the quiet sage who has seen and done it all, or maybe make up a quick new tack right on the spot. Either way, you have to elbow into that limelight and show you deserve to be there. That means shooting down their ideas and furthering your own, all while self-importantly working the BlackBerry instead of paying attention to anyone else talking.

The big loser is the convener of the meeting. Instead of just validating the work already done, now there’s a rat’s nest of new concerns, options, and points of view. Everybody is engaged and empowered, although nobody wants to do any real work. Just looking smart in meetings is good enough. Losers do legwork.

So, the problem with meetings is meetings and the egos of those attending them. By definition, meetings ensure that broad viewpoints are represented. They also ensure that nobody gets anything done except ongoing posturing at the inevitable follow-up meetings. For managers who always pace the sidelines instead of influencing the game on the field, the conference room is its own battlefield.

Readers Write 8/13/08

Siemens Medical Solutions Layoff Rumors

From The Walrus: “After years of making ugly PowerPoint presentations, ignoring to the customer voice, and mainly keeping themselves busy with internal fights and not much more, Siemens Medical Solutions, Malvern PA has started the dreaded massive layoffs. 480 people have lost their jobs this week out of a team of 1100 So-Aryan developers. And this is just the beginning … What happened to all those ‘world class leaders?”

From Azkaban: “It’s no rumor. Siemens Med laid off around 350 in Malvern, and about 250 in Bangalore who were working on Soarian Clinicals. Lots of senior people let go in Malvern. Feel free to speculate on what this means for the future.”

From Bestürzt: “About 400 people were laid-off today at Siemens in Malvern, PA.”

Note: I e-mailed a Siemens spokesperson to confirm or deny and received no response, so this should be taken as nothing more than a (widely reported) unconfirmed rumor. Still, the parent company announced barely a month ago that it would be axing 17,000 workers.

Planning to Fill the “Career Is Over (CIO)” Position
By Art Vandelay

At least once I month, an article, blog post, vendor or consultant makes reference to CIO meaning "Career Is Over." This is happening at the same time that many organizations are realizing their leadership positions are graying. Some are not only graying in the leadership ranks, but also in their key technical positions. One organization realized that over 2/3 of their leadership and 3/4 of their technical positions supporting their major application were within five to 10 years of retirement.

The only way to ensure a flow of qualified candidates exists for the CIO position is to prepare the staff and to fill the pipeline. This post is about preparing the staff. A future post will be about filling the pipeline. Staff need to be prepared for what the job is now and what the job and our departments should be.

From my view of the world, some organizations have begun to reexamine their career ladders and formally defined succession plans. Fewer have provided leadership training or formally defined mentors with time carved out for key leaders to mentor staff. The fewest have defined cross-department leadership rotation programs. These are all traditional human resources and organization development techniques.

To ensure the best prepared candidates, I’d recommend each of the techniques contain the following. Career ladders need to encourage the ability to work horizontally across rungs to gain knowledge of other disciplines within your department and in the organization. Succession plans need to groom the staff for the position rather than just aging them in their departmental barrels without guidance. Mentor programs need to be supported by executives who want to participate and these executives need the time to participate. The mentors should include IS and non-IS executives to provide alignment with the business. Also realize that not everyone is good mentor and protégé material. Cross-department rotations need to include real opportunities to run projects and operations.

All of this needs to be done while taking into account individual learning styles. Some people learn by observation, some by doing, and some by discussion and reflection. One size doesn’t fit all. It also needs to take into account how the workforce is changing. Expectations of and tolerance for telecommuting, communication styles and techniques, diversity in race, ethnicity and age, along with work-life balance expectations, are elements of the changing workforce.

If someone creates, implements, and continues to operate such a program, let me know. That is a place I want to work. This type of a program would deliver aligned and well-rounded leaders. It would also foster mutual respect between IS and the business. I am planting the seeds of this in my own organization. I hope they grow.

Pharmacy Barcoding
By Mort R. Pescle

You said it right. The technology most vendors are peddling would not have helped those 17 Texas babies who were overdosed with heparin when pharmacy staff put the wrong drug dose in their IVs.

Most errors that harm patients are caused by IVs. Most of those that don’t get caught are due to mistakes in mixing, not mistakes in ordering or hanging. The huge investments in CPOE and bedside barcoding systems haven’t addressed the majority of potential patient harm even in the unusual situations where those systems are actually used as planned without workarounds or deficiencies. Minimally trained pharmacy technicians put clear drug solutions in clear IV solutions, so the only check is to compare the containers they said they used with what the label says.

The fix involves barcoding inside the pharmacy walls. Barcode what is received from vendors to make sure nothing was shipped incorrectly. Barcode again when packages are broken down to stock shelves in the IV room to make sure drugs are put in the right place (which they aren’t in many cases, surprisingly). Barcode again when mixing the IV to compare what was ordered against what was chosen to mix.

Unlike bedside barcoding, this is really not very hard. The pharmacy system “knows” what items were intended. Each of those can have a list of acceptable NDC numbers defined. Scan the label against the product and it either matches or it doesn’t (with some exceptions due to imprecise ordering when employees aren’t necessarily aware of the exact packages that will be used to prepare the IV).

No technology can detect having the wrong dose drawn up of the right drug, but catching wrong drug IV mistakes should be a piece of cake, at least if there’s any money left that wasn’t squandered on unused CPOE systems.

Open Software Review -  WebVista
By The PACS Designer

With all the talk about the VistA EMR System and how it is languishing in the healthcare space, TPD thought it would be good to review an open source solution from ClearHealth called WebVista.

ClearHealth has taken the powerful VistA EMR system which powers the Veterans Administration health network and modernized it. With added, seamless, scheduling and billing WebVista offers the only fully comprehensive VistA based system in a cost-effective, Web 2.0 package. Utilize all of the capabilities from a standard web browser.

ClearHealth’s WebVista system has many examples of forms and dashboards on their website which can be accessed at:

http://www.clear-health.com/content/view/41/51/

After clicking on an example, you can zoom the document by clicking once on it for easy reading.  Since there are quite a few to view, it is recommended that you proceed through each one to get a better perspective of its usefulness to you.

ClearHealth is still looking for more Beta testers, so if you want to help, feel free to contact them to further the VistA movement.

You  can contact ClearHealth at info@clear-health.com or call 877-571-7679.  Also, you can go to the Open Enterprise Platform for more on ClearHealth at:

http://www.op-en.org/

While there is a reluctance to use the VistA EMR system by the DoD and other government agencies, it is worthwhile to use the open source path to perhaps make VistA more usable by other healthcare organizations around the world through enhancements to WebVista.

Readers Write 8/6/08

The following are recently received writings from readers of HIStalk. Your submissions are welcome, subject to editing and with a suggested length of 500 words or less. E-mail me.

Campaign 2008
By Donald Trigg, Managing Director, Cerner UK

Don lived in Washington, D.C. for ten years where he worked in a number of senior public policy roles prior to coming to Cerner in 2002.

Barack Obama swung through London recently for the final stop on a global tour designed to buttress his foreign policy credentials in advance of the Denver convention later this month. Even the oblivious found it hard to miss, as Obama met separately with Prime Minister Gordon Brown and Tory opposition leader David Cameron.

But the US election will not be decided by foreign policy photo-ops. The economy is set to dominate the next 100 days. And the question that Mr. H posed for my guest column was: what are the implications for healthcare if the economy defines the fall campaign?

An understanding of the US healthcare debate begins with what Theda Skopol described as “the rise and resounding demise of the Clinton plan.” From a grand start that embraced Health Security amid an economic downturn, it ended in stunning defeat.

The assumed political lessons for the two parties have held for the better part of fifteen years. The Democrats, wounded by Arlen Specter’s organizational chart and Dick Armey’s glossary of terms, embraced “smaller, faster” policy pursuits. The Republicans, with the exception of the Medicare Modernization Act (MMA), decried calls for more government-funded coverage such as their depiction of SCHIP reauthorization last fall as “welfare for the middle class.”

The trend lines of the core policy issues, meanwhile, have been almost as stubborn as the political framing. On cost, spending as a percent of GDP has risen from 13 percent in 1993 to 16 percent today. On access, the number of Americans without health insurance exceeds 47 million. On quality, OECD data shows the US with the third-highest rate of medical error among the 26 countries submitting data.

Of course, the intractability of these health issues is a claim that might have been advanced in 2004. The shift in 2008 is a relative decline in Iraqi violence (allowing electoral mindshare for other issues) coupled with a teetering economy that offers a powerful contextual framework for a debate on healthcare.

In June, more than 60,000 non-farm payroll jobs were lost. Existing home sales dropped for the sixth straight month. Inflation increased to its highest level in seventeen years. These uncertainties have stoked middle class anxieties and healthcare costs are part of that increasing duress.

Substantively, Obama and McCain play to type on healthcare.

Obama’s starting point is coverage for the uninsured –guaranteed eligibility and a new National Health Insurance Exchange to ensure individuals can purchase private plans. He advocates greater transparency. He champions disease management. He backs strategies to elevate care coordination, including $10 billion per year for five years to drive “broad adoption of standards-based electronic health information systems” (not quite as catchy as “Yes, We Can!” and unlikely to make it to yard signs in Ohio).

Like Obama, McCain supports elevated transparency. He promotes “21st Century information technology” (absent much detail). He also calls (notably) for a single patient bill for high-quality disease care over the lifetime of treatment. McCain’s animating principle is cost containment, with choice and competition as core strategies.

As we watch the two candidates in the months ahead, we shouldn’t anticipate exchanges on whether Obama knows what CCHIT is (he doesn’t) or whether McCain had the same problems with EHR becoming HER as he was drafting his plan (he didn’t). Neither Obama nor McCain have the deep healthcare policy acumen of a, say, Hillary Clinton. It is not their comfortable terrain.

We will see broad brush strokes. Obama will challenge McCain for failing to offer a true plan to cover everyone. McCain will question Obama on cost. They will make competing claims about who will be better at standing up to special interests and working across party lines. The exchanges will definitional and foundational.

And so, if the global tour that ended here in London begins to answer the threshold national security question for Obama, the past will be prologue. A recessionary economy will make fiscal matters the paramount campaign topic, delivering a mandate –including healthcare—to a new President for the first time since 1992.

Transformation of the IT Department
By Art Vandelay

There have been a number of articles about CIOs taking-on responsibilities beyond simply the Information Systems (IS) Department. Here are two of them (1, 2).

For once, this change is happening at nearly the same pace in health care as it is in non-health care organizations. The CIOs of Alegent, Trinity Health System, and UPMC own significant functions outside of IS. These functions are more than clinical engineering.

Alegent’s CIO owns the project management for construction, retail business, and the budget process. This has come after some glowing successes in managing the build-out of a new facility with new technologies. UPMC’s CIO has struck some innovative partnerships and created new products. This has lead to revenue as well as some notoriety. Paul Browne, from Trinity, operates the organization’s program management office and functions as a COO. This evolution has occurred while they developed and deployed their Project Genesis.

Why has this happened? There was true alignment. This was spurred by their dynamic CIOs and leadership teams. These IS departments have successfully delivered major enterprise-wide projects.

We (IS) often lament about being in the back room. From the case studies and first hand accounts I have heard, IS didn’t tell them what wasn’t possible. They showed what was possible and drove the transformation. These leaders were able to garner business support in the forms of trust and human and financial resources.

In these organizations, IT matters. Structurally, the organizations have strong project management (PM) functions and business analysis (BA) capabilities. In many of our organizations, PM capabilities haven’t developed or matured. This has occurred while our BA capabilities have eroded.

As applications have become more easily configured, more users are comfortable owning their own destiny. Our organizations have a major decision to make. Will they support our transformation to deliver these capabilities, or will they develop them elsewhere in the organization? Think Allina. There is definitely a balance to strike between IS central control and departmental ownership in health care. At the same time, PM and BA resources are scarce and need to be centrally managed for the good of the organization.

What I Did on My Summer Vacation
By Matt Grob

We were in Mexico and stopped in at a couple of pharmacies looking for an topical anti-histamine gel that we like which is used for treating bug bites, but is not yet available in the US. I had always heard about the availability of prescription drugs available in Mexico OTC, but was truly amazed that virtually everything was available.

Aside from getting a kick out of watching the men (and some women) lining up to buy their Viagra, Levitra, and Cialis, what truly caused concern was the lack of knowledge on the part of the customers regarding potential interactions, side effects, and dosage limits. On top of that, many active ingredients for even common OTC drugs were in Spanish and therefore not easy to decipher. Sure, many customers asked the people behind the counter questions regarding the drugs, but these are – for the most part – simply retail clerks with no pharmacy training at all. I finally found one guy in a shop who, while not a pharmacist, did have some training and knew enough to answer my question by pulling out their version of the PDR to look up the active ingredient.

Were the drugs cheaper? For the most part, yes. Were they easy to obtain? Certainly. This is why so many people – especially in the current economy – are seeking their meds from beyond our borders. I wonder, however, what happens when they then re-enter our healthcare system with ailments or illnesses caused by improperly self-medicating.

The Future of RHIOs
By William A. Yasnoff, MD, PhD

Bill is founder and managing partner of NHII Advisors, a consulting firm, and was previously HHS Senior Advisor, National Health Information Infrastructure.

In answer to your question about the future of RHIOs, I’d direct your attention to the health record bank (HRB) model, a central community repository of complete health records controlled by patients (including both medical records and patient-entered information — all clearly marked as to source).  

Whenever a patient receives care, the new information generated is deposited in her health record bank account (note that HIPAA requires that all records be released on patient request, thereby ensuring that such deposits will occur when patients ask for them). A non-profit community organization provides governance and hires a for-profit to develop and operate the HRB (the for-profit would raise the capital, and pay ongoing fees to the non-profit to defray its operating expenses).  

The HRB accounts are free to everyone, with the costs defrayed by a combination of advertising (to patients), fees to researchers for searches (to protect privacy, patient permission would be required and only anonymized tables of summary results would be released), and fees for reminders (paid by patients and/or third parties). In addition, the HRB would incentivize physician use of EMRs by either paying physicians a small fee (e.g. $3 each) for deposits of standard encounter reports from their EMR (for those who have them already) or subsidizing ASP-model EMRs for those who do not.  

Thus, the HRB model solves the key problems of making all the information electronic (by subsidizing physician EMRs), ensuring stakeholder cooperation (via HIPAA), earning and maintaining public trust (through patient control and community governance), and establishing financial sustainability (with a realistic business model that does not depend on charges to health care entities or capturing health care savings).  

The central repository is much simpler and cheaper to operate than the financially and technically infeasible "fetch and show" model that has been widely promoted (but is not operational on a large scale anywhere). In addition, HRBs do not need to connect to each other since the complete records for each patient are in a single HRB — this eliminates an entire class of interoperability. An HRB using this approach can be started for a modest one-time investment in a community non-profit (less than $1 million), since the cost of building the infrastructure would be paid by the capital raised by the for-profit HRB provider and ongoing operational expenses are covered by the business model.  

Washington State, Oregon, Louisville (KY), and Kansas City (MO) are all working towards this model. Note that while Microsoft, Google, and Dossia have all embraced the central repository approach, they are not complete HRBs because they lack community governance and mechanisms for incentivizing physician EMRs. The Health Record Banking Alliance (http://www.healthbanking.org ) is a national non-profit that is promoting this approach and has developed a set of principles for HRBs. I’d be happy to share more details with anyone who may be interested.

My blog has detailed articles about the concept, including Why Your Complete Lifetime Health Record Needs to be Stored in One Place, Health Record Banking: A Practical Approach to the National Health Information Infrastructure, and Health Record Banks Facilitate Consumer Control and Promote Privacy.

LinuxWorld Presentation Response
By Randy Spratt

Randy is the CIO of McKesson.

You apparently read Information Week regarding my recent address at LinuxWorld and were unfortunately not able to attend and listen in person. I’m afraid that Information Week got it a bit wrong: I said nothing about insurance companies footing the bill, and I do not regard that as a viable option.   

Rather, my point was that healthcare providers are increasingly insistent on technology that provides a real and demonstrable benefit – either a strong ROI or strong guardrails regarding patient safety or both – and that vendors who layer on costs without providing those benefits are unlikely to succeed. I noted that hospitals and physicians are heavily regulated, under enormous financial pressure, and struggle to be able to afford the technologies that have proven benefits. 

The case studies I advanced showed how systems that have a reduced third-party embedded cost (the basic value proposition of open source architectures) allow hospitals to absorb more needed technology without expanding their budget, or to divert money to other areas while attaining critical levels of reliability and performance. 

Finally, my discussion about MUMPS was not about the adequacy or quality of the platform – after all, our own STAR platform is MUMPS-based – but rather to show that IT investments in healthcare tend to have long lives, as hospitals cannot afford to make a mistake and require many many years to gradually and continuously improve their IT portfolio. The solution to funding, I opined, is to drive to the standards and the technologies that will allow reliable and facile interchange of healthcare information electronically amongst all of the stakeholders in the healthcare system. Until we achieve that, the high administrative costs we see today will continue to permeate the reimbursement system.

In every other information-based industry, where market forces are alive and well, LINUX and other open-source strategies have delivered exceptional levels of performance at much lower cost when compared to the alternatives. We are showing that the same value proposition can be delivered to the healthcare sector.

MedicalPlexus
By Brijesh P. Mehta, MD

Brijesh is a co-founder of MedicalPlexus and a medical resident at Mass General and Brigham & Women’s. He asked for a little PR for his new company MedicalPlexus, so since he’s a medical resident, I agreed. Here’s an abbreviated version of the e-mail interview.

What’s your background?

I have done clinical neuroimaging and translational laboratory research in neuroscience with publications in high impact peer-reviewed journals. I Completed medical school at the University of North Carolina and am currently a resident physician in the department of neurology at the Massachusetts General and Brigham & Women’s Hospitals. I plans to become a vascular and interventional neurologist.

What led you to start MedicalPlexus?

Advances in medical technology, the electronic transformation of medical education, and widespread use of digital tools in medical practice has led to a proliferation of digital multimedia content with valuable educational merit. However, the content is scattered on individual physicians’ computers, department intranets, and behind firewalls, making content management and sharing among physicians extremely ineffective. Concerns about patient privacy and intellectual property issues have also restricted content sharing.

Because the medical community is predicated on continuous learning, many physicians and researchers have begun to share digital medical multimedia on existing social networking communities such as iTunes, YouTube, Flickr, Slideshare, and even Facebook. Given the uncontrolled nature of these broad communities, physicians simply are not able to efficiently find relevant content, trust the content, or candidly discuss the content.

Based on their frustrations finding, accessing, and sharing digital medical multimedia content as a medical student and a resident physician, respectively, Mr. Nallasamy and Dr. Mehta created the MedicalPlexus concept for the purpose of improving patient care by more effectively disseminating medical knowledge.

Who is your intended audience?

Two tiers. Individual users: physicians (academic and community), residents/fellows, medical students. Groups: medical societies, clinical departments, residency training programs, medical schools, research laboratories.

Who are your competitors?

Online physician communities are still in an early stage with low barriers to entry, moderate competition, and uncertain revenue models. Although a few companies have grown their membership base, there is yet no market dominance.

Current sites range in their focus from enabling physician interactions to social networking to information sharing. The majority of these sites provide a service to physicians with the packaging of traditional social networking sites. Most do not address important patient privacy guidelines, content ownership guidelines, or ensure the exclusivity of these communities to physicians. This combined with the lack of appropriate content oversight is a barrier to providing an online educational platform to physicians that is  trustworthy.

For other sites, trust and privacy concerns stem from their revenue model, which is dependent on providing third parties, such as pharmaceutical companies, fee-based access to physician postings and interactions on their sites.

How would MedicalPlexus be used?

View content with a built-in media streaming module.
Upload, manage, share, rate, discuss content.
Aggregate content from online medical sites.
Subscribe to physician profiles and medical groups.
Add meta tags to community content.
Search PubMed, link e-publications to content.
Receive newsletters and email alerts of activity on MedicalPlexus.
Full access to unlimited multimedia content.
Personal, scalable storage space for archiving content.
Browse and bookmark content by specialties, groups, ratings, times.
Search with tags, labels, groups, diseases, imaging modalities.
Create personal user profiles to display own content, showcase work.
Assign sharing level for each piece of content: private, specific users, groups.
View, share media on mobile devices.
Private messaging between physicians.

Is the site live?

Currently we have presented the platform to select Harvard medical school departments for beta testing and their feedback has been very positive. As such, at this time, we have a couple hundred users which reflects the departments we have presented to. We have not done any publicity so far. It has been primarily word of mouth and through our presentations. At this time, any medical student, physician, or resident around the country who is affiliated with an academic medical center may create an account and begin using MedicalPlexus.

How will you get the word out?

Viral marketing, company blog to provide updates and highlights of  platform features, recent launch of a revenue sharing model, and reaching out to influential blogs such as yours to profile the site. Once we obtain funding, we will launch a national ad campaign in print/online media such as scientific/medical journals and presentation booths at annual medical society conferences.

What are the next steps? 

Traction at key Harvard medical school departments and tracking usage with our analytic tools. Adding more interactive features to the platform based on feedback from our users. Collaboration with Cisco Systems’ global life sciences group to add live video conferencing, chat. Partnerships with medical societies to develop clinical registry database.

What do you hope to get from HIStalk’s readers?

We’re looking to spread awareness of the platform to ramp up usage and make improvements. As such, we would be very interested if your readers, who may have great deal of experience in health IT, take a look at MedicalPlexus, sign up for an account, and ideally give us some feedback on their initial impressions, dream features they would want, parts of the interface they may or may not like, etc.

We have some great ideas in the pipeline about future directions for the site, but we’re very interested in making sure that we continue to develop a product that will be useful to doctors and researchers in their daily workflow.

If your readers really like what they see, it would be great to have them pass it along to physicians in their respective hospitals. The more use we have, the more content there will be on the site with potential to translate into a valuable resource.

Readers Write 7/31/08

Mike Gleason on Reasons Small Practices are not implementing EHRs a fast as we would like

A little history on me so you don’t think I’m some new hire right out of training class.

I first started in this field known as HIT in 1984. After completing a run in Washington DC as a Manager of a third party maintenance company I decided the switch to hardware support for a small company, (who doubled my salary) would be a great move. The second week at my new company as the new hardware support guy, every software support tech quit. Yep, both of them. Not due to me, mind you, but due to “budgetary constraints” or some people would say bounced paychecks. I had already bought my groceries for the week and I was able to stick it out till new checks were cut next Wednesday. (One time where it paid to get a keg vs. 2 or three 12 packs). I figured, “How hard could it be to support Medical software” and cracked open the user manuals and then quickly developed a relationship with my vendors phone support. And like all pain in the rear VAR’s I eventually worked directly with the president of the company. (Articulate Publications, Medicalis and Dentalis) He was also one of the chief software designers. Back then CEO’s still knew how to code too. I think Bill Gates retiring has completed that run as CEO’s who also code.

My journey of 24 yrs has lead me through titles of account manager, territory manager, inside sales, regional sales manager, Project Manager, Implementation specialist and a host of other titles with 3 prominent HIT companies.

Being an EHR implementer for the past 7 years has given me (I think) a unique perspective on why Dr’s make decisions and defer decisions. It differs for most Physicians’ but I think I can provide a few reasons. I’m sure it applies to all of us as well.

1. Fear
2. Ego
3. Money
4. War Stories
5. No one wants to go first
6. Product not perfected yet
7. Waiting on Govt mandates
8. Waiting on hospital install or Stark gift
9. I have people for that
10. Change

Fear

We all have it but MD’s and Nurses often fear the EHR implementation more than taking a rectal temp. Doctors don’t want to appear inept in front of their patients, nurses don’t want to feel inadequate when they are used to getting what they need in a few lines in a chart. Both have invested years in education and residency training and this little laptop can erase all that prestige in one office visit. Many clinicians start off training with these fears.

A proper implementation can alleviate most of these fears. Small steps like outlining the install process. Training the practice to customize their EHR so they feel comfortable making changes. Implementing in phases to minimize the changes. Outlining workflow ahead of time and training to your workflow documents are a few ways to calm fears.

I also like involving all levels of the practice in the implementation; this allows the whole practice to own the process.

So not only MD’s, NP’s, PA’s, LPN’s, RN’s and MA’s but also the Ultrasound tech, The lab phlebotomist, front desk, surgery scheduling, office admin, billing, etc. Many times in small practices these are the same people.

Involving the billing office is key. This assists in customizing with proper ICD-9’s, CPT’s, admin codes, modifiers etc., a benefit not often felt till we start passing charges from the EMR to the PM charge entry. We need to build the EHR customization so we are billing properly to maximize reimbursement.

I also recommend to all my installs prior to go live to take live patient charts randomly from the day’s schedule and complete a few notes per day with the current customization on test patients. This helps in guiding where you might need to add or adjust your customization. I also recommend Faxing sample scripts and progress notes to your own fax machine if possible from these same test patients. Set up a test pharmacy with your fax as the pharmacy fax. Print the DME scripts and the referrals and make sure you are happy with how they look. Seeing the fax coming out on your manual fax goes a long way to calming fears.

In typing this paragraph I’m reminded of an event at an install 5 years ago. I was teaching a nurse class and we often pair class members according to computer confidence levels. Experts with experts, newbie’s with newbie’s etc. I was teaching what I refer to as a catch all class. All nurses thrown into one class. One nurse was really struggling and I was not sure if she was just a smart alec or really dense… After struggling through the class we had a lunch break. I asked the nurse that was slowing down the class if we could speak in private. We went to a conf room and when I asked if there was anything I could do to help her get up to speed…. she proceeded to tell me with tears in her eyes that she had feared this EHR for this exact reason. She’s had a learning disability since elementary school and it was causing her to drop behind the other nurses. She was the Lab supervisor and felt she was looking bad in front of younger nurses that were better at computer skills than her and were thinking she was slow. I told her I was sorry for not noticing and offered to teach her over lunch breaks the next 3 days. She came every day and we spent our lunch hour teaching her the EHR instead of hitting Chick-Fil-a. This gave her confidence and she was very adept at the lab functions and able to run lab audits etc. by the end of my week of training and go-live support. On my last day onsite I came early about 7:30am and she called me into the lab. She introduced me to her husband who had come to work with her that morning. He wanted to meet me, shake my hand and thank me for helping his wife out and for helping her confidence in her job. He let me know she had not been the same for the previous 2 weeks and was complaining and thinking of quitting and he knew something at work was not right. Once we started our lunch training sessions he said she would come home and talk about what they learned that day and they made dinner together while she talked to him and she was so proud of sharing what she learned. He then gave me a bottle of wine from their favorite local winery, told me how proud he was of his wife and shook my hand and told me thanks for taking the time to work with his wife. She was just all giggly and had to show him all the lab screens and how she could replace manual processes with the EHR. I was blown away. I never realized how such a small thing on my part could help someone so much.

I still have that bottle of wine unopened on my desk…along with a Viagra clock a Urologist gave me for helping him learn to e-prescribe 4 years ago. My desk is littered with little drug rep tokens that all represent specific people at clients who have said thanks for taking time to give them some extra support to alleviate their fears. Even transcriptionists have thanked me. I collect these drug rep freebies as a hobby and my clients often show their thanks by presenting me with their favorite drug rep pens, clocks, note pads etc. I’m very proud of my collection all proud EHR students. Knowledge is power and power goes a long way in alleviating fear.

Ego

Not all installs go well. Many physicians think implementing an EHR turns them into a transcriptionist and they went to school to practice medicine and not type progress notes.

Also not wanting to look inept in front of patients applies here.

Money

We all know the reason here. New EHR or college tuition. Many Doctors are faced with tough monetary decisions every day.

War stories

Every practice has colleagues, or neighbors who have had a failed EHR implementation. These failed implementations are the bad news that circulates 10 times more than the one good install. I’m currently working with a solo MD that is now on his fourth EHR since 2000. Wish me luck.

No one wants to be first

Being the first is often a drawback for many physicians. They want to see what other practices implement and then ask them how it went.

Product not perfect yet

You see it all the time. Wait and buy the third generation of the computer not the first version. Vista is a good example of this. Many physicians’ think the current levels of EHR’s are just not advanced enough for them yet.

Govt Mandates

Why spend the money until the Govt says I need to? We all know this has occurred now with the recent house resolution. First they provide incentives then they provide penalties. Smart way to do it.

Waiting on local Hospital or Stark donation

Many practices don’t understand that hospitals move in 2 or 5 year increments not quarterly. If you’re waiting for a hospital to make a decision will they cover your loss of incentives and pay your penalties between now and 2010?

I have people for that

And many are the MD’s relatives… My mentor back in 1984 explained the HIT market to me this way. A doctor is the only business person I know that will place their business success in the hands of a high school graduate rather than a CPA or MBA. Meaning many office managers or front desk managers in small offices, are high school graduates with little to no business experience. Not as true today as it was back in the 80’s.

Man, many of these Doctors are loyal to a fault. I know many clients who have called me asking for advice on how to catch an embezzling biller, office manager, front desk employee. Or worse, how can we find out how much they stole? I have seen all types: Changing check names, billing false claims, taking cash payments, writing off to collectors that are their family members and getting kick backs. Many doctors have little fiefdoms and they love being the overlord. This can often cause them to become detached from their day to day operations. They often think, Doctors see patients and dictates, transcriptionists transcribe, nurse gives injections and prep patients to maximize my time, and medical records handles the charts. Sometimes the wife as the office manager really helps in this instance. If they are spending too much money at the office they have less to spend at home.

Many Physicians’ are very proud of how they can provide a living for their employees. They often develop deep bonds similar to family ties with employees. If you are selling them on reducing FTE’s know that they may not want to get rid of their “Family members”. If you approach it with freeing up the Medical records clerk so they can attend MA school or Ultrasound school to become a revenue generator they are much more receptive. One of my first large installs (22 MD’s) back in 2002 had over 8 medical records clerks in one office. Five of the eight were related to each other and they were all related to the office manager. Today the medical records room is gone and one person handles all incoming faxes electronically and scans all incoming paper and handles all outgoing faxes of medical record requests. They now have over 75 MD’s on the EMR with 3 specialties. What happened to the family members? One manages the records requests, two are MA’s, one is an office manager of a new remote office and one is now a PA. Key is: THEY ALL STILL WORK FOR THIS PRACTICE.

Change

Many people fear it some embrace it. Why is there such disparity? If you fear change it may be due to lack of knowledge or lack of a comfort factor. Training and exposure to the new workflow as well as input into the new workflow goes a long way in alleviating fear of change. I’ll be the first to agree many nurses and Dr’s can write in a chart faster than they can use an EHR. Keep in mind they have used paper for hundreds of years in medical charts. Tough argument to win with a new client only interested in time factors of documenting the current visit. Just ask them to run a report of all patients they gave X injection to with Y lot number and you will win that argument. Graphing lab trends from the last 3 labs also helps win this argument. I often take before and after pictures of the practice and bring them out at my 2 month follow up to show them how many paper charts were just laying around in stacks. You would be amazed at the change in just 2 months much less 2-3 years on an EHR.

One Dr had a funny take on it. He had a nurse that decided to retire after 25 years of nursing at the practice rather than under go EHR training. I was talking to him about it and apologized for not doing a better job of getting her trained enough to stay.

His reply? “If I knew all it took to get her to quit was implement an EHR I would have done it 2 years ago when I bought the practice!” That made me feel better.

Workflow documents are key here. Making sure the Dr and Nurse can get their pre EHR duties done quickly and easily helps many clinical staff to buy into the process at go live.

There is a process all clients go through. Some take 3 months others take 6 some take a year or two.

Phase one is the Go-Live. You are basically shooting for 100% EMR documenting as the goal and if you hit it you’ve done your job as an implementer. You may leave the practice somewhat worried if they can keep it up.

Phase two is when they can see the same amount of patients per day pre EHR vs post EHR. This can take 3 months sometimes. You do still get those freaks that do it from day one.

Phase three is when the practice starts looking for new ways to maximize efficiency and use modules like reporting, PQRI, advanced customization, interfacing more office devices, implementing lab or radiology interfaces etc. Show me more that I can do with your EHR. They become an EHR user who does not know how they ever worked on paper. These are the golden reference site,

So I think the rate of adoption in a small practice is a combo of all of these and maybe a few we have not thought of. Just my take on it from someone who is immersed weekly with new installs at new clients.

Readers Write 7/17/08

Samantha Brown on Most Wired

There are some of us who just aren’t filling out these ridiculous surveys anymore. They are nothing more than vanity plates for CIOs. There are a lot of better wired hospitals who are not on the rankings at all.

Spanky on Most Wired

After 10 years, only 556 organizations see any value in responding to the survey.

The PACS Designer’s Open Software Review – OpenMRS
By The PACS Designer

The ROW (rest of world) is starting to get the digital sense when it comes to record management systems for healthcare. Developers have come together to specifically respond to those actively building and managing health systems in the developing world, where AIDS, tuberculosis, and malaria afflict the lives of millions. They are using OpenMRS to achieve a  better outcome for patients. Most of the core developers are from the Regenstrief Institute and Partners in Health.

OpenMRS is an open source medical record system which is focused on developing countries. Open Medical Record System (OpenMRS®) was formed in 2004 as a open source medical record system framework for developing countries. OpenMRS is a multi-institution, nonprofit collaborative led by Regenstrief Institute, Inc. (http://regenstrief.org), a world-renowned leader in medical informatics research, and Partners In Health (http://pih.org), a Boston-based philanthropic organization with a focus on improving the lives of underprivileged people worldwide through health care service and advocacy. It is web-based, written in Java, and is under active development.

There are several layers to the system:

(1) The OpenMRS data model borrows heavily from the Regenstrief model, which has over a 30-year history of proven scalability and is also based on a concept dictionary.

(2) The API (application programming interface) provides a programmatic wrapper around the data model, allowing developers to program against more simplified method calls rather than having to understand the intricacies of the data model.

(3) The Web Application includes web front-ends and modules that extend the core functions — these are the user interfaces and applications themselves built upon the lower levels.

OpenMRS® is a community-developed, open-source, enterprise electronic medical record system framework. Their mission is to foster self-sustaining health information technology implementations in these environments through peer mentorship, proactive collaboration, and a code base that equals or surpasses proprietary equivalents.

As the ROW gains confidence in OpenMRS, you will see more countries joining this effort to digitize their medical records for patients to improve outcomes. OpenMRS has been implemented in several African countries, including South Africa, Kenya, Rwanda, Lesotho, Zimbabwe, Mozambique, Uganda, and Tanzania.

TPD Usefulness Rating:  8.

http://openmrs.org/wiki/OpenMRS

Art Vandelay on Enterprise Architecture

A number of organizations outside of healthcare have been developing "enterprise architectures" (EA) for some time. My first exposure to the concept was when Gartner introduced, "3 Documents for Healthcare IT Planning" in 1998. Outside of healthcare, there have been some success stories, but many more failures. The cases of failure seem to be due to a poor link to business value (ROI). With the growing complexity of our environments, some level of EA is needed. It is more than a passing fad.

In 1998, we looked at EA as basic standards and filling in the cells in the "Zachman Framework." While a great technique, this was fairly academic at the time. There was little guidance on looking at the present while projecting the future. There were also no formal linkages between the cells or a step-by-step process.

Knowing there was still value in this space, we evolved our concept to what we feel is a practical approach to enterprise architecture. To ensure that we keep true to providing business value, we trace the business value expressed in the form of the principles through all our decisions. We’ve defined a process that is iterative. It involves defining the current state and the path to migrate to the future state.

Whatever technique you use, it is important to set the goals and be sure your key stakeholders buy in to your approach. The proper level of input is important. This usually comes in the form of a steering or governance committee. We then start with reviewing our business and technology strategy. Next, we establish our principles for a defined period of time. Examples of our principles include looking an existing vendors for solutions to consolidate our spend to get preferential pricing and support. Another principle is to look to local vendors to help the economics of our area.

We then define standards maps for how we envision the layers in the architecture evolving over time. At its broadest level, think of the different layers involved in hardware, software and application integration. Within each layer, we also define another dimension for support processes, monitoring, change control, problem management, etc. For example, for integration, there is integration of healthcare applications – usually based on HL7. There is also non-healthcare application integration. We’ve chosen to use XML for the data standards layer.

The standards maps are supported by an approved buy list. We attempt to select the items in the buy list based on some no-nonsense requirements. For example, we use Altova’s XML Suite for working with XML. For servers, we’ve picked a major vendor but work with a local reseller to stimulate our local economy.

Most of the work goes into synchronizing the maps of various technology layers. We also establish reusable patterns to provide standardized solution templates across layers. For example, we have patterns for the various 9’s of availability (ex: 99.99%). Other patterns involve how we work with application service providers (ASPs).

With the advent of service-oriented architectures (SOA), the patterns have evolved to include application services. For example, we have defined an application authentication service that works with our single sign-on vendor and directory services. This is referenced by our web applications. Services have brought about the need for a new level of governance and coordinated planning. Fortunately, with the work we’ve done to define some of the EA, we seem to be adequately positioned to work through the challenge.

If you haven’t started to develop an EA, I encourage you to do so. From a purely IS point of view, as our vendors adopt SOA and virtualization and more integration is expected, the level of coordination increases exponentially. It will also start to evolve our support and project delivery models.