Curbside Consult with Dr. Jayne 2/3/14

News is always pretty slow leading up to HIMSS, but I’m pleased to see things are picking up a little. We learned over the past couple of days that Apple leadership met with the Food and Drug Administration to talk about mobile medical apps. Rumor has it that Apple is working on a health-monitoring smart watch. Insiders are debating whether this was a fact-finding mission or a mission to try to push an existing application through the process.

Neither Apple nor the FDA have responded to comments as far as I can tell, but the news just broke on Friday, so there’s still time. We’ve heard the iWatch rumor before from a couple of different angles. Reports last year covered the announcement by Corning Glass Technologies that it had created bendable glass. Other companies have developed Bluetooth watches. Most speculate that the watch will link to an iPhone and will run iOS. Some sources have the number of product developers working on the project at more than 100.

Apple better get it in gear because the recent patent agreement between Google and Samsung might make Android devices more competitive. There are already several on the market. Having the companies play together nicely rather than litigate each other to death will put an interesting spin on things. Samsung also struck a licensing deal with Ericsson that addresses patent issues with GSM, UMTS, and LTE standards for both networks and devices.

As I’ve mentioned before, I’m interested in wearables, but they have to look good. After years on the wards and in the emergency department, I finally gave up my waterproof dive watch for something more grown up looking. Even if it was cool, I don’t think I’d want to wear something that looks like I’ve strapped an iPod Nano to my wrist. I don’t want to look like an old Dick Tracy cartoon. Most of the current offerings fall into that category.

Hot news this week, though, is that there will be new offerings for Google Glass including prescription-ready frames and detachable sunglasses. They’ve also partnered with eye health insurer VSP to train eye care providers how to fit the device and attach it to frames. I might consider trying if it I could get it mounted on my own sassy frames rather than the relatively sci-fi looking standard Google Glass platform.

Speaking of less-fashionable tech, it may not look glamorous but I’m intrigued by Fin, which is a ring-like accessory worn on the thumb to capture gestures meant to control phones, radios, TVs, and other Bluetooth-enabled devices. It reminds me of vintage Bakelite jewelry. I’m not opposed to wearing something a little more towards the geeky side if it’s not intended to replace a “normal” accessory.

A photo on the Fin site showed a child wearing it as a substitute for a gaming joystick. That got me interested in the potential for wearables for children. One interesting device that was shown at the Consumer Electronics Show was Sensible Baby’s SmartOne real-time sleep monitor, which can relay information on a baby’s temperature, sleep position, and movement to a smartphone or tablet. Alerts can be customized for the infant’s developmental stage. Unfortunately, the product’s blog features a photo of a man watching a baby sleeping on his stomach, which flies in the face of current medical advice that babies should be put to sleep on their backs.

I think my favorite wearable tech of the week is June, a monitor for ultraviolet exposure. It can be worn on a bracelet or attached to clothes or other accessories. It ties to a smartphone app and alerts the wearer when a particular UV exposure threshold is reached. I’ve been devoted to my SPF 70 for years because I have a fine line between being ghostly pale and turning into a lobster. If it’s released before summer, I’d consider giving it a try.

What’s your favorite wearable tech? Email me.

Email Dr. Jayne.

Morning Headlines 2/3/14

Castlight Health files secretly for IPO

Castlight Health, a web-based healthcare benefits management platform, files for an initial public offering. The company was founded by Todd Park, former US CTO and Athenahealth co-founder, in 2008 and is rumored to be seeking a $2 billion valuation.

Athenahealth accepts incentives deal, picks Austin for expansion

Athenahealth finalizes plans to open offices in Austin, TX after agreeing to a 10-year $670,000 incentives package offered by the City of Austin and a $5 million in incentive package from the State of Texas.

iWatch + iOS 8: Apple sets out to redefine mobile health, fitness tracking

Apple will introduce a new core health and fitness app in its next iOS release. The app will reportedly track activity, calories burned, vitals, hydration levels, and blood glucose levels. While current iPhone’s do not have the hardware necessary to capture some of the metrics reported, like blood glucose, there have been persistent rumors suggesting that the iWatch may introduce this hardware.

Monday Morning Update 2/3/14

From The PACS Designer: “Re: Apple’s solar iPhone. As we head deeper into 2014 ,you will be hearing details on the next generation of iPhones. The rumored solar iPhone 6 that will be introduced in second half of 2014 will use the tough sapphire outer casing as a solar panel. Apple was granted a new solar touch screen patent that will allow the solar panel to operate without the need of a boost converter, thus providing optionality in the use of a power charge or a solar charge.” I was on the fence between the iPhone 5 and the Samsung Galaxy last time. Now that I’ve used an Android tablet at a fraction of the cost of the Apple equivalent, I think my next phone will be a Samsung. Apple seems to be moving into that mature product phase where everything gets more features and interesting tweaks without blazing any new ground. I’m not willing to pay a premium for that.

From Country Girl: “Re: Stage 2 quality measures. In 2014, quality measures did change for both EP and EH regardless of where you are in the attestation  stages. More measures have to be reported and they must also be tied to the national quality goals. This information was published in the Stage 2 rule, not in December. However,  many of the measures are aligned with PRQS for reporting guidelines. The final rules on PQRS was published in December and the reporting requirements came out December 31. As a result, it appears some vendors are still working on their reporting methodology to incorporate the changes. The problem for many organizations will be understanding where the data has to be recorded in the system to pull properly for reports. We are having trouble getting this information from the vendor as well. If you are trying to attest in the first quarter and don’t have the requirements, you could find the reports do not accurately capture your measures when you get the 2014 reports.”

From HIMSS EHR Association: “Re: Stage 2 quality measures. The required format for electronic submission changed for hospitals (EHs) in November, and in January for physicians (EPs). These changes, as well as Spring 2013 versions of the quality measures which are required for electronic submission, will require further development and implementation at the same time that EHR developers are pushing hard to implement the 2014 certified edition for their customers. More generally, there have been many changes to the methods, requirements, and process to submit CQMs electronically over the last year, and they continue changing. Some changes were promulgated in other CMS rules, such as the annual hospital and physician payment rules, and other changes were not part of rulemaking. And this does not take into account all of the significant changes that have occurred in certification over the last year, as well as additional updates to the CMS quality programs using electronic CQMs. In part because of the extent of these changes, CMS is permitting manual attestation on clinical quality measures for meaningful use in 2014, as has been done through 2013, not just for those in their first year. The EHR Association has been in dialog with CMS on issues with the requirements over the past several months. We understand that CMS will be issuing a CQM submission Tip Sheet within the next couple of months. We welcome any further discussion and explanation of these facts, in order to help our customers understand the current requirements for reporting CQMs to CMS.”

 

From Frank Poggio: “Re: CCHIT and certification. It’s a movie I’ve seen many times. A member organization wants to push the industry forward and generate some revenue, so they get in bed with regulators. Members get upset and view the association as part enemy, so the association wakes up and drops out of the program they helped start. CCHIT had the best tools and knew healthcare, so their interpretation of test rules and steps was sometimes different from the other ATLs. It was clear to me that they were overwhelmed. This had to be a money-losing effort for them given the Stage 2 (2014) complexity and the expanding complexity coming with the new 2015 Test Edition. Interestingly, all the remaining ATLs are non-healthcare companies and are learning the healthcare nuances as they go along. That should make for some interesting results.” Certification was created to reduce the risk of buying an EHR, which it arguably hasn’t done since the biggest risk isn’t misjudging functionality that you can plainly see or lack of interoperability that you don’t care about, but rather the possibility that your vendor will stop delivering high-quality enhancements and support. Which ironically some have because they are off chasing the government’s other “optional but not really” programs, Meaningful Use and ICD-10. Plenty of certified EHRs have unhappy customers, inadequate R&D budgets, and crappy support. You’ll see a bunch of them opt out of not only certification, but the EHR market in general as the HITECH teat dries up and those with no particular healthcare allegiance wander off seeking greener pastures.

From Albi Qeli, MD: “Re: EHRs. As a computer friendly practicing physician, I find the current vintage EHR software not only inadequate, but disgusting. The fundamental problem is that the software is not designed around physicians and patients’ requirements. Current systems try to replicate the paper forms that they are trying to replace, thus recreating a very faulty system and adding a few other defects to it. Add in the mandates and the penalties, and EHR has now become a dirty word. In every other field of human endeavor, computers solve specific problems and increase productivity. In a physician’s office, the EHR creates new problems (hackable, insecure, expensive, unwieldy, data silos) and increases staff requirements. All in the name of progress. People like me might be able to solve some of the practical and technical issues, certainly in order to have a workable efficient record keeping system for use in my own clinic. But such a system would not satisfy Uncle Sam.” As I’ve said many times, medicine is the only area in which the highest-paid resource is expected to perform data entry into a system whose benefit to them personally is coincidental at best. The EHR at its worst is a manual entry black box recorder for the government and insurance companies. Doctors who took HITECH money as a bribe to impulsively buy and use EHRs they now hate hasn’t helped push the market in a doctor-pleasing direction. Today’s systems reflect the financial reality for insurance-accepting practices — your customer isn’t the patient and you aren’t the boss. It would be interesting to review the systems used by cash-only practices, assuming they use any at all.

From One Tin Soldier: “Re: Best in KLAS. We won but weren’t included in your list.” The company in question didn’t actually win Best in KLAS, but it’s confusing enough to warrant an explanation. That title is reserved for products listed in the first two pages of the “Best in KLAS 2013” report, which lists solutions that “lead the software and services market segments with the broadest operational and clinical impact on healthcare organizations,” however KLAS defines that. Less rationally, the same report also includes Category Leaders 2013, defined above, but those don’t earn the title of Best in KLAS. Allscripts is the only vendor I’ve seen so far to incorrectly label a Best in Category win as Best in KLAS (had they included the word “in” after “named,” the headline above would be correct.) All of this is needlessly confusing – KLAS should use the term Best in KLAS for only the award, not as the title of a report that also includes other results. Either that or extend the Best in KLAS label to the category winners as well. The way they are using that title now seems a bit fuzzy, but then again some folks say that about the entire KLAS process. 

Upcoming Webinars

February 5 (Wednesday) 1:00 p.m. ET. Healthcare Transformation: What’s Good About US Healthcare? Sponsored by Health Catalyst. Presenter: John Haughom, MD, senior advisor, Health Catalyst. Dr. Haughom will provide a deeper look at the forces that have defined and shaped the current state of U.S. healthcare. Paradoxically, some of these same forces are also driving the inevitable need for change.

February 12 (Wednesday) 1:00 p.m. ET. Healthcare CO-OPs and Their Potential to Reduce Costs. Sponsored by Health Catalyst. Presenters: David Napoli, director of performance improvement and strategic analytics, Colorado HealthOP and Richard Schultz, VP of clinical care integration, Kentucky Health Cooperative. Consumer Operated and Oriented Plans (CO-OPs) were established by the Affordable Care Act as nonprofit health insurance companies designed to compete in the individual and small group markets. Their intended impact was to provide more insurance options for consumers to pay for healthcare.

February 13 (Thursday), 12 noon ET. Advancement in Clinician Efficiency Through Aware Computing. Sponsored by Aventura. In an age of information overload, a computing system that is aware of the user’s needs becomes increasingly critical. Instant-on roaming for virtual and mobile applications powered by awareness provides practical ways to unleash value from current HIT investments, advancing efforts to demonstrate meaningful use of EHRs and improve clinical efficiencies. The presenters will review implementation of Aventura’s solution at Orange Coast Memorial Medical Center.

A HIStalkapalooza update: registration has closed and invitations will go out on Tuesday. Demand was high, so unfortunately more than half of those who signed up will be getting a “sorry, we’re full” email instead. We always give priority to providers, who registered in overwhelming numbers. Please don’t email Inga or me if you didn’t get an invitation because there’s no secret stash of them for us to hand out no matter how much we like you.  

Eighty percent of poll respondents check their work email in the evening and on weekends, with 20 percent checking it at least hourly. New poll to your right: when were you last promoted?

My latest grammar peeves: (a) people who start sentences, especially written ones, with the word “so”; (b) the bizarre omission of the word “of” following “couple,” as in, “So I had a couple beers.”; (c) rampant overuse of pointlessly emphatic words such as “really,” “actually,” and “frankly,” which I excise by the dozens from some interview transcriptions.

Welcome to new HIStalk Platinum Sponsor InteHealth. The Malvern, PA-based employee-owned company connects patients, doctors, hospitals, and health plans cost effectively. InteHealth Exchange is a cloud-based, vendor-agnostic integration platform that is flexible and extensible; rapidly deployable; comes complete with a clinical data repository, data map library, and a messaging and alerts engine; and is MU2 ready. The company’s certified patient portal allows patients to view their records, make payments, schedule visits and tests, receive reminders, request refills, and share and download information. It is Stage 2 certified, integrates with 100 EHRs, has full CCD capability, and connects to the Direct exchange. The physician portal allows remote access and eliminates faxing and calling nursing and medical records for information. Hospitals can use InteHealth Exchange to solve problems related to information management, ACO care delivery, and discharge management. The company’s solutions are used by 1,900 sites and 20,000 physicians each year, processing 82 million transactions. Thanks to InteHealth for supporting HIStalk.

TeraMedica is supporting HIStalk as a Gold Sponsor. The company’s Evercore Clinical Enterprise Suite connects and manages a healthcare system’s digital image infrastructure all the way from the modality to the EHR and clinical desktop. It is vendor neutral, flexible, and scalable as an enterprise archive that manages both DICOM and non-DICOM (photos, videos, PDFs) clinical content. Its architecture features a scalable database, parallel application services running on enterprise-scale servers, n-tier storage, image storage and distribution rules, and tools to migrate legacy data, all architected to handle the explosion in imaging volume that’s coming, all with a lower total cost of ownership and true vendor independence. Thanks to TeraMedica for supporting HIStalk.

I found this YouTube video describing Duke’s TeraMedica VNA setup that’s integrated with Epic. It’s a very good overview of image management by Christopher Roth, MD, assistant professor of radiology and director of imaging informatics strategy at Duke Medicine.

Starting this week, you’ll see a single, short-term ad for various companies at the top of the HIStalk page, to the right of the logo. I’ve always turned down requests for “special” ads like this, but I agreed under these terms: (a) I’ll donate a big chunk of the proceeds to DonorsChoose to support students and teachers in need, reporting back here the projects that we (as HIStalk readers) funded as a result; and (b) it will be single ad that will run for only three days at a time so we don’t get tired of looking at it. Companies always want a burst of extra exposure for specific events, especially right before the HIMSS conference, and I can live with that since it will support classrooms.

Here’s a photo tweeted out by AMIA VP Jeff Williamson from iHealth 2014. This is like one of those fan convention photos of all the “Star Trek” captains together, only for a different variety of nerd: former National Coordinators Brailer, Kolodner, Blumenthal, and Mostashari. I would welcome a report on the conference if you attended. Orlando is in the low 80s every day, so I’m sorry to have missed seeing all of those informatics people in shorts and tee shirts.

A rumor suggests that Apple’s iOS 8 will include Healthbook, a fitness tracking app that will not only measure steps taken and calories burned, but also blood pressure, heart rate, and blood glucose (although the rumor doesn’t say how it would collect glucose levels.) The app will supposedly allow the user to enter medication schedules to allow the iPhone to issue reminders. All of that is related to the upcoming iWatch wearable computer. Apple has hired several health experts in the past year and has met with the FDA on undisclosed topics.

Athenahealth chooses Austin, TX for its R&D office, pledging to create 600 jobs that will pay an average salary of $132,000. The company will receive $680,000 from the city and $5 million from the state in incentive payments over 10 years to occupy the Seaholm Power project that’s under construction on West Cesar Chavez Boulevard. 

Vince Ciotti is one of the most hilariously cynical people in healthcare IT, so even he recognizes the irony in this HIS-tory episode in which he lustily guzzles the Epic Kool-Aid right at the factory. Epic fans will not be surprised that Judy invited Vince to present some industry history to several thousand Epic employees too young to remember it. This is a great episode that also includes a fun fact: one of Judy’s early mentors was Neil Pappalardo of Meditech, so when she started Human Services Computing in 1979, she targeted only large hospitals to avoid stepping on Meditech’s turf.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

HIStalk Interviews Mike Merwarth, CEO, Aperek

Mike Merwarth is CEO of Aperek of Raleigh, NC.

Tell me about yourself and the company.

My dad was a physician. He went to Duke. My mom was a nurse. She went to Duke. My wife was a nurse. She’s still my wife, but she’s no longer practicing. My older daughter is getting her RN degree in May. My younger daughter is taking the MCAT this Thursday. All of which is to say, I have been immersed literally since the minute I was born over at Duke in a healthcare’s aura. It affected my life and continues to affect my professional life as well.

I was diagnosed with adult onset type 1 diabetes at 41 out of the blue. Every quarter I go over to Duke to see an endocrinologist. Between that and customer visits, I’m in hospitals a lot. The potentially strange thing about that is I feel at home in hospitals. That’s why I bring the level of commitment and passion I do to Aperek.

Aperek is focused on the healthcare supply chain. We do not offer services or product to any other industry other than healthcare, which distinguishes us from some of the other vendors. We changed our name from Mediclick to Aperek this past November.

Who’s buying your systems and why do they choose Aperek instead of non-healthcare specific vendors?

In the ‘90s when we were still part of Global Software and in the the early 2000s after we had spun off and formed Mediclick, hospitals were buying ERP solutions. General ledger, accounts payable, fixed assets, payroll, human resources, and last and unfortunately least, materials management. That would be the typical package.

It was largely a financially-driven decision process. The materials management system was what we call in this industry a drag-along, in many cases. In other words, they would — not throw it in for free, that’s a little strong – but they would offer it as part of the package at effectively no additional charge.

It’s also interesting that two of the companies that now have significant market share brought a distribution system into healthcare from non-healthcare markets or industries — specifically distribution and retail — and added some capabilities like par management. Frankly, they were the only game in town and they did an admirable job of capturing market share.

Those systems were OK for a number of years – let’s call it a decade — where the fundamental job was to manage a perpetual inventory of stock items, replenish the par levels on the nursing floors, and do the purchasing. All the clinical areas largely did their own buying.

That limitation of focus on the scope of what they needed to do for the hospital was  fine. Today, it’s not fine because now there’s a cost crisis. There’s a bunch of crises we could talk about, but there’s certainly a crisis of getting costs out of the system. One of the remaining ways to do that is in the supply chain. These systems and companies are not adamantly and singularly focused on doing that, at least in the way I think they should be.

In hospitals, the real experts and professionals in materials management are buying tissues and bedpans, while people with no training are buying the most expensive items that represent most of the overall cost.

That’s the irony or tragedy, pick your word. Roughly 80 percent of dollar value is purchased in the clinical areas. These multi-million dollar systems that were painful to install preside over only 18 percent, give or take, of the dollar value of the product that comes in the door. That’s a general statement and there are exceptions, but you are absolutely right.

How does your system control those higher-cost items that clinicians buy?

Technically, there are capabilities in these products to manage multiple inventories. You can have pars up in the OR, for example, and they could theoretically be managed by the decent systems out there. But there’s a significant usability issue that comes with the the necessary interaction at certain points with the clinicians. They rightfully resist anything that unnecessarily distracts them from their main job, which is taking care of patients. That’s where the usability of the traditional materials management functionality falls completely apart.

The reason I would advocate buying Aperek supply chain solutions would be, number one, there’s merit to focus. We live and breathe healthcare, specifically the acute care market but we also have several clinics as clients. Our clients span from single 200 bed-hospitals up into the 20- and 30-hospital IDNs.

Second, we recognize that the 80 percent that is spent on the clinical area is where the focus needs to be. I have referred to it as the Wild West, with stories about OR nurses hiding product up in the ceiling tiles and the bottom desk drawers. I know; I’ve actually seen that. It happens because they ran out one time and there are negative consequences to that. Maybe it’s just the surgeon yelling at them. But for whatever reason, they’re not going to run out again. There are millions of millions of dollars of inventory in the clinical areas that, if properly managed, does not need to be there.

Fundamentally, what this company is working very hard to complete is a set of capabilities that allow the supply chain professionals to do their job in the clinical areas. That requires some new tools that aren’t available from most vendors. Most importantly, it allows the clinicians to do the supply chain management they need to do in as non-disruptive a way as possible. We’re obsessively focused on the user experience here in what we’re developing right now.

A specific example is a product that we’re just now installing in two initial sites called Pulse. It’s implant tracking. It’s on the iPad. In my 25-plus years in this business, I have never bonded with clinicians like I have in the last year because of this product. I have never been so gratified by the excitement that I see that they have a visceral attraction to the ways that we allow them to record product.

With another company in the industry, it’s all barcode driven. We’ve got a Bluetooth barcode capability. It’s great. It reads all the bar codes and it’s intelligent and can discern what lets you go where. But the nature of implants is that there are screws and plates, thousands of parts. Those parts are not going to have bar codes associated with them in the near future. It’s going to take a new and cheaper technology to either embed or somehow associate those with a bar code that could be read, or RFID or whatever it is.

Those are three-figure to four-figure items relative to cost. They have to be recorded. Today, they’re often recorded on sheets of paper. They’re recorded on sleeves of surgical gowns. They’re yelled out to the surgical nurse to hand write.

What we have provided is a multitude of ways that they can quickly record the usage of the product that doesn’t have a bar code. Once the tension of the case is over, you can quickly come back and resolve the identity of the product that’s been used. You can have a little Bluetooth headset on and speak a description and the translation software in the iPad writes it out. You can go in and scribble it and hand write it. You can take a picture of it. You can do a combination of those things and move on, but you know you’ve got enough data such that when the case is over, you can come back and capture it.

Hospitals that are trying to cut costs, which is pretty much all of them, usually look at labor and then try to do something with patient utilization. Do they pay less attention to supply chain other than just trying to negotiate favorable pricing? Are they missing something?

Tragically, yes. I’m not sure I understand why. It’s not simple,  but it’s doable and it’s a progression. Nobody’s going to reach perfection in my lifetime. It’s going to take some naming standards like GS1 to come into fruition before perfection can even be approached. But there’s a lot of things that can be done.

If you think about the flow of product in the OR, it’s largely driven by physician preference cards, the list of stuff that they want on the case card that goes into the room. Those physician preference cards are maintained in the OR system, when in fact they’re the key to standardization. Elimination of product that goes up the clean elevator and down the dirty elevator every day. Basically 50 percent of the product on case carts is never used. It’s put on there just in case.

There are so many opportunities to reduce SKUs, to standardize on the implant products that cost thousands of dollars, and to lower the cost of the inventories that are managed in these areas if it’s put in the hands of people whose job it is to do that. You can’t expect the clinicians to do it. They’ve got their hands full already. Everything we’re doing is devoted to that.

Are hospitals looking at choices they didn’t find politically expedient before now that they’re under the margin gun, such as perpetual inventory and true cost accounting?

Sophistication in areas like cost accounting will continue to be looked at and be increasingly pertinent. But the example that immediately comes to mind is in product standardization. For example, you’ve got five orthopods who use three different knee implants, three different companies, because that’s what they were trained on in school. If they get together and realize that the outcomes of all three are virtually identical and the cost of one of the three is significantly less than the other two, and either through competitive motivation or collaborative motivation they agree to standardize, they’ve certainly simplified inventory management.

But from a purchasing perspective, and this is our product called Ellipse, you can standardize to say a single vendor for total knees. Then you can commit unprecedented volume to that particular supplier. That means a tremendous amount to them and you’ll get better pricing. There are those types of things that can be done with the right tools. The good news is for us, selfishly speaking for the growth prospects of Aperek, it hasn’t been done.

As hospitals acquire practices and also each other and take on financial risk, how do you see that dynamic changing supply chain and contract management?

The surgeons clearly have a direct interest in improving outcomes, standardizing outcomes, standardizing treatment protocols, and standardizing product. It’s in their self interest because in the ACO environment, to the degree that ever takes real hold, they will be getting paid out of the pot of money that is left over when the costs are subtracted from the reimbursement.

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

We’ve got a supply chain system today, as well as a GL and AP, that are ranked number one by KLAS and MD Buyline. They’ve been number one for five years. We’ve got that spend analysis tool that I mentioned that can show you volume and market share. We’ve got the Pulse product going in to its initial sites. That Pulse product will in the next six months be expanded into full product capture so you can get a full product cost per case.

As we progress into that, I’d like to take control of the preference cards and manage those. Put those capabilities in the hands of the supply chain professional. Along the way, I want to optimize the management of product inventory in the clinical area. I can do that with much of my existing supply chain system logic.

We’ve got a lot of the pieces, but we want to bring — you could say best practices — harmony, if you will, into the clinical arena and cut significant, millions of dollars out of the expenditure that’s taking place there today. Not just by reducing the price of things, but by standardization of products and standardization of treatment protocols.

Morning Headlines 1/31/14

DoD Healthcare Management Systems Modernization (DHMSM): Draft Request for Proposal

The DoD publishes an open solicitation for a new EHR that will replace all of its existing legacy systems. The usability testing scenario’s outlined within the proposal describe a medic calling up evidence-based guidelines and documenting care while providing emergency treatment to a wounded marine in the field. Subsequent scenarios describe field surgeons using the system to coordinate care delivery once the Marine arrives back at the forward operating base, then medications being administered by nurses during an air medevac to a larger hospital in the US, and finally the transfer of care from the DoD to a VA rehabilitation facility. The last scenario requires vendors demonstrate the exchange of medication lists and narrative care summaries between DoD/VA facilities.

Thousands of providers rank healthcare software and services in annual Best in KLAS report

athenaHealth dethrones Epic from the top spot on the Best in KLAS 2013: Software and Service report. Epic had held the number one position for the past eight years.

eHealth Exchange Survey Reveals Dramatic Increases in Participation and Online Transactions

The eHealth Exchange, a non-profit, public-private HIE collaborative, reports that its membership has grown to include 800 hospitals, 6,000 mid-to-large medical groups, 800 dialysis centers, and 850 retail pharmacies.

Hospital’s new IT system ‘has increased waiting times and led to lost patient data’

In England, staff at Croydon University Hospital are blaming their recent Cerner go-live for increased waiting times and lost patient information. The university’s director of quality maintains that the implementation of Cerner went well in technical terms, but members of the board were not convinced and are insisting that "patient care has definitely suffered."

News 1/31/14

Top News

The Department of Defense opens bidding to replace all of its EHR systems, saying the new system will use off-the shelf technologies running on ONC-approved standards. The VA solicited bids Tuesday for the next step in its replacement of VistA. Evidence is scant that the two groups plan to work together to implement a single EHR systems as mandated by the President and Congress, with their only obvious common ground being a willingness to separately enrich the usual government contractors with massive taxpayer dollars.

Reader Comments

From Silversand: “Re: MU Stage 2 CQM measures. In meeting with our vendor, we were told they can’t submit them electronically yet because the standards changed in December and their software hasn’t been updated. I can’t find anything on a standards change. Is this true? Are other vendors running into the same issue? I would love to know what your readers think.” So would I (cue readers to chime in.)

From Ockham: “Re: vendor market share. KLAS estimates by bed size, i.e. ‘Meditech has 18 percent of hospitals over 200 beds.’ This is meaningless. It should be expressed as the number of beds in all hospitals using a system, which would be easy to calculate using information from HIMSS Analytics. Having a lot of beds means having a lot of clinician users, which pushes product development. Epic blasted into a leadership position is because having 400 hospitals that are large and larger trumps having 2,000 hospitals that are small (Meditech).” That’s true, as long as your product is suitable for large hospitals and you have the competence to sell it to them. Epic’s timing was perfect because soon those big, Epic-using hospitals will have bought all the smaller ones and replaced their incumbent systems, putting Epic in hospitals that couldn’t have afforded or supported it on their own. It’s like the political system – you’ll see all kinds of parties on the ballot, but only two of them get a significant number of votes.

HIStalk Announcements and Requests

A few HIStalk Practice highlights from the last week include: physicians prefer smartphones to tablets to perform most professional tasks. Practice Fusion offers free Google Chromebooks to new users. CMS reminds EPs of pending deadline to attest to MU for the 2013 Medicare EHR incentive program. In part three of our series, HIT vendor execs share details about technologies on their company’s roadmap for the next 12-18 months. Thanks for reading.

Welcome to new HIStalk Platinum Sponsor Optimum Healthcare IT. The Jacksonville Beach, FL-based full-service consulting firm provides expert consultants at competitive rates. Services include EHR deployment (all major vendors); integration services (interface development and integration engines); staff augmentation (program directors, project managers, application builders and testers, clinical experts, analysts, security experts, trainers); security and identity management; and regulatory guidance (Meaningful Use, ICD-10.) The company provides small-business flexibility with large-business stability, but without the high cost. Thanks to Optimum Healthcare IT for supporting HIStalk.

Upcoming Webinars

February 5 (Wednesday) 1:00 p.m. ET. Healthcare Transformation: What’s Good About US Healthcare? Sponsored by Health Catalyst. Presenter: John Haughom, MD, senior advisor, Health Catalyst. Dr. Haughom will provide a deeper look at the forces that have defined and shaped the current state of U.S. healthcare. Paradoxically, some of these same forces are also driving the inevitable need for change.

February 12 (Wednesday) 1:00 p.m. ET. Healthcare CO-OPs and Their Potential to Reduce Costs. Sponsored by Health Catalyst. Presenters: David Napoli, director of performance improvement and strategic analytics, Colorado HealthOP and Richard Schultz, VP of clinical care integration, Kentucky Health Cooperative. Consumer Operated and Oriented Plans (CO-OPs) were established by the Affordable Care Act as nonprofit health insurance companies designed to compete in the individual and small group markets. Their intended impact was to provide more insurance options for consumers to pay for healthcare.

February 13 (Thursday), 12 noon ET. Advancement in Clinician Efficiency Through Aware Computing. Sponsored by Aventura. In an age of information overload, a computing system that is aware of the user’s needs becomes increasingly critical. Instant-on roaming for virtual and mobile applications powered by awareness provides practical ways to unleash value from current HIT investments, advancing efforts to demonstrate meaningful use of EHRs and improve clinical efficiencies. The presenters will review implementation of Aventura’s solution at Orange Coast Memorial Medical Center.

Acquisitions, Funding, Business, and Stock

GNS Healthcare, a provider of big data analytics products and services, completes a $10 million Series B financing round led by Cambia Health Solutions.

VMware reports Q4 results: revenue up 20 percent, adjusted EPS $1.01 vs. $0.81., beating earnings estimates.

CommVault releases Q3 results: revenue up 20 percent, adjusted EPS $0.54 vs. $0.39, beating estimates on both.

Quest Diagnostics announces Q4 results: revenue down one percent, adjusted EPS $1.03 vs. $1.01, beating estimates on both.

McKesson announces Q3 results: revenue up 10 percent, adjusted EPS $1.45 vs. $1.44, beating revenue expectations but missing expected earnings of $1.84. CEO John Hammergren said the results of Technology Solutions was disappointing (revenue up 6 percent, margins 8.55 percent) because the company had to  “take action in response to the anticipated timeline for Meaningful Use 3 and to size our organization in Horizon Clinicals appropriately” and took a $42 million restructuring charge to reduce headcount.

CPSI anounces Q4 results: revenue up 7 percent, EPS $0.90 vs. $0.83.

Sales

Texas Children’s Hospital selects OpenTempo’s scheduling and workforce management solution.

Valley Health (VA) selects Capsule Tech to integrate medical devices in operating rooms with Epic EMR.

Greater Regional Medical Center (IA) implements PeriGen’s PeriCALM fetal surveillance system.

People

Cumberland Consulting Group promotes Greg Varner and Mike Penich from principals to partners.

Community Health Network (IN) names Ron Thieme, PhD (AIT Laboratories) chief knowledge and information officer.

Population health management vendor Welltok hires Michelle Snyder (Epocrates) as chief marketing officer and Vance Allen (Pearson eCollege) as CTO.

Charles Denham, MD, accused by the Department of Justice of accepting $11.6 million in kickbacks from CareFusion to promote its skin disinfectant product at the National Quality Forum, resigns from the board of The Leapfrog Group. The DOJ has assessed a $41 million fine against CareFusion; Denham says the allegations are false. There’s a healthcare IT connection: when Dennis Quaid started limelighting  for patient safety after his newborn twins were overdosed with heparin at Cedars-Sinai (he had breezy good intentions, but minimal knowledge even for an actor), HIMSS put him on stage at the 2009 conference and inexplicably donated to his foundation. Dennis apparently found another shiny object and merged his foundation a year later with Texas Medical Institute of Technology, which was founded and run by Chuck Denham (who didn’t live in Texas, but instead in a $14 million oceanfront estate in Laguna Beach, CA.) Denham claimed that TMIT’s “national research test bed” involved 60 percent of US hospitals, although few people seemed to have heard of it. the other healthcare IT connection is that CareFusion sells Pyxis drug dispensing machines and Alaris smart IV pumps, just in case your hospital feels the urge to buy something from a company willing to bribe its way to the bedside.

Microsoft’s board is rumored to be preparing to name Satya Nadella, VP of the company’s cloud and enterprise group, as CEO as soon as Friday. The board is also discussing the possibility of replacing Bill Gates as their chairman with an unnamed candidate. Nadella would be the company’s third CEO following Gates and Steve Ballmer.

Announcements and Implementations

More than 800 hospitals and 6,000 medical groups are participating in the eHealth Exchange, a group of government and non-government organizations that agree to support interoperability standards to exchange information.

Scott & White Memorial Hospital (TX) goes live on Epic.

Greater Baltimore Medical Center (MD) goes live with the PatientRoute Systems patient flow solution.

Other

Members of the governing board for the UK’s Croydon University Hospital raise concerns that the hospital’s new Cerner system has led to increased waiting times and has lost patient information. Despite Cerner’s assurances that the system issues have not harmed patients, at least one board member expressed doubts:

You say that no harm has occurred, but while we’ve had no direct incident so far, patient care has definitely suffered. You talk about increased waiting times and there’s a risk that harm may occur because of the difficulty in getting in touch with clinicians who actually know what is going on with the patient. I’m very concerned from a quality point of view that our main provider has a serious problem with its information systems.

CCHIT announces that it will no longer offer ONC testing and certification and will change its business model to become a certification consulting firm. CCHIT recommends that its customers work with ICSA Labs for future testing and certification services.

Federal prosecutors charge former Allscripts director of internal audit Steven M. Dombrowski with insider trading, alleging that in 2012 he used a secret account in his wife’s name short MDRX shares ahead of a poor financial report, netting him $286,000.

The Wall Street Journal describes the analytics challenges of Memorial Hospital of Gulfport (MS), which can’t get much useful information from its separate inpatient and outpatient EHRs now, but hopes things will improve after a Cerner go-live in March followed by implementation of Health Catalyst analytics afterward. The hospital selected Allscripts EHR/PM in 2009.

In Israel, the health ministry launches a medical data sharing project for health fund clinics and hospitals.

Recently released documents from the antitrust lawsuit against St. Luke’s Medical Center (ID) reveal that its merger with Saltzer Medical Group could have raised pricing for outpatient visits by 60 percent and increased insurance rates by about 30 percent. Last week a federal judge ordered St. Luke’s to divest itself of Saltzer, saying the acquisition would give the health system an unfair bargaining position with insurance companies.

Epic is unseated for the first time since 2008 as the top overall vendor the 2013 “Best of KLAS” awards, with athenahealth leading the pack. Winners (with links to HIStalk sponsors) include

Athenahealth athenaCollector (practice management 1-10 physicians)
Athenahealth athenaCollector (practice management 11-75 physicians)
Athenahealth athenaCommunicator (patient portal)
CareTech Solutions (IT outsourcing, extensive)
CareTech Solutions (IT outsourcing, partial)
Cerner (application hosting)
Cerner CommunityWorks (community HIS)
Cornerstone Advisors (planning and assessment)
Cymetrix (extended business office)
Dolbey Fusion Speech (speech recognition)
Epic Care Everywhere (HIE)
Epic EpicCare (acute care EMR)
Epic EpicCare Ambulatory (ambulatory EMR 11-75 physicians)
Epic EpicCare Ambulatory (ambulatory EMR >75 physicians)
Epic OpTime (surgery management)
Epic Radiant (radiology)
Epic Resolute (patient accounting)
Epic Resolute/Prelude/Cadence (practice management >75 physicians)
Epic Willow (pharmacy)
Impact Advisors (clinical implementation principal)
J2 Interactive (technical services)
McKesson ERP Solutions (financial/ERP)
Merge Healthcare Cardio (cardiology)
Precyse (transcription services)
PwC (revenue cycle transformation)
QlikTech QlikView (analytics)
Quest Diagnostics ChartMaxx (document management)
Rays (teleradiology services)
Sagacious Consultants (clinical implementation supportive)
Sectra PACS (PACS)
Siemens Novius Lab (laboratory)
SRSsoft EHR (ambulatory EMR 1-10 physicians)
Thornberry NDoc (homecare)
Unibased USA RMS (enterprise scheduling)
Wellsoft EDIS (emergency department)
ZirMed (claims and clearinghouse)

Weird News Andy says this doctors has it. A New Zealand doctor spearfishing with friends is attacked by a shark, fights it off with a knife, stitches his leg wound on the beach, and heads to a bar for a beer. He goes to the hospital for more stitches only after bar employees notice him bleeding onto the floor.

WNA uses his less-cynical alter ego “Wonderful News Andy” in this story of medical dedication. A neurosurgeon working at an Alabama hospital is called to a cross-town hospital to perform emergency brain trauma surgery. His route is blocked by snow-related traffic, and as his cell phone signal fades, the second hospital’s neuro intensive care unit nurse hears him say, “I’m walking.” Which he did, covering six miles in a trek of several hours and then heading straight to the OR with the patient, who had a successful outcome.

Sponsor Updates

• HIStalk sponsors winning KLAS Category Leaders 2013 awards include Siemens (Soarian Clinicals), GE Healthcare (Centricity Perioperative Anesthesia), Merge Healthcare (cardiology hemodynamics), Elsevier (CPMRC), Wolters Kluwer (Sentri7, MediRegs Comply/Track), PatientKeeper (Physician Portal), 3M (360 Compass, Codefinder), Allscripts (EPSi), Phillips (IntelliSpace Portal), lifeIMAGE (image exchange), GetWellNetwork (interactive patient system), iSirona (DeviceConX), MedAptus (Pro Charge Capture), Passport (IntelliSource), TeleTracking (Capacity Management Suite), McKesson (EnterpriseRX Outpatient), Xerox (Midas+ Solutions, financial ERP implementation services), Fujifilm (Synapse RIS), Craneware (Bill Analyzer, Chargemaster Toolkit), Imprivata (One-Sign), API Healthcare (Staffing and Scheduling, Time and Attendance), VMware (vSphere), Emdeon (eligibility services), Encore (go-live support services), and Aspen Advisors (ICD-10 consulting).
• McGraw-Hill Professional partners with RelayHealth to make the AccessMedicine online medical platform available to providers.
• AirWatch adds a professional certification level to its Enterprise Mobility Certification Program.
• Besler Consulting publishes a white paper focused on Medicare Transfer DRG underpayments.
• AT&T sponsors a series of articles that explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans.
• ReadyDock founder and president David Engelhardt discusses when and how to clean and disinfect mobile devices in a blog post.
• Extension Healthcare founder and CEO Todd Plesko explains the future of secure messaging app in a blog post.
• Passport Health posts a white paper discussing the benefits of front-end patient financial patient triage.
• A Virtelligence case study profiles Allina Hospitals and Clinics (MN), which implemented Epic with support from the company’s consultants.
• SimplifyMD publishes proof statements highlighting various successes and stats as of the end of 2013.
• QPID offers a case study highlighting Massachusetts General Hospital, which saw improvements in clinician productivity, higher throughput in the GI suite, and improved outcomes by avoidance of adverse events following the implementation of QPID’s automated record review.
• Predixion will provide academic institutions with the free use of Predixion analytics software for students and teachers of data science.
• NVoq highlights what’s new in its version V8.3.
• Culbert Healthcare Solutions discusses the optimization of Epic work queues in a company post.
• LifeIMAGE offers a series of customer testimonials highlighting their use of lifeIMAGE technology for image sharing.

EPtalk by Dr. Jayne

Mr. H published a rumor earlier this week about CCHIT leaving the EHR certification business. As many HIStalk rumors are, it was confirmed a few days later. CCHIT cites the complexity of testing and changing federal requirements as contributing factors. They plan to move into the consulting business.

This seems to be the big news of the week, which isn’t surprising considering we’re in the run-up to HIMSS. Major vendors aren’t going to be announcing much of anything, and instead will be saving any upcoming news for release at the big show.

I guess I’m also not surprised to see CCHIT exiting the testing business. Keeping track of the constantly changing testing criteria can’t be easy. I can barely keep track of the provider-based Meaningful Use requirements and the ongoing parade of CMS Frequently Asked Questions that cause ongoing re-interpretation of how we need to comply. If you haven’t seen the testing criteria, I’d recommend taking a look – they make some of the most complex projects I work on look like a cakewalk by comparison.

I know some of the people who participated on our ambulatory vendor’s certification testing team. The process sounds like it’s about the same level of fun as going through med school, trying to make sure you know everything, and then being an intern and having the worst call night ever – sleepless, stressed out, and having to deal with endless minutiae. I would imagine that being on the other side and having to deal with an ongoing parade of vendor teams who are similarly at their wits’ end may not be the most satisfying or stress-free job.

I’m not sure about the direction they’re taking. It seems like the consulting world is already saturated with Meaningful Use advisors, stakeholders, and other thought leaders. They plan to have a “series of summits and events to support that work,” but I’m not sure who will attend. Most of us in the trenches don’t have the budget to attend conferences and meetings we attended in the past and want to keep attending, let alone add other meetings to the docket.

The first CCHIT Summit will be held on Wednesday during the HIMSS conference. It will feature several former National Coordinators reviewing health IT during the last decade. It will be followed by an audience participation session to discuss what role health IT should play in the next decade. If they keep the CCHIT Summit events as part of existing conferences, they will definitely increase their chances for meaningful participation.

Along with the change in mission, CCHIT has restructured its board of trustees and will be replacing the CCHIT commissioners with stakeholder advisory groups. CCHIT was a leader in EHR certification and it will be sad to see them go, but I’d bet they’re not the only one that exits the business. At this point, there are fewer EHRs certified for MU2 than there were for MU1, and as more vendors abandon the Meaningful Use arms race, there won’t be as many products going through the process.

What do you think about CCHIT leaving the certification business? Leave a comment or email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

HIStalk Interviews Dean Sittig, PhD, Professor, UTHealth

Dean F. Sittig, PhD is professor of biomedical informatics at The University of Texas Health Science Center at Houston and a co-author of the SAFER (Safety Assurance Factors for EHR Resilience) Guides that were developed for the Office of the National Coordinator.

Describe the SAFER Guides and their purpose.

Following the IOM report in 2012 on patient safety and health IT, ONC promised that they would create some guidance to help organizations improve the safety and utility of their EHRs. The SAFER Guides were their attempt to do that. They contracted with us to develop them.

What do the Guides contain and  how would you recommend that a hospital or health system use them?

There are some complex organizational structures, but mostly the Guides have about 10 to 25 recommended practices that are very general. Something like, “You need to back up your mission-critical hardware and software.” The Guides also have examples to help people understand what that means, so for a backup, that ought to be an encrypted, offsite backup taken on a daily basis.

There is also a rationale to help people understand why they would do that particular practice. There are a lot of references to link people to different aspects of the scientific literature from where those ideas came from. If the items on the list were either from the HIPAA guidelines or the Meaningful Use guidelines, we link those to give people a renewed emphasis on why they need to do certain aspects.

As to the answer to how an organization would use them, we think that in a large organization, you would convene a multidisciplinary team with someone from IT, some clinical people, some nursing, some of the ancillary services, maybe medical records people. Try to bring all those stakeholders together. Some people know the answers to certain questions and know the nuances of those. In smaller organizations, you’d probably have to contact your EHR vendor or your IT consultant that’s helping you to get the answers to these questions.

It looks like some of the items could be incorporated into an RFP.

While we were doing this, we started out going to a lot of different healthcare provider organizations and talking to them about what they were doing and trying to understand what things were working and weren’t. Some of them, we realized that the EHR vendor really has to do these things. 

When we say something like, “The patient’s name should be on every screen and maybe it should have a picture of the patient,” the EHR vendor has to make that capability available. Then the organization has to implement that capability. You’re right; some of these things are very particular and only the vendors can do them.

How do you think the average hospital would do? Are these stretch goals, or would a hospital that’s competent in IT do fine?

Of the leading organizations — I think about the Scottsdale Institute members, for example, IHC, Mayo Clinic, and Partners in Boston, those kind of places –  I would expect they’re doing between 50 and 75 percent of the recommended practices. Of the 25 percent that they’re not doing, probably half of them they’ve consciously decided not to do them for one reason or another.

Some of these things are still a little bit controversial in terms of whether they’re really a good thing to do or whether an organization can really do them. For example, not allowing a user to open more than one chart for a patient on the same computer terminal. Most people would agree that that’s a good safety measure and would reduce wrong patient orders. But most clinicians would say, “I can’t survive if I can’t look at two charts at once.” 

Then it becomes a push-pull at the organizational level of whether the organization’s administration is going to make that kind of a proclamation to make that happen. If you look at a company like Epic, for example, they limit you to only opening five charts on one screen, but that’s a user-configurable parameter. You could say only one chart is allowed to be open on one screen.

A parallel would be hiring an external auditor to do a hospital IT audit. They evaluate their checklist of things that are important. You don’t have to do all of them, but since the report goes to your management, you would at least justify why you don’t. Would a rational use of the SAFER Guides be not necessarily checking every box, but at least recognizing that you should have a good reason for not checking them knowing they affect patient safety?

That’s a good way to say it. You need an explanation. If I were a CEO reading over the results and you were the IT person that came to me, I would want an explanation for why you think you should open more than one chart on it. You can say that the clinicians disagreed and we’ve decided to limit it to two. We could talk about that and decide whether that was reasonable or not. 

Intelligent people who are safety conscious could agree to disagree on certain of these items. But it’s something you definitely need to think about and understand why you’re doing it.

The beauty of an external IT audit report is the accountability. It seems as though like the audience that would be most interested, from an exposure from a patient care or legal liability standpoint, would be a hospital’s CEO.

I agree completely. We are really hoping that that’s the way they’re used. Either insurance companies will pick these up and ask organizations whether it’s doing this, or someone like the Joint Commission might take these up. 

We’re hoping that this is something that starts a conversation between what I’ll call the clinician, the EHR vendors, and leadership within your organization. That conversation is the key to improving the safety.

The IOM’s To Err is Human brought a lot of activity with regard to medical errors. The IOM’s EHR patient safety report was the genesis of the SAFER Guides. Will that make the idea easier to sell?

I would think that reasonable people would agree with these recommendations. The problem is that these recommendations generally are going to cost some extra money and some extra time.

Right now, with everyone thinking about Meaningful Use Stage 2 and ICD-10 coming up, I’m sorry to say that I think patient safety has been pushed to number three on the list. That is going to be the biggest struggle with these Guides and trying to get patient safety moved up to a high level of awareness within an organization.

Meaningful Use gets you a check, ICD-10 makes sure you keep getting checks, and patient safety doesn’t get you anything except possibly a lawsuit avoided. Is ONC going to market this like they do their other programs?

We’re hoping they’re going to do that. If they can keep their focus on this, I think that will happen. But like you said, this is really a cost avoidance thing. The organizations that seem to do the best in terms of meeting most of the recommended practices are those organizations that have had the biggest accidents. It’s like you don’t get religion until you need the religion.

In some of the organizations here in the Texas Medical Center after Hurricane Ike, they really got some newfound impetus to make sure they had better backup systems in place. They were ready for bad weather. It was Hurricane Alison that was like around year 2000 where we realized we couldn’t have our data centers in the basements any more in Texas Medical Center when they all flooded. It turned out the first floor of our buildings flooded, too. Now all of the hospitals in Texas Medical Center have their data centers at least on the third floor. 

It was interesting to me that when they had Hurricane Sandy in New York City that New York City still hadn’t learned that lesson about putting data centers and power generators and backup systems in the basement. Because when there’s a really big flood, the basements flood. It seems like we should be able to learn those things from other organizations. You shouldn’t have to experience them yourself. But for some reason, people always think that it couldn’t happen here. Like, do they think that New Orleans was a one-off, Houston was a one-off, and now you think New York City was a one-off? The important points are that these things can happen to anyone, anywhere.

What kind of resources would be required to complete the series and come up with a conclusion for an individual hospital?

It depends what you start with. We’ve had some pushback when we mentioned that you ought to have all your hardware systems backed up and you ought to have duplicate hardware. Sometimes that means two servers running in parallel and another one sitting off to the side, so when one of those that are running in parallel breaks, you have one to replace it. Some people say, “We can’t afford to have three of them on site all at one time.” We hear them say, “Our vendor promises 24-hour delivery.” A lot of it are those kinds of expenses and there are a lot of examples in the contingency planning about warm site backups, for example.

That’s just a matter of how much money you want to spend to get the kind of response and get the kind of availability that you think you need. You can always spend way too much money on any aspect of your process. You’ve certainly got to balance the amount of money you spend with the safety that you need. That’s a hard question to answer. 

The other way to answer it is, there are some other guides that would recommend that, for example, when you’re doing physician order entry that you ought to have all of your orders go through the physician order entry system. This idea of trying to get 30 or 60 percent of your orders through the order entry system — we think that sort of partial implementation of CPOE is a real danger because then you have some orders on paper and some on the computer system. 

That’s not really a cost in terms of money. That’s a cost in terms of the political capital of the leadership of the organization, of how much pressure they can put on the physicians — those final holdout physicians who aren’t using it. How much pressure can you put on them to incentivize them to use the system? There’s cost, both financial cost as well as a political cost.

If a hospital downloads the Guides, how much effort does it take for them to get far enough into the process to know where they stand?

In our preliminary evaluations, if you have either a very knowledgeable person or a group of knowledgeable people together, you can go through a Guide in under 30 minutes. There are nine Guides, so we’re talking four or five hours. If you took a half day, you could go through and get a pretty good feel for where you stood on these different items.

The obvious question without an obvious answer is that the government is paying incentives to get people use electronic health records. Now the government has issued a set of guidelines that says, “This is how you keep them safe,” and yet those factors are not tied to any incentive. Who’s supposed to run with this?

We’re not really sure right now what’s going to happen with them. Like I said, I’m placing my bets on insurance companies. The payers are the ones that can really enforce this. 

In one sense, the federal government is a payer. You could imagine CMS incorporating some of these recommendations in their Conditions of Participation and then making the Joint Commission responsible for looking at them. You could imagine public health departments saying something like this, or insurance companies saying, “We’re not going to approve this, or maybe we’ll incentivize you to use the SAFER Guides and give you a little more money if you have completed the SAFER Guides.”

We’re in the midst of negotiating with a lot of different organizations to try to get them to see who will step up and say, “This is a good idea. The people  we are working with ought to explain to us why they are or aren’t doing these kinds of things that are in the Guides”.

Are there other phases planned?

We have work planned, but we don’t have funding to do the work. Most of the criticisms we get fall into two categories. One is that there’s too much stuff on the Guides and they need to be shorter. The other criticism is, you left something out. When they say that we’ve left something out, they say, “We really need a Gguide for clinical documentation that would help people to understand how much copy-and-paste is allowable in a document.”

There’s also a lot of people who have been talking about a Guide for how to do  the patient engagement aspects of it — how should you configure your personal health record and what policies and procedures should go around the patient portal and their access to information. We certainly know there are at least two more Guides that would be very well received and are needed, but right now there’s no funding to develop them.

Do you have any final thoughts?

I would strongly encourage organizations to take a look at these Guides. They can really help an organization understand where they are and understand what the issues are.

A lot of people think that they’re unique and that things that they hear about don’t apply to them. When they see these Guides, they’ll realize that a lot of people are going through and struggling with these same issues. The leading organizations have pretty well come together and decided that backups are a good idea, for example, or physician order entry is a good idea. An organization would learn a lot by going through the Guides and seeing where they stand.

Morning Headlines 1/30/14

CCHIT Announces New Strategic Direction With Global Focus

CCHIT announces that it will exit the EHR certification business. The company will pivot to a consulting model that will offer services to both hospitals and HIT vendors.

Former Allscripts CPA charged with insider trading

Steven Dombrowski, former Allscripts director of corporate audits, has been indicted on 16 insider trading charges. Federal prosecutors allege that in Q1 2012, Dombrowski opened a trading account in his wife’s name, and then made $286,000 short selling Allscript stock.

Proposed Law Would Give US Chief Technology Officer Oversight Of Major IT Projects

Representatives Anna Eshoo and Gerry Connolly introduce a bill that will require the federal CTO to review all major IT project undertaken by the federal government. The CTO’s office will have the authority to manage, or co-manage, the project on behalf of the initiating agency. The bill was drafted in response to charges that CMS lacked the technical expertise to properly manage the Healthcare.gov project itself.

U-M Kellogg Eye Center performs first two retinal prosthesis implants in U.S. since FDA approval

Surgeons at the University of Michigan implant the first FDA-approved prosthetic retina which is expected to restore enough vision for the otherwise blind recipients to be able to see objects, light, and people standing before them.

Readers Write: Ominous Outlook for Meaningful Use

Ominous Outlook for Meaningful Use
By Evan Steele

CMS passed up a golden opportunity to stave off the potential demise of the EHR incentive program when it failed to delay the start of Stage 2. What was already a complex program in Stage 1 becomes exponentially so in Stage 2, and its pace is outstripping the realities of medical practice and of software development. The facts speak for themselves:

• 17 percent of the physicians who successfully attested to 90 days of Meaningful Use at Stage 1 in 2011 walked away from the second incentive ($12,000) in 2012, which required a full year of Meaningful Use. I find this dropout rate very surprising. The requirements were exactly the same as the first reporting period for these physicians, so they and their staffs had already established the necessary workflows. The fact that many of these first attesters were early EHR adopters and therefore already more adept at EHR use than the average physician makes this statistic even more alarming. When surveyed by CMS, many of the dropouts cited the program’s complexity as a key reason for their failure in Year 2. Physicians who gave up on Stage 1 will likely not even attempt Stage 2.
• 12 percent of attesters who used one of the top 25 EHRs to demonstrate Meaningful Use in Stage 1 do not yet have access to a 2014-certified EHR, according to a January report issued by Wells Fargo Securities, while this year’s reporting period must begin within nine months. Some EHRs will never achieve 2014 certification. The first announcement of a vendor abandoning Meaningful Use came a few weeks ago, leaving its physicians out in the cold. Of the 49 ambulatory EHRs that have been 2014 certified to date — winnowed down from a Stage 1 field of 472 — very few have yet been deployed to physicians. This is clear evidence of the complexities associated with Stage 2 and the significant challenges facing vendors in making their EHRs compliant yet practical.
• I would estimate that at least another 15 percent will walk away from Stage 2 because of its dramatically increased complexity, added costs, and impact on productivity, particularly when weighed against the declining incentives (as little as $4,000 and $2,000 for physicians whose first year of Meaningful Use was 2011) and penalties that will average only a few thousand dollars.
• How many additional physicians will be driven to cry “Uncle” and abandon Meaningful Use because they are besieged by the demands of so many other programs at the same time—ICD-10, PQRS, Value-Based Payment Modifier, ACO participation, etc.? Physicians and their clinical teams are weary and can only do so much.

If you add these numbers together (acknowledging some overlap), the conclusion that 40 percent of past attesters will give up on Meaningful Use is inescapable. Then there’s the 37 percent of eligible professionals who have never earned an EHR incentive, including 18 percent who—if failure to even register is an indication of lack of intent—are so overwhelmed by the program that they have no interest in participation even in the “easiest” first stage (Source: CMS Presentation to HIT Policy Committee, January 14, 2014).

The delay of Stage 3 will be too little, too late. What was needed was a more reasonable approach to Stage 2.

Evan Steele is CEO of SRS, Montvale, NJ.

Readers Write: Once a Nurse, Always a Nurse

Once a Nurse, Always a Nurse
By Lisa Cannon

We all wear various hats in our lives, but some experiences are never forgotten. Through the years, I’ve been the road warrior healthcare consultant and then moved to positions supporting consulting operations. Yet nothing remains in my heart more than my early days as a nurse. I never knew how much I would appreciate having been a nurse until my mom’s health took a sizeable downward turn last year.

My mom’s chronic cardiac condition resulted in several hospital visits and treatment by various specialists in her last months. At home, coordinating her care among her medical team was no easy task. Keeping her out of a nursing home meant visits from home health nurses, nurse aides, and multiple therapists. This was a great deal of care synchronization for my aging father to deal with, but he welcomed it, knowing the alternative. He organized her medications and had everything written down. Thanks to my nursing background, I trained him in the art of taking her blood pressure, doing daily glucose checks, and measuring her oxygen saturation.

I was constantly running cover on what was being prescribed for Mom and monitoring how Dad was delivering the recommendations. Sadly, we hit an issue that in hindsight makes me question if it was the action that ultimately caused her death. Could information technology (IT) have made a difference? Perhaps. Maybe the application of common sense and additional family education could have.

Mom’s renal specialist ordered a diuretic water-releasing medication to be given once a day for seven days with a quantity prescribed of 14. The discrepancy between the dose and the quantity wasn’t realized immediately. After Mom fell twice, at a subsequent visit to her primary care physician, my dad indicated he was still giving this medication. That’s when we realized we had a serious issue. This was Day 13, well past the seven-day mark. Mom had received the medication for almost a full week more than had been intended. We realized it was significantly lowering her blood pressure.

I questioned the pharmacy that filled the prescription. They indicated they just did what the physician had written. I was outraged. Could they have provided some family education and made that clear? Since there were still pills in the bottle, Dad merely was continuing to give the medicine. Could a computer system combined with standard operating procedures prompt alerting of education requirements for a time-limited dosing medication helped? I think so.

After subsequent falls, my mom ultimately was admitted to the hospital, where a CT scan showed she had developed a massive brain hemorrhage. Dad and I were told that the combination of falls and blood-thinning medication resulted in a weakened blood vessel in her brain, which finally gave out.

Afterwards, when the renal specialist was asked why the prescription was written the way it was, she remarked that it was so we wouldn’t have to return to the office should we have needed to continue it. In her mind, she was doing us a favor.

This experience made me wonder how patients without involved family members manage their medical care journey as their health deteriorates. While I may have forgotten all of the details of the ICU setting I spent so much time in years ago, I am very thankful for the skills I learned and my ability to recognize the situation regarding the healthcare needs that come to the surface.

Having witnessed firsthand patients struggling with understanding their care requirements, it reiterates to me the imperative that health professionals do their part in educating patients and their families and communicating specifics. Training my dad to take blood pressure and glucose checks was possible (and these days, essential). His recognizing a perfect storm of low blood pressure, over diuresis, and blood-thinning medicines was not.

As healthcare IT professionals, we can’t forget that the role of IT is to supplement common sense and standard operating procedures, not to replace it. There is no fail-proof means to ensure mistakes don’t occur, even with the best of intentions and systems. We must remember that the people, process, and technology changes we’re making impact real people every day. Are we making healthcare better? We must –our families are counting on us. 

Lisa Cannon is director of resource management for Aspen Advisors of Pittsburgh, PA.

Readers Write: The Revenue Cycle’s Transformation with Big Data

The Revenue Cycle’s Transformation with Big Data
By Steve Johnson

Big data is pushing clinical care to new heights as healthcare organizations use it to support diagnoses, target care delivery, and improve patient health outcomes. Organizations can realize a similar level of success in the revenue cycle when they apply data and analytics to the myriad of steps involved in billing and collections.

When organizations effectively leverage financial and administrative information — such as claims, payer payment, cost, patient financial, and patient demographic data — they can see improvement on both the front and back end of the revenue cycle. For example, organizations can use data to increase collections by detecting fraud at registration, quantifying patient payment responsibility, identifying patients who qualify for financial assistance, and revealing errors that impact billing.

Strong data and analytics can also drive more accurate revenue forecasting. Unlike the past, where healthcare organizations relied on historical summary statistics to predict future financial trends, big data empowers a real-time view of individual patients and their financial situations. When aggregated, this data allows an organization to make an accurate bottom-up forecast of revenue. In other words, organizations can leverage specific account information to build a collective model of overall performance based on each patient’s unique financial situation.

Just as big data can improve forecasting, it also can enable more exact patient population benchmarking and assist in decision-making relative to those populations. For instance, data and analytics can show how a facility’s patient population compares with the general patient population regarding financial need. This level of data and analysis facilitates deeper patient segmentation, clearly differentiating those more likely to qualify for assistance compared to the surrounding geographic area. In addition, data and analytics help define optimal workflows or interventions for specific groups.

Organizations already have all the big data they need to effect change: financial, administrative, and claims and payment data are all present in an organization. To get the most out of this data, organizations need to link it together and form one complete picture of the patient experience. This will provide a better understanding of the patient’s current and historical situation and allow for stronger forecasting and risk mitigation as well as enable better financial conversations with patients.

Patients usually welcome conversations about their financial responsibility and how they can meet it, especially those who do not understand the complexity of their coverage and may not know the right questions to ask. By using financial and administrative data to determine the best financial course of action for a patient, staff can proactively offer different payment options and answer patient questions, increasing the likelihood of patient payment, improving collections, and strengthening the revenue cycle. This data-driven, customer-focused approach also reaps the added benefit of higher levels of patient satisfaction.

Clinical use of big data has dramatically impacted care delivery. The time is right to adopt the same philosophy for the revenue cycle and leverage big data as a business tool to strengthen billing, collections, and overall financial operations.

Steve Johnson is chief technology officer and vice president of data and analytics at Experian Healthcare of Austin, TX.

Health IT from the CIO’s Chair 1/29/14

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.

Prologue

Two CIOs before me have written regularly for HIStalk. I’m honored to follow or join in their footsteps. I hope I can be a tenth as insightful as John Glaser was under his regular/irregular column of the past. I also promise to stay away from the leadership and life lessons offered up by Ed, as I could not come close to being that inspirational.

Instead, my focus will be observational healthcare IT industry stuff offered up with a style best described as, “A mix of sarcasm, adequate grammar, and poor spelling.”

Epic Bingo

One of the many things I enjoy in my role as a CIO is the ability to hear about new ideas from new companies.

In a given week, I likely participate in 2-5 calls or meetings related to new products from startups. I learn a lot, I see many emerging concepts taking shape, and I get to observe trends as patterns of companies start to form to fill new gaps.

Sometimes sitting through the presentation is an exercise in patience, as the product idea falls flat.  But it all becomes worth it when you can discover the right thing to fill the white space between or within our current application portfolio. It really is encouraging how many smart people are working on solutions to solve problems in healthcare these days.

How do we find the 1-5 cool products a year among the 200+? Good question. Perhaps I will address that in a future column.

But for now, let me offer up the observation of Epic Bingo. Not just a trend, but a fun new game to play when talking to startups. I’ll offer some advice, too.

I think conservative numbers would put Epic market share at 40 percent. It feels higher to me, but admittedly I work at a place that has Epic, so I hear a lot about them. Epic customers tend to share traits. A key one is the vision of a single patient record. Epic’s tagline (“One Patient, One Record”), workflow, and single pane of glass are keywords that Epic clients to focus on.

When a new company comes to pitch their wares at an Epic site, they are keenly aware of needing to answer the “integration with Epic” question. The result is what I would like to call the new game of Epic Bingo. Here’s how you keep score during the pitch.

Score Card

• Saying Epic. No points for the first five times, but a quarter point every mention after.
• Using “Judy” or “Carl” in a sentence. Half a point (everyone can do that.)
• Using “Madison” in a sentence. Half a point. Double points if “Verona” is used.
• Saying Epic is closed and based on MUMPS. Half a point. No originality.
• Making reference to open.epic.com. A full point just for being current.
• Stating you have one or more former Epic employees working for you. Two points each. This can really add up!
• Telling a story about actually meeting or talking to Judy or Carl. 2-5 points. Depends on the story. Charming and funny earn extra.
• Dropping other Epic employee names. 2-3 points, depending on the employee. Using “Sumit” or “Stirling” and spelling them right gets five full points each.

Have fun with it. See how your questions of the presenter may generate more points! A good score is 10 or more.

Advice

While I am writing this with Epic in mind, I bet it applies to Cerner and other systems as well.

1. Hospitals can be segmented along lots of criteria. One is those that have deployed enterprise EMRs and those that have not. Know your customer. If you are presenting a new solution to an enterprise customer, be sure it really fills a new space.
2. If you have an idea to compete with a core function of an enterprise EMR, your difficulty is not integration, it is competition.
3. A single better feature does not make a product. Not every product idea can actually become a company. Make sure you have scope and scale.
4. Go six degrees to the left or right of the core vendors. Don’t pitch a better mousetrap — pitch an idea disruptive to the mousetrap itself.

In the mean time, have fun playing bingo.

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

Morning Headlines 1/29/14

Vista Evolution Workgroup Coordinators Sources Sought Notice

The VA is soliciting a vendor to lead the VistA Evolution Workgroup, an initiative that will update the VistA EHR platform and incorporate interoperability standards defined by the joint DoD/VA Interagency Program Office, which oversees all work done on the long awaited iEHR program. With proposals due by February 6, interested vendors have been given just nine days to prepare and submit their proposals.

Analytics Startup Health Catalyst Nets $41 Million

Data warehousing and visualization startup Health Catalyst raises a $41 million Series C investment round which the company will use the funds to develop 200 new analytics tools designed to help customers zero in on inefficiencies and evaluate care variances.

Hearst Corporation Announces Formation of Hearst Health

Hearst Corporation, parent company of First Databank, Zynx Health, MCG, Homecare Homebase, and Map of Medicine, announces a new brand called Hearst Health that will encompass all of its health IT businesses. Hearst will also launch a new innovation lab and a venture capital portfolio as part of the business unit.

TigerText Caps Record Year with $21 Million Series B Investment to Accelerate Market Penetration

TigerText raises a $21 million Series B for its healthcare focused secure messaging platform that delivers HIPAA compliant text messages which automatically delete after a pre-defined period of time.

News 1/29/14

Top News

The VA opens procurement for VistA Evolution workgroup coordinators, the next step in replacing VistA Web with a single VA-DoD EHR viewer that supports mandated interoperability requirements. The solicitation was posted on January 27, leaving just nine days for interested companies to assemble and submit proposals by the February 6 due date.

Reader Comments

From Green Stamp: “Re: Dave Henriksen. Left Carestream Health, as you mentioned last week, and has moved on to NexTech Systems as president and CEO.” Dave’s LinkedIn profile confirms his new position with the PM/EHR vendor.

From Believe Me: “Re: CCHIT. Exiting the ONC certification business.” Unverified, but reported by more than one reader. CCHIT hasn’t responded yet. UPDATE: Verified, from an update on CCHIT’s site. CCHIT says ONC 2014 Edition certification requires a lot of testing and its federally-driven business is unpredictable, so it won’t accept any new applications for certification and recommends using ICSA Labs instead. CCHIT will change its business model to become a certification consulting firm and will partner with HIMSS to “provide both counsel and thought leadership to the health care provider and HIT vendor communities” that will include summits starting at the HIMSS conference, apparently still operating as a non-profit.  The most recent Form 990 I could find was from 2011, at which time it was paying Chairman Karen Bell $409K, Executive Director Alisa Ray $250K,  and five other employees over $100K. It would seem to me that given CCHIT’s genesis, mission, and name, it should just go away rather than trying to morph itself into the already overcrowded thought leadership business. It probably would if HIMSS wasn’t riding in on a white horse to save it, not surprising given that HIMSS formed CCHIT (along with partners AHIMA and NAHIT) in 2004.

From Hit Newbie: “Re: CMS. The MU attestation portal is having issues to Healthcare.gov. It’s laughable that there is still no API or portal designed for the volume. CMS says it won’t allow appeals for late attestations due to website downtime.”

From Bill Pare: “Re: HIMSS travel site. I notice that the login page is not encrypted. I find that ironic.” HIMSS uses a travel portal from nuTravel. I checked the company’s documentation and it says the registration page is encrypted with 128-bit SSL, but the HIMSS travel registration page is not encrypted.

HIStalk Announcements and Requests

HIStalkapalooza registration has closed with quite a few more requests than we have capacity. Imprivata will email invitations Tuesday, February 4.

Listening: new Dum Dum Girls, lo-fi jangly indie pop.

Welcome to new HIStalk Gold Sponsor Treehouse Resources. The company connects qualified Epic consultants with clients interested in hiring them at market-leading rates with hassle-free paperwork. The free, five-minute signup for consultants allows them to privately review opportunities that meet their career and life balance goals, even optionally becoming a W-2 hourly employee of Treehouse. Treehouse checks references and approves the consultants, then clients review the consultant profiles, arrange interviews, and let Treehouse manage the invoicing and billing. The company’s model (which is kind of like Angie’s List or Match.com) focuses on efficiency and doesn’t require recruiters or salespeople, meaning consultants make more money and clients pay some of the lowest rates in the country. At the moment, 487 consultants (of 1,100 who requested to participate)  and 88 clients have signed up. You most likely know the principals behind Treehouse, Glenn Galloway and Mike Tressler, both previously with Healthia Consulting and longtime friends of HIStalk. Thanks to Treehouse for supporting HIStalk.

Upcoming Webinars

February 5 (Wednesday) 1:00 p.m. ET. Healthcare Transformation: What’s Good About US Healthcare? Sponsored by Health Catalyst. Presenter: John Haughom, MD, senior advisor, Health Catalyst. Dr. Haughom will provide a deeper look at the forces that have defined and shaped the current state of U.S. healthcare. Paradoxically, some of these same forces are also driving the inevitable need for change.

February 12 (Wednesday) 1:00 p.m. ET. Healthcare CO-OPs and Their Potential to Reduce Costs. Sponsored by Health Catalyst. Presenters: David Napoli, director of performance improvement and strategic analytics, Colorado HealthOP and Richard Schultz, VP of clinical care integration, Kentucky Health Cooperative. Consumer Operated and Oriented Plans (CO-OPs) were established by the Affordable Care Act as nonprofit health insurance companies designed to compete in the individual and small group markets. Their intended impact was to provide more insurance options for consumers to pay for healthcare.

February 13 (Thursday), 12 noon ET. Advancement in Clinician Efficiency Through Aware Computing. Sponsored by Aventura. In an age of information overload, a computing system that is aware of the user’s needs becomes increasingly critical. Instant-on roaming for virtual and mobile applications powered by awareness provides practical ways to unleash value from current HIT investments, advancing efforts to demonstrate meaningful use of EHRs and improve clinical efficiencies. The presenters will review implementation of Aventura’s solution at Orange Coast Memorial Medical Center.

Acquisitions, Funding, Business, and Stock

Secure messaging provider TigerText raises $21 million in a Series B round. Its secure, industry-agnostic solutions sends encrypted messages that self-destruct after a preset time.

Perceptive Software reports adjusted revenue growth of 70 percent in Q4.

Patient engagement provider Relatient closes its first round of funding led by former AIM Healthcare Services president Jim Sohr. The company sends health-related messages including reminders for appointments, outreach, collections, and surveys.

Covisint reports Q3 financials: revenue up one percent, adjusted EPS -$0.10 vs. -$0.09.

Informatica reports Q4 results: revenue up 18 percent, adjusted EPS of $0.49 vs. $0.41, beating analyst estimates on both.

Apple reports Q1 numbers: revenue up 5.7 percent, EPS $14.50 vs. $13.81, beating expectations but releasing disappointing current-quarter guidance. Shares dropped 8 percent Tuesday on the news. Sales of the Mac and iPad beat expectations, but iPhone sales fell short and iPod sales were down more than 50 percent year over year. Analysts variously blamed smartphone sales, lack of new products, slow growth in China, and the inability of the iPhone 5c to create a strong low-cost entry in the smartphone market.

Kaiser Permanente Announces Data Warehouse Project

Health Catalyst closes $41 million in Series C funding led by Sequoia Capital and announces plans to invest $50 million in product development over the next 24 months. Investors also include customers Kaiser Permanente and Partners HealthCare.

I spoke to CEO Dan Burton and President Brent Dover before the announcement.

Burton says Kaiser will roll out Health Catalyst’s data warehouse platform for all 38 of its hospitals. “While we have worked with other large health systems – earlier in the year we signed with Partners in Boston and Providence – but Kaiser is almost in a class by itself in terms of size and scale. The nature of the first project is system-wide, a terrific test of the scalability of our platform.”

Burton says Kaiser will initially use Health Catalyst for two projects. “They have a specific need for system-wide access to a subset of data around transplant patients,” he explained. Dover added that Kaiser is working on a specific project for diabetic patients in Colorado. “Kaiser is reaching out to diabetic patients. They were going after patients using spreadsheets and complex SQL extracts. They told us Health Catalyst builds a cohort in 180 seconds when it used to take 180 days. This allows them to proactively go after patients for population health management.”

Eleven of Health Catalyst’s customers, including Kaiser, are Epic clients. I asked Burton why Kaiser chose a third-party tool over Epic’s Cogito data warehouse and reporting platform. “In our experience, it’s an apples to oranges comparison,” he said. “Cogito offers basic functionality from a data storage perspective that could meet rudimentary needs. We’re offering a data warehouse as a platform for transformation from an advanced clinical apps perspective.” Dover added, “When I worked at Medicity, customers always asked for analytics tools. No client really knows what they want to analyze – it’s a never-ending list. The market demands an incredibly flexible platform. We have 17 case studies and none of them have anything to do with each other – it’s what each of them needed to improve quality and cost.”

I asked Burton about the $50 million in product development to create 200 advanced clinical applications. “A couple of our longstanding customers, Texas Children’s and Stanford, worked on specific areas to identify inefficiency and variation of care in heart failure and asthma patients, showing where the variation existed, what needed to change, and tracking progress, even tracking the return on investment of the improvement. At a CEO level, said they need to target 20 applications per year over the next five years to measurably and meaningfully bend the cost curve to allow them to not only survive, but thrive and lead. That opened our eyes that what our clients are seeking is a roadmap. We decided to become a company that offers hundreds of analytic applications so we can be a long-term partner to help these health systems transform themselves.”

Sales

Vermont IT Leaders will incorporate Orion Health’s Rhapsody Integration Engine into its statewide HIE that runs on Medicity.

VHA selects Xerox to automate its healthcare claims pricing process.

Allina Health (MN) chooses Strata Decision Technology’s StrataJazz for cost accounting.

People

VMware names Chris Wolf (Gartner) CTO for the Americas.

Culbert Healthcare Solutions promotes Gibran Cotton to director of GE and Allscripts consulting.

Halifax Health (FL) promotes Tom Stafford to CIO.

Brian Ahier was interviewed last week in studio on WFED, Federal News Radio, where he talked about health IT and ONC’s recent annual meeting. He also gave a nice plug for HIStalk as the best place to keep up with healthcare IT news.

Divurgent hires Jeff Powell (AT&T) as client services VP and Anthony Jones, Shaun Sangwin (Vascular and Interventional Physician Partners), and Justin Stefano (MedSys Group) as regional client services directors.

Announcements and Implementations

Walter Reed National Military Medical Center (MD) implements AtHoc Interactive Warning System for mass notification and interactive hospital communications.

Long-term care provider Levering Management (OH) deploys the COMS Interactive Daylight IQ product suite covering disease management, care guides, and nursing assessments.

HIMSS announces that the ONC’s Karen DeSalvo, MD will offer opening remarks at 8:30 am, Thursday, February 27, the closing day of the HIMSS conference.Too bad the mass exodus of attendees will begin Wednesday afternoon.

OhioHealth O’Bleness Hospital goes live on McKesson Paragon.

Memorial Hospital (MS) goes live on Cerner March 15 and will later implement analytics software from Health Catalyst.

Hearst Corporation announces the creation of Hearst Health, a new brand that encompasses its healthcare information businesses that include First Databank, Zynx Health, MCG, Homecare Homebase, and Map of Medicine. It also involves a new startup fund, Hearst Health Ventures, and Hearst Health Innovation Lab, which will prototype internal and external health IT projects. The innovation lab will be run by Chief Innovation Officer Justin Graham, MD, MS, previously CMIO of NorthBay Healthcare (CA), who joined the company in July 2013.

Mobile Heartbeat announces Mobile Heartbeat CURE, a smartphone-based location and communications application for clinical teams.

Mobile charge capture vendor pMD will announce Wednesday a partnership in athenahealth’s More Disruption Please program in which its product will be integrated with athenahealth’s billing and practice management systems.

Other

A Commonwealth Fund study finds that practice EHR adoption rose considerably from 2009 to 2012, but solo physician practices lag in use of functions such as electronic data exchange with other providers. Practices associated with IDNs had the highest rate of technology adoption.

Black Book names its #1 HIE vendors in several categories: Covisint (payer/insurer based); ICA (core HIE); Cerner (inpatient EHR); Allscripts dbMotion (ambulatory based); and Infor (complex technology services).

Microsoft will rename its SkyDrive could storage to OneDrive after losing a trademark battle with British broadcaster BSkyB.

Concierge medicine provider PlushCare launches an Indiegogo campaign to create its service and to provide children with immunity to measles. It’s a confusing combination, but donors who are California residents get email, telephone, and video visits, and as a bonus, recognition for immunizing a child. The company says two Stanford MDs will diagnose and treat simple illnesses or injuries the same day. The tech guy is Ryan McQuaid, former product head for AT&T ForHealth.

Something’s fishy here: a Canadian company called Kallo Inc. claims to have sold the Republic of Guinea $200 million US worth of healthcare software that includes systems for hospital, telehealth, and pharmacy. The fishy part is that the company’s shares trade OTC for $0.15, valuing the entire company at $46 million, with shares having dropped almost 30 percent on the news of the big sale.

Weird News Andy is breathless over these stories. Researchers find that use of mouthwash raises blood pressure and increases the risk of heart attack, although the study involved only 19 patients and the increase in diastolic blood pressure was small. Another group of researchers finds that dogs can be trained to smell cancer in the same way they can sniff explosives or human scents, leading to the possibility of creating instruments that can detect the same odors to sense cancer.

Sponsor Updates

• Madison Memorial Hospital (ID) reports an annual benefit of $327,658 following the implementation of Craneware’s Chargemaster Toolkit and Pharmacy ChargeLink.
• Wolters Kluwer Health and Laerdal Medical introduce vSim for Nursing, an online learning solution that simulates curriculum-driven patient scenarios.
• 3M Health Information Systems releases an enhanced version of its Code Translation Tool to convert ICD-9-based custom problem lists into ICD-10 coded problem lists for import back into a provider’s existing EMR.
• Forbes names Kareo to its annual list of “America’s 100 Most Promising Companies.”
• Sandlot Solutions will offer the White Pine Systems SPINN patient engagement platform to its HIE and ACO clients.
• InstaMed reports it enables payers to achieve the highest levels of electronic payment adoption with its fully integrated Claims Settlement Complete.
• Physicians’ Choice (CA) discusses in a case study how it uses Capario to process more than 24,000 claims a month.
• In a case study, Bozeman Deaconess Hospital (MT) shares how Quantros Safety Event Manager improved patient safety and satisfaction.
• Nuance Healthcare reveals details of its Conversations Healthcare 2014 conference April 6-9 in Phoenix.
• Alan Lundberg, Informatica’s principal marketing manager for emerging products, blogs about the value of business intelligence in business operations.
• SCI Solutions launches Provider Network Manager, a technology platform and service for health systems to create better managed affiliations with independent and employed providers.
• Bethesda Magazine spotlights GetWellNetwork founder and CEO Michael O’Neil, who discusses the creation of his company.
• Novation awards Paragon Development Systems (PDS) a VAR agreement for hardware and IT services.
• BlueTree Network co-founder Reggie Luedtke shares four healthcare trends to be excited about in a Forbes article.
• CCHIT certifies that Healthwise Patient Education EMR Module version 10.0 is compliant with the ONC 2014 Edition criteria as a Modular EHR.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 1/28/14

Where Are We on the Diffusion Curve? Trends and Drivers of Primary Care Physicians’ Use of Health Information Technology

EHR adoption in the practice environment hit 69 percent in 2012, but a large divide still exists between solo practices, which have only reached 50 percent adoption, vs. large practices of 20 or more physicians, which have reached a 90 percent EHR adoption rate.

ACOs struggle with data sharing

The National Association of Accountable Care Organizations publishes the results of a survey that solicits the opinions of 35 ACOs. Respondents report that the average cost to transition to an ACO model was $2 million. The ACO organizations rated their IT satisfaction at 6.4 on a 10 point scale, with an “overwhelming number" of participants reporting that learning to access and process CMS data was a significant hurdle. Predicted gains from the transition range from a $9 million increase to losses of $10 million.

Epic launches at Yale Health

Yale Health (CT), a three-hospital health system, goes live on Epic, replacing Allscripts.

Curbside Consult with Dr. Jayne 1/27/14

To practice or not to practice, that is the question. Among the other CMIOs I talk with regularly, it’s a nearly 50-50 split as to whether they continue to actively practice medicine or not.

For some of them, the decision was made based on factors related to medical specialty. Others gave up licensure when they pursued administrative work and found it too difficult to go back. Some chose informatics as a way to escape patient care. But it’s not always straightforward. It seems that those of us who are earlier in our careers are more apt to try to continue seeing patients, with those in the primary care disciplines hanging on longer than others.

I’ve been lucky because my EHR background has given me experience with multiple vendor systems. This allows me to work as a locum tenens physician and fill in for a week here or there in a traditional family medicine practice. Seeing how different practices function is interesting and I often get ideas for performance improvement projects or bring back tips and tricks that can help my providers.

I’ve also worked for the last several years in various emergency departments and urgent cares. Although I do a fair amount of “real” emergency medicine, it’s mostly the same kind of conditions that I’m used to handling in the family medicine office.

I try to work consistently, but it has been more and more difficult to find opportunities that will work with my ever-expanding CMIO work. My “day job” is full time and my hospital doesn’t provide much accommodation for my clinical work. Now that we’re in the throes of Meaningful Use and preparation for ICD-10, it seems like there isn’t enough time to do anything else.

During the last six to eight months, one of the hospitals where I worked has closed their fast track area in the emergency department. Another replaced all the part-time physicians with nurse practitioners and physician assistants. I took some time off while I was preparing for informatics boards and that impacted my seniority on the scheduling board at my remaining facility, which has made it harder to get back in the rotation.

Continuing clinical work doesn’t yield a lot of income compared to the cost of being an independent contractor. Although I don’t pay for professional liability insurance, there are many other costs: board recertification, maintenance of certification, state licensure, Drug Enforcement Agency registration, state drug enforcement registration, hospital medical staff dues, hospital recredentialing fees, and more. There’s also the cost of professional society memberships and continuing medical education.

Continuing education has been a thorn in my side the last couple of months. For emergency department work, I have to maintain certifications in basic, pediatric, advanced cardiac, and advanced trauma life support. They’re all due this spring, and trying to work them in with everything else that is going on has been enough to make me think twice about seeing patients. Thank goodness I finally got to stop maintaining the obstetric life support credential because I’m not entirely sure I’d be able to fit it in.

For most of the classes, I’ve been able to find programs that offer at least part of the course online, although all of them require a practical component. Some are sponsored by national organizations and others are modules that have been purchased by one hospital or another. I figured doing them online would give me more flexibility but I’m not sure it’s doing much good. The differences in quality are tremendous. When I compare it to what we’ve been trying to achieve with e-Learning for our EHR program, it’s even more striking. Some of the “e-Learning” is little more than written textbook sections punctuated by the occasional embedded video.

They vary greatly in the length of the modules and whether users can pause at any time or only at pre-defined points in the course. One of them was so restrictive that I might have been better off using a vacation day and attending an all-day course rather than trying to fit it in as time permitted. The cost of the courses is the same as what I have paid in the past for in-person courses except for the basic life support. It used to be free when our hospital education department offered it, but now that it’s offered online by a third party, we have to pay for it.

Despite being an attending physician, I couldn’t even register for the class until my check cleared. Rumor has it that employees have to sign up months in advance so a purchase order can be processed and a check delivered. Another negative is the lack of interaction with colleagues. I enjoyed meeting nurses, patient care techs, therapists, and other colleagues during the classes even if it was just for some chit-chat over lunch or a break. I know the hospital is saving money with the online classes because they require staff to complete them during non-working hours; previously, hourly staff members were paid for attending class.

I’m starting to feel like this might be the last time I do this. Although I enjoy seeing patients, it’s getting harder to manage. There are many things competing for what’s left of my free time after I leave the office. I’m thinking about exploring volunteer opportunities where I could use my healthcare skills but where there would be less overhead than I currently have trying to maintain half a dozen certifications.

I’d be interested to hear from other CMIOs whether they’ve hit this point in their careers and what they decided. Is there a right time to hang up the white coat? How do you know? Have any creative ideas for trying to do it all? Email me.

Email Dr. Jayne.

HIStalk Interviews Alan Rosenstein, MD, Disruptive Physician Behavior Consultant

Alan Rosenstein MD, MBA is an educator and consultant in disruptive physician behavior. He welcomes contact by email.

 

Tell me about yourself and what you do.

I’m a physician. I also have an MBA. I still do a clinical practice in internal medicine a couple of days a week. I do a lot of consulting work around care management.

One of my other positions is being medical director for a company called Physician Wellness Services, which is in Minneapolis, although most of my career has been involved on getting physicians around best practice care.

You’ve done a lot of work with disruptive physician behavior. How is that defined or evidenced?

I got into this as vice president and medical director for the VHA West Coast. We would always look at how we could help the medical directors focus on the issues that they think are important. The usual span of issues are quality of care, cost of care, and physician relationships with the hospital. 

I started noting that they were putting down disruptive behavior as one of their key issues. This really got exacerbated during the nursing shortage. That’s when I started the original survey on what is disruptive behavior? Are you witnessing it? Who’s doing it? Where is it occurring? That led to all the research about how significant an issue it is and then what we can do about it.

We describe disruptive behavior as any inappropriate behavior that can negatively impact patient care. That’s the simplest definition.

When you look at other professions, are physicians more likely to be disruptive, or it just more easily perceived because of the work environment they practice in?

It’s a combination of both. There are certain personality traits that lead people to go to medical school. It’s very competitive. They’re very ego-centric. During the medical school process, you’re taught very autocratic, independent, autonomous types of behavior. Physicians give orders. There is that personality that’s built in. 

Healthcare is a very hierarchical system. Physicians are on top of the totem pole. They’ve usually had their free way in giving orders and not taking any responsibility for their actions, although their actions are really aimed at best patient care. 

That in combination with the fact it’s a really stressful environment. In fact, if you look at where disruptive behaviors occur most frequently, it’s in either stressful areas — such as surgery, the emergency room, or OB — or in very stressful situations where the patient is having a negative outcome or the severity is increasing and they’re taking a turn for the worse and the physician needs to get involved. Sometimes they don’t do that in the most cordial manner.

In my experience , physicians who staff perceive as problematic and prone to explosive tempers are often respectful to their patients and even have great bedside manner.

I’m not sure they have great bedside manner with the patients. I think their intent is 100 percent, “I want to do the best for you, and in a crisis situation, I’m the one who knows best and I really need to take control.” That’s all appropriate, but many of these physicians are not good. 

in our research and others, we’ve shown that three to five percent of physicians — and nurses, actually — are truly disruptive. This can have a significant impact on the organization. But what we also found is that 40 to 45 percent of them are ineffective communicators. If you go back to that medical school, you’re trained in technology, you’re trained in knowledge competency, but you’re not trained in personal skill development. 

Now with healthcare being so complex, there’s many physicians in on a case, many other providers who are not physicians. The physician needs to better communicate and coordinate with them and also to present it effectively to the patient. 

I’m not sure that they have the best bedside manner, but they certainly are doing it with the intent of, “I need to take control.”

Is that behavior rewarded more readily for certain specialties, like cardiothoracic surgeons versus pediatricians?

Why do people act disruptively? First of all, many people act disruptively and they don’t even know they’re doing it because they don’t understand the downstream effect. A lot of the research has shown there’s a significant downstream effect where patient care is actually compromised.

They’re acting disruptively because they need to take control. They feel like they need to give the orders and get the best patient outcome. They’re doing it to try to provide best patient care, but they don’t realize what they’re doing or how it’s impacting, or most importantly, the long-term impact of what they’ve done. 

Eventually it gets to the point where you antagonize a person so much … in the short term, they’ll hopefully do what you’re asking them to do, but moving further down after the crisis, they don’t want to communicate with you any more. These communication gaps lead to problems with the patient outcomes of care.

Does medical training encourage or at least support disruptive behavior? Do you see that changing as newer generations of practitioners emerge who have been trained more as a team member rather than a single player?

Yes, absolutely. What we’re finding right now in medical schools is that they’re beginning to realize how important personal skills, communication skills, and teamwork skills are. 

Three things are happening. One is the MCAT, which is the Medical College Admission Test. They’re now posing more questions on the humanities, not just math and science. Two, as far as the people who are majoring, they used to major in chemistry or biology, now they’re looking for people who major in sociology and philosophy. Three, and most importantly, a lot of the more progressive medical schools are beginning to teach communication, collaboration, and personal skills during the freshman year of medical school to get away from this autocratic or independent behavior.

For physicians trained under that different model that no longer applies, it must be difficult when hospitals are acquiring practices, exercising more control in ACO-type arrangements, and mandating use of EHR systems that impose standardized care guidelines and require doctors to document themselves in ways that don’t benefit them. Does that feeling of loss of control elicit disruptive behavior?

Absolutely. One of the things that I talk about is why do people behave the way they do. I talk about the internal things. Age — those different values and attitudes based on your age and your generation. There are gender differences between men and women in how they view stress and how they handle stress. There are differences from culture and ethnicity, power, issues related to gender, issues related to dominance. Then there’s all the stuff from your life, upbringing, what you’ve been exposed to.

Those are the internal factors. Those can be addressed, maybe by sensitivity training or communication skills training. 

The external events — one of them you hit on — is from healthcare reform and initiatives and the electronic medical record. There’s now more and more pressure on providers, not just physicians, to be able to demonstrate and document good value care based on what other people think, not necessarily what they think. More adherence to guidelines telling you what you can and you cannot do. Taking people away from the bedside, spending more and more time on fulfilling all the requirements of the documentation. That gets everybody very frustrated because they just want to practice good care. 

One of the key concerns right now is the significant amount of stress, burnout, and frustration that’s hitting our physician workforce as well as others. A lot of them are trying to change jobs, get out of the profession, or retire early. That’s a real issue right now, because we are — if not currently, tomorrow — going to have a workforce shortage. 

One of the things that organizations need to do as they acquire physician practices and as they get them to adhere and be compliant with their protocols, their electronic medical record — they have to work with them to help them bring them up as a precious resource and not tell them, “This is what you have to do or else.”

What tips would you have for CIOs and CMIOs on the most constructive way to deal with physicians, especially those who have a reputation of being disruptive or resistant?

On the global level, physicians needs to understand why you’re asking them to do certain things. You need to raise the business case of why reducing variation and improving efficiency is going to get you the best patient outcome. That’s what you really want in the end, whether it’s a quality issue, whether it’s a cost issue, or whether it’s a satisfaction issue. Our goal is to make the patients get the best value out of a healthcare interaction and no one, no matter where they’re coming from, is going to say that’s not an appropriate goal. So you need to set the business case.

The second thing is you need to talk about what protocols and what enhancements you have, either technological or care management, and explain to them why we’re doing this — the idea that you reduce variation, we’re trying to do best-practice care, this will give you the best practice outcome. 

The most important thing is they want us to sit down and talk to them and listen. One of the frustrations from physicians is, “I have a concern, I have a problem, I have an issue, but no one is taking the time to talk to me about what my individual concerns are.” 

One of the key steps is that you need to sit down and talk to the physicians and find out what their resistance is based on what their barriers are. If you can potentially address some of those barriers, that’s something that the organization really needs to do. 

The last piece is that besides the business case and the support, you want to provide ongoing training. When you implement or you go live, make sure that you have these work groups that are readily available to help the physician get through what they really need to get through.

Pushback against systems like CPOE seems to have lessened. Are people learning how to deal more constructively with physicians or are physicians just resigned that they have to do it?

A combination of both. People are being resigned. Remember, for physicians, it’s not just the inpatient record, it’s also the office record. With Meaningful Use and with billing, you need to get into the electronic, so there is a business reason for them. I think the technology is there.

Certainly with the newer physicians who were brought up on technology, this is not an issue. It’s mostly the physicians who have been in practice for 20 to 30 years. They’re very used to their ways of doing things and don’t understand why they need to change. With the growing need that everybody is going to have to be up and running on electronic medical records, the physicians are recognizing that this is something they really need to participate in. 

The organizations do realize this, and as they implement these new medical records, they are very concerned about getting them on board and doing the appropriate training.

Do you have any final thoughts?

Part of it is the electronic medical record and part of it is the way the physicians behave. Physicians are a precious resource. I really do believe that all they really want to do is to do their job. Everything seems to get in the way, and some of those things are right.

Reducing variation, improving efficiency and productivity, and maximizing best patient outcomes is an absolute right thing to do. But I think organizations need to recognize that physicians are frustrated, they’re angry, they’re burned out, and they’re stressed. They need to spend more time in working with the physicians to prevent the inappropriate and truly disruptive behaviors, which can have a profound, negative impact on the organization.