Time Capsule: Rogue IT Shops: Provide Rules, but Leave Them There

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in April 2007.

Rogue IT Shops: Provide Rules, but Leave Them There
By Mr. HIStalk

An ongoing hospital IT dispute involves the common existence of so-called “hidden IT shops.” Those are pockets of specialized IT that, instead of reporting to IT, are managed within their individual departments, such as patient financial services, human resources, and laboratory.

I’ve been on both sides of that particular fence, so I feel qualified to opine.

More than once, I’ve been in an IT leadership role as we reined in rogue IT operations. We cracked down on non-rules following departments that were spending IT funds unwisely, exposing the organization to risk, and insulting our IT leadership by flaunting their minimally supervised existence.

Also more than once, I’ve worked for a clinical department’s rogue IT operation, born of necessity after a Dilbert-esque IT shop couldn’t meet our department’s needs. The IT suits talked endlessly about professional IT management, but they were mostly known for starting projects they could never finish, using help desk analysts as human shields to prevent users from talking to the few experts they had, and conducting endless meetings to grind down the rational opposition to whatever they had already decided to do behind closed doors. They were much like a questionably motivated vendor, in other words.

If I have to take a position, I’ll side with allowing user departments to keep their existing IT employees.

“Common plumbing” is an IT responsibility. Departments shouldn’t have their own network technicians, e-mail administrators, server experts, or database administrators. They should not negotiate IT contracts or make capital purchases. I’m sure we agree on this.

Beyond that, my experience is that departmental IT people do a better job than their IT counterparts. They have the luxury of working hands-on with their users, free of the distrust that IT departments often generate. Since they understand the workflow and the specific technologies in place, they excel at setting priorities, can develop creative system workarounds and extensions, and are unsurpassed at retrieving and analyzing system data.

They also are keenly motivated because they are judged exclusively by their departmental co-workers, who ensure their high performance by lauding them for even the most mundane and sometimes comically easy accomplishments that seem hard to a layperson (I think that last issue is what steams the IT guys.)

I know the IT arguments because I’ve used them myself, although only half-heartedly:

• IT systems involve risk that only an IT department can assess and manage
• Centralizing IT creates efficiencies and prevents critical reliance on an individual
• Project funding should be centrally administered based on overall organizational priorities, not the needs of a single department
• Standardized practices should be used for the help desk, change management, knowledge management, and project management

What I’ve seen in reality from both sides of the fence:

• All the logical arguments aside, the primary motivator for IT centralization is the ego of the IT department’s management
• The IT department’s insistence on rules is often at the expense of creativity and flexibility
• Despite all the available tools, the IT department can’t match the service levels of locally assigned and managed IT employees
• As soon as IT gets in trouble or tries to hide staff shortages like a balding man’s comb-over, it’s all hands on deck to save the tanking projects, meaning those previously dedicated departmental resources will be yanked to put out some new fire, often self inflicted by poor planning
• Department employees often despise working in the detached, command-and-control bureaucracy of the IT department, so they leave, taking years of specialized experience with them and disproving the theory that IT can provide more resource depth than was already in place

I have loyalties both ways. These conclusions come from multiple personal observations.

Certainly other less dramatic options exist. You can have local IT resources report via dotted line to the IT department, providing guidelines on what they can and can’t do. You can insist that those teams follow documentation and change management standards. You can steer them toward standard technical tools, provide them with training, invite them to meetings, roll up their budgets under IT, and even move their chairs to the soulless cubes that IT departments love.

If you do decide to absorb the hidden IT shops, beware. Unless your IT shop is superbly managed, you’ll probably set unattainable expectations that you can’t deliver.

Time Capsule: My Secret Nostalgia for Small Hospitals

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in March 2007.

My Secret Nostalgia for Small Hospitals
By Mr. HIStalk

I have a dream at least once a week. I’m working in a tiny hospital in a flyspeck of a town, an architecturally outdated cinderblock building plopped in a big field in the shadow of lofty mountains. I’m running my little department nearly single-handedly. I’m feeling good, relaxed, and confident that I’m making a great contribution. I like the administrators, the physicians, and my co-workers.

If you’ve ever worked in a small hospital, you know how honorable and satisfying a profession that can be. The commute is traffic-free and I just might stop off on the way to work to buy bag of biscuits for the people I work with. If anyone in my family has medical needs, I know they’ll be treated very well by my peers who are – dare I say it? – friends. The “we’re all in this together” feeling is universal.

In other words, I’m back in the 50-bed hospital I worked for right out of college. The soft gauze of time has probably softened the memory of low pay, stretched resources, and plain-Jane facilities. Still, I never had to attend meetings, I didn’t worry about being on the wrong end of a corporate back-stabbing, and I knew I could make a difference in just about any way I chose. I was on top of my game and I knew it.

I miss it, even though I’m sure it’s changed since then. Sometimes I think I shouldn’t have been so anxious to move up to bigger and allegedly better places with their layers of bureaucracy, unchecked egos, and big but sometimes poorly managed budgets and IT projects.

I like small-hospital IT, even though it’s the minor league of the industry. I keep reminding myself that the majority of hospitals aren’t sprawling medical complexes – they’re little buildings where proud locals are born and will die, with no interest whatsoever in heading off for an impersonal and often dangerous big-city medical center.

Any plans to raise healthcare’s technology bar must include that majority of hospitals that are small, poor, and under-resourced. They need simple, affordable technologies that work, not $25 million systems that require a small army of support staff and an ego- driven CIO making $400,000 a year.

Luckily, some very good vendors are happy to sell into these little hospitals at an affordable price. In fact, some of their customers have outdone their big- hospital peers in rolling out CPOE, paperless medical records, and IT-driven improvements in outcomes. I love to see that. Too often, they feel inferior at the modest scope of their efforts.

I’m sometimes guilty of getting on my high horse about big-hospital IT. That’s odd since, as an insider, I know how poorly it can work even in a big hospital. I’ve played a role in huge IDNs that bought little hospitals and haughtily tossed out all their highly functional systems just for our own IT convenience, i.e. “standardization,” knowing that they were actually way ahead of us with their little econobox IT stuff because they actually used it right. Too bad.

Maybe I’m just being uncharacteristically and overly sentimental, but I’d like to give a respectful nod to that great majority of hospitals that vendors, consultants, and member groups often forget about. Some of us in seemingly glamorous places have a secret: we recognize that you sometimes do a better job for your patients than we do for ours. And, in our dreams, at least, we sometimes come back home.

Time Capsule: Brailer’s Santa Barbara RHIO Baby Goes Down the Tubes

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in March 2007.

Brailer’s Santa Barbara RHIO Baby Goes Down the Tubes
By Mr. HIStalk

The nation’s first RHIO is officially defunct. The Santa Barbara County Care Data Exchange (SBCCDE) locked its doors and quickly took down its website last week. David Brailer’s child star died an ugly, lonely death at age nine.

SBCCDE was a “big hat, no cattle” kind of project that left two sad legacies: (a) it blew millions in grant money,  and (b) it seduced politicians and reporters into thinking they’d seen the Second Coming of CHINs, only destined for success this time. They were half right.

It wasn’t for lack of trying by the California HealthCare Foundation (CHCF). That organization gave CareScience, of which Brailer was then CEO, $10 million to create and run SBCCDE. Uncle Sam chipped in a few more bills along the way.

CHCF bragged, incorrectly as it turned out, that SBCCDE had solved the funding model issue, based on the assumption that providers would happily pony up to keep the lights on. They were wrong. With only two organizations sharing data, neither was willing to fund SBCCDE’s ongoing operation.

Actually, SBCCDE left one other lasting legacy. It focused nearly all the government’s interest in healthcare IT on interoperability to the exclusion of everything else. That’s hardly surprising since Brailer got the healthcare IT czar job riding his SBCCDE credential, with few critics remembering CareScience’s 2001 struggles, shareholder lawsuits, and eventual sale to Quovadx for just $14 million over its cash reserves in 2003.

Perhaps Brailer provided some hints of a cloudy future for his RHIO. In an early SBCCDE presentation, he listed “substantial first-mover disadvantage” as a concern. He was right: new entrant CalRHIO is hot stuff now, planning to spend $300 million to blanket California in interoperability. SBCCDE was suddenly yesterday’s news, falling behind even upstart RHIOs in actually moving data around to anyone’s benefit. For that reason, no one is mourning the dearly departed SBCCDE very much.

Brailer also hinted more than once that the entire RHIO movement could be a throwaway technology, an interesting experiment to kill time until the massively more expensive Nationwide Health Information Network comes online. We’ll have to see if he was right about that.

In any case, I predict that at least one-fourth of RHIOs will fail within 1-2 years. Not because they don’t have noble goals or sound technologies, but because reality is working against them just like it did SBCCDE and CHINs before them.

• Like the many other misaligned incentives in healthcare, providers have to pay for the common RHIO plumbing, but get little value from it. Patients and insurers get a free ride in many cases.
• A mishmash of federal and state privacy laws ensures that expensive lawyers will guarantee nothing when it comes to avoiding HIPAA violations, opt-in guarantees, and privacy lawsuits.
• Back-end interfaces are expensive and difficult to maintain.
• The lack of an information sharing pipeline wasn’t the only reason competitors didn’t hold hands and sing Kumbaya before.
• The primitive state of most provider computer systems means that information is often not available electronically. The least-capable hospital or practice reduces the value for everyone else. Clinical information is always of suspect quality and completeness.
• Providers have many more projects that are more fundamental to their survival that will always take precedence.

In other words, RHIOs have all the same threats that CHINs had, other than the advantage of using the Internet for connectivity.

Perhaps the best lesson from SBCCDE’s flameout is the one we’ve already learned from failed physician order entry, enterprise resource planning, and physician electronic medical records system implementations. Technology is rarely the problem.

Time Capsule: EMRs: Free May Not Be Cheap Enough for Physicians

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in March 2007.

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

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 whatever 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 thrown 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.

Time Capsule: US Healthcare Value is Low – Follow the Fancy Buildings

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in March 2007.

US Healthcare Value is Low – Follow the Fancy Buildings
By Mr. HISTalk

Cerner CEO Neal Patterson made a characteristically blunt comment to a newspaper reporter at the HIMSS conference. Referring to what he quoted as the 31% of healthcare costs wasted on administrative functions, he said, “One of our goals is to eliminate insurance companies as they exist today.”

Many of us in healthcare would agree. It makes me boiling mad to drive by the palatial offices of Blue Cross Blue Shield and other companies like them. God forbid that a living, breathing patient or provider should cross their doorstep. I bet they’d call security.

On the other hand, I seem to recall that Cerner has some pretty nice digs out there in Kansas City. Neal’s sitting on about $300 million worth of Cerner stock, all of it due to the free spending of hospitals buying his product. Maybe insurance companies should state a goal of eliminating computer vendors who get rich by trading paper-pushing for mouse-clicking with little patient benefit.

Like they say about banks, casinos, and car dealers, “They didn’t build those big buildings by giving their customers good deals.”

I can’t blame insurance companies or Cerner for taking advantage of the messed-up healthcare system we’ve all allowed to be created. And in their defense, BCBS is no less hilariously “not for profit” as those big medical centers with hundreds of millions in bottom-line “excess revenue” and their own version of the $3 million a year executive. They usually have Taj Mahospitals themselves.

I’m not smart enough to figure out who the good guys and bad guys are in healthcare, so I look at just one thing: buildings. When I see stunning hospitals, vendor headquarters, insurance offices, and doctors’ houses, I figure they’re doing a little better than I’d like. Make a nice income, but don’t flaunt it.

There’s little question that we’re getting a poor return on our healthcare investment. We spend head and shoulders above the entire rest of the world on healthcare, which continues to chew up more and more of our gross domestic product, yet we have life expectancy and infant mortality that rival that of third-world countries. The costs keep climbing faster and faster.

It seems to me that hospitals, insurance companies, and IT vendors have a symbiotic relationship. You wouldn’t be selling many $8 aspirin if people had to pay up out of their own pockets. And without those, your hospital wouldn’t be buying expensive IT systems to spit out bills and document care. Everybody needs big profits to pay for those buildings.

There’s plenty of blame to go around for our poor bargain healthcare system. About all we IT types can do is to apply technology to process change. Not just buying Neal’s systems, in other words, but actually doing something useful and measurable with them to increase quality and decrease cost.

If we do that, then maybe all of those big buildings – owned by hospitals, insurance companies, and IT vendors – will become a little less opulent.

Time Capsule: Want To Anger a Nurse? Make Smug Comments about Grocery Store Barcoding

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in February 2007.

Want To Anger a Nurse? Make Smug Comments about Grocery Store Barcoding
By Mr. HIStalk

One reason we hospital IT types aren’t taken seriously is the “grocery story” analogy. You know, when some well-meaning government official, non-healthcare CEO, or your next-door neighbor smugly proclaims, “There’s more automation in the grocery story checkout line than in most hospitals.” Ha, ha, what an insightful observation – first time we’ve heard that one.

Randy Spratt, McKesson’s CIO, recently trotted out the old warhorse in an interview with Fortune. I’m sure his intention was benign (i.e., “buy more of our barcoding stuff to enlarge my executive bonus”) but perhaps his lab systems background makes him insensitive to how steamed nurses get when someone trivializes the barcode verification process on their end. If it were easy, everyone would be doing it.

(Hint to Randy: those same nurses are often involved in barcode system selections, with one of their possible choices being your employer’s product. Better stroke them a little next time.)

Ann Farrell, BSN, RN and Sheryl Taylor, BSN, RN sent me a list of why the grocery store analogy is not only inappropriate, but offensive to nurses. Their list was detailed, persuasive, passionate, and soon to be published, so naturally I decided to go more for the ironic and humorous by creating my own imitative list. Until their higher purposed tome sees daylight, this will be your amuse-buche.

If grocery stores were like hospitals:

• They would buy Doritos by the bag, but would have to repackage and label individual chips and then track every chip – who bought it, who ate it, and whether they ate it in an appropriate quantity and with only complementary foods and according to dynamically calculated nutritional needs.
• They would have to set up an internal barcoding factory since grocery makers would refuse to barcode their products until all stores collectively agree to pay extra.
• Each clerk would serve 15 checkout lanes simultaneously.
• Every customer would enter the store at precisely 9:00 a.m., 1:00 p.m. and 6:00 p.m. and clerks would have to check all of them out within 15 minutes.
• It would be the clerk’s job to prevent customers from buying both Doritos and potato chips since they serve the same purpose.
• Barcode scanners would be poorly designed by programmers, grocery store managers, and former clerks who haven’t worked in a store in 10 years. Clerk training would require two days and a 500-page manual.
• Stores would not be self-service. Instead, clerks would take the customer’s list, try to decipher their illegible handwriting, and run around the store to assemble several such orders for different customers at the same time. Each item would have to be documented twice: one when pulling it from the shelf and again when giving it to the customer. Customers would be encouraged to change their lists constantly. Most stores would not have the capability update the clerk’s list electronically, so the clerk would have to scratch off and write in items on the same ratty sheet of paper.
• Somber-looking inspectors could show up unannounced demanding to see a list of customers who bought hot dogs in the last year or the complete grocery purchases of a specific person named John Smith, but only the right John Smith.
• Clerk supervisors, exasperated over loss of productivity, would suggest keeping paper copies of commonly used barcodes to save time over scanning the real thing, flagrantly bypassing the whole purpose of buying the system in the first place.
• Instead of wheeling their cart to the checkouts, customers would ring the little “I need help” button wherever they happen to be, requiring the clerk to lug the cash register to their location to scan their item.
• The loyalty card of every customer would have to be scanned before selling them anything, even if they ruined its barcode by taking it into the shower.
• Soda would be sold like paint – the clerk would have to mix and label whatever flavor the customer wants using stock ingredients.
• Once barcodes were scanned, instead of being recorded electronically, the information would print a duplicate paper receipt to be filed forever.
• Clerks ringing up the wrong price could kill the customer, would be barred from future clerk jobs, and could be jailed.
• When working alone in a 24-hour store after everyone else has gone home, the clerk would cut meat, mop the floors, make pastries, unload the truck, show compassion, attend to family needs, and humor abusive superiors who take credit for accomplishments that mostly occurred while they were offsite making ten times what the clerk is paid.

Time Capsule: Despite Your Resolutions, I Know What You’ll Be Doing at HIMSS

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in February 2007.

Despite Your Resolutions, I Know What You’ll Be Doing at HIMSS
By Mr. HIStalk

Punxsutawney Phil aside, you know spring is at hand when it’s time for HIMSS (already?) For those of us who go, it seems like the entire healthcare IT industry is there, most of them angrily checking their watches in the Starbuck’s line or barking self-important cell phone commands to their holding-down-the-fort underlings back home.

If you’re not going, don’t feel bad. It’s a great time to get work done without being interrupted, much like the dead week between Christmas and New Year’s. Or, if your boss will be there and you’re so inclined, to screw off with little fear of detection.

Everyone heads for HIMSS with a firm agenda, pledging this year to get serious work done instead of wasting time like at the previous ten conferences. Demos will be dutifully studied, job-related networking will be pursued, and vendor relationships will be cultivated for the benefit of the employer picking up the tab. You’re here to work. Or, so the rationalizing goes.

All those worthy goals evaporate once the first heady breath of conference air is inhaled deeply, that energizing tang of carpet cleaner, coffee, collateral, and cologne that puts you in conference mode. Like a recovering alcoholic vowing to take just one sip of beer, you’re off the wagon. Before you know it, your agenda looks more like this:

• Plan shopping, golf, or spa time from the tourist literature left in your hotel room.
• Find someone before or during the opening reception who might give you a drink ticket they don’t need.
• Walk the halls trolling for people you know, encouraging a hearty greeting and keen interest about what you’ve been up to, then silently cursing the arrogant jerks when they pass by with a vacant stare.
• Look soulfully into the eyes of vendor booth people and speak profoundly and positively about whatever they’re selling, hoping they’ll dig deep under the counter to furtively slip you an invitation to a really cool party that’s not open to the masses.
• Expect profuse chumminess from booth people who pretend to remember you and harbor no ill will from that time you cut their product from the shortlist.
• Decide just how much honesty everyone else applies when completing their CE forms, figuring that walking outside an auditorium door and catching a couple of words should be worth the full CE credit.
• Blame the speaker’s boring delivery when you decide to bag their talk 15 minutes in, climbing fearlessly over the entire row of knees, in front of the projector, and against the tide of incomers and door-standers, figuring no one knows you anyway.
• Check the agenda and decide to sleep in, leave the afternoon sessions early, and maybe sit out in the sun at lunch.
• Thrust your chest out proudly, knowing that booth people will pretend to be impressed with your title, your employer, and your town, even though they are silently sniggering at all three and looking over your shoulder for a better prospect or an incognito competitor who might hire them.
• Cruise the perimeter of the larger booths, trying to catch the eye of someone who looks like a doctor, executive, or hot rep, steering a wide berth around low-ranking losers who earned a HIMSS trip for some geeky company accomplishment like programming.
• Gather lots of vendor material for take-home study, then chuck it all in your room’s trash can before you leave for the airport.
• Having already planned to skip the Thursday sessions since everyone else does, call the airline on Wednesday afternoon to see if you can get out earlier.
• Wear your Mardi Gras beads home, bring your kids crappy booth junk, and impress the spouse with fake doubloons and a box of Café Du Monde beignet mix purchased at the airport.

Have a safe trip to New Orleans.

Time Capsule: Why You Should Root for Cerner, Even if you Hate Them

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in February 2007.

Why You Should Root for Cerner, Even if you Hate Them
By Mr. HIStalk

Cerner announced fourth-quarter earnings of 48 cents a share last week, handily beating last year’s Q4 profits of 34 cents despite sales growth of “only” 17%. That met analysts’ expectations exactly. Even then, the stock shot up nicely. Neal Patterson now has nearly $300 million worth. Nice.

Plenty of people dislike Cerner or its products. Many are competitors envious of their growth or market capitalization. Some don’t like the company’s brashness or its ready-fire-aim product development tendencies.

Even those folks should relish Cerner’s stock performance. In an age of multi-national, multi-industry conglomerates dabbling half-heartedly in healthcare IT, Cerner is one of the few pure plays left. For that reason, their stock is a proxy for the entire industry and our future employment prospects in it.

OK, just between us girls, how is Cerner doing?

Cerner’s most important customer — Wall Street — is fickle. Cerner is a relatively small and narrowly focused company. Continuously increasing profits are required to keep the stock afloat. Once you lose investors and analysts by disappointing them with a slowdown, it’s almost impossible to drag them back.

Signs suggest that Cerner is about to hit an earnings growth wall. The big bubble in hospital clinical systems, their bread and butter, appears to be slowing. Everybody’s installing all the systems they bought and can’t afford to replace for 7-10 years. That’s a nice, steadily profitable business, but it can’t fuel a stock that arouses investors.

Another chink in their armor is Epic Systems. Big hospital selections nearly always involve Cerner and Epic as finalists. In most cases I’ve heard of lately, Epic wins. Few would have expected that back in 2002 or so, when Epic suddenly roared out of the ambulatory systems market with a vengeance, much like Cerner exploded out of its lab system roots to dominate the world (at least just behind Meditech.)

It seems to me that Cerner’s aggressiveness in selling not-quite-ready systems has cost them some reputation points. ProFit financial system problems and rumblings of system performance issues and stalled implementations haven’t helped.

Still, for a company whose products are generally KLAS mid-packers, Cerner sets the standard for broad product lines, a razor-sharp healthcare focus, and outstanding management that skillfully meets Wall Street’s expectations every time (which is nearly unheard of in healthcare and is a core competency that should not be trivialized.)

Cerner’s management is smart. They’re spending their expansion and acquisition dollars on life sciences, non-US healthcare IT, and downstream automation development such as medication dispensing cabinets. Diversification into high-growth areas is good and their rich market capitalization pays for it.

None of this should alarm customers or prospects. Skilled management means that Cerner will either find a way to beat earnings expectations or they’ll sell out to a larger competitor.

(That particular rumor won’t die, of course. Even though GE says they’re finished with acquisitions for awhile, few would be surprised if they picked up Cerner with their spare change. Based on GE’s track record, however, only Epic and McKesson would be cheering. Cerner’s customers and employees would not be nearly as elated.)

Cerner steps on toes, but we need them to succeed. We have darned few vendors already, fewer still that write and install their own systems instead of re-labeling someone else’s, and fewer again who focus on healthcare and keep a lot of healthcare people like you and me productively employed.

I want Cerner to grow. I want them to compete aggressively and win frequently. I want Neal Patterson to keep right on being Neal Patterson, a pig farmer turned Wall Street darling SOB who bootstrapped Cerner out of nothingness and runs it however he damned well pleases, the antithesis of button-down interchangeable bankers-turned-CEOs who manage companies they don’t own as dispassionately as a mutual fund.

If Cerner is neutered one way or another, our industry will be just as boring as it was before they elbowed their way into the limelight. I enjoy trashing them as much as the next person, but I’m secretly rooting for them.

Time Capsule: What Paul McCartney Can Teach Providers about Contract Penalties

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in February 2007.

What Paul McCartney Can Teach Providers about Contract Penalties
By Mr. HIStalk

This is top-secret provider stuff. If you work for a vendor, why not skip on down to the news items? I’m about to tell your prospects to take actions that you’ll dread.

As a hospital IT person, I would never sign a vendor’s software contract without including a variety of specific and severe performance penalties. From recent Inside Healthcare Computing articles, many or most hospitals will. I’m shocked. I like vendors, but money makes people (and companies) behave badly. Be friendly, but get everything in writing.

Vendors (software or otherwise) can say anything they want about their product’s performance and reliability. Those statements can have one of three possible outcomes:

• If the company is both knowledgeable and honest, you will be pleasantly unsurprised when their product works as advertised, but at least you won’t be caught unaware by a major meltdown. That’s the best (but not necessarily the most common) outcome.
• If the company is honest but doesn’t have broad enough experience with their product in a setting like yours, you’ll probably be miserable together, hoping they’re as responsive as they are honest. That’s bad. Sometimes you hit architecture or design flaws that can’t be fixed, in which case you’ll use resources to work around the problems.
• If the company is lying or has wildly oversold their wares, nothing else matters because you’ve been suckered into a long-term, expensive, and contentious relationship with a vendor that has already demonstrated its willingness to take your money under false pretenses. That’s the worst case.

The biggest mistake hospitals make is uncovering problems with previous implementations, but then buying the product anyway. The most common rationalization: “We’re smarter than those rubes who couldn’t make it work, plus we really like the product and the salesperson.” That combination of naiveté and misplaced bravado has lined many a sales rep’s pocket. It often benefits an executive recruiter, too, since the CIO who ignores a product’s well-known, spotty history often has plenty of free time to reflect after he or she has been shown the door.

Vendors may not be thrilled to see the list of penalties you want, but they aren’t your best buddies. They have their bottom line price and terms. You’ve got yours. Negotiation is meeting somewhere in that middle ground, fighting for the bigger chunk of the unclaimed territory on the table. If the vendor doesn’t visibly hate you during negotiations, you’re not pushing hard enough. Nice guys and gals don’t get good deals.

Contracts without penalties are binding only to the customer. If the software fails to provide value, crashes constantly, or can’t be used like you were told, you still pay unless you were smart enough to write in penalties. Your want their skin in the game with yours.

The most important eventualities to cover with penalties:

• If the software doesn’t do what you were promised in a way that makes it unusable.
• If you have problems that will cause you the most harm: downtime, poor response time, or cancelled development plans.
• If the software or vendor has weak areas that sound like trouble. If the salesperson’s teeth clench up when you lay out penalty terms for failing to deliver a richly functional ED package or a CPOE-to-pharmacy interface, maybe you haven’t heard the truth.

A hard-hitting, predefined penalty is your best hope for getting undivided attention when a problem arises. The cash won’t be much consolation, but it does create an automatic escalation path respected by all.

I know we all like to throw harmless little love words around like “partner” and “shared vision,” at least until you’ve signed the deal. Vendors pretend to be wounded when you sully the honeymoon bed with legal requirements. Take a lesson from Paul McCartney – maybe the vendor is a wonderful partner who loves you for something other than your money, but make them sign an air-tight prenuptial agreement just in case. Secretly, they’ll admire you for it.

Time Capsule: Want Physicians to Use Systems? Standardize Screens Like You Do Back-End Interfaces

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in January 2007.

Want Physicians to Use Systems? Standardize Screens Like You Do Back-End Interfaces
By Mr. HIStalk

The premise of RHIOs and physician portals is that, given the lack of industry coordination, everybody’s computer system stores data differently. It’s up to you (vendor or provider) to match their standard layout. How hard that is for you to do isn’t their problem. If vendors don’t have uniformity on the front end, at least they will on the back end.

It’s an important concept in standardization. The RHIO makes the rules. That’s a political reality, not a technical one. Not surprisingly, providers and their vendors can standardize when they have to. The problem is lack of incentive.

Not long ago, hospitals and doctors were paranoid about sharing patient information. The vital secrets of John Smith’s CBC result or mole removal notes were far too incendiary to let a competitor sneak a peek. Coldly formal hospitals weren’t about to stoop so low as to let the other guy see their data, even though it might improve care for a given patient.

That seems pretty silly looking back. For nonprofits to be arguing over information that could help patients seems incredibly provincial and self-serving (“We’re not telling you what she’s allergic to because you may steal our market share …”). The patient didn’t get to vote, but luckily, common sense prevailed anyway.

With that battle mostly won, let’s move on to doctors. They see patients in two or more hospitals in the same service area, both of which are determined to push their CPOE agenda forward because they spent a lot of money and effort on implementing that system. Doctor, we’d like to make you a data entry clerk.

Hospitals never seem to get how illogical it is to physicians that every hospital buys a different system, but expects community-based doctors who cruise in for an hour a day to master all of them without burning up more hours of their self-employed day. They seem puzzled when doctors jeer at their zealous requests to bone up on Cerner when he or she is fuming at Eclipsys across town and McKesson at the university hospital. Are those systems really different enough that everybody has to buy a different one?

Given the mediocre at best state of clinical systems and CPOE, mastering even one of them as a community-based doc is a stretch goal. Mastering two or more? It will never happen.

When I drive a car, I expect the instruments to work basically the same. If I pick up a TV remote, I don’t want to attend training or read a poorly developed manual. I don’t care how creative your engineers are, I still want the buttons on a telephone to be arranged the same.

Vendors who don’t want to follow standards won’t get my business. A car rental company that decides to creatively swap the brake and gas pedals would fail quickly. Nobody has to pass a law to prevent that; vendors aren’t that stupid. Standardizing the user interface is a market expander that benefits everyone.

In HIT, vendors claim product superiority, but systems have been commoditized to the point where they accept pretty much the same information. There are only so many ways you can order meds, labs, and rads. Still, each vendor manages to design their physician user interface with enough quirks to ensure distinction from competitor offerings. If you’ve seen one system, you’ve seen one system. There’s no such thing as best practices.

Maybe it’s time to develop the equivalent of a portal or RHIO for physician ordering, decision support, and communication. Standardize the user input just like the RHIO’s accepted data format. Why should every doc have to learn every system?

Vendors would hate that, but they weren’t fans of RHIOs either because the importance of their link in the chain was diminished. Data coming from a Cerner system is no better or worse than that coming from a Meditech or McKesson system, so nobody on the other end cares which one you use.

Knowing the HIT vendors aren’t about to support that level of standardization, perhaps some third-party scraping-and-scripting tool vendor could make Meditech look exactly like Cerner for doctors. Think that wouldn’t sell in towns where both are used by hospitals with medical staff crossover?

Time Capsule: Crossing the Cliché Chasm: Banished HIT Words for 2007

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in January 2007.

Crossing the Cliché Chasm: Banished HIT Words for 2007
By Mr. HIStalk

In its tremendous continuing service to humanity, Lake Superior State University has issued its 2007 list of words and phrases that should be banished from the English language (or American, anyway.) It exposes those overused and misused language extensions that might have been cute for about five minutes, but are just plain annoying now. Think mullet haircuts once hicks started wearing them (and, in some cases, never stopped.) Or, those oft-repeated but outdated bon mots like “Makin’ copies” or “Party on, Garth.”

Some examples from their list are “Gitmo”, “truthiness”, “we’re pregnant”, and “awesome.” I’m trying not to form my hands into a choking pattern just picturing someone using them in my presence or on TV.

As my contribution to the literature, here’s my list for healthcare IT.

Actionable – “information” wasn’t good enough, now it has to be “actionable,” a legal term turned into sales babble.

Applauds – vendors attempting to steal a free ride from someone else’s publicity have hijacked this word. If the President or anyone other than a competitor says anything that might sell more of their product, out comes the “we applaud” press release consisting of one sentence of praise, then a page full of hard-sell hype of why that news is so pleasing to them.

Chasm – blame IOM and their “Crossing the Quality Chasm” for turning a geographical term into a synonym for any tough problem. People writing articles and giving cliché-filled speeches often latch on to this overused word.

Clinical transformation – into what? Hasn’t anyone been transformed yet? Shouldn’t the transformational consultants stop invoicing? Are they just transforming your hospital’s money into theirs?

Closed loop – this is an engineering and biology term gone bad at the hands of HIT vendors. Any two systems they sell are now “closed loop,” even though customers have found many areas in which the loop is quite obviously gaping.

Collaboration – a positive term for everything involving two or more people: a meeting, a loud argument, or a knock-down catfight.

Continuum – healthcare doesn’t start or end in a hospital, which is apparently news to people who keep throwing out “continuum” like it’s a new concept.

Electronic Health Record – “clinical systems” became “electronic medical records” and then “electronic health records,” all without programming changes. You don’t have an EHR unless you are importing information from retail pharmacies, dentists, chiropractors, and home health services. Since no one does, please call vendors out when you hear them throw EHR around in an attempt to put lipstick on their pig.

Integrated – no vendor has ever called their products “disintegrated,” even when they bought them one day before from a defiant competitor. Poor definition and blatant misuse have rendered the word useless. It often displaces the correct but degrading word “interfaced.”

Partnership – a vendor selling a product to a customer. Any resemblance to a real partnership is unintentional, since any partnership base on one partner writing checks to the other would quickly dissolve.

Reimbursement – a cute euphemism for when hospitals or doctors making millions get a check, often for far more than any cost they expended and therefore a far cry from being “reimbursed.”

Robust – possibly the most clichéd of all HIT adjectives. Any application with more than one screen is “robust.” The word is never defined, just repeated as if describing a religious experience.

Solutions – slick salespeople have been calling software “solutions” for years, trying to inflate its value by making it sound more all-encompassing and thoughtful. It forces readers of their brochures and press releases to guess at what the hell they’re talking about.

Space – a sorry dot-com relic pressed into service as a synonym for “market.” Example: “we’re in the business intelligence space.” Fortunately, its use is mostly now limited to those who have it between their ears.

Streamline – every product or service claims to streamline something. It rarely happens, but the appealing image of putting a mess in order is intended to incite demand.

Suite – even tiny vendors repackage their harmless little applications into individually named products to make themselves look bigger, allowing them to claim a “suite” as the result. My eyes roll every time I hear it.

Thought leaders – people smarter than you and me, at least in their own minds. Companies often present their high-ranking employees as thought leaders when they want to sell you something. Thought leaders don’t have real jobs, they just think and cling to HIMSS podia. Picture that Rodin statue wearing a suit or black turtleneck and bringing Dilbert-laced PowerPoints.

Tipping point – usually claimed by someone who would benefit if it really is. It usually isn’t.

Time Capsule: Happy 2007 – Now Get Back to Work!

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in January 2007.

Happy 2007 – Now Get Back to Work!
By Mr. HIStalk

Happy New Year! Considering the alternative, be glad that you were alive and well enough to eat and drink too much over the past couple of weeks. Now get back to work!

You’ll notice your local newspaper, having slyly given many of the real news staff time off for the holidays, is padding out their already-slim editions with time-insensitive material written in advance or copied off the wire services: witless phony New Year’s resolutions for local politicians, tired rosters of the biggest personalities and celebrity deaths of 2006, and pleas for donations to community causes.

I can see why. Healthcare IT news is sparse this time of year, too. No one wants to bring out new products, start implementations, hire or fire people, or make changes in the strategic plan when no one is paying attention (hmm: this would actually be a good time to announce bad news, wouldn’t it?)

If our industry was a sport, the season would begin at the HIMSS conference in late February. It sets the tone for the upcoming year, as companies save positive announcements to coincide with the annual bacchanal. Vendors who make a bad impression at HIMSS will find it difficult to recover throughout the year, with attendees critically evaluating their demonstrations, booth size, staff attire, and cheery spirit or lack thereof. No wonder that even those companies in imminent danger of collapse spend the equivalent of a small country’s gross domestic product on one glorious, go-for-broke HIMSS splash, hoping against odds to get their money’s worth in new business.

Hospitals, too, get busy after months of letting IT projects lie fallow. No wonder ROI is hard to come by — projects come to a screeching halt because of non-IT staff refusal to get involved during (a) the November to January holiday block; (b) summer vacations; (c) school spring breaks; (d) impending JCAHO or state inspection visits; and (e) local, state, or national conferences involving anyone remotely involved in projects. No wonder implementations take forever – they’re on hiatus half the year.

CIOs have plenty of work to do. All those clinical systems projects still need to be finished. Celebrate the completion of major phases with some downtime and reflection, don’t forget to keep pushing at needed process changes and system improvements, and then jump into the next round of work. Clinical systems projects are like painting the Golden Gate Bridge: they’re never finished.

Speaking of clinical systems, if you haven’t yet made a commitment to bedside barcode verification of medications, then now’s the time. Same, too, with tightening up your Pyxis access with biometric security, override vigilance, and double-checked stocking procedures. Your patient safety experts aren’t sitting in IT, so get them involved and listen to their recommendations.

Microsoft has a new operating system and Office version – yay! Users will be upgrading at home, scornfully wondering why your IT department is holding them back in the Stone Age with systems they shamefully underuse anyway. You needed that non-strategic headache, right? At least PC hardware keeps getting cheaper, right about the time Vista will neutralize the benefit by requiring more of it.

RHIOs will want your attention in 2007. Your data, too. Maybe now’s the time to catalog all the electronic data elements you have available and to develop a plan to move important paper-based ones to electronic formats.

If you haven’t already, let one of your computer geeks play around (officially) with Linux, both server and desktop. If you aren’t running it at all now, you will be soon. In fact, you might as well encourage your nerds to bring in whatever compiler, software, scripts, tools, or websites they’re fooling around with because the gap between hobby computing and work computing is narrowing. At least you’ll be able to explain to youthful users why your hospital doesn’t need an official MySpace page.

Stark relaxation means you may need to support a new class of impatient, computer-illiterate users: doctors in private practice and the inconsistent employees they hire. Keep stats to get budget dollars since those support hours have to come from somewhere. It’s a warning you don’t need: office EMRs are going to be hot for the foreseeable future, which means lots of newbies are going to need help.

Lastly, if you’re in management, please make sure to recognize and reward those who work for you. When you get too full of yourself, make a list of which essential personnel would be needed in case of system failure, natural disaster, or clinical emergency. You’re probably not on it.

I hope our industry and all of us working in it have an excellent 2007. If in doubt about a particular course of action, remember WWIWAAP (which you may pronounce WEE-WEE-WAP, since I just made it up): what would I want as a patient?

Time Capsule: Can EMRs Sweeten their ROI by Moonlighting as Research Databases?

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in December 2006.

Can EMRs Sweeten their ROI by Moonlighting as Research Databases?
By Mr. HIStalk

I’d never heard of the Clinical Data Interchange Standards Consortium (CDISC) until last week. That’s when that group announced the kickoff of a new interoperability project, this one involving linking EMR systems to the information systems of clinical investigators who are performing drug or disease research.

The audience is researchers, the Centers for Disease Control and Prevention, or registries for patients or disease. The IHE is involved in the testing and will demonstrate the results at the HIMSS conference.

I’m not usually interested in this sort of project. I’ve seen first-hand what an insurmountable effort it can be just to get hospital systems to swap clinical data across the hall, much less with national third parties. Still, this is an exciting indicator of how quickly the now-common idea of interoperability has taken hold. If nothing else, RHIOs have made hospitals think about the value of their patient information and how to exchange it in standard electronic formats.

Getting and keeping drugs and devices on the market is expensive and information-intensive. Several small, highly profitable companies have sprung up to help enlist patients in studies, to do the rigorous paperwork required, and to design research methodologies. Their key commodity is information.

Hospitals have patient information that’s available nowhere else, the kind that arouses researchers and manufacturers that have far deeper pockets. Repurposing that existing information by making it available to those willing third-party customers, even when motivated purely by mission-supporting cash, is at least more beneficial to society than running a McDonald’s or building medical office buildings.

Let’s say your hospital implements a well-integrated, information-rich EMR system that can easily tie together everything about patients from medical history to demographics to procedure history. Suppose you add genomic data to the mix, storing information about family history, lifestyle, and a longitudinal history of disease, treatment, and outcomes. Your patients will benefit, but the information has an equally high value to those third parties trying to assemble or execute big research projects.

Drug companies and device manufacturers need the data that lives in your clinical systems. How else will they be available to target research to a very narrow range of patient types, maybe even those with a rare genomic profile? It could help them identify appropriate research subjects, design post-marketing surveillance, study population-based outcomes, and catalog adverse events. The information you provide could either be de-identified or made available only if individual patients opt in. The benefit to patients is access to a wider variety of treatments and protocols, most likely free to them if tied to a research project.

You wouldn’t just give that information away, of course. Hospital information is far deeper and more detailed than what’s available from any other source, with a wide scale to match. All you need is sophisticated EMR functionality and a relentless push to get every scrap of clinical information codified, categorized, and cross-referenced.

In the movie Wall Street, Gordon Gekko says, “The most valuable commodity I know of is information.” That’s true of clinical data, especially when those who value it can pay. Just don’t sign away too cheaply the rights to your treasure trove of data, even if the interested customer is a RHIO or third party data vendor.

Time Capsule: 2006 Product Rankings – Pay Some Attention, But Not Too Much

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in December 2006.

2006 Product Rankings – Pay Some Attention, But Not Too Much
By Mr. HIStalk

The 2006 Best in KLAS Awards were just announced. I know a lot of folks wait anxiously for those, especially vendors.

KLAS has its critics, of which I’m occasionally one. I like the idea of surveying customers, but having taken KLAS surveys myself, I’ve seen first-hand how poorly designed some of their questions are. A respondent can’t complete the survey without in-depth knowledge of product functionality, support, documentation, executive relationships, hardware, and so on.

In other words, either the person cares so much that they carefully enlist the assistance of 3-10 colleagues, or they just wing the damn thing so they can get back to work instead of wasting time on yet another hard-to-finish survey. You guess which. At least KLAS sometimes follows up by phone.

All of that data collection and interpretation imprecision is masked by a numbing array of graphs, charts, and tables in the final product. No one pays attention to those, recognizing them as a way of padding out the sometimes-skimpy data to make it more impressive and convincing.

The scores tend to wander a lot from one report to the next, which KLAS attributes to swings in vendor or product performance. It’s much more likely to have been caused by the imprecision of the survey methodology. Do you really believe that Meditech’s client-server EMR was improved so much that it earned itself a move from sixth in an eight-horse race all the way up to second place in just one year? Me neither. KLAS marks it as having a low confidence level, so how do you interpret its score?

Still, I’d definitely pay attention to the top-ranked product and be careful with the last-place finishers. I wouldn’t try to overanalyze products in between, especially when the scores are close. Read the customer comments instead, the best part of the KLAS reports if you ask me (although you don’t know what kind of organizations and employees are being represented.)

The most discouraging point is that no vendor does everything well, if you believe the scores. If you look at KLAS’s 15 main general solutions categories, you’d find 13 top-ranked vendors. If you’re a best-of-breed shop, you’ll end up with a lot of interfaced systems if you chase the winners. If you’re a single-vendor organization, some of your departments are going to be stuck with systems far short of being the best. And of course, in the next survey, they may all shuffle around anyway.

My takeaway is this: somebody has to be last, and if the scores are tight, it may not mean much. On the other hand, why can’t a #1 ranked vendor in one product area use that knowledge to excel in the others? Or, do vendors selectively invest in some strategic lines and allow the others to languish? What does the #1 vendor know or do that everyone else doesn’t?

You don’t have to be a KLAS subscriber to see who’s #1. Just check out the HIMSS booth walls and vendor marketing material. You will need to pony up, though, to see who earned worst in KLAS and which vendors did well in important categories like “would you buy it gain.” That’s where the subscription is worth it. Use it like Consumer Reports for car-shopping – at the beginning and end of your selection process. The work in between is on your own.

Time Capsule: Embrace FDA Oversight If You Want Clinical – not Clerical – Systems

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in December 2006.

Embrace FDA Oversight If You Want Clinical — not Clerical — Systems
By Mr. HIStalk

Most hospital information systems are old. Faded pictures of the original system architects feature bushy-haired guys wearing plaid pants, wide ties, and leisure suits. Given their unfortunate fashion sense, it’s not surprising that their precognition of today’s healthcare environment didn’t include having physicians and other clinicians use their creations directly. The goals of information technology were simple: capture charges, batch-bill the heck out of Medicare and Medicaid, and maybe provide a simple order entry function just good enough to support those first two items.

Today’s so-called “clinical” systems mostly sit atop that antique and unsuitable foundation, outdated not because of old programming languages and hardware platforms, but because their original design mindset is now hopelessly obsolete. Clinical applications are really just green-screen type data entry forms that happen to accept clinical information. It’s the mainframe mentality at its worst – the all-knowing system that requires regular data feedings from subservient users who, despite their occupational disposition, are relegated to being keypunchers.

Eventually, some company will actually design a new inpatient clinical system from the ground up. We can fervently hope that when they do, they’ll start with a blank slate and not simply port outdated, monolithic thinking to a newer technology platform. With that innovation, though, will come the crossing of a huge chasm: that no-man’s land between “information systems” and FDA-approved medical devices.

Clinicians gripe that systems are user-unfriendly, do little to help them perform their jobs, and add minimal value to personal productivity or patient outcomes. They’re just accounting systems whose widgets are clinical. One reason: HIT vendors are terrified of FDA regulation. It’s easier to make sure systems are too dumb to require it than risk exposing sometimes bad software practices to government oversight.

Clinicians are overwhelmed by too much raw data whose presentation can’t be individualized, i.e. they insult bone marrow docs with low platelet warnings (if they have alerting capability at all, that is.) That picture that’s worth 1,000 words can’t be included because 1980s-era programmers didn’t see cheap multimedia and storage coming. Failure to rescue can’t be detected in crashing patients. Systems deliver data like an obedient mailroom clerk, adding equally unimpressive value. The average automobile, riding on even older design, has better data aggregation and presentation capabilities, replacing data lists with idiot lights, navigation capability, and easy-to-comprehend gauges.

It’s like Lucy working on that candy assembly line – reams of often irrelevant information are unceremoniously dumped faster and faster into the laps of physicians and nurses, who are expected to manually figure out what’s useful and then “process” it, often by entering even more on-screen information. Eventually, the administrivia buries someone who ought to be making patient care decisions instead of romancing a keyboard.

IT vendors have good reason to fear the FDA, which won’t be happy to hear about buggy code, poor testing practices, slow updates for known defects that have clinical implications, and head-scratching user interfaces that merited no more than an afterthought. Maybe that level of scrutiny would slow development and increase costs, but accepting possibly dangerous software as long as it’s fast to develop and cheap (both debatable) doesn’t seem like much of a bargain.

A smart clinical systems vendor would include FDA approval into their long-term plans and build killer applications around it, thereby scooping their competition by years. Redesign the first-generation systems, step boldly into the FDA-regulated space before the device vendors instead invade the IT space, and build systems that improve patient care, not just turn paper forms into on-screen forms.

Today’s software was designed around old constraints and its design shows it. Someone should get clinicians together (no programmers allowed) to design the systems of tomorrow, software whose effect on patient care is less interruptive and more assistive. Doing that right will require FDA approval. For that reason, the industry should welcome it.

Time Capsule: Sounds Like Somebody’s Industry Has a Case of the Mondays

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in December 2006.

Sounds Like Somebody’s Industry Has a Case of the Mondays
By Mr. HIStalk

Is it just me, or is the industry in the doldrums? The news is boring, optimism is in short supply, and both provider and vendor people seem to be uncharacteristically cranky and burned out.

What happened? Just a few months ago, we were on what looked like an unstoppable, exhilarating ride. Everybody was talking about healthcare IT and momentum seemed to be building toward something cool. Now we’re just trudging joylessly along.

Maybe everybody is just hunkering down to get the jobs done that were promised back then, moving us into the less-sexy execution phase from all the high-profile jabbering. That’s good, at least for awhile.

No, I think I’ll blame RHIOs for the industry’s malaise. Like a furnace in winter, it takes a lot of energy to keep that RHIO hot air flowing. Even though most of us don’t have anything to do with RHIOs, it seems like our collective focus has swarmed around them like mosquitoes to a bug zapper.

Or maybe it’s ambulatory EMRs. It is apparently the 11th commandment that ambulatory EMRs are to be “hot” and “inevitable,” except for the vast majority of physicians who still refuse to use them. Once again, we ground troops who are locked in long, desperate inpatient CPOE and clinical systems wars that were started before this latest round of new ideas were conceived have been forgotten, but we’re still holding our own deep behind enemy lines.

Speaking of which, maybe the big hospital applications vendors are bringing us down. Nobody seems to be innovating anything. Everybody claims big R&D spending, but the products are starting to all look alike, kind of a no-nonsense 1980s Soviet Union version of software by committee. Or it could be their customers, blaming everyone except themselves for poor ROI. Nobody’s shaking anybody up.

Maybe it’s the government. Brailer’s gone and no one wants his job, Hillary’s threatening to run for President, and the politicians who promised big IT spending took their (our) money elsewhere.

Company mergers and acquisitions … that’s the problem! Instead of highly strategic, widely cheered absorptions of great little companies by bigger and better ones that energize employees and shareholders, it’s mostly one boring and struggling company being acquired by another, with misplaced expectations of synergy.

Maybe it’s poor management or lack of real strategic planning that’s forcing a “work harder and like it” mindset, just as a new generation of workers makes it clear they won’t be motivated by fear or the desire to help a few company insiders line their pockets.

Whatever it is, I’d like to see it fixed. Not enough people are having fun in healthcare IT. They’re taking themselves too seriously, stifling their own creativity and everyone else’s, and breeding a risk-averse culture that’s exactly what we don’t need just as the world realizes we’re 20 years behind. We’ve got a bunch of self-important stiffs in suits and no one wearing lampshades on their heads, more like General Motors than Google.

If you’re a person or a company with fresh ideas, a sense of humor, endless creativity and resourcefulness, and a passion for patient care, we need you desperately. Bring on your innovation, new ways of looking at old problems, and a passion for doing something other than propping up the company’s stock price.

Like the line from the movie Office Space, I think somebody’s having a case of the Mondays. Lately in healthcare IT, it’s been lasting seven days a week. Still, as it always does, this too will pass.

Time Capsule: HBOC 1, Everybody Else 0

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in November 2006.

HBOC 1, Everybody Else 0
By Mr. HIStalk

I didn’t even know Charlie McCall was on trial. The former HBOC chairman was acquitted of a securities fraud charge last week and got a mistrial on six more counts as a lone juror’s holdout deadlocked the jury. I feel deprived that I missed a blow-by-blow report of his being grilled and then left to await his fate. All these years of waiting: “Wonder when they’ll get Charlie?”

In case you’re a newbie, HBO & Company was the pre-Enron corporate malfeasance poster child, a prodromal symptom of dot-coms in waiting that used its optimistically valued stock to buy everything in its path. The frenzied transacting caught the attention of drug wholesaler McKesson like the mating dance of a spider, which paid a mind-boggling $14 billion for the company in January 1999.

Industry long-timers chuckling knowingly, having watched similar companies take it in the shorts for the same expensive, ill-advised, and dispassionate dabbling in healthcare IT. Investors scratched their heads after running their calculators and finding no possible way that HBOC was worth that kind of money. The general consensus of all interested parties: what the hell was McKesson thinking?

Three months later, McKesson’s stock tanked on charges of book-cooking by Charlie’s crowd. Shareholders lost $9 billion of wealth in a single day, thereby unwillingly participating in the ultimate assessment of HBOC’s value.

McKesson’s executives were perhaps the only people on the planet who weren’t suspicious about the Atlanta high-flyers. Everyone was swapping insider horror stories. I sent two anecdotes to a healthcare IT publication in 1998 (who missed out on the scoop of the century by ignoring them.) First: I’d heard from an HBOC employee that he was ordered to mail out empty tape boxes to customers for not-ready enhancements so revenue could be recognized anyway. Second: HBOC programmers, all of whom in some areas had revenue targets, griped about booking their estimates long before any work was done. Recognizing revenue on the basis of a shipping receipt? Oh, my.

You know how it ended. HBOC’s brass were indicted, McKesson’s were fired. Charlie went off sailing (so the story goes.) The reeling McKesson lost employees, came up with strange ideas like co-CEOs, jumped on the dot-com era right as it imploded (taking with it hastily conceived names like i-this and e-that), and retired the stench-ridden Pathways name.

Cipher in the nearly $1 billion they eventually paid to settle shareholder lawsuits and the grand total for those few weeks of financial fornication is $10 billion. What they got for their trouble was a mongrel pack of products HBOC had hastily snapped up for financial growth without any real plan except to keep the printing presses busy running off stock certificates.

Among those involved were certainly some crooks and some fools, but let’s not forget those who suffered most, those McKesson lifers who had stashed away years’ worth of shares of their unexciting company’s stock instead of risking their future on flaky fads like Microsoft and Dell. When lonely old conservative widower Dad McKesson brought home a sexy young step-mom named HBOC, she stole the kids’ piggybank.

The stock went from the mid-80s to the mid-teens. People I knew glumly tried to estimate how many more years they’d have to work until retirement with 80% of their investment gone. Even today, after eight years and with good company management, McKesson’s stock has recovered by only about half.

Only the jury can decide whether Charlie McCall and his associates are guilty or innocent, but I can say one thing: if they are found guilty, then I hope the pain they receive is commensurate with the pain they caused.