Curbside Consult with Dr. Jayne 4/21/14

Next weekend is my medical school reunion. Although I can’t make it, the fact that it is happening spurred me to try to re-connect with old friends and colleagues. Some are from med school, others are from residency, and a few are friends I made when I was a young solo practice doc trying to figure out how to fit into the medical establishment.

I had a nice chat with a friend of mine who is a pediatrician. It was interesting to catch up because her practice is different from what I see every day. Hers is a traditional group private practice, but they only take commercial payers – no state or federal programs. As such, they’re not on the Meaningful Use treadmill. They document in paper charts that are filed by family rather than individual – totally old school as far as most health information management folks are concerned.

I had talked to her several years ago when they were trying to implement the same EHR that we were rolling out to our employed physicians. They had purchased their system through a local reseller, hoping to get good service from people close to home rather than buying directly from our vendor who is headquartered halfway across the country.

Unfortunately that local reseller was purchased by another reseller who didn’t have the greatest track record for customer service and most of their local resources were let go or quit. Because of that situation (coupled with turnover in their practice leadership), they had halted their implementation after bringing the billing system live.

They were heavy admitters to one of our hospitals, so I did a courtesy consultation to provide some advice on how to proceed. I talked to them about working with their reseller to come up with a phased implementation plan that would help them transition slowly since they weren’t in a huge hurry and had multiple older physicians who would need convincing and a lot of hand-holding.

We had run into each other in the newborn nursery almost a year after that, so I knew they continued to struggle with the system and ultimately went back to paper, although they were doing well with the billing system.

When I caught up with her a few weeks ago, I learned that they had made the decision to replace their entire system. They never got the EHR off the ground, largely because the older physicians perceived the software as too complicated and too clicky. They had not taken any upgrades since their initial installation in 2009, so I can see why they thought that – early versions of the software were indeed clicky and it wasn’t easy to save physician-specific defaults and preferences.

The practice had tried to re-implement on that version even though our vendor had since rolled out a redesigned user interface that vastly improved the workflow. She said that due to a lack of confidence in the reseller coupled with the physician resistance, they were afraid to take any upgrades.

They decided to go with a specialty-specific product, rolling out the practice management system first without any kind of conversion from their previous system. For a busy practice with nearly a dozen physicians, that surprised me – not even a demographic conversion. They went live on April 1 and every patient had to be re-registered, whether they were presenting for an appointment or calling in.

They made no adjustments to the schedule to accommodate the change because the providers refused to risk a revenue loss. As a result, they are running hours behind by the end of every day. Talk about an April Fool’s Day joke! Needless to say, no one is happy – the providers, the staff, or the patients.

Patients are complaining about the registration process because they have to provide information they didn’t previously, specifically race, ethnicity, and preferred method of contact for patient reminders. Sounds familiar! I asked her why they’re doing that since they’re not attesting for MU, don’t participate in any research or quality programs where those fields are needed, don’t do email or texting, and it’s not required by payers in our area (yet). The answer: those fields are required in the system and can’t be turned off.

I asked her how the system handles other information that may be needed for MU but not for the way the practice currently delivers care. She has no idea. I wouldn’t be surprised if there are plenty of other required fields that they’re not going to be happy about once they start implementing EHR.

I asked what their plans are for that. She didn’t really know whether they plan to implement EHR in 60 days, 90 days, or a year. There’s no burning platform, but I would expect a partner to at least have some kind of understanding of the group’s strategic plan. I asked about the family charting – which is very different from individual charting – and she had no idea how they plan to resolve that, either.

I’m sure I was giving her some funny looks during this discussion because my brain was positively spinning. They’ve traded one system (where at least they could have turned off those required fields) for another with no long-term plan for whether they’re simply converting to paperless charts or whether they plan to use an electronic health record to transform care.

I suspect that as time passes they’ll find themselves in substantially the same position they were in six months or a year ago, except they’ll be paying down another initial investment. I didn’t ask about the cost of the new system, but I hope that at least their monthly software maintenance payments are a little less. Until they start having some serious conversations with all the physicians though about what having an EHR means to them, what they want to get out of it, and how they plan to go about it, there is the potential for some serious unhappiness down the road. They’ll be doing the same dance but with another vendor.

Although they were never stressing about Meaningful Use, they were having mild heart failure over ICD-10 and were very grateful for the recent reprieve. As a relatively small single-specialty group, their transition will be less complicated (and hopefully less arduous) than some of ours and I wish them well. Given their payer mix and patient population, some of their challenges are different from those faced by my practices on a day-to-day basis, but many are the same. I left her with some good discussion points for her next practice management meeting and a promise to check in more frequently to see how they’re doing.

There are a fair number of physicians and practices in the market for replacement systems. I wonder what percentage of those purchases are truly from system deficiencies (including lack of certification)? I’d like to compare that to what fraction of them are due to a lack of understanding around how to successfully transition to electronic health records coupled with a vendor who is unable/unwilling to take a hard stance with its customers to force them to do things in a manner that will make them successful.

Are you in the market for a replacement system? What makes you think it will be different the second time around? How are you planning to do things differently? Email me.

Email Dr. Jayne.

Morning Headlines 4/21/14

UPMC data breach may affect as many as 27,000 employees

UPMC (PA) reports that hackers have stolen the personal information of 27,000 of its employees. 788 are reporting that their tax returns were stolen when the information was used to file fraudulent tax returns, while others are reporting that unauthorized bank accounts are being opened in their names.

A Robust Health Data Infrastructure

HHS publishes a JASON report on health information interoperability which concludes that without a sophisticated data exchange framework, health IT will continue to struggle to improve care quality or reduce costs. The report recommends that Stage 3 Meaningful Use be used "as an opportunity to break free from the status quo and embark upon the creation of a truly interoperable health data infrastructure."

T.J. Samson Community Hospital announces job, salary cuts Nearly 50 employees losing positions

49 employees at T.J. Samson Community Hospital (KY) will lose their jobs, while most remaining employees will face salary cuts as part of a new plan designed save $3.6 million between now and October. CEO Henry Royse says the cuts were needed due to problems with a Siemens install which he summaries by explaining "One year after going live, the product’s inoperability is still costing the hospital tens of millions of dollars in unrecoverable bad debt, consultant fees, and lost productivity.”

Even After Doctors Are Sanctioned or Arrested, Medicare Keeps Paying

In 2012, Medicare paid at least $6 million, but likely much more, to physicians that were actively suspended or terminated from state Medicaid programs for committing fraud, according to a ProPublica report.

Monday Morning Update 4/21/14

Top News

UPMC (PA) says that the information of 27,000 of its employees was exposed in a February breach and the hackers have filed fraudulent tax returns for 788 of them so far. A lawyer seeking class action status of his lawsuit asks the obvious question: why did the breach involve only 27,000 of UPMC’s 62,000 employees? The attorney points out that UPMC first claimed that only 20 employees were affected, then 322, and now 27,000, obviously concluding that all employees may be at risk despite the announcement. The tax scam is a smart one since the IRS, like HHS, pays first and asks questions later.

Reader Comments

From Weary CIO: “Re: branding. I have background in market research and healthcare IT branding is useless. It works in retail, so marketers in vendor companies use it to have something to do. They come up with thin and useless stuff like logos on napkins because if they don’t, they are out of a job. If marketing is what you do, that’s what you do. Private industry is more acutely aware that overhead positions are more vulnerable to reductions so they have to try to stay relevant. Waste creates so many employment opportunities!” I had questioned offline to Weary CIO the value of expensive signage and “branded” items at events when I rarely notice them. My enjoyment of HIStalkapalooza was unaffected logos on lampshades.

From Down Boy: “Re: athenahealth. Down Friday – all sites, communications, interfaces, etc. Confirmed with hospitals and practices in CA, MO, SD, NH, and ME.” Unverified.

From Locked Box: “Re: athenahealth. Their ‘More Disruption Please’ program was supposed to be a collection of companies offering easily integrated products that would give athena customers functionality the company doesn’t offer, which would support innovation by giving those companies access to customers. In return, the companies would offer a discount to their customers, lowering the barrier to innovation. Now athenahealth has changed the program to a revenue share model, which is a 20 percent tax on interoperability for us and our customers, which is why we joined. We are leaving the MDP program.”

From Excelsior: “Re: JASON report. HHS’s report is similar to the 2010 PCAST report, including calls to represent health information as ‘atomic data with associated metadata.’ Two people involved in the PCAST report were also involved in the JASON report: Craig Mundie and Sean Nolan, both of Microsoft.” The report says “the entire health data infrastructure will be crippled” without better interoperability and recommends that EHR information be stored using common mark-up language and that EHR vendors should open up their systems via APIs that allow third parties to build on them with new applications. EHR vendors aren’t likely to embrace this concept enthusiastically given that the report recommends architecture that can “provide a migration pathway from legacy EHR systems,” but of course their EHR customers would need to apply pressure on their vendors to make it happen anyway since government reports have zero bottom line impact. Other findings:

• Meaningful Use criteria “fall short of achieving meaningful use in any practical sense,” mostly having replaced faxed machines with electronic delivery of page-formatted records that patients can’t access directly.
• Current EHR interoperability work hasn’t developed opportunities for entrepreneurism.
• HHS could take an active role by using future Meaningful Use stages, starting with Stage 3, and certification to force an open software architecture. ONC should publish standards to accomplish that within one year.
• Researchers need better access to EHR data.
• Meaningful Use Stage 3 should require vendors to develop, publish, and verify APIs that allow searching their systems with semantic harmonization and vocabulary translation. System acquisitions by the VA and DoD should require those published APIs.
• EHR-powered fraud detection tools should be developed.

From Guillermo del Grande: “Re: consultants. Here’s a list of ‘Things Consultants Wish Their Customers Knew.’”

1. Very few consulting companies have a bench.
2. If you post a position with six different vendors, a consultant with a resume on Dice will receive six different calls.
3. If you yell at a consultant for looking at Facebook, chances are that’s why you need a consultant in the first place.
4. Trying to find someone with seven years of experience in an application that’s only been around for five years probably won’t end well.
5. If people can’t manage in the operations side, what the hell does putting them into the IT department going to accomplish?
6. Recruiting firms are really good at making phone calls and searching job boards. This is pretty much it. Many consulting firms are actually recruiting firms.
7. If you are going to be managing consultants, please do not panic when they know more than you about the application that you scraped through getting a certification in, and then ignored for several months before deciding you needed to augment your staff.
8. If you want the FTE to learn from the consultant, you may want to see if the FTE has a pulse and an IQ.
9. If you fire four consultants in a row, chances are that it’s not them, it’s you.
10. Two hiring managers with a feud fighting through hiring consultants and making them mess with each other is annoying, expensive, and somewhat common.
11. Yes, consultants have faults. Thank you for pointing them out every morning. Why did all your FTEs leave again?

HIStalk Announcements and Requests

The White House is most responsible for the ACA-related failures such as Healthcare.gov that led HHS Secretary Kathleen Sebelius to resign, according to 47 percent of poll respondents. New poll to your right: do you feel better or worse about HHS after its release of Medicare physician payment information? I felt worse: the lawsuit-mandated release of the data reminded that like pretty much all federal programs, taxpayers should be appalled at how their money is being spent, the cost of the self-protecting bureaucracy required to spend it, and the remarkably breezy oversight that expensive bureaucracy provides in return. Not to mention that Medicare payment rules are so convoluted that even they can’t figure out when they (meaning we) are being defrauded. HHS is like the IRS in that regard and I don’t trust either of them to enforce politics-embedded rules that nobody understands.

Listening: new from Atlanta-based melodic hard rockers Manchester Orchestra.

Upcoming Webinars

May 1 (Thursday) 1:00 p.m. ET. Think Beyond EDW: Using Your Data to Transform, Part 2 – Build-Measure-Learn to Get Value from Healthcare Data. Sponsored by Premier. Presenters: Alejandro Reti, MD, senior director of population health, Premier; and Alex Easton, senior director of enterprise solutions, Premier. Once you deploy an enterprise data warehouse, you need to arrive at value as quickly as possible. Learn ways to be operationally and technically agile with integrated data, including strategies for improving population health.

Acquisitions, Funding, Business, and Stock

From the athenahealth earnings call:

• The Epocrates team “continued to struggle on new booking attainment” and missed revenue targets with an eight percent reduction since the acquisition. The company is looking for a VP of sales.
• The company started using the Net Promoter Score and fell short of its goal with a 44.7 vs. planned 47.3 (vs. a high 70s score for Amazon and Apple.)
• The company urged investors to look at full-year results instead of quarterly.
• In admitting that athenaCoordinator’s planned “one percent of system revenue” model was not followed in its first two sales, Jonathan Bush said that the company was desperate to get those sales and had no references for the prospects. The plan remains to collect a percentage of health system collections.
• The company blamed an increase in its AR days to health plan deductible resets, slower patient payments, vacation days, bad weather, and a weaker flu season.
• Low-margin real estate investments hurt gross margin.
• Bush says an obstacle to the company’s growth is that consulting companies can’t earn fees from its implementation, so it will be “repositioning ourselves around the larger process improvement for the health system around coordination and care that actually will generate very productive, useful as oppose to wasteful consulting fee in the interest of the consulting firms.”

Here’s a one-year view of ATHN’s share price (blue) vs. the Nasdaq (red).

Healthbox, which runs medical accelerator programs, raises $7 million in expansion funds. One of its investors is Intermountain Healthcare. The company also announces that it will launch Healthbox Solutions to showcase healthcare IT products to hospitals.

Government and Politics

A ProPublica analysis of the CMS physician payments database finds that doctors previously charged with fraud and Medicare overbilling continue to make big money from the program. Medicare paid a psychiatrist who was arrested and barred from the Medicaid program in 2011 $862,000 in 2012. Sen. Chuck Grassley (R-IA) said Medicare and Medicaid programs need to communicate since, “The new transparency makes it harder to ignore when doctors who harm patients or defraud taxpayers in one program face no consequences in the other program” (how about a little bit of interoperability push there?) A doctor who was convicted of paying patients via his charity to use his pain clinic was paid $500,000 in 2012 for treating 80 patients despite his pending 50-month prison sentence and $3.5 million fine, but his lawyer claims his conduct didn’t cost Medicare anything because somebody would have treated the patients even if it wasn’t him. A Michigan oncologist charged with misdiagnosing patients with cancer so he could bill them for unnecessary treatments was paid $10 million by Medicare in 2012. Pay-and-chase is working really well for criminals.

Innovation and Research

The consumer wearables fad seems to be over as Nike fires 55 of the 70 members of its FuelBand team and cancels the planned fall release of a new model. Nike says it wants to focus on software, not hardware. Most likely they realized that (a) high-tech versions of a $5 pedometer not only don’t usually motivate anyone except those who are already motivated, and (b) spending money to bring out new hardware versions is risky now that the competitive field has opened up. FeulBands may die off just as quickly as those once-ubiquitous yellow Livestrong wristbands that people couldn’t trash fast enough once the headlines forced them to belatedly realized what a scumbag Lance Armstrong is. There’s a Nike connection there too – they used to make Livestrong-branded products until Lance finally admitted that he’s a cheater and a liar.

Technology

John Gomez from Sensato provides suggestions on dealing with the Heartbleed SSL vulnerability, warning that hospitals “have an obligation to deal with it because it is a serious threat to privacy.” Even Healthcare.gov is telling users to change their passwords. John’s suggestions:

• Inventory systems that use SSL or similar encryption.
• Ask  technology partners providing services through an information or hosting agreement (HIE, hosting companies, portal vendors, kiosk vendors) for certification that they have determined that they are not vulnerable to Heartbleed.
• Ask HIPAA business associates to provide documentation of how they have eliminated their Heartbleed risk, especially companies who use online system to collect patient payments for billing or collections.

Other

T. J. Samson Community Hospital (KY) announces that 49 employees will be laid off and all employees will temporarily have their pay reduced due to effects of the Affordable Care Act and “the costly rollout of an inadequate software program.” That system is Siemens Soarian, which the hospital purchased in February 2012. Interim CEO Henry Royse says that Soarian “is still costing the hospital tens of millions of dollars in unrecoverable bad debt, consultant fees, and lost productivity” a year after it went live. He specifically says the implementation was rushed, Soarian can’t connect to its practice management systems, it can’t produce needed operational reports, and the hospital has been unable to send bills for 60-90 days at times. The hospital implemented Soarian to earn Meaningful Use payments.

Fast Company profiles SharePractice, which it describes as “a Yelp for medical treatments” in allowing physicians to review the success peers have had with specific treatments. The company calls its iPhone app “experience-based medicine.” The founder is a Naturopathic Doctor who works for San Francisco-based Care Practice, opened “like one would open a neighborhood restaurant with a focus on patient experience and developing a compelling identity and brand in a tough urban marketplace with fewer and fewer doctors.”

The outpatient clinics of Salem Health (OR) will begin their pilot with OpenNotes on Monday.

The CEO and CTO of Mississippi-based Samarion Solutions, which sold long-term care IT systems, are indicted for defrauding investors.

A study finds that US healthcare isn’t expensive because we use so much of it – the problem is that we pay the highest prices in the world for drugs and hospital procedures. As patients, it’s not altogether our fault that US healthcare is so expensive and produces unimpressive results for the impressive outlays. A day in the hospital costs less than $500 in Spain, $1,300 in Australia, and $4,300 here (and $13,000 for hospitals in the 95th percentile.)

A New York Post article names the highest-paid doctors in New York City, with two from Mount Sinai Hospital’s medical school topping the list: a urologist paid $7.6 million and a spine surgeon who made $6.9 million. The medical director of Consumer Reports Health summarized, “Whenever I see compensation data in health care, I’m stunned and nauseated. I’m embarrassed for the profession.”

In England, a review of a woman’s death after inpatient surgery finds that she was screaming and vomiting in her room afterward, even begging her children to call an ambulance to remove her from the hospital. Her doctor did not respond, the investigation found, because he was in the hall outside her room playing a video game.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Advisory Panel: Your Personal Mobile Device

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

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

This question this time: What brand/model of mobile device do you use most often and what do you like most and least about it?

I use an iPhone and an iPad and I am happy with the fact that I can access my email from anywhere and can respond on the fly, but for the business of medicine it is cumbersome, difficult to type, not secure, and the constant need for iOS updates makes it difficult to use and upgrade apps. I do not like the "Walled Garden" approach from Apple that does not allow certain applications on their platform like Adobe Flash and it is also very expensive. I read somewhere  — on LinkedIn, I believe — that it seems only wealthy people use iPhones and it is almost like a statement of status, sort of the same stereotype that wealthy folks drink wine and the not-so-wealthy drink beer…just saying.

Interestingly enough, I did not end up with an iPhone by my sheer choice, but it was rather imposed on me by Allscripts of all people. They bought my initial e-prescribing "I scribe" which I had on a Palm for free and when Allscripts bought them they, did away with the Palm. In order to preserve my data, I had no choice but to get an iPhone and there you have it: there is no such thing as "free" and consumer choice, is it really? Mr H touched on this on one of his posts: the fact that it looks unprofessional to respond to emails from the iPhone (folks do not correct spelling, grammar, and at times it looks like mutilating the English language) but I admit I am guilty of doing it myself because on the other hand, what is the sense of the whole mobility trend? I cannot always wait for access to a desktop to respond to my emails, but I promise to correct the spelling.

Apple iStuff. They work as a consumer device (for which they are designed). I just wish they had enterprise devices.

HP laptops >> iPhones>> iPads

Personally I use an iPhone >iPad>>MacBook Air

I have used an iPad for a few years but switched to a small Dell Iconia W5 last year. I thought the Microsoft OS would make life easier working with my corporate applications. The Iconia certainly beats lugging a laptop on and off aircraft as I travel but it still isn’t as easy as the iPad. Last month I picked up an iPad Air. The smaller size is great. I think the Iconia is going back on the shelf and the Air will be my travel companion going forward. Now if only I could find something the size and ease of the Air combined with the MS OS….

Can’t live without my iPhone 5 and my iPad 2 (with a keyboard/case combo). Allows me to stay easily reachable and to work at home without lugging a laptop every night. What I like most about the iPad – Microsoft OneNote and the ability to keep all my data and projects current across devices and operating systems. This has been a huge help in organizing an extremely busy life. I literally walk into a meeting, pop open the iPad, and jump right in. I have all the meeting notes organized, all the action items up front, and I can take notes at the same speed as if I had a full keyboard. The search feature helps me quickly find pages by keyword. I share Notebooks with my team and that is working well, too. Note: I’m ordering some Microsoft Surface Pro 2s this week to trial for potential laptop/tablet replacement.

Personally I use a HTC smart phone and an iPad. I’m not crazy about the phone mostly because of the battery life (or lack thereof). My contract is up so I need to make a decision on a new device, but I’m not sure at this point what I will choose. I am very fond of my iPad. I use it primarily for reading and distractions and very little for work. I know that Ed Marx said in one of his blog posts that he doesn’t trust anyone that uses paper, but I went back to a paper notebook for meetings. When I take my iPad, I don’t generally take a pen to the meeting. The majority of the time someone passes out paper and I need to make note on a section so that I can follow up later. If I could get the groups to move to a paperless culture I would use the iPad exclusively.  

iPhone. I love the consistency between my Mac, iPad and iPhone. Battery life and the lack of a SD slot are the downside. I also never use Siri.

Samsung Galaxy S3 and Nexus 7 tablet. The Samsung battery is dreadful, but other than that, both devices are excellent. Google’s services and products are nicely integrated. The processors are fast, multitasking works great, and the Android OS is very reliable. And I can’t live without Swype and Dragon.

Apple iPhone 4S. I use maps, social media, email, calendaring, travel (airlines), weather, stocks, search, music, text, sports updates, news (around the world to help reduce spin), shopping (Amazon), restaurant ordering, restaurant reservations, and so on. There is not much I don’t like about it except for Siri. She is not very smart and does not take a clue when I am upset with her ;-). I find it works better without the protective film on the glass, to be sure.

My iPhone 5 is my most used mobile device. I find it great for email use and I have several apps that I use for business and personal needs. My AT&T service is great for talking and browsing. With the latest iOS upgrade my battery life is terrible. 

iPhone5. I love the iPhone. I will happily pay for something that is intuitive, quick, consistent, and has a lot of people writing for it. With that said, I am starting to see the Samsung users smirk as their product may take pictures better, get better Wi-Fi access, doesn’t charge extra for some little things. I am hoping the iPhone6 has some nice breakthroughs. But I will likely stick with Apple as the service has been phenomenal if I have any problems on any device and that is worth A LOT in  my book.

I’m not a Mac person, but my iPhone is my most favored and trusted sidekick (iPad comes in a close second.) Portability is the best feature. Clearing out my email inbox while waiting for elevators, looking up info on Google on the fly, quickly populating and reviewing my ToDo list, and other mundane tasks are much faster and more fun. With aging eyes, the screen size on the iPhone is the biggest impediment, but any increase in size would make it harder to stash on my belt and therefore easier to lose.

Apple iPhone4s. I like the Apple devices because most physicians use them and I can have an intelligent conversation with them about the pros and cons. I haven’t upgraded to the 5 series because my really cool case that looks like a cassette tape won’t fit the bigger phone. 

Personally, I use Droid devices. I think the capabilities are superior to iPhones (at least at this minute)  I think the openness and “less control” that has been placed on the Droid market have created these newer capabilities.

HIStalk Interviews Charles Corfield, CEO, nVoq

Charles Corfield is president and CEO of nVoq of Boulder, CO.

Tell me about yourself and the company.

I started off life as a mathematician. The company that we’re talking about today is nVoq, which is based in Boulder, Colorado. It is a tech company. It does voice-assisted workflow, or voice-automated workflows.

Did you find that you had an aptitude for entrepreneurship that you didn’t expect, or is it truly related to your mathematical training?

If I may quote someone, when I was a teenager, I had the good fortune to observe a couple of entrepreneurs in action in the UK. John McNulty was his name, one of those entrepreneurs, who said, “The reason most people become entrepreneurs is because they’re fundamentally unemployable, so they have no choice.” [laughs] 

If you’re one of these people who is a constructive troublemaker, that you’re always poking at things and asking questions, then entrepreneurship is a fairly natural thing to do, even if by personality traits you may not be the most obvious candidate for it.

For example, mathematicians are notorious for being somewhat shy, retiring, and socially awkward. I certainly plead guilty to being something of a social retard myself. The joke used to be that you can tell an extrovert mathematician because he or she stares at your shoelaces instead of his or her own. [laughs]

What you figure out as a mathematician is that there’s a pattern to all these things. Go learn the pattern and go figure it out. It’s really actually not that strange for a mathematician to become an entrepreneur.

What characteristics about yourself, other than being rebellious, would you say have been important in your career as an innovator, investor and now running nVoq?

At least willing to ask awkward questions, if you can characterize rebelliousness somewhat more charitably.

Two attributes which I think are key in this are, one, the willingness to sink your teeth into something and just stick at it. One of the things that I have observed over the years as I applied my trade in technology is that many people have folded their hands far too early. They’ve just sort of given up. Somehow they didn’t in the end have the courage of their convictions.

That brings me to the second point, which is, mathematicians can often have insights into the way things work and see things which are not always easy for other people to see. If you have the good fortune to have the right insights, then that’s probably more important than having a big VC backing you. In other words, good insights can make up for a shortage of dollars.

You were an investor in BeVocal that was sold to Nuance a few years back for a pretty good chunk of change. That became Siri, right?

That I could not comment on. [laughs]

I wondered if I’d get a “yes” out of you on that.

I think I shall refer you to Nuance to comment on matters of Siri or otherwise. [laughs]

How did you get involved with speech recognition?

The story behind it was that I met up with several would-be entrepreneurs in Silicon Valley who wanted to do something with speech recognition. They were not ready for prime time as far the VC community there was concerned.

However, I liked what I saw, and so I worked with them in formulating the business. I invested in at as well, as did eventually a number of VCs once they got to a stage where they were a candidate for taking funding from the VC. 

It was an interesting model, because before we had the term "cloud," they were actually doing a cloud-based IVR. This was also one of the not very common times when you could do a gain share model and control enough of the levers to make it work.

In that environment, it was well known in the industry what percentage of your incoming phone calls to customer care you could automate, or not as the case may be. If you couldn’t automate it, it had to go to an agent and that’s really what drove your expense. The approach at BeVocal was that we would use a judicious amount of speech recognition to increase the — as some people call it — call deflection, meaning deflection away from an agent, or call automation or containment within the IVR. 

The deal we would make with the customer is that for every percentage point we can increase that automation, you pay us X cents per minute. That turned into a very good business model. The reason that type of model is not very common is because often technology companies can’t control enough of the levers to influence the outcome in their favor. Gain share models are often very good for the client and lousy for the technology company.

Nuance is probably the name people people think of most often when they hear the term speech recognition. How are NVoq’s offerings different and how do you compete against Nuance?

We take a different approach. As you said, Nuance is the brand name or the 800-pound gorilla that is known in healthcare. Their primary offerings are back-end transcription as they have absorbed transcription companies and put that on to their back-end speech recognition. Then the front-end product, hich is more widely known, the medical version of Dragon. That is a desktop product. It’s what is called a fat client. All the functionality has to be installed either on the enterprise server or the user’s desktop. 

Our observation is that by taking a different approach, which is to supply functionality out in the cloud, we are able to meet the needs of people who are more cost conscious and need a very simple and portable access to speech recognition. By simple, meaning it’s very easy for them to learn what they need to learn. By portable, it respects the fact that they are working in multiple locations. They’re going from offices to clinics to hospitals and so on and they really need just one account that can follow them around. 

The cloud, as long as they have Internet connectivity, allows them to hook up to their account wherever they are. Then from a user experience point of view, what we have focused on is to make that process upon boarding the user — that is, training them up from ground zero — very simple for the user. The process of supporting that user in their daily use is to make that very simple as well. 

Let me give you a for instance. Because the functionality is in the cloud, we or the reseller can see exactly what the user is doing during the early days and can make judicious interventions to true things up for that user: introduce vocabulary items or tweak the system in a way that meets the user’s actual usage. What is nice for the user is that the system seems to be proactively addressing their needs without them having to pick up a phone and ask for help. 

This brings us to, I think, one of the big opportunities of using speech recognition in the healthcare space, which is to get a higher adoption rate. Nuance has in effect set the standard, so you will see roughly 50 percent of people who have started on Dragon end up abandoning it. Not because Dragon is a bad product. Dragon is a perfectly good speech recognition product. The issue is that when they need support, it’s not convenient to get it. 

We make a very strong push in that direction of delivering good customer service and timely customer service that makes the difference for these users. Because to be blunt, they’re all far too busy to pick up manuals on speech recognition or wade their way through indexes trying to figure out, what did I get wrong? Why isn’t this working for me? Far better that before they even realize they’re having issues, someone can intervene behind the scenes and make the system do what it needs to do.

How do you see the market for voice-operated commands in healthcare or the use of speech recognition by non-physician clinicians for something other than dictation?

If you consider the numbers, there are 800,000 physicians, plus or minus, in America. But the total number of people working provider side in healthcare is closer to 16 million. There is clearly a large, unserved market or potential market of people who need something which can speak to their needs, speak to their workflows, if you will. It’s simple. It’s affordable. It can automate their rote tasks. 

Providing a solution for these people is something we are very interested in and are already doing. We look at it as being ultimately that we should see millions of people who are working on the provider side who are able to benefit from driving the EHR or whatever application they’re using for scheduling or some other type of documentation where they can use voice where appropriate.

I don’t mean to ask too many Nuance questions, but companies that have been successful in anything vaguely related to speech recognition usually end up being bought by Nuance. Is that a concern of clients or an interest that you have?

Well, the future’s always very hard to predict, isn’t it? So I shall defer on that one. We’ll stay focused on providing a very attractive user experience and also financial experience for the users. Where that takes us in the future, who’s to know? [laughs] We’re not courting Nuance, nor are they courting us.

Talking about those potential non-physician users, how do they find you or how do you make your presence known in ways for something the average hospital hasn’t thought of?

There’s nothing like word of mouth that you make something easy for someone who had no idea it’s possible. The fact is that Nuance has invested heavily in creating awareness of speech recognition. So people have thought about potential applications, but they may not be able to implement those applications using what’s available from Nuance. 

As much as anything, that’s just a fact of life. It’s very hard for one company to cover all possible eventualities. We focus on the ones which are probably not in their sweet spots. But we are in a sense down market from where they are pushing with natural language recognition, the coding engines and what have you. We are much more focused on bread and butter and workflow, and in a sense, a  more mass market offering.

I don’t know how you distribute your product or who your customers are, but who’s doing something really interesting with it that would be a notable name?

First of all, how people are getting their hands on the product. The approach we take is it’s channel based. We will work people in the reseller community who, over the years, they know a lot about end users in their neck of the woods. They know where to go hunt, so to speak. 

I think in respect to people whether or not they want their names used, we do have end users who are some well-known names and who certainly appreciate the fact that there is an vendor out there who is taking an attractive approach both for support and also financially. Budgets are under pressure and it’s a very low-risk way for them to use speech in their applications, because for example, we are a subscription base, which means the financial risk is fairly low. If you really don’t like the product or it doesn’t work for you, well, stop paying. [laughs] It’s a monthly subscription, as simple as that. On the other hand, if it works for you, the fact that it’s now a monthly expense rather than a large capital outlay is for a number of users a very attractive proposition.

Other than BeVocal, one of the other big successes you had business-wise was Frame Technology. You sold that to Adobe for $500 million a while back. You’ve had a lot of success in creating and selling these companies. What kinds of investments would you be looking for today in healthcare?

Everything around workflow. There’s opportunity here to look at a script we have seen before, which is with the ERP software or database software that took place in the enterprise world. You had companies like Oracle and SAP and Powersoft and others rising out of that technology wave, if you will. 

The big databases are in a sense the equivalent of the big EHR systems going in. Now that we are probably most of the way through adoption of EHR, that big data repository is now in place into the hospitals or clinics. The opportunity is now for a second generation of applications to come along which can ride on top of the big iron EMR and they can then address particular types of workflow. 

I think we will see a wave of companies emerging in the next five years who build on top of the EHR and go and address some of these point workflows that are hard for the big manufacturers to address because they already have their hands full with Meaningful Use and a list a mile long from their clients about the other things they need.

What are you priorities or strategies for the company for the next few years?

It’s really all about customer service. We are in the business of productivity, taking cycles out of people’s workflow. Anywhere where we see inefficiencies that we can address, we go after that. 

The thesis in high tech is that it’s really an arbitrage game if you will, because you’re always taking an existing process and re-implementing it, leveraging technology to lower the cost point of that process. The difference you’ve opened up between what it costs today versus what it will cost once you put in the technology – that’s the arbitrage that you can then take your cut of and run a business on. So for us, it’s all about productivity.

Do you have any final thoughts?

For anyone reading this interview, if you would like a very friendly and approachable and high-impact customer service approach to using voice recognition in a workflow, come give us a call. I’m sure we can make you happy.

Morning Headlines 4/18/14

Nuance PowerShare Network Unveiled for Cloud-Based Medical Imaging and Report Exchange

Nuance announces that it has acquired image sharing vendor Accelarad and will immediately begin marketing a cloud-based document and image sharing platform called the Nuance PowerShare Network. Financial details were not disclosed.

Athenahealth Posts Loss, Misses Street; Stock Down 10% – Quick Facts

Athenahealth reports Q1 earnings: revenue was up 30 percent at $163 million, but missed analyst estimates of $170 million, EPS $0.12 vs. $0.38.

Epic Wins Tender For Royal Children’s EMR

In Australia, Epic wins a $48 million deal at Melbourne’s Royal Children’s Hospital, concluding a vendor search that reportedly included all major US vendors as well as representation from local Australian vendors.

One Medical Group Raises $40M To Help Reinvent The Doctor’s Office

San Francisco, Calif.-based One Medical Group, a startup building technology-laden primary care offices across the nation, raises a $40 million investment round to continue its expansion.

News 4/18/14

Top News

Nuance confirms its acquisition of Accelarad (reported on HIStalk  last weekend) and the immediate availability of the newly branded Nuance PowerShare Network.

Reader Comments

From Worth HIT: “Re: tradeshow blooper. At HIMSS Middle East, 3M’s booth described a new service offering, ‘Coding and Groping Quality.’ Go to love the high-tech fix … white tape.” The sign is full of inconsistencies: “groping” and “intelligence” are the only words not capitalized, “ICD-10” also appears as “ICD10,” some random commas found their way onto the page, and some lines end with periods while others don’t. You’re gonna need a bigger roll of tape.

From Pure Power: “Re: your 2009 thoughts about EHR data. Worth looking at again.” Well, here you go then, as I was referring five years ago to a research study about using EHR data in nephrology:

I don’t have access to the full text of the article, but I truly believe that once the pain of getting EMRs running as data collection appliances is over (meaning we’ve got data collection clerks known as doctors and nurses in place, which is the “pain” part), the benefit will be incredible. This article apparently deals with having nephrologists automatically consulted when the EHR finds problems. There are other benefits. You could do society-improving medical research by just slicing and dicing data from millions of patients, at least the parts of it that aren’t just clinical-sounding billing events that are useless or even misleading. You could find candidates for research trials. Patients could be followed over many years, even as they move around and use the services of a variety of providers. And for individual patients, there could be great value in putting research findings into the hands of front line doctors. Not to mention giving patients a platform whereby they can participate in their own care and add non-episodic information related to lifestyle, personal health assessment, etc. Clinical systems will not save time, as clinicians know – they exist to create data whose value mostly accrues to someone else. My advice to providers: much of your future income may be based on the data you create and the ownership in it you retain. Don’t be like the Native Americans and let greedy outsiders buy your land for trinkets.

HIStalk Announcements and Requests

A few highlights from HIStalk Practice this week include: US physicians produced $1.6 trillion in direct and indirect economic advantage in 2012. Steven Posnack creates a fun proof of concept graph that matches Medicare payment data with MU incentive payments. Boston doctors prescribe bike riding. AAFP’s president points out the disparity in compensation between family practice physicians and specialists, as evidenced by the recent release of Medicare payment data. CMS offers guidance on the Attestation Batch Upload option. A urology practice employee sends details on 1,114 patients to a competing practice to help the competitor solicit business. Thanks for reading.

This week on HIStalk Connect: Nuance acquires image-sharing vendor Accelarad, which will power a new cloud-based image and report exchange platform that integrates with its existing transcription product lines. In England, the NHS kicks-off a campaign to use telehealth and mHealth apps to reduce ED visits. The Mayo Clinic is funding a medical research assistant app designed to help consumers responsibly look up their symptoms and conditions. Dr. Travis recounts past mistakes the health IT industry has made with EHR data exchange and questions whether the same mistakes are being made with newer payment and care delivery models.

Upcoming Webinars

May 1 (Thursday) 1:00 p.m. ET. Think Beyond EDW: Using Your Data to Transform, Part 2 – Build-Measure-Learn to Get Value from Healthcare Data. Sponsored by Premier. Presenters: Alejandro Reti, MD, senior director of population health, Premier; and Alex Easton, senior director of enterprise solutions, Premier. Once you deploy an enterprise data warehouse, you need to arrive at value as quickly as possible. Learn ways to be operationally and technically agile with integrated data, including strategies for improving population health.

Acquisitions, Funding, Business, and Stock

Athenahealth announces Q1 results: revenue up 30 percent, adjusted EPS $0.12 vs. $0.38, missing analyst estimates for both.

Liaison Technologies raises $15 million in funding.

HCA subsidiary Health Insight Capital makes an equity investment in Intelligent InSites.

One Medical Group, a 27-location practice that heavily promotes its use of healthcare IT in providing care, raises $40 million in growth capital, bringing its total to $117 million.

Great Point Partners makes a “significant investment” in Orange Health Solutions to finance the acquisition of MZI Healthcare, developers of EZ-Cap and other technologies for ACOs and IPAs.

CareCloud reports that it added 170 clients in Q1.

Sales

Australia’s Royal Children’s Hospital in Melbourne awards Epic a $48 million contract.

Sisters of Charity of Leavenworth Health System (CO) selects Allscripts EPSi as its financial decision support system.

University Health System (TX) will deploy PeraHealth’s PeraTrend real-time patient status system, which calculates a score of acuity called the Rothman Index.

People

Crain’s Cleveland Business names Cleveland Clinic CIO Martin Harris, MD as its CIO of the year.

Healthcare data analytics firm GNS Healthcare hires Mark Pottle (N-of-One/Optum Insight) as CFO.

Aventura names Bill Bakken (Nordic Consulting) COO.

NaviNet promotes Sean Bridges to CFO, Sridhar Natarajan to VP of software development, and Thomas Smolinsky to VP/CISO.

Announcements and Implementations

Steward Health Care System launches the StewardCONNECT patient portal based on Get Real Health’s InstantPHR patient engagement platform.

Park Nicollet Health Services (MN) will implement StrataJazz from Strata Decision Technology for cost accounting, contract modeling, long-range financial planning, and rolling forecasting.

The Patient-Centered Outcomes Research Institute (PCORI) provides an update on its $100 million initiative to develop the National Patient-Centered Clinical Research Network that was originally announced in December. PCORI’s executive director Joe Selby, MD outlines details on governance, data security, privacy, and interoperability as participants work to build a database of 26 to 30 million EHR records in support of retrospective clinical research.

The 25-bed Dan C. Trigg Memorial Hospital (NM), which is owned by Presbyterian Healthcare Services, implements Epic.

The Whitman-Walker Clinic (DC) is implementing Forward Health Group’s PopulationManager and The Guideline Advantage.

Cincinnati’s fire department rolls out Tempus Pro, a real-time vital signs monitoring system developed for battlefield use that allows hospital-based physicians to monitor patients being transported by ambulance.

Mayo Clinic and startup Better announce a $50 per month membership-based app that includes a symptom checker, health information, and access to a personal health assistant.

Government and Politics

The HHS’s OIG warns that some state Medicaid agencies may be putting patient health information at risk by outsourcing administrative functions offshore.

Innovation and Research

A VA survey of 18,000 randomly chosen users of its My HealtheVet system finds that a third of them use Blue Button, with three-quarters of those saying its main value is collecting their information in one place. Barriers to adoption were identified as low awareness and usability issues.

HIMSS Analytics says that healthcare IT systems with the highest growth potential are bed management, ERP, and financial modeling.

TechCrunch profiles One Medical Group, which has raised $117 million (the latest funding announcement is above) in funding to create a new kind of technology-powered medical practice, with its custom-developed EHR and portal offering appointment scheduling, refills, lab results, and access to a patient’s records from any of its 27 locations. Patients pay $149 per year for access and can use their health insurance.

Other

It’s not exactly health IT related, but appalling: Yahoo fires its COO of only 15 months after he fails to improve the company’s advertising revenue. He didn’t get a bonus because he didn’t make his numbers, but he still walked out with a severance check of $58 million.

The Bloomberg School of Public Health at Johns Hopkins University tweets that it has exceed 1 million enrollments in its free Coursera courses. Starting soon: Community Change in Public Health, Mathematical Biostatistics Boot Camp 2, The Data Scientist’s Toolbox, Getting and Cleaning Data, Exploratory Data Analysis, and The Science of Safety in Healthcare.

BIDMC CIO John Halamka, MD offers common sense HIPAA-related tips to hospitals using patient data for fundraising:

• Disclose fundraising activities in the Notice of Privacy Practices and include clear opt-out provisions
• Manage the data centrally and don’t allow departments to create their own databases
• Allow only experts to query the database and create views that respect the “need to know”
• Keep audit trails
• Provide tools to eliminate the need to query clinical systems directly

Interesting facts from an article on clinicians who use social media in the OR:

• A Texas woman died during a low-risk surgery because the iPad-using anesthesiologist didn’t notice her decreasing blood oxygen levels until she turned blue
• Nurse anesthetists and residents were distracted in 54 percent of cases, most often because they were on the Internet
• 56 percent of perfusionists admitted to talking on their cell phones during procedures, and only about half thought it was dangerous to text during surgery
• A quote from anesthesiologist who studies unfocused OR staff: “Airline pilots don’t allow themselves to be distracted by social media because they themselves do not want to die. To replicate that in healthcare, we’d have to say if there’s a wrong-site surgery or other error, we will shoot everybody in the OR.”

UNC Healthcare (NC) reduces patient volumes as it adjusts to its April 4 Epic go-live.

A seventh grader undergoing cancer treatment “attends” classes in his school more than 1,100 miles away from Children’s Hospital of Philadelphia by using VGo, an audiovisual-equipped robot he can steer down the school hallway and into classrooms as he says hello to classmates. The same VGo robot is used by hospitals for patient monitoring  and telemedicine.

Weird News Andy calls this story “Doc on the Run.” An Arkansas gynecologist allegedly takes smartphone pictures of his patients without their consent while they are in the stirrups. Police investigating a patient’s complaint find her photos on the doctor’s phone, but don’t initially find him (and thus WNA’s headline). Since then, however, he has been arrested and charged with video voyeurism.

Sponsor Updates

• PMD releases pMD Messaging, a secure text messing solution for providers that is integrated with the company’s mobile charge capture application.
• Surescripts awards DrFirst and 31 of its EMR partners that have integrated Rcopia e-prescribing software within their EMR with its White Coat of Quality Award.
• The Professional Association for Customer Engagement presents nVoq with its 2014 Technovation Award for demonstrating superior technological innovation and leadership in customer engagement.
• CCHIT certifies that PatientKeeper v8.1 software is compliant with the ONC 2014 Edition criteria as an EHR module.
• Netsmart joins Carequality, a collaborative formed to accelerate health data exchange, as a founding member.
• The Omega Management Group awards RelayHealth Financial its NorthFace ScoreBoard Awards for excellence in customer service and support.
• O’Reilly Strata RX Conference posts a wrap-up video from its Strata RX 2013 conference.
• GetWellNetwork announces details of its GetConnected 2014 conference in Chicago June 3-5.
• Deputy National Coordinator Jacob Reider, MD will deliver the keynote address at the 2014 Aprima User Conference in Dallas, TX August 8-10.
• Craig Greenberg, associate practice director for Beacon Partners, suggests in the company’s blog five areas of focus for improving and sustaining cash flow.
• Capsule Tech will exclusively resell in North America Clinical Vigilance for Sepsis software from Amara Health Analytics.
• A local news station highlights Jane Phillips Medical Center (OK) and its use of PatientTouch for nurse communications and patient documentation.
• Orion Health co-sponsors the Fifth National Accountable Care Organization Summit June 18-20 in Washington, DC.

Highlights from the Atlanta iHT2 Health IT Summit
By Jennifer Dennard

This was my third year in a row attending the Health IT Summit in Atlanta. It continues to be a great experience.

The conference, hosted by the Institute for Health Technology Transformation (iHT2), was held at Georgia Tech’s Academy of Medicine. It was an intimate gathering of providers, government healthcare reps, and vendors, with a few lab and pharma folks thrown in for good measure.

The topics of discussion both on stage and during networking breaks have moved over the last two years from Meaningful Use and EMRs to accountable care and patient engagement. Providers are concerned with:

• Finding the right leadership (including physicians) to implement and champion IT projects.
• Establishing trust between hospital executives and departments, including trust in the data they review.
• Analytics.
• Business process reengineering and Lean Six Sigma.

Mary Jane Neff, senior director of regional IS; Katheryn Markham, VP of IS planning; Lynda Anderson, senior director of regional IS, all of Kindred Healthcare.

Thea-Marie Pascal, certified Epic clinical documentation application coordinator; Susan Still, RN, Epic ASAP lead application coordinator; Makeba Lippitt, certified Epic clinical documentation application coordinator, all of Piedmont Healthcare.

The panel on "Transforming Health Care Through HIE: Driving Interoperability" featured (from left to right) moderator Kimberly Bell, executive director, Georgia Health Information Technology Extension Center at Morehouse School of Medicine; panelists Eddy Brown, VP of business development, TeraMedica; Steve Sarros, VP/CIO, Baptist Health Care; and Sonya Christian, CIO, West Georgia Health.

The keynote presentations were solid, though a high bar was set a few years ago by Naomi Fried, chief innovation Officer at Boston Children’s Hospital (MA). My favorite session was the last, with West Georgia Health’s CIO, CFO and director of nursing all participating on the same panel, answering questions about workplace culture, Lean Six Sigma, and patient safety.

Ten companies exhibited, among them Merge Healthcare, TeraMedica, VMware, Information Management Consultants, and Jvion. Nicole Cirillo from LabCorp explained how patients can review their own lab results through its portal (Georgia is not a right-to-know state.) LabCorp now offers its own portal through which patients can, with guidance from their physicians, access results.

EPtalk by Dr. Jayne

I had a run-in with one of our employed physicians yesterday. Some of these folks are really starting to wear me down. He’s been with us for a while, and unfortunately the EHR we purchased for our large multispecialty group many years ago does not have specific content for his specialty.

We knew this when we implemented him. We gave him the ability to use speech recognition to essentially dictate all of his office visit documentation except for orders, physical exam, and review of systems, which must be entered discretely. His staff enters other discrete data for patient history, allergies, etc.

Most of our other physicians (even those who do have content for their specialties) would kill for this arrangement. Still, it’s not enough for this guy, who demanded that I come to his office and personally shadow him to see how deficient the system is. I’m trying to win hearts and minds, so I agreed to go out. Rather than take the opportunity to show me how he sees patients and let me assess what his needs truly are, he preferred to spend the time we had standing in the hallway complaining about templates.

It turns out he has been using internal medicine templates to try to document his visits because he doesn’t like the dictation arrangements. He has the option to either dictate in the exam room with the patient present (many of our surgical consultants like this because it gives another opportunity for the patient and family to hear the diagnosis and plan of care one more time and ask questions), to release the patient to checkout and dictate in the exam room after the patient leaves, or to go to his administrative office to dictate. He has his own reasons why each of these is inadequate, but doesn’t have any suggestions for what he wants.

Of course, the internal medicine templates are completely overkill for what he’s trying to do. He has to weed through primary care clinical protocols and other information that’s not relevant to his specialty and feels frustrated. I reminded him that we didn’t train him to do this, that we recommended he use a specialty set that’s closer to his own instead, but he doesn’t like those either.

Most of our other specialists who don’t have content for their specialties are perfectly happy to dictate because it changed their workflow minimally from the paper world. Our primary care docs would love to be allowed to dictate as much as these guys can, but unfortunately for them, we need discrete data from more parts of the chart to meet payer incentive programs and other quality initiatives that we’re working on.

I’m not sure what he really wanted to get out of the visit other than to vent, which is fine, but it doesn’t change anything as far as documenting in the EHR. He wasn’t interested in any of the options I had to present and isn’t going to change his opinion. He doesn’t want a scribe. He doesn’t want to point and click. He doesn’t want to dictate. He doesn’t want a pen solution like Shareable Ink. His continued push-back (going on two years now) is an exercise in futility.

As I was driving back to my office, I got to thinking about that. This is a physician who deals regularly with patients who have life-altering injuries and conditions that cannot be fixed. His specialty is centered on helping people maximize the functionality they currently have and to compensate for what they have lost. He’s very good at what he does, yet he can’t see his EHR issues with the same perspective he uses when treating patients – helping them use what they have to the best of their abilities and not dwelling on what they don’t have or have never had.

We learn in medical school and residency to identify when interventions are futile. We call the code when there’s no hope of getting the patient back. We don’t perform surgeries when they’re not going to improve the patient’s condition. We understand that there are limits to technology and our ability to treat and cure. We’re pretty good at helping patients understand the options when they’re faced with a lack of good choices.

When it comes to limitations in information technology, however, we’re struggling mightily with the thought of applying those same concepts. The EHR of the future is going to look a lot different than what we have today – just like the laparascopic surgeries we do now are completely different from the open surgeries we did in the past. Maybe in the future we’ll beam your gallbladder out of your abdomen instead of having to cut you at all. But for the time being, we have to work with what we have as best as we can. We have to realize there are limits to everything. There’s no psychic module for EHR that’s going to document directly from your thoughts, at least not for now.

Fighting is good when it’s appropriate, but at some point, we have to realize when it’s futile and either accept our current situation or move on. I’m not sure what else to do with or for this physician since we’ve not been able to make him happy as long as we’ve been trying. I suspect there are other factors at play that have nothing to do with EHR, but they’re not within my realm to tackle. We’ll keep reinforcing his options, pair him up with peers that are successful, and encourage him. Until he’s ready to leave the group or retire, I’m not sure what else we can do.

Well, I guess there’s one more thing we could do – pastry therapy. I just dropped a little surprise at his office to thank him for his time yesterday. A girl can hope.

Contacts

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

More news: HIStalk Practice, HIStalk Connect

Morning Headlines 4/17/14

Scientists embark on unprecedented effort to connect millions of patient medical records

PCORI will invest $100 million to build a nationwide database containing 26 to 30 million EHR records in an effort to begin supporting retrospective clinical research.

Telehealth Medical Treatment Coming to all 50 States, Brought to You by MeMD

MeMD announces that its subscription-based telemedicine service has expanded to include licensed providers in all 50 states.

Budget Office Lowers Estimate for the Cost of Expanding Health Coverage

The Congressional Budget Office expects that expanding insurance under the ACA will cost $100 billion less than previously forecast over the next 10 years, according to a report published Monday that cites an increase in non-elderly coverage and a decrease in the forecasted cost of insurance subsidies.

Readers Write: Can Intuitive Software Design Support Better Health?

Can Intuitive Software Design Support Better Health?
By Scott Frederick

Biometric technology is the new “in” thing in healthcare, allowing patients to monitor certain health characteristics—blood pressure, weight, activity level, sleep pattern, blood sugar—outside of the healthcare setting. When this information is communicated with providers, it can help with population health management and long-term chronic disease care. For instance, when patients monitor their blood pressure using a biometric device and upload that information to their physician’s office, the physician can monitor the patient’s health remotely and tweak the care plan without having to physically see the patient.

For biometric technology to be effective, patients must use it consistently in order to capture a realistic picture of the health characteristics they are monitoring. Without regular use, it is hard to see if a reading is an anomaly or part of a larger pattern. The primary way to ensure consistent use is to design user-friendly biometric tools because it is human nature to avoid things that are too complicated, and individuals won’t hesitate to stop using a biometric device if it is onerous or complex.

Let’s look at an example.

An emerging growth area for healthcare biometrics is wireless activity trackers—like FitBit—that can promote healthier lifestyles and spur weight loss. About three months ago, I started using one of these devices to see if monitoring metrics like the number of steps I walked, calories I consumed and hours I slept would make a difference in my health.

The tool is easy-to-use and convenient. I can monitor my personal metrics any time, anywhere, allowing me to make real-time adjustments to what I eat, when I exercise, and so on. For instance, at any given time, I can tell how many steps I’ve taken and how many more I need to take to meet my daily fitness goal. This shows me whether I need to hit the gym on the way home from work or whether my walk at lunch was sufficient. I can even make slight changes to my routine, choosing to stand up during conference calls or take the stairs instead of the elevator.

I download my data to a website, which provides easy-to-read and customizable dashboards, so I can track overall progress. I find I check that website more frequently than I look at Facebook or Twitter.

Now, imagine if the tool was bulky, slow, cumbersome and hard to navigate. Or the dashboard where I view my data was difficult to understand. I would have stopped using it awhile ago—or may not have started using it in the first place.

Like other hot technology, there are several wireless activity trackers infiltrating the market, each one promising to be the best. In reality, only the most well-designed applications will stand the test of time. These will be completely user-centric, designed to easily and intuitively meet user needs.

For example, a well-designed tracker will facilitate customization so users can monitor only the information they want and change settings on the fly. Such a tool will have multiple data entry points, so a user can upload his or her personal data any time and from anywhere. People will also be able to track their progress over time using clear, easy-to-understand dashboards.

Going forward, successful trackers may also need to keep providers’ needs in mind. While physicians have hesitated to embrace wireless activity monitors—encouraging patients to use the technology but not leveraging the data to help with care decisions—that perspective may be changing. It will be interesting to see whether physicians start looking at this technology in the future as a way to monitor their patients’ health choices. Ease of obtaining the data and having it interface with existing technology will drive provider use and acceptance.

While biometric tools are becoming more common in healthcare and stand to play a major role in population health management in the future, not every tool will be created equal. Those designed with the patient and provider in mind will rise to the top and improve the overall health of their users.

Scott Frederick, RN, BSN, MSHI is director of clinical insight for PointClear Solutions of Atlanta, GA.

Readers Write: Addressing Data Quality in the EHR

Addressing Data Quality in the EHR
By Greg Chittim

What if you found out that you might have missed out on seven of your 22 ACO performance measures, not because of your actual clinical and financial performance, but because of the quality of data in your EHRs? It happens, but it’s not an intractable problem if you take a systematic approach to understanding and addressing data quality in all of your different ambulatory EHRs.

In HIStalk’s recent coverage of HIMSS14, an astute reader wrote:

Several vendors were showing off their “big data” but weren’t ready to address the “big questions” that come with it. Having dealt with numerous EHR conversions, I’m keenly aware of the sheer magnitude of bad data out there. Those aggregating it tend to assume that the data they’re getting is good. I really pushed one of the major national vendors on how they handle data integrity and the answers were less than satisfactory. I could tell they understood the problem because they provided the example of allergy data where one vendor has separate fields for the allergy and the reaction and another vendor combines them. The rep wasn’t able to explain how they’re handling it even though they were displaying a patient chart that showed allergy data from both sources. I asked for a follow up contact, but I’m not holding my breath.

All too often as the HIT landscape evolves, vendors and their clients are moving too quickly from EHR implementation to population health to risk-based contracts, glossing over (or skipping entirely) a focus on the quality of the data that serves as the foundation of their strategic initiatives. As more provider organizations adopt population health-based tools and methodologies, a comprehensive, integrated, and validated data asset is critical to driving effective population-based care.

Health IT maturity can be defined as four distinct steps:

1. EHR implementation
2. Achievement of high data quality
3. Reporting on population health
4. Transformation into a highly functioning PCMH or ACO.

High-quality data is a key foundational piece that is required to manage a population and drive quality. When the quality of data equals the quality of care physicians are providing, one can leverage that data as an asset across the organization. Quality data can provide detailed insight that allows pinpointing opportunities for intervention — whether it’s around provider workflow, data extraction, or patient follow-up and chart review. Understanding the origins of compromised data quality help recognize how to boost measure performance, maximize reimbursements, and lay the foundation for effective population health reporting.

It goes without saying that reporting health data across an entire organization is not an easy task. However, there are steps that organizations must take to ensure they are extracting sound data from their EHR systems.

Outlined below are the key issues that contribute to poor data quality impacting population health programs, how they are typically resolved, and more optimal ways organizations can resolve them.

Variability across disparate EHRs and other data sources

EHRs are inconsistent. Data feeds are inconsistent. Despite their intentions, standardized message types such as HL7 and CCDs still have a great deal of variability among sources. When they meet the letter of national standards, they rarely meet the true spirit of those standards when you try to use.

Take diagnoses, for example. Patient diagnoses can often be recorded in three different locations: on the problem list, as an assessment, and in medical history. Problem lists and assessments are both structured data, but generally only diagnoses recorded on the problem list are transported to the reports via the CCD. This translates to underreporting on critical measures that require records of DM, CAD, HTN, or IVD diagnoses. Accounting for this variability is critical when mapping data to a single source of truth.

Standard approach: Most organizations try to use consistent mapping and normalization logic across all data sources. Validation is conducted by doing sanity checks, comparing new reports to old.

Best practice approach: To overcome the limitations of standard EHR feeds like the CCD, reports need to pull from all structured data fields in order to achieve performance rates that reflect the care physicians are rendering– either workflow needs to be standardized across providers or reporting tools need to be comprehensive and flexible in the data fields they pull from.

The optimal way to resolve this issue is to tap into the back end of the EHR. This allows you to see what data is structured vs. unstructured. Once you have an understanding of the back-end schema, data interfaces and extraction tools can be customized to pull data where it is actually captured, as well as where it should be captured. In addition, validation of individual data elements needs to happen in collaboration with providers, to ensure completeness and accuracy of data.

Variability in provider workflows

EHRs are not perfect and providers often have their own ways of doing things. What may be optimal for the EHR may not work for the providers or vice versa. Within reason, it is critical to accommodate provider workflows rather than forcing them into more unnatural change and further sacrificing efficiency.

Standard approach: Most organizations ignore this and go to one extreme or another: (1) use consistent mapping and normalization logic across all data sources and user workflows, making the assumption that all providers use the EHR consistently, or (2) allowing workflows to dictate all and fight the losing battle to make the data integration infinitely adaptable. Again, validation is conducted using sanity checks, comparing new reports to old.

Best practice approach: Understand how each provider uses the system and identify where the provider is capturing all data elements. Building in a core set of workflows and standards dictated by an on-the-ground clinical advisory committee, with flexibility for effective variations is critical. With a standard core, data quality can be enhanced by tapping into the back end of the EHR to fully understand how data is captured as well as spending time with care teams to observe their variable workflows. To avoid disruption in provider workflows, interfaces and extraction tools can be configured to map data correctly, regardless of how and where it is captured. Robust validation of individual data elements needs to happen in collaboration with providers to ensure completeness and accuracy of data (that is, the quality of the data) matches the quality of care being delivered.

Build provider buy-in/trust in system and data through ownership

If providers do not trust the data, they will not use population health tools. Without these tools, providers will struggle to effectively drive proactive, population-based care or quality improvement initiatives. Based on challenges with EHR implementation and adoption over the last decade, providers are often already skeptical of new technology, so getting this right is critical.

Standard approach: Many organizations simply conduct data validation process by doing a sanity test comparing old reports to new. Reactive fixes are done to correct errors in data mapping, but often too late, after provider trust has been lost in the system.

Best practice approach: Yet again, it is important to build out a collaborative process to ensure every single data element is mapped correctly. First meetings to review data quality usually begin with a statement akin to “your system must be wrong — there’s no way I am missing that many patients.” This is OK. Working side by side with the providers to ensure they understand where data is coming from and how to modify both workflow and calculations ensure that they are confident that reports accurately reflect the quality of care they are rendering. This confidence is a critical success factor to the eventual adoption of these population health tools in a practice.

Missed incentive payments under value-based reimbursement models

An integrated data asset that combines data from many sources should always add value and give meaningful insight into the patient population. A poorly mapped and validated data asset can actually compromise performance, lower incentive reimbursements, and ultimately result in a negative ROI.

Standard approach: A lackluster data validation process can result in lost revenue opportunities, as data will not accurately reflect the quality of care delivered or accurately report the risk of the patient population.

Best practice approach: Using the previously described approach when extracting, mapping, and validating data is critical for organizations that want to see a positive ROI in their population health analytics investments. Ensuring data is accurate and complete will ensure tools represent the quality of care delivered and patient population risk, maximizing reimbursement under value-based payments.

We have worked with a sample ACO physician group of over 50 physicians to assess the quality of data being fed from multiple EHRs within their system into an existing analytics platform via CCDs and pre-built feeds. Based on an assessment of 15 clinically sensitive ACO measures, it was discovered that the client’s reports were under-reporting on 12 of the 15 measures, based only on data quality. Amounts were under-reported by an average of 28 percentage points, with the maximum measure being under-reported by 100 percentage points.

Reports erroneously reported that only six of the 15 measures met 2013 targets, while a manual chart audit revealed that 13 of the 15 measures met 2013 targets, indicating that data was not being captured, transported, and reported accurately. By simply addressing these data quality issues, the organization could potentially see additional financial returns through quality incentive reimbursements as well as a reduced need for labor-intensive intensive chart audits.

As the industry continues to shift toward value-based payment models, the need for an enterprise data asset that accurately reflects the health and quality of care delivered to a patient population is increasingly crucial for financial success. Providers have suffered enough with drops in efficiency since going live on EHRs. Asking them to make additional significant changes in their daily workflows to make another analytics tool work is not often realistic.

Analytics vendors need to meet the provider where they are to add real value to their organization. Working with providers and care teams not only to validate integrity of data, but to instill a level of trust and give them the confidence they need to adopt these analytics tools into their everyday workflows is extremely valuable and often overlooked. These critical steps allow providers to begin driving population-based care and quality improvement in practices, positioning them for success in the new era of healthcare. 

Greg Chittim is senior director of Arcadia Healthcare Solutions of Burlington, MA.

CIO Unplugged 4/16/14

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

How Snow White Changed My Life

OK, life change is a stretch, but Snow and some of her peer princesses did remind me of a critical aspect of leadership—creating special moments. In the case of Disney, it’s “where dreams come true.” For my Starbucks aficionados, it’s, “Handcrafted beverages are the secret to making life better.”

Five years ago, I added “create perfect moments” to my personal strategic plan. It’s one technique to help ensure “creating perfect moments” moves from bench to bedside. In the big things of my life, this has worked well, but not the common everyday stuff of earth.

While in Orlando recently, I spent time exploring Disney’s Epcot. Just for fun — and to make my wife and 20-year-old daughter smile — I decided to grab a photo op with Snow White.

Was my pride ever challenged! There I was, sandwiched between animated toddlers and star-struck preteens, in line to take a pic with Ms. Purity herself. Seemed everyone was dressed like a princess except me. I stood close to one toddler hoping passersby would think I was part of her family. Heaven forbid someone I knew might see me standing in line at Disney for a personal princess pic.

My turn came. I sheepishly held my arm out for Snow White. My friend took the pic.

I was ready to run, but Snow would not let me go. Help! She turned, looked me in the eye, and engaged me in conversation. I was pulling away, but she kept me there. It was longer than a moment, but not excessive, maintaining eye contact the entire time. As if someone just discovered my hand in the cookie jar, I was about to break out in a nervous sweat.

I texted the pic to my wife and daughter and they both replied ROTFL. So when I saw Sleeping Beauty, I stepped in line again.

This time, I carefully observed all the interactions between the princess and her devotees. Miss Beauty held eye contact with every fan and engaged in brief conversation.

My turn came, and though I tried to pull away, she clung to my arm until we talked. Awkward, yes, but so enlightening. Ditto with Belle, Cinderella, and last but not least, Ariel. They were indeed making dreams come true for their fans. They made me feel important.

How can we take something as simple and yet profound as a Disney princess engagement formula and put it into practice ourselves? How can we allow this to become a natural part of who we are?

As leaders, we are so rushed. I preach to myself here. We walk past our staff with nary an acknowledgement. When we do stop to talk, we are thinking about the meeting we are headed to.

On one hand, we claim that the right people in the right places are our most valuable assets. But do we give them the gift of our time, fully present, even for just a minute? This proves a contradiction in our leadership.

Since my return from Disney, I’ve been doubling down on creating special moments, this time with my staff. I am making sure every interaction, however brief, is meaningful. Eye contact. Genuine interest. While the other person may be rushed, I will remind myself that my agenda is their agenda, and my role as a leader is to serve them. True, not every person will want the time, but for those who do, I am there.

Before the end of my final day at Disney, I was looking for the next princess. Why? Because I enjoyed the way they made me feel. Special. If a princess can do this for strangers, we can do it for those we serve. Pics or no pics.

Create special moments.

Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.

HIStalk Interviews Jim Prekop, CEO, TeraMedica

Jim Prekop is president and CEO of TeraMedica of Milwaukee, WI.

Tell me about yourself and the company.

I’ve been in health IT for about 30 years. The last 10 have been with TeraMedica. Before that, I was in the EMR space and companies like PeopleSoft and Dun & Bradstreet software.

TeraMedica is middleware. The industry term is vendor-neutral archive. We collect clinical objects and are responsible for making them available to the source system, but also making them available in a patient-centric view to additional consumers of that data, whether they’re outside in institutions, exchanges, or new technology that gets adopted by the provider. We perform that role in the healthcare architecture.

How has the unbundling of PACS from single-solution vendors changed the demand for vendor-neutral archives and what’s the end result for the provider and the patient?

It’s a natural progression. With systems, historically, the new idea is a more or less a closed-loop answer. It’s the same way with accounting systems going back decades. 

What was a box has now become a layer in the architecture, the process of acquiring and managing an image and then making it available down the road to new consumers or later in my lifetime. The solution has had to evolve. The VNA, or the ability to seamlessly have the interaction with departmental activity but yet be the conduit into the enterprise, it’s a natural progression. It’s not to say that PACS is bad, just that the focus going forward on PACS will be different, just as the responsibility for the VNA will change over time as well.

What about universal viewers?

The universal viewer is interesting. They’re approaching this through the lens of the physician, whereas the VNA approaches it from the infrastructure up. 

The advantage for the enterprise viewer is that they can combine data from multiple sources. But the other thing that has to be kept in mind is that there is response time and there is certainty that is needed in what is delivered to the enterprise viewer. You get into a federated discussion of going after 20 different data sources, combining that answer, and then delivering it in one view to the clinician versus the ability to have all of that patient matching resolved by the VNA. It’s one-stop shopping. It goes to any consumer of the VNA.

We see the consumers being an EMR. We see the consumers being an enterprise viewer. Going forward as more adoption comes into the United States, it will be different exchanges that imaging will become part of. So to us, it’s just a consumer. We optimize its ability to be confidently assured that they’ve asked for and gotten the right information and that all the information is there. If you have a federated view and make a request and one of those systems is down, you might not get the answer.

Enterprise viewer implies that there’s behind the scenes fetching going on that then presents a unified view, as opposed to the VNA where it’s actually stored in a single system.

Yes. It’s already stored and normalized and you’re having one conversation behind the scenes. 

Unless somebody’s invented something new in IT that I haven’t seen, you pretty much have to ask the same question across multiple systems or go to some sort of index and find out all the Jim Prekops and then go and find out where they’re located, go get them, and then present it to me in an organized way. Can those enterprise viewers do that? Absolutely, and we have great partners in that space. Is it the best experience for the provider or the clinician? Maybe not.

What are the optimal ways to integrate a variety of images into Epic or Cerner?

I call it a landing page. EMRs address all the departments in the organization and rightfully so. But if I want to go look at all the different clinical objects that Jim Prekop created in a facility, chances are the links to that information are within various locations within the EMR. 

One of the advantages that TeraMedica brings to the table to leverage the investment that the provider has in the EMR is to give a patient-centered view of all the clinical objects, should they want that. That’s an option in our system. We can be tied to a report and just show that image, or we can present a complete inventory of what we have in the VNA, so that in one location, a clinician can see things that might be related to other departments. I don’t necessarily have to navigate over to that section of the EMR to see those objects.

It’s probably important to note that all images are objects but not all objects are images. Are you seeing demands for new object types?

Absolutely. When I first got here, I had to get an education on DICOM and all the nuances and it was a big education. But not everything is DICOM when it comes to clinical objects. 

Our customers asked us very early to not just manage DICOM. It’s a wonderful thing and is the heavy lifting in our business. But to be truly patient-centric, you have to address all different types of file types, whether it be JPEGs, MPEGs, PDFs, a Word document, or in the case of cancer care, lots of calculations are done using Excel and other types of planning systems.

To represent that an image is just a DICOM object is not fair. It’s usually one of the arguments when you try and decide what a VNA really is. There are lots of folks that manage DICOM and they do a good job, but they declare themselves as the VNA. That doesn’t meet our definition of a VNA.

What’s the distinction between storing non-DICOM data in its native format instead of using a DICOM wrapper?

Unlike other industries where you can create data marts and if there’s a problem you just snap another copy of the data, we’re into terabytes and hundreds of terabytes of data. As you acquire that information as the VNA, you have to be clinically responsible to the source system. If I go get a PDF of Jim Prekop from a clinical system and I wrap it in DICOM and that system wants it back, I either have to create duplicate storage — which is not cost productive — or I have to be able to unwrap it from that DICOM and enter that as a PDF to that source system.

The overhead of doing that simply doesn’t work and it doesn’t scale. To believe that you have to wrap everything in DICOM so it follows how your system works … I would suggest you have the wrong system if it only works with DICOM.

A well-known VNA consultant who comes from a PACS mentality is adamant that everything should be wrapped in DICOM. We needed to get him to sign an updated non-disclosure agreement, so I had my engineers wrap our NDA in DICOM before I sent it to him. His asked me what I had sent him since he operates on a Macintosh that doesn’t understand the file type, which is a .UCM. He didn’t even recognize that I had sent him a DICOM file. He didn’t understand that he was essentially justifying the reason why we believe that it’s DICOM and non-DICOM.

Who are your main competitors and how do you differentiate your product from theirs?

Since the VNA term was adopted — I prefer Vendor-Neutral Architecture — lots of folks put their hat into the game. As you would expect, a lot of PACS vendors have begun to open up and allow multiple DICOM systems to enter data in there.

It’s usually TeraMedica and Acuo that end up being the finalists in any evaluation. There are some other ones that are out there that do some of the things that we do. There’s some newcomers — Mach7 is out there, but I think they have more activity outside the US than they do within the US. But there are others that are coming into the space, and rightfully so. It’s a competitive market.

Hospitals acquiring medical practices and each other have left them trying to figure out how to get their systems to talk to each other. Is that true of imaging systems or other systems that would populate a VNA?

There’s two aspects of that. We’re having organizations that are buying us because they’re strategically positioning themselves to acquire other entities. They know that they can’t rip out those clinical systems, so they will use us as part of their strategy to get control of the data and share it across the enterprise.

As far as the other way, we have sites that are established either because of acquisitions or because of differences on campuses that have multiple EMRs. Our technology allows, again using myself as the example, Jim Prekop to be referenced, and if I know the request is coming from Epic, I’ll behave one way to put it properly in Epic. At the same time, I can put it into Cerner. There’s one source of the truth.

One of the value propositions that we bring as a VNA is that we can identify consumers and react accordingly. We can also respond to multiple consumers, but yet give them the exact data that they’re looking at, whether they come in through the physician’s office with one EMR or they come in through the hospital with another EMR. It’s one source of the truth with multiple consumers.

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

I think it’s based around being a good partner with our customers and bringing to them more use cases, more managing the data. As you would expect, we can sit behind a PACS, but the thing about VNAs is we’ve had to come around the curtain. We’ve always considered doing the plumbing behind the scenes. But now we’re very active in different departmental workflows.

We’re getting involved with our iPad app, as an example, in departments like wound care and dermatology, where the clinicians are actually interacting with our software and we are part of the EMR, but the clinician doesn’t even know we’re there. A lot of times when someone says, “I didn’t know you were there,” that’s a bad thing. For us, that’s a good thing, because we want seamless integration into these different systems. I can see us doing more of it.

I can see us taking responsibilities for more functions of a generic nature in the provider space so that they can optimize the platform that they’ve invested in. Clearly the leading investment is the EMR. But the VNA is also a strategic investment, and we need to do more for them when it comes to clinical workflow.

Morning Headlines 4/16/14

Public Workshop – Proposed Risk-Based Regulatory Framework and Strategy for Health Information Technology, May 13-15, 2014

The FDA, ONC, and FCC will co-host a free three-day public workshop at NIST’s campus in Gaithersburg, MD from May 13-15. The event will provide experts and stakeholders an opportunity to provide input on the recently published FDASIA health IT report.

ICD-10

CMS finally acknowledges the ICD-10 delay in a new post on its ICD-10 readiness website that says, "CMS is examining the implications of the ICD-10 provision and will provide guidance to providers and stakeholders soon."

Meaningful Use Not Correlated With Quality in Study

A study at Beth Israel Deaconess Medical Center (MA) that compared the quality scores of 540 physicians who achieved MU with those of 318 physicians who did not finds that adoption of Meaningful Use does not correlate with improved quality.

IT landscape changing for sharing Oklahoma patient medical records

A local paper covers the launch of two competing health information exchanges in Oklahoma and discusses the impact the competition will have on the overall sustainability of the project.

News 4/16/14

Top News

FDA left unanswered questions about its FDASIA report, such as how to submit the comments the report solicits. The agency announces a free, three-day public workshop May 13-15 at NIST in Gaithersburg, MD that will also be presented via webcast. Comments on the FDASIA report can be left here.

Reader Comments

From Lois Lane: “Re: short label names for ICD-9, CPT, and MS-DRGs. Any source for these other than an EMR vendor?” If anyone knows, please leave a comment.

From Guillermo del Grande: “Re: signs that whoever is talking about Epic doesn’t know what they’re talking about.” GDG’s list:

1. “Model the Model”
2. “EPIC”
3. They think NVTs are actually meaningful.
4. They ask where they can buy Epic stock.
5. They wonder why Epic doesn’t hire doctors and nurses to help improve their product.
6. They don’t know that the god-awful screen they are looking at is customizable.
7. They think Epic was born as a billing product.
8. They don’t know real people work there, just implementers.
9. They actually think there’s no internal politics at Epic.
10. They think Epic’s the only software running a MUMPS descendant.

From Bill Kilgore: “Re: VerbalCare. I think you might like these guys. Very cool product.” Inpatients get an VerbalCare icon-driven tablet instead of the 1950s-era call button, allowing them to choose the icon describing their need instead of just pushing a call button or trying to communicate through a drive-through quality speaker-microphone. Employees can receive and acknowledge requests on their smartphones or from a central console. The interactions are also tracked for later analysis. VerbalCare offers a commitment-free pilot. Everything looks good except they spelled HIPAA as “HIPPA” on their site, which is almost unforgivable. You should at least correctly spell the name of the requirement with which you are claiming compliance.

HIStalk Announcements and Requests

Ms. Dayton, a Teach for America teacher in Arizona, sent pictures and her thanks to HIStalk readers for supporting her magnet school sixth graders by providing them with math stations. She explains, “You have truly transformed my classroom. My students now look forward to math and enjoy the time spent playing the wonderful games that you donated. On a daily basis I hear from my students, ‘Ms. Dayton, can we play the games today?’ or ‘Ms. Dayton, can we skip writing and do math all day?’ I hear these things because of you!”

Upcoming Webinars

April 16 (Wednesday) 11:00 a.m. ET. Panel Discussion: Documents, EMRs, and Healthcare Processes. Sponsored by Levi, Ray & Shoup. Presenters: Charles Harris, senior technical lead, Duke University Health System; Ron Peel, technical advisor, LRS; and John Howerter, SVP of enterprise output management, LRS. IT department in hospitals implementing EMRs often overlook the role of document-driven workflows. Prescriptions, specimen labels, and discharge orders, and other critical documents must be reliably delivered with minimal impact on IT and clinical staff. This panel discussion will discuss the evolving use of documents in the “paperless/less-paper” environment.

May 1 (Thursday) 1:00 p.m. ET. Think Beyond EDW: Using Your Data to Transform, Part 2 – Build-Measure-Learn to Get Value from Healthcare Data. Sponsored by Premier. Presenters: Alejandro Reti, MD, senior director of population health, Premier; and Alex Easton, senior director of enterprise solutions, Premier. Once you deploy an enterprise data warehouse, you need to arrive at value as quickly as possible. Learn ways to be operationally and technically agile with integrated data, including strategies for improving population health.

Acquisitions, Funding, Business, and Stock

Truven Health Analytics acquires Simpler Consulting, a provider of Lean enterprise transformation services to healthcare, government, and other commercial organizations.

Struggling BlackBerry invests in Patrick Soon-Shiong’s NantHealth. The companies are jointly developing a smartphone optimized for viewing diagnostic images, scheduled for a late 2014 release.

Vocera opens an innovation center in Bangalore, India.

Sales

Lahey Health (MA) selects Phytel’s population health and engagement platform in support of its ACO.

Dialysis Clinic, Inc. will implement Sandlot Connect and Sandlot Dimensions from Sandlot Solutions for care coordination and analytics.

Shenandoah Medical Center (IA) will deploy Allscripts Sunrise solutions for its 78 beds.

The 260-provider Phoebe Physician Group (GA) selects athenahealth for EHR/PM and care coordination.

Citizens Medical Center (TX) will implement T-System’s EV emergency department information system and Care Continuity patient transition management solution.

People

Explorys appoints Tom Chickerella (Vanguard Health) COO.

Precyse promotes Christopher A. Powell from president to CEO, replacing company founder Jeffrey S. Levitt, who will assume the role of executive chairman of the board.

ESD promotes John Alexander to testing practice director and hires Mia Erickson (Epic) as Epic practice director.

CHIME names George McCulloch (Vanderbilt University Medical Center) as EVP of membership and professional development.

Edifecs names Dave Arkley (Parallels, Inc.) CFO and Michiel Walsteijn (Oracle) EVP of international business.

Health Data Specialists promotes Angie Kaiser, RN to clinical informatics officer.

Donna Scott (McKesson Health Solutions) joins USA Mobility as SVP of marketing.

MHealth Games names investor Keith Collins, MD as its board chair. He was at one time CIO of the University of Massachusetts Medical School.

Medicomp appoints Michael Cantwell, MD (National Library of Medicine) to its MEDCIN terminology team.

Healthcare technology services provider CitiusTech names Gary Reiner and Cory Eaves (both of its recent investor General Atlantic) to its board.

Announcements and Implementations

Kids First Pediatrics Group (GA) integrates PatientPay’s electronic billing and payment solution with its Greenway PrimeSUITE practice management system.

Memorial Community Hospital & Health System clinics (NE) will transition to Epic starting June 25.

The HEALTHeLINK clinical information exchange launches an automated syndromic surveillance state reporting service.

North-Shore-LIJ (NY) rolls out the Allscripts FollowMyHealth patient portal for its Plainview and Forest Hills hospital patients.

Geisinger Health Plan (PA) implements Caradigm Care Management for population health.

Government and Politics

CMS introduces a Code-a-Palooza Challenge to encourage developers to create apps that use the new Medicare payment data to help consumers improve their healthcare decision-making.

CMS, which has been strangely quiet about the implementation delay for ICD-10, finally acknowledges the legislation but notes only that it “is examining the implications of the ICD-10 provision and will provide guidance to providers and stakeholders soon.” Meanwhile, CMS still lists October 1, 2014 as the date ICD-9 will be replaced by ICD-10.

ONC invites voting for ideas submitted in its Digital Privacy Notice Challenge, which include games, responsive templates, a Web widget, and an NPP generator.

Innovation and Research

Meaningful Use of EHRs was not found to be correlated with performance on clinical quality measures in a study published in JAMA Internal Medicine. The  research compared quality scores of 540 physicians affiliated with Brigham and Women’s Hospital who achieved MU with those of 318 physicians who did not. Critics note several factors making the validity and applicability of the study difficult to evaluate, including the fact that MU quality metrics are so specific that they exclude many patients with particular conditions.

Technology

Google files a patent for a contact lens system that would include a built-in camera and could potentially be used as an alterative to Google Glass. That’s technology I could embrace since I don’t see myself as one of those nerdy hipster-types that Dr. Jayne and I continually made fun of as we walked the HIMSS exhibit floor.

Awarepoint introduces an RFID tag that monitors room humidity.

Other

The Coalition for ICD-10, an industry advocacy group whose members include CHIME, AHA, and AHIMA, calls on HHS to establish October 1, 2015 as the new ICD-10 implementation date.

The Oklahoman looks at the soon-to-be-launched Oklahoma City-based Coordinated Care Oklahoma HIE and the more established Tulsa-based MyHealth Access Network and considers the impact of having two competing networks in the state. It’s a scenario that will undoubtedly be repeated numerous times in coming months as funding disappears for older HIEs and newer organizations emerge.

An InstaMed report on trends in healthcare payments finds that patient payments to providers jumped 72 percent from 2011 to 2013, with the average amount increasing from $110.86 to $133.15.

Attorneys specializing in representing whistleblowers in healthcare pounce on the newly published Medicare data to search for evidence of fraud.

Travelers who pass through Madison, WI’s Dane Country Regional Airport (MSN) can now enjoy free Wi-Fi courtesy of Nordic.

The SMART project at Boston Children’s Hospital, which has been pretty quiet since its big “EMRs should work like smartphone apps” announcement four or so years ago, names a 14-member advisory board to promote its mission.

I paid a visit to my neighborhood ER over the weekend. Despite being the patient, I couldn’t help but check out their use of IT systems. It’s a boutique ER attached to a surgery center about two miles from my house. I was the only patient at the time (good to know that all my neighbors had better things to do on a Saturday night.) In terms of IT, what surprised me the most was the lack of it, at least at the point of care. They must have some sort of EMR because they printed out all my information from a visit last year, but everyone who treated me used pen and paper to note my vitals and whatnot. At discharge they handed me a generic patient education sheet with aftercare instructions, but no details on what meds they gave me (I recall one was a narcotic) and no medication information sheet warning me about possible side effects. They advised me to follow up with my regular doctor, but I’m now realizing that in my narcotic-induced haze I didn’t ask anything about the results of the tests from my blood draw. I’m sure if I had gone to the ER at the big chain hospital another 10 minutes away I would have left with more complete information, but I chose (and probably would again) the more convenient ER that otherwise provided good care. For all the great stories we constantly share about the amazing strides in automating healthcare, I’m sure there are just as many anecdotes that serve as a reminder that we are not “there” yet.

Sponsor Updates

• Talksoft Corporation makes its appointment reminder app Talksoft Connect available for Android devices.
• Columbus CEO magazine profiles CoverMyMeds in an article highlighting characteristics of top workplaces.
• The AHA exclusively endorses MEDHOST PatientFlow HD patient flow management solution.
• LifeIMAGE celebrates the growth of its network, which connects 533 hospitals and has exchanged 1.1 billion images over the last five years. 
• Health Catalyst releases a free eBook that explores common approaches to data warehousing in healthcare.
• AdvancedMD introduces the 1.5 version of its iPad app.
• A NueMD ICD-10 survey conducted prior to the official delay shows that the majority healthcare professionals participating wanted the ICD-10 transition to be pushed back or canceled.
• The Boston Business Journal ranks Nuance number two on its list of  top publicly traded Massachusetts software companies based on its $5.2 billion market capitalization.
• Kareo CMIO Tom Giannulli will discuss the role of technology in improving patient care at UBM Medica’s Practice Rx conference May 2-4 in Newport Beach, CA.
• Madhavi Kasinadhuni, consultant for The Advisory Board, explains the importance of measuring care episodes and not just individual encounters when identifying missed revenues.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 4/15/14

DeSalvo calls for big data use over next decade

In a speech on Capitol Hill last Thursday, Karen DeSalvo, MD, said that one of the ONC’s goals for the next decade would be bringing about the benefits of big data, which she says will require that “the underpinnings of EHRs” be reconfigured to support the free flow of information.

Lawyers start mining the Medicare data for clues to fraud

Lawyers specializing in healthcare fraud cases begin analyzing the recently published Medicare payment data, looking for potential signs of fraud.

Dutton "Committed" To Electronic Health Record

In Australia, Health Minister Peter Dutton expresses support for the country’s EHR program, leading to speculation that while the federal government will not keep the program in its present form, it does not plan to cancel the $700 million project outright.

New York’s electronic medical record plan gets $55 million boost

New York approves an additional $55 million in funding to support its health IT goals, including a $4.5 million investment in the state-run Healthcare Information Exchange of New York.

Curbside Consult with Dr. Jayne 4/14/14

I wrote last month about our health system purchasing another physician group in a bid to strengthen its primary care base for Accountable Care activities. The IT team is always brought into the acquisition phase too late, which is a shame. Our ability to identify potential issues and prepare for a smooth transition is always forgotten until we’re later asked to deliver a miracle after the ink is already dry. That was the beginning of my “pastry therapy” sessions, which have progressed significantly.

At the time, my biggest worry was figuring out how to get them through the EHR upgrades needed to get their first-timers ready to attest for Meaningful Use. My team was tasked with preparing for the upgrades, which is a standard duty for us. In reviewing what they had done to the EHR, I was entirely unprepared for the volume of customizations they have put in place. I was also unprepared for how ridiculous some of them are.

They have a robust EHR that allows creation of custom workflows even though the out-of-the-box workflows are pretty solid. This is good for customers who have specialties the EHR doesn’t cover, but not good for customers that use the EHR as a means of managing physician behavior.

After several weeks of reviewing their content and consulting with our development, training, and support teams, I was ready to meet with the combined medical leadership of our two organizations with a plan to gradually bring their workflows to our standard so that eventually we can convert them onto our database. (Initially the Powers That Be wanted an immediate conversion, but I was able to convince them we couldn’t do it on the timeline we have.)

Allowing for a slow retirement of their customizations would allow us to make two smaller steps rather than one giant leap, which I felt would be better for physician adoption and user acceptance. The first move would happen with their upgrade to the EHR version certified for 2014 and would involve addressing customizations that either impaired MU data-gathering (such as creating custom fields rather than using existing vendor fields that feed canned reports) or didn’t make sense (extra navigation buttons that cluttered up the screen and distracted from important clinical data.) The first step would also allow them to get used to our training style and expectations so that next time we can just use our proven franchise model with them.

The second step would be the true move onto our content, although we’d keep them on their own database until the dust settled. The final step would be to perform a relatively quiet migration a few months later.

Although the overall plan would take more than a year, we felt it would adequately balance the need to keep the volume of change manageable with the fact that we aren’t getting very many additional resources or dollars to pull this off. Although we’re going to assimilate their IT and training teams, we quickly discovered that they only had a rudimentary knowledge of the software since they had referred nearly all their changes out to consultants and contractors. We’ll have to retrain them not only on the product, but also add some discipline and critical thinking to the mix if they’re going to stay with us.

Our meeting with the medical leadership started out well with them nodding at all the right places as we presented the high-level plan. They agreed in principle, but it started turning ugly when they began asking about which specific customizations we planned to retire in the first phase.

My ever-OCD development manager quickly produced a spreadsheet. Her team had carefully catalogued every customization on a template by template basis with helpful information including why we recommend retiring it and what the proposed replacement workflow would be. They also attempted to gather information on why the changes were made in the first place, but for the vast majority, there was no compelling business case that any of the analysts could remember.

I was proud of my team for pulling this together in such detail on a tight timeline, especially when they had absolutely no documentation to work from. They literally had to do a visual inspection of each part of the workflow because our new partners apparently had never heard of a build specification document, let alone an approval tracker or anything else.

We began to work through the spreadsheet and were immediately stopped by our new colleagues. For every item we proposed retiring (even if it was actually contrary to the stated goals of meeting Meaningful Use, being an ACO, and providing quality care) they had an excuse why we needed to keep it. Many of the excuses took the form of, “This is something Dr. Jones really needs,” but they couldn’t provide any concrete reasons to back their statements.

After a dozen or so of these exchanges, it became apparent that rather than only modifying the EHR when it was deficient, they had been using EHR design changes as a way to appease cranky providers.

I’m all for modifying the EHR when it’s needed – if it’s truly deficient, if the workflow is inadequate, or if you are trying to document a specialty that’s not available from your vendor. Our group has been at this nearly a decade and all our customizations have a robust business case and have been vetted through a formal review process. We have design standards that keep pace with our vendor, so even when we customize, it appears seamless to our users.

We also log every single customization with our vendor so they know there’s a deficiency, defect, or workflow need. We can’t fault them for not designing to meet our needs if we haven’t told them what our needs are. Often we find that in the process of logging an enhancement request, the vendor is already coding what we want in their next version. We can make our customization look like what they’re doing so that when we upgrade, it is truly seamless.

I finished my mini-lecture on rational customization. The folks on the other side of the table just sat there with blank stares. They clearly either weren’t buying what I was selling or simply didn’t care.

Pulling out my best behavioral health “motivational interviewing” skills, I tried to get them to at least acknowledge a need to change even if they didn’t like it. It became obvious that they are scared to death of having to actually deal with their peers, let alone actually manage employed physicians.

Our trainers are pretty tough, but if management is not going to help us lead the physicians through a meaningful change process, we are never going to be successful. What makes me the angriest, however, is that we’ve been through this. We know what needs to be done to achieve success. We were in the same place many years ago. We have a proven track record of not only bringing practices live, but actually achieving clinical transformation and improved outcomes. We also have been able to do this without a significant change in practice revenue or any loss of clinical quality.

Unfortunately, we’re now being faced with providers who have been coddled and apparently don’t know the meaning of being an employee. Rumor has it that some of them are so politically charged that they’re being paid above fair market value just to keep them from leaving.

With those kinds of forces at play, the idea of achieving standardization seems impossible. If we can’t get them to agree on EHR workflows, how are we going to get them to agree on clinical content such as order sets or care protocols for chronic disease management? Looking at the impassive faces across from me, it was clear that we’re going to have to bring some bigger guns to support us. I’ve scheduled a follow-up meeting with our CIO and CFO as backup, but I’m not optimistic.

There’s nothing in medical school or informatics training that prepares you for this. I’d love to be able to turn to some of my CMIO pals for advice, but the idea of admitting this level of dysfunction — even to my closest confidantes — makes me squirm. It’s good, then, that I can turn to my virtual colleagues for advice. Leave a comment if you have some words of wisdom.

For those of you who just want some pastry therapy, that was Martha Stewart’s Chocolate, Banana, and Graham Cracker Icebox Cake. I didn’t have any milk chocolate, so I pulverized and melted several dark chocolate Easter rabbits, which was therapeutic in its own right. I also left off the whipped cream topping that Martha recommended – it was a little too over the top for my primary care brain.

Email Dr. Jayne.

HIStalk Advisory Panel: IT Service Management

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

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

This question this time: Does your organization use a formal IT service management program such as ITIL, and if so, what results have you seen?

Responses indicating no: 4.

[from a practicing physician] No , I am not aware of any formal IT management program used by my now very large company, but that is not to say that they do not need one.

We started with one, but we didn’t have the institutional memory to keep it alive. As new people came, it became increasingly difficult. Some good remnants remain, but only if somebody remembers to enforce them.

Yes and no. We’re a small shop, so we use ITIL and other models as a source of best practices and implement what makes sense for us. We don’t want to reinvent the wheel, but a full-scale implementation in a small organization is not cost-effective. The processes, templates, etc., that we have pulled in are extremely useful and allow us to more efficiently manage a large workload with a small team.

Not at this time. We have evaluated the use of ITIL and COBIT, but our plates are too full at this time to put any formal processes in place. Luckily the management team has experience with ITIL, so we apply the concepts to change management and service delivery as much as possible.

We have begun to install ITIL. It has been challenging given we are short on resources and when busy, people tend to fall back into the old way of doing things. We have had success with incident management, which is a good thing.

I was one of the first to enthusiastically jump on the ITIL bandwagon, many years ago, then I saw firsthand how the ITIL process became the goal, not a means to a goal. After two ITIL implementation attempts with two different teams, in which internal client satisfaction with IS declined and my employees became demoralized drones, I threw away any philosophy to implement the details of ITIL and instead focused on the concepts and the end goals. Those end goals are (1) internal customer satisfaction with IS; (2) IS employee satisfaction; and (3) achievement of both #1 and #2 at the lowest possible IS budget.  Since then, I’ve watched ITIL spread to other organizations and watched the same pattern that I experienced. There seems to be an inverse relationship, or at least a tipping point of inflection, between dogmatic adherence to ITIL and IS success and creativity.

At this time we don’t have a formal service structure methodology. We are beginning to look at this due to our organization growing and that all areas now have a major IT component. We most likely would lean towards ITIL.

Yes, we do. If you agree that using ITIL can be helpful and that every part of ITIL may not apply to your operations, it can provide consistency in support that many organizations need. We have found that it is helpful in many aspects of providing end-user services more consistently and more timely with much fewer variations.

We do not use ITIL formally. We will soon be joining a larger system and they have adopted ITIL and we are comparing our current practices to this framework.

We have been trained in the basics of ITIL and have incorporated several concepts and processes. We have not gone full out at this point.