HIStalk Interviews Eddy Stephens, VP/CIO, Infirmary Health

Eddy Stephens is VP/CIO of Infirmary Health of Mobile, AL.

Tell me about yourself and the organization.

I have been with Infirmary Health System for 32 years. I have a background before that in banking and in food service for a few years. My educational background is more related to accounting and operations research, back before people called it management engineering. I have been in IT for the greater part of my career, 35 years or so. 

Infirmary Health is a regional health system located on the Gulf Coast of southwest Alabama, in Mobile. We have locations in Mobile and Baldwin County, which splits the Mobile Bay, if you’re familiar with the Gulf Coast region, over the northern part of the Gulf of Mexico.

We have a 700-bed hospital which is our flagship, Mobile Infirmary Medical Center. We have a 150-bed hospital, Thomas Hospital, in a bedroom community in Fairhope, Alabama. We have a 65-bed hospital in the northern part of Baldwin County called North Baldwin Infirmary. On the campus of Mobile Infirmary, we have a long-term acute care hospital. We also have a Rotary and rehabilitation hospital that are both located on the campus of Mobile Infirmary. We have a clinic network of about 30 physician clinics, our largest being a multi-specialty clinic that has about 70-plus doctors in it, and it actually has multiple locations scattered around Mobile and Baldwin County. We have three freestanding diagnostic and surgery centers and are in the process of expanding our network out into a couple of other communities within the greater Mobile, Alabama area.

What’s the secret to being a long-term CIO?

I became CIO here about 14 years ago. I had come here as an IT analyst from a financial standpoint. I guess the secret is just trying to keep my head down and maneuver the politics of the system. It’s a great place to work and I have just tried to ingratiate myself to the team.

I’ve tried not to have a philosophy that said we’re going to use technology for technology’s sake, but rather see technology and the IT department as a service department. We’re here to serve the needs of the business and our business is healthcare. We try not to let the technology get in the way of doing what needs to be done.

Infirmary closed one of its hospitals a while back, saying the Affordable Care Act is requiring hospitals to reevaluate how they deploy resources. Including that, what are the biggest trends you are facing?

We closed that hospital. It was an acute care hospital in the west part of town. We relocated the long-term acute care hospital on that same campus to the main campus of Infirmary.

Because of the regulatory environment that we’re in and the change of healthcare, we see a shift naturally to population health management. To keep the patient from getting sick rather than just treating the disease.

We’ve already started that move toward a focus on wellness with our own patient population. We have about 5,500 employees in our own network. We’ve spent the last two or three years focusing on wellness and prevention of disease within our own organization. We’ve begun to reach that out into the community. We have external wellness programs that we offer to businesses. We’re seeing that taking shape.

I also see the hospitals becoming affiliated more — whether it’s through merger and acquisition or whether it’s through some kind of virtual affiliation — to where there are fewer primary inpatient acute facilities over time and more freestanding emergency room-type diagnostic centers that feed main campuses of fewer hospitals, rather than every little community having its own hospital like has been the case for 100 years in this country.

Population health management and wellness management are changing the way we look at IT and the service that we have to deliver.

What technologies do you use or expect to use with those new objectives of population health management and wellness?

We signed a contract with Epic back in 2008. We looked at Epic primarily because of the ability for us to have a single record across the continuum. That has served us well to this point.

It has taken some philosophical rethinking from where a physician’s office talked about having its own record, versus the hospital having its own record, to now having more of a patient-centered record. Where the record doesn’t really belong to one of those entities, even though it never really did in the first place — that was just a concept that we had.

Interoperability is going to be a big issue. In our city alone, every major hospital or health system has a different EMR vendor. Interoperability becomes an issue. Being able to share information with other agencies, rural health, those kinds of things. All of that feeding together in addition to communicating with payers so that we can have a complete picture of the patient.

Historically we have had our view of the patient and where the patient touched our system. For us to truly be able to be effective at wellness and population health, we’re going to have a more holistic view of the patient and everywhere the patient touches the healthcare system.

Are you getting Medicare claims data or other information from payers?

We are getting some. There is still a little bit of resistance in our world, because in Alabama, Blue Cross is the largest provider. They are also the Medicare fiscal intermediary. There’s still a lot of reluctance to share a lot of that information because of competition and other things.

I was just at a meeting where Karen DeSalvo was speaking here in Mobile. One of the things we talked about regarding interoperability is that we still have this mindset about competing from a business standpoint. We all view our data as somewhat of a competitive edge. Sharing of data is still philosophically a little bit of an issue in terms of how open and honest we want to be.

I see that in most of our medical staffs, even. Physicians are reluctant sometimes to share a lot of information with other physicians because of the competitive nature for the patient. “That’s been my patient, I’ve taken care of that patient, and I don’t want that patient to go down the street to someone else.”

Those things are changing. Some of those attitudes are changing. Some of the attitudes are ingrained from years and years ago. People are becoming more open and willing to share information as we see that, both from a regulatory and from a philosophical standpoint, you can only regulate to a certain point. Philosophically, people are changing their attitudes about how important it is.

From my personal perspective, I want everybody to know everything they possibly can about me if they have any inkling that they’re going to be involved in my care. A lot of people we encounter are not like that. This physician group was on Epic and our hospital was on Epic – a patient said they might not go to that doctor any more because of sharing of the information between those two entities. It’s a little bit confusing to me why some people think the way they do, but it’s a lot about the philosophical mindset that people have about their healthcare.

Other than your internal connections to the practices you own, how are you connecting Epic to the outside world?

We have almost as many non-owned clinics who have affiliated with us by installing Epic in their office through an arrangement with us as we do our own clinics. But we are also now working to share information with those physicians’ offices who may have Greenway or Allscripts or whatever in their office and did not want to go onto Epic because they already had an investment into a particular system, whether they liked it or not.

Also, under the safe harbor provisions of the Stark Law, there’s some things that I can do for a clinic who didn’t have any kind of electronic medical record versus someone who already had one that wanted to throw it out and put a new one in. We’re working that through our HISP and being able to provide CCDs, but we’re also talking about taking it to another level using EpicCare Link, which is a portal where we can provide certain level of Epic information outside to other people.

We’re also working with nursing homes to use the Kryptiq patient portal to be able to share information electronically. We’re finding that nursing homes do not have a lot of electronic health record information. For us to be able to move a patient out to that transition of care from the hospital setting to the nursing home, we’re looking at tools that we can provide to be able to electronically share that information with them. Even though they might not have a receptacle for that information, we can provide them a portal where they can securely access only the information that they need about their particular patient. We’re trying to attack it from multiple fronts, particularly as we try to meet Meaningful Use Stage 2.

Is anybody coming to you for an alert if their patient is admitted to your hospital or otherwise exchanging information for patients for whom they bear risk?

Some businesses are certainly interested in that, where they have a self-insured kind of situation. We do have some dialogue going on between different businesses and we are beginning to provide some of that service, at least from a wellness standpoint, which I think is the first foray into the population health management.

In the State of Alabama, Medicaid is trying to set up Regional Care Organizations in multiple regions throughout the state. We’re working in our region to see how that’s going to fit together. Huntsville Hospital is the main player in that whole region, almost having their own private RCO.  That kind of arrangement works well in our environment with Medicaid being spread across multiple facilities. There’s much more of a collaborative effort that seems to need to take place. We are having conversations among ourselves, the hospitals in our region, about how we’re going to be able to work within that RCO model with Medicaid.

How did you use speech recognition in your Epic implementation?

We have been a long-term user of speech recognition in some form or fashion. We Used PowerScribe for a number of years in the radiology area. We transitioned a number of years ago to back-end speech recognition in the medical records area. Subsequently we have gone to full outsourcing of transcription to Nuance. In our clinics, we had the traditional Dragon installed on a workstation with a PowerMic for many of our physicians.

As we begin to roll out CPOE and physician documentation into our hospitals at a required level, as in an “everybody’s going to have to do it now” situation, we were concerned about how we were going to get that progress note on the chart in a timely manner. We had — whether it was because of attitude, skill level, or technologically challenged — physicians who were used to either dictating some of the information and it showed up on the chart later or hand-writing in the chart. We knew that a progress note had to be an immediate action that appeared within the electronic record.

Some of them were challenged in using either NoteWriter within Epic or a template-driven kind of progress note. Many of them to this day don’t have any problem with typing or using a structured note of some type. But with a large percentage of our physician staff, we knew it was going to be a problem. They kept talking to us about how they could use transcription and how they could use dictation to be able to get their progress note on the chart.

Particularly at our two largest hospitals, we have a situation where most patients who are an inpatient at our facility have multiple clinicians following their care. There certainly would be a primary physician who is managing the care, but multiple specialists who might be involved in the patients due to the complications and co-morbidity of our patients. We knew that when Dr. A rounded, we had to have that progress note immediately available on the chart.

We were challenged with how we were going to be able to do that and also facilitate the needs of our physicians and try to make it as palatable for them as possible to transition from a paper record to a fully electronic record.

I saw Nuance’s SpeechAnywhere at UGM and purchased 10 licenses as a trial. I got my CMIO, who is a practicing rheumatologist as well, and a couple of other physician champions to try this. It worked extremely well. They began to show it to some of their peers and my 10 licenses were used almost immediately. We saw it as a way to get the progress note on the chart and to avoid the complaint that we don’t have enough devices for them to access.

Many physicians tell me they don’t do technology, but they have an iPhone on their belt and an iPad in their lab coat. They can use Epic’s Haiku application to pick their patients or for rounding or results review, so they could then pick their patient, dictate their progress note, review it, accept it, and then immediately have it show up on the chart. It was a home run for us. We have about 300 licenses active today.

It’s not for everybody. There’s a lot of people that would rather just sit down and type in their note or fill out a structured note template. But we have about 300 physicians today who are using SpeechAnywhere with the Haiku and Canto applications.

When you look ahead two or three years, what do you see as your biggest challenges?

The biggest challenge that I see for all of IT and healthcare is the onerous regulatory rules that we’re having to meet.

I’ve got a chart on the wall that shows all the things that have to be implemented by 2020. Regulations saying that not only do you have to provide a patient portal and lead that horse to water, but I have to force that horse to drink. It’s not enough for us to be able to provide that. The rules say that a certain percentage — and it’s fairly low right now, but I anticipate that going up — that I somehow have to engage the patient and make them use the technology. That to me is a little bit of a challenge — how we’re going to force people to use technology who just don’t want to use the technology. 

On the other hand, we talk about interoperability and we just say, “You just need to make it happen.” I’ve got Payer A coming to me and wanting me to do interoperability this way. Payer B wants me to do it this way. The hospital across town wants me to do it this way. 

You want me to make the healthcare system more efficient and you want me to drive cost out of healthcare, but yet you make rules that are nebulous. If you want interoperability in healthcare that works nationally like an ATM system in banking, the government is going to have to say, “Everybody is going to do it this way. This is the format and we’re all going to use it.”

It’s like HL7. HL7 is supposed to be the standard, but HL7 is not HL7 is not HL7. Everybody who uses HL7 wants to do it a little different way and add their own little nuance to it to make it somewhat proprietary.

That’s one of the big challenges that we have in moving towards this interoperability, Not only the philosophical and the attitude changes that have to take place, but making smart regulatory requirements. Let’s don’t regulate things that don’t make sense. Let’s regulate things where we really want to make things happen. By having a strict standard, we can actually accomplish interoperability.

Morning Headlines 7/30/14

Former Procter & Gamble CEO Tapped as New VA Secretary

Robert McDonald, the former Procter & Gamble CEO, is unanimously confirmed as the new VA secretary.

Many health-IT success stories to note

National coordinator for health IT Karen DeSalvo, MD, publishes a response to an earlier Boston Globe article which reported that rushed EHR implementations are introducing new, sometimes serious, patient safety risks into care delivery.

Graduate Medical Education That Meets the Nation’s Health Needs

The Institute of Medicine publishes a report analyzing what value taxpayers get from the $15 billion in annual funding that is provided to pay for medical student residencies. The report concludes that the investment is warranted, but that improvements, including more transparency and accountability, are needed.

Medical identity theft can threaten health as well as bank account

CBSNews reports that medical identity theft has become the low hanging fruit of

the criminal underworld because the security protections that banks and credit card companies have put in place to protect consumer data have not yet reached healthcare infrastructures.

News 7/30/14

Top News

House and Senate leaders approve spending $17 billion to improve services at the Department of Veterans Affairs by leasing new facilities, hiring more clinicians, and paying for care delivered outside the VA for veterans who can’t get timely appointments. Most of the “cost of war” funding goes straight to the $18 trillion national debt. In related news, former Procter & Gamble CEO Robert McDonald is unanimously confirmed as VA secretary.

Reader Comments

From Legume Enumerator: “Re: Cerner earnings call. You missed the laughter toward the end of the call when EVP Zane Burke said that EMRs that don’t interoperate are borderline immoral. This supposedly ’open’ versus supposedly ‘closed’ systems debate that is beginning to surface in Congressional testimony and now on investor calls will become the battle cry for why the kids from Wisconsin should not be allowed to win the DoD (or any other, for that matter) contract.” “Open” has become a marketing term, jumping the shark when since-deposed Allscripts CEO Glen Tullman confidently and repeatedly declared that all of the company’s potpourri of acquired systems are open and interoperable because they all run on Microsoft SQL (showing little widespread openness, not counting Glen’s mouth). It is indeed worrisome when politicians start using the word as though they understand it and aim legislation accordingly. I challenge readers thusly: what core set of published standards or capabilities must a given EHR support to be considered open? We need to put some collective thought into this.

From Gold Watch: “Re: Xerox Midas+. The managing director apologized to customers in June 2013 that the acquired product marketed as Midas+ Live failed to meet their needs. The company replaced him with the key person from the former company of the failed product, who reassigned most developers to the Juvo cloud-based product being developed using the failed product as its basis. The developers and an India-based contractor were supposed to finish the product by January 2015, but it exists only in demo form and numerous employees have left the company. Sales of the flagship product will be halted in August 2014, hoping to convince Midas+ customers to switch to Juvo, although employees have been forbidden using the word ‘sunset.’ The company’s stated mission is now to double its 2013 revenue by the end of 2016.” Unverified. A Xerox spokesperson provided this response:

We take all customer concerns seriously and address them directly to ensure our customers are delighted with our products and services. As a leader in our field, Midas+ is always working on developing new products that will enhance customer satisfaction and help improve the quality of care.

From Headcount Reduced: “Re: Siemens. You missed the 7/25/14 layoff in Malvern. It wasn’t just contractors and consultants. Rumor is that 200 employees were impacted.” Unverified.

From Stocky Lad: “Re: Health Evolution Partners. What was CalPERS thinking to put $700 million into Brailer’s first foray into private equity? It pisses me off as a California taxpayer. I assume HEP’s Summit will continue regardless since they were considering spinning it off even before this latest news. It’s a super event.” Enthusiastically endorsing the deal on behalf of CalPERS back in 2007 was its CEO, Federico Buenrostro, who was fired in 2008 and just pleaded guilty a couple of weeks ago to accepting bribes, defrauding workers and retirees, and obstructing SEC regulations. The next invitation-only HEP Summit is in April 2015. Some of its sponsors are Emdeon, McKesson, Optum, Walgreens, Healthagen, Oracle, and WellPoint. This year’s agenda featured a panel of past and present National Coordinators: Blumenthal, Brailer, DeSalvo, and Mostashari.

From ThanksForPlaying: “Re: Norbert Fischl, CEO of CompuGroup Medical US. Has been removed from his position by Germany. His tenure, similar to that of his predecessors, was just over a year.” Verified. I interviewed him a couple of months ago. My surprise is minimal.

What a Cerner Acquisition of Siemens Health IT Would Look Like
By Chester of Malvern

• Does the remote client operations (RCO) data center belong to the suitor?
• Allegra, Invision, and Soarian customers would become service level agreement fodder – positive revenue – and customers of the first two would be targeted to replace their aging software.
• Siemens US clients plus Cerner sites would push Cerner past Epic in size.
• Soarian sites are happy with their financials, which are better than Cerner’s.
• Siemens has a better and more stable international presence (see NHS Cerner replacement by CSC’s iSoft). Cerner has made some progress internationally, but regional capitation (most offer socialized care) and ease of implementation is Cerner’s burden.
• Invision sites love their accounts receivable – tough to convince happy CFOs.
• Soarian clinicals / financials could complement Cerner in the community hospital space where Cerner has historically been too expensive, specifically implementation support – complex integration.
• Siemens MobileMD is a sound HIE platform, Cerner would be better at packaging and selling it. We like Cerner’s ACO and population management approach, so CareXcell would be gone, or at least have a bake-off with Cerner’s PM solution, and Cerner’s solution would win because they have an install base.
• Siemens Intelligence could play a role as long as Soarian is not demolished.
• Love the Soarian business process manager — the rules engine is quite impressive.
• Siemens’ EDMS is better than Cerner’s and it is standalone.
• Siemens RIS — legacy, so that is not a question. Doubt if a proprietary PACS would be needed Cerner has an acceptable image management solution, but neither company is popular in radiology or cardiology.
• Siemens Lab is a legacy system that customers love. KLAS rating is high even though they do not really manage pathology very well (lab is standalone).
• Siemens Pharmacy and MAK works with Soarian – different platform, but functional. A keeper if there is a willingness to port the technology to the same Soarian foundation (pharmacy not so standalone).
• Cerner Millennium is difficult to install. Consultants who install Soarian do not have the same complaints.
• Cerner services are about as effective as Siemens services – they both lose equally to consulting firms that are or have a lot of ex-Cerner / Siemens implementation and project management personnel.
• Cerner could simply acquire Siemens for the client base and would, as most acquirers do, have a heavy hand in redundancy. However, Siemens has a surprising number of seasoned veterans if the transition is handled well and they don’t all run for the hills.
• Soarian is not worth burning, but acquisitions for market share are rarely kind. Usually they are disruptive to a point of discontent.
• Siemens need to prove a profitable community hospital IT model since Cerner hasn’t played well there. Over 3,000 hospitals have fewer than 200 beds and perhaps a Cerner Soarian campaign could help those most negatively affected by ACA.
• Both Cerner and Siemens have had challenges in the ambulatory space. Cerner touts its progress in ambulatory care, but it’s mostly IDNs with ambulatory care centers that serve as feeding conduits to the hospital. Siemens hasn’t made the commitment to acquire or build a viable product.
• The silver bullet for Epic is scalability. Even though Epic can control without collusion their pricing model, they cannot be the only choice for hospitals with fewer than 200 beds.

Acquisitions, Funding, Business, and Stock

GetWellNetwork acquires patient rounding and satisfaction system vendor Marbella Technologies.

Personal vital signs analytics software vendor Naperville, IL-based VGBio changes its name to PhysIQ and raises $4.6 million in Series A funding. The VA Center for Innovation is piloting the software in its VitaLink program, which warns caregivers of developing health issues by analyzing information from sensors worn by patients at home.

Oncology data vendor Flatiron Health moves its headquarters to a newly leased 15,000 square foot office space at 96 Spring Street in New York City.

The CEO of Roper Industries, speaking about its Sunquest division in Monday’s earnings call: “Sunquest had an all-time record quarter. There is Meaningful Use implementation and our ability to approve Sunquest’s ability to execute really paying huge dividends now, lot of upgrades in the hospitals. And we continue to invest very aggressively internally in Sunquest to capture more of the anatomic pathology and genomic testing opportunities that we see ahead. That’s lot of internal investment in there, but we’re also very active in the acquisition pipeline area around those areas … we’re going to expect double-digit growth for some time out of Sunquest that areas that we’re taking them into are very exciting areas. There is a lot of opportunity in the short run … It generates lot of cash.”

Sales

Nebraska Methodist Health System (NE) selects Strata Decision’s StrataJazz for decision support, cost accounting, operating budgeting, management reporting, and productivity improvement.

Advocate Health Care (IL) will deploy vendor management technology from Connance.

Comanche County Memorial Hospital (OK) selects Merge Healthcare iConnect Enterprise Archive and iConnect Access.

Eskenazi Health (IN) selects Streamline Health’s Looking Glass business analytics solutions.

Cape Regional Medical Center (NJ) will implement Summit Provider Exchange to connect its multiple EHRs to the NJSHINE HIE.

War Memorial Hospital (MI) will deploy the JEMS Telehealth System.

People

Quantros names Annie Callanan (Systech International) as president and CEO, replacing interim J.P. Fingado.

Steven Davidson, MD, MBA (Maimonides Medical Center) joins PatientSafe Solutions as CMIO.

Impact Advisors hires Tonya Edwards, MD (Bon Secours Medical Group) as physician advisor.

Dave Cannell (Deloitte Consulting) joins Cumberland Consulting Group as managing director of the company’s life sciences practice.

Announcements and Implementations

Cerner names Rainbow Services, Inc. (KS) as the test site for its Community Behavioral Health mental health EHR.

SSI introduces its A/Rchitect suite, which includes analytics, denial management, and contract management. 

Maryland’s CRISP HIE issues an RFP for a pilot to add image exchange to its query service.

Government and Politics

National Coordinator Karen DeSalvo writes a letter to the editor of the Boston Globe, saying that the paper’s story about EHR safety problems failed to mention positive EHR outcomes. She also pitches ONC’s proposed health IT safety center – the one Congress keeps saying ONC isn’t empowered to create.

A VA investigation finds that one of its pulmonologists copied and pasted old clinical information into its electronic patient records more than 1,200 times, possibly committing insurance fraud as a result if third-party payers were billed for his services. The unnamed doctor blames his “technical incompetence” and “stupidity.”

Innovation and Research

Baltimore startup Quantified Care, run by mostly Johns Hopkins graduate students and selling evidence-based mobile apps and hardware, starts a $15,000 Indiegogo fundraising (and PR-generating) campaign that offers an old-school but high-tech doctor’s black bag for a $300 contribution.

Other

A new Institute of Medicine report says that while taxpayers are spending $15 billion per year to pay for medical residencies and fellowships — much more funding than any other profession receives and giving hospitals cheap and obedient medical labor — the government imposes little accountability and the system is not producing the kinds of doctors needed. The report also concludes that the program overemphasizes hospital training, reflecting its 1960s-era origins in falling short on healthcare IT, preventative care, and chronic disease management. The report recommends making changes to Medicare regulations over the next 10 years to create a more accountable and performance-based system, then deciding at that time whether taxpayers should be funding graduate medical education at all.

Schools of osteopathic medicine, which grant the DO rather than the MD degree but are otherwise nearly identical except for their emphasis on community medicine and preventive care, are producing a third of all new medical school graduates. Last year, 144,000 applicants competed for 6,400 DO school spots. Sixty percent of new DOs enter primary care vs. 30 percent of MDs.

A CBS News report says that medical identify theft is “the low-hanging fruit” for criminals and is increasing dramatically because the healthcare system doesn’t protect their information and those whose identities are stolen don’t find out unless their bills go to collections. The article points out that the impact isn’t just financial – a patient could be given the wrong meds or blood products or have their insurance terminated. The article leads off with the story of a woman who almost lost custody of her children because a drug user gave birth using her identity.

It’s a Pyxis for pot: Medbox obtains patents for its biometric-powered marijuana dispensing technology. The company offers related services that include armored car cash transportation.

Weird News Andy notes “keeping cancer in the dark” as an animal study suggests that breast cancer becomes resistant to treatment with tamoxifen if the test subject is exposed to light at night, which suppresses melatonin production.

Sponsor Updates

• Frost & Sullivan awards Validic its best practices award for value and customer focus in healthcare interoperability solutions,
• Healthcare Data Solutions (HDS) releases a new white paper, “How EHRs Can Become More Than Just Vendors.”
• DocuSign posts an article called “Don’t Risk Your Health (Data) with Paper.”
• Beacon Partners posts a new blog entry titled “Four Questions the Proposed Meaningful Use Rule Doesn’t Answer.”
• ZirMed announces partnerships with JASE Health, HAS-Software, AmeriCare, medQ, and Scorpion Healthcare.
• University Hospitals (OH) expands its Premier relationship to include Premier Connect Enterprise as well as extending the supply chain services agreement for three years.
• Health Catalyst adds keynote speakers and sessions and expands the attendee limit for its Healthcare Analytics Summit 2014 September 24-25 in Salt Lake City.
• InstaMed announces that 70,000 healthcare providers have been paid through Member Payments since its launch one year ago.
• Predixion Software CEO Simon Arkell is named a finalist in the “Outstanding CEO” category of the Orange County Technology Alliance.
• Jen Reese shares how telemedicine technology is creating the need for doctors to have licenses in multiple states on pMD’s blog.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Morning Headlines 7/29/14

Lawmakers reach $17B deal on VA bill

House and Senate lawmakers announce a $17 billion plan aimed at addressing appointment wait times.  The bill would provide $10 billion for veterans to seek medical treatment from non-VA providers, with another $5 billion going toward hiring additional medical to help the VA keep up with appointment demands.

Almost half of Kaiser Permanente members book appointments, request refills and send messages online

A new Kaiser Permanente report claims the health system’s portal and mobile app saw 131 million visitors during 2013. Kaiser ties their web presence to impressive gains in medication adherence rates and chronic disease management.

Early Q2 financials show reform benefiting hospitals’ bottom lines

The ACA is generating increased patient volumes, and thus having a positive impact on quarterly earnings for publicly traded hospitals, according to Modern Healthcare.

Geisinger CEO will step down

Geisinger Health System CEO Glenn Steele, MD, will retire next year after 12 years leading the organization.

Curbside Consult with Dr. Jayne 7/28/14

I had a chance to catch up with an old friend this weekend. He’s an OB/GYN, and as an employed physician, he’s had EHR in both the hospital and ambulatory settings for years.

Their efforts have resulted in massive amounts of data that can be mined to improve patient care. Surgeons can easily access their own outcomes data and compare morbidity and mortality data when incorporating new techniques (such as robotic surgery) into their practices.

There’s a dark side to that big data, however, and it’s starting to rear its head.

Although most laypeople are aware that babies are going to arrive when they’re going to arrive, administrators at his hospital may have missed that part of health class. They’re creating reports looking at delivery times and labor lengths under the guise of optimizing patient care. The seedy undercurrent of their research, however, is a desire to reduce staffing costs. Although they haven’t overtly said it, he suspects they’re on the verge of asking physicians to start acting in the hospital’s best interest rather than the patient’s.

I delivered babies at the beginning of my career. When you’re caring for a mother in labor, it can be hours of waiting punctuated by moments of terror. Although delivering a child is a natural human process, in the US, we’ve medicalized it for a variety of reasons. As a result, over the past quarter century, we’ve seen an increase in the percentage of babies delivered surgically (it sounds a little scarier when you say it that way, rather than “by C-section”) and there have been concerted efforts to try to reduce this trend.

It’s not just a problem in the United States. The World Health Organization has set a goal of 15 percent C-sections as realistic number for the procedure. In the US, it’s at about 28 percent, in Britain it’s 25 percent, and in Brazil, nearly 80 percent of women delivering in private hospitals have C-sections. Some blame cultural factors for the rise in the procedure. The ability to deliver “on schedule” is certainly a plus for some women as well as for their physicians. Others blame our medical payment system, because reimbursement is higher for a surgical delivery.

It’s not just C-sections, though. We’ve seen a rise in labor inductions, where drugs are used to start labor, often before the due date. Although there are definitely medical reasons when this might be indicated, it had become so prevalent (one in every five women) that ACOG, the OB/GYN professional organization, issued revised guidelines to try to ensure appropriate use of medical interventions.

Why would someone want to electively deliver a baby (through induction or C-section) anyway? Some blame the risk of litigation in the case of a poor outcome. Others blame physicians who want to deliver babies at their convenience. In my practice, I had a fair number of women request induction because they live far from their families and wanted to schedule the delivery to ensure relatives could travel to assist with the baby or help with young children at home.

In countries that spend a lot of money on post-partum home visits or in-home assistants, this may be less of an issue, because women may feel more supported at home after a delivery. Data is shared between community-based caregivers and coordinating physicians so that care can be delivered outside of the hospital. That kind of care has a cost, though, and isn’t an option for many US women, hence the request for inductions.

When thinking about cost controls, however, the idea of asking physicians to intervene in the labor and delivery process to try to better match facility staffing capacity is just too much to accept. Using data in this way sets us on a very slippery slope. What’s a little extra Pitocin? We can convince ourselves that it would be better for the baby to be delivered sooner than later, and if it happens so we can deliver before shift change, so much the better. Looks like the extra drugs may be creating some fetal distress, better prep the OR.

I haven’t delivered a baby in years, but I can’t imagine the stress of having my labor and delivery management decisions questioned by someone who has motives other than reducing maternal and neonatal morbidity and mortality.

Pregnant women are some of the most empowered patients I see in practice. They have more time to research various options and choose the best for themselves and their families, unlike patients facing cancer, injuries, and other unexpected issues. They share the knowledge of how to fight back against the medical establishment (as proven by anyone who has had a patient arrive with a 20-page Birth Plan) and are increasingly demanding of alternatives to the hospital birth experience. Many women in my area are using Doulas and Labor Coaches to have a dedicated patient advocate with them if they do deliver in hospitals. Some can cite the labor and delivery data and the risks of interventions better than a med student prepping for boards.

If the hospital is serious about this, I hope the physicians and nursing staff stand their ground. Better yet, I hope the patient community gets wind of it and reacts strongly.

As for my friend, he’s trying to work from the inside to convince hospital leaders that this is the wrong way to use big data. I hope he’s successful, but I also know he’s fearful for his job as an employed physician.

Have any other examples of misuse of Big Data? Email me.

Email Dr. Jayne.

HIStalk Interviews Linda Reed, CIO, Atlantic Health

Linda Reed is VP of integrative and behavioral medicine and CIO of Atlantic Health System of Morristown, NJ.
 

Tell me about yourself and your job.

I’m the vice president of integrative and behavioral medicine and chief information officer. I’ve been at Atlantic Health 10 years. For the first six, I was vice president and CIO.

About five and a half years ago, I got integrative medicine, which is massage, yoga, supplements, functional medicine, and acupuncture. Then about three years ago, I got behavioral health. One of my doctor friends here says, “Who did you annoy that you were able to get such a wide variety of things?” It’s funny because I tell the CFO here that I’m like the empress of everything that is expensive that makes no money. It’s interesting. My day is right brain, left brain.

I’m a nurse by background. I’ve been a CIO for almost 20 years. I just love what I do every day. I’m an activity junkie and this job really suits that.

How much of your IT effort is focused on plumbing type work like Meaningful Use and ICD-10?

I’d say it’s probably 60 or 65 percent.

We try really hard to do some other interesting things. We’ve put a lot of effort into mobile health. We’ve got a mobile health strategic plan. We just published a mobile health app. Taking a look at some interesting new and different kind of things to do with mobile health. We’re trying to spend a lot of time there doing a little more with telemedicine. There’s all this new, cool stuff you want to do, but you’re really anchored back in the ICD-10, Meaningful Use world.

We’re doing a lot of acquisition. We’ve added two hospitals in the last three and a half years and we’ve got one more coming at the end of December. They’re all different. One hospital was on a really old platform, not the one that we’re on, so we kind of ripped and replaced. The second one that we got had put some money into the platform that they’re on, so we decided to leave that one alone because they had attested. The third one that we’re getting is a little bit of both. They’ve got two different systems on the front and back end, so we’re still looking to see exactly how that one’s going to transition in. We just went live on Tuesday with a brand new ambulatory system for our physicians. It never stops.

Which ambulatory system did you go live on?

Epic ambulatory.

Are you still primarily a McKesson shop?

Yes, we’re still McKesson.

They’ve sent some mixed signals about their healthcare IT direction. How do you see that playing out?

Their direction is Paragon. The hospital I said that had a pretty good platform that we left in place is Meditech. 

We belong to a consortium called AllSpire. That is us, Lehigh Valley, Lancaster General, Hackensack Medical Center. Of the seven members, four are already on full Epic.

We know the direction McKesson is going with Horizon. We’re going to have to make a decision in the next couple of years as to where we’re going to go. We know we’re not going to stay on Horizon.

My job is to try and give the organization options. When you take a look at what’s going on in healthcare and you start looking at the trajectory of hospital buy-ins, can you really justify a huge expense?

Nobody goes ambulatory Epic unless they’re going inpatient as well. Isn’t that predetermined?

I don’t know. I’m not really sure. Before we did this, I talked to a number of consulting companies. How much cross do you have between the people that come into your ambulatory and are in the hospital? How much back and forth do you really need? Could that be done by a summary of care, CCD, and CCDA? I’m not sure — that might be.

We’ve got a direction we could take, where we have like-for-like licenses because of all the investment we’ve made over lots of years. We’ve got an option for an integrated platform that already exists in one of environments — it might be something we want to do. We’ve got a third option that we’ve already got the ambulatory component in, and then if we wanted to work with our partners in our coalition, we could do that. What I’ve tried to do is try to give Atlantic Health multiple options to choose from.

What do you think the driver will be as to which way they go?

I think it will be looking at where we are from a volume perspective, where we want to be on the risk side, how much we want to manage what we have.

We’ve got two accountable care organizations. If we do a good job in that realm, aren’t we going to be driving patients out of our own hospitals? If we do that, we want a really, really robust ambulatory system along with population health management, analytics, and care management tools. How big does the hospital system really now have to be?

Have you looked at any of those technologies for ACOs, population health management, and analytics?

No. We stepped in gingerly. We took our time. We tried to use what we had in place.

We started off with RelayHealth. We’ve been a big user of RelayHealth for many years. RelayHealth provides the platform for our regional health information exchange. We’ve got 30 hospitals on that here. We started off with that, and then we moved into some business intelligence. We have MedVentive for population and risk management. McKesson does a lot of work in the payer space for disease management, so we’re working with them right now on putting in their care coordination tool.

We spent a little time understanding what it is we needed to do, then tried to put a few technologies in to be able to do that. We’ve got the business intelligence. We’ve got to work on the care coordination tool — that’s next. We’ve got Relay to do some of the health information exchange.

We use Imprivata Cortext, a secure texting tool. We’ve built specific directories for the ACO physicians so that they can now use that as a secure referral tool for each other.

I’ve been a customer of Imprivata in multiple organizations. They’re an easy company to do business with. I’ve used their OneSign. Our doctors love the tap-and-go because they all have their little card and their one workstation. They don’t even log off, they just tap. It closes the screen and they tap it again wherever they go — it brings up their session wherever they are. They just love that. We started using their secure texting about a year ago.

They’re using Imprivata Cortext it as their communications clearinghouse so they don’t have to play phone tag? They just send the text message and walk away?

That’s right. Our ACO put together a per-member, per-month incentive for physicians up front so the physicians don’t have to wait until savings at the end of the year. There’s a number of different sections there. There’s one for the use of technology. If they use RelayHealth, if they use Imprivata Cortext, if they automate their offices, they get a certain amount of money. For some process measures, they get it. For some outcomes, they get it. There’s a couple of other things. Their whole per-member per-month incentive is based on certain activities that they do.

I assume you need to analyze your data across the Epic on outpatient and McKesson and Meditech on inpatient. What are using for a data warehouse?

We use Horizon Performance Manager. The pop stuff all comes out of MedVentive. MedVentive has data from the EMRs, from the HIE, and whatever they might need from the hospital.

Are you looking at any technologies that can help support the clinician-patient relationship and patient engagement?

Our app is a patient-facing app. We’re constantly working on we help physicians and patients communicate.

A number of years ago, we put in RelayHealth, which had secure messaging with physicians. I had one doctor say to me, “ I will never, ever, ever, ever trade an email with a patient.” Then about a year ago, she came back and she said, “That’s not so bad.” She was telling another doctor, too, “I talk to my patients on email all the time.” It’s really interesting to see the dynamics. I think we’re probably going to be looking at doing something very similar on the mobile front.

Tell me about the mobile app.

It’s called Be Well. We have one for each one of our hospitals, because our physicians are more specific to our geographic area. It’s got a physician directory, ED wait times, and a whole bunch of different health trackers, including a way to download your Fitbit information.

Did you develop that yourself or have it developed?

We worked with a company called Axial Exchange. Everybody today will tell you that it doesn’t make any sense to go out and do that kind of work yourself when there’s just so many other companies that you can work with. 

There’s a health encyclopedia in there, but it’s the same kind of health encyclopedia we use on our website. For us, now we’re migrating from the web to mobile. That’s where we’re going there.

As a nurse, do you think nurses are underserved as far as technology that helps them do their clinical role rather than just documenting so that somebody else can send a bill or have the doctor read their notes?

That’s an interesting question. We put in Vocera a lot of years ago now. One of nurses’ biggest issues was the phone tag that they were playing with doctors. They don’t all carry around organizationally-provided smartphones. From an access to information, it could be more helpful if they did.

Do you discourage them from using their own?

We don’t. We do discourage them from SMS texting on their own. It is one of the reasons why we went out and got Cortext. Just telling people not to use SMS text and not giving them something to use makes no sense. It’s like spitting in the wind. 

The interesting thing about nurses is that we’ve got those computers on wheels. They’re on those things all the time. To take them off takes them out of their work flow. The Cortext component has a PC-based user interface, not just mobile. You can be on the COWs or you can be on the mobile.

Right now for nursing, I think it’s moving in that direction. I just don’t think that it’s quite as mobile-enabled as some of the physician tools right now.

What are the organization’s biggest strategic issues that need IT help?

Care coordination is huge. We’re kind of schizophrenic because we still are fee-for-service and we still are doing procedures and patient care in the hospitals, but we also have these ACOs. While we still need to be able to get people in and have great turnaround time, decrease the length of stay, get more turns in as much as we can, on the other side, we’re still working on how do we keep people out of the hospital and in the ACO and keep and have that gap and address all the gaps in care and the transitions of care? 

It’s like two different initiatives that we’re working on. We still have to keep the whole patient engagement and satisfaction thing going on the other side.

One of the things we did a few years ago –it’s on paper and we’re just getting ready to take a look at how to automate it — is we had created a patient itinerary report. One of the big things that patients always complain about is that they don’t know what’s going to happen to them during the day. We created a report that pulled it from different parts of our technology — what’s the patient’s name, why are you here, when did you get here, who are the care providers on your case, what medications are you on, what labs did you have ordered for you, what were the results of the labs that you had yesterday, are you going for any other tests? Then there’s a little spot for “questions to ask my doctor.” That really was pretty popular and the patients seemed to like that. We’re probably going to automate that. 

One of our next ventures in the mobile space is probably a bedside app that would give you that whole access to “my care team, my itinerary, my meds.” We also have that on our TVs right now, but we’ll look at putting it on an iPad.

Most hospitals would use an interactive patient system approach and put it on the TV, but you’re going to give patients iPads. Has anyone done that?

No. There’s a couple of places that are looking into doing it. There’s also a company out there called PadInMotion. They do some of that and they also give patients access to like Netflix and things like that on the iPad. 

The more of this education stuff that you’re going to put in front of patients, a TV on a foot wall is really a tough user interface to give patients unless the thing is like 120 inches. I don’t know how big the screen has to be. Giving them an iPad is probably a good way to do that, but again, we also have to take a look at the patient population. When my dad was in the hospital, he could barely work the remote control on the TV, much less an iPad. It’s just trying to meet the needs of the patients that are there. You have to have multiple user interfaces to help patients through all the technology we throw at them.

Physicians are moving, or moving back, into leadership roles in health systems. What advice would you offer nurses who want to move into leadership roles outside of nursing?

Don’t say no to anything. I have a job today that practically didn’t exist when I first started in my nursing career. Take on any opportunity. 

The one thing that sometimes you see with nurses is that they like to have things that are very concrete. It’s interesting because we work on the fly every day. We are the leaders of multitasking. But sometimes I think having a job that doesn’t have a very concrete job description or isn’t very clear on the time or the hours or the responsibilities — I think they shy away. They don’t realize how freeing a job that’s maybe not quite baked can be, because you can bake it yourself.

Nursing is also very isolating because you’re in those nursing units all the time. Sometimes you don’t get a lot of opportunity to meet and speak to board members, meet and speak to senior leadership. You’re just tucked away enough that you’re not exposed. That’s the other thing–say yes to any committee. Get out of the nursing unit and get some exposure.

Do you have any final thoughts?

For anybody who’s in a hospital and just thinks of healthcare as a hospital, where we are going should be frightening to you. We’re not going to be a hospital, especially if we start taking a look at the people who are going to disrupt us the most — retail medicine. 

We have to start thinking about ourselves as the providers of retail medicine. We have to think about fast access, customer service, the customer’s always right — those things that you’ve traditionally heard about retail environments. We have to stop thinking about healthcare as a civil servant-type environment where you call and you get an appointment four weeks later. It’s going to change everything we do. We’re going to have to get faster, better, and more consumer friendly very quickly.

Morning Headlines 7/28/14

Departments of Labor, Health and Human Services, and Related Agencies Appropriation Bill 2015

The Senate Appropriations Committee cuts ONC’s requested $75 million budget for 2015 down to $61 million and adds a stipulation that ONC should decertify and publicly report any EHR vendors that “proactively block sharing of information.”

NPA seizes over R1bn contract claims

In South Africa, a $133 million Siemens implementation is put on hold over allegations that the local Siemens reseller engaged in bid-rigging to close the deal.

Self Regional announces security breach of patient info

Self Regional Hospital (SC) announces a data breach affecting at least 500 patients stemming from a Memorial Day office break in that led to the loss of an unencrypted laptop.

Board recaps fair at monthly meeting

In a local article, 71-bed Nevada Regional Medical Center CFO Greg Shaw blames its Cerner billing system for the hospital’s $5.6 million YTD net loss, claiming that the system incorrectly classified insurance payers and aging accounts.

Monday Morning Update 7/28/14

Top News

A draft report from the Senate Appropriations Committee, responding to HHS’s FY2015 budget request, proposes to give ONC $61 million of the $75 million it requested. It adds that ONC should publicly report and then decertify EHRs that “proactively block the sharing of information.” It also wants the Health IT Policy Committee to create a report describing the challenges to interoperability and whether certification helps or hinders it. Reading down the long list of funded projects, it’s depressing to see how much taxpayer money is being dumped into government programs that claim to help one issue or another. All that aside, the interesting dynamic here is that ONC, like every government agency unwilling to reduce its budget or authority, keeps trying to expand its mission while Congress seems to think it is overstepping its authority and questions its effectiveness. I suppose $75 million is a rounding error in the federal budget, but as a taxpayer, I might question ONC’s value, along with what I’m getting for my $25 billion in HITECH handouts to providers who mostly regret having given up control in return for strings-attached government money.

Reader Comments

From EarsToTheGround: “Re: Siemens. Well-placed sources say they’ve been told that their consultant and contractor positions are being terminated by the end of September as they phase out several EHR vendors. I don’t know if this is related to the possibility of a Cerner buyout.”

From All Hat, No Cattle: “Re: pic from the Redwood Mednet conference in Santa Rosa, CA. I see the audience is a lot of older hippie types and open source geeks like Wes Rischel, Will Ross, John Mattison, David McCallie, etc. discussing HIEs with John Halamka.” There’s nothing like that "bald spot meets gray ponytail" look when it comes to self-identifying as an IT geek or that vaguely creepy “stuck in the 1970s” sound guy at the local music bar who doesn’t have the talent or nerve to be on stage but toils in the worshipful shadows of decades-younger musicians who do.

From Laredo Dave: “Re: Weird Al. Almost every buzzword you have ever heard, all in one video.” I’ve always detested Weird Al and his heavy-handed, sophomoric parodies of current events, but this one might make me a convert since even the music is good (very CSNY-like). It even includes one of my least-favorite, unnecessary pseudo-words: “administrate.”

From Lupe: “Re: Childhood Cancer Awareness Month. It’s in September. I don’t have a million dollars to give for research, but I am the very lucky mother of a 16-year-old diagnosed a year ago. My goal, short of a cure, is to make the gold ribbon representing these horrific diseases as recognizable as a pink one for breast cancer.”

From PP: “Re: Android tablet. Which inexpensive one did you buy that you liked quite a bit?” I got an Asus MeMO Pad HD 7 in December 2013 for $119 when it was on sale at Office Depot, frustrated that a newer version of my first-generation iPad was more expensive than a laptop. I still use the Asus tablet regularly and have no regrets. Android-powered tablets are just as good or better than the ones Apple sells for multiple their price, which may be why iPad sales are nosediving. I’m a casual user (checking email, looking up stuff on the Web,  watching Netflix, and reading Kindle books around the house, all over WiFi instead of cellular), so I don’t need a $499 iPad Air or even a $229 Google Nexus 7. The just-released latest model of the MeMO Pad is $134 on Amazon.

HIStalk Announcements and Requests

The intrepid Dim-Sum provided a detailed update about the Department of Defense’s EHR procurement, so I posted it separately.

Athenahealth provided a response to the question from Watertown Boy about the effect of the company’s updated Meaningful Use calculations on those practices that have already attested. I posted their comment under the original question.

Half of my poll respondents own stock or other equity of a healthcare IT company. I’m in the other half that doesn’t. New poll to your right: do EHR vendors have too much influence on related government policy?

Welcome to new HIStalk Gold Sponsor DocuSign. Its solutions allow business to sign, send, and manage documents in the cloud, making them available and legally enforceable. Healthcare organizations such as Blue Cross Blue Shield, Cedars-Sinai, HCA, and New York-Presbyterian use DocuSign to streamline document-based processes. The result is HIPAA compliance, faster patient inboarding, shortened turnaround time for Medicare billing, and faster handling of paperwork involving credentialing, supplier contracting, and HR. I interviewed the company’s founder, Tom Gonser, a few months ago. I have received documents that required DocuSign signatures and it was infinitely easier than printing, signing, scanning, and emailing. Try it yourself with the company’s 14-day free trial. Thanks to DocuSign for supporting HIStalk.

I’ve mentioned before the really cool (and free for personal use) remote control software I use: TeamViewer, from Tampa, FL. You can remote in to someone’s computer to fix something, remote into your own desktop from your phone, transfer files, and even hold online meetings or training sessions for up to 25 people. It is unbelievably simple, reliable, and satisfying to use. Just this week I’ve used it to remote into a colleague’s PC to diagnose a Windows problem and to remote into my home desktop from my phone.

Listening: a new hard-rocking single, “Cool Kid,” from The Eeries, an unsigned Philadelphia band. Also: Young the Giant, great California indie rock. Here’s one more, this one with a healthcare IT angle: VEX (above), a locally popular early 1980s college punk band (Georgia College & State University) featuring a young Larry Stofko, now EVP of the Innovation Institute of St. Joseph Health System of Irvine, CA. VEX’s music is now on CollegeBand, which tracks down long-defunct cult college bands, digitizes their music, and sells it along with merchandise and music rights for movies and TV. That’s my kind of business.

Last Week’s Most Interesting News

• Cerner turned in another solid quarter with record quarterly numbers. Epic may be winning most of the high-profile health system deals, but Cerner’s win rate is creeping back up, its Intermountain partnership looks promising, and the company has diversified itself into enough areas of healthcare that its future isn’t dependent on new Millennium sales. Both companies will benefit as Siemens shops its IT division and McKesson sends mixed signals about its health IT commitment.
• The Boston Globe reviewed EHR safety in a wandering, anecdotal article that decried a lack of mandatory EHR problem reporting and the overall influence of vendors on government policy. It uncovered new information in revealing that a recent study of 5,700 malpractice claims found that EHR-related issues contributed to 46 patient deaths, although the study’s definition of EHR harm was loose: it included incidents involving missing information, incorrect user entries, and problems with providers trying to run EHRs and paper systems at the same time.
• Two UK hospitals signed huge deals with tarnished vendors. North Bristol will replace Cerner Millennium with CSC’s Lorenzo, whose legendary vendor shortcomings (both product and implementation) killed the government’s $20 billion NPfIT, while the trusts overseeing Watford General Hospital signed a $44 million infrastructure contract with CGI, most widely known for its deep involvement with the failure of Healthcare.gov.
• Leapfrog Group’s annual report found higher hospital CPOE use, but a third of those systems fail to detect major ordering problems.
• NantHealth SVP Dave Dyell confirmed an HIStalk reader’s rumor report that he’s leaving the company, Patrick Soon-Shiong’s wildly ambitious conglomeration of a billion dollars’ worth of acquired companies. One of those was Dave’s former employer, medical device integration company iSirona.
• Health Evolution Partners, a healthcare IT investment vehicle launched by former National Coordinator David Brailer when he left his government position in 2007, appears to be on its last legs. Its only investor, California Public Employees’ Retirement System, wants to cash out after the rookie private equity manager Brailer delivered years of near-zero investment returns despite promising 20 to 30 percent annually. HEP lists seven current portfolio positions, none of them related to healthcare IT.

Webinars

August 12 (Tuesday) 1:00 p.m. ET. City of Hope Improves the Cancer Patient Experience With Salesforce.com. Sponsored by Salesforce.com. Presenters: Fred Stevens, director of call center operations, City of Hope National Medical Center; Todd Pierce, EVP of operations and mobility, Salesforce.com. Learn how City of Hope improved patient satisfaction and intake inquiries in 16 areas, gave 75 call center representatives the information they needed to deliver a personalized and seamless interaction, improved first-call resolution, and reduced average call transaction time by 42 percent (90 seconds) for over 1 million inbound calls per year. A live demo of Salesforce1 will follow.

Acquisitions, Funding, Business, and Stock

From the Cerner earnings call:

• Sales revenue was up 15 percent and the total backlog is at $9.69 billion.
• The company says many population health vendors are not aggregating and standardizing data across multiple systems, which makes them of limited value. Cerner says it offers more of a CRM-type system that includes registry functions, data warehouse, analytics, and patient engagement.
• The ambulatory user count increased to 65,000, double number from “just four years ago” as the company says it is displacing key competitors.
• Cerner says it is commit to “having the most open EMR,” whatever that means when marketing-minded companies claim they have it while scoffing at open source alternatives.
• The company says its services and hosting offerings differentiate it from competitors.
• An analyst asked if Cerner would have a rich opportunity to earn business from clients of Epic given that Epic is “relatively uninterested or unmotivated in pursuing pop health based on some of the chatter in the marketplace.” Zane Burke declined to comment, saying only that the industry needs EHR-agnostic solutions and Cerner’s will work with any EHR.
• Marc Naughton said that Cerner will have more specifics on their Intermountain project next quarter.

I missed this earlier announcement: Google launches Calico, a health and wellness company that has already hired four prominent physicians and named as its CEO the board chair of Apple (who is also board chair at drug maker Genentech.) It seems that Google is dipping toes all over the healthcare waters right after Google co-founder Sergey Brin complained that it’s a waste of his time because it’s too regulated. Maybe he was just being cranky over the FDA’s pressure on his wife’s consumer genetics business 23andMe, which still hasn’t complied with FDA’s requirement that as a medical device, it has to submit validated proof of its accuracy to earn the agency’s marketing approval.

People

Surgical Information Systems names Jim Linder (Norwest Equity Partners) as acting CEO and executive chairman, replacing Ed Daihl.

Announcements and Implementations

 

Healthgrades joins athenahealth’s More Disruption Please program, giving athenahealth’s practice customers the ability to post appointment availability online for patient self-scheduling. In the spirit of disruption, I would urge Healthgrades to stop sticking the superfluous “Dr.” in front of every provider’s name – we understand that MD is a doctorate without needing its conferees redundantly identified as “Dr. John Smith, MD.” Every time I see that, I think of chiropractors and podiatrists, whose DC and DPM credentials don’t provide adequate ego stroking since many people don’t know what they mean. “Dr.” in front of a name should be used only in social situations where you might otherwise use Mr. or other titles – it should never be used on a website, business card, sign, online article, or obituary unless you want to emphasize your smug pomposity.

Technology

Qlik announces availability of a free desktop version of its data visualization and discovery tool.

Other

The CFO of 71-bed Nevada Regional Medical Center (MO) blames its Cerner system for ongoing financial losses, saying that its incorrect billing requires the PFS department to analyze claims by hand. IT Director Chris Crist adds, “There’s a lot of problems from the Cerner perspective. Service requests, work orders, take a lot of time to stay on top of, and if you don’t respond to Cerner within a certain amount of time, they close the request.“ That’s a major black eye for Cerner given that its Healthy Nevada community health project is also in Nevada, MO and the hospital ended up with Millennium as part of that deal. The hospital’s CEO provided a predictably laudatory Cerner quote when Healthy Nevada was announced in July 2012, but she and the hospital’s board agreed that it was time for her to leave in February 2014.

In South Africa, the government freezes the Siemens-related EHR and radiology system contracts of Gauteng Department of Health, worth $133 million, following allegations of bid-rigging. The winning bidder of the 2007 tender, Siemens reseller-controlled Baoki Consortium, provided a health department executive with free housing. Prosecutors added that the bid was issued even though the health department didn’t have the money, infrastructure, or trained users to operate the proposed systems for 37 hospitals and 300 clinics. The systems were never implemented. The contracts were terminated in 2009 when new a Member of the Executive Council was elected. Siemens has been named innumerable times over many decades as being involved, directly or otherwise, in bribery-related contract awards, although it was a subcontractor in this transaction and wasn’t accused of doing anything wrong.

Self Regional Hospital (SC) goes public with the news that a laptop stolen in a Memorial Day weekend break-in contained information on at least 500 patients. The laptop was not encrypted. Police arrested two suspects, who said they panicked and threw the laptop into a lake. Perhaps the hospital’s apparently lack of technology sophistication in failing to encrypt PHI-containing devices extends to its website, which automatically starts playing the cheesiest, blandest royalty-free music imaginable as soon as its home page displays, with no option to shut the racket off.

Bonny from Aventura did some self-study on the CMS “Two Midnights” rule and decide to memorialize her newfound knowledge as a cartoon.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

DoD EHR Update from Dim-Sum 7/28/14

Use cases. My goodness, is there anything more exciting than creating “To Be” scenarios where major COTS vendors can look at the DHMSM scenarios and can say with a suspicious smile, “Is that all they want, is that all they need?” The features and functionality exist in today’s EHRs. However, the operational and technical architecture to pursue this capture are complex. Not impossible, but complex.

Will a single environment that shares clinical data be enough to support a global clinical data vault? How can any team perfect performance and balance that with improving the delivery of military health? How will synchronization improve and not attenuate data collaboration? Do EMPIs become active participants in providing a variety of global patient identification aliases? Commercial EHR solutions are being deployed each and every day across the United States that meet the DHMSM requirements outlined in acute as well as ambulatory environments. How can we translate those lessons learned in to the psyche of our service integrator / partner / prime?

Now for THEATER.  In my experience with beltway software vendors, I can say with a degree of confidence that they cannot design from scratch a theater-worthy solution. These folks seem to think COBOL is cutting edge and that FTP/SFTP transfers are the only conveyance vehicles for data. These are the same folks that design their user interfaces to look like Microsoft Access or a DOS-based Excel worksheet with enough data to push all the data available in the local database. This equates to a single chaotic and cluttered view.  

Workflow means something! It really does. It is not just a word on a marketing slick. Understanding how the clinician (I am including down range medics here), technologist, and nurses work. Teams have to take the time to talk to clinicians. Translate those conversations in to a cogent way to view data respective of the clinician’s specialty.  Establish when and where it is essential to provide drill-down views — a nurse does not need to have 14 alerts that sourced data pulls from a year ago on a bunion. Data view is about relevance and moving the patient and their care along an uncluttered path. With that lesson in mind, it is my assertion that it is a mistake to assume that a CMMI software development firm could actually provide a salient solution for theater. If you doubt this, take a look at the systems that are put together today.

The smart architects will solution along the lines of repurposing a backbone of an existing patient-centric portable EHR and emergency / occupational health solution(s). Heaven forbid we take a look at solutions that actually have a client base. Low communication and non-communications standalone systems exist – they can provide portable clinical applications that can bridge the combat medic with resuscitative care as well as make the wrinkle in patient timelines affected by airevacs merely a data entry point — a step in patient care. I understand that many believe it is as complex as ear hair removal for men hitting their middle ages, but it is easier to fix than that.

The ultimate theater solution will become an invaluable transfer tool rather than a manual harbinger of medication mis-management and shadow record keeping. Therefore, the theater challenge is keeping data succinct, aligning casualty care with best practices, and an enabler for medics to stabilize data transference in preparation for transport away from harm and to the safe harbors that military medicine can afford. A transfer is a transfer, not unlike moving a patient to a skilled nursing facility or stepping a patient from critical care to a more mundane and therapeutic homeostatic environment. Recovery, therapy, and rehabilitation are the natural progression. Why not assume that the element most needed to evacuate a patient should connect rather than be an island of information that cannot be assimilated and or aggregated after the clinical data is needed?

Clinical decision support requires algorithms and data entry at key intervals in care no matter the monitoring mechanism. Closed loop medication begins with initial care folks! The perfect test bed is to automate the airevac Patient Movement Record. This has to be done and is crucial for survivability and clinical collaboration at the next point of care. Telehealth has a role and cannot only be focused on monitoring, but on collaboration and en route data transference / collaboration. Tc3 needs to add a C for computerization to embed all elements of care allowing intra- and inter-theater transfer of patient-centric data to the folks that need it most. Blood means life, as does airway management, shock management, and the medic’s ability to simplify the medication, pain, and sedation med management.  

In a nutshell, it means that the service integrators cannot rely upon CMMI firms to take an innovative approach to the theater solution. These firms lack the fundamental qualifications necessary to understand patient care and the continuum that translates into lives saved. Teams have to marvel at the way military healthcare is provided today in spite of the shortcomings of poorly constructed and non-integrated clinical solutions that have been acquired to date. No finger-pointing, just an observation as a clinical HIT guy.

Perhaps the best place to start is by simplifying and modernizing the medical terms used across all data dictionaries and tables. Design “practical” pathways that can be assumed at the next duty station, base, and post. Data liquidity and actionable analytics can only be realized with a focus on the patient and the care he or she receives. I believe that today data (in the military theater) is deemed as a commodity that needs to be dissected for affect, rather than a kinetic, ever-changing, non-quantifying entity. We have to structure that which is unstructured and assume that sharing clinical data is not a burden, but a directive.

Patient identification is a challenge. We are aware of that. Someone has to lead and state that the axiom “right care, right time, right location” really starts by implementing a uniformed medical language. Patient identification reconciliation is the cornerstone of appropriate care and avoidance of medication errors. Interventions will occur with or without an EHR. Documenting it, though, has everything to do with adherence to standards so care can be provide in a seamless manner. Even if care started in some desolate stretch of land, the care initiation is key – ask any field medic.

What efforts are being made to ensure that we do not design the same menagerie of databases that cannot be deemed as up to date? Are data sources reliable when they were designed to spec to be isolated and un-retrievable? When you manufacture anything, you start with the end in mind. How could any reputable vendor equip any clinician an EHR contributor system without any thought of data integrity to share across the enterprise?

Believe it or not, the longitudinal care record is not a mythological creature. If it was, it would be  a unicorn with a bunion and the "As Is" would relegate care to a podiatrist instead of a vet that specializes in equine hoofcare. I fear that many of the beltway firms use archaic technologies and proprietary protocols that effectively eliminate the concept of one patient ,one record.

Understanding down range medical operations as well as the rules constructed to improve survivability means effective transfers of data. This is the only tenable path to measurable outcomes.

I do hope that myopic views will be avoided and that proprietary protocols will become a lessons learned and will translate into improving the way combat care is assimilated in to a viable path to healing.

In spite of ACA legislation, ARRA HITECH investments, and CMS incentives, the commercial EHR market is not expanding, but is instead becoming more and more consolidated. Vendors are trying to compete with strategic service organizations that leverage existing HIT solutions and endeavoring to focus on smarter ways to work, applying analytics to figure out improved ways of deploying service lines that make sense. DHMSM will receive solutions that can address the ever-changing landscape of healthcare and the manner in which clinicians deliver that care. The question is more along the lines of how will teams refine the way data is shared, how liquidity of clinical data can become actionable?

The “As Is” environment is daunting, not the challenge of feature and functionality requirements. Applying the same techniques used in the commercial market segments requires an understanding of how clinicians practice medicine. A great deal of time has been invested in understanding the military enrollment process the deployment systems and even where authoritative data is being sourced. This opportunity will be won — not lost by the way transition and education proliferation is managed, how parallel operations can be kept succinct and orderly.

The transient population of 1.4 million service members is relying on the teams that are pursuing an award, but the eventual winner has to be the troops we serve. This is not a DoD solution. It is an honor to know that the real customer is that lady and that man who wears the uniform of a US service. Sorry for the soliloquy, but this is my way to convey what is on the minds of men and women designing and solutioning every hour, if not on paper or in meetings, but in our minds.  Be innovative folks, and do not lose focus on what needs to be done.

I promise next time to throw salted pretzels at primes and vendors. After all, that is why I started my controlled rants.

Morning Headlines 7/25/14

Health-Care Technology Firm Cerner Posts Higher Profit

Cerner reports Q2 results: revenue is up 20 percent to $852 million and bookings for the quarter are up 15 percent to $1.08 billion, adjusted EPS $0.40 vs. $0.34.

North Bristol to swap Cerner for Lorenzo

In England, North Bristol NHS Trust will replace its Cerner Millennium EPR with CSC Lorenzo. North Bristol’s medical director says that Lorenzo “ We also have significant ambitions, and we were impressed with the vision and appetite CSC showed for working with us to build a truly world-class approach to patient care.”

Health Information Technology and Health Information Services: 2014 Mid-Year Review

Healthcare Growth Partners releases its healthcare IT mid-year review, which covers investments, M&A activity, and the expansion of the health IT footprint.

NEA Baptist Clinic and Hospital will soon be integrated with an electronic medical record

NEA Baptist Clinic and Hospital (AR) will go live on Epic across its entire organization, migrating from a previous vendor in its clinic and introducing its first EHR in the hospital.

News 7/25/14

Top News

Cerner reports Q2 results: revenue up 20 percent, adjusted EPS $0.40 vs. $0.34, meeting estimates of both. Orders for the quarter totaled $1.08 billion, the best Q2 in the company’s history.

Reader Comments

From Medium-Sized Data: “Re: data extraction. I challenge all of the companies promising world-changing analytics to extract all of your HIStalk posts to produce a list of hot topics by month and year, a cool infographic, or a detailed report.” That would be pretty cool. There’s a wealth of information in those old posts: tracking vendors that promised something that was never delivered, big announcements that were just hot air, and public perception items trended by vendor based on positive or negative HIStalk mentions. Companies are welcome to take a swing at it, and if they come up with something useful, I’ll toot their horn.

From Watertown Boy: “Re: athenahealth. In a recent email to clients, they announced what appears to be their problem in over counting some of the MU items. What happens to practices that already submitted this year?” A July 21 email to customers says athenahealth “identified a need to improve our calculation logic” and will complete that work by July 25, adding its apology to customers whose performance numbers will suffer as a result. Athenahealth provided this response:

There is no impact on eligible providers who have already successfully attested for Meaningful Use (MU) this year. Athenahealth takes great pride in the integrity of our data and we proactively monitor guidance and interpretations issued by the Centers for Medicare and Medicaid Services (CMS) to ensure our system remains accurate and up to date.  Accordingly, when changes that affect our measure calculation logic are identified, athenahealth works to make the appropriate system changes and notifies clients of all recalculations, as we did this week.  In the event of system changes that impact MU measure calculations, athenahealth supports providers who have yet to attest by recalculating all associated data to determine the best time for those providers to attest with the most up to date data.

From WellTraveledGal: “Re: Beacon Partners. Announced mass layoffs of sales and consultants. Paul Sinclair, formerly of Cerner and UnitedHealth / Ingenix, joins as sales VP.” President and CEO Ralph Fargnoli provided this response:

We have not had mass layoffs of sales and consultants. Beacon Partners continues to grow because of the excellent work our experienced team of healthcare professionals is providing to health systems throughout North America. Recently, we have realigned some of our business development and consulting personnel to better support the operational, clinical, and financial performance engagements of our clients, and to meet our goals for continued growth. As we execute our business objectives for the second half of the year, we are actively recruiting for both business development and professional services positions. 

From Boy Wonder: “Re: MU timeline for 2014. I wonder when your readers think CMS will announce a decision on the proposal to change the MU timeline for 2014? It better be quickly since many providers will be targeting Q4 as their one and only shot at MU2.”

From The PACS Designer: “Re: genome discovery. Genome sequencing will cost as little as $1,000, according to the CEO of Illumina. The company has an improved MyGenome app.” It’s a pretty amazing advance, but the really amazing one would be to figure out how we’re going to pay for treating the new problems such testing reveals. We love snazzy new diagnostic techniques and decisive interventions, but aren’t so great at making them affordable. The most amazing development would be to figure out a way to get people to lose weight, exercise, and turn off their phones and interact with others in a genuine rather than electronic way to move the population health needle. Genomic discoveries are cool, but our health problems have little to do with a lack of technology.

HIStalk Announcements and Requests

This week on HIStalk Practice: MGMA begins the search for a new CEO. Kansas Health Information Network and ICA announce a record number of HIE connections. Harbin Clinic and Cigna team up for collaborative care. ONC alludes to a specific interoperability timeline by 2015. PCC Director of Pediatric Solutions Chip Hart discusses the sometimes challenging world of pediatric HIT. The HIStalk Practice Reader Survey is live. Thanks for reading.

This week on HIStalk Connect: Dr. Travis discusses the new interest in health data aggregation from Google, Samsung, and Apple. Researchers with Cedars-Sinai have successfully tested a biological pacemaker concept in pigs. TechCrunch reports that women’s health apps are leading in the mHealth segment in both funding and consumer engagement.

My latest pet peeve: going to a company’s site and getting hit with one of those intrusive pop-up “your opinion is important” windows asking me if I want to take a survey. No, actually what I’d like to do is instantly leave any site that is clueless about annoying its web visitors with pop-ups. It’s nice to know your customer better, but nicer still to not drive them away with heavy-handed tactics whose only benefit is to make some marketing VP feel like they are contributing to business success. At least the HIMSS version doesn’t require answering before proceeding, so even though it’s annoying, I can live with it.

Listening: Phantom Planet, Southern California indie pop that’s been around for 20 years minus a hiatus or two.

Acquisitions, Funding, Business, and Stock

Quality Systems, Inc. (the NextGen people) reports Q1 results: revenue up 8 percent, adjusted EPS $0.13 vs. $0.24, beating revenue estimates but falling short on earnings. The hospital unit continues to turn in poor performance with a loss of $3.5 million. Overall, bookings were down, earnings were down, and expenses were up.

Streamline Health reports Q1 results: revenue up 7 percent, EPS –$0.16 vs. –$0.24.

The parent company of Lumeris announces $71 million in new financing from new and existing investors, which it will use to boost its population health management capabilities and expand from eight to 20 markets for its value-based care solutions. The parent company’s other companies are Accountable Delivery System Institute (accountable care education),  Essence Healthcare (Medicare Advantage plan), and NaviNet (communication network).

Sales

Aspirus (WI) chooses Strata Decision’s StrataJazz to help manage costs in its six hospitals. 

New Haven Community Medical Group (CT) chooses athenahealth’s PM, EHR, and patient portal.

In England, North Bristol NHS Trust signs for CSC’s Lorenzo EHR, replacing Cerner Millennium. Lorenzo was the only choice offered with the now-defunct NPfIT, but previous owner iSoft and then CSC repeatedly botched implementations and missed deadlines, which was arguably the main reason that NPfIT went up in a $20 billion taxpayer-funded mushroom cloud in 2013. North Bristol admitted that its $37 million Millennium system was nothing but trouble right after its December 2011 go-live, much of that due to its own failings in not testing and training well, shortcutting data migration, and letting IT run the project. The go-live resulted in cancelled surgeries, incorrectly assigned appointments, and patients who were sent home because doctors couldn’t access their records. The trust also admitted it had underestimated Millennium’s cost, drawing the ire of government officials demanding to know why the average trust implementing Cerner was spending three times as much as those going live on System C’s Medway, which was later acquired by McKesson and then recently sold off to Symphony Technology Group as McKesson dumped its European IT business.

Healthcare Growth Partners issues its always-insightful and downright eloquent healthcare IT mid-year review. This snippet is as brilliant as anything that’s been said about our healthcare challenges:

Inefficient markets typically result in a mispricing of goods and services. The cause is often due to monopolies, poor regulation, and a lack of market transparency. Each is a contributor to inefficiency in the US healthcare economy, but the primary shortcoming is the lack of market transparency, or information, needed to define the cost and quality of goods and services, otherwise known as value. In many markets, information is a tool for power and a proprietary competitive advantage. However, healthcare is not like most markets. Healthcare information is unique because it serves both a humane and a commercial purpose. At stake is the health of family, friends, neighbors, and ourselves, as well as the economy and corporate profits. Healthcare information exploited for the benefit of a few compromises the efficiency of the healthcare system as a whole. Nothing makes this clearer than the abysmal statistics of healthcare in the US. The power and profit potential for disruptive innovation in this nearly $3 trillion market is unfathomable. The advent of transparency will translate into a myriad of opportunities to drive down costs, improve outcomes, generate higher profits, and result in a stronger economy. 

The report says that companies that sell out for high multiples have these characteristics:

• SaaS delivery that generates recurring revenue
• Pricing alignment so that the company makes money when the customer realizes value
• Scalable distribution that lowers the cost of acquiring a new customer
• Providing value that will carry into the post-ACA environment instead of just exploiting current system flaws
• Rights to the data created by their customers
• Market leadership, strong management, and growth

Government and Politics

Women & Infants Hospital of Rhode Island will pay $150,000 to settle data breach charges resulting from a 2012 incident in which 19 unencrypted backup tapes containing the information of 12,000 prenatal diagnostic center patients disappeared. That’s not a federal HIPAA fine – $110,000 of the payment is a state civil penalty, $25,000 is for attorney fees, and $15,000 will fund an attorney general data security education campaign.

The GAO will release a report next week that outlines Healthcare.gov’s go-live problems, the cost to fix them, and the work remaining.

FTC Commissioner Julie Brill, concerned about a May report that showed 12 mobile health and fitness apps were sharing user information with 76 companies, says that third-party data use is where “the rubber hits the road when it comes to patient harm.” Despite urging that consumers be given more control on the use of their information, Brill says that no new regulations are planned.

A California appellate court dismisses a class action lawsuit that sought $1,000 for each Sutter Health patient whose information was stored on a stolen computer, a suit that had exposed Sutter to a potential $4 billion payout. The court found that the state’s Confidentiality of Medical Information Act requires proof of unauthorized access to patient information, not just possession of the physical form of the data (a hard drive, in this case) by an unauthorized individual. One of the attorneys for the patients originally said that an unencrypted computer storing the information of 4 million patients should have been stored in a windowless room under lock and key instead the office that was broken into.

The Wall Street Journal profiles William LaCorte, MD, a Louisiana internist who has pocketed $38 million as his share of 12 Medicare fraud lawsuits he filed, mostly against drug companies. He even named his newly purchased 34-foot boat Pepcid. The article also mentions a former pharmacy that found whistleblower lawsuits to be a more lucrative business, having netted it $425 million so far.

Former Procter & Gamble CEO Robert McDonald, in his confirmation hearings for Secretary of Veterans Affairs, says the agency needs to “continue to expand the use of digital technology to free human resources” and “create, with the Department of Defense, an integrated records system.”

Innovation and Research

UnitedHealthcare makes its Health4Me app available to all consumers, not just its customers. It providers doctor search and medical price review.

Technology

Allscripts receives an Intel Innovation Award for its Windows-powered Wand mobile EHR navigation system. 

Google’s Google X research group will analyze genetic and molecular information from 175 volunteers to define a healthy human, hoping that the Baseline Study’s new diagnostic tools will allow Google’s computers to find patterns that allow earlier detection of disease. That project may or may not be related to the company’s recently announced glucose-measuring contact lens.

Other

The administrator of Bradley Healthcare and Rehabilitation Center (TN) says employees really like its new PointClickCare EHR, but adds that the system caused Medicare payment delays in its first two months. The system was configured to use the facility’s five-digit ZIP code instead of the required nine-digit code and nobody knew how to open warnings from its intermediary about incorrectly formatted claims. The facility admits that it should have trained users better before going live.

An NPR report says HIPAA was created to protect patients, but healthcare organizations are intentionally or unintentionally using it to protect their own interests, such as hospitals that refuse to give patients their own medical records claiming it’s a HIPAA violation, when in fact the law intended the opposite. It also mentions that VA management used HIPAA threats to squelch potential whistleblowers.

A patient who starting shooting in the psychiatric unit of Mercy Fitzgerald Hospital (PA) is shot by the psychiatrist he wounded, who returned fired using his personal firearm despite the hospital’s policy barring on-campus weapons except by on-duty police.

Sponsor Updates

• Elsevier Clinical Solutions will use the clinical evidence platform of Doctor Evidence LLC in its Evidence-Based Medicine Center.
• Perceptive Software’s Acuo Vendor VNA earns DIACAP certification as part of its 2012 DoD contract to manage clinical content for US Army and Navy hospitals around the world.
• Etransmedia Technology shares the process of taking a state-of-the-art urology practice with on-site PT through their EHR implementation and decreasing the cost of clinical documentation by 75 percent.
• Allscripts EHR solutions connect to the State of Arkansas HIE.
• Ingenious Med CEO Hart Williford shares four core beliefs that have enabled him to transition companies from startup to explosive growth and maintain company morale.
• Truven Health Analytics links clinical data to claims, enhancing oncology-focused outcomes research studies.
• Shareable Ink’s CTO Stephen Hau discusses its expansion to an iPad version and the risks and successes involved.
• e-MDs ranks fifth overall in the Medscape EHR Report 2014.
• ACO Buena Vida y Salud (TX) partners with Sandlot Solutions to connect with the Rio Grande Valley HIE (TX) using Sandlot Connect.
• The Association of Community Mental Health Center of Kansas will implement Netsmart’s CareManager while the Kansas Health Information Network will implement Netsmart’s CareConnect solution.

EPtalk by Dr. Jayne

Jenn tweeted about this recent Washington Post piece on Maintenance of Certification (MOC). Since I now have to maintain certification in both clinical informatics and my primary specialty, it hit close to home. Although board certification is technically “voluntary,” in my market it’s a necessity – no payers will credential you if you’re not certified.

I agree with the author that merely having certification doesn’t add a lot to my actual practice of medicine. I don’t treat chronic disease or deliver babies any more, other than in an absolute emergency. I do, however, perform a mean laceration repair and reduce dislocations like a boss. None of that is on my board exam, however.

You may be asking what this has to do with healthcare IT. It’s this: nearly everything for MOC is online and some of it is a true pain. Plus, there’s not a lot of content for some of us who are largely administrative or don’t have true continuity practices.

Case in point: my Board offers a handwashing module for MOC. If you’re in traditional practice, you’re supposed to survey your patients then key in the results and analyze them. If you’re not in continuity practice, they give you mock data that you still have to key in and analyze. How hard would it have been for them to preload the data? I’m sure the argument is I need to have the experience keying in data since the others do, but that’s ridiculous.

We’re claiming that primary care physicians should be quarterbacking healthcare delivery teams and working at the top of their licensure, yet we have them manually keying in data for recertification. Physicians at my institution are burning out at an alarming rate. This is just one more thing we ask them to do. Manually keying data isn’t a good use of our time.

On the flip side, some organizations have tried to partner with EHR vendors to extract data for quality studies. My vendor used to do this for two specialties but ended up stopping it, supposedly because the burden of keeping up the code was too great and the functionality wasn’t adopted widely by customers.

I have to admit I’ve been somewhat of a slacker with regards to MOC for my newly-minted clinical informatics subspecialty. I’m in the middle of an online cultural competency module for my primary specialty that I keep having technical difficulties, with so the idea of digging into other content doesn’t excite me.

I do obtain regular Continuing Medical Education credits, typically double what is required by my Board, which is four times what is required by my state licensing board. That’s the most valuable to me as far as keeping up because I can choose CME that’s relevant to what I actually see in practice. Cramming for a test once every 10 years (even when I can listen to all the lectures on my handy-dandy iPod) doesn’t say much about my skills listening to patients or being a clinician who can actually speak with patients in a way that they understand and makes them confident in the treatment plan.

Readers may ask, if we don’t have ongoing board certification, how will patients tell if we’re quality physicians?

It’s my great hope that eventually when we are truly meaningful users of EHR technology (not the government-speak kind of MU, but the real kind) we’ll be able to show what kind of physicians we are. How many of Dr. Jayne’s patients had failure of their laceration repairs? How many had unexpected scarring? Was her documentation readable and did she provide a patient plan in a way that the average person with a fifth-grade reading level could understand? Did she communicate back with the patient’s primary physician and arrange a follow up?

A friend of mine does minimally invasive knee replacements. He puts all of his data on his website for the world to see. He’s published multiple studies on his outcomes. All he does is knees. To me, seeing his data (including infection and complication rates) is a much better marker of his skill and competency than knowing he passed a board exam that covered the rest of the realm of orthopedic practice.

Before EHRs, trying to mine paper charts for that kind of data was nearly impossible. Most of my colleagues who were doing outcomes research used separate databases and registries and there was a lot of manual entry. Now we have the ability to study our populations at a moment’s notice. As a CMIO, I provide my physicians a sheaf of reports each month that let them know how they’re doing with respect to national standards and also to their peers. That kind of data will drive behavior change far more than reading a board review book might.

I’m hopeful for the future, but meanwhile I’m stuck with the expense and tedium of MOC.

What does your CMIO think of MOC? Email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Morning Headlines 7/24/14

Panel approves Robert McDonald’s nomination to VA

The Senate Committee on Veterans’ Affairs confirms the nomination of Robert McDonald as the next VA Secretary in a 14-0 decision. His nomination will now move to Senate for a final vote.  In his post-confirmation statement, McDonald said that the VA needs to prove “ that it can create, with Department of Defense, an integrated records system; (and) that it can regularly and accurately produce key data for decision-makers and oversight entities.”

Study Finds 10.3M Uninsured Gained Coverage Under ACA

A NEJM study finds that 10.3 million uninsured American’s gained health insurance during the ACA open enrollment period, with eight million signing up for private insurance and 2.3 million taking Medicaid. Enrollment variations between age, gender, and ethnicity are also included in the study.

Court halts $4 billion privacy suit against Sutter Health

A $4 billion class action lawsuit against Sutter Health stemming from an earlier data breach has been thrown out because patients could not prove that their data had been accessed by anyone or used in any illegal way.

Readers Write: Bench, Bonus and Bondage: The Sorry Side of IT Consulting

Bench, Bonus and Bondage: The Sorry Side of IT Consulting
By Mike Lucey

If I could lose 20 pounds, I would be ready to model swimwear. That’s a nasty image for those who know me, but if I were serious, hiring a personal trainer would make sense. Or better yet, a personal exerciser!

Why not both? One person to tell me what to do and another to go and do it. I might not get the results I want, but much less effort. Think of what I would save in sneakers and tee shirts!

This wacky logic seems to be in play in our industry when it comes to hiring consultants. When I moved into consulting, it was because I figured I had some unique smarts and skills that a hospital would need. Once my smarts became their smarts or my skills were no longer needed, off I would go to the next guy. For this I would get a nice rate and the fun of doing new projects.

But what I am finding is hospitals have some consultants who offer guidance, and then other “consultants” who do the work, work that hospitals really need to be doing themselves. Part of why this happens can be found in the way consulting companies can market their services.

Bench: To start a consulting company, scrape up a pile of resumes, format them nicely, and throw them at every hospital problem you hear about until some of them stick. Now you have consultants working. As these consultants roll off projects, they go to the Bench. Yikes! Good news: you now have consultants ready for the next project. Bad news: every hour they sit on the bench they cost money (until you pull the bench out from under them). A way companies can lighten the bench is to give bonuses to the consultants that are still working to find work for the benchwarmers.

Bonus: Let your working consultants know that they will get a bonus for every benchwarmer they place. This is where the worm turns. Now those consultants you hired to solve a problem are to some degree degraded or distracted by the incentive to be a sales guy. The inclination to teach a hospital employee how to solve the next problem conflicts with an inclination to pull in a colleague from the company. Good for these companies, maybe not so good for the hospital.

Bondage: With each additional placement, each incremental bump in the billable hours (and bump in that bonus income), the idea of ending the engagement becomes more ugly and the motivation to extend more attractive. It is stressful to see a project end and face the uncertainty of the next job, stress that is magnified with the addition of each colleague and the bonus income they represent. Suddenly maintaining my value as a smart guy may depend on maintaining a certain amount of client ignorance and so client dependence – knowledge bondage.

This is how you end up with a consultant who is not just the captain of your hospital softball team, but the batting champ three years running.

We consultants have a great part to play as our industry continues to change. We bring real value helping hospitals make decisions, helping them act on those decisions, and providing resources when big projects need extra hands. That value is based on smarts, skills, and experience that hospitals don’t yet have, but can gain with our input. 

When that value wanes, not to worry — I’m off to the next project. Or I always have the modeling gig to fall back on. (note to self: find my Ab-Master.)

Mike Lucey is president of Community Hospital Advisors of Reading, MA.

Readers Write: Is DIY Network Security a Good Idea?

Is DIY Network Security a Good Idea?
By Jason Riddle

Patients and clients count on healthcare providers, payers, and business associates to protect their electronic health records. For optimal care, patients need to feel comfortable divulging personal information that could cause them injury—financially, emotionally, and/or physically—should it be illegally accessed or corrupted by hackers or malware.

Additionally, covered entities are required by HIPAA/HITECH laws to maintain a certain level of network security. Violation of these regulations could result in stiff fines, a disruption in operations, and a general loss of goodwill among the people who do business with them.

Many small to medium-sized organizations are managing some if not all of their network security on their own. Here is one question they often ask:

Do we have enough protection for our patients’ data, or do we need to hire outside professionals to do the job for us?

While there is no right or wrong answer to this, there are a few factors that need to be considered.

HIPAA/HITECH was designed with built-in flexibility so that organizations could make their own decisions about their level of investment in network security. For example, a large organization may choose to hire an outside cyber security firm to monitor their networks around the clock, but a three-person doctor’s office might be hard pressed to put such an aggressive solution in place. Office for Civil Rights (OCR) auditors who are responsible for monitoring HIPAA compliance recognize that organizations of various sizes make decisions based on practical restraints.

As covered entities make decisions for (or against) increasing security, the reasoning and conclusions should systematically be written down. OCR auditors generally take into consideration all well-documented justification.

One way to think about whether or not to hire an outside vendor to assist with network security is to recognize that a solution doesn’t have to be all or nothing. For example, some companies will hire an independent third party to conduct an initial security risk analysis. This gives them the objectivity where it counts—identifying vulnerable areas and obtaining guidance on how to address them.

Once the fix-it plan is set, the internal IT team can assume the responsibility of maintaining the network’s security from there on out. This hybrid solution can oftentimes save money. Cyber security professionals will likely identify problems faster and provide guidance to tools that are both free and/or low cost.

If an organization is committed to a DIY network security solution — whether starting out with the help of professionals or taking it all on independently — it takes more than someone who is just an IT whiz to manage a network security program. There are six main areas that a security officer must be well versed in to carry out the required responsibility:

1. Understanding HIPAA compliance. A security officer must understand the HIPAA/HITECH regulations and what compliance really means. This includes (but is not limited to) regular security risk analyses, documenting all security measures. and reporting any breaches that may have occurred.
2. Securing the data. Firewalls and antivirus software are a must, but that’s just the minimum. Some of the other areas to be addressed are data encryption, regularly scheduled reviews of all logs (on the firewall and the server), restricted access, and regular data backups.
3. Securing the facility and equipment. Physical access to computer equipment must be controlled at all times. Doors to the server room should be locked. When appropriate, screens should be protected from nosy passers-by. The security officer should have an eye for the logistics of the facility and areas that might pose a risk to keeping patient data secure.
4. Monitoring mobile access. Decisions need to be made about how employees are able to access data from mobile devices. Types of data that can be obtained wirelessly might need to be limited, and employees will need to be aware of the whereabouts of their mobile devices at all times.
5. Training the staff. A lot of security breaches are the result of human error. Everyone in the organization needs regular reminders that they are handling sensitive data and to be aware of actions they might be taking to jeopardize it.
6. Understanding relationships with business associates. Responsibility for protecting client and patient data extends to everyone that has access to it. If a third party does the billing, for example, it’s critical that they are compliant as well.

A DIY network solution for healthcare organizations is not necessarily a bad idea. But it does need to be a well thought out one. Patients and clients are counting on it.

Jason Riddle is practice leader with LBMC Managed Security Services of Nashville, TN.

Readers Write: EMR vs. EHR

EMR vs. EHR
By Steve Blumenthal, JD

HIStalk has asked me to explain the difference between an EMR (electronic medical record) and an EHR (electronic health record). Clearly, HIStalk needs to get out more. But I’m a nerdy lawyer and analyzing defined terms ranks up there with reading blogs about who’s being cast in the “Star Wars” reboot.

Let’s start with the source of most healthcare IT terminology, the feds—specifically, ONC. ONC’s website (healthIT.gov) says that an EMR is “a digital version of a paper chart that contains all of a patient’s medical history from one practice.” On the other hand, an EHR is “a digital version of a patient’s paper chart.” So, clearly an EMR and EHR are differ…. Wait a sec. Is it me, or do those definitions look remarkably similar?

I think I’ve figured it out. An EMR and EHR are both a digital version of a patient’s paper chart, but an EMR only has one practice’s patient chart. So, if I never see a physician other than my internist at Vanderbilt, Vandy’s electronic record system is an EMR with respect to me. However, my daughter has seen two doctors in different practices within Vandy’s health system, so Vandy’s electronic record system would be an EHR (not an EMR) with respect to her. No, that can’t be right.

Wait, ONC has more to say. An EHR is “more than just a computerized version of a paper chart in a provider’s office.” Whew, that clears up everything. An EHR is more than an EMR. Now I can go home and finally hang the curtains in the guest bedroom.

On second thought, that didn’t clear up anything. The curtains will just have to wait another year.

“EHR systems are built to share information with other health care providers and organizations—such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics—so they contain information from all clinicians involved in a patient’s care.” I think we’ve found something. “Built to share information” is the key. I feel an analogy coming on.

An EMR is an earthworm, a useful creature that burrows into the earth, carrying organic material down into lower levels, breaking down dead plant material, and aerating the soil. But an earthworm is not transformative. Its life is spent toiling in the soil as an earthworm (and usually ending underneath a person’s shoe or in a bird’s gullet). On the other hand, an EHR is a caterpillar, a worm-like larva that will eventually transform into a beautiful butterfly (or somewhat less attractive moth or fruit fly). An EHR is designed for great things—collecting and distributing data from EMRs and other sources like butterflies cross-pollinating fields of flowers.

The difference between an EMR and an EHR isn’t what they are today. Let’s face it, given the interoperability issues with most EHRs today, they’re pretty much toiling in the same soil as EMRs. The difference lies in what an EHR is designed to become. That’s why the “Base EHR” definition in ONC’s EHR certification regulations says that an EHR must, in addition to including patient health information, have the capacity to do more—to provide clinical decision support, support physician order entry, capture and query information relevant to health care quality, and exchange electronic health information with other sources.

It’s actually kind of inspirational when you think about it. If you’ve got a kid, you’ve read “The Very Hungry Caterpillar.” Sure, the caterpillar eats a couple tons of food that could otherwise have been used to feed impoverished children, but then he spins a cocoon and, a short time later, becomes a beautiful butterfly. So maybe we’re spending a lot of resources on EHRs right now, but the payoff will be amazing in the end.

Unfortunately, the process of changing from a caterpillar into a butterfly is, well, disgusting. As “Scientific American” puts it, “First, the caterpillar digests itself, releasing enzymes to dissolve all of its tissues. If you were to cut open a cocoon or chrysalis at just the right time, caterpillar soup would ooze out.”

Ew.

(For those of you wanting to double-check me on my quotes from ONC’s website, see here and here.

Steven E. Blumenthal is an attorney with Bone McAllester Norton PLLC of Nashville, TN.

Health IT from the CIO’s Chair 7/23/14

The views and opinions expressed in this article are mine personally and are not necessarily representative of current or former employers.

Enterprise IT Says “No” (again…)

Nobody really likes to hear “no” as an answer. Unfortunately, I think it may be part of my job to give it. That does not mean I have to like it.

The role of enterprise IT differs across large healthcare organizations, but likely also has a few common threads. Here are three I would guess to be constants.

1. To manage total spend on IT capital and operating budgets required to maintain the operations of dozens of existing applications (most of which are mission critical).
2. To prevent any breach of security or privacy and ensuring adherence to a growing number of regulatory obligations.
3. To be accountable to a wide range of diverse stakeholders with many ideas on how to do more with IT.

None of these things on their own drives IT to say “no,” but together they can create enough pressure to want to leverage “no” as the answer to slow or to temporarily stop the chaotic pace that many enterprise IT groups face.

This post is not meant to be a complaint about enterprise IT. I lead an enterprise IT organization and I think central IT groups can be integral to the core of any business. But IT is changing. It’s time we challenge how we approach the IT department itself. Here are some crazy ideas to try.

Problem: IT budgets are either constrained in growth, frozen, or expected to drift down year over year.

Idea: Reduce the central IT budget to cover just the basic shared services and infrastructure — help desk, user security, dial tone, and the data network. IT should be pushed to make this part of the budget more efficient. It should be subject to the same budget expectations as, say, plant operations. Everything else should live in a line of business operating cost center or a cost center dedicated to the initiative. For example, put the lab system in the lab cost center and the expenses for that new ACO initiative in a dedicated ACO cost center.

Enterprise IT Challenge: Without budget authority, IT will be included at the table with influence. IT will need to educate many on the challenges of not just the cost to acquire and implement, but the ongoing costs to manage and support.

Benefit: Less frequent need to say “no.” More stakeholders will be involved in the shared budgeting and fewer will ask for new toys when they are still helping to find ways to pay for their own existing ones.

Problem: New solutions must be secure and avoid introducing risk.

Idea: Approach risk like an auditor evaluates risk. Health systems are filled with some of the smartest people around. Someone can always come up with an obscure edge case to represent why it might not work, but that does not mean the whole idea is bad.

Auditors understand that risk is everywhere. The objective is to manage and mitigate high risk and to prioritize focus. Enterprise IT should start to evaluate the risk of a solution based not only if risk is possible, but if it’s likely. Some problems are so big that solutions are welcome even if they don’t solve all the issues.

By way of example, using a consumer cloud storage service is better than a USB drive and probably more secure than many laptops, even if the cloud does not meet every IT requirement.

Enterprise IT Challenge: Get comfortable with incremental improvements to pave the way for the big wins. Understand that a less-secure, easy-to-use approach that will improve what is used today is better than the higher-friction perfect one we are waiting on for tomorrow.

Benefit: Faster iterations towards solutions, more “yes” answers, and a greater appreciation and understanding when a less-frequent “no” is delivered.

Problem: IT has become part of so many pieces of the healthcare delivery system. Instead of celebrating this win, IT gets caught up in the constant stream of new demands for new things. IT just can’t do it all.

Idea: Decentralize more of IT and stop asking IT to do it all. If delivering care is more efficiently done in a team setting, why can’t IT be approached the same way? This will take work in establishing guidelines, tools, and governance, but it may just be time to reimagine enterprise IT. Reporting, clinical content, workflow optimization, and new products to pilot are all great candidates to experiment with decentralization.

Enterprise IT Challenge: Three things: change, trust, and infrastructure. Like most hard things to do, sooner or later it may just come down to trust. The goal of decentralizing IT is not to let everyone just do whatever they want, but rather to work as a larger team with shared responsibility to the same outcomes. This change takes careful planning and focus. If that is not hard enough, our IT systems are probably working against us in that we lack some of the tools and infrastructure to adequately matrix our work.

Benefit: Shared goals, shared outcomes, deeper penetration of IT in the organization, and over time, the best people working on each solution (some from IT, some from the rest of the enterprise). Maybe in the end there aren’t fewer “nos,” but fewer from just IT.

The role of IT should be to enable and encourage IT. It’s time to turn enterprise IT into more of a team sport.

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.

Morning Headlines 7/23/14

Hazards tied to medical records rush

The Boston Globe reports on the sometimes tragic results of the nation’s hasty implementation of EHRs, and the anti-regulatory message being broadcast by vendors.

Swiss Walgreens? $4 Billion Tax Cut Considered At Corner Of Happy, Healthy & Tax-Free

Walgreens considers moving its headquarters to Switzerland through the acquisition of Swiss-based Alliance Boots, a move that would save the company $800 million in taxes annually.

Characteristics Associated With Post-discharge Medication Errors

A small study examining post-discharge medication errors finds that 54 percent of cardiac patients reviewed had at least one error on their discharge medication list.

Hospital trust makes ‘biggest investment in IT for more than a generation’

In England, West Hertfordshire Hospitals NHS Trust signs a $44 million contract with CGI to update the IT infrastructure of its 600-bed hospital, Watford General, which came under scrutiny last year when its EHR was blamed for a scheduling issue that resulted in the death of two cancer patients.