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.

Readers Write 7/9/08

First-Hand KLAS Experience
By Jazzbo Depew

I work for a vendor. We crush everyone in our KLAS category, but we’re not happy with KLAS.

I firmly believe that they don’t cheat with their scores or comments. Some of their vendors might try really hard to get folks to fill out surveys, but KLAS tracks down every user they can and stops using them if they’ve milked that cow too much.

We are one of those "obscure" companies that gets the good scores. Why is ‘Spence Holmes’ surprised that agile, targeted companies will score better than the generic behemoths? Does it have to be a cheating conspiracy? Could it simply be that software written and supported for a specific speciality or service will make its users happier than those that aren’t? 

If the survey for KLAS is biased, the implication must be that my company has somehow cheated. As the KLAS contact, I assure you that I haven’t. We’re too small and have too little money, believe me.

But I do think KLAS is biased in another way – the opposite of what Holmes implies.

We got a call out of the blue one day saying, "Hey, we’re from KLAS and we’re going to start finding your clients whether you like it or not. You can help by giving us your client list." We waited the three months they told us it would take to get listed. Nothing. So, we called. "Well," they said, "when we see scores that are so out-of-line with the norm, we need more data." Huh? Good or bad? They wouldn’t tell us. 

So, we mentioned the survey to our clients. Eventually, after something like 12 months, we got listed. However, we had a BIG ASTERISK next to our name and were put among the other software vendors as "Component, Updated, or Replacement" software or something like that.

Why?  Because our scores were so good and we are a small specialty company. It’s that simple. They don’t want us listed next to our much larger competitors. Our specialist prospects will be misled to think the "Best in KLAS" folks are better for them than we are. I’ve been fighting with them about this for three years. We even see some well known vendors claiming to have the highest scores in more of the ~30 categories than anyone else – which is patently false – but because they are one of the big fish, they don’t have to pay attention to us.

So, some KLAS stories:

When our scores first came out, I was reading the comments section. One of our clients said something about us that isn’t true, but made us look better than we are ("they won’t hire anyone who hasn’t worked for three years already," when, in fact, we hire college kids every chance we get). I called them up to fix it and once the person on the phone said, "Wait, you’re the vendor?" she all but hung up on me. "We don’t talk to the vendors, period." Given that I wasn’t complaining about the bad comments, I was impressed.

We know our clients really well. When it’s a bad one (we have so few), I know EXACTLY who it is. And I can tell you that the comments are VERY real and are the GOLDMINE for KLAS users. We read them religiously and use them to direct our efforts. I could write you another five pages (I’ll spare you) about my efforts to get KLAS to understand their real value. My impression was that they are a nice little company with a family atmosphere and not the greatest sense of business.

We’ve had a number of clients tell us, "Oh, KLAS called me!" whose names we never provided and who hadn’t contacted KLAS. KLAS reads through web sites, checks out newsletters, and asks customers about other customers.

KLAS specifically reported to us more than once that our "degrees of confidence" were about to slip because they had been getting data from our same customers for almost too long. If some new customers didn’t report, we’d lose a checkmark or two.  Whether this is lip service or not, I’ll never know, but the information was delivered in a manner that I believed. We did what we always do: sent out a customer-wide e-mail saying, "Don’t forget to fill out your KLAS survey. P.S. Give us a good score or we cut off your support." [Kidding about that last part.]

KLAS made a BIG DEAL about needing a proper sample size. Ours represents a FAR greater section of our clients than from the big vendors. In fact, during the first discussion I had with them, it was clear that there was a BIG vendor bias, not the other way around. KLAS can’t have the little guys winning all the awards and driving the hospitals away from the GEs, etc. Plus, what kind of blackmail would I have to use to get KLAS to give us those scores? They hate me there – I call to complain all the time about our lack of recognition. They’d love nothing more than to have us be average.

There is probably a correlation between being publicly traded and scores. This is largely a service industry and being beholden to two masters (shareholders vs. customers) doesn’t work, as we know.

ED Software Seen First-Hand
By Lukas

[From Mr. HIStalk: I removed the vendor’s name from this writeup because I can’t verify the source or its accuracy, but it was claimed to be one of the biggest ones and it’s not Cerner, Epic, Eclipsys, or Siemens.]

During a busy couple of weeks taking parents and going myself to the local ER, I got very close to watching the ED system in action and had the opportunity to talk with my nursing and physician colleagues about what they thought of the [vendor] ED system.

The most common answer was that it was cumbersome and didn’t provide the level of documentation needed in the ED. All of the treatment rooms in the ED were equipped with wall mounted PCs, but in the four visits, no one even turned on the PCs in the treatment rooms.

What’s even more scary, when one of my parents was admitted and the information in the ED was supposedly sent to the inpatient system, the medication records were a mess. Doses were wrong, medications missing, assessments didn’t move to the inpatient system. The nurses were not happy since they are spending time on the floor updating the inpatient system with the correct information.

None of the nurses or physicians in the ED were involved in making the system selection. The nurses on the floor want to go back to manual charting.

This hospital invested heavily in COWs, but they are currently in storage. They are also cumbersome and not much help.

The PACS Designer’s Web Software Review – Adobe Acrobat.com
By The PACS Designer

Adobe has launched a new website called Acrobat.com to provide new collaborative features for Internet users. The features are:

(1) Adobe Buzzword® – online word processor
(2) Adobe® ConnectNow – web meeting platform
(3) Create PDF – convert up to five documents to PDFs for e-mailing
(4) Share – work online with others, sharing large files without  e-mailing
(5) MyFiles – ability to store up to 5 gigabytes of files for sharing with others

You can use Acrobat.com to create and share documents, communicate in real time, and simplify working with others.

The First Real Web-Based Word Processor, Adobe Buzzword®, is a key feature of the new Acrobat.com website. Adobe has promised to keep adding new features into the future as users get more experience using their new site.

Create PDF is something new that Adobe has decided to give us in an online format. Since TPD has been posting about the new PDF/H for healthcare it would be good for HIStalkers to try to record their medical information securely in a PHR on their hard drive or USB drive and then using Acrobat.com Share to e-mail their PHR as a PDF/H. Adobe is permitting up to five different PDFs for free.

Adobe Acrobat.com is a nice addition to the Adobe portfolio of products and should attract new users with its free online word processor, Create PDF capability, and its sharing function.

TPD Usefulness Rating:  9.

http://www.adobe.com/acom/

Readers Write 7/2/08

Circadian Rhythm of the Organization
By Art Vandelay

All organizations seem to have times when they are and aren’t receptive to certain communications and changes. In order to convey this concept to my staff, I found an effective metaphor, the human circadian rhythm. This rhythm is the master clock for a human being (ex: when we sleep, when we are awake). This graphic explains it all.

When I use the rhythm to explain an organization, the clock applies to an entire calendar year, rather than a 24-hour period. The "clock" for the year is impacted by the overlay of the fiscal year and the seasonality of the business. For providers, the timing of the arrival of the new residents is another example of an impact. For payers, open enrollment is an example of an impact.

Many times in the information systems department, we are separated from the rhythms of the organization. We may have the best intentions, a great idea, and the perfect message tailored for the perfect audience, but introduce them at the wrong time. My organization is nearing its "fastest reaction" and "best coordination times" (see the graphic at 14:30). So this is when I look to introduce ideas where we are making broad changes. Examples include changes to our work request and project management processes. It is also the time when I start floating trial balloons on capital investments for the following year. In the same vein, I wait for the right time to celebrate the successes (see 21:00 – a "happy bed time story").

Finding your organization’s rhythm is an important part of a communication approach, as is tuning the message for the audience. Avoiding the bad times (ex: 2:00, 8:30), can be a key to success.

The PACS Designer’s Open Source Software Review – DBDesigner 4/MySQL Workbench
By The PACS Designer

DBDesigner 4 is a popular open source database that has been in existence for many years. It is now renamed MySQL Workbench 5.0.23 with the help of Sun Microsystems and the developers of DBDesigner 4.

DBDesigner 4 is a visual database design system that integrates database design, modeling, creation and maintenance into a single, seamless environment. It combines professional features and a clear and simple user interface to offer the most efficient way to handle your databases.

DBDesigner 4/MySQL Workbench can be compared to: 

(1) Oracle’s Designer
(2) IBM’s Rational Rose
(3) Computer Associates’s ERwin
(4) theKompany’s DataArchitect

DBDesigner 4/MySQL Workbench 5.0.23 is available for Microsoft Windows and Microsoft Vista only. With the release of the upcoming MySQL Workbench 5.1, support for Linux and OS X platforms will be added to enhance its usability. Additional MySQL Workbench 5.1 enhancements will provide live database querying functionality and should grow to a fully featured SQL IDE.

DBDesigner 4/MySQL Workbench 5.0.23 has reached the 400,000 download level, so it is a popular database choice of those who want an open source solution. Now that DBDesigner 4 has the support of Sun Microsystems in its merge into MySQL Workbench, users can feel confident that they will get support from a broad base of developers.

TPD Usefulness Rating:  9.

http://www.fabforce.net/dbdesigner4/screenshots.php
http://dev.mysql.com/workbench/

EMRs: Free May Not Be Cheap Enough for Physicians
By Mr. HIStalk

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter for a "Best Of" series for HIStalk. This editorial originally appeared in the newsletter in March 2007. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

Now that Stark restrictions have been relaxed, hospitals are rushing headlong into the ambulatory EMR business. It makes sense. Hospitals have a lot of technology expertise and private physician offices usually have none. The government wants to increase the embarrassingly small number of EMR-capable practices, so throttling back Stark is a free solution that makes almost everyone happy.

Are EMRs the peace pipe that will suddenly bring the traditionally wary partners/competitors together in a long-awaited passionate embrace? Probably not.

Community-based physicians are often scornful of hospitals, seeing them as a hotbed of meddling management, questionable quality, and carefully hidden profits. Imagine what they’ll think when they first encounter hospital IT types, those grudging emissaries of a department built around rigid conformance to rules, perpetual understaffing, and a vision for the common good that squelches the individuality and self-determination that doctors thrive on.

Hospital CIOs like service-heavy, expensive vendors that won’t get them fired. They also like standardization and vendors that offer the theoretical possibility of integrating office-based EMRs with inpatient systems and RHIOs. For those reasons, I expect most CIOs will favor EMRs from big-iron, old-line ambulatory vendors like Misys, Epic, and Allscripts.

These are the vendors that small practices studiously avoid in many cases. They dislike them for the same reasons CIOs love them.

I spoke about this with Jonathan Bush, CEO of athenahealth, at the HIMSS conference. He has an interesting perspective, although not surprising considering that his company sells simple, easy to use systems that increase physician income through reduced claims denials.

Bush described the EMR offerings of the big, inpatient-oriented vendors as “elephant’s ass systems.” The little two-doc practice sees the hospital IT truck back up and out comes a complex application with loads of customization options, stacks of thick manuals, and no direct support except what the providing hospital has decided to offer. Free or not, there’s training to attend, configuration choices to make, and conversion from existing systems to plan. Oh, goody.

Doctors aren’t that thrilled with EMRs. Most of their benefit goes to insurance companies, studies have shown. Until pay-for-performance kicks in, there’s not much incentive. Plus, docs are always paranoid that hospitals will see how much money they make.

Benefits aside, EMRs take more of the doctor’s time to use. Something that’s free but consumes an hour or two more of the doctor’s day is hardly a welcome gift. All the doctor has to sell is time, and suddenly there’s less of it available.

Bush predicts what he calls a “hairballing up” of these feature-rich EMRs. The hospital may spend the money, staff a support center, and hand-hold the implementation, but there’s still a good chance the doc will throw up his or her hands and announce, “I’m not using this. I don’t have the time.” Then, they’ll either ditch the whole EMR idea or find an easier-to-use system that gives them a financial benefit.

Remember when insurance companies and hospitals gave away free PDAs with all kinds of supposedly doctor-friendly software on them? Docs lined up to get one. No one was smart enough to realize until afterward that asking for a free gadget was hardly a commitment to change practice patterns.

Perhaps hospitals have underestimated this hairball effect. They’re giving doctors systems that are mostly loved by hospitals: feature-rich, committee-designed for a large range of practice settings, and with extensive clinical capabilities that may or may not interest the physicians who are expected to use them enthusiastically.

It’s great that hospitals will help drive EMR adoption by private medical practices. Hopefully they’ll give the docs a voice in choosing systems that they’ll use before spending too much money on a monolithic system that may not fit all.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update.  To subscribe, please go to:  https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

Readers Write 6/25/08

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!

Providers Facing Identity Crisis as NPI Vexes Claims Processing
By Martin Jensen

Hospitals, labs, clinics and physician practices large and small are used to the "flaming hoop" cycle — slicing and dicing the data each government and private health plan wants to see in order to get paid. The regulations enacted under HIPAA to establish a single National Provider Identifier were designed to correct a small but critical component of that: replacing the various payer-controlled identification systems with a single, universal numbering system that all payers would have to adopt, discarding all the state-specific Medicaid numbers, the half-dozen or more Medicare numbering systems, and various governmental and payer-specific legacy IDs.

The rule was that individual providers (i.e. human beings — doctors, nurses, physician assistants and the like) could obtain only a single number which would identify them in all contexts.  Organizational providers could obtain one or more identifiers as they saw fit, based on identifiable differences like location and care setting (acute inpatient hospital vs. rehab unit vs. outpatient surgery) and their own self-determined business requirements. Payers were specifically enjoined from telling providers how to enumerate.

But when the May 23, 2007 deadline approached, it was clear that, as usual, the industry was "unprepared" for the cutover. Providers weren’t ready to walk on their NPI legs and payers weren’t ready to drop their legacy ID crutches. Regulators at the Centers for Medicare and Medicaid Services (CMS) announced a one-year contingency period and CMS’s own Medicare division quickly adopted a phased contingency plan. First they would require billers to submit their own NPIs in combination with legacy IDs, then gradually wean them off to the mandated "NPI only" transactions. The critical issue of how to represent all of the other providers on the claims (such as the referring provider on a radiology claim, or the ordering physician on a lab claim) was left for a last-minute, untested cutover for May 23, 2008.

CMS, as usual, blamed the perennially unprepared providers for the delay. But the true culprits may lie a bit closer to home. Medicare, in what observers saw as direct violation of the regulation, issued a thinly-veiled threat (warning: PDF) to its providers to obtain NPIs according to their existing suite of Medicare numbers.

This wasn’t just a fairness issue. It was tantamount to an admission that Medicare was not gearing to deal with the post-NPI world of provider-determined identification schema. They also set an unhealthy precedent for other payers, including a number of state Medicaid plans, who subsequently communicated their own "expectations."

"If Medicare can tell them how to enumerate, why can’t we?" 

Well, how about, because if providers use one numbering system for Medicare and another numbering system for you, the claims which list both organizations as payers (many millions per day) will break down for lack of a consistent identifier? One ID per claim sort of requires that everyone use a common number, does it not?

The initial spike in claim rejections was startling, even to those familiar with the reports that some early adopters had gone unpaid for months. According to one source, Medicare rejections spiked by a factor of four, while Medicaid denials went up six-fold and Blue Cross rejections doubled.

Many of the problems have certainly settled out as providers regrouped for the new line of flaming hoops. But just as things seemed calmer, CMS imposed a new requirement: Employer Identification Numbers and Legal Business Names on NPI records needed to match an unnamed IRS data source or the NPI would be de-activated. While there was no recognition that such a change might trigger a mismatch downstream, our analysis indicates that virtually all of Medicare’s crosswalk logic relies on EIN, and nearly half of the matching goes against all or part of LBN. What’s more, secondary changes required on the Medicare side could, again, leave those claims unpaid for months, thanks to well-documented bureaucratic delays.

Catch more of our ongoing NPI coverage at the HIT Transition weblog.

It’s Time to Wake Up …
By Recruit Guy

In the realm of HIT, healthcare is unique. Healthcare is not unique. We have become so engrained that healthcare is a totally “different animal” with its own idiosyncrasies that we have totally ignored the advances and expanded maturity levels that exists in other industries. Sure, the clinical process is specialized and requires experienced trained clinicians and healthcare professionals to design and support advanced clinicals that support the care process. However, there are two broad general areas critical to any health delivery organization where we have not leveraged the advances and maturity levels that have been achieved in other industries.

The first area is often referred to as ERP that cover areas such as Supply Chain (Materials/Purchasing), HR, EDI, Accounting/Budgeting, etc. We are experiencing a severe shortage of capable practitioners that have experience in specific HIS solutions. The critical distinction here is differentiating between specialized clinical and reimbursement or revenue cycle application areas of I.T. and the other areas dealing with ERP applications. The shortages are not so much anchored around the lack of process expertise. The shortage relates to training and certification specific to the solutions (i.e. Cerner, Epic, Meditech, etc). The only way to expand or grow these qualified resources are to receive the build and design training associated with a client contract and play a principle role in the implementation project. This creates a very closed and restrictive supply of experienced professionals that very quickly join the ranks of consultants and installers that leave the provider organizations and join consulting organizations and go from project to project. These exits create an even greater shortage overall so we constantly have one organization stealing from another with many going to the highest bidder. Why exacerbate this phenomenon with the non-clinical HIS modules and applications for which there is greater expertise and functionality outside the traditional HIS solution sets?

The second area deals with technology infrastructure. Technical infrastructure is comprised of areas such as network and system architecture and processes that support the best practice components of ITIL (Service Support and Service Delivery). This expertise more abundantly exists in other industries in areas that are truly generic between healthcare and other industry environments and are substantially more advanced than healthcare.

Recruiting experienced personnel out of these mature and established industries achieves a much greater value for our organizations. Granted, a redesign of the departmental I.T. structure may be needed to align in the manner outlined. This model pushes the clinical application expertise more into the user departments that relate to clinical and revenue cycle processes. I’ve always been a proponent of this model because it fosters greater ownership and responsibility within these user departments.

Wake up healthcare. Let’s quit thinking we’re so unique in areas where we’re not and let’s join the big league. This massive amount of in-breeding has caused greater costs for less quality and we’ve created a treadmill we can’t seem to dismount.

Girls’ vs. Boys’ Clubs
By Wompa1

Ms. DeBell’s post on women moving higher into the IT ranks brought to mind a recent conversation I had with a candidate with whom I am working. For those that are unfamiliar, I recruit in the HIS field (five years). I thought some of the points of the conversation would be worth sharing. It may also help the perpetually offended to wad their panties. I promise to not refer to myself in the third person (we love you, TPD).

I called this fellow while working for one of his company’s local competitors. He returned my call months after I placed someone. For several reasons, the time had come to move on, not the least of which was the recent promotion (over him) of someone with lesser skills, but a master’s degree. His goal now is to complete either a MS/MIS or MHA.

This fellow had been in a variety of roles, including management (hospital administration, not IT), and he felt that IT need not be his only option. He asked what I thought about widening his options. I began with the usual disclaimer: “My field of specialty is Healthcare IS.” This is true; my market knowledge is limited to HIS. However, I did note to him that healthcare administration is more of a girls’ club than is IT (which is ALWAYS referred to as the boys’ club).

My response? Women earn the majority of undergraduate and graduate degrees, AND they are vastly over-represented within healthcare administration, which means more competition for the higher level roles (manager and director level for the case in point). My thought was (and I am interested in reader opinions) that he would have an easier time finding management opportunities in IT, since there are likely to be more men (fewer degrees) than women. I see him having better growth with fewer women around. The other factor is that he has spent the last 10 years in IT, not in administration.

Anyone disturbed by my analysis may send complaints to Lawrence.Summers@harvard.edu. Larry offered to field them for me. Let me also state for the record: my specialty is strongly focused on clinical IS. Women make up the majority of my placements. The rest are very likely to fall into other “protected” classes. I am curious if my perceptions match the reality (real or perceived) that you experience.

A final point that I did not share with this fellow: I’m asked all the time about “how the market looks.” Since that is the most frequent question I hear, I figured I would share. Now is not a bad time to look for something new. I’m not selling here; as far as I know, only Mr. H. and Inga know me by other than my pseudonym. Given the general perception of the economy, many people are reluctant to explore right now (being low man on the totem pole, can’t sell the house, etc). Less people exploring means less competition, especially if you work in a higher level role.

Thoughts on HCSC’s Proposed Acquisition of MEDecision
By Lazlo Hollyfeld

I’m not surprised that MEDecision got bought by HCSC, but the price they paid was pretty baffling. They were on the block since last year, when everybody in the C-suite except St. Clair was ousted/left. The way I figure it, HCSC folks wanted to have more a direct say in things, including development, and saw this as a way to compete with the other big plans who have already made these types of strategic moves (e.g, Aetna with Active Health Management). 

But why the crazy price tag? If anything, HCSC could have driven a hard bargain and picked it up on the cheap, potentially. MEDecision does it as a way to clear off a ton of debt and keep development moving forward. Otherwise who knows? That’s just conjecture, though.

While they have a solution (Alineo) that is pretty good and better than some of their competitors (e.g, CareAdvance) their client base is primarily Blues plans. It is just too expensive, really, for any mid-market plan with less than 200-250k covered lives. Say that they are focusing on TPAs and government plans but TPAs don’t have money to spend on a solution this robust (and expensive). Same for government plans. 

That means they really are just making money on customers that are migrating and upgrading to the new Alineo platform off a stable but limited install base. The only way to really upgrade their revenues there to win a whale (say at least 750k covered lives) but they’re facing a bunch of competition from existing vendors (Trizetto, McKesson Health Solutions, Landacorp) and a cost of small upstarts using newer technology (ZeOmega, others).
    
NextAlign is interesting and the Patient Clinical Summary actually does deliver some valuable data to providers (even if it’s administrative data). It makes particular sense in emergency rooms if select physicians can just get over their bias that all administrative data is garbage (yes, problematic, but is it really better than nothing or relying solely upon a patient’s recall when they have multiple chronic diseases? Problem is, it is just way too expensive for providers to seriously consider purchasing this even if subsidized by a local payer. Will providers take it for free?  Sure, and they will use it some select cases, but they balk at paying for it and they have a bit of a point.
 
This is really not an issue just for MEDecison. Every payer is facing this same challenge of how and where it makes sense to touch/interact with providers. Every large payer is conducting pilots this year with select providers, but they are mum about the results, either because they have nothing yet or regard it as too important of a differentiator from competitors.  My bet is a bit of both, but mainly the former reason. 

One thing I would love to see is some actual decent survey stuff on what/how physicians view using administrative data for clinical reasons, including diagnosis and treatment. My bet is that older physicians and those with a heavy bias against insurers are also those most likely to never use anything the payer sends regardless of its actual utility or value. 

I’m curious to see where this goes and what is actually under the hood of the latest version of  MEDeWeaver (RHIO/HIE play). Is it similar to what Ingenix is doing for State of Wisconsin with their recently announced deal? I’m also interested to see where the whole NextAlign thing goes, too.

The PACS Designer’s Open Source Software Review – Endrov
By The PACS Designer

Endrov is both a library and an imaging program. The design has made strong emphasis on separating GUI code from data types, filters and other data processing plugins. The idea is that the program can be used for most daily use or prototyping, and for bigger batch processing or integration, the code is invoked as a library.

As a program, Endrov can do what you expect from normal image processing software. It is meant to be hackable; integrating new editing tools, windows and data types is meant to be simple. The main features that set it apart from other imaging software is that it can handle additional dimensions (XYZ, time, channel) which is needed for more serious microscopy. Filters can also be used without being directly applied, and can be composed into filter sequences. Data (for example, derived from analysis) is stored together with the images.

The native image format is OST(Open Spatio-Temporal) Imageset Specification, but most other formats are also supported.

Version 2.10.0 is out, with a big overhaul of 3D rendering. It supports multiple transparent objects better and has many internal improvements to simplify writing new plugins. Other than reacting faster to user input and making use of all your CPUs/cores it comes with the following:

(1) New voxel renderer, render modes and improvements to the old one
(2) Clipping planes
(3) Scale bar
(4) Partial OST3-support
(5) Reworked Matlab bindings
(6) New nuclei rendering options

This new version supports expanded multi-modality viewing.

Endrov is for the image analysis professional who wants an open source solution that can be customized to their liking when downloading image files for interpretation. The files can contain images and data so better analysis can be obtained from a single image view. Version updates have been frequent and come from the highly regarded Karolinska Institute, a medical university in Sweden.

TPD Usefulness Rating:  8.

Screenshots

Readers Write 6/18/08

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!

What to Call Your Boss in 10 Years: Ms. CIO
By Kristin DeBell

Since the first computer nerd was named manager of a hospital’s billing system, the chief information officer role has been dominated by men. As the CIO moved from the basement to the executive suite, rarely did hospitals have to make allowances for a female executive washroom. Folks, the times they are a-changin’.

Parity in the CIO ranks will come within the next 10 years and here are a few reasons:

1) More senior CIO roles will be coming available. The CIO role really hasn’t been around that long and only evolved to the executive level in the last 25 years. Many of the “original” executive-level CIOs are men or nearing retirement. Look for CIO more openings over the next few years. As these men retire, more qualified women will have a chance at these positions.

2) The perception that CIOs must be technologists is changing. Hospitals are looking for executives that can communicate business concepts. I’m not suggesting women aren’t technologically savvy, but in your average hospital you’ll find a lot of talented women beyond the walls of the IT department. As hospitals look for potential executives, a strong leader will win over a strong technologist who can only talk bits and bytes.

3) The world of nursing is changing and many nurses are looking for new roles. There are still far more female nurses than men so assume that the majority of the nurses I’m discussing are women. More nurses are coming out of school and looking for healthcare roles outside of bedside care. And why shouldn’t they: nurses are underpaid, underappreciated, overworked, and stressed out. However, they are well educated and have valuable skills that are in demand. The new nurses will be working their way through the ranks and in time plenty will be ready to explore that CIO role.

4) Also ready for new roles: senior level nurses with great management experience, with hands on technology experience, with excellent execution skills, and who are terrific coaches and expert communicators. Sure, not all of them, but there are plenty that fit this bill so need I say more?

5) Money. We want more of it and will look continue looking for opportunities to advance our careers.

6) Because we are female. Hospital boards understand the need to have more balance in their senior executive ranks. The CNO shouldn’t be the only female member of management.

7) Qualifications. Rightly or wrongly, healthcare institutions are looking for CIO candidates with advanced degrees. Anyone been noticing that more women than men have been getting those degrees in recent years?

I could probably come up with 10 reasons and I realize I’ve oversimplified a few things. However, if you are a senior technology type, I would encourage you to look around you and identify a few potential candidates to groom and don’t overlook the fairer sex. There are too few female role models in the CIO ranks but there is no reason that can’t change. Women are excellent leaders, organizational experts, and communicators. Truly – just think of at your mother.

The PACS Designer’s Open Source Software Review – Mirth Project
By The PACS Designer

The goal of the Mirth Project is to continually improve Mirth, an open source cross-platform HL7 interface engine that enables bi-directional sending of HL7 messages between systems and applications over multiple transports. By utilizing an enterprise service bus framework and a channel-based architecture, Mirth allows messages to be filtered, transformed, and routed based on user-defined rules. Creating HL7 interfaces for existing systems becomes easy using the rich client interface and channel creation wizard which associates applications with Mirth engine components.

HL7 has established itself as a prime method of healthcare information exchange. To integrate your existing services with HL7 systems, you must implement an adapter layer to transform messages between your domain and the HL7 world. Mirth makes this step easy by providing the framework for connecting disparate systems with the required protocol adapters and message transformation tools.

Mirth uses a channel-based architecture to connect your systems with other HL7 systems and it consists of the following:

(1) Endpoints(both inbound and outbound)
(2) Filters
(3) Transformers

Endpoints are used to configure connections and their protocol details. Inbound endpoints are used to designate the type of listener to use for incoming messages, such as TCP/IP or a web service. Outbound endpoints are used to designate the destination of outgoing messages, such as an application server, a JMS queue, or a database.

Multiple filters and a chain of transformers can be associated with a channel. The Mirth web interface allows for reuse of filters and transformers on multiple channels.
Mirth can be configured to listen and send HL7 messages and connect to a variety of protocols:

(1) TCP/MLLP
(2) Database (MYSQL, Postgres, Oracle, MS SQL, ODBC)
(3) File (local file system and network shares)/PDF
(4) JMS
(5) FTP/SFTP
(6) SOAP (over HTTP)

Mirth’s open architecture allows for the easy addition of custom and legacy interfaces.  Mirth has processed millions of messages and is in use in hundreds of production environments.
The Mirth Project has an active Support Forum and also has a fairly quick response mechanism when it comes to bug fixes needed by Mirth participants.

When dealing with HL7 interface issues, it is never easy satisfying everyone through application programming interfaces, so Mirth is a welcome addition to interface professionals in healthcare who need to solve communications issues between systems. New participants can look forward to a large contingent of professionals who have worked to solve HL7 interface issues using Mirth.

TPD Usefulness Rating:  8.

Readers Write 6/11/08

HIStalk will feature articles written by its readers in a weekly issue.

I encourage submission of articles of up to 500 words in length, subject to editing for clarity and brevity. Opinion pieces, issues summaries, or humor are welcome, provided they would interest a primarily healthcare and healthcare IT oriented audience. Submissions are subject to approval. For copyright protection, authors must indicate that the material has not been published elsewhere, that it contains no copyrighted material, and that published submissions become the property of HIStalk (to keep intellectual property lawyers at bay). Authors must include their real or fictitious name for purposes of attribution. All opinions are those of the respective author.

Send your article (as e-mail text or in Word) and become famous! Thanks to our authors, who voluntarily share their time and expertise with the readers of HIStalk.

A Pharmacy Perspective About CPOE+CDS
By augurPharmacist

Here is a pharmacy perspective about CPOE+CDS. I have worked as a staff pharmacist with three different CPOE+CDS systems over many years.

In my role, I am “catching” the order output from these computerized order entry systems. Basically, I review incoming med orders for appropriateness (a pharmacists’ term that involves checks for safety, likely efficacy and concordance with established guidelines). I then seek modification of errant med orders as necessary. Finally, I oversee order fulfillment.

I suspect that the mixed messages in the medical informatics literature about how CPOE+CDS seemingly improves med safety (Kaushal, Bates) yet also facilitates new types of med errors (Koppel, Campbell) might be explained by a closer examination of three things: available functionality, deployed functionality, and scope of implementation.

CPOE+CDS systems have been engineered differently and therefore they offer dissimilar functionality. Some functionality differences are important and obvious to staff pharmacist users. For example, a CPOE function that can calculate, round, and automatically cap weight-based doses using predetermined, safe maxima is an important function from the pharmacists’ point of view. Not all CPOE systems can do that.

To be fair to our vendor colleagues, it is also true that certain CPOE functions may be available but underutilized. In this case, the client may not have implemented the most recent software version or they may have made strategic decisions not to enable particular functionality due to a variety of organizational, socio-technical constraints.

Finally, the scope of implementation is important to consider. For example, where chemotherapy is concerned, many CPOE+CDS systems are presently unable to provide the chemotherapy cycle and regimen management tools necessary to order and manage these high risk, multi-drug therapies. If CPOE+CDS is deployed in particular areas without functionality to support identifiable unique or rapidly changing medical practice requirements, one has to ask if the scope of implementation is appropriate. In such specialized areas, perhaps it would be advisable to remain with the status quo of written orders until CPOE+CDS systems are further developed.

In terms of medication safety, the availability and deployment of particular functions and the scope of use for CPOE+CDS may help explain divergent reports about the ROI and patient value of CPOE+CDS.

Never Underestimate the Determination of Your Customers
By Nick Khruschev

After an eight-year absence from any MUSE event, for reasons too political to articulate in less than 500 words, I finally attended a MUSE conference again last month in Dallas. Considering that I’d attended and participated in the 10 consecutive international conferences prior to Atlanta Y2K, I wasn’t exactly sure what kind of event I’d find in the post MEDITECH MUSE era. I’m happy to report that I found a first-class event run by an organization that is absolutely flourishing.

Aside from the opportunity to connect with many former acquaintances and colleagues, I felt free to explore the myriad of offerings from the many vendors who may overlap, but mostly fill a gap. There was no apparent threat to MEDITECH’s prominence as the centerpiece to all of these services and products which mainly serve to add value to that primary core system which all customers in attendance share.

It was evident to MEDITECH customers in attendance that they are or will be approaching a major technology cross-road. And they’re right, there will be a lot of change in the next few years, much more than most of MEDITECH’s customers have ever experienced during their time as a MEDITECH shop. Currently, information related to this significant change is trickling out into the consciousness of the customer base through inconsistent and sometimes inaccurate sources. It was clear from my personal observations that there was much confusion and mis-information circulating among the nearly 2,000 attendees at MUSE. Significant change can be a scary thing, particularly when it is not well managed or communicated. People know it’s coming, but excusing the "Clintonese" for a moment, many don’t know just what the definition of "it" is.

At this year’s conference, the vendor which best communicated MEDITECH’s new technology to MEDITECH’s customers was Iatric Systems. In my opinion, the vendor which should take that accolade in Vancouver next year should be MEDITECH. If there were ever a time to re-think the position on this eight-year cold war, it’s now.

The PACS Designer’s NPfIT Software Review
By The PACS Designer

The UK’s National Audit Office has released its 2008 progress report on the National Programme for IT. While some aspects of the program are performing well, other parts are lagging behind because of slow adoption by system users.

The NAO states "delivering the National Programme for IT in the NHS is proving to be an enormous challenge. All elements of the Programme are advancing and some are complete, but the original timescales for the electronic Care Records Service, one of the central elements of the Programme, turned out to be unachievable, raised unrealistic expectations and put confidence in the Programme at risk."

The progress report concludes that the original vision remains intact and still appears feasible. It now looks like one part of the program will take much longer to install at the various trusts and that is the Care Record System. They are now forecasting the CRS to be fully installed everywhere by 2015, four years later than originally planned.

The Picture Archiving and Communications System has fared much better than everything else with all the 127 trusts now using PACS. The PACS has reduced waiting times for diagnostic radiology and also increased the IT skill set of the PACS users. PACS up-times have generally met the 99.87% up-time goal but there has been some under performance in some of the trusts sectors. The Philips/Sectra team has had the best performance over the 18 month period that was measured starting in 2006. The Philips/Sectra team only had one month that did nor meet the 99.87% up-time goal. GE and Agfa fared much worse with GE missing the goal in six out of the 18 months and Agfa coming in last with seven months of misses out of eighteen months.

The Department’s latest survey, conducted in spring 2007, showed that 67 per cent of nurses and 62 per cent of doctors expected the new systems to improve patient care. As far as the electronic Care Records Service is concerned, it appears to be a lack of proper planning that has slowed adoption from TPD’s viewpoint. The blame can be shared by all, since a massive roll-out needs to be carefully planned in phases to insure the users get the proper training at the most convenient time. TPD’s not sure if it was used, but the use of a "Train the Trainer" program will make it more palatable for early adoption of new concepts in record keeping and could bring in the expected 2015 completion date for the Care Record System.

While much more needs to be done to complete the entire roll-out, it appears that the negative sentiment towards the implementation of IT solutions is dissipating. This change to a better attitude towards IT should be used to encourage all participants to put in a maximum effort to help each other to adapt to these new concepts for the betterment of the NPfIT,its patients, and providers.

Readers Write 6/4/08

HIStalk will feature articles written by its readers in a weekly issue.

I encourage submission of articles of up to 500 words in length, subject to editing for clarity and brevity. Opinion pieces, issues summaries, or humor are welcome, provided they would interest a primarily healthcare and healthcare IT oriented audience. Submissions are subject to approval. For copyright protection, authors must indicate that the material has not been published elsewhere, that it contains no copyrighted material, and that published submissions become the property of HIStalk (to keep intellectual property lawyers at bay). Authors must include their real or fictitious name for purposes of attribution. All opinions are those of the the respective author.

Send your article (as e-mail text or in Word) and become famous! Thanks to our authors, who voluntarily share their time and expertise with the readers of HIStalk.

HIStalk vs. Trade Magazines
By MrDan

I’m sure that trade magazine has never made a mistake. No wrong facts, no bad sources, no mistakes. Unlike you anonymous bloggers who write whatever you want, despite being rated by thousands of readers as their primary source, the most reliable, and better then all the rags.

Or, gosh … maybe they feel threatened?  That you produce better content in less time for free and threaten their institution? 

The publisher could have e-mailed you, identified the issue, and requested a correction. You know, the exact process they want people to follow for their publication. But apparently he thinks that, since bloggers are inferior people who can never rise to the level, caliber, and pure nobility of him and his colleagues, it’s a better idea to throw a bitch-fit and smash you in your own forum. And you STILL issue a clarification (much faster than the rags do, I might add – within days, not months), and take his criticism in stride, answering without insulting.

Have I seen his publication? Yep. Been curious?  Yep. Am I someone they want as a reader, as a senior at a major vendor? Probably.

After this, will I ever subscribe or read a copy? Nope. The bias and lack of foresight and careful thought reflected by the publisher has tainted the entire organization for me.

Sorry, I feel very defensive of you and that just pissed me off. Hope all is well, and keep it up!

M.U.S.E Conference
By Green Tea

The independent MEDITECH users group (M.U.S.E.) met May 27-30th in Dallas, TX for their 2008 International conference. I understand that there were approximately 1,900 in attendance, including vendors. I am surprised that there have been no postings, so I thought I would provide one user’s view.

If you haven’t been to a MUSE conference, this may be one of the few conferences that keeps a strong focus on user networking with limited interference by vendors. Most of the sessions are presented by users and vendor education sessions are clearly identified. MUSE has also done a pretty good job trying to screen out user education sessions that have been sponsored by vendors. The user sessions may not be as polished as some conferences, but you typically get the straight story without any spin.

The hot topic was MEDITECH’s new platform – FOCUS. Doylestown Hospital (MEDITECH’s first conversion from Magic to FOCUS) presented about their journey. It was an interesting presentation considering they just went live a couple of weeks ago (I smell a HIStalk interview!) They kept it very objective and educational. 

It was interesting to hear CIO comments on FOCUS. Some are embracing it, others are questioning it. Unofficially, I would score it 25/75 right now. Of course, the rumor mill was at work that MEDITECH will lock out third-party vendors such as Iatric Systems, I-People, Shams, etc. It seems like a bad idea to me since these vendors often take the heat off MEDITECH when MEDITECH can’t deliver niche solutions.

The vendor hall was modest compared to many other HIT conferences. Iatric Systems had some of the biggest crowds, at least when I was looking. JJ Wild (Now "A Perot Systems Company") had a much larger contingent than years past. I-People brought in a couple of Dallas Cowboy Cheerleaders if you are into that sort of thing. Best give-away goes to Valco for the cowboy hats — they were everywhere. 

One prominent vendor was missing again– MEDITECH. 

Well, that just scratches the surface of some of the conference highlights. It might be interesting to hear from a few other readers to get their interpretations/opinions.

Personal Health Records
By Tommy Callahan

You agree with Carol Wayne and Neil Patterson that patient-entered data can not be trusted, yet you reference an article that states that data entered by young patients into a tablet PC vs. paper is more valuable to a physician in providing care. 

The bottom line: when physicians see new patients, they must "trust something typed in by the patient for medical-legal reasons" (or written) in order to provide care.

As a consumer, at a minimum, I would find value in a PHR that would auto-populate my history data into a physician’s PM and EMR, if for no other reason than my memory stinks and I have kids that get sick and get hurt, particularly while on vacation, and I have had to complete too many histories to count. There is also a bit of value to the provider if his staff does not need to read my usually awful handwriting to enter my demographics into the PM/ADT system.

I attended a conference in DC last year that included a dozen or so PHR vendors. I can’t recall the name of one of the vendors that maintained the form formats for most doctors and/or interfaces to most of the PM/EMR systems. The concept was that you simply indicate the doctor or clinic that you will be visiting as a new patient and the company will provide your data to the office in a usable format in advance of your visit. Pretty valuable to me as a consumer.

Open Source Software Review – caGRID 1.2
By The PACS Designer

caGrid is the service oriented architecture for the cancer Biomedical Informatics Grid (caBIG), whose goal is to develop applications and the underlying systems architecture that connects data, tools, scientists, and organizations in an open federated environment. To meet this goal, caBIG will bring together data from many and diverse data sources.

caGrid enables numerous complex usage scenarios, but its basic technical goals are to:

(1) enable universal mechanisms for providing interoperable programmatic access to data and analytics in caBIG
(2) create a self-described infrastructure wherein the structure and semantics of data can be determined through programming efforts
(3) provide a powerful means by which services available in caBIG can be discovered and leveraged.

caGrid implements grid technologies and methodologies that enable local organizations to have ultimate control over access and management.

With caGrid’s support by some of the most prestigious universities, the user of caGrid is getting a first-class operating environment as a tool in fighting cancer. Since caGrid uses the service oriented architecture approach, it leverages many legacy cancer databases. Support is broad through a membership of well-regarded universities such as Ohio State University and also the National Cancer Institute.

TPD Usefulness Rating:  9.