HIStalk Interviews Pat Cline, CEO, Lightbeam Health Solutions

Pat Cline is CEO of Lightbeam Health Solutions of Irving, TX.

Tell me about yourself and the company.

I’m a 53-year-old cross between father, husband, entrepreneur, healthcare IT investor, and company operator. I started in healthcare IT about 34 years ago.

Most of my career has been with NextGen Healthcare. I retired from that company in 2011. I found that I was terrible at retirement. I came out of retirement a few months later and started to put together the concept of Lightbeam.

Lightbeam Health essentially is a population health management platform that aggregates data from many different sources and normalizes that data, represents it properly, mines that data for gaps in care, and does risk stratification. Then puts those gaps in care back to providers at the point of care, where we can affect change.

How big is the company?

Relatively small. It’s a software is a service model, so building revenue is slow in the early stages. From a revenue standpoint, we should be about five million run rate by the end of this year. From an employee perspective, I think we’re about 22 or 23 employees.

It seems like everybody’s next big thing after EHRs was electronic data warehouse and analytics. A lot of those companies are going to fail. What do you think will distinguish the winners from the losers?

Great question, and I think you’re right. One of the things, I believe, is experience. The team at Lightbeam has very broad and very deep experience in end-to-end data management based on our background in ambulatory health records.

When I talk about aggregating data, normalizing it, representing it properly, and de-duping it, there’s a lot of heavy lifting involved. That’s an area where we see some of our competitors faltering.

Many of our competitors are doing similar things, but with claims-based data, and as you know that data tends to be eight or 10 weeks old. This company can not only use claim data feeds and drug claims and those kinds of things, but also can get at the real-time or near-time electronic health record data.

Another uniqueness is, as I mentioned, our software as a service or our subscription model. It makes the cost of entry very, very low. Based on all of the costs that have imposed on medical providers and health systems recently with the move to ICD-10 and the costs involved with achieving Meaningful Use, most of them seem to find a subscription model without an upfront fee more palatable.

How does the integration with EHRs work technically?

I’m not a technologist any more. They threw me out of that profession in the 1980s. But the experience that too much of our team went through or gained during our years in electronic health records for provider organizations includes integrating and interfacing with many, many different systems, all of the prevalent systems both in hospitals and on the ambulatory side, and participating as we did at NextGen with many of the different early pilots and actually developing an HIE and those kinds of things. 

We’ve got a team that’s experienced in doing that. Beyond that, if I start talking the actual technology, I’ll get in over my head pretty quickly.

Are your provider customers expecting a lot of hand-holding or do they know what data that they want and what they’re going to do with it?

There’s always a certain amount of hand-holding, but generally as providers move more toward shared savings programs — whether that’s participating in or forming an ACO or commercial-shared saving or move more toward risk-based or value-based reimbursement — they tend to want some of the standardized guidelines and managers. They want data mined for gaps against some of these standard measures, like HEDIS measures and ACO measures and those kinds of things.

At least for the interim, providers are going to have mixed panels where they’ll have some patients that will be under some new payment model and then others that are traditional fee-for-service. Will they ask for data to treat those patients differently?

So far, we’re not seeing that. So far, practices seem to want to include all of their patients in population health management.

If you believe that proactively managing patients is a good thing, then you want to spread that across your entire population. The difference is, as you pointed out, many of them are fee-for-service and therefore the providers aren’t paid for the proactive management as much as they are more reactive point of care or fee-for-quantity or fee-for-service business. But by and large, we’re seeing that providers want to manage care for all of their patients the same way.

What’s your assessment of the ambulatory EHR market, looking back on your time with Quality Systems and NextGen?

The market is maturing. While it’s not saturated, it’s reaching that point.

Over the next few years, there will be a tremendous replacement market, where providers that perhaps moved too quickly or made mistakes purchasing systems that didn’t quite meet their needs circle back and replace systems. That will also lead to a robust services market over the next few years.

It seems to me that it’s also increasingly difficult for the smaller companies in electronic health records to keep up with all of the government-mandated changes as well as market pressures. In the near term, we’ll continue to have a robust market even if it’s largely replacement oriented, and then in the long term, a lot of those companies will be adding features like the ones that Lightbeam Health provides.

HITECH created a big market. Was it a good thing?

Yes. The stimulus was needed.  We would otherwise be at far less than 50 percent saturation. Once EHRs are installed and we move from that era of physician adoption — getting physicians to use the systems and enter data — to an era of doing something intelligent and actionable, it can move the needle relative to clinical outcomes and therefore costs.

As a business coach, mentor, and investor, what advice would you have for healthcare IT newcomers and startups?

You’re probably looking for a different answer than this, but as a coach and mentor at this stage of my career, I would tell you that I see a lot of healthcare IT people that work awfully hard. It doesn’t seem like there’s ever an end to the work to be done. I would tell those people to slow down a little bit and spend a little more time with their families and smell the roses along the way.

Along those lines, I’m fascinated that you’re a sommelier. If you were spending $30 in a red wine, what would you choose?

I would probably spend it on one of the mass-produced California or Oregon cabernets.

Getting back on track, what trends or factors will be important in the next handful of years?

The next few years will continue to be very exciting. The folks that predict that market saturation will cause a drop-off and things will level out I believe are wrong. As providers move from fee-for-service or fee-for-quantity to value-based reimbursement, it will be a very interesting time, both for the existing vendors and for new vendors like Lightbeam.

Specifically, I think we’re moving to a new era of interoperability. While interoperability and system connectivity have been talked about for a long, long time, there are strides being made and strides in standardization as well. That will bode well for the whole system and will improve quality and outcomes and will lower cost. I’m looking forward to the day when data mining might even lead to cures, which will also be extremely exciting.

Do you have any concluding thoughts?

First, I want to thank you for the opportunity and for the exposure. Young companies like Lightbeam can use it and we really appreciate it. Secondly, I’d say that Lightbeam Health has a number of unique advantages relative to population health and helping physicians move to value-based reimbursements to invite those in the market to speak with us.

Morning Headlines 5/21/14

CMS rule to help providers make use of Certified EHR Technology

CMS and ONC publish a proposed rule that would extend MU stage 2 through 2016, explaining "By extending Stage 2, we are being receptive to stakeholder feedback to ensure providers can continue to meet meaningful use and keep momentum moving forward.”

Commonwealth Fund EHR Survey

A Commonwealth Fund survey finds that federally qualified health centers have increased adoption of EHRs by 133 percent since 2009, with nearly all centers now using EHRs and 76 percent qualifying for MU Stage 1 incentive payments.

Review recommends new name, direction for PCEHR

In Australia, a review of the floundering nationalized personal health record program concludes with a handful of recommendations aimed at bringing the project on track, including: changing the name from personally controlled electronic health record to My Health Record, pivoting from an opt-in enrollment process to an opt-out process, a redesign of the PHR layout that would make it more usable for clinicians, and the dismantling of the organization responsible for rolling out the PCEHR program and replacing it with a new organization comprised of clinicians, vendors, and bureaucrats.

News 5/21/14

Top News

CMS and ONC publish a proposed rule that would slow down the Meaningful Use program by extending Stage 2 through 2016 (starting Stage 3 in 2017) and allowing providers to attest for FY2014 using a 2011-certified EHR. National Coordinator Karen DeSalvo, MD seemed to express concern that EHR vendors would not have their products certified under the 2014 criteria in time, referring to users would would miss the dates “through no fault of their own,” while the bill referred to “availability and timing of product installation, deployment of new processes and workflows, and employee training.” Public comment on the proposed bill will be open for 60 days. The proposed change follows CMS’s acknowledgment that almost no providers have attested for Stage 2 so far. CMS had also previously defined a easily claimed, one-year hardship exception for providers unable to meet Meaningful Use dates.

Reader Comments

From Hogan: “Re: Centura. Their selection of Epic hurts Meditech since they are a large percentage of Meditech’s Stage 7 hospitals. In England, InterSystems was named vendor of choice against Epic and Meditech in a three-trust procurement called SmartCare. Epic won the clinical vote, but lost on price. It’s interesting that outside the US, Epic and InterSystems compete.”

From Topaz: “Re: health equipment innovators. I live in the Netherlands and a colleague is looking for help for his 16-year-old daughter Doreen, who is paralyzed. It is hard to get equipment in Dutch healthcare. Are companies in America looking for people to test their developments?” I created an online contact form for anyone who wants to get in touch.

From Arborio MD: “Re: Health Datapalooza. I am so happy that Mr. H decided to go this year so we can all enjoy vicariously the platitudes from Vinod Khosla, who believes that 80 percent of doctors can be replaced by technology, and 20-cups-a-day coffee drinkers who in their garages and basements hope to disrupt healthcare and become millionaires overnight in the process. The sad part is that even respectable HIT leaders like Ed Park recognize the big schism between the promise of Big Data in healthcare and the reality. Last year athenahealth sent 40 people, while AMA – whose president, Dr. Ardis Dee Hoven, has not even heard of this conference — sent only one. I wonder how many docs toiling down in the trenches are even aware that a bunch of geeks are about to eat their lunch?”

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor Healthcare Data Solutions. The healthcare-only Irvine, CA-based company offers databases of providers (physicians, dentists, PAs, NPs, pharmacies, hospitals, and EHR users); email lists and services;  and real-time physician verification for open payments, state license verification, and DEA/NPI validation. Customer testimonials on the company’s site vouch for its “great pricing,” “most dependable data,” and “data models [that] are a perfect fit.” EHR vendors use the company’s physician database for marketing and to determine if the provider has implemented an EHR. The company offers white papers, webinars, and database layouts on its site. Clients include MD Anderson, UC Irvine Health, Cedars-Sinai, NextGen,, and Philips. Thanks to Healthcare Data Solutions for supporting HIStalk.

Acquisitions, Funding, Business, and Stock

Excited to announce my investment in @CrowdMed! Check out the @WSJ story by @lorakolodny: http://t.co/KhJbIW8szc. @jaredheyman @patrickchung

— Patrick Dempsey (@PatrickDempsey) May 20, 2014

”Grey’s Anatomy” actor Patrick Dempsey invests an unspecified amount in startup CrowdMed, which crowdsources diagnoses using volunteer clinicians called “Medical Detectives.” PR from someone who used to play a doctor on TV may not be all that appealing to the real experts whose free labor fuels the business model.

Cleveland Clinic forms a joint venture with telemedicine kiosk vendor HealthSpot and will integrate its product with the clinic’s Epic system.  

Sales

Vanderbilt University Medical Center chooses Allscripts EPSi for financial planning.

American Samoa Medical Center will implement Medsphere’s OpenVista EHR.

Atlantic Health System (NJ) selects TeraMedica’s Evercore Clinical Enterprise Suite for vendor-neutral archive storage of both DICOM and non-DICOM data.

Delaware Health Information Network will implement Halfpenny Technologies’ intelligent integration technology hub.

Advocate Health Care chooses identity and access management systems from Courion.

Avita Health System (OH) will implement NextGen Healthcare’s EHR, practice management, patient portal, population health EHR Connect, and ED solutions at its two hospitals.

People

Karen Chapman (Northrop Grumman) joins Medicomp Systems as senior product manager.

Phoenix Health Systems names Jim Griffith (Siemens Medical Solutions Health Services Division) as EVP/COO.

Vocera announces that CFO William Zerella will resign on June 6 to become CFO of an unnamed pre-IPO consumer wearables company. Vocera also announced that Bob Zollars has transitioned from executive chairman to chairman of the board.  

Terry Cameron (Emdeon) joins Recondo Technology as president and COO.

Announcements and Implementations

Beacon Partners will implement and offer advisory services to providers deploying Caradigm’s Risk Management and Care Management population health management products.

Philips releases eCareManager 4.0 that includes acute care, part of its Hospital to Home telehealth program.

MyMedicalRecords adds three more patents to sue EHR vendors over: EHRs in clinical trials, online sharing of medical records, and legal records including power of attorney and wills. As you might expect, the announcement promises litigation rather than innovation: “MMR’s goal is to leverage its products and services and patents and other intellectual property to create working relationships with more companies in the biotechnology field so that patients and shareholders ultimately benefit.”

Pharmacy systems vendor PioneerRX will replace its existing drug database with Elsevier’s Gold Standard Drug Database.

Greater Regional Medical Center (IA) goes live on PeriGen’s PeriCALM.

Government and Politics

The VA opens an investigation of the Gainesville, FL VA hospital after discovering that employees were keeping follow-up appointment schedules on paper instead of on the electronic system that made results visible to VA management.

House Oversight Chairman Rep. Darrell Issa (R-CA) chews out the CMS official in charge of fraud prevention for falling several months behind on delivering a report that will document the effectiveness of CMS’s fraud prevention software.

Other

The CEO of Massena Memorial Hospital (NY) blames Meditech’s LSS software, which he says “created some kind of strange numbers off the report,” for incorrect financial reports. He adds, “We’ve been experiencing over the last couple of months some significant issues with our LSS software system that was recently installed in a number of our physician offices.” 

The AMA’s American Medical News shuts down after 55 years due to a 67 percent drop in annual revenue caused by declining circulation and ad revenue. The publication transitioned poorly to an online format and was hit hard by declining drug company advertising.

In Australia, a review panel suggests that the personally controlled health record (PCEHR) be renamed to My Health Record, that participation be changed from opt-in to opt-out to increase enrollment from the current single-digit percentages, that physician usability be improved, and that doctors be paid incentives tied to meaningful use metrics and their contribution of patient data to the common record. The panel also recommends that the National eHealth Transition Authority be dissolved and its oversight role transferred to a group called Australian Commission for Electronic Health that would include clinicians and software vendors.

The City of New York temporarily halts its 911 communications project, which was supposed to take five years and cost $1.3 billion, now at the 10-year mark with estimated costs at over $2 billion.

A Commonwealth Fund survey finds that EHR adoption by federally qualified centers more than doubled from 2009 to 2013, with 93 percent of them running an EHR and 75 percent meeting MU requirements. Most of them do CPOE, clinical documentation, and lab results, but only about half say their providers have access to clinical decision support beyond canned drug warnings. The FQHCs say their biggest EHR-related problems are undertrained staff and loss of productivity.

A former nurse at Houston Methodist Hospital (TX) files suit against the hospital and hopes to turn it into a class action, claiming that the hospital’s time tracking system deducts 30 minutes for lunch even when the employee’s duties preclude stepping away.

In England, the CEO of a hospital is criticized for describing hospital patient care errors in her tweets. She has only 200 followers and uses her account mostly to praise employees and promote hospital events, but had some such as, “Signed patient letter enclosing incident investigation report following medication error openness+learning essential feedback= improvement.”

A care coordination “virtual health village” and single, real-time electronic health record for students of two Pennsylvania school districts has enrolled only 4,000 of 32,000 students, a quarter of the expected number. Health officials planned to make enrollment opt-out until attorneys from the school districts told them that HIPAA requires opt-in, meaning students have to request access. The schools used $850,000 in grant money to hire an outside vendor to create the exchange and connect it to the EHRs of local hospitals.

Weird News Andy calls this story “Wide-Eyed Wonder.” Texas doctors are working on an app that detects “white eye,” the opposite of the red-eye reflection effect that is normal when someone takes a flash picture. A white reflection is abnormal and indicate the possible presence of several eye problems, including a rare eye tumor.

Sponsor Updates

• InstaMed releases its “2013 Trends in Healthcare Payments Annual Report” as a video.
• CompuGroup Medical’s three EHRs earn ONC 2014 certification as Complete Ambulatory EHRs.
• McKesson Total Payment achieves a CMMI Level 3 appraisal rating.
• Arcadia Healthcare Solutions offers a white paper on pay-for-performance strategies.
• Extension Healthcare is participating in an elite platinum sponsor two-year initiative of the National Coalition for Alarm Management Safety.
• MissionPoint Health Partners (TN) and Hospital Corporation of America’s South Atlantic Division (SC/GA/FL) are awarded the 2014 Crimson Physician Partnership Award during The Advisory Board Company’s national Crimson summit in Orlando.
• EBSCO Health’s Patient Education Reference receives certification as an EHR Module for inpatient and ambulatory settings.
• Ingenious Med is named a Pacesetter by The Atlanta Business Chronicle.
• Sagacious Consultants launches Sagacious Go-Live Success for hospitals and clinics at the go-live juncture with Epic.
• Covisint launches its Certified Service Partner Program.
• NantHealth SVP and iSirona founder Dave Dyell is named a finalist for Ernst & Young Entrepreneur of the Year award.
• RazorInsights will incorporate TruCode’s Encoder Essentials into its ONE Enterprise HIS solution offering an integrated encoding solution with its HIS.
• Walnut Hill Medical Center (TX) opens its doors with 75 Voalte smartphones following its iHospital initiative.
• Valence Health launches Valence Partner Network to offer complementary solutions to its client base.

Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

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Morning Headlines 5/20/14

VA Faces Systemwide Problems With Patient Scheduling

In a Senate Veterans Affairs Committee hearing today, VA Secretary Eric Shinseki said that he is "mad as hell" that new instances of waitlist gaming tactics had been reported from around the country, and that he was ordering a system wide investigation in response. Since the news that the Phoenix VA Medical Center had been maintaining an off-the-record waitlist, similar stories have been reported from whistleblowers in Colorado, Florida, Texas and Wyoming. President Obama has assigned White House deputy chief of staff Rob Nabors to work alongside Shinseki to investigate the allegations.

Pilot at Boston’s Beth Israel Deaconess gives patients electronic access to therapists’ notes

Beth Israel Deaconess Medical Center is expanding its Open Notes program by providing patients online access to their therapists notes, a decision that has spawned extensive internal debate at BIDMC.

MyMedicalRecords Receives Three Major Health IT Patents Expanding PHR Portfolio to Add Clinical Trials & Legal Records

MMRGlobal is on its way to securing three new health IT related US patents, including: one that describes functionality that allows patients to use a PHR to self report clinical trial data, one that describes patients sharing PHR data with secondary care providers, and one that describes expanding what is stored in a PHR to include wills, powers of attorney, and other portions of the legal record.

Surgeon Cuts Vendors Out Of EHR Quest

Dr. Lloyd Hey of Hey Clinic for Scoliosis and Spine Surgery (NC) hires a full-time programmer to build a custom EHR after concluding that the systems available today were designed for primary care physicians rather than surgeons, and that none deliver the benefits he believes EHRs should generating.

Curbside Consult with Dr. Jayne 5/19/14

Outside of healthcare, very few people understand what a CMIO does. Usually when I meet new people I explain that I’m a doctor, but I work in the information technology world. If I get a totally blank stare, I might go on to say I work on the electronic records systems that hospitals and physician offices use.

Some will ask why I’d want to give up the money and excitement of being a physician. I suspect they don’t have any idea of what being a primary care physician actually looks like. Occasionally someone will ask me if I can help them with some home networking problem, which I find pretty funny that people assume that everyone “in IT” knows how to do desktop and network support.

Inside the hospital, I’m not sure that many physicians actually understand what we do either. They know we’re the people to call when they have complaints and that we’re usually the figurehead telling them they have to do something for Meaningful Use or CMS audit purposes. Physicians may not understand the role we play as their advocate or the depth of the battles that we fight on their behalf.

I’m not sure our role is always fully understood by the IT teams either. Some analysts think we’re just super-nerdy physicians or that we had to leave full time practice for some reason. Others are afraid that having a physician on the team means that we’re going to try to call the shots or be the boss all the time. Frankly there are some days that I’m not even sure what I do. Teams work more effectively when they understand where the various members are coming from. In that spirit, here’s a week in the life of a CMIO.

I started Monday with a half-day of teach-back training for a couple of our new implementation team members. Our organization is a stickler for making sure that training is consistent and reproducible so that no one can complain that he or she didn’t have every opportunity to learn the material. As part of that process, I deliver train-the-trainer sessions for the team.

Some of our team members come from non-clinical backgrounds. It’s important that they understand the training scenarios and clinical pearls we incorporate for our end users. Having that knowledge helps them build credibility and trust with the end users. They’ll also shadow other members of the training team so they can see various presentation styles before it’s time for them to start deliver their own sessions independently.

Over lunch, I returned a couple of phone calls from cranky colleagues who don’t understand why we won’t customize the system for their individual needs. Although our EHR is template-rich, it lacks content for some of our subspecialty physicians. They all have access to voice recognition so they can dictate narrative as part of their notes, but some are insistent on wanting click-the-box type templates.

From experience, we can build them whatever they ask for and they still won’t like it, so our bent has been to steer them to using dictation, but creating macros and templates to make it even faster. One of them agreed to try our standard approach but the other was more skeptical, so I convinced him to shadow one of his colleagues and see how well it can work. I’m cautiously optimistic.

The afternoon was filled with a mountain of email that had built up from taking Friday off. I make it a habit to not work on the weekends unless it’s an upgrade situation or a critical outage. I hope setting that example for our team means something, but I still see entirely too much correspondence originating during the off hours. Maybe it’s time for another work-life balance discussion with a couple of them.

Tuesday began early with the hospital credentialing committee, which is always somewhat of a snoozer. I appreciate the need to have medical staff committees, but they can be pretty dry. In a world where I preach the gospel of working to the top of the license, it’s hard to justify having 10 physicians sit in a room and make decisions that would be quite amenable to the committee equivalent of a refill algorithm or a standing order.

After that, I had a meeting with one of our physicians who is interested in our open associate medical director of informatics positions. He’s qualified, but reluctant to give up any of his current duties to make it a reality. Somehow he thinks he can just fit it in, and that’s not going to be the case. I keep trying to explain that we’re not going to put someone in a position where they’re destined to fail, but he isn’t getting the message. I’d really like to add him to the team, but you can’t just squeeze 16 hours a week of informatics work in between patient appointments.

I met in the afternoon with our project team to run through the presentation we’d be doing for our bi-monthly steering committee meeting on Wednesday. The budget numbers looked a little funny, so we had to dig into the reports and the time-tracking system, which is never fun. It turned out to be some operating expenditures that should have been capitalized, but it took forever to find the discrepancy.

In between meetings, there is a steady stream of email, requests to visit practices, and occasionally help desk tickets that providers want escalated directly to “a real doctor who will understand.” Most of the time those end up being user error or training issues, but they take a lot of time to explain, reassure, and arrange for retraining when needed.

Wednesday can only be described as Meet-a-Palooza. We started with the steering committee. One of our hospital VPs must be reading some kind of leadership book because he was all over asking hard questions just for the sake of asking hard questions. Although no one of them stumped us, it drives me crazy when people use meetings to try to make a name for themselves. Following that was our regular project leadership team meeting, followed by an implementation team meeting, which I usually sit in on so I can stay on top of any practices that are having difficulty with EHR.

I hid in my office with the door closed during lunch because one of our junior analysts has decided he wants to go to medical school and is driving me crazy. I think he’s watched too many episodes of “Grey’s Anatomy” and his expectations are completely unrealistic, but he’s persistent. Unfortunately he didn’t like biology or chemistry in school, and although he has a masters in health information management, his undergraduate major was political science. He’s not willing to concede that he’ll have to go back and take all the science 101 classes, so until he does, I’m avoiding him.

The afternoon’s scintillating meetings included: monthly clinical quality measures review; MU status review; new provider on-boarding; and a red-hot discussion of whether or not we should pay our providers to attend training (we don’t, but they always ask us to).

Thursday is my work from home day, which is the only day I can get anything done. I had a couple of presentations to prep – one on change leadership that I’m submitting to present at a conference, the other for a local residency program on the business of healthcare. I was able to get them mostly done, but I like to let them rest for a week or so then revise, so I’ll be back at them again. In the afternoon I worked on performance reviews. Although I don’t have any direct reports, our organization believes in a 360-degree evaluation, so I end up doing reviews of most of the implementation team and support analysts. I can only do a couple at a time before my brain shuts off, so I punctuated them with some gardening, which was pretty therapeutic.

Friday I met with our testing coordinator to review the test plan for a new specialty we’re bringing up. She’s going on maternity leave soon and I suspect she won’t be coming back, so we’ve been spending time making sure we document the process we use to evaluate new content, build scripts, and ultimately test new content. Although that will make on-boarding her replacement easier, I hate to see her go. We’ve had too much turnover in that position and I’d like to find someone who will stay for the duration.

Next it was on to our monthly ICD-10 update for senior leadership. The delay has taken the wind out of our sails. I wish someone would just cancel the meeting for a couple of months and then we can pick it up full steam, but instead it languishes on the calendar and doesn’t have a real purpose. It’s not my meeting, though, so all I can do is suggest a different path, and when we run out of agenda items, be the one to recommend we adjourn early.

Friday afternoon I came full circle with the implementation team, this time being the student instead of the teacher. I have to say I was impressed with how quickly they were able to pick up the material and how well they did. We cleared them both to go out into the field and work with seasoned trainers. They’ll initially just shadow and assist with the hands-on portions, but over the next month they’ll start teaching parts of the new employee sessions until they’re eventually teaching the entire course with another trainer as backup. By mid-June they’ll be out of the nest and on their own.

I always end Friday by looking over my calendar for the next two weeks. It gives me an idea what I need to focus on for the coming week and lets me see any conflicts or major issues in the one that follows. Sometimes our administrative assistants get a little cavalier with our schedules, so if we want to be able to breathe or eat during the day, it pays to be proactive. I realize they’re trying to squeeze every minute out of the day and respect what they do, but ultimately I’m the one who looks bad when I’m absent or late due to an overcommitted schedule.

Some weeks are different, but many are the same but with just different meetings and different cranky colleagues. When we’re close to a major upgrade, it looks completely different, with much more focus on the new version but with all the same standing meetings continuing. It can be quite the juggling act at times. Nevertheless, I enjoy doing what I do. But sometimes it’s just easier to be “the doctor who works in IT.”

Email Dr. Jayne.

HIStalk Interviews John Gobron, CEO, Aventura

John Gobron is president and CEO of Aventura of Denver, CO.

Tell me about yourself and the company.

We were founded at Denver Health. We were built to fix and improve a problem called clinical work flow. In the Denver Health case, especially with respect to roaming desktops. In the process, we came up with some pretty neat ways to solve security problems and came up with some mobile innovations as well.

I’ve been in healthcare IT for 20 years. I helped build a company called Sentillion. I spent time with Microsoft’s Health Solutions Group in the UK and ran the healthcare vertical for Symantec.

What are the big issues in trying to balance clinician convenience, access to systems, IT security, and device standardization and setup?

The big challenges often come down to workflow. Ultimately, we’re trying to facilitate a system that improves patient care and does it largely in a digitized way.

If you go back 20 or more years, everything was paper. The physician-patient relationship was based on intimate eye-to-eye contact. The doctor wrote stuff down and still maintained eye contact, but that wasn’t perfect. 

We’ve tried to introduce computers, with a lot of success in some areas and less so in others. Innovations like CPOE tried to help with the mistakes that were being made largely through human error, like handwriting and things like that. But the problem is that computers tend to interrupt workflow, especially when it comes to a physician or a nurse treating a patient. 

We get in the middle and make the interactions faster and more intuitive. For all the great work computers do, they are fundamentally dumb instruments. They don’t know what to do until you tell them what to do. We provide what we call awareness to the computing experience. We try to know what the user wants to do and tell the computer that before the user actually interacts with the computer itself.

Who are your competitors?

We’re doing new stuff. We don’t have any directly line-of-sight competitors, but we have a lot of what I will call peripheral competitors.

The most notable is probably Imprivata on the single sign-on front. We’re often compared to the traditional space of access and identity management and you have Caradigm in there and Imprivata as well. Two big ones. On the virtualization side, we’re largely complementary to our partners like Citrix and VMware.

In the sense of awareness, we really don’t have anyone. We can provide user awareness and that’s largely thought of as a single sign-on. but we’re also providing location awareness, device awareness, patient awareness and a combination of those. There’s really not anyone in our direct line of sight.

What can you do with that information?

We create effectively an immediate and customized user experience for the doctor and nurse. Capture their badge or otherwise identify themselves to a machine. Because of who they are, where they are, and what they want to do, we custom-mold that desktop to say, the user might need this set of applications. They might need to be in this area of this application. We deliver it in generally four to six seconds.

You can do this with any major system, such as Epic, Cerner, and Meditech?

Yes. We’re 100 percent application agnostic. We’re really managing the desktop itself and then the applications on the desktop. We haven’t had an application we couldn’t interface with or a workflow we couldn’t solve. We’re pretty agnostic when it comes to what applications a doctor and a nurse might be using.

The earlier challenge was to get clinicians to use systems since that use was not mandatory. Now it’s mandatory in most cases, so instead they complain about the overhead required. Is that better or worse for the company?

That’s a very interesting way of saying it. It’s very accurate. In my life with Sentillion, we were largely dealing with a voluntary user population. The nurses today and yesterday were largely employed by the hospital and had to do what the hospital told them to do. Doctors weren’t employed.

Today, there’s still a mismatch and there’s acquisitions going on. But from a hospital perspective and even an outpatient perspective, they’re needing to use the EHR or risk not getting money or getting fined. It doesn’t fundamentally change the need to make it better because it’s not optimal.

But the way we go about it is different in that the days of, “We can save you some time, that’s great, let’s buy this system” are mostly in the past. The world in front of us, the world we live in now, is “show me the hard ROI.” If I’m going to buy something like your solution or anything like it, show me how you reduce my actual spending or increase my actual revenue into the hospital.

It must be tough with EMR optimization and mandatory regulatory work to convince people to look at your system in addition to everything else.

It is. Probably every vendor reading HIStalk probably has a similar perspective on this. We look at what’s important to the hospital we’re talking to, overlaid with whatever will bring the most amount of value. Then we have a good match, and if we don’t, we come back and talk to them at a later date.

Hospitals are interested in anything that can help them with Meaningful Use, integration acquisitions, or connecting with physician practices. Does Aventura’s product look more attractive with those issues?

Absolutely. That’s where we stand out. 

I mentioned awareness. A lot of the core measures go way beyond just getting into the application. That’s good, but that’s commoditized technology. The next generation is not just getting me to an app, but getting in the right place of that app, eliminating a lot of the clicks and menu choices and navigation that get me where I need to be in order to hit my Meaningful Use number, in order to hit my 60 percent CPOE or my core measures or things like that.

That’s where we’re looking to innovate and have been innovating, with respect to putting information up. We can help navigate to a patient record. We can put some information there that may assist with helping the hospital achieve their Meaningful Use numbers in particular.

When you think about acquisitions, you largely think about the drive in healthcare across America right now to move care outside of the four walls of the traditional hospital and out to an outpatient setting, or even ideally out to the home. That’s the ultimate mobility. Historically we saw mobility as a doctor and nurse going from room to room to room rounding or providing care or surgery. That happens in the inpatient workflow. But the outpatient workflow is where we as a health system or as an ecosystem are going to see some of the bigger financial savings and impact and obviously outcomes as well. People heal better faster and less expensively in their homes, in places of greater comfort. 

As healthcare looks to do that, people will still need to use the computer systems. They’re just going to be more mobile. That’s a really good place for us to innovate with the ability to go back and forth between desktops and mobile devices, whatever they may be. Still bringing access to the information, but doing it anywhere they want to be.

You’ve worked outside of the US and for big companies outside of healthcare. What is the most striking thing about healthcare right now?

I had a wonderful experience in the UK. I had moved there in 2008 to lead Sentillion’s European expansion. It was a privilege to learn about how healthcare is delivered in different parts of the world.

The striking similarity is that workflow, is workflow, is workflow no matter where you are. Clinicians in Birmingham, England see patients and use computers largely the same way as doctors and nurses in Birmingham, Alabama do. In socialized medicine countries, these systems are obviously less concerned with transactional billing, but the core focus of improving patient care is still the same, as are the core struggles of improving this workflow

Where do you see the company going in the next three to five years?

The excitement that I have, and that is shared by Aventura and our customers, is that we’re really onto something with respect to a platform called awareness. We can be aware of a user, their location, their device, and the patient they’re in front of.

But my favorite question when I wrap up meetings is, what else should we be aware of? What else could we be aware of to help you? Those discussions are fun to have and they help drive our innovation in the company.

At a high level, where we will be going is an expansion of our awareness platform, to be able to do more things to drive efficiency, security, all those good benefits into the clinical workflow.

Do you have any final thoughts?

I just wanted to say thanks for HIStalk. I’m a huge fan and I really appreciate the work that you do. It’s not only informative for people like myself, it’s fun to read. I helps foster a nice sense of  camaraderie in our industry and I’d just like to say thanks for that.

Morning Headlines 5/19/14

Veterans Affairs Chief Accepts Resignation Of Robert Petzel, Under Secretary For Health

Robert Petzel, the top VA official for health care, resigns after it was discovered that the Phoenix VA Medical Center had been falsifying appointment wait lists to appear compliant with the VA’s standards. Petzel was already scheduled to retire in just a few months, so the resignation is more political than a meaningful effort to remove a problematic leader.

Health Care Leaders Gather to Address Challenges, Opportunities of Open Health Data at Health Datapalooza 2014

Health Datapalooza unveils a packed speaker lineup for its June 1-3 conference: US CTO Todd Park, HHS Secretary Kathleen Sebelius, AHIP CEO Karen Ignagni, author and surgeon Atul Gawande, athenahealth CEO Jonathan Bush, UK Secretary of State for Health Jeremy Hunt, and Time author Steven Brill, among others.

LIJ Medical Center Introduces One-of-a-Kind Video Monitoring Project to Enhance Patient Safety in ORs

Long Island Jewish Medical Center (NY) has installed a new real-time auditing system in its operating rooms that use video cameras to monitor the procedure and provide real-time guidance. The system ensures that timeouts, surgical checklists, and pre and postoperative equipment inventories are all being properly conducted according to protocol. Hospital executives say that within a few weeks of implementing the system, they saw meaningful quality improvements.

IBM Reveals New Companies Developing Watson-Powered Apps

IBM unveils the first consumer apps that integrate services from its Watson supercomputer. Modernize Medicine, a dermatology EHR system, is included on the list with its new point-of-care reference app called schEMA.

Monday Morning Update 5/19/14

Top News

Robert Petzel, the VA’s undersecretary of health, resigns over allegations of falsified electronic wait time records at  the Phoenix VA hospital. The only benefit is political since Petzel had previously announced plans to retire this year. Arguably the VA and Kaiser have led the healthcare industry in innovation, quality management, and use of technology even though the VA is, like all federal agencies, a politically motivated money pit. The VA’s problem is the tsunami of returning veterans who were sent off in huge numbers to fight pointless political wars that left many of them physically and psychologically damaged, leaving the VA to pick up the healthcare pieces with minimal increases in funding. It would be interesting to see the VA’s volume and quality metrics over the past 10 years. The VA is the ultimate ACO provider that might be able to provide warnings about the hazards ahead to the ready-fire-aim pioneers charging down the path of managing populations even though their outcomes and cost effectiveness in managing individual encounters have been unimpressive.

Reader Comments

From Beth: “Re: IT productivity. I’m looking for better ways to measure and compare with other facilities. Do people use closed help desk tickets, number of network nodes, number of user accounts, adjusted patient days, or some other formula?” Leave a comment if you can help Beth. It’s always tough to benchmark IT as an entire department since hospitals configure it differently – outsource parts of it, include biomedical engineering or not, have field support in individual hospitals in the system that aren’t assigned to corporate IT, use external consultants for application support or training, etc. I’m always skeptical of benchmarking since it’s hard to find a two hospital IT shops that are mostly alike, not to mention that once metrics have been identified, everybody’s goal shifts to gaming them rather than actually improving service (see: VA patient scheduling.) It’s like school testing: the metrics are supposed to be a by-product of excellence, not the sole focus of the program where teachers teach run entire classes on how to pass standardized tests rather than comprehend reading and math. Maybe that’s a case for metric opacity vs. transparency – let an independent organization define and report the metrics as broad themes without telling anyone, including management, how they are measured. That keeps your help desk people from begging users on Friday to let them closed unresolved tickets so that Monday’s numbers don’t get them in trouble.

From The PACS Designer: “Re: Apple and biosensing. They have a patent for a pedometer that could be a biosensing device as well for an iWatch. Apple has hired biomedical engineers from Vital Connect, Masimo Corp., Sano Intelligence, and O2 MedTech.” The timing is good since the fitness tracking device craze is in full retreat, making it ripe to become just another part of your smartphone rather than a dedicated piece of hardware, much like portable music players. Few people want to pay $100 for a not terribly intelligent pedometer that needs to be recharged separately.

HIStalk Announcements and Requests

The recent buzz about athenahealth’s prospects and share price was negative to one-third of respondents. New poll to your right: should ONC require certified EHRs to offer open APIs? You can elaborate further after voting by adding comments to the poll.

Welcome to new HIStalk Platinum Sponsor Glytec. The Greenville, SC-based company is admirably focused on one big hospital problem: improving insulin management and glycemic control. Around 40 percent of inpatients experience hyperglycemia or hypoglycemia during their stay, which requires lot of clinician time and contributes to infection, length of stay, and mortality. Glytec’s Glucommander Suite is the only FDA-cleared glycemic management and surveillance system. It delivers physician-directed computer algorithms to both adult and pediatric patients and those on either IV or SC insulin. It offers one-click access to the patient’s chart in the EMR. GlucoSurveillance flags patients in real time who may require glycemic therapy, while GlucoMetrics Analytics monitors the success inpatient glycemic control initiatives. According to the VP of medical affairs of Sentara Healthcare, “If you aren’t using Glytec, you aren’t using the standard of care,” while University of Virginia’s consult team reported a length of stay reduction of over one full day in the first six months of using Glucommander. Thanks to Glytec for supporting HIStalk.

I found this just-published YouTube video by Sentara Healthcare describing  in a remarkably frank manner the problems it was having with glycemic control and how it uses Glytec’s eGlycemic Management system. It isn’t the usually glossy overview – the physicians in the video get into specific details, such as how they made EMR changes to drive some improvements but then “hit a wall.”

Listening: new Tori Amos.

Announcements and Implementations

Health Datapalooza announces the speaker lineup for its June 1-3 conference in Washington, DC: US CTO Todd Park, HHS Secretary Kathleen Sebelius, AHIP CEO Karen Ignagni, author and surgeon Atul Gawande, athenahealth CEO Jonathan Bush, UK Secretary of State for Health Jeremy Hunt, and Time author Steven Brill, among others. I’ll be there, so you’ll read more about it on HIStalk. I don’t attend many conferences and in fact I don’t even hear about most of them (the appetite for HIT-related conferences is apparently ferocious given the number of people who seem to make a career of tweeting from them), so if there’s one you recommend that’s worth the time and money to attend, let me know.

Massachusetts Health Data Consortium elects four new board members: Frank Barresi (VP/CIO, Fallon Health); Julie Berry (CIO, Steward Health Care System); Joseph Frassica, MD (VP and chief informatics / chief technology officer, Philips Healthcare); and James Noga (VP/CIO, Partners HealthCare.)

IBM announces that Modernizing Medicine is one of three partner companies that will release “Made with Watson” apps this year. The company offers specialty EMRs and is developing an iPad app that will guide physicians through a patient encounter to provide evidence-based medicine suggestions.

Other

Constantine Davides of AlphaOne Capital Partners LLC has updated his HIT Family Tree that shows pretty much every company’s acquisition history over the years. It is fascinating, useful, and sometimes a bit scary when you see the number of acquired pieces and parts that make up a vendor’s “integrated” systems.

Apple and Google drop their smartphone lawsuits against each other and agree to work together on patent reform.

The Chicago business paper describes interesting hospital-doctor conflicts at 313-bed Swedish Covenant Hospital (IL) following the hospital’s firing of its chief of medicine after he and other of his independent practitioner colleagues joined a rival hospital’s accountable care organization. The issues: (a) new payment models make it difficult for doctors who practice at multiple hospitals to choose their loyalties; (b) independent doctors say they are forced to take ED call, but most of the patients they see there are sent to the hospital’s employed physicians; (c) the hospital is demanding that independent practices adopt EHRs that integrate with their systems, leading to concerns that the hospital will use the information in them to tell them how to practice medicine (which of course they will since that’s the whole point of analytics-powered population health management, which like most powerful forces can be used for both good and evil.)

The former president of the Philippines, now a representative, proposes creating an Electronic Medical Record Center (an HIE-like central records strorage center) under the Department of Health, with initial funding of $230,000 USD.

Long Island Jewish Medical Center (NY) installs video cameras in all of its 24 operating rooms as a remote video auditing (RVA) system. Staff will check the cameras every two minutes to make sure the surgical teams take the mandatory pre-procedure timeouts and patient safety measures. The cameras will also be used to alert housekeeping of completed procedures so they can clean the room and as a video record that room disinfection was performed properly. The video can be monitored live throughout the OR and on smartphones. The system was provided by the hospital’s anesthesia contractor and Arrowsight, Inc., whose video system the hospital installed in 2011 to improve hand hygiene rates to nearly 90 percent (I’m picturing in-room loudspeakers from which emanate the stern voices of invisible handwashing video overlords who tell doctors to step away from the door and toward the sink.)

Centura Health (CO) will replace Meditech with Epic, a good source tells me.

Police say they may make more arrests in the identify theft case at Albany Medical Center (NY), in which a nurse and her boyfriend have been arrested for using the Social Security numbers of over 100 patients to apply for credit cards, write bad checks, and file fraudulent tax returns.

New tax returns filed by UPMC disclose that CEO Jeffrey Romoff was paid $6.6 million in 2012, with 30 other health system executives and physicians exceeding $1 million each in compensation. SVP/CIO Dan Drawbaugh makes the list with $1.6 million in 2012 income, a big drop from the $2.3 million he took home the previous year. UPMC is famously embroiled in a lawsuit with the City of Pittsburgh in claiming that it is a humble non-profit that should not contribute to the city’s budget by paying taxes.

Here is Regina Holliday’s keynote speech from the We Can Do Better conference from a couple of weeks ago.

Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

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Readers Write: EHR Usability – Whose Job Is It?

EHR Usability – Whose Job Is It?
By Michael Burger

Near misses, good catches, or serious reportable events – how many of these could be a design flaw of the EHR used? This was an underlying question in an article published recently entitled, “Poor Prescription documentation in EHR jeopardizes patient safety at VA hospital.” This article caught my eye because I thought perhaps there would be information on a design flaw that might need to be addressed in ePrescribing software.

The article referred to a Department of Veterans Affairs Office of Inspector General report from December that cited a variety of documentation lapses regarding opioid prescriptions at the VA Medical Center in San Francisco. The EHR was a factor in the report primarily because the EHR is the place from which the documentation was missing.

From the headline of this article, the reader assumes that the EHR figures prominently in the patient safety hazard. In all probability, the same lapse in documentation would have occurred in a paper chart environment. The report found that 53 percent of opioid renewals didn’t have documentation of a provider’s assessment. I’d lay a sizable wager that the percentage would be the same or higher were the hospital to be using paper charts versus an EHR.

It seems to be sport these days to throw daggers at (dare I say beleaguered) EHRs and EHR vendors. Studies are published showing the levels of dissatisfaction with EHRs. ONC responds by introducing EHR usability requirements in the Meaningful Use standards and certification criteria. Inevitably, the focus of these activities centers on the notion that vendors purposely build EHRs that aren’t usable, are inept at training, and are uncooperative (or even sinister) about working together.

In reality, vendors are anything but purposefully uncooperative, inept, or builders of unusable products. Logically, how could a vendor stay in business if they weren’t cooperative, sold things that didn’t work, and were failures at teaching people how to use their products? In the world of EHRs, there are forces at play that help to explain these perceptions.

EHR vendors, like creators of any other product, build software features based upon demand. The limitations to a development budget are time, scope, and resources. While any feature could be built, priorities must be set as to what to build and in what order, given the limitations.

Meaningful Use has disrupted this prioritization process by inserting requirements that have become high priority because they are necessary to pass the certification test but for which there is little or no customer demand. For example, no EHR user is asking for a way to document patient ethnicity. But there are plenty of requests for workflows that don’t require dozens of clicks. The challenge vendors face is that Meaningful Use requires focus on marginally useful features, such as tracking patient ethnicity, and doesn’t leave bandwidth to eliminate clicks in the workflow.

Ineptitude in training is an interesting claim. One very successful vendor is renowned for their “our way or the highway” mentality when it comes to training. Very effective to be certain, though not a lot of fun for those receiving the training. But this method does set an appropriate expectation that workflow modification is required for successful EHR adoption. Other vendors are renowned for their mostly failed attempts to “make the software accommodate your workflow so you won’t have to change a thing.” The reality is that it’s not possible to insert a computer into a manual process like clinical workflow and expect not to have to change a thing. It’s not that a failing vendor is inept, it’s that expectations aren’t being set correctly.

Meaningful Use has inserted a perverse twist into this already unpleasant reality by forcing vendors to train clients to perform workflows that are out of context of what doctors would typically do but are now required to be able to attest.

The uncooperative accusation is the most laughable of all. Interfaces have been around since before there were EHRs – HL7 was founded in 1987. It’s a question of supply and demand. When customers demand an ability to connect disparate systems, vendors build interfaces. It’s true that vendors have built products using proprietary architectures, because till now no one was asking for common standards. Even today, with the availability and mandated use of common standards, less than 30 percent of doctors regularly access HIE data. There’s not a lot of demand for all of that external data. It’s not that vendors don’t build interfaces because they’re being uncooperative; it’s because providers aren’t asking for it.

The principal of supply and demand is a fundamental market driver. It’s disappointing that Meaningful Use has sidetracked the natural evolution of the market by creating artificial demand for EHR functions that aren’t being asked for by actual consumers. MU has had the unintended consequence of stifling innovation of the functionality being asked for by users, which would have spurred widespread organic adoption. We’ve not (yet) seen the iPod of electronic health records because vendors have been too busy writing code to pass the MU test.

Rather than introducing a voluntary 2015 Edition EHR certification, CMS and ONC should give vendors the year that the start of MU Stage 3 has been deferred to innovate features the customers really want, rather than adding more features and another certification to continue a harsh cycle. 

Michael Burger is senior consultant with Point-of-Care Partners of Coral Springs, FL.

Readers Write: Liberating Data with Open API

Liberating Data with Open API
By Keith Figlioli

Today, people all over the world use Twitter as a means of everyday communication. But how useful would the application be if you had to contact the company and get a custom code each time you wanted to post a thought? As ludicrous as this seems in the social media space, it’s reality in healthcare information technology.

For all the hype around electronic health records (EHRs), healthcare providers still lack the ability to easily access data in EHRs. This in essence means that developers can’t just build applications that meet a use case need. This is because each system is closed behind a proprietary wall that requires custom coding in order to be unlocked for add-on workflow applications. If you want to marry EHR with pharmacy data so that doctors can be alerted when a medication hasn’t been refilled, for instance, health systems must contact their EHR vendor and pay to have that application developed to their specs.

These walls around data have real consequences. Not only are healthcare providers spending millions on one-off applications, but they are missing innovation opportunities by requesting custom builds. In the case of smartphones, both Apple and Google released their application programming interfaces (API) for any developer to leverage, creating thousands of apps, many of which users would not have imagined on their own. In healthcare, these APIs don’t exist, meaning that apps are only developed if they are imagined by either the provider or the vendor, with all potential for crowdsourced innovation completely cut off.

Although it’s hard to put a price tag on missed opportunity, a McKinsey & Company report found that the US loses between $300-$450 billion in annual economic potential because of closed data systems.[1] With more “liquid” data, McKinsey predicts new applications that close information gaps, enable best practice sharing, enhance productivity, support data-driven decision making, pinpoint unnecessary variation, and improve process reliability — all sorely lacking in today’s healthcare environment.

There’s also a price for patients. According to a recent Accenture poll, 69 percent of people believe they have a right to access all of their healthcare data in order to make decisions about their personal care. Yet almost none of these patients (76 percent) have ever accessed their EHR, chiefly because they don’t know how to, nor do they have the ability to integrate EHR data with other applications, such as those that track weight, diet or exercise via a smart phone or home computer.

Two forces need to align in order to facilitate change. In the marketplace, healthcare providers and patients both need to advocate for open API and liquid data in order to get the most out of healthcare applications. With increased demand for open access, market forces will be unleashed to prevent closed systems from being introduced for a single vendor’s financial gain. Moreover, with open systems and free access to development platforms, EHR vendors can differentiate themselves with the diversity and utility of the apps that are built to work with their systems, creating an added value to end users.

Secondly, we need a policy environment that enables innovation. One way this could be achieved would be for the Office of the National Coordinator to require open API for health data. In an optimal environment, vendors should have to demonstrate that data can be extracted via open API and leveraged by third-party software developers.

The business of healthcare should not be predicated on keeping data trapped behind proprietary walls. Given the critical need to use data to better predict, diagnose, and manage population health, the truly differentiated vendor is one that allows open access and third-party application development in order to create systems that providers and patients truly value. It’s time to liberate information and unleash innovation in healthcare.

[1] McKinsey & Company, “Open Data: Unlocking innovation and performance with liquid information”, October, 2013, p.11.

Keith Figlioli is senior vice president of healthcare informatics for Premier, Inc. of Charlotte, NC.

Advisory Panel: Web Hackers

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Have web hackers ever impacted your operation?

Hackers did once penetrate our organization. They never got close to any HIPAA-related data. What they did do is get into our phone systems so that they could make international calls for free for a short time until we shut things down.

We have not seen any specific attacks or hacks. We have had several security audits, so I believe we are well documented and not just whistling past the graveyard. I know that larger providers in our area have had these types of attacks but I think we remain below the radar.

Aside from a virus outbreak many years ago, we have not had any known breaches or attacks that have affected our operations.

Our organization has not documented DDOS attacks, unauthorized network access, or server compromises. 

Not yet. We do penetration testing / white hat hacking to help reduce our risks. I am not sure if any organization can ever reduce their risks to zero.

No. The bigger issue has been phishing.

So far, no. We use some network appliances that monitor and protect the perimeter. I’m sure it will happen some day!

Fortunately we haven’t had any major attacks or unauthorized network access. Roughly five years ago we did experience a compromised windows 2003 server hosting DNS externally for our organization. It was a known OS vulnerability and we didn’t have it patched on time. At the end of the experience we ended up removing and rebuilding the server vs. attempting to correct the unauthorized access.

We have not had any impact to date, though there have most certainly been attempts. I have a very talented IT security team that does an amazing job every day to keep us safe. I do have concerns, however, about the increasing attempts to hack us through biomedical devices. This is not an area where these vendors are very robust, so we are building capabilities to better monitor and support security in this area.

No. However, we are concerned about our ability to monitor and discover these types of activities. We continue to focus our security efforts to create a multi-layered infrastructure and provide better discovery tools for our staff members. We also feel it is important to implement as many “self-healing” security services as possible (example: the system can “see” a phishing message and automatically create a rule that protects our users, even if they click on the link).

Not hackers, but a virus. Lesson learned. Remove the exclusions from all application servers on a regular basis and run virus scan. Applications that will not run with AV scanning certain directories are places for a virus to take hold. Implementing an IPS and proper network design can help minimize the impact when something does take place.

Morning Headlines 5/16/14

Medfusion sues Allscripts for breach of contract

Medfusion files a breach of contract lawsuit against Allscripts because the company acquired and then began marketing a competing patient portal system while it still had an active contract to resell the Medfusion patient portal. Allscripts announced the acquisition at the start of HIMSS 2013, giving "virtually no advance notice to Medfusion, whose representatives were attending and prepared to jointly market the portal with Allscripts at the show.”

Medicare Fraud Strike Force Charges 90 Individuals for Approximately $260 Million in False Billing

The Medicare Fraud Strike Force announces that a nationwide investigation running across six cities has resulted in 90 individuals, including 27 clinicians, being charged with Medicare fraud. Collectively, the defendants received $260 million in fraudulent reimbursements from Medicare.

Seeking Your Meaningful Use Experiences

The Health IT Policy Committee’s Meaningful Use Workgroup is soliciting the feedback of providers, hospitals, payers, and vendors. HITPC is interested in hearing about experiences in developing, adopting, and meaningfully using electronic health records. Webinars will be held on May 20 and May 27.

Group urges Congress to make telehealth mandatory

The Information Technology & Innovation Foundation issues a report calling on Congress to pass the Telehealth Modernization Act of 2013, a bill that was introduced by Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio) on December 12, 2013 and immediately referred to the Subcommittee on Health, where it remains.

News 5/16/14

Top News

Medfusion files suit against Allscripts, claiming the company didn’t live up to its agreement to resell Medfusion’s patient portal to EHR customers of Allscripts. Medfusion says Allscripts owes it $5 million, with damages potentially tripling the lawsuit’s value. The lawsuit claims:

• The companies signed a five-year agreement valid through July 17, 2014.
• Allscripts delayed implementation and billing of the Medfusion portal for more than a year for some customers, creating an unpaid backlog for Medfusion and causing the companies to amend the agreement to require Allscripts to start billing new customers within 30 days. Medfusion says that backlog cost it more than $10 million.
• Because Meaningful Use requirements were expected to boost demand for patient portals, Allscripts agreed to include the Medfusion portal in every new Enterprise and Pro deal it signed and market the product as its only portal solution.
• Allscripts refused to integrate Medfusion’s online forms capability.
• The companies amended their agreement to give Allscripts 55 percent of net revenue and recurring charges while Medfusion would get 45 percent.
• Allscripts acquired Jardogs early in 2013 and announced it without warning at HIMSS13, where Medfusion was co-marketing its portal with Allscripts.
• Allscripts started marketing the Jardogs product as its preferred solution (FollowMyHealth) before its contract with Medfusion ran out and also started converting customers waiting to have Medfusion’s portal implemented to the FollowMyHealth product.
• Allscripts created marketing material that compared the FollowMyHealth product to Medfusion’s with the conclusion that its own product was better.
• Allscripts stopped developing its end of any portal enhancements and blamed Medfusion when clients reported issues.
• Medfusion accused Allscripts of breach on April 14, 2014, saying it had not paid $5.5 million worth of outstanding invoices. Allscripts, it says, sent payment of just under $1 million in response and disputed the remainder.
• Medfusion says customers told it that Allscripts made misleading statements in trying to get them to sign three-year contracts with Allscripts, including that: (a) Allscripts had terminated the agreement due to Medfusion problems; (b) Medfusion was going out of business; (c) Medfusion wasn’t providing portal updates and the customer would have to implement the Allscripts product to qualify for Meaningful Use; and (g) customers would be invoiced for May even though Medfusion wasn’t invoicing Allscripts that month because of their dispute.

Reader Comments

From Hobie Cat: “Re: Google Glass. Being handed out to all medical students at UC Irvine. The link made the rounds this morning with the subject, ‘Does this have HIPAA violation written all over it?’ Perhaps someone from UC Irvine can chime in with thoughts on how they’re approaching HIPAA. I’ll also be curious about how patients respond to this technology during rounds and the perception of a student talking to themselves and head nodding toward the ceiling to wake up Glass while in the room with the patient… ‘Just turning on the Glass, yo!’” The medical school says students in their first two years will use Glass during anatomy and clinical skills courses, while those in their third and fourth years will wear it during their hospital rotations, especially in the ED and OR. Google stores the information saved by off-the-shelf Glass, so in the absence of a business associate agreement with Google (which they probably won’t sign since it’s a consumer device) and because Glass doesn’t encrypt, I would say its use in patient care settings is a HIPAA problem. However, the UCI announcement says they are using proprietary software that is HIPAA compliant, probably the Pristine system they were piloting earlier this year, so they are trusting their vendor.

From TooMuchCoffee: “Re: UK’s Royal Devon. Going to Epic, although ‘affordability is a huge issue.’ At least they’ll get something that works – NHS spent billions on a failed decade-long project involving GE Healthcare and other vendors that produced nothing.” Royal Devon and Exeter NHS Trust chooses Epic as vendor of choice. It will now undertake a 12-week study to see if it can afford it.

From Fighting Accountants: “Re: Northwestern telestroke team. Congratulations for winning the Innovation Award at their annual nursing fair. They save lives and improve outcomes where it wouldn’t otherwise be possible. Not all health IT is as painful as an EMR.”

From Joey Junior: “Re: Mayo. Heard any rumors about the Cerner-Epic faceoff?” I haven’t. I will defer to readers.

From Concerned: “Re: voice mail messages. I need HIStalk reader insight. A large academic hospital organization would like to store their voice mail messages on Exchange Server. I don’t feel that this is ideal, but does it actually violate HIPAA?” I’m sure an expert will weigh in, but my interpretation is that voice mails left by patients (which I assume is the content you are referring to) are not covered by HIPAA since they didn’t start out in electronic form, the provider didn’t listen to them initially, and nobody suggested the patient leave PHI-containing voice mails. Providers leaving messages for each other might be problematic, though, but the server is still inside the firewall and the messages can’t be forwarded outside or accessed without security credentials. I haven’t convinced myself, so let’s hear some other viewpoints.

HIStalk Announcements and Requests

Several of the reader-submitted items you see here came from the all-purpose contact form, which accepts comments and attachments and whisks them straight to my inbox, where they may age gracefully until I get to them.

Highlights from HIStalk Practice this week include: Xerox fares poorly when it comes to state Medicaid management systems. GA-HITREC’s Dominic Mack, MD weighs in on the HIMSS 2014 Regional Extension Survey results. Physicians have differing opinions about the business model of CrowdMed, which is looking to turn a profit via crowdsourced medical advice. ONC approves ANSI for a second term as an approved creditor for its HIT certification program. Athenahealth finds itself in the same quagmire as Facebook and Tesla. "Anonymous" sends letters to 30 patients alerting them to the ease of stealing their medical information. A solo-practice physician becomes the first in New Jersey to attest for MU Stage 2, thanks to help from NJ-HITEC. Thanks for reading.

This week on HIStalk Connect: Dr. Travis discusses the state of patient engagement and questions whether the Patient Engagement Framework, developed by the National eHealth Collaborative and HIMSS, is an ideal tool for benchmarking progress. Researchers at Johns Hopkins develop a smartphone-based carbon monoxide breathalyzer that they hope will provide smoking cessation programs the tools to objectively measure smoking abstinence more easily. Cedars-Sinai Health System announces that it has formed a partnership with MemorialCare Health System to create a shared health technology VC fund called Summation Health Ventures

Ms. Barnes sent this photo from her Mississippi kindergarten classroom, for which we as HIStalk readers provided write-and-wipe boards and markers (you can see them in front of the students) in response to her DonorsChoose grant request. She reports that the class is using them for practicing their writing and they wouldn’t have them otherwise because of district budget cuts.

Acquisitions, Funding, Business, and Stock 

Oscar, a technology-powered startup that sells medical insurance only to New York residents so far, raises another $80 million in funding, bringing its valuation to nearly $1 billion.

Sales

The VA chooses Agilex and Calgary Scientific for enterprise viewing of radiology images on a variety of devices.

People

Applied Health Analytics hires Craig Smith (The Advisory Board Company) as president of its Coalesce consulting division.

Lee Fowinkle (McKesson) joins InformedDNA as CTO.

Announcements and Implementations

 

Mercy Hospital (MO) breaks ground on its four-story, 120,000 square foot, $50 million virtual care center that will house its 300 telemedicine program employees for remote management of ICU, stroke, cardiology, sepsis, radiology, pathology, nurse on call, and home monitoring.

Health Care Cost Institute, a non-profit funded by UnitedHealth Group, will in Q1 2015 make available to the public medical claims data from private insurers, the first non-government healthcare pricing data to be released. Aetna, Humana, and Kaiser Permanente have signed on.

Government and Politics

HHS’s Medicare Fraud Strike Force charges 90 people, including 27 clinicians, for fraudulently billing Medicare for $260 million. The defendants were charged with a variety of activities that include paying pharmacy kickbacks, billing for undelivered products and services, charging the government for 1,000 unneeded power wheelchairs, and laundering money using Medicare beneficiary information. HHS also announced that it has indicted the Brooklyn surgeon who billed Medicare for $85 million worth of surgeries that he didn’t actually perform.

ONC chooses ANSI for a second three-year term as the accreditor of its certification bodies.

Innovation and Research

A study of primarily Iowa VA hospital ICUs finds that telemedicine didn’t reduce 30-day mortality rates or length of stay.

Other

A free, eight-week online course, “Exploration of SNOMED CT Basics,” runs through June 13 if you have time to double up on the video lectures to finish in time.

The Chicago-area nurses union National Nurses United launches a heavy-handed campaign against “experimental, unproven medical technology” (specifically, EHRs.) Much of it rings true, unfortunately, even the dot matrix printer.

Roshni Nadar Malhotra, the only child of a technology billionaire from India, will spend $168 million to build a network of Johns Hopkins-affiliated health clinics starting in New Delhi. She says IT will be a key component.

The Pittsburgh business paper reviews the federal tax forms of West Penn Allegheny Health System, noting that Allscripts was its second-highest paid contractor at $7.3 million.

Employees of a company that won a $1.2 billion HHS contract to process paper insurance applications from health insurance exchanges are staring at computer screens with nothing to do, a whistleblower claims. The whistleblower says the employees have been told to refresh their screens every 10 minutes to give the appearance that they are accomplishing something. Serco, the British contractor that won the big contract, is under investigation in England for overbilling the government. I wrote about the company in October 2013, including the patient harm it caused when it took over the largest pathology labs in England’s NHS in 2009.

An editorial by Newt Gingrich on the VA’s problems says the VA and DoD need to integrate their IT systems (which is much more of a DoD problem than a VA problem):

Every effort to integrate Department of Defense and VA medical record systems has failed. The result has been an absurd process of transitioning from active duty health services to VA health services. At a time when you can instantly make airline and hotel reservations or get money from an ATM worldwide in seconds, it takes 175 days to transition a veteran’s care from the Defense Department to the Department of Veterans Affairs. The DoD and VA spent $1.3 billion to build a joint electronic medical record system for their health care services before the two secretaries announced in February that they were abandoning the effort. This is on top of the over $2 billion the Defense Department has spent on a failed upgrade to its own electronic medical system.

The mHealth Summit opens its call for presentations for the 2014 meeting, due June 27. The meeting will be December 7-11 in National Harbor, MD.

Interesting: a suspicious fire in the medical records department of a psychiatric hospital in Trinidad and Tobago erupts one month after the health authority requested copies of the hospital’s medical equipment purchasing records. The hospital, which is looking at EHRs, says it will have to create records by asking patients about their history. It hopes to make a second set of paper records for patients to take home.

Weird News Andy says when it comes to cancer vs. measles, it’s no contest for this patient. Mayo Clinic doctors try a desperate cancer treatment in injecting enough genetically modified measles virus into a female patient to inoculate 10 million people. The doctors say the use of viruses to fight cancer, known as oncolytic virotherapy, has been tried since the 1950s and in this patient’s case, seems to have worked.

Sponsor Updates

• Extension Healthcare sponsors the National Coalition for Alarm Management Safety.
• Capario shares five facts about eligibility verification.
• Capsule’s Halley Cooksey relates the NFL draft to selecting a committee to evaluate technology.
• PatientKeeper posts its summer conference event schedule.
• Orchestrate Healthcare posts an article called “What is Healthcare IT Integration?”
• HDS will attend MUSE on May 27-30 in Dallas.
• Park Place International offers seven tips for project managers to get and stay organized.
• Jennifer Crowley from MedAptus discusses the importance of time in the daily life of a provider.
• The Outsourcing Center names Springhill Medical Center (AL) and Allscripts winners of its 2014 Outsourcing Excellence Award in the Best Healthcare category.
• TriZetto will offer  grouping, edit, compliance and pay-for-outcomes logic from 3M in its NetworX Pricer and NetworX Modeler solutions.
• Iatric Systems launches Business Associate Manager as a tool for compliance with the HIPAA Omnibus Final Rule.
• Sentry Data Systems completes a Service Organization Control 3 examination.
• Summit Healthcare joins the federal initiative for standards-based healthcare communication DirectTrust.
• Black Book names ADP AdvancedMD, Allscripts, Aprima, Care360 Quest, eClinicalWorks, eMDs, Greenway, Kareo, McKesson, and Optum to its list of top EHR, PM, and billing vendors.

EPtalk by Dr. Jayne

I was excited to hear about HR 4077 , which would exempt physicians and other healthcare professionals from antitrust laws when they take part in contract negotiations with health plans. Although it doesn’t apply to Medicare, Medicaid, or other governmental payers, it seems like it could help independent physicians as they fight the big payers. Having been part of such a physician network in the past (although it was determined that we violated antitrust laws and our contracts were voided) it could be a help for many providers.

My informaticist friend @techydoc tweeted a link to this healthcare data map last week. It’s amazing all the places our data goes, sometimes whether we want it to or not. Apparently one place data doesn’t go, however, is to my mom’s doctor appointment. Her physician recently moved from one practice location to another within the same physician group. Despite the fact that they’re on a common EHR platform and also have an HIE in place, she was told they had to key in all her information again. It’s a shame they didn’t catch her last name and give a better answer, because I implemented the EHR and HIE in question. Sounds like someone needs an in-service.

HIStalk Practice picked this up first, but I wanted to throw in my two cents on this study that concluded that costs rise when hospitals own physician practices. The data used for the analysis was for the period 2001-2007. It doesn’t take into account the shared savings plans that have come into play during the last six or seven years. There are also just too many confounding factors present. To get an accurate analysis, I think you’d have to have to control many more of the variables. Maybe in a couple of years we can get some robust data from Accountable Care Organizations that have both employed and independent provider participants.

From The Major: “Re: site visits. As usual, thanks for sharing. I have been through a site visit (as a consultant, and my client was the jerk) like that. We had an hour ride back from the site to his hospital, where I naively told him he wouldn’t learn anything if he didn’t listen and ask good questions.” Several readers wrote to commiserate about my recent site visit experience. I’m happy to report that I received a note of apology and a cookie basket for my staff. Either the CMIO understands his behavior wasn’t appreciated or one of his accompanying colleagues is trying to smooth things over for him.

From Oceans Eleven: “Re: site visits. A long time ago we were an early adopter of a particular vendor. Based on our success, we eventually did about 100 site visits over the first few years. What became apparent after the first few minutes with a couple of them was that they had no intention of signing with any vendor. Much to the chagrin of the sales guys, we immediately scaled back our planned agenda and sent them on their way to the beach, which was probably the covert reason for the visit.” I’ve looked at dozens of products over the years and that approach hadn’t occurred to me. I’m thinking the next site visit we do might have to consider geography as well as how similar the facility is to ours. Besides, it’s been a long winter and I’m feeling a little pale. I’m sure an increase in my Vitamin D would be beneficial.

Anyone who has ever engaged in a friendly game of Office Bingo should appreciate this card, courtesy of a reader at Authentic Medicine. I used it during a recent pep talk from our chief medical officer. She was trying to explain why it was a good idea that all the experienced emergency physicians are being let go so we can replace them with cheaper independent contractors who don’t know our hospital or our patient population. Did I mention the emergency department is barely a third of the way through with a massive construction project that has required everyone involved to bend over backwards to preserve quality patient care? The hospital is transitioning in a little over a month – it will be interesting if nothing else since we’ll have new residents and new attending at the same time. I reached BINGO after barely a handful of sentences.

Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

Get HIStalk updates.

Readers Write: FDASIA and Healthcare’s Moon Shot Goal of ICU Safety

FDASIA and Healthcare’s Moon Shot Goal of ICU Safety
By Stephanie Reel

Preparing for the FDASIA panel was an energizing opportunity. It allowed me to spend a little time thoughtfully considering the role of government and the role of private industry in the future of health IT integration and interoperability. It gave me an opportunity to think a great deal about the important role ONC has played over the past few years and it made me question why we haven’t achieved some of the goals we had hoped to achieve.

As I was preparing my remarks, I reflected on the great work being done by my colleagues at Johns Hopkins and our vendor partners. We have the distinct privilege of having the Armstrong Institute at Hopkins focused on patient safety and quality, which is generously funded by Mr. Mike Armstrong, former chairman of our the Board of Trustees for Johns Hopkins Medicine. It is unequaled and a part of our fabric and our foundation. The Armstrong Institute is inspirationally led by Dr. Peter Pronovost, who is an incredibly well-respected leader in the field of patient safety, and also a trusted colleague and a good friend.  

We in IT at Hopkins receive exceptional support from our leadership – truly. We also have amazingly strong partnerships with our school of medicine faculty, our nurses, and our enterprise-wide staff. I suspect we are the envy of most academic health systems. The degree of collaboration at Hopkins is stunning – in our community hospitals, physician offices, and across our academic medical centers. Our systems’ initiatives derive direct qualitative and quantitative benefit from these relationships. Our CMIO, Dr. Peter Greene, and our CNIO, Dr. Stephanie Poe, are the best of the best in their roles. The medical director of our Epic deployment, Dr. John Flynn, is a gift.  

We are luckier than most. We could not do what we do without them. But despite this impressive and innovative environment, we still have significant challenges that are not unique to Hopkins. 

Despite huge investments and strong commitments to Meaningful Use, we have challenges across all  health IT initiatives. They aren’t new ones and they aren’t being adequately addressed by our current commitment to Meaningful Use criteria. We are still not operating in a culture adequately committed to safety and patient- and family-centered care. We are still not sufficiently focused on technologies, processes, and environments that consistently focused on doing everything in the context of what’s best for the patient. 

We decided to try harder. All across Johns Hopkins Medicine, we published a set of guiding principles that guide our approach to the deployment of information technology solutions. These guiding principles reduce ambiguity and  provide constancy of purpose. They drive the way we make decisions, prioritize our work, and choose among alternatives – investment alternatives, deployment alternatives, vendor alternatives, integration tactics, and deployment strategies. They provide a “true north” that promotes the culture we are hoping to create.

Our first guiding principle expects us to always do what is best for the patient. No question, no doubt, no ambiguity. We will always do what is best for the patient and for the patient’s family and care partners. We are committed to patient safety and it is palpable. This is our true north.

Our  second guiding principle allows us to extend our commitment even further. We commit to also always doing what is best for the people who take care of patients. So far, we have never found this to be in conflict with our first guiding principle. We view the patient and the patient’s family as our partners. Together, we are the team. Our environment, our work flow, our processes, and our technologies need to do what is best for all members of the team and all of the partners in the process of disease prevention, prediction, and treatment.

Our remaining guiding principles deal with our commitment to integration, standardization, and best practices. We know that unmanaged complexity is dangerous. We know that there are opportunities to improve our processes and our systems if we are always focused on being a learning healthcare system. We know we can achieve efficiencies and more effective solutions if we also achieve some degree of standardization and data and system integration. This is essential, critically important, and huge. It is something FDASIA (the FDA,FCC, and ONC) and the proposed Safety Center may be able to help us address. 

Is this the best role for government?

Government has an important role and government has the power to convene, which is often critical. But I also feel strongly that market forces are compelling and must be tapped to help us better serve our patients and the people who care for our patients. Health systems and hospitals have tremendous purchasing power. We should ensure we define our criteria for device and system selection based upon the vendor’s commitment to integration, standardization, and collaboration around best practices. We must find a way to promote continuous learning if we are to achieve the triple aim. 

We need to step up. We need to say we will not purchase devices, systems, and applications if the vendors are not fully and visibly committed to interoperability and continuous learning. This must be true for software, hardware, and medical devices. It must be true for our patients and for the people who care for our patients.

Moon shot goal

This relates my plea that we define a moon shot goal for our nation. We must commit to having the safest healthcare delivery system in the world. We should start with our intensive care units. We must ensure that our medical devices, smart pumps, ventilators, and glucometers are appropriately and safety interoperable. We must  make a commitment to settle for nothing less. We must agree that we will not purchase devices or systems that do not integrate, providing a safe, well-integrated solution for our patients and for the people taking care of our patients.

Let’s decide as a nation that we will place as much emphasis on safety as we have on Meaningful Use. Or perhaps we can redefine Meaningful Use to define the criteria, goals, and objectives to be achieved to ensure that we meet our moon shot goals. We will ensure that we have the safest hospitals in the world and we will start with our ICUs, where we care for the most vulnerable patients. We might even want to start with our pediatric ICUs, where we treat the truly most vulnerable patients.

More than 10 years ago, I was given an amazing opportunity to “adopt a unit” at The Johns Hopkins Hospital as a part of a safety program invented at Hopkins by Dr. Peter Pronovost. Each member of our leadership team was provided with an opportunity to adopt an ICU. We were encouraged to work with our ICU colleagues to focus on patient safety. We were educated and trained to be “preoccupied with failure” and focused on any defects that might contribute to patient harm. We didn’t realize it at the time, but we were learning how to become a High Reliability Organization.  

I learned quickly that our ICUs are noisy, chaotic, extremely busy, and not comforting places for our patients or their families. I learned that our PICU was especially noisy. Some of our patients had many devices at their bedside, nearly none of which were interoperable. They beeped, whirred, buzzed, and sent alarms – many of which were false alarms — all contributing to the noise, complexity, and feeling of chaos. They distracted our clinicians, disturbed our patients, and worried our family partners. 

Most importantly, they didn’t talk to one another. So much sophisticated technology, in the busiest places in our hospitals, all capable of providing valuable data, yet not integrated – not interoperable – and sometimes not even helpful.

I realized then, and many times since I adopted the PICU, that we all deserve better. Our patients and the people who care for our patients deserve better. We must build quiet ICUs where our care team can listen and learn and where our patients can receive the care they need from clinicians who can collaborate, leveraging well-integrated solutions and fully integrated information to provide the safest possible care. Many of these principles influenced the construction of our new clinical towers that opened two years ago. Again, we are fortunate, but huge challenges remain.

What about Quality Management Systems? Are we testing and measuring quality appropriately?

In many ways, I think we may focus too much on the back end. Perhaps we focus too much on testing and not enough time leading affirmatively. A commitment to excellence – to high reliability – might lessen the complexity of our testing techniques. I am very much committed to sophisticated quality assurance testing, but it seems far better to create and promote a culture that is committed to doing it right the first time. It will also be important that we affirmatively lead our design and deployment of systems that rely only on testing our solutions. 

With that in mind, I would prefer to see an additional focus or strategy that embraces High Reliability at the front end in addition to using quality management techniques. We undoubtedly need both. 

As I have recently learned, most High Reliability Organizations have much in common related to this dilemma. We all operate in unforgiving environments. Mistakes will happen, defects will occur, and we need to be  attentive. But we must also have aspirational goals that cause us to relentlessly focus on safety at the front end. We must remain passionate about our preoccupation with failure. We must recognize that our interventions are risky. We must have a sense of our own vulnerabilities and ensure we recognize we are ultimately responsible and accountable despite our distributed and decentralized models. We must continue to ask ourselves, “How will the next patient be harmed?” and then do everything possible to prevent harm at the front end as well as during testing.  We must create a culture that causes us to think about risk at the beginning.  And of course, we must be resilient, reacting appropriately when we do recognize errors, defects, or problems.

I should note that many of these ideas related to High Reliability are very well documented in Karl Weick and Kathleen Sutcliffe’s book, Managing the Unexpected. They encourage “collective mindfulness” and shared understanding of the situation they face. Their processes are centered around the five principles: a preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise.

Why the moon shot goal?

As Dr. Pronovost at Johns Hopkins Armstrong Institute often says, “Change travels at the speed of trust.” We need to learn from one another. We need to be transparent, focused, and committed to doing what is best for our patients and for the people who care for our patients. We must commit to reducing patient harm. We must improve the productivity and effectiveness of our healthcare providers. We must have faith in our future and trust our partners. We need to make a commitment to no longer expect or accept mediocrity. 

From a recent study performed at the Armstrong Institute under Dr. Pronovost’s leadership, we know that patients around our country continue to die needlessly from preventable harm. Healthcare has little tangible improvement to show for its $800 billion investment in health information technology. Productivity is flat. Preventable patient harm remains the third leading cause of death in the US.

In addition, costs of care continue to consume increasingly larger and unsustainable fractions of the economy in all developed countries. While cutting payments may slightly decrease the cost per unit of service, improving productivity could more significantly deflate costs. Other industries have significantly improved productivity, largely through investments in technology and in systems engineering to obtain the maximal value from technology. Yet healthcare productivity has not improved. Our nurses respond to alarms — many of them false alarms – on average, every 94 seconds. This would be unthinkable in many other environments.

Despite my view that we must encourage market forces, we know that we have a long way to go to have an ICU that has been designed to prevent all patient harm while also reducing waste. Clinicians are often given technologies that were designed by manufacturers with limited usability testing by clinicians. These technologies often do not support the goals clinicians are trying to achieve, often hurt rather than help productivity, and have a neutral or negative impact on patient safety.

Moreover, the market has not yet integrated technologies to reduce harm. Neither regulators nor the market has applied sufficient pressure on electronic health record vendors or device manufacturers to integrate technologies to reduce harm. The market has not helped integrate systems or designed a unit that prevents all patient harm, optimizes patient outcomes and experience, and reduces waste. Hospitals continue to buy technologies that do not communicate.

It is as if Bloomberg News would have been successful if there were no standards for sharing of financial and market data. It would be unthinkable that Boeing would continue to partner with a landing gear manufacturer that refused to incorporate a signal to the cockpit informing the pilot whether the landing gear was up or down. We need the same engineering, medical, clinical trans-disciplinary collaboration expectations to ensure the same is true for healthcare.

Back to the moon shot….

An ideal ICU is possible if we decide it matters enough. If we agree to combine trans-disciplinary collaboration with broad stakeholder participation and demand authentic collaborations, we can get there in less than five years. But it won’t be trivial. It will require a public/private partnership.

The cultural and economic barriers to such collaborations are profound. Engineers and physicians use different language, apply different theories and methods, and employ different performance measures. We must take a holistic approach to create the ideal ICU and the ideal patient and family experience.

A safe, productive system is possible today. Technology is not the barrier. Let’s make it happen. Let’s have a goal for 2020 that we will have the safest ICUs (and the safest hospitals) on the planet – focused on patient- and family-centered care, disease prevention, and personalized and individualized healthcare.

Stephanie L. Reel is CIO and vice-provost for information technology at Johns Hopkins University and vice-president for information services for Johns Hopkins Medicine of Baltimore, MD.

Morning Headlines 5/15/14

Royal Devon edges towards Epic

In England, Epic is named vendor of choice at Royal Devon and Exeter NHS Foundation Trust. Financial details were not disclosed, but an insider familiar with the process explained,  “Epic presents incredibly well to clinicians, when they’ve seen it they just don’t want anything else, but affordability is a huge issue.” Epic’s total project costs at Cambridge University, its first and only UK site, came in at $335 million over 10-years.

Health IT Summit: Halamka predicts only 20% will achieve MU Stage 2

During a speech at the iHT2 Health IT Summit, BIDMC CIO John Halamka, MD predicts that only 20 percent of hospitals will attest for Stage 2 Meaningful Use this year.

Big Data Treasure Trove From Routine Medical Checkups

The Wall Street Journal reports on several recent clinical research projects that use retrospective EHR data analysis rather than clinical trials. In some instances, the findings resulted in new medical discoveries, and the development of new clinical tools.

Health IT from the CIO’s Chair 5/14/14

The views and opinions expressed in this article are mine personally and are not necessarily representative of current or former employers. Objects in the mirror may be closer than they appear. MSRP excludes tax. Starting at price refers to the base model; a more expensive model may be shown.

Hockey and Health IT Innovation

I grew up in Montreal, Canada, so hockey is in my blood. With the playoffs in full swing, I thought I would write my post themed to my hometown sport.

(There was no reason to include this photo, it just seemed like a fun thing to do.)

Innovation is on everyone’s mind in healthcare today. Much of that focus is either directly or indirectly tied to IT. As healthcare models continue to evolve, many believe that given the rapid pace expected, IT innovations will be needed to fuel the change.

As health systems prepared in the past to meet the demand for EMRs, what will they need to do differently to meet this growing expectation of delivering innovation?

Using hockey as a backdrop, here are eight themes.

1. Learn to skate. Learning the fundamentals is clichéd advice for a reason. In health IT, this means implementing an electronic medical record. EMRs can be big, complicated projects and can lead to great things, but having an EMR only means you can skate. It is the starting point to becoming a hockey player. Innovation starts after the go-live.
2. You have to lose a lot to win. The teams with the best regular season records won just 56 of 82 games this season, which means they lost 34 percent of the time. To innovate, you have to be prepared to fail. Hospital cultures are not set up up for this mindset. On the other hand, new entrepreneurial companies are often forced to pivot to new models to stay alive — it is in their DNA by design.
3. Icing is a delay-of-game penalty. Delays or failing to make a decision will not work in today’s rapidly changing healthcare environment. Yesterday’s news was the need for change. Today’s news is improving our velocity of change. Health IT innovation needs to be supported around a model adoption. This is what a health system team can do best. Others who are better equipped to iterate might need to create the innovations themselves.
4. Three referees are on the ice during the whole game. Like hockey, healthcare has rules, regulations, and operating procedures. They are in place to help protect everyone. But that does not mean you can’t play aggressively, increase your tempo, and skate hard. Playing hard also does not mean the rules don’t matter. Health systems are experts at operating procedures. Find a way to be part of the process without feeling the need to own it.
5. The team is more that just a star player. Healthcare is no doubt a team sport, but sometimes the team needs to viewed as being beyond the four walls of the hospital. The innovation team should not be viewed as just employees, but also all of your great partners. If you don’t have great partners, it is time to make that a priority.
6. If you can’t make the shot, pass. Making the great shot is often about being in position. If you are not in the right position, then pass to someone who is. Some of the best hospital IT departments I have seen are amazing at implementing and understanding the complex workflows of healthcare. That does not mean they are best positioned to develop new software.
7. Skate to where the puck is going to be, not where it has been. What has worked in the past for healthcare and health IT will not necessarily work in the future. The puck has moved.
8. You miss 100 percent of the shots you don’t take. Innovation in health IT is all about taking the shot (and the risk.)

Game on!

Darren Dworkin is chief information officer at Cedars-Sinai Health System in Los Angeles, CA. You can reach Darren on LinkedIn or follow him on Twitter.

HIStalk Interviews Sai Raya, PhD, CEO, ScImage

Sai Raya, PhD is founder and CEO of ScImage of Los Altos, CA.

Tell me about yourself and the company.

I’ve been in medical imaging for a long time. For 30 years, from my university days at Hospital of the University of Pennsylvania. I started a little company for 3D imaging workstations and that kind of stuff. 

After that company, I started this company with a different mindset, with zero investment from any external people. I wanted to take one customer at a time and build a good ecosystem with customers. That’s what we have done.

What effect have publicly traded conglomerates and startups had on the healthcare IT market?

The fundamental problem with quarter-to-quarter financial reporting is that middle managers are forced to sell whatever they can, say whatever they can, and show the numbers. In the process, they have to go out and acquire new companies and change the solutions and whatnot.

Over time, they are working with one hospital. Maybe in about 10 years, there may be a couple of forklift updates. They acquire Company A and they have a solution for that. Then they acquire a new company, so they take the Company A solution out and put the second company’s solution in. In the process, hospitals are paying more. They don’t have the continuity in terms of what the hospital would like to do with data mining and all that stuff. 

Small companies, on the other hand, can’t survive without proper financial backing. It is a competitive world. 

From the lessons that I learned in my first venture, it’s very clear to me that the only way to build a solid company with a good financial foundation and bring that equilibrium is to have customer loyalty, and then continue the same solution over and over again. That’s why we have customers still with us since 1996. We never did the forklift update. The programs that we rolled in 2000 still work fine. That’s why there’s a kind of loyalty and a relationship between vendor and the hospitals and the physicians. That’s what we’re trying to enjoy.

It’s tough being an early adopter, like those pioneers who wanted to get rid of film and paper and move to PACS and EMRs before those systems were ready. Did hospitals jump on board too early?

Absolutely. Some people jumped on board without much thought. Somebody came and said, if you go to digital, you will save 50 cents per film or something like that. But first generation is first generation. They chose certain solutions. 

Now we may be in the third generation. But in the grand scheme of things, digitization of the enterprise is just the first phase of what is going to happen to this healthcare IT in general. Whatever digitization that we’re trying to do these days, it is not dead yet. We’re maybe 70 percent of the way there. 

This becomes kind of a building block for the future healthcare IT, where information and imaging have to co-exist. There cannot be any boundaries between these two things. A patient record is a patient record. It has to have everything that patient has ever done.

How do you see the market shaking out as imaging systems and EMRs try to figure out that co-existence?

If you went to something like RSNA in 2007, everybody was a PACS vendor. Everybody was changing film. But if you went to the latest RSNA, some companies went away and some got merged. A lot of consolidation is going on. In the process, certain hospitals learned something and some did not. 

Images are growing. The image pointer that’s in the EMR seems to be the buzzword right now. That will go on for some time.

What are the most important workflows that an imaging system needs to address?

When we started this product we call PICOM, the fundamental point that I was trying to make was, if you go to any department — doesn’t matter, radiology or other — you see images and information. You have images and then lots of requisition sheets and observations and tech notes and physician notes and all kinds of things.

We wanted to create a platform that combines images and information together. Of course, we’re talking data in terms of components in the departments. We’re not talking EMR kind of systems.

For some of them, we had standards like DICOM and document exchange kind of things. Others we did not. We started acquiring them in their native format and put that solution together.

These days, if you go to any kind of imaging system, you have people talking about not just images, but information. Once this total data package is available, it needs to be seamlessly available to the front-end portal that the physician is going to interact with. There’s a lot of work to be done there. In my opinion, that is going to be the key for people that are involved with imaging.

How often do physicians who aren’t radiologists want to see the original image versus the interpretation from the radiologist?

We are coming from a multi-departmental type of company. We treat both radiology and cardiology together. In fact, we deal with radiology, cardiology, OB-GYN, and orthopedics all together. That’s one product for us.

Any patient that goes to the hospital many times, you get the ECG done more than you get chest film done. Images and waveforms are all together. In the case of ECG-type studies, as soon as the physician gets some kind of test result for the patient and before the physician wants to consult with the patient, they do want to take a look at these waveforms to tell them exactly what’s going on. 

Modalities like ECG where the waveforms and interpretation are together – they are bound to open those kinds of things. Similarly these days, mainly for the orthopedic things, they generally use the images, but if it is a big CT study, I don’t think they’ll be using it.

What’s the status and challenges of sharing images across organizations?

The basic problem is there’s no universal patient identifier. We have our own way of doing it, but fundamentally it’s exchanging information from one PACS system to another system or one ordering system.

We created what is known as a universal MPI translator. That’s what we do. Right now, 20 percent of our business is interoperability, where we have to pull and push information from disparate systems and consolidate the reading and that kind of stuff. 

That seems to be the name of the game for the next two years before somebody has to come up with a standard. If that somebody is the government, it’s not going to happen any time soon. [laughs]

What are the most pressing issues you are seeing from providers?

On one side, it’s the image life cycle management. It’s well defined and many companies have good solutions, including us.

But in the whole process, the diagnostic physician contributes the most complex and important content. The diagnostic physician’s impressions need to be distributed everywhere, wherever it’s needed. In fact, even for Meaningful Use, we have to take certain key measurements or key statements that need to be delivered to the EMR in a separate channel. 

These are all the challenges. We have doubled up a good set of tools to do those things. Of course other people have also done that. But in the process, we’re still learning. 

I see the importance of  driving the subset of information from the diagnostic report and making that information co-exist with the image pointers or images and making them travel across the enterprise or make them travel outside the enterprise. That is the challenge.

Is there anything that’s being discussed that would allow images to be searched on qualities that weren’t noted by the interpretation, like the content of the image itself that might interest a researcher?

We have a lot of metadata in these images. If you want to search by image type or study type, it is possible. But the quality of the image, still it’s a visual perception, and a trained eye is the only one that seems to be doing a good job in terms of image quality audit.

But in terms of searchable images using, for example, something like “mitral valve prolapse,” that is easy to search and get information. It depends on the system. Some systems can do it. 

In our system, we maintain an outcomes database and analytics and other things that we take very seriously. Every data object that comes into our system has the metadata latched on. It’s embedded right there in the image itself. It becomes easy to share that information or maybe make it available as an API for other systems to search.

With the rise of the vendor-neutral archive, what data types are people wanting to store that you wouldn’t have expected five years ago?

That’s funny. In 2000, we started an online “PACS in the cloud” type of environment called PICOM Online. Those days it was not cloud — it was an America Online-type of company name, so we called ourselves PICOM Online. [laughs] 

My fundamental thing there was exactly this. It’s not just images. You’ve got to get all your documents, your spreadsheets, your PowerPoint presentations, and your business documents or billing statements — whatever is needed. They all get packed up into one object. It’s called study object. That study gets archived. The intelligence on the back end of the archiving system should handle based on how the client is interacting with it.

That’s exactly what we have done. After 14 years, more than 100 hospitals are using our online cloud solution. It’s a complete PACS, including reporting, voice recognition, and all kinds of crazy things. Some of the big companies these days are now finally opening their eyes and looking at the importance of delivering the documents with the images.

But 80 percent of the industry is still DICOM in, DICOM out, DICOM in, DICOM out. That’s all they talk about.

What’s the future of the industry or the company or both over the next few years?

Interoperability and making the image pointers universal. That’s one thing. 

Security seems to be the biggest factor now, in terms of how securely we can encrypt this data and make it available to the right people at the right place at the right time and have the complete audit trails going with it? That is the key technology that we as an imaging provider needs to provide to the EMR companies.

No matter what, the biggest companies like Epic, when it comes to imaging intensified activity, it’s going to be with PACS vendors and image workflow vendors. We collect the data and then we have to make this data properly available to these people. That is a growing opportunity for us and I think it’s going to be there for a long time to come.

There’s going to be major consolidation and all that stuff, but still lots of hospitals don’t like this cookie cutter type of an approach. They would like to have customizable solutions that works for their hospital. That’s the opportunity smaller companies like us have.

Do you have any final thoughts?

We like what we are doing and we’re having fun. Being a private company with a good balance is a nice thing to do. We’re enjoying our little company.