Morning Headlines 3/18/14

CMS Wants Money Back from PQRS, eRx Programs

According to a Federal Register notice, CMS will launch a four-year program that will survey PQRS and eRx program participants to verify data quality. The project will include efforts to "evaluate incentive payment information for accuracy and identify improper payments, with the goal of recovering these payments.”

Group advocates for single-payer system over HIX

Several states, including Pennsylvania, discuss following in Vermont’s footsteps by creating a state-level single-payer system as an alternative to supporting expensive and problematic health insurance exchanges.

Massachusetts to Cut Ties With CGI Group Over Troubled Online Health Exchange

Massachusetts fires healthcare.gov contractor CGI Federal over the state’s own failing health insurance exchange rollout. CGI Federal is also under investigation for fraud in Vermont stemming from another failed health insurance exchange rollout there.

Curbside Consult with Dr. Jayne 3/17/14

There was a great response to last week’s Curbside Consult and my mention of the therapeutic powers of baking. Despite everything going on at the office, it ended up being a fairly low-key week, so the only things coming out of my kitchen were a pan of brownies and a batch of banana bread.

(I admit I played a little bit of the Mad Scientist game with the banana bread. Although it was good, it wasn’t significantly better than the original recipe, so maybe I’ll stop trying to mess with perfection.)

We made a fair amount of progress in our due diligence efforts around bringing the patient records from the practice we acquired onto our system. Although some people might find it boring, I actually enjoy rolling up my sleeves and digging in. It’s predictable work in some regards.

Our DBAs started looking at their system’s data structure to identify how many custom fields they are using compared to a vanilla version of the software. Some of our EHR analysts started looking at the actual user screens to identify custom fields from that perspective as well as to begin diagramming the workflow they’ve built in the EHR.

We’ll send people on site and work with their training team to determine whether the EHR workflow matches how they operate in the practices or if this is an opportunity to retire any custom elements that aren’t actually working in the field. I’ve seen plenty of instances where physicians have customized their systems to the point where efficiencies are lost. This tends to happen more when users don’t have adequate training or don’t agree with the design intent of the software.

Where there are customizations in the workflow, we’ll also do some statistical analysis to look at how many times custom fields are actually used. Just because they were built doesn’t mean anyone uses them regularly.

Our medical group has grown substantially over the last few years. Given the number of physicians who currently use an EHR, we’ve had to do a fair number of conversions. Some of them are simple, especially when the source EHR is fairly primitive or doesn’t have a robust data structure. In those situations, we might convert the patient notes to PDF files and bring them in as if they were scanned documents. It doesn’t give us a lot of discrete data, but in some regards it may be safer than trying to map imprecise data.

I’ve seen systems that don’t use any kind of formatting on data fields (such as restricting blood pressure entries to numbers only) that lead to garbage in the record. In those situations, I typically sit down with the physician and explain the choices: we can either bring the data as images (akin to scanning a paper chart as far as patient safety is concerned) or we can spend a lot of time and money trying to map it. In the latter scenario, they will need to sign off on any corrections.

Most physicians who hear about the time commitment for mapping data run shrieking out of my office and I never hear from them again until I see their signature on the checklist approving the test extract that’s been pulled into the imaging system. Those who aren’t scared off by the time commitment are usually scared off by the budget, which our medical group usually isn’t very keen on funding.

I’m surprised (at least at some level) but the number of physicians who realize they have dirty data but don’t do anything about it. They see the typo’d letters in the BP fields and authenticate their notes anyway rather than talking with their staff about data accuracy. Very few have thought to talk to their vendors about why the system even allows typing of letters into a BP field.

I guess I shouldn’t be that surprised, because I’ve seen even wackier things in the paper world, such as subspecialists who had their staff stamp consult letters with nonsense like, “Dictated but not read; signed by secretary to expedite.” Someone who is OK with that probably doesn’t care about potentially erroneous data in their notes.

So far, the potential conversion doesn’t look that bad from a technical perspective. Although there is a fair amount of customization, it’s not being used extensively. In fact, overall use of the EHR is pretty light. From a change management perspective, though, that’s pretty ominous, especially since our group requires significant commitment to documentation via discrete data. We’ll have our work cut out for us in helping them truly adopt EHR as well as in helping them adapt to our culture.

I almost wish the technical aspects of the conversion were more daunting because I could use that to buy more time with the powers that be. Our analysts still have a bit of digging to do and the workflow teams will find plenty of issues when they go on site, but I’m not sure we’ll have as much time to formulate an effective plan as I’d like. We’ll have to see how things unfold.

Regardless of what we find, I know we won’t have anywhere near as much budget as we need to do our best. We’re pretty good at delivering the impossible, though, so I’m hopeful. And when all hope is gone, there will always be pastry.

Email Dr. Jayne.

HIStalk Interviews Bill Anderson, CEO, Medhost

Bill Anderson is chairman and CEO of Medhost of Franklin, TN.

Tell me about yourself and the company. 

I’ve been in business a long time, more than 40 years now. This is my first foray into the healthcare IT business. My background has generally been in the financial area and financial technology. I was about 20 years in consulting, went to be CFO of a large public company, and ended up doing the Internet with a company called Bankrate.com. As I got into technology, I got more and more interested in different types of technology and ended up in healthcare.

We’re a diversified technology company, an HCIT company with enterprise software and some innovative new products. We’re just finishing up our audit, but we think we’ll be around $180 million this year. We’re really proud of the fact that we’ve grown in excess of 20 percent a year over the last five years. We have about 1,000 customers, about 60 percent of in general acute care, but with significant market share in some specialty areas like LTACs, inpatient behavioral, and inpatient rehab.

Even experienced industry people were confused about HealthTech’s multiple product brands until the names were changed to Medhost in December. What took so long to consolidate?

We realize the importance of consistent branding. We had a couple of choices, and so we had to sort through the situations where we could actually get good title to names as well as having the URLs and all the other type of connectivity that you’d like to have. We settled upon the fact that Medhost was the best choice for us. We’ve been very happy with the reception from that so far.

I don’t think I ever noticed HealthTech’s booth at previous HIMSS conferences, but with the Medhost name this year, it was a nice presence and the booth had a lot of activity every time I went by. Did you notice a change?

We did, and thank you for the compliment on the booth. I think that many HCIT buyers did not realize what a comprehensive line we had. When we pulled our different product lines together in the Medhost booth and did some promotion around the new branding, we got some much higher response rates or levels of interest than we had in the past. We were very pleased with the HIMSS conference.

I would assume most people know the company from the EDIS product line that provided the company’s new name. But you have a variety of products, many of them from acquisitions. How do you portray the company’s identity now and how hard is it to support a fairly diverse and extensive product line?

We do have a diverse and extensive product line. It’s come about principally through acquisition, but also some significant organic growth.

We acquired a company called HealthCare Management Systems, which was an enterprise software business, because two of the most important departments in a hospital are the perioperative and the ED. We acquired a company called Acuitec, which essentially was selling the Vanderbilt surgery and anesthesia system. And Medhost, with EDIS.  Today we think we’ve got leading products in these very important areas. Those came in by acquisition, as three pieces.

There are also two product lines that you may have noticed that we’ve built internally. One being our YourCareCommunity platform with our first app that runs on that platform, which is our patient portal. Also, our profitability solutions.We call those solutions because they’re a combination of our patient flow product, our business intelligence product, and a consulting group. We have the full range of the products necessary to deliver a higher profitability to our customers.

Is there sales synergy across these products or do they each have to be sold on their own?

Oh, absolutely. You know, we view ourselves as a distribution company. One of the things that has characterized Medhost is that about 60 percent of our customers are associated with a multi-facility organization. Over the years, we’ve demonstrated an ability to distribute products into our customer base, who are growing rapidly themselves. We have tried to tailor our products — acquisitions and the parts we’ve developed — to meet the needs of that customer base. That’s been a successful strategy for us.

Who are your biggest competitors and what advantages do your products offer?

We view our sales as being a middle market provider in the HCIT business. I would say our principle competitors in the general acute care space would be McKesson’s Paragon and probably Meditech. We obviously see Cerner, who comes down into the middle market with a hosted solution, as well as CPSI, who comes up market with their product line. But as far as direct competitors, we would probably identify those two as the most directly comparable.

What are you seeing as the key drivers of the decisions made by that market?

In our customer base, we think we’ve got customers for which ROI really makes a difference. We have a heavy concentration in the for-profit healthcare business. What we view is that for our customers, a combination of market-appropriate features plus ease of use results in a low total cost of ownership. As a result of that, that’s what differentiates us in the marketplace.

It’s always interesting that for-profit hospitals buy and deploy differently than the not-for-profits. Why do you think that is?

Our customers are not only good at delivering healthcare, but they are very good at running businesses. As a result, I think they’re looking for the effectively the right product for the facility they have. In many cases, we’re in customers that have segmented their bases, and we tend to be in the hospitals and other facilities where our features match up  with what that facility’s doing. And again, we offer what we believe is a low total cost of ownership.

Where does the company’s future lie?

We’re pretty happy with our menu of products for the inpatient world right now. We think we’ve covered bases with that. We would like to do additional acquisitions, because we think our customers have needs, and we’d like for them to be able help serve those needs.

We would be looking at areas like post-acute care. Many of our customers are going to be more and more involved in dealing with patients outside the four walls of a hospital. Also in services, because again those are becoming more and more important to both our corporate customers and our standalone customers. Things like revenue cycle outsourcing, some other types of services like that, we think are going to be very important to these customers as margins are squeezed and they need to be able to control their costs.

Probably the biggest area that we are interested in either building products or acquiring products or partnering with customers is in this YouCareCommunity platform. Essentially what we’ve done is combined an HIE with an enterprise master patient index to allow people to pull records from both ambulatory and inpatient EHRs into the cloud. Using that platform, we’ve launched some initial applications, being our patient portal, and we’re working on a disease management product and some other products. But we’re also looking for partners and acquisitions that add additional applications to that platform.

Is this product the answer to the HIMSS buzz around population health management or analytics, or do you have other strategies or do you even want to be in those markets?

Yes, we absolutely want to be in that market. This would be the platform that we use to address the needs of our customers in that marketplace. 

Population health has a number of different facets. The really important thing, though, would be to help manage the patient, or even better to help the patient manage themselves, to prevent things like readmission, disease management, things of that nature. We think that with our cloud-based platform and our strategy to engage the patient on a regular basis, even when they are not currently in the hospital or have recently been in the hospital, will allow our customers to help affect their downstream cost on those customers.

What are your customers telling you about their state of readiness or state of interest in Meaningful Use and ICD-10?

Everyone is very focused right now on the Meaningful Use program. I think that’s been a challenge, particularly to our smaller, standalone customers. They’re interested in trying to attest as quickly as possible and move on to other things, one of those things being ICD-10.

We view this as being a very difficult transition for many of our customers, and one that we hope we’ll be able to assist them with. We believe we have the right tools in place for them to do that, but it will be a significant change in training and how a facility has to deal with some of their billing and coding issues.

Evidence suggests that smaller hospitals may be walking away from Meaningful Use money after the first couple of years. Do you see that happening?

That’s going to be difficult to do. There will be some in the very small end of the hospitals. We have less than a 100 critical access hospitals in our more than 1,000 customers, and with many of those really small facilities, the economics are not going to work for them.

The cost of attesting and maintaining the Meaningful Use progression is going to be more than the potential penalties or the rewards. That is going to be an issue globally for healthcare, because it is in the best interest of the healthcare delivery system in general for those customers — our customers — of that size to participate, as well as other facilities of that size. That will be an issue that ultimately the government will have to address — how to pool those customers into the system. Because it is going to be difficult.

You are emphasizing a touchscreen user experience in the keystroke-heavy world of healthcare. Do you think that is the market changing to now accept and even demand a touchscreen experience?

Absolutely. While we think of our users as healthcare professionals, they’re also consumers. Every day they use mobile platforms. They use consumer software. Healthcare professionals, like other consumers, are going to be more demanding about the quality of their software.

As a result, we’re making and are continuing to make significant investments in things like workflows, usability of the product, and making it mobile agnostic. Our belief is that tablets will be very important in the medical area. We do have some phone apps and some others that are in process, but inherently the phone apps or smartphone apps are going to be more difficult to use.

Tablets, however, will give the clinician much better access to data and the ability to kind of process data without being tied to a particular workstation or having to sign in and sign out. The convenience and the ability to increase productivity will make that important for all software providers.

Many of the early claims vendors made about mobile access involved Citrix running a desktop session on an iPad. How is the industry is progressing in creating a true mobile experience?

The industry in general has had a lot of demands upon it and has been distracted from some of the work flow and ease-of-use type of objectives that I think are shared by most vendors. Everyone will have to cycle back to that.

Almost four years ago now, we started a renovation of our enterprise systems to put an HTML 5 interface layer on top of it. The reason for doing that is that the combination of wanting to have a more inexpensive hosting solution as well as being mobile agnostic. You can do that an HTML 5 interface as long as you’re paying attention to form factors and how you design a page. Then the same page I can view on a computer, I can view on my tablet and get a very satisfactory experience. Those types of solutions are going to be very important in the future.

What are you priorities for the company in the next three to five years?

Our priorities are to continue to grow our base and our enterprise business, but also at the same time, to take these new product lines that we have in our profitability solutions and YourCareCommunity and to try to meet more the needs of our customers in those areas.

We think in particular, our ability to provide a patient portal in both the ambulatory and inpatient area that is certified and can pull together the care community is going to be a really important thing. We are out trying to talk to as many of our customers as we can about the advantages of being able to build this community in terms of improving patient care, giving the patient better ability to manage their own care, as well as keeping revenues within the network.

Do you have any final thoughts?

There’s a lot of changing coming and has been coming in both the healthcare provider industry and in the healthcare IT industry. With change, there’s always opportunity. Our goal is to try to take advantage of that opportunity and return as much benefit to our employees and shareholders as we can.

Morning Headlines 3/18/14

Castlight Health Soars in Stock Market Debut

Castlight Health’s stock price climbed 149 percent during its Friday IPO. The company was seeking a $1.4 billion valuation, but closed its first day of trading at $3 billion. Some are calling the IPO evidence of a tech bubble because Castlight ended 2013 with only $13 million in revenue and a net loss for the year of $62 million, yet was still valued as a billion dollar company.

VA Is Competing For The Pentagon’s Electronic Health Record Contract

The VA will enter its newly revamped VistA EHR platform into the competition to be the DoD’s next EHR.

Form 8-K for ACCRETIVE HEALTH, INC.

Accretive Health has been delisted from the NYSE after failing to file restated financial reports from 2012.

Hospital database hacked, patient info vulnerable

Valley View Hospital (CO) discovers that a computer virus within its network has been taking screenshots of sensitive patient information, including social security numbers and credit card numbers, and saving them in a hidden folder on one of its servers. The virus went undetected for three months and captured information on 5,400 patients.

Monday Morning Update 3/17/14

Top News

Castlight Health’s share price climbs dramatically after its Friday IPO, surging 149 percent from $16.00 to $38.90. The company was valued at $1.39 billion at the IPO price, placing it in the $3 billion plus range after Friday’s market close. The company had $13 million of total revenue last year and lost $62 million, reportedly placing its loftily priced IPO price (107 times revenue) as the highest multiple since the dot-com era. Still, the company’s underwriters left a lot of Castlight’s money on the table at pricing the shares so far below their first-day closing price. Nobody’s saying how much shares owned by the already-loaded founders are worth (Todd Park, CTO and co-founder of athenahealth; Bryan Roberts, PhD, chairman and co-founder of venture capital firm Venrock; and Giovanni Colella, MD, founder of RelayHealth.) They might want to sell their shares soon: studies show that shares of companies valued at this level of frothiness have historically had a three-year return of –92 percent.

Reader Comments

From Krikey: “Re: ongoing column writers. There are some very perceptive and witty folks out there, just a challenge to find and encourage them to contribute. I have ideas, but hesitate to name names.” I enjoy the writings of Ed Marx, Darren Dworkin, Dr. Gregg, and others on the provider side who have an interesting perspective and an entertaining way of presenting it. I’m happy to entertain the possibility of adding to that roster, but with the added comment that lots of folks think it sounds great until they realize it’s an ongoing commitment.

From Orange Belt: “Re: hospital salaries. Why are you so down in paying high-performing executives what the market demands?” Because non-profit hospitals shouldn’t be a market – they are a charity for taking care of sick people and should pay comparably to other charitable organizations even though they are inexplicably forced to run like a big business instead. I’m pretty sure that while the talent pool might be different if a health system paid its CEO only $500K instead of several million dollars, that amount would still be sufficient to hire a committed and skilled candidate. Making excuses such as (a) “We have to pay too much because everybody else does”; (b) “We have to compete against the giant corporations our executives would be lured away to run given their vast experience in dealing with nurses and insurance companies in a non-consumer driven market”; and (c) “Our executives are worth every penny because we’ve made a fortune since they took charge” are just excuses to avoid admitting that running a hospital has become a lucrative profession rather than a selfless calling and has attracted leaders who would wander off in an instant if they were paid responsibly.

HIStalk Announcements and Requests

Quite a few readers reported their annual job compensation, breaking out into the categories above. New poll to your right: should patients have a greater role in the HIMSS conference?

Thanks to everyone who completed my reader survey. I’ve emailed $50 Amazon gift cards to three randomly selected winners (I use a random number generator to choose from the available Excel rows of responses). I will be reviewing the results carefully over the next several weeks and will report back, but the item above is the one I watch most carefully, in which 92 percent of respondents said that reading HIStalk helped them perform their job better in the past year.

Another DonorsChoose classroom update: Mrs. Pew’s Louisiana second graders are already enjoying the books you and I bought them four weeks ago using proceeds from the top HIStalk banner ads during the HIMSS conference. She reports, along with sending the photo above, “Your donation has helped make it possible for all students to be actively engaged in my classroom in one way or another. They are able to interact with one another, discuss the books they listen to, and learn new words. Thank you for your generous donation and for bringing such joy to my classroom.”

Listening: Dead Confederate, country-tinged hard rockers from Athens, GA.

Upcoming Webinars

March 19 (Wednesday), 1:00 p.m. ET. The Top Trends That Matter in 2014. Sponsored by Health Catalyst. Presenters: Bobbi Brown, VP and Paul Horstmeier, SVP, Health Catalyst. Fresh back from HIMSS14, learn about 26 trends that all healthcare executives ought to be tracking. Understand the impact of these trends, be able to summarize them to an executive audience, and learn how they will increase the need for healthcare data analytics.

Acquisitions, Funding, Business, and Stock

Mobile open source healthcare network vendor Cytta and telehealth technology provider ViTel Net announce plans to merge some or all of their companies. Sounds like they suffer from either commitment issues or premature declaration.

Announcements and Implementations

As expected, formerly high-flying Accretive Health is notified by the New York Stock Exchange that its shares have been delisted because the company has not filed its revised 2012 annual report. Above is the five-year share price chart of AH vs. the DJIA. The company’s market capitalization is still at $790 million, but shares are down 75 percent from their July 2011 high. The company tangled to its eventual disadvantage with Minnesota’s attorney general in early 2012 over is aggressive collection practices for hospital patients, including strong-arming patients with no outstanding balances who were still in their ED treatment rooms. I explained my mixed feelings about the company’s practices at that time:

The question raised by the Accretive mess that nobody wants to ask or answer is this: how much collection effort is too much? If the model forces a hospital to operate as a business, is it fair that some customers get away without paying, quite a few of them perfectly capable but just unwilling to do so because it’s not exactly a pleasurable purchase? Or that they don’t pay because hospital list prices are absurd, with insurance companies getting huge discounts on the $4 aspirin that cash-paying patients are expected to pay at list price? Accretive probably went too far, but it’s a slippery slope. They are the symptom, not the problem. Imagine if a restaurant couldn’t turn away hungry but broke patients, has to serve them steak and lobster if that’s what they want, and has to welcome them back for meal after meal even though they’re capable but unwilling to pay. Is that fair to the other diners who will have to make up the difference?

Duke LifePoint Healthcare, a joint venture between Duke University (NC) and for-profit LifePoint Hospitals, will acquire Conemaugh Health System (PA) for $500 million, adding to its total of 60 hospitals and 29,000 employees. LifePoint, whose annual revenue is $3.68 billion, paid its CEO $9 million in 2012, with its other six officers making between $1.8 million and $3.4 million each. 

Government and Politics

The VA Secretary Eric Shinseki says the VA will enter its VistA Evolution in the Department of Defense’s EHR procurement project, claiming that the upgraded system will be equal to the commercially sold EHR systems that the DoD seeks. The VA announced its interest in receiving bids for developing VistA Evolution in late January, allowing eight business days to receive responses. It requested $269 million for 2015 to develop it.  I can’t decide if Shiseki is just yanking the DoD’s chain, calling DoD out publicly knowing they would rather use stone tablets and chisels than admit that the VA’s systems are better, or if he really thinks the DoD is open-minded and taxpayer-respectful enough to use what makes sense instead of what it can control with an iron hand and an army (pun intended) of government contractors. Hopefully he won’t trigger a DoD-led military healthcare junta.

At the same House Veterans Affairs Committee meeting, the American Legion scolded both agencies in written testimony, saying the agencies “squandered more than a billion dollars of taxpayer money and wasted years in an ultimately empty pursuit of a joint electronic medical record system that would have streamlined and simplified logistics between the two agencies …The warfighter turned veteran is the same patient and deserves a system that honors that person with continuous care and seamless transition between agencies.  It is unforgivable that DoD and VA have spent the past several years infighting rather than actively developing a comprehensive solution that is in the best interest of the American service member.”

The Defense Health Agency expects to spend $1.5 billion in 2017-2019 to buy a new EHR, according to new budget documents. I’m guessing that line item didn’t come from the VA’s RFI response.

Innovation and Research

Patrick Soon-Shiong says on Larry King that like fellow billionaires Warren Buffet and Bill Gates, he has signed the Giving Pledge and will thus donate more than half of his wealth to charitable causes.  He also announces his latest invention: a $300 hearing aid that can be tuned by smartphone, making hearing correction affordable for the 700 million people who need it. He used the same technology to develop the $100 Notes personalizable headset and will donate a hearing aid for each two headsets sold, hoping to give away one million hearing aids in the next five years.

Other

Washington’s state medical commission files unprofessional conduct charges against the former physician head of Harborview Medical Center’s burn unit, finding that he testified about the value of using flame retardants in furniture without disclosing that he was being paid by the companies that produce the chemicals. Government scientists had concluded that the products are toxic and don’t work, leading the chemical companies to create a phony three-member consumer watchdog group to create public fear about fire danger and to pay experts for favorable testimony. The group was quietly shut down in 2012. The doctor is also accused of making up compelling patient stories and violating patient privacy laws by using a minor patient’s photo without permission. 

Valley View Hospital (CO) notifies 5,400 patients that technicians found an encrypted, hidden server folder that contained their credit card, Social Security, and demographic information, adding that the information may have been used for identity theft. An unnamed virus collected and stored screen shots of online web pages that may have been sent outside the facility. The hospital says it has since improved its antivirus and firewall systems.

The Sacramento paper profiles Davis, CA-based Cedaron Medical, which offers software for cardiac care, rehab documentation, speech pathology, occupational therapy, and worker’s compensation evaluation. I’m fascinated that founders Malcolm and Karen Bond also started Bondolio, an award-winning olive oil business.

An editorial in BMJ says that doctors would provide better care if they knew that patients were recording their encounters, even suggesting that doctors record sessions themselves and offer patients a copy. It addressed a debate in England in which the UK General Medical Council eventually changed its position that such records would not be admissible in professional practice reviews. The article concludes that there’s no way to stop patients from recording their physician interaction, so the medical profession might as well figure out how to use that information to improve care.

Former Epic project manager Brian Stowe is sentenced to 38 years in prison for sexually assaulting six of his female Epic co-workers and a 17-year-old girl and filming the attacks. The victims were unaware of his activities until video from his computer surfaced years later, leading to the unproven possibility that he drugged them, that speculation bolstered by the fact that one his computer’s video folders was labeled “drug assaults.” One set of photos was apparently made during an Epic business trip. Stowe apologized, said he was “out of control,” and added, “The only part about getting caught that truly upsets me is that it’s caused the lives of all these people I love and care about to implode.” Stowe, who had pleaded guilty, faced a sentence of more than 400 years for 62 felonies, but that count was reduced to 27 felonies in a plea deal.

A former contract ED doctor working at Spectrum Health (MI) sues the hospital group, claiming it banned her from working there for making a Facebook comment. She thought she recognized a patient depicted in an ED nurse’s Facebook photo of a woman’s backside, so she added a comment, “OMG. Is that TB?” The doctor claims the hospital was unhappy that she was planning to consult with other EDs using materials she had developed, so they falsely claimed her comment was a HIPAA violation. She adds that a nurse was reprimanded rather than fired for leaving a comment, “I like big butts and I cannot lie.”

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 3/14/14

Validic Secures $1.25 Million in New Funding, Adds Key Executives

Durham, NC-based Validic closes a $1.25 million convertible note to support expansion for its mHealth integration engine.

MMRGlobal and Cerner Announce Patent Agreement

Cerner signs a confidential agreement with MMRGlobal over MMR’s Personal Health Record patents.

Unique Database Collaboration Will Enable Improved Care for Heart and Lung Surgery Patients

The Society of Thorasic Surgeons will link its database with CMS to provide researchers a means of tracking long-term outcomes.

Wearable Computing at BIDMC

John Halamka, MD, CIO at BIDMC, writes about his hospital’s trial use of Google Glass in the ED.

News 3/14/14

Top News

Validic, which offers a platform for accessing data from mobile health devices and wearables, secures a $1.25 million convertible note.

Reader Comments

From Professional Zac: “Re: Mat Kendall. Has given ONC exemplary service in leading its workforce, REC. and rural programs as director of the Office of Provider Adoption Support. He is leaving.” Mat is one of those people who gets a lot done, not only running those ONC programs, but before that working for New York’s EHR program and before that leading a FQHC. Like everybody who works for ONC, he sacrificed income and lifestyle for public service since it’s generally true that only low-level government employees fare better than they might in the private sector. I haven’t heard where he’s going.

HIStalk Announcements and Requests

This week on HIStalk Practice: Practice Wise CEO Julie McGovern addresses EHR users who refuse to admit they might be causing their own system problems. Users of drchrono’s free EHR will be rushing to apply for MU hardship exemptions after the company announces that its Stage 2 certified release won’t be ready until  “later this year.” A Rand study finds that physicians recognize the value of EHRs in concept but believe they undermine professional satisfaction and can negatively impact patient care. Between 2011 and 2012, the percentage of EPs participating in  Medicare’s MU program dropped 16 percent and the percentage dropping out of Medicaid’s program fell 61 percent. CareCloud CEO Albert Santalo discusses a possible IPO, company growth, and how its offerings differ from athenahealth’s. While you are checking out the latest in ambulatory HIT news, take a moment to subscribe to the email updates so you’ll never miss a post. Thanks for reading.

This week on HIStalk Connect: Proteus Digital Health announces large-scale trials and plans for a new manufacturing plant in the UK. Nintendo will refocus its strategic direction to capitalize on the growing health and wellness market. Validic raises $1.25 million to expand its mHealth integration engine.

Last chance to help me out plus be entered into a drawing for three $50 Amazon gift certificates: complete my reader survey before I close it Saturday. I appreciate it.

Upcoming Webinars

March 19 (Wednesday), 1:00 p.m. ET. The Top Trends That Matter in 2014. Sponsored by Health Catalyst. Presenters: Bobbi Brown, VP and Paul Horstmeier, SVP, Health Catalyst. Fresh back from HIMSS14, learn about 26 trends that all healthcare executives ought to be tracking. Understand the impact of these trends, be able to summarize them to an executive audience, and learn how they will increase the need for healthcare data analytics.

Acquisitions, Funding, Business, and Stock

Telus Ventures invests $3 million in PatientSafe Solutions and becomes the exclusive reseller of the PatientTouch point-of-care mobile system in Canada.

Covisint announces preliminary Q4 revenue of $24-$25.5 million, short of estimates, and appoints Sam Inman (Comarco Wireless Technologies) as interim CEO.

Accretive Health says it will probably not meet the SEC’s deadline to file restated financial results from the last three years, which will likely cause its stock to be delisted from the NYSE next week. 

General Atlantic is said to be the frontrunner to make a $100 million investment for a 30 percent stake in 1,400-employee healthcare IT services firm CitiusTech, which seeks capital to fund growth in Europe and the Middle East.

People

Validic hires John Turnburke (MedFusion) as SVP of business development, Chris Edwards (Allscripts) as VP of marketing, and Ben Clark (Allscripts) as VP of operations.

Janet Dillione, executive vice president and general manager of Nuance’s healthcare division, will step down on March 21, according to an SEC filing.

Richard Paula, MD (Tampa General Hospital) is named CMIO at Shriners Hospital for Children (FL).

Brian Ahier (Advanced Health Information Exchange Resources) is named director of standards and government affairs for Medicity.

Connance names Michael Puffe (Huron Consulting Group) SVP of sales.

Announcements and Implementations

MMRGlobal announces a confidential patent agreement with Cerner relating to MMR’s MyMedicalRecords PHR portfolio, including the one above submitted in 2005.

OCHIN and Health Choice Network launch Acuere QOL, a data aggregation, analytics, and quality solution powered by the Caradigm Intelligence Platform that will help CHCs and PCAs manage populations and improve quality.

PatientsLikeMe launches a media campaign urging people to share their medical information. How the for-profit PatientsLikeMe makes money: selling the medical information people share to drug and device manufacturers.

Government and Politics

A GAO report recommends that HHS pay more attention to the reliability of EHR data used for quality measures and use them to measure progress.

Other

BIDMC CIO John Halamka reports that the ED has been beta-testing Google Glass since December to view the patient dashboard during examinations. He says its greatest strength is being able to provide real-time updates at the bedside and will become valuable when tied to location services.

Executives of three Madison, WI-area healthcare IT companies were among the 35 invitees who were briefed by White House and HHS officials on healthcare innovation and entrepreneurship last week, including a session with National Coordinator Karen DeSalvo, MD.  The companies were Nordic Consulting, Forward Health Group, and healthfinch.  

Speaking of the White House meeting, HIStalkapalooza winner and Nordic Consulting President Drew Madden broke out socks appropriate to the occasion. It’s apparent that he has worn them before, with the obvious question being, “To where?”

I recently mentioned that I rarely complete a HIMSS member survey because the are so long and poorly designed. I just received one asking for feedback on the annual conference that ran eight online pages and 1,100 words. Needless to say my incompletion record remains intact.

A Fitch Ratings report says hospitals may face weakened credit ratings as a result of their ICD-10 conversion.

The Department of Homeland Security warns users of the now-unsupported Windows XP that they should at least replace Internet Explorer with a more secure browser for which security updates will be issued.

The Society of Thoracic Surgeons will connect its clinical database to CMS claims data, allowing researchers to track readmissions, second procedures, and long-term survival.

Weird News Andy wonders if the hospital gets a commission on tickets as local police install a red light camera near the ED of University Hospital of Tamarac (FL), snaring at least one patient experiencing chest pains. WNA quotes a related story in which most people with chest pain in Northern Utah drive themselves to the ED, slowing their treatment since ambulances can run ECGs during transport and alert the cath lab team to be ready at the door.

Sponsor Updates

• Shareable ink Founder/CTO Steve Hau will run in the Boston Marathon on April 21 and will personally match up to $10,000 in donations for victims and survivors of the 2013 bombing. 
• Capsule Tech will showcase Capsule SmartLinx Medical Device Information System at the American Organization of Nursing Executives annual meeting in Orlando.
• Fujifilm Medical Systems and Fujifilm SonoSite will participate in the National Consortium of Breast Center Meeting in Las Vegas March 15-19.
• Perceptive Software launches v10.3 of its Enterprise and Workgroup Search.
• Holon Solutions and Texas Organization of Rural & Community Hospitals (TORCH) will build a health information exchange (HIE) that will connect North Texas Medical Center (TX) to local clinics.
• HealthCare Anytime offers two-minute video overviews of their enterprise and SaaS portals.
• NTT Data is doubling the size of its US headquarters in Plano, TX.
• Seven healthcare CIOs shared strategies for managing IT cost while maximizing its value at the CIO Summit in Chicago co-sponsored by Impact Advisors.
• NexxRad Teleradiology Partners selects Merge PACS to integrate with its NexxRIS.
• ZirMed partners with Precyce/HealthStream to offer client ICD-10 education to the ambulatory market.
• WiserTogether and Truven Health Analytics partner to help consumers make better healthcare decisions.
• Porter Research President Cynthia Porter shares her thoughts on the Health IT Marketing and PR Conference in Las Vegas April 7-8.
• pMD announces that all of its new mobile charge capture implementations will be ICD-10 compliant.

EPtalk  by Dr. Jayne

I was pleasantly surprised in my personal Yahoo mail account this morning when they returned a feature that was taken away with its redesign last fall. Although I’m glad I can now see my folders and their contents, I still wish they would bring back the tabs across the top that allowed multiple emails to be open at the same time. They also followed up with an email response to my original complaint letting me know. After the original annoyance of the upgrade, I moved most of my real email activity to Gmail, so pretty much all I use Yahoo for anymore is coupons and shopping promotions.

Inga tipped me off to this piece regarding physician professional satisfaction. The study showed multiple factors as having a positive impact on physician professional satisfaction:

• Perception of whether high-quality care is being delivered
• Control over work environment, pace, and content
• Common values shared with leadership
• Respectful professional relationships
• Fair and predictable incomes

Not surprisingly, these have more to do with how practices and physician organizations run rather than with EHR. Although there are problematic EHRs and other IT systems out there, my sense over the last few years is that physicians often use them as a scapegoat. My local colleagues have voiced the thought that they can have some degree of control over EHR (refusing to use the system, demanding de-installation, blaming the vendor) but that some of the other factors (control over work environment, salary issues) are simply untouchable.

Thinking about this from a pure behavioral health standpoint, this is classic behavior. When people experience trauma, they tend to cling to the things they can control even when the rest of their lives are out of control.

Although the timing of the study didn’t allow assessment of the impact of the Affordable Care Act, I see a lot of physicians ready to use it as a scapegoat even though the majority of its changes have not yet impacted anything other than the access issue. I liked the fact that the study had a qualitative portion, which included open-ended interviews rather than just survey-type items. Those types of questions allow respondents to share direct responses without feeling the need to fit them into a predefined response box.

Unfortunately, the responses may also fail to allow full understanding of or exploration of the results. Physicians stated that “their EHRs required them to perform tasks that could be done more efficiently by clerks and transcriptionists.”

Since I spend a lot of time working on efficient clinician workflow, I would have wanted a follow up question. Is it really the software that is requiring the workflow, or is it also impacted by organizational policies that require physician data entry where it is not necessary? Is it impacted by continued administrative cost cutting that forces work onto physicians because they are perceived as “free labor” since the hospital doesn’t bill for their services as community physicians? Of course those would be rather leading questions, but that’s what I see a lot of in our metropolitan area.

Due to my CMIO responsibilities, I cobble together my clinical experience at several different hospitals. Two of them have the same EHR vendor, yet the user experience difference is night and day. One system has been configured to require endless busywork. The order sets are poor, in a confusing order, and missing seemingly key components. Physicians are required (by administrative decision) to key a PIN for each individual order rather than being able to authenticate a cohort of orders at once. That kind of thing is fixable through educating the decision makers and ensuring that physicians are part of that decision-making process.

Don’t get me wrong, there are a lot of bad EHRs out there. It’s hard to sort that out though when poor leadership, incomplete training, and lack of understanding can cripple a perfectly good system. We need to remember that there are plenty of “causal” factors to go around, In order to truly deliver physician usability, we have to address both the hardware/software issues and how the system is implemented and governed.

In addition to EHRs, physicians cited multiple sources of dissatisfaction:

• Obstacles to care, such as unsupportive practice leadership or payers refusing to cover recommended services
• Income instability
• Burdensome regulations, including Meaningful Use

Unfortunately, these aspects of physician practice are mostly outside our control. We can’t control payers and spend countless hours of uncompensated time trying to get care for our patients. We can see more patients, but we can’t control the wide variation in payments for the same service that we see across payers. We certainly can’t control the regulatory environment.

So what do we do? We circle back to the EHR as something we think we can have some control over.

I don’t have any good answers here and wish I did. I’d love to have a magic wand or even a sparkly Band-Aid to make it all better. How do we empower physicians to be part of the solution? How do we help administrators make rational decisions around system selection and implementation? How do we get them to share the reins with providers? Email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 3/13/14

Late on restatement, Accretive expects stock to be delisted

Accretive Health, a healthcare focused revenue cycle management firm and debt collector, announces that it will miss its deadline to file restated financial statements and expects that the NYSE will delist it as a result.

GAO comes down on meaningful use program

A GAO report finds that the EHR Incentive Program is not helping CMS improve overall quality because there are "reliability issues" within the clinical quality measures data that is being collected. The report concludes, "Although HHS expects that the use of EHRs can help achieve improved outcomes and support other efforts that are also intended to improve care, that result is not yet assured."

EHR Incentive Program Exceeds $22.5 Billion Payout Estimate

According to the January 2014 EHR Incentive Payment report, $22.7 billion has been paid out in incentive payments to hospitals and providers thus far, passing CMS’s estimate for what the total cost would be for the program over a 10-year timeframe.

Leidos Awarded Contracts by Department of Veterans Affairs

Leidos, an SAIC spinoff made up of former MaxIT and Vitalize consulting firms, signs a $16 million deal with the VA to provide IT support for several health IT initiatives, including technical development services for the VA’s Repositories Program, an project that will consolidate administrative and clinical data from across all VA sites into a single set of databases that centralize EHR data within the VA.

Readers Write: What Is Population Health Management, Exactly?

What Is Population Health Management, Exactly?
By Steven Merahn, MD

While at HIMSS, I stopped by the KLAS booth and ended up revisiting the October 2013 KLAS report on population health management. I was both impressed and concerned about its findings. Impressed because of the level of market commitment to population health-related solutions, but concerned because I still don’t think the market gets it when it comes to population health management.

The real power of population health is the opportunity it offers those delivering care to disintermediate those we now call payers — removing or disrupting a layer insulating patients from their providers – or at least put physicians and provider networks in a position of strength in negotiations with those contracting for care (unfortunately, it also puts hospitals at risk for similar disruption, like what happened to the railroads when airline travel began to get traction).

HIMSS was full of vendors hawking analytics and care management platforms, but population health is really not at its heart a technology play. In the executive summary of the KLAS report, author Mark Wagner tried to address this issue when he said,  “…automation is a misnomer for vendor solutions and PHM remains largely a manual process.”

However, the use of the phrase manual process is itself a misnomer. It presumes that automation is even possible for population health management. Elements of a technology stack can enable (and may be necessary for) population management, but these elements – individually and collectively – are wholly insufficient for successful implementation of a population management infrastructure.

Wagner again alludes to this in his reference to the value of “collaborating with physicians early,” but there’s more to this than simply physician engagement. It’s far more fundamental, as physician leaders, provider networks, and healthcare delivery systems are discovering. In successful population management, the databases, software analytics. and care planning platforms — whether EHR-based or independent but interoperable — are largely subordinate to a more dominant factor:  the human factor.

If there’s one thing that has been consistently affirmed to me in the 30+ years since medical school graduation, it is that health and healing is impossible without the human connection. I submit that the value in value-based care – improving quality of care and quality of health based on more efficient use of effective healthcare resources across a cohort or defined population – is more powerfully achieved through reconsideration of the organizational principles and operating relationships among the people, programs, platforms, and partners that comprise healthcare delivery and care management.

Population health management transcends the technological elements that may fulfill some of its specific functional requirements. Product, services, and channels may be necessary, but are insufficient to truly influence the trajectory and quality of a person’s health. That influence occurs at more tactile and emotive levels in people lives, “tactile” referring to the responsiveness, reliability, consistency, and convenience of care; “emotive” referring to the sincerity, authenticity, integrity, and dignity associated with the experience.

I am reminded here of Dr. Lipton, our family physician in the 1950s and 1960s, For him, what we now call population health was just the way he practiced medicine. If my grandfather – who had his first heart attack in his mid-30s – missed his quarterly blood pressure check, we would get a call. After my grandmother’s sigmoidoscopy — then done in an operating room as an inpatient — he stopped by the house.

His technology for this: the work of worry — and a weekly index card tickler file. But despite what would seem to us some technological limitations, time and time again he demonstrated to us that we were very present for him even when we were absent from his waiting room.

He did get paid in cash for services rendered, on a fee schedule and sliding scale, but he also worked to earn our trust. There was no doubt that this was an important form of compensation for him. His value proposition was threefold:  mastery of his craft, demonstrable commitment, and genuine consideration. As such, his responsibilities for our health extended beyond the doors of his office.

For our family, he provided comfort and a safe harbor – despite some looming health threats — because there was a person, and not just a person, an expert, who worried along with us and that was in many ways a more powerful influencer of our healthcare quality then the medicines he prescribed. His recommendations were followed, even when there was intellectual resistance, because we could not imagine letting him down.

Our current approach to technology is focused on “managing measureable variables,” but the real challenge is that quality of health is based on a different set of variables than quality of care. Our technology may allow us to identify and attempt to control dozens of evidence-based clinical factors, but is still not powered by factors representing the capacity to influence a patient in ways that truly matter.

Which means that if we truly want transform care delivery with technology, we need to shift our focus from the meaning of the data to what we mean to each other.

Healthcare technologies should be instruments of human expression in service of health and healing, with a fundamental mission to provide the patient and their family the same sense of comfort, safety, and reliability provided by the Dr. Liptons of the world – where professionals are valued for their commitment to mastery and human service and patients are helped to find the meaning of health in the context of their relationship with themselves and others.

This will require us to reconsider what we mean by population health by designing systems of care that amplify the humanness in our care delivery, where technology supports goal-directed collaboration between humans and machines and where we are allowing people to find meaning and value within themselves and from each other.

Steven Merahn, MD is senior vice president and director of the Center for Population Health Management at Clinovations of Washington, DC.

Readers Write: Why a Unique Patient Identifier is Critical to Improve Patient Matching

Why a Unique Patient Identifier is Critical to Improve Patient Matching
By Barry Hieb, MD

In a recent HIStalk article entitled “National Patient Identifier: Why Patient Matching Technology May Be a Better Solution,” Vicki Wheatley argues that, “… healthcare organizations should instead focus on strengthening their existing enterprise matching strategies” rather than work to implement a national patient identifier (NPI). The article makes several valid points that contribute to the ongoing debate about an NPI:

• No solution, including an NPI, can solve all patient matching problems.
• Patient matching errors and healthcare fraud will continue to require special attention.
• Accurate tracking of an individual’s information across healthcare silos is becoming increasingly important.
• Any proposed patient matching solutions must not negatively influence privacy, security, or clinical outcomes.
• Accurate patient matching is essential for activities ranging from clinical care to healthcare analytics to population health management.

In these and several other areas, Ms. Wheatley’s article makes a valid contribution to the ongoing debate concerning a national unique patient identifier.

There were a few areas, however, where we have a somewhat different viewpoint. The first of these is the implied assumption that healthcare organizations must make a choice between having an EMPI and having a national patient identifier. We believe that this is a false dichotomy.

Clearly, healthcare organizations must continue to improve their existing EMPI systems as much as possible. However, years of analysis and experience indicate that this will not allow them to achieve the levels of patient matching accuracy that are being required going forward. Those requirements include identification of individuals across disparate healthcare systems, the need for matching against ever-increasing patient populations, and the fact that patient demographic data has known variability and ambiguities.

These represent just three of the reasons why unassisted EMPI demographic matching cannot represent the sole patient matching strategy. Rather, the EMPI approach will need to be supplemented by techniques such as the use of an NPI, biometrics, digital certificates, and other technologies.

Virtually every EMPI system uses a patient’s Social Security number as a data element to improve the performance of their demographic matching algorithm. I was puzzled by the statement, “… even in theory, every single potential patient in the country would need to be assigned one…” as a condition for an NPI to work. Ms. Wheatley acknowledges that there are many people in the US who require healthcare but do not have an SSN. Despite this deficiency, the use of the SSN clearly adds value in those situations where it is accurately available. Similarly, an NPI would benefit each patient who chooses to use one.

An important point to keep in mind is that there is no mechanism to check for data entry errors in most of the data elements currently used for demographic matching. This includes the SSN, names, and addresses. For example, there is no reliable way to detect transposition of digits when a SSN is manually entered. Nor is there an easy way to automate the capture of a patient’s SSN.

Contrast that with a well-designed national patient identifier system. In most situations, the NPI would be read using automated technology such as a barcode reader or a smart chip that would virtually eliminate errors. Even when the NPI is manually entered, embedded check digits can ensure that any data entry errors are immediately detected and the operator is prompted to re-enter the NPI. When added to a person’s demographic profile, the NPI thus becomes the single demographic element that can lead to accurate patient identification on its own. These proposals represent a major advance from the current situation – i.e., an 8 percent or more error rate in EMPI matches.

It is very clear that healthcare organizations will continue their use of EMPI systems for the foreseeable future. That fact, however, should not blind us to the reality that these EMPI systems need to be augmented by additional capabilities going forward if they are going to meet the patient matching accuracy needs that are emerging in healthcare.

The use of a national patient identifier, even if it is initially only chosen by a subset of providers (or patients, on a voluntary basis), will enhance the patient matching accuracy for those patients and help avoid the medical errors that are associated with patient matching errors.

Barry Hieb, MD is chief scientist with Global Patient Identifiers, Inc. of Tucson, AZ.

Health IT from the CIO’s Chair 3/12/14

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

Attending HIMSS Made Me Wonder: Does IT Matter?

Flying home from HIMSS after spending a week in Orlando and reflecting on the conference it made me think about Nicholas G. Carr’s book from over 10 years ago that made everyone it IT defensive. Mr. Carr asked, with a provocative title, Does IT Matter?

After spending a few days on the HIMSS show floor, the collective group of exhibitors might have colluded to try to make Mr. Carr’s point.

Before I run the risk of losing my secret CIO decoder ring (which gives me wide, sweeping powers to say “no” to things, an important task of a CIO), let me skip to the end and say, “Heck yes, I think IT matters.” But it sure was hard to see at this year’s show.

Let me add context. Mr. Carr never claimed that IT didn’t matter. People who only read the title of the book argued thinking that, but his main point was that IT yielded diminishing returns as a continuing source of strategic differentiation.

Since I already shared that I don’t agree with his thesis and I think that IT does matter, let me explain more why it was hard to hold my ground at HIMSS.

I believe that real strategic value from IT comes from cumulative and sustained use of our systems.

The show floor at HIMSS is best at being a live shopping catalog. If strategic value comes from health systems hunkering down and “just using what they own,” it really means we should all be at our core vendor’s user group to get focused instead of out shopping. This is not to say that there weren’t some interesting new ideas and companies at the show, but I would contend that most health system should be implementing, optimizing, or perfecting the use of their existing systems.

The problem with not staying focused is that it makes us forget that IT is only a tool, not a panacea. Shopping for the latest technology because it can be installed now does not usually translate to having our problems magically solved. 

Especially for those institutions that have achieved MU Stage 1 or HIMSS EMRAM Stage 6 or higher, the goal really needs to be to make use of everything we have by using our systems more deeply. Most big vendors I talk to often complain that they have trouble getting their existing customer base to either stay current on latest versions or to implement and use all of the already-live functionality.

But it is not simple. New technologies will continue to give companies the chance to differentiate and first movers who take risk will gain advantage. But understanding the opportunity and deciding when the right time to make the bet is not for the faint of heart. It is among the toughest choices for CIOs and the rest of the C-suite to make these days, with constrained budgets and scarce ROI from previous large IT projects.

Mr. Carr makes the claim that widespread adoption of best practices through the use of IT software makes advantages disappear. It is obvious to me that Mr. Carr never spend time trying to enforce common content in a large health system. If he saw our slower pace, he would certainly declare we had a long way to go and had a low risk of IT not mattering.

The reality is that a lot of the IT mystique has been eliminated as consumer use of technology continues to grow. IT teams now need to play by the same rules as other business units by having clear objectives before money is spent. The age of technology for technology’s sake is probably in the rear view mirror. As technology infrastructure becomes a commodity (the cloud), how we use our tools or the depth of our use of IT will define and create our advantage.

Adding to the challenges of the CIO will be the realization that just because we find a new innovation, it does not necessarily mean that it will pay to be a pioneer. Our focus might be better spent on hunkering down and optimizing.

If we are going to make IT matter, as a mentor once told me,“Let’s get ‘er done.” Then we can go shopping.

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

HIStalk Interviews Mark Bakken, CEO, Nordic Consulting

Mark Bakken is CEO of Nordic Consulting and an investor in several healthcare IT startups.

How’s Nordic’s business these days?

Our business is booming, like everybody else in healthcare IT right now. We’re doing a lot with optimization, helping a lot of Epic customers as they figure out how to leverage their investment in Epic and the EMR to not only improve care, but reduce costs at the same time. 

It’s been pretty fun to be able to send in experts to quickly do an assessment and say, hey, if you enabled all these features and other things, you could most likely make your co-workers very, very happy by saving them some time, and at the same time, get better results or hone in on a cure a little faster, leverage the technology you have while at the same time get more done with less. It’s like the equivalent of robots for manufacturing. It’s fun to do these. 

These organizations are so large. Nobody likes to eliminate positions or let people go if they don’t have to. But since most of them are so big, they can reduce the number of staff they need relative to them growing. If they do acquisitions and mergers, they don’t need to hire as many. The net effect is their efficiency gets better from a cost perspective, or they could do it through attrition if they say we no longer have to do registration, for example. Customers and patients are doing it automatically, so we need a lot of people. That person can then take a new career opportunity within a healthcare organization.

It’s fun to be on the forefront, to see organizations starting to leverage their initial investment into that second wave.

The company just moved to a new headquarters location. Epic is known for some interesting and fun buildings. What’s yours like?

[Laughs] It’s nowhere near as Disney or Google-like as Epic’s, but it’s nice and open and airy. We pride ourselves on transparency. We made it nice and professional looking, but within reason, I would say.

What’s the overall state of healthcare IT innovation and the business climate in Wisconsin?

Obviously with Epic in Madison — and I’m in Madison — there’s a lot going on here. There’s a lot of really sharp people that either come to the University, work at Epic, and then they have some ideas. Epic’s road map isn’t going to get around to building those into their core products for a few years, so they say, hey, maybe I can do it, grab some friends, and give it a shot at the new American dream — starting your own company and making it big some day. There’s a lot of that going on.

There’s a lot of support around that from the investment community here. Madison, Wisconsin was one of the leaders in the whole biotechnology wave that started taking off with stem cell research and everything else. Not to mention all the providers in Wisconsin were some of the early adopters, especially with Epic in our back yard, where they tried some things and are benefitting from some of those early advances with healthcare IT. We’ve got a lot of the good raw ingredients here.

Neither you nor Judy Faulkner would have fit my mental model of what education a founder would have since you both have degrees in computer science. Is there something different about being educated at University of Wisconsin or does Epic just create things that are like Epic?

It is interesting because usually that isn’t the background. We’ve taken different paths. Judy has been at it obviously for a long time. Trying to figure out the right mix and perseverance is a big piece of it and you do find that in computer science people that gravitate towards that. There’s always a problem you’re trying to figure out and there’s many different ways to go about it. 

Maybe there’s something to that. Who knows? It might just be coincidence or maybe it is one of those things, as computers and technology are becoming much more relevant in a services-based economy, where you can use computers to automate things. That’s a good question.

What are you doing with your investing and what kinds of things you look for in companies?

What I look for, like most people, is a great management team, leadership, and passion. People that can inspire people, whether it’s people that follow them or just believe in their vision and their dream, whether it’s customers, or potentially investors. Then other employees that have the same desire or vision to do that. 

With healthcare and IT and everything going on right now, all the pressure and all the change and everything else, there’s lots of ways you can use technology to not only get the patient more engaged and more accountable and figure out how to do that from the Fitbits, smart scales, to the whole continuum of care that say, it’s all about responsibility. It’s not just the physician, it’s not just the healthcare organization. Let’s all try to leverage technology to be healthier and live longer and find things sooner so we can find a cure.

Learn from each other. I heard a stat that says something like an average 40 percent of physicians’ initial diagnoses are incorrect. If that’s true, we can definitely do better than that by leveraging data. If we can leverage technology, leverage data to find things, to hone in on things sooner before they’re uncurable or unfixable, that ends up being a good thing. That’s basically what you look for. 

Epic, Cerner, athena, Meditech, McKesson, AllScripts — the list goes on and on. They’ve got a really good platform and a good foundation, but healthcare and driving down costs and improving care is much more than just the clinical data. You got to take everything into account and there’s lots of different ways to do that. There’s a lot of bolt-ons.

I saw a ton of this with the whole Microsoft wave and revolution in 1990s and early 2000s where Microsoft has a platform, and then there’s lots of other companies out there like, hey, we can build on it and we can make something better for what you specifically need. The thing is, the bigger the companies get, they can’t come out with that specific module or niche. It might take them three to five years, and by the time they come out with it, the market may have moved on. They might have a different need or something else came up. 

Young, small startups that are agile and can get things done quickly … it’s fun to be part of that.

What are some companies you’re investing in?

I would probably start with Catalyze.io. They’re creating repeatable platforms for healthcare IT. It’s HIPAA compliant. Instead of reinventing the wheel, there’s a lot of things that we could learn from each other. We can share that framework to do quick custom development stuff.

Forward Health is a great analytics company, population health, medical intelligence organization. Great way to slice and dice information easily. Not just clinical data, but when you look at RX data, claims data, consumer data, or anything else that you need in order to make better decisions faster for actuaries and statisticians as well as physicians.

Wellbe.me is another organization. Patient engagement before they come in for a surgery or when they leave, making sure they do all the things ahead of time and they fill out all the forms and all the checklists. They do it in a very easy way that’s a nice wraparound any of the EMR programs out there. Very affordable, works very, very well. Lots of interest from everybody to say, hey, when you come in, if you do all these things ahead of time, the odds of you not having to be readmitted greatly increase. Then afterwards, make sure you do all the follow-ups. It makes it easier for a healthcare organization to manage tons of people before they come in and after they come in and leverage their social network to do so.

Moxe Health, which is the connection and interfaces. Just think of all the different things you have to connect out there. Instead of paying someone to customize all those at the end of the day, maybe there’s 50 different systems that someone has to connect to, why do you have to custom build all those things over and over and over again? They’re making reusable app store type connectors out there.

Healthfinch is another one that makes a great way to save physician time. That’s their whole goal in life is to reduce the number of clicks. Right now there’s a lot of frustration on the physician side saying, hey, I just want to do what I do. Trying to find the best use of their time, finding that right mix without making them all hire scribes to follow them around. There’s some clever things they’ve done with prescription refills, which is interesting. On average, physicians spend seven percent of their time doing that. They have a way they can get it down to one percent. For every 100 physicians, if you can free up six physicians’ time doing things that could be automated, that’s a good thing for everybody.

What’s your vehicle for investing? Do you just make a personal investment or do you have a fund of some sort?

It’s all new territory for everybody. It’s either go to friends or family, which is tough because you don’t want to mix friends and family. It’s to try to do a round, or do a convertible note is what they would call it, where you can do a loan and then down the road, if they raise money, once they have more customers and more success than the valuation.

The trick is, you want to make sure the people actually doing the work have some substantial stake in the outcome and some motivation to make sure they can create something that’s creating value out there. If they do, they benefit and that would be good for me, too.

I just am a huge, huge fan of entrepreneurs. I know how tough it is to get going. You need the right mix of everything. You need the stars to all align and a little bit of guidance from “don’t do this” or “how do you do that?” Everywhere from how do you work with large organizations, how do you contract with them, how do you get insurance, how much insurance, to payroll, to taxes, to a lot of little things that everybody needed despite what they’re doing. If I can help point them in a direction that will save them a bunch of time so they can focus on what they really are good at, then I think that’s a good thing.

Is there a way the average person can invest now that some of the rules have loosed up, such as for crowd funding, for instance?

Not as easily as you would hope yet. You read all about the crowd funding. Some of the laws in Wisconsin, thankfully, have changed. You can actually get them some equity instead of some kind of token gift or something. It’s going to be easier without having to be accredited and all this other stuff and all these hoops. 

There’s some other things I’m looking at personally trying to do. Change the business lending laws to be more in line with America’s economy, which is more of a services-based economy. The business lending laws that were set up 70 years ago were based on America being a manufacturing-based economy. You need inventory, you need all these other things, assets, you need buildings that a bank could repossess in order to get a line of credit or a loan. If we can make that easier for people so they don’t have to spend a bunch of time trying to get people to invest in their idea and everything else, I think that would be a good thing. It would be good for them, good for America.

What do the companies you’re investing in need most, other than money?

They need a mixture of things. You’ve got to have a customer that is willing to work with you, to at least do the pilot, to work out the kinks, to figure out how to price it, how to package it, how to deliver it. That’s one.

They need mentors from every angle, from lawyers, from LLCs or S corp to C corp to some other structure, and then all the other mentor types around like that. In Madison, we have something called 100health, which is geared towards helping people figure out where they can go for different resources and packages to get their idea off the ground in the most efficient manner.

I do have to say, there is a lot of other interest in investment in healthcare IT right now from the venture capital community, even down to the tens or hundreds of thousands of dollars, whether they’re from Chicago or all over the country. I just was in an advisory board meeting where they said that VC funding has more than doubled in the last four years in healthcare IT space. The rest of the world’s starting to take notice, to say, hey, I think there’s something to this whole EMR and healthcare IT technology wave that will be good for everybody.

Money comes at a price and companies give away their equity too early or get taken in a direction that seems to be the quickest path to profitability and not really what their vision was. Do you see that as a challenge?

Yes, absolutely. There are strings attached. Part of it is finding the right way to do that. Typically in Wisconsin and other states around the country, there’s a lot of older money. They don’t quite understand this new world economy; the Silicon Valleys and WhatsApp be worth $18 billion, not to say healthcare IT is going to go that kind of crazy.

It is basically trying to find that right balance. That’s why I think I can, because I know the healthcare IT space. Me personally making some kind of investment of faith at some kind of valuation to at least set the bar that is fair. Then other people can piggyback on that and do things at the same ratio with the entrepreneurs and the people doing all the work feel like, OK, that’s fair, I don’t feel like I’m getting held over a barrel.

What are the start-ups most naive about?

Most of them really, really get excited about their idea and their program or whatever they’re going to do without 100 percent going to the market and knowing are people willing to pay for this, and if so, how much, and is it enough where they can actually make a good living by providing that value to a customer. People can think great thoughts, but if the market isn’t ready, if there isn’t a budget, if it really doesn’t make sense, if it’s a nice to have instead of a need to have, then it’s one of those lessons learned type things.

How do you think healthcare IT will look different than it does today in five years?

It will be hugely different in a very, very good way. There was another study that came out like one in eight hospitals had an EMR back in 2009, five years ago. Five years from now, I think almost everybody will. With that, hopefully we’ll be able to analyze that data to be able to find other Patients Like Me type thing, where physicians, nurses, everybody in the healthcare world can use that data to hone in on a cure faster or to diagnose something before it’s unsolvable. I think we really, really, really will be using data a lot more so to make care better so people can live longer, healthier, happier lives.

Do you have any final thoughts?

It’s pretty fun to be part of it right now, the whole healthcare IT revolution that’s going on. The one thing I look at is saying roughly 18 percent of our economy is spent on healthcare and it’s basically flying blind. We’re using data for everything else, so it would be nice to actually use this data to make care safer and better. It’s fun to be part of it.

Morning Headlines 3/12/14

Federal panel approves MU Stage 3 recommendations

The Health IT Policy Committee approves the Stage 3 Meaningful Use requirements that were recommended by its health policy workgroup, but only after cutting 30 percent of the functionality that was originally proposed.

2014 CEHRT Hardship Exception Guidance

CMS publishes its revised hardship exemption criteria for EHs and EPs. The new criteria essentially rubber stamps the exemption application for anyone that asks for one so long as they report "2014 Vendor Issues" in their request.

Carolinas HealthCare seeks to cut costs through prevention, technology

Carolinas HealthCare System is turning to predictive analytics to help identify ED patients that would likely be readmitted so that preventative measures can be taken. The hospital recorded a $5 million loss this year, its first loss in 30 years, and executives hope that analyzing the data from its EHR system will help it recover that loss.

Integrating Electronic Health Records into Clinical Workflow

A report from the National Institute of Standards and Technology finds that ambulatory EHR vendors are not doing a good enough job building key clinical workflows into EHR software.

News 3/12/14

Top News

The HIT Policy Committee submits its Meaningful Use Workgroup’s Stage 3 recommendations.

Reader Comments

From Pointy Toes: “Re: CEHRT Hardship Exception Guidance. This is a joke. All you have to say to qualify for the Medicare hardship exemption to avoid the 2015 payment adjustment is say you  had ‘2014 Vendor Issues.’ Tavenner previously said some ‘narrow’ hardship exemptions would be granted. Sounds like anyone wanting an exemption can request it and presumably one will be granted one. Why not just push the deadline back for everyone instead of requiring providers to jump through an extra hoop?” CMS issued guidance Tuesday for EPs and hospitals worried about being hit with penalties, even going so far as to provide instructions to choose “2014 Vendor Issues” no matter what their actual issue. It is ridiculous – setting the bar high officially, then accepting a wink-wink rubber stamp excuse for anyone who can’t make it. Maybe someone should track the vendors whose non-compliant yet certified products forced their users to claim hardship.

From Canuck: “Re: rumore that UHN in Toronto is replacing QuadraMed EHR with Cerner. I believe instead it came down to Cerner and Epic and Epic won.” Unverified.

HIStalk Announcements and Requests

Welcome to new HIStalk Gold Sponsor SyTrue. The Chico, CA-based company offers a business and clinical intelligence platform that tells hospitals how their clinical objectives are being deployed; what physicians are doing; and who in the market is providing services at a given cost and outcome. It integrates and structures disparate EHR information for predictive and clinical analytics used for data analysis, electronic abstraction, outcomes analytics, operations, population management, clinical research, and patient engagement. Thanks to SyTrue for supporting HIStalk.

Here’s one final mug shot featuring Tammi’s office de-stresser, which must have traveled furthest from Orlando while still not leaving the continental US (the UFO on a stick in the background should give a strong hint of her location).

Thanks to the 355 folks who have completed my reader survey so far. That number provides respondents with good odds of being randomly drawn for one of three $50 Amazon gift cards, but represents only around 1 percent of HIStalk’s 30,000+ readers. Spend less than five minutes completing the survey and you’ll help me plan the next year of HIStalk and earn my appreciation besides.

I’m always looking for interesting people to interview. Know someone who would be stimulating, fun, and a straight shooter? Let me know.

Upcoming Webinars

March 19 (Wednesday), 1:00 p.m. ET. The Top Trends That Matter in 2014. Sponsored by Health Catalyst. Presenters: Bobbi Brown, VP and Paul Horstmeier, SVP, Health Catalyst. Fresh back from HIMSS14, learn about 26 trends that all healthcare executives ought to be tracking. Understand the impact of these trends, be able to summarize them to an executive audience, and learn how they will increase the need for healthcare data analytics.

Acquisitions, Funding, Business, and Stock

First-half results from Scotland-based Craneware: revenue up five percent, pre-tax profit up seven percent.

CompuGroup Medical acquires three European HIT providers: lab software provider vision4health Laufenberg & Co and office-based physician software vendors Imagine Editions and Imagine Assistance.

Quest Diagnostics completes its acquisition of Solstas Lab Partners Group and raises its full-year 2014 financial guidance.

Employer benefits platform provider Castlight Health raises the price range of its IPO to $13-15 per share, up from the $9-11 range it set just a week ago. The company, which lost $62 million on $13 million of revenue in 2013, would receive proceeds of $140 million, valuing it at $1.5 billion. The company’s founders are Todd Park (US CTO and co-founder of athenahealth); Bryan Roberts, PhD (chairman and co-founder of venture capital firm Venrock); and Giovanni Colella, MD (founder of RelayHealth).

Sales

The Royal Free London NHS Foundation Trust selects OpenText to manage its scanned legacy case notes.

The Community of Hope (DC) is implementing Forward Health Group’s PopulationManager and The Guideline Advantage.

The VA awards Leidos three contracts worth $16 million to support blood bank software and the MyHealtheVet program.

People

TeleTracking Technologies names Diane Watson (Tilt, Inc.) COO and Joseph Tetzlaff (inVentiv Health) CTO.

Michael Hart is promoted to VP of IT applications at Arkansas Children’s Hospital.

Craig Joseph, MD (Agnesian HealthCare) is named ICD-10 and EHR physician advisor at Texas Children’s Hospital (TX).

Announcements and Implementations

Cox Health (MO) deploys Phytel’s population health and patient engagement platform.

McKesson announces QICS for Cardiology, a CVIS-based workflow and critical results communications platform. OSF Healthcare (IL) is piloting.

QuadraMed announces GA of its QCPR 6.0 enterprise EHR, which includes bar code medication administration, a comprehensive problem list, a Web-based patient portal, the ability to create a CCD, and Canada-specific architecture requirements.

In Canada, Bluewater Health will roll out patient flow software from Oculys.

University of Colorado Physicians goes live on the DocASAP self-scheduling system.

Government and Politics

Office of Civil Rights fines the public health department of Skagit County, WA $215,000 for HIPAA violations involving information on 1,581 people exposed in its public web server, the first time a HIPAA fine has been levied against a local government.

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The White House launches #GeeksGetCovered, encouraging technology entrepreneurs who can now buy their own non-employer health insurance because of the Affordable Care Act to start their own businesses.

President Obama riffs hilariously with comedian Zach Galifianakis, appearing on “Between Two Ferns” to plug Healthcare.gov (“I wouldn’t be with you here today if I didn’t have something to plug … Healthcare.gov works great now.”)

The phrase “healthcare exchange” always seems to be preceded by “troubled,” so add Maryland’s $200 million version to the list.  Like other states, it decided to create its own site, hired a contractor that it later said underperformed, missed its go-live date, and had to create a backup plan to accommodate people who wanted to enroll but couldn’t. HHS announces that it will investigate.

Hillary Clinton’s financial disclosure forms for 2012 reveal that her husband Bill took a $225,000 speaking fee from the struggling, non-profit Washington Hospital Center as it was laying off employees. The hospital also brought in George W. Bush to speak, but since his wife isn’t running for office, his fee remains confidential. Bill made a bunch of money in 2012 for addressing money-losing non-profits. Somewhere in those records is the payment he received from HIMSS if anyone knows how to locate them. I’d bet $400K.

Innovation and Research

A NIST report says that inadequate workflow integration forces users of ambulatory EHRs to develop system workarounds, suggesting that EHR vendors develop these capabilities:

• At-a-glance physician views of patient schedules
• Task reminders from previous patient visits
• Redacting and summarizing lab results
• Draft creation of patients orders in advance
• Conversion of working diagnoses to formal diagnoses
• Skip or defer tasks when workload requires
• Role-based views of progress notes
• Visually differentiate copied-and-pasted progress note text from newly entered documentation
• Manage referral and consultation messages with specialists
• Track scheduled consults and lab results review

The Charlotte, NC newspaper says that Carolinas HealthCare System will use innovative (unnamed) software and the information collected by its multiple EMR systems to identify ED patients who are likely to be readmitted, allowing team-based intervention and remote management. The system’s chief medical officer weighs in on hospitals that don’t use electronic medical records: “You don’t know how bad it is until you actually go back. It was like a time warp. The care is unsafe, it’s uncoordinated. It’s a nightmare…The system was absolutely stupid, and frightening.” I interviewed SVP/CIO Craig Richardville in September 2013. It might be time for a follow-up to talk about analytics.

Technology

Wellocracy provides a well done comparison chart of wearable activity trackers.

Other

A column by InfoWorld’s executor editor says a disconnect exists between complex government EHR requirements and the stubbornness of the healthcare industry to embrace them, summarizing, “We have a mess of proprietary EHR systems with highly customized processes, a set of HIEs that use different standards and protocols to connect them, and a mandate to provide human-readable data from these disparate systems. What could possibly go right?”

In England, University Hospital of North Staffordshire plans to conduct video consultations via Skype, saying the service will reduce outpatient appointments by 35 percent.

The Gainesville, FL newspaper profiles Shadow Health, whose founder licensed avatar technology from the University of Florida to create nursing school education tools that students buy for $89.

A study finds that incorrectly flagging patients as being allergic to penicillin increases overall inpatient days by 10 percent and increases resistance to broad-spectrum antibiotics. Up to 95 percent of patients who say they are allergic to penicillin really aren’t.

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New York-Presbyterian Hospital will host a hospital hackathon this weekend in which teams will design apps for its portal that improve patient access to care. The hospital is offering $85,000 in prizes and has filled all of its slots with 120 participants. Dr. Oz provides the video introduction.

Sponsor Updates

• Kinetic Data names CareTech Solutions “Innovator of the Year” for realizing $4.7 million in cost savings by implementing Kinetic Request.
• Premier enhances its OperationsAdvisor labor management solution to give healthcare organizations the ability to analyze labor efficiency across multiple care settings.
• Ryan Uteg, senior advisor for Impact Advisors, is named to Consulting Magazine’s “35 Under 35.”
• Allscripts Sunrise is selected by Black Book as top inpatient EHR.
• Iatric Systems will deploy integration in the EDIS and vital sign monitors as Southeast Alabama Medical Center (AL) upgrades its McKesson Paragon HIS.
• MedAssets’ National Sourcing Collaborative cumulatively saves providers $135 million over the last three years.
• Wolters Kluwer Health launches Bates’ Visual Guide demonstrating evidence-based physical exam techniques.
• Santa Rosa Consulting’s Fred L. Brown is inducted into Modern Healthcare’s “Health Care Hall of Fame 2014.”
• Kareo announces that its ICD-10 Success Checklist is available on a write-on poster.
• NextGen Healthcare’s CMO Sarah Corley is elected to serve on the EHR Association Executive Committee.
• Medical Economics spotlights e-MDs customer John Bender, MD of Miramont Family Medicine (CO) for expanding his practice while 30 percent of local practices have sold or closed.
• Health Catalyst publishes a free white paper with a candid 12-point review of population health management software vendors.

Contacts

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

More news: HIStalk Practice, HIStalk Connect

Morning Headlines 3/11/14

GOP senators want specifics on hardship exemptions

Six Republican senators are calling on CMS to provide more details on its plan to grant healthcare providers more lenient hardship exemptions for Stage 2 Meaningful Use.

Coroner blames "failure" of NHS computer system for boy’s death

In England, a coroner at Royal United Hospital blames a new outpatient scheduling system in his report after a three-year-old boy passes away because he missed months of appointments booked to monitor a heart condition. The appointments were properly scheduled but were lost when the hospital migrated its scheduling data to the new system.

County Government Settles Potential HIPAA Violations

The HHS Office of Civil Rights settles a HIPAA violation with Skagit County, WA for $215,000. The case marks the first time that the OCR has targeted a county government.

Curbside Consult with Dr. Jayne 3/10/14

This week was the beginning of what I suspect will be a long and painful project at work. If I wanted to deal with mergers and acquisitions, I would have gone to business school. Instead, I went into medical school, but nevertheless here I am.

Like so many other health systems across the US, mine has been in growth mode. We were accelerating the growth of our employed medical group going back as far as 2008. The push towards more tightly integrated delivery systems has only added fuel to the fire.

We had previously been purchasing groups in the three- to 10-physician practice space, with a couple of outliers that had 15 or so physicians. Now we’ve gone and purchased a 75-physician group. I’m sure it looked great to the hospitals as a way to further consolidate their referral bases. It was also a grab for the revenue that the new group’s imaging division was bringing in on the side.

I had the opportunity to speak with a few of their physician leaders in a couple of weeks ago. My ears perked up when they mentioned one upside of being part of our health system as “better support with IT projects including Meaningful Use and PQRS.”

Red lights started flashing in my head and alarms were going off. Thinking that PQRS or Meaningful Use are “IT projects” is like thinking that a heart/lung transplant is a “plumbing project.”

I immediately scheduled a series of meetings with their leadership and IT teams and our counterparts to figure out what had been promised by the C-suite and how we were going to deliver it. It’s bad enough to have to deal with a culture shift, but when technology and millions of dollars in incentives are involved, the problem is magnified. Our C-suite has a track record of promising technology projects that they can’t deliver (such as a complete EHR conversion in 30 days) so we quickly formed a betting pool to entertain just how bad this might get.

One of the reasons they get us into these kinds of binds is they’re afraid to involve too many people in the acquisitions. They fear that other physicians will get word of them and become demanding or that there will be a loss of bargaining power if it’s public too early. I understand that, but I also understand the need to do due diligence around merging or converting IT systems before the promises are made and the papers are signed.

Every once in a while, one of the VPs will ask someone from IT to “look under the hood” at an acquisition target, but it’s usually more along the lines of valuing their hardware, calculating their maintenance, and figuring out how to connect them to the hospital backbone than it is to assessing the quality of their data and how well their workflows and care gel with our existing best practices.

Unfortunately, the ink was already dry before I knew about it. Our group president made some assumptions that since our target was on the same EHR as we are that it should be fairly easy to just “throw them on our system and have them attest with our docs.” Oh, so much easier said then done, my friend. When I started throwing out reasons why it doesn’t really work that way, he actually referred to me as Debbie Downer and reminded me that we have to make it work because we already said we would.

I can’t believe that’s what passes for leadership these days, but our health system seems to love this guy. He’s personable and kind of a teddy bear, but he’s generally all fluff and no stuff, which leaves the rest of us to scramble around behind him to try to make things work.

This week began the series of meetings to try to figure out how to deliver the impossible. We now have two installations of the EHR to deal with. Their group has a lot of primary care docs that refer to our specialists. Given the number of common patients between the platforms, I’m not confident of being able to do a clean conversion without a lot of data integrity issues and a substantial commitment for clinical cleanup even if we had a nice long time interval. That’s problem number one.

Problem number two is that both installations have to take a major upgrade before we start the attestation period for Meaningful Use on July 1. Leadership assumed we could combine the systems quickly and do a single upgrade, but in addition to the patient issue, we also have a fair amount of customization and client-specific configuration on each system that will have to be evaluated. We can’t just throw it all away and assume physicians will be immediately facile on a plain vanilla system.

We also have the issue that at least 40 of their providers are going to be attesting for MU the first time. That means that not only do we have to get their upgrade live early enough prior to July 1 that the users have enough time to burn in the new workflows and make sure they’re entering quality data, but we need to plan to have our MU and auditing teams work around the clock at the end of the quarter so we can attest for them by the deadline. Problem number three.

Let’s see, the end of that quarter also puts us at October 1, which is ICD-10 go-time. That makes problem number four.

Let’s back up a little, though. If they’re such a solid, established group, I wonder why more than half of them are just now going after MU Stage 1? That was the topic of Wednesday’s half-day working session, when I really dug into the fact that they think MU, PQRS, and other quality initiatives are IT projects. That’s when I came up with problem number five, which unfortunately is the biggest one of all. The reason they haven’t attested yet is they’ve been attempting to have IT lead all these projects without adequate operational and clinical support.

They seriously think that there is some kind of magical IT wand that will be waved around and the physicians will do what they are asked along with all the support staff. They have zero physician alignment strategy. Physicians have no financial skin in the game for MU or any of the other incentive programs. They don’t even have a standard physician contract. All the physicians have been able to negotiate their own deals even those in the same physical location. That makes it a little tricky when partners are able to earn the same income seeing dramatically different numbers of patients per month.

The IT team listed off more than a dozen resentful bitter physician disagreements without even taking a breath. At least all of our physicians were migrated to a common contract in tandem with our EHR project more than half a decade ago because we realized only money would align them with our goals. These folks (including the one operations person that bothered to show up at the meeting) acted like they have never heard such a thing.

Their staffing ratios are also a mess. Everyone has the same number of support staff regardless of specialty, productivity, or how they run their offices. There is no common scheduling methodology across their locations, which adds another worry of how we’ll do an appointment conversion if we decide to do one when we move them to our database. No wonder they were ripe for the picking — they were undoubtedly losing money with how they were running. By the end of the meeting, I was scarfing down Advil like they were the green M&Ms in Inga’s Quipstar dressing room at HIMSS.

I spent most of Friday with my trusted lieutenants trying to figure out how we’re going to do this and still preserve our sanity and keep our team intact. After looking at all the pros and cons, I think I’m going to be lucky to make it through the next two quarters without losing my own mind or quitting my job. My liver can’t take as many martinis as I think I’ll need to get through the inevitable goat rodeo this will become, so I figured it was time to find a less-harmful way to self-medicate.

My drug of choice: pastry. This week’s offering is pictured at top. I’m a big fan of doing things old-school so I can let out my stress cutting the butter into the flour by hand as I pursue the perfect crust. I can release my creative energies by trying different fillings. If I really need to escape, I can do decorative top crusts or make little designs with dough cutouts.

I may not be able to make this project work, but I’m armed and dangerous where an egg wash is concerned. I’m going to go all Martha Stewart in my free time, just without the insider trading or the prison term.

Got a recommendation for pastry therapy? Email me.

Email Dr. Jayne.

HIStalk Interviews Regina Holliday, Patient Advocate

Regina Holliday is a Washington, DC-based patient advocate and artist known for painting a series of murals depicting the need for clarity and transparency in medical records. After her husband’s death from kidney cancer in 2009, she painted "73 Cents," a mural showing her husband dying in darkness surrounded by inaccessible technological tools in a closed data loop. The title refers to the cost per page charged to patients to obtain their medical records in the state of Maryland.

Give me some background about what you do and what The Walking Gallery is.

Almost five years ago, my husband had cancer. He was in the hospital for 11 weeks. We had very little access to his electronic medical record. He died in the 12th week. I  decided I would do everything in my power — speaking, painting, writing — to try to change healthcare and make it become where the patient’s story is front and center, and within hospitals, you can get to your medical record in real time.

That’s why I paint giant murals and that’s why I started a movement called The Walking Gallery, where people have paintings on the back of their business suit jackets and the goal of the patient’s story is front and center.

You just spoke at the HIMSS conference. Did you leave it feeling that patient engagement and advocacy are really taking hold or is it just a few folks hoping that it is while the rest are indifferent?

I’ve spoken now at several different informatics societies. I’ve been excited to see how much HIMSS is embracing patient advocacy in a real way. It doesn’t seem to be token and it’s growing every year, which is real exciting to see. I’m sure it’s incredibly frightening for them to watch it take off.

HIMSS tries to serve two factions, high-paying vendors who want to sell products and providers who are their prospects and users. But usually absent from those discussion are the patients all of that technology affects.

Before I worked in healthcare, I came from the toy industry. I’m very familiar with Toy Fair, which is gigantic trade show. There’s a lot of similarities, because just like in that world, you’re focused on sales, high-dollar items, and what’s going to move that year. But you’re also really focused on the fact that your customers are children. There’s this wonderful, youthful spontaneity to that product line, the concept of selling toys.

In healthcare, we have somewhat distanced ourselves from the end user, which is patients. I’ve been wanting to see the realization come back that when you’re a vendor, when you’re a provider, whoever you are at HIMSS, inside of you, you are a patient. It’s been really exciting to see people flip and relate to themselves as their patient self before they relate to themselves as their vendor-provider self.

Will patients ever have that kind of power where they’re like a customer in any other industry?

Yes. It’s coming. The beautiful thing that happened to medicine was social media. The ability for patients, regular folks who have no organization behind them, to have an equal voice to a company.

While I was at HIMSS, they had trouble getting my hotel room. I was tweeting about it, and within less than two hours, I was talking to Hilton, the national channel. Later that day, I was talking to Hyatt, the national channel. That kind of power didn’t exist before — the ability as an individual to communicate with large organizations. It’s changing everything.

Do you think that’s really the case? At Hilton or Hyatt, you’re paying the bill, and if you’re unhappy, you stop using them. But in healthcare, you don’t necessarily get to choose where you receive your care or control what you pay for …

I disagree with that. The model of care is rapidly changing. With the Affordable Care Act and a lot of consumers becoming high-deductible plan payers, they’re determining where they’re getting their care. The ability to make choices about where you’re going to get your care affects the bottom line in institutions. With things like HCAHPS scores, patient satisfaction scores, now being publically available, with transparency in pricing becoming more and more demanded, you have an end-user consumer that’s actually becoming very empowered.

What do you see as the impact of the Affordable Care Act?

Major major groundswell change. People becoming very interested in the fact they have choices in policies. 2008 really hurt a lot of this country. People were wedded to a location, a job, and insurance that came with that job. Which meant that, unfortunately, a lot of people who should have been able to move so they could economically better themselves found themselves not in a position to do so.

Affordable Care Act comes on the stage. Now all of a sudden we are getting the ability to untangle our health life from our job life. That allows for a whole bunch of people to work at different organizations, start new businesses, go the freelance, self-employed contractor route when they thought they couldn’t do that before because they couldn’t get insured. That allows us to have a looser economy.

Honestly, when it comes to Americans, we are spectacular at innovation and creativity. Those things are squashed if you’re forced to stay in a job that you don’t want to be in any more. For a long time, the way we set up our insurance in this country, you were forced in that position.

Inpatient demand is dropping, so hospitals are using their money and clout to buy physician practices to shore up their protected markets. Will they be able to end run the trend that would place them less at the center of the healthcare universe?

Not if we do a really good job with transparency exposure in social media. You’re opening people up to what’s really going on and then make different decisions. Also, we need to get in the world view wonderful facilities that are the future of healthcare.

I just toured Eskenazi Health in Indianapolis. It’s a safety net public hospital. It’s astounding. They get it. They get where the future’s heading, which is a health and wellness hub where the community is still going to the hospital, but they’re not going to the hospital for the same reasons they used to go.

Hospitals that get it, that see the future as the way it is coming, are going to succeed. The hospitals who don’t get it, there’s a really good chance they’re going to go down.

It’s rare anything takes root in healthcare unless someone makes money from it. The right thing to do doesn’t always win. Does patient involvement have a strong business case?

Yes. We in the past have not looked at the potential the facility has. We were all about, “Fill the beds, fill the beds.” That’s not necessarily the future way people are going. 

Videoconferencing, mobile technologies, people wanting to have a health community. Patient communities are really, really skyrocketing. You have to think in a different way. It’s more of like a library hub direction with wellness activities and physical activities. Why can’t there be sick child care? I was in Lawrence, Kansas back when they were doing that back in the 1990s.

There’s different ways that you can make money that are wonderful, legitimate ways to make money that actually helps citizens, as opposed to the system that we’ve had that were incentives for failure. There were incentives for person getting an infection and staying longer. We have to flip that matrix to where healthiness is the incentive.

Putting patients at the center of healthcare is, unfortunately, a big change. For those overwhelmed by the long-term vision, what would be some short-term goals you would settle for?

I often look at the intersection of health and art. That’s one of my focuses. We need way, way more realistic visuals of care. Less stock photography, more painting. More involving regular people into the life of your hospital. 

I would like to see patients — not just a patient advisory council at hospitals, which a lot of them have — on every board and council throughout the entire facility. I’m talking like EMR workflows as well as M&M reports. We need to be part of the conversation. Because what is absolutely beautiful if you do this is that patients can say things that staff can’t. Staff may be thinking it, but politically they’re put in a position where they can’t say it. Their job can be affected. We don’t want to rock the boat. 

Patients, not in a bad way, can say the words, since we’re not hired by the institution, that everybody might be thinking but don’t feel the power to say. Once we’ve said it, all of a sudden things break open. Doors break open and pathways change. 

One of the major things I would love to see is truly embracing us as part of the team. Not a token. Don’t have us design your lobby again. But really, seriously involve us in decision-making processes and get our feedback. That’s a great short-term goal, very doable by next week.

What do you think would happen if you bought a random patient a HIMSS conference badge and said, “Tell me what you think about what you saw there?”

I think that would rock. We should totally do that next year. Let’s have a scholarship fund. We’ll call it the HIStalk Scholarship Fund. We will just take random people and send them to HIMSS. Let’s do it.

I think they would not only feel uncomfortable there, they might actually be angry to see all the machinations that go on behind the scenes that affects them but doesn’t involve them. 

I think you’re right. There’s some people who would be very freaked out. I would recommend a cross section throughout the United States. Since I speak nationally, I do find there’s major regional differences in the way people talk to folks, strangers in crowds and things like that. If we had a good cross section — West Coast, Midwest, South, East — attend HIMSS, that would be spectacular. Since it’s in Chicago this coming year, it can be an entire concept since that’s the middle of the country. I would totally be behind you on that.

Did you see any technology in the exhibit hall that excites you in being able to allow patients to get more involved in their care and see their own information?

This year I felt HIMSS wasn’t showing a lot of new product. I thought HIMSS was truly embracing the stuff they were introducing as new products a few years ago. Now mobile health wasn’t like this weird new thing of will it work, but pretty much an accepted reality, which that was really great to see.

I don’t know if you saw my painting, HIMSS and HERS, that I painted at the event. I was still frustrated by the way larger demographic that is male than female at HIMSS. I even went by a booth where the women were complaining about their heels. I said, “Why don’t you just wear sensible shoes?” They were like, “Well, you know, we have to wear nice clothes because somebody could come to the booth and see us not dressed appropriately.” Whoa, is this the 1950s? Do you really think you have to be a booth babe when you’re just as competent at technology as all these guys that are in the space?

I heard that HIMSS had some resistance to bringing you this year because of cost even though they’ve helped you out in years past.

Well, they invited me to attend. They said they had no funding for travel or lodging.

You’re self-funded, right?

Yes. I don’t have an organization behind me. I started a Gittip fund, a crowdsourcing, sustaining model which is pretty cool. I was very excited. I had never seen that before. To help pay for me being at HIMSS. 

Between my babysitting fees and going there, I spent close to a thousand dollars just getting there. As patients, we aren’t being paid back by our business to be there because there isn’t one. It is one of those things that can be a hardship. That’s why I was really excited to see Chicago’s coming up, because at least it’s in the middle of the country and it’s easier to fly there so it’s not so much of a hardship to be part of the experience.

Not that your role wasn’t substantial this year because they at least did put you on the patient engagement stage, but what do you see as your involvement next time?

Hmm. I’d love to be on a main stage. That would totally be great. That hasn’t happened yet. My goal is one day to keynote at HIMSS. I’m sure it will happen. It’s just a matter of time.

How did you feel that the opening keynote, the most important speaking slot at HIMSS, went to an insurance company CEO?

It was sort of an odd choice. I think it might have been partially because of the Affordable Care Act kind of year. They thought that talking to someone from the industry, especially the insurance industry, would make a lot of sense in this timeframe.

I tend not to judge necessarily so much where a person comes from, what business they come from, but whether they are they an amazing speaker. Do they get the space and do they inspire people? I was really excited when Eric Topol’s keynote last year because he gets it. He understands the space. He understands how to inspire.

When people come to a convention or a conference, they’re not just coming there for the most current information and to get the good vendor deals. Those are really important things. But they’re also going there to recharge, to have the energy to go into next year and be better than they were the year before.

At times, it seems that HIMSS has lost sight of this. Why don’t we just stay home? We can get good deals from home. We go to an event to network with people and to recharge our soul. I look forward to embracing that more deeply in the future.

What would you say to healthcare software vendors?

I want you to think of your parent in that bed or your child or your wife or your husband when you’re designing software. I want you to think of them. Because every single thing you do should be to make sure they get the best possible care. God, I hope you get to that point before it happens in your very own life. If I can do anything or say anything to get you to emotionally that point where you’re thinking about them while you’re designing, then I’ve done my job.

An article called you the Rosa Parks of healthcare.

Because I’m a regular person. I was a teacher, a special needs mom, and a wife. I worked in a toy store for 16 years. I was normal. I decided that as a normal, regular person, I’m going to stand up to injustice. That’s what Rosa Parks did. I didn’t come from healthcare, but I will do everything I can to make it better for folks who live within it.

What are your thoughts for the future?

One of my major goals is that when we get to Stage 3 of Meaningful Use, we have real-time access to the medical record – nurses’ notes, progress notes, doctors’ progress notes, all labs, all information. That should be available to the hospitalized patient just as much as the discharged patient because the hospitalized patient is spending the most money and they need that information in the most timely fashion. That’s my overarching goal and everything I do is toward that overarching goal.

Any concluding thoughts?

This has been absolutely delightful. I look forward to us putting together the HIStalk Scholarship Fund for next year.

That would be fun. Unfortunately, it’s become somewhat predictable in how conferences handle patients on the podium. The person tells a moving, compelling story about a something bad that happened to them, everybody in the audience feels embarrassed and gives them a standing ovation, then they just wipe the tear from their eye and go  back to what they were doing before that allowed the problem to occur. The emotional tug is there, but nobody can figure out how turn it into something useful.

Years ago, I was a motivational speaker before lunch at a CMIO boot camp. They said, would you like to stay for lunch? I said yes, I’d love to stay for lunch, so I ate lunch with them. Then they said, now we’re going to go into our work sessions and there was that quiet pause moment. I said, can I go to the work session, too? They said, uh, well, yes, it’s going to be very technical, but you’re welcome to come. 

I sat in this giant hall with 40 CMIOs. They were talking about a specific vendor system that I had actually seen. I had gone to the company and seen it person. They were talking about problems with files where they didn’t know who the person was, like recognition of the correct patient. I said, I’m confused, you’re using so-and-so’s system and I know they have the ability to have a visual avatar. Every field can have a picture of the patient right there on the field. Why are you having this problem?

They said, no, it doesn’t, it doesn’t have that feature. I said, yes it does. The only way it doesn’t have it at your hospitals is that somebody turned it off. Everyone’s head turned to the front of the room where the man was standing in the front who’d been speaking and was in charge of these all of these facilities. He said, yeah, I just turned it off because I thought nobody would want that. 

What was so cool about that moment was that I may have been the motivational speaker of the morning, but I had information to give those individuals that they didn’t have prior to that. That’s the beauty of involving patients. They can often be that little hinge pin that can change things.

Did you ever consider developing a checklist of how to make an EMR more patient friendly?

We’ve talked within the Society for Participatory Medicine about concepts like that. I don’t think there’s a uniform thing yet, but it’s definitely something to put on the list of things we need to do.

There’s things about standardization at work and then there’s some things that don’t work regionally, so you want to have an overarching checklist that you can work with. But the really thing that’s important to remember is every institution works a tiny little bit differently. It’s important to catch their unique differences. That’s one of the things that overarching standards often miss.

What do you think about the Open Notes project?

Love it! I was on Twitter back in 2010 complaining about not having open doctor’s notes when the Robert Wood Johnson foundation tweeted to me. I was like, what are you doing? They said, we’re just holding. We’re doing this amazing study. Watch what we’re doing for the next two years. And I did. 

I was so excited at the 2012 press conference when they talked about it. I was there. It was really exciting to paint about it and talk about it. I went to Tom Delbanco and was like, you know, your whole concept made me think of the open note within music, the whole note, the patient is everything, it’s part of the communication with the provider. And Tom Delbanco said you know, it really is that. I’m a musician. The whole concept behind Open Notes was a musical note.

Isn’t that beautiful? It’s one of those things that’s the idea of all of us as provider and patient working together in the totality of ourselves.