Morning Headlines 11/15/13

Credit-rating agency downgrades Cone Health

Standard & Poor’s has changed its outlook on Greensboro, NC-based Cone Health from stable to negative based on poor financial performance. Despite more than 300 layoffs during 2013, Cone reported a Q3 operating loss of $17 million on $806 million in patient revenue. The S&P has affirmed Cone’s AA credit rating, saying that the financial problems of 2012 and 2013 were are based largely on one-time costs. Cone spent $90 million to implement Epic and $40 million in additional Epic operating expenses over three fiscal years, as well as adding 90 full-time employees to help with maintenance and operation of Epic.

Vendors Rushing to Mark Territory in Population Health Management Land Grab

KLAS releases a report evaluating the emerging population health software market, finding that no single vendor is leading but that a handful of vendors are beginning to emerge as early segment leaders.

IBM to open up Watson to third-party developers

IBM has launched an API that will allow developers to build applications that make use of the Watson Supercomputers ‘cognitive computing’ power. One developer that has already announced intentions of developing an app is Hippocrates, from MD Buyline, that will help clinical users make real time decisions.

DOD Seeks Value, Quality in Modernizing Health Records System

In a press release issued by the Department of Defense, DoD and VA Interagency Program Office director Christopher Miller outlined what has been happening with the DoD/VA integrated EHR project as of late. Miller wears two hats within the DoD, one heading up the DoD’s EHR vendor search and the other overseeing the VA/DoD interagency department responsible for successfully planning and completing the iEHR project. Miller’s letter highlights a focus on interoperability a need to pursue meaningful data exchanges so that the DoD can coordinate not only with the VA, but also with civilian healthcare systems that often provide referral services for active duty service members.

News 11/15/13

Top News

Moses Cone Memorial Hospital (NC) sees its credit rating downgraded from stable to negative after spending $90 million to implement Epic, with plans to spend another $40 million and to add another 90 employees to support it over the next three years.

Reader Comments

From Head Scratcher: “That Allscripts announcement about implementing Sunrise at two newly acquired Montefiore hospitals comes just days after Montefiore announces the signing with Epic. Interestingly, Jack Wolf is not leading the Epic install.” Unverified.

HIStalk Announcements and Requests

Are you current with all the latest HIStalk Practice news? Some highlights from the last week include: “better-performing” practices use patient-satisfaction surveys to evaluate and improve practice operations. Doctors blame EMRs for slowing them down and reducing productive face-time with patients. Emdeon reports a Q3 loss of $16.2 million and a nine percent increase in revenues. Practices charge for online access to patient portals. Dr. Jayne’s personal physician shares impressions from NextGen’s User Group Meeting, including a review of the NextGen Patient Portal solution. Thanks for reading.

On the Jobs Page: Director of Business Development, Solution Sales Executive, Sales Excellence Manager.

Acquisitions, Funding, Business, and Stock

RightCare Solutions, a provider of decision support and transition of care technology developed by a University of Pennsylvania Nursing professor, raises $5 million in a Series B funding round.

Healthcare messaging company docBeat secures $1.1 million in a pre-Series A round.

Sales

Signal Health (WA) selects HealthUnity’s HIE, analytics, and PHR platform.

Albert Einstein Medical Center (PA) will integrate MedCurrent’s OrderRight radiology decision support system Cerner Millennium.

Wentworth-Douglass Hospital (NH) selects PatientKeeper Charge Capture and PatientKeeper Sign-Out solutions for its hospitalists and intensivists.

People

The Care Continuum Alliance appoints ICA CEO Gary Zegiestowsky to its board.

An internal McKesson email indicates that Kevin Torgersen, president of Imaging & Workflow Solutions, resigned this week for personal reasons. IWS will be reorganized under the acute care product line and several personnel changes were announced to employees.

Kevin Brown (athenahealth) is named VP of West Coast sales for CareCloud.

Announcements and Implementations

Accenture and The Phoenix Partnership deliver the first phase of an EHR across nine NHS systems in Southern England.

Virtual Radiology releases its free Radiology Patient Care benchmarking metrics.

Orion Health launches Rhapsody 5.5.

pMD announces ICD-10 Converter, which automates ICD-9 to ICD-10 conversion.

Government and Politics

CMS releases the Virtual Research Data Center, a data sharing tool that provides researchers access to Medicare and Medicaid data from their own workstations for performance analysis and data manipulation.

The Obama administration won’t require insurance companies to upgrade existing individual plans to meet ACA requirements for 2014 as long as the insurers notify consumers what ACA protections their plans don’t include and of the additional options available through insurance exchanges. The announcement comes a day after CMS revealed that 106,185 individuals had selected plans in the first period of open enrollment, only 26,794 of them through the federal exchange.

Technology

Even if I talked on the phone more I don’t think I would be an early adopter of this technology. Google files a patent for an electronic skin tattoo that sticks to your neck and serves as a hands-free microphone for your cellphone. The tattoo could also carry a lie detector that would detect skin response caused by nervousness. To be clear, I was a “no” before the lie detector part was mentioned.

Other

In Oregon, a university-based pediatric intensivist remotely diagnoses a baby’s life-threatening bacterial infection using a telemedicine workstation controlling a robot-like device. The mother says the telemedicine technology “is the greatest thing ever invented” and does not think her daughter would be alive without it.

A KLAS report finds that no single vendor leads in the population health management tools market, though early leaders are emerging based on their portfolio breadth, experience, and ability to deliver. Those vendors include The Advisory Board Company, Conifer Health, Explorys, Healthagen, Optum:Humedica, i2i Systems, McKesson, Optum: Care Suite & Impact, Phytel, Premier, and Wellcentive.

Three US organizations win the 2013 Malcolm Baldrige National Quality Award, including Baylor Regional Medical Center at Plano (TX) and Sutter Davis Hospital (CA).

Steven Brady, SVP for administration at SUNY Upstate Medical University, resigns after the university discovers that he received outside income without permission from its affiliate MedBest Medical Management, which has a $22 million contract with the university to implement a PM/EMR system.

Sponsor Updates

• Gartner positions CommVault in the leaders quadrant of its Magic Quadrant for Enterprise Information Archiving.
• Kareo launches Kareo Marketplace, a solution center to help private practices identify cloud-based applications and services to optimize their operations.
• VMware announces it will provide HIPAA business associate agreements to its customers.
• Visage Imaging will demonstrate new features for its Visage 7 Enterprise Imaging platform at RSNA December 1-5 in Chicago.
• The ICA-powered Kansas HIN reaches the connectivity milestone of providing access to more than one million patients.
• Great River Health Systems (IA) shares how Encore Health Resources provided contract review and pre-implementation assistance while transitioning to Cerner.
• EDCO Health Information Solutions recommends three point-of-care record scanning articles.
• ICSA Labs offers five tips for keeping enterprises safe from mobile app threats.
• Wolters Kluwer Health is providing a free emergency resources portal to Philippine hospitals and healthcare institutions in support of typhoon disaster relief efforts.
• HIStalk sponsors named to Deloitte’s Technology Fast 500 list for 2013  include AirWatch, Awarepoint, Kareo, InstaMed, Etransmedia Technology, Allscripts, Liaison Technologies, SRSsoft, Greenway Healthcare, Halfpenny Technologies, Imprivata, Valence Health, Vocera Communications, and VMware.
• Impact Advisors principal Laura Kreofsky discusses MU audits at next week’s Oregon & SW Washington Healthcare, Privacy & Security Forum.
• Elsevier launches Elsevier Adaptive Learning study solution for improved learning and memory retention for healthcare professionals.

EPtalk by Dr. Jayne

I’ve been digging through provider quality reports this week and it’s so tiresome. I have to know which physicians are in jeopardy of missing their bonus targets so that when they call screaming at me that the reports are wrong, I can be prepared. It’s surprising how badly some of them are doing. They receive a package of reports monthly so that they can see where they are, and our chief medical officer works with those that are underperforming to institute changes in the practice to try to increase their success. There’s only one month left in the year, however, and unless providers are only under their targets by a fraction of a percent (or see small numbers of patients), it’s not likely that they can turn things around now.

What kills me is that some of the measures they fail to hit seem to be no-brainers. Our EHR has tons of prompts to make sure that certain services are done – both passive alerts (icons, exclamation points) and “in your face” type modal window popups that they cannot get past without acknowledging. We have standing orders available that providers can print, sign, and institute in their offices (and in the EHR) so that their clinical staff can administer vaccines without individual patient orders. We have signage available reminding diabetic patients to remove their shoes and socks so the providers can examine their feet. Inevitably, though, providers miss the mark.

Sometimes I really wish I had gotten a psychology degree instead of a chemistry one – it would have been much more useful in figuring out what makes my colleagues tick. Why wouldn’t you want certain services to be on autopilot? Why would you want to have to give individual verbal orders (or heaven forbid ,enter them into the EHR yourself) for flu shots or tetanus shots? And what makes some providers very eager to get on board with these kinds of clinical protocols when others dig in their heels? If I could crack this code I could retire early.

Maybe it’s being afraid of “cookbook medicine” or just not wanting to be told what to do by others. In some cases, it’s being in denial of the clinical evidence that shows that standing orders prevent disease and disability. Maybe it’s just feeling beaten down by what the healthcare system has become. Another one of my friends just made the decision to leave clinical medicine – she finished her MBA and is off to work for one of the major health IT vendors.

I’m looking forward to 2014 as a chance to reset. Those providers that missed the mark can start over. We only have to attest for 90 days instead of the full year, so that will reduce some stress, although our impending EHR upgrade and some other payer initiatives are adding to the overall tension. I suspect that CMIOs at other hospitals and health systems are feeling the same kind of pressure, but there is not a lot we can do about it since the forces are largely external.

For me, it’s back to the quality reports. But first, another NextGen User Group special report from our roving reporter. Inga shared comments from my personal physician about the NextGen User Group this week in Las Vegas. Here’s her second installment:

NextGen UGM Update

The customer appreciation parties thrown by vendors on Monday were a lot of fun. My favorite was IMO’s elegant cocktail party held in a suite with a balcony overlooking the strip. They had Monday Night Football showing on the balcony’s big screen TV (that’s the way to live!) and an excellent wine assortment, although rumor was the MGM wouldn’t let them serve reds due to the all-white décor of the suite. The buzz on the street was that Navicure’s party was best and had nearly 1,000 attendee at the Hard Rock. I’m just a little PCP, though, so didn’t score an invite.

I noticed this display appear on Day 2, near the escalators where you enter the conference center. Only in Las Vegas can you get walk-in IV hydration and a B12 shot. It’s a cash practice with no insurance billed, so of course they can do whatever they want. One young IT guy I overheard in a session said he took advantage of it after a night of too much fun. He mentioned that the nurse who administered his IV normally works in a pediatric ER and loves working the “spa” because the patients have big veins.

There were many good educational sessions on ICD-10, Meaningful Use Stage 2, and how to improve revenue cycle and clinical documentation. A fair amount of continuing medical education credit was offered as well. The MGM did a great job with logistics for 5,000 people. This was my first User Group and the build-up to the Tuesday client event was huge. They always keep the entertainment a secret and past musical acts have included Sammy Hagar, Styx, Foreigner, Huey Lewis and some other well-known groups. The first act turned out to be the Brian Setzer Orchestra, which would have been good if the acoustics weren’t so distorted. The second was Big and Rich, which provoked a mass exodus. I was among the scattering crowd so I can’t report after that. Wednesday was a little more low-key with only two education sessions and I suspect many people left early to avoid the chaos that is the Las Vegas airport.

I forgot to send this picture earlier in the week, you have to love an airport with a liquor store in baggage claim. I relaxed on the plane on the way home reading the Twitter feed for the event and some of my favorite tweets were:

• Either I’m in ICD-10 hell or they have the heat on in room 309

Followed by:

• Do you know the ICD-10 code for burning up like you are Lucifer’s step sister?

And then:

• Depends on whether burning is via a coal- or wood-fired oven, nuclear meltdown, etc. Please consult CMS GEM mappings.

You have to make fun of ICD-10 or you’d cry, so I found it particularly funny.

All in all it was a successful meeting. I got some CME, heard some great speakers, and learned some things that should make my EHR documentation quicker and easier. I’ll definitely be back next year!

I’m glad she got to go and I was able to live vicariously through her – I’ve only been to my own vendor’s meeting. I’d love to see how the grass looks on the other side of the fence. Maybe that’s an idea – we could auction off a chance to have Dr. Jayne attend and review your user group meeting (under an assumed name, of course). Proceeds could go to charity. What do you think? Email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 11/14/13

Blue Cross and Blue Shield of Texas and Tenet Healthcare Corporation Collaborate on Statewide ACO to Improve Quality and Efficiency of Care

Blue Cross and Blue Shield of Texas will launch a state-wide ACO with Tenet Healthcare’s 10 Texas-based facilities in January 2015.

MIT’s shapeshifting display lets you reach out and touch someone

Researchers at MIT have created a prototype of a 3D monitor that it hopes will have implications in medical imaging by providing 3D visualizations of CT scans.

US, UK open public health cloud

The US and UK will begin consolidating de-identified patient data from CMS, the FDA, and the NHS in England. The data will be stored in a UK-hosted health data cloud, where it will be made available to researchers all over the world.

JAMA Delves Deep Into What’s Ailing American Healthcare

The November issue of JAMA delves into some of the critical issues within the US healthcare system and proposals to fix them. Topics included healthcare costs and outcomes, industry consolidation, and the tension between population health and individual healthcare. Ezekiel J. Emanuel, MD, PhD, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, contributed a piece challenging the healthcare industry to shrink US per capita health care cost growth to no more than GDP + zero percent by 2020. He calls for, among many things, an increase in EHR adoption and remote patient monitoring as a means to this end.

CIO Unplugged 11/13/13

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

Grilled Cheese Sandwich, Please

As a new CIO, I spent the first five years volunteering after hours for our health system. They assigned me to the greatest volunteer opportunity available. Each Wednesday afternoon, I went room to room delivering $10 gift shop vouchers to all the winners of our closed circuit TV bingo game. Bingo was the highlight of the week for hundreds of patients and their families. The game normally finished around 4 p.m. I’d pick up the certificates at  5 p.m. and hand-deliver them to the winners.

While striving to take our IT shop from bad to good, I was not always Mr. Popular with my customers. Thus, volunteering became the highlight of my week. It got me out of the office and into our hospitals. Everyone wanted to see me. Everyone welcomed me. Wednesday evenings became a salubrious respite from the work grind I faced the rest of the week.

Observing joy in the recipients’ faces brought my heart pleasure. Think about it. These citizens were stuck in a hospital. Receiving a voucher for a $10 credit at the gift shop meant everything. And their responses had an impact on me. I stopped taking life for granted and started embracing the simple things.

Volunteering routinely also broke my heart, especially those dreaded deliveries to the fifth floor of our children’s hospital. As I scrubbed in before entering the floor, I took twice as long to wash in an attempt to delay the inevitable. I was about come face-to-face with kids the same age as mine, except these children were dying.

I’d knock gently on the door and they would be looking right at me. Expectant. Picturing my own two children in their situation, I’d swallow hard and muster up a smile. But then the joy in these young patients’ faces made the grief worthwhile. Before leaving the floor, I’d stop in the restroom and let my smile fade to a cry.

I learned the value of listening. When I delivered vouchers to the elderly, they always wanted to chat. They cared more about having company and far less about the vouchers. Oh, the loneliness I witnessed! As much as I wanted to hurry the interaction and get on to the next winner, I envisioned my own parents and thought how I would love for someone to spend time with them if I could not be there.

I met many interesting characters. The love I saw between seasoned married couples encouraged me in my marriage. I recall one man holding the hand of his sickly wife. The lines in their faces proved a beautiful testimony of a life well lived and a true commitment through health and sickness.

I’ll never forget the mom who met me in the pediatric ICU waiting room. Before I could reach her child’s room, she said, “Can I use the voucher in the cafeteria?” Although the vouchers were strictly for the gift shop, I took her down there to see what we could negotiate. She went to the grill and asked for a grilled cheese sandwich. “We don’t serve grilled cheese sandwiches,” the cook said. The exasperated mother all but begged. “My daughter just woke up from months in a coma, and her first words were, ‘Mommy I’m hungry, I want a grilled cheese sandwich.’” Tissue, please. The cook made the off-menu grilled cheese sandwich while the woman wept.

Ask anyone who knows me, and they’ll tell you — often with a shudder — that I’m a Type A personality. My wife tells me I’m an extremist, all or nothing. I am wired to compete and win. I can’t climb just any mountain, I have to summit the highest peaks, all of them. Army combat training taught me to kill with my hands, and my kids say when I’m overly focused on a project, I look ticked off at the world (I’m not really, and I’m working on smiling more). But volunteering became my counterbalance. Interacting with the sick, feeble, and dying helped shave the edge off my hardcore design.

What keeps you balanced? When you see a bed of roses, do you stop to enjoy their scent? Or does just the thought of pausing to take in the “life” happening around you ruffle your nerves?

I miss bingo. I miss weekly interactions with patients. The memories still stick with me. The emotions still live vividly. And I’m ready to jump back in and refresh the experience.

Grilled cheese, anyone?

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

Morning Headlines 11/13/13

Joint Center for Cancer Precision Medicine established

In Boston, Dana Farber, Brigham and Women’s, Boston Children’s Hospital, and the Broad Institute of MIT and Harvard have announced a collaborative partnership that will pursue advances in cancer genetics to create “precision medicine treatment pathways” for patients with advanced cancers.

WESTMED Accountable Care Collaboration with UnitedHealthcare and Optum Yields Significant Health Improvements

White Plains NY-based WESTMED Medical Group reports that its year-old ACO has led to improvements in nine of 10 health quality metrics, increased patient satisfaction, and reduced health care costs.

First Estimate On Insurance Sign-Ups Is Pretty Darned Small

Fewer than 50,000 people signed up for health insurance through Healthcare.gov during the month of October, according to the Wall Street Journal. The administration had been targeting 500,000 for October, but the site launch was plagued with technical issues.

CMS Reconsiders ‘End-to-End’ ICD-10 Testing

CMS is reconsidering its earlier decision to forego end-to-end ICD-10 testing with physician’s offices, claiming at the time that it was confident that its own internal testing was sufficient. The change in tone comes in response to growing public concern about its testing of Healthcare.gov.

DrFirst Launches New Tool to Alert Doctors to At-Risk Patients and Identify Patient Medication Adherence Rates

DrFirst has enhanced its e-prescribing routine to present physicians with prescription fill rates and unfilled prescription alerts for patients at the point of prescription writing. The information will used to help physicians gauge medication adherence. It will be available either on DrFirst’s own e-prescribing system or within an EHR system that uses it.

News 11/13/13

Top News

AMIA announces in an email to members that Kevin Fickenscher, MD will step down as president and CEO on November 30, 2013 to return to industry. He took the position for 20 months ago. The search for his replacement will start immediately.

Reader Comments

From Pitiful: “Re: U. Arizona Health System. More than 9,500 glitches in its Epic EHR, claims to have solved more than 6,000. The health system is financially precarious.” Unverified. They were scheduled to go live November 1.

Acquisitions, Funding, Business, and Stock

Vocera reports Q3 results: revenue flat, adjusted EPS -$0.02 vs. $0.13, missing earnings estimates.

Alan Dabbiere, chairman of mobile device technology vendor AirWatch, expresses an interest in acquiring BlackBerry’s services division and integrating the Blackberry server technology into its device management technology to provide corporate customers a single dashboard for all devices.

Long-term care EHR provider PointClickCare acquires Meal Metrics, the developers of a web-based nutritional management solution.

AuthentiDate announces a $2.46 million private placement from unnamed investors. The company offers telehealth, referral management, and discharge management solutions, with the VA as a notable customer.

Sales

Star Valley Medical Center (WY) selects Access E-forms on Demand to eliminate paper forms.

ValleyCare Health System (CA) will implement CareInSync’s Carebook mobile communication platform for care team coordination.

The 11-provider Ocean Eye Institute (NJ) selects SRS EHR.

Denver Health (CO) selects Besler’s BVerified Screening and Verification solution.

The Nevada HIE will deploy the Orion Health HIE.

Montefiore Health System will upgrade its newly acquired hospitals in New Rochelle and Mount Vernon to Allscripts Sunrise, including EHR, Analytics, Radiology, and Laboratory and implement the FollowMyHealth patient engagement platform.

SummaCare (OH) selects Wolters Kluwer Health’s Health Language to convert ICD-9 codes and DRGs to ICD-10.

People

PaySpan names Cheryl King (First Data) CFO.

Candace Smith (Medline Industries) joins Voalte as CNO.

The VA appoints Arthur L. Gonzalez (TISTA Science and Technology Corp.) deputy CIO for service, delivery, and engineering.

Direct Recruiters, Inc. promotes Dan Charney to president.

Scotland-based Craneware appoints Colleen Blye (Catholic Health Systems of Long Island) to its board.

Announcements and Implementations

Nextgen introduces NextGen Share, an interoperability solution based on the Mirth HIE platform that facilitates clinical data exchange and referrals from within the NextGen EHR.

CSI Healthcare IT completes a Cerner activation at the University of Tennessee Medical Center.

Merge Healthcare will exit the consumer medical information kiosk business, which reportedly accounted for $10 million of the company’s $250 million in sales last year. Merge, which spent $2.8 million on 500 of the kiosks last year with an ultimately failed plan to roll them out throughout Chicago, said technology upgrades were too expensive and it agreed to get out of the business following a patent infringement lawsuit. The kiosks made up one of 11 deals between Merge and companies owned by its chairman and largest shareholder, Michael Ferro, who stepped down in August 2013.

Westmed Medical Group (NY) reports that its ACO program with UnitedHealthcare and Optum improved nine of 10 health quality metrics, increased patient satisfaction, and reduced costs since its establishment in mid-2012.

DrFirst launches the Patient Advisor Report Card, a medication adherence alert system that provides a physician with medication adherence rates for each patient.

NextGen announces NextPen Voice, a pen that accepts either voice or written input depending on user preferences and activities. It uses digital pen technology from Sweden-based Anoto, which announced three weeks ago that it couldn’t survive another 12 months without issuing new stock rights.

Four large Boston-area organizations – Dana-Farber, Brigham and Women’s, Boston Children’s Hospital, and Broad Institute – form the Joint Center for Cancer Precision Medicine, which will study the genetic characteristics of tumors to choose the best chemotherapy drug treatments for individual patients.

Government and Politics

The Wall Street Journal reports that fewer than 50,000 people signed up for health insurance through Healthcare.gov during October. Despite my “success” about 10 days ago signing up for insurance, my application now appears to be in limbo. After two support chat sessions, two support phone calls, and an email exchange with my selected insurance carrier, I’ve been advised that the normal 48 hour “acceptance” process has been delayed. I’m trying to remain optimistic that the new plan will be in place in time for me to cancel my current plan so I won’t be stuck paying for two plans come January.

Innovation and Research

The New York Digital Health Accelerator celebrates its first year and the recent success of two graduates of its nine-month mentorship program: Avado (patient relationship management tools, acquired by WebMD) and Cureatr (secure physician messaging, obtained $5.7 million in funding).

Other

If you are like me, you may be a little flash-mobbed out. However, this video of a woman dancing with the OR staff minutes before undergoing a double mastectomy brought tears to my eyes. Got to love the doctors, nurses, and techs who busted some moves with Deborah Cohan, an OB/GYN and mom of two who I wouldn’t mind having as a BFF.

Patient Privacy Rights launches a “Save Health Privacy” campaign on crowdfunding site Indiegogo, hoping to raise $10,000 to purchase privacy-friendly technology and to create a privacy education app. Donate $500 and you’ll get a dinner with PPR Founder Deborah Peel, MD.

The National Patient Safety Foundation releases an online, self-paced course titled “Health Information Technology through the Lens of Patient Safety,” targeting physicians, pharmacists, nurses, and quality professionals who are involved with both IT strategy and patient safety. Topics include organizational culture, transparency, patient engagement, integration of care, and human factors engineering. The course costs $30 and CE credits are provided. McKesson provided an educational grant to make the course possible. I’ll most likely take the course myself and report back.

A Pittsburgh internist sues a local medical billing company after its systems fail with no usable backup. The doctor concludes, “It is all in the cloud, and if the cloud disappears someday, we are all in trouble.”

Weird News Andy notes the story of an ABC reporter who got her first-ever mammogram on live national TV to call attention raise awareness for Breast Cancer Awareness Month, only to have the test reveal that she has cancer. Amy Robach, 40, will have a double mastectomy performed this week. WNA observes that under new guidelines, she would not have been a mammogram candidate until she turned 50, assuming she had lived that long without treatment.

Sponsor Updates

• Salar sponsors the Student Design Challenge: Reinventing Clinical Documentation at next week’s AMIA 2013 Annual Symposium in Washington, DC.
• Amcom Software hosts its annual user conference, Connect 13, this week in San Diego.
• NextGen Healthcare is hosting 5,000 attendees this week at its user group meeting in Las Vegas. Dr. Jayne’s personal physician offers her impressions of the conference on HIStalk Practice.
• Hyland Software and Bottomline Technologies will integrate their mobile data capture and ECM technologies.
• Elsevier adds new content types and an enhanced mobile app to Mosby’s Nursing Consult .
• Kootenai Health (ID) estimates that its implementation of the Summit Interoperability Platform saved the organization $50,000 to $75,000 in 2012 through the elimination of duplicate interface purchases and maintenance costs and the reallocation of hospital IT staff.
• ChartMaxx hosts webinars November 13 and 21 discussing ways to provide high quality care while cutting costs and improving revenue cycle.
• LDM Group sponsors the iPatientCare National User Conference November 15-17.
• Strata Decision Technology hosts a November 18 webinar on high performance decision support operations.
• Market research firm Harvey Spencer Associates ranks Nuance Communications the world’s leading scanning and capture software vendor based on market share.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 11/12/13

With Enrollment at 200K, VA’s Million Veteran Program Inks Contracts for Genetic Analysis

The VA has enrolled 200,000 veterans in the Million Veteran Program, a long-term genetics research study the VA hopes will uncover genetic links to various diseases and lead to personalized treatment strategies for veterans. With steadily increasing enrollment, the VA has also announced that they have contracted with the BioProcessing Solutions Alliance and BioStorage Technologies to provide genome sequencing for the program over the next five years.

State apologizes for patients’ records posted on Internet

The North Carolina Department of Health and Human Services is apologizing after accidently publishing the names, addresses, and payment information of 1,300 patients to a public website.

NextGen Healthcare Unveils New Interoperability Platform — NextGen Share —at 18th Annual NextGen Healthcare User Group Meeting

NextGen unveils a new secure exchange platform called NextGen Share. The product is the first collaborative product launch with Mirth since acquiring the open-source HIE vendor in September.

Curbside Consult with Dr. Jayne 11/11/13

Jayne Goes to the Doctor

Like many Americans, I’m going through my employer’s open enrollment period for health insurance and other benefits. Additionally, my health insurance is changing at the beginning of the year, so there’s a bit of a double whammy trying to pick a new plan that has the physicians I see as well as coverage that works for me. Trying to read through the various summary plan descriptions is a bit like reading a foreign language. If it’s that difficult for someone who is a healthcare professional, I can’t imagine how difficult it is for the average patient.

My hospital requires that I complete a health risk assessment (online, of course) and have biometric testing done in order to receive a discount on the employee portion of the premium. I got the results today after receiving an email to access the lab vendor’s secure portal. There I experienced what I’m sure many patients also experience – confusion and misleading information.

First, there were graphics with screaming red exclamation points indicating problems in the “heart” and “other” categories. Navigating through the results showed that anything outside the reference range flags an alert. Looking more closely, it flags the same alert whether a value is high or low, which I think is confusing for patients. My cholesterol was a few points below the reference range. Having been through several epidemiology and biostatistics classes, I know how reference ranges are derived, but the average person doesn’t understand this.

According to the accompanying text, low cholesterol “can indicate malnutrition, intestinal malabsorption, hyperthyroidism, chronic anemia, liver disease, or other medical conditions.” I happen to know I don’t have any of those conditions since I just had other (more extensive) lab work done a few weeks ago with my new primary physician. Unfortunately, my employer’s third-party health contractor wouldn’t accept that lab report and made me go again to have blood drawn. Why is this kind of waste in healthcare OK? Could they not trust labs I had done at the same national reference lab? Did I really need to fast again and have another needle stick?

Conversely, had I not been to my primary physician recently, wouldn’t it have been nice if there was a way to securely send the results to my physician? No such luck unless I wanted to print it. I’m baffled that physicians and hospitals are being required to view / download / transmit patient data but the rest of the health vendors such as pharmacies, labs, etc. are not held to the same standard.

Going forward through the website’s report for me, it displayed the US Preventive Services Task Force recommendations for a person my age. It wasn’t surprising that USPSTF recommends screening less frequently than my employer requires. Based on my age and values, I don’t need another blood pressure screen for two years. I don’t actually need a cholesterol screen at all – I have no risk factors and am below the screening age. I don’t need a diabetes screen either, yet I was required to have both of these two tests done in order to receive a discount on my insurance premium. I’ll also have to do them again next year despite the fact that I still won’t need them.

There were some things about the visit to the biometric screening lab that were less than optimal – they relied on my reported height rather than measuring me and didn’t bother to ask if I had fasted or not. I don’t advocate cheating on health-related tests, but I wonder how many people do? Another inch of height always makes a girl’s BMI look a little better.

At the draw station, tubes from multiple patients who had gone before me were sitting in a rack with names visible. I was required to sign a form that said the blood tubes had been labeled in my presence and were accurate, but I didn’t actually see the tubes and the phlebotomist didn’t actually ask me to sign the form but instead pointed and shoved a pen at me.

Bottom line, though: I did my health assessment and got my discount. Now I get to spend the next couple of weeks trying to fit in various health appointments before my insurance changes. I’m sure it will be fine, but it’s always a pain to figure out new coverage and I’d rather just get things done on the plan I’m familiar with (and with my deductible already satisfied for the year).

My previous physician’s practice had issues with its patient portal, including erroneous demographics that they never could correct and a kludgy user interface. My new physician has a slick portal and actually sent timely and relevant information to me after my visit, so I’m glad I get to keep her.

Have a good health IT story from the patient side? Email me.

Email Dr. Jayne

HIStalk Interviews Terry Edwards, CEO, PerfectServe

Terrell “Terry” Edwards is president and CEO of PerfectServe of Knoxville, TN.

Tell me about yourself and the company.

I started PerfectServe in the late 1990s. Prior to that, I was with a company called Voicetel, which was one of the early pioneers in the interactive voice messaging space. While I was there, I identified needs to improve communications in the healthcare industry, starting with the physician practice. All of our early development was working with physicians and independent practices, group practices around the country. We began to grow the company. 

In 2005, the practice opportunity led into the hospital in the acute care space. We entered that market in 2005 and that’s been driving PerfectServe’s growth ever since. In terms of where we are today, we have 80 hospitals under contract. We’re serving doctors in about 12,000 practices in the country. There are more than 30,000 physicians on the platform today. We’ve had good growth.

In the old days, hospital people would  have a list of pager numbers for doctors or would call their answering service. How has that changed?

There’s more variability today than there was. We’ve got not only pagers, we’ve got secure messaging apps, we’ve got websites where we can go to get messages to people. We still have a plethora of answering services, call centers, and hospital switchboards. It’s all this variability that results in the inefficiency in communications overall, between clinicians especially.

You mobile app does just about everything—doctor-to-doctor calls, calls to patients that mask the originating number, and secure messaging. How are doctors using all those options?

The mobile app for us is just one interface into the platform. It’s designed for the doctors to do a number of different tasks, some of which you mentioned. 

The real core value that PerfectServe provides is enabling more accurate and reliable processes. We’re taking out a lot of the variability, some like we described earlier, and as it relates to different contact methods or different contact modalities. There are also process rules that tend to be based around clinical work groups, whether it be three cardiologists over here or maybe it’s a STEMI team or a stroke team or a group of internal medicine doctors. 

For every one of these little groups of practicing clinicians, there are a host of if-then type rules to determine just whom to get a communication to.  For example, if we need to contact a hospitalist, we may need to know whether this is about a new admission or an established inpatient because the clinician who receives that communication is likely to be different. If it’s an inpatient, it’s which hospitalist is caring for this patient right now at this moment in time. It’s those things that add another layer of complexity. 

PerfectServe’s strength is in building those routing algorithms into software so that we eliminate the need for the initiator to know who to contact. We’ll route the communication automatically to the appropriate provider. That’s how clinicians are using PerfectServe. It’s about connecting with the right person. 

If I’m a doctor, it’s about making sure that I’m getting the calls and messages I’m supposed to receive when I’m supposed to receive them. That mobile app that you see enables me to do some things like change my call schedule, change my contact modality, follow up with a patient, access messages securely, and access colleagues.

You’re saving time and improving efficiency, but what’s the patient benefit or the satisfaction benefit to the clinician?

We’re taking waste out of the communication cycle time. This is important because in every hospital, every day, hundreds — or if it’s a large hospital, thousands — of times a day, nurses and other hospital staff or other clinicians are reaching out to doctors in the course of providing care. Some of them are in the hospital. Many of them are not. Sometimes it’s not just a doctor, it’s another member of the care team, such as a nurse practitioner. 

We’ve done a number of studies — time motion studies, process flows — and PerfectServe has proven to reduce the subsequent or repeat call attempts by 81 percent and cut the nurse-to-physician communication cycle time by more than two-thirds. In fact, we did one study at the Orange Coast Memorial Medical Center in Orange County, California where we took the average nurse-to-physician contact time from 45 minutes down to 14. 

What that means is that clinicians are able to intervene more quickly because these are all care-related communications. They will range everywhere in urgency to “I need you right now, a patient could be coding” to “this is something that’s important, you probably need to know about it by tomorrow morning so you can take action when you come in to round.” These things have an impact on patient care risks in terms of reducing sentinel events and can have an impact on throughput. We’ve had clients measure improvements in ED throughput, impact on length of stay, reduction in code blue events, and many, many areas of hospital operations.

Does your system help close that loop where you page someone, you never get a call back, and the ball gets dropped?

It depends. Oftentimes there may need to be multiple contact methods deployed. Just due to the increased concern around HIPAA, we’ve had a higher adoption of secure messaging as a primary means of contact when a message is involved versus a live phone call. But secure messaging is reliant on our mobile app, which means we’re dependent on the wireless networks, whether it be Wi-Fi or the cellular. While we’ve got much better cellular coverage and Wi-Fi coverage than we had five or 10 years ago, we still have areas where the coverage might be somewhat spotty. 

As we’re working with our clients and our physician end users, we will try to get them to adopt fail-safe processes. In a fail-safe process, we might be notifying one or multiple wireless devices, so we could be sending a push notification out via Apple’s push notification services, for example, but if the message is not retrieved within a certain time period, we might escalate to a pager, which a doctor still may need to carry based on where he or she goes in the course of practicing medicine. That still may be the most reliable device for them.

Most people would say that texting and paging aren’t HIPAA-accepted ways to communicate PHI. Do you think hospitals are worried about that?

There’s a lot of confusion in the market related to HIPAA compliance and secure texting. It stems from not a real good understanding of what the laws say. There’s nothing in HIPAA regulations that says sending a text message is a violation. What the laws say is that you as an organization, as a covered entity, need to conduct a risk assessment. Based on that risk assessment of where PHI is being transmitted and floating around in your organization, you need to establish effective policies and then implement those policies using various tools and technologies. Then monitor your performance over time. 

There’s like this spotlight that’s  being directed towards just text messaging. But when we look at clinical communications, it’s like a floodlight. What we see is that there’s PHI floating in a lot of different places via a lot of different means. That’s the part that I think the industry doesn’t fully understand right now. We’re doing our part to educate people. We’re beginning to see people understand that there’s more to that issue than just texting.

How are you finding the quality of the average hospital’s Wi-Fi?

Because we are able to work with a number of different modalities, we’re device agnostic from that standpoint. But it is interesting. We see a variety of different qualities of Wi-Fi infrastructure and we also hear a variety of different things. Wherein some organizations, the IT group might say that the Wi-Fi network in its organization is really robust, and then you talk to some of the physicians and they’ll tell you exactly the opposite. So it’s kind of spotty. I wouldn’t say universally across the board that the industry has overall a real robust infrastructure. I would still say that it’s fairly spotty and organization dependent.

One of your selling points is you don’t just work within the four walls.

That’s right. PerfectServe is really about improving clinical communication processes. That’s the heart of what we’re about doing.

I talked about getting into the acute care space. The core application that’s driven the growth there is improving the hospital-to-doctor communication process, because it’s one that’s filled with a lot of complexity. As we come into an organization, we’re about enabling the clinical leaders to enact and drive a process change across the entire medical staff. We have the technology to do that, but we also have the implementation services to make sure the technologies are implemented properly. In other words, the algorithms are built based on the workflows of the different groups and the physician preferences. We’re also able to share best practices because we’ve learned so much working with doctors around the country. 

We’ve also have the support services to help them maintain that improvement over time. Our client advisors work with our customers to then build on those improvements. That’s really key, because a lot of the problems that organizations might want to solve — whether it be say around a consult process, critical test results communication, or ED patient notification — many of these problems can’t be fixed because the underlying process infrastructure is broken. When we deploy, we’re coming in and fixing that underlying process. Once you have it fixed and you have everybody on a common platform, you can then build on it, and that’s where the client advisors come in. 

The other piece is that the applications work not only in the acute space, but they work in the pre- and the post-acute space as well. We may have, for example, a group of hospitalists and a group of referring primary care doctors. We’re able to manage communications between the two of them, between the nurses and the hospitalists, among the primary care doctors and their patients, as well as maybe the skilled nursing facilities or the long-term care facilities where those doctors are also seeing patients. It’s just one system that the doctors have to manage the communications that flow from all these different sources. That’s a real strength of the organization. We’re able to do it via platform that enables them to achieve their HIPAA compliance standards as well.

The company’s been around 16 years and you’ve been there the whole time. What are the biggest lessons you’ve learned about building a company?

Oh, gosh, there are a bunch. I think I’m going to write a book one of these days. There really are many. There are lessons from just general things of starting up any kind of business to working with venture capitalists in raising money and the challenges you go through as you take a company through its various stages of growth. Organizations change significantly when you’re going from $1 million to $5 million in revenue, and then from 5 to 10, and 10 on to 20. The fact that I’ve been able to go through all those various stages has been quite an experience. 

Just selling into hospitals is tough. It takes time to get traction. You’ve got to be persistent. You have to be patient. I love working in healthcare because I enjoy the people. Most of the people that we get to work with — the doctors, the nurses, the executives running hospitals — really want to do the right thing. That’s what we’re here to help them do. But it’s been a lot of fun at the same time.

Morning Headlines 11/11/13

White House tech expert gets subpoena to testify on HealthCare.gov

Todd Park, the US chief technology officer, has been issued a subpoena by the House Oversight and Government Reform Committee to testify at a hearing next week about what went wrong with the Healthcare.gov website. The committee says he was not willing to appear voluntarily, while the White House responded that the subpoena was unnecessary and poorly timed because Park is heavily involved in fixing Healthcare.gov and had already volunteered to testify in December.

Region Zealand and the Capital Region points to Epic as a provider of Health Platform

Epic, working with NNIT as a prime contractor, will sign a contract to provide EHR systems for all of eastern Denmark, according to a translated press release. The deal will involve 40,000 users and is valued at $180 million.

University Hospital sees banding together for survival

University Hospital (GA) will likely join Novant Health Inc., a 20-facility network based in Charlotte, NC. University Hospital’s CEO cites ARRA and the ACA as having too significant an impact on the bottom line to keep up as a standalone facility. The hospital spent $50 million on Epic and is looking for an additional $30 million to cover needed upgrades.

Report: CCO diversion program working

In Oregon, a recent report finds that a statewide coordinated care program has managed to reduce overall ER visits by 9 percent from 2011, before the program was launched. Emergency care spending also declined 18 percent from 2011. Outpatient primary care visits have increased by 18 percent and spending for primary care is up 7 percent.

Monday Morning Update 11/11/13

From Dash Riprock: “Re: Allscripts. Cliff Meltzer leaving a year after being elevated to the tech savior is troubling. Customers give him credit for fixing the technology problems left behind by the previous executive team. Was it a difference of technical opinion or something else?” Allscripts seems to be betting its future on the hope that the recently acquired dbMotion and Jardogs will allow it to jump on the fashionable population health bandwagon to avoid the competitors that are beating it soundly in hospital and practice new sales, with hosting and add-on services generating recurring revenue from existing customers of products that are rarely mentioned these days (the stable of practice systems, Sunrise Financial Manager, the former Premise, Allscripts ED, e-prescribing, etc.) providing revenue to give the battleship time to turn. Putting Jim Hewitt from Jardogs in charge of development might reinforce that perception. Paul Black came from Cerner and that sounds exactly like Cerner’s strategy, other than Cerner was already highly successful with better management, the broad and deep Millennium product line was more credible, it developed rather than acquired its core systems, it knows how to meet the expectations of both Wall Street and clients simultaneously, and Cerner’s DNA doesn’t include the comically mismanaged Misys, Eclipsys, and late-stage Glen Tullman Allscripts. The Allscripts pitch seems to be entirely focused on population health and whatever of its pieces and parts can be cobbled together to claim a solution for it, and given the frothy enthusiasm in population health technology, why not? To the company’s credit, Wall Street seems to be buying it for now, probably because it’s trusting Paul Black to figure it all out. He’s been in charge since December 2012 and MDRX shares are up around 20 percent since then, although their performance lags the Nasdaq index, which was up up 30 percent in the same period.

From The PACS Designer: “Re: Apple’s LTE hub. As our IT environment fills up with more iPads, it becomes practical to ensure connectivity options are available no matter where you may be daily. With the Apple LTE communications function, everyone present can connect to the Internet and cloud services as long as at least one laptop is running the Apple iOS with the LTE mobile hotspot option. There is some disadvantage in that as more iPads join the group, the LTE network will have a slower response time for Internet queries.”

Buy Cerner shares if you want to invest in healthcare IT, poll respondents say. Looking back one year, your $10,000 investment would now be worth $22,488 (athenahealth), $14,811 (Cerner), $11,818 (Allscripts), $8,106 (Merge Healthcare), and $13,688 (Quality Systems). New poll to your right: how well do hospitals and practices use the data they already have to make improvements? Dr. Jayne pointed out that hospitals that don’t seem to have much interest in doing anything with the piles of data they’re already collecting are inexplicably salivating over big data. There’s no need for big data envy until you’ve wrung out every possible improvement from the “little” data you already have, which few hospitals and practices have done.

Thanks to the following sponsors, new and renewing, that recently supported HIStalk, HIStalk Practice, and HIStalk Connect. Click a logo for more information.

Jeffrey Allport (JLA Insights) is named VP/CIO of Valley Presbyterian Hospital (CA).

The House Oversight and Government Reform Committee subpoenas US CTO Todd Park to testify at its November 13 hearing about Healthcare.gov, saying that he is the only administration witness “unwilling to appear voluntarily.” The White House responded that the subpoena was not necessary since Park offered to appear in December after he finishes work on the struggling site. The White House says it will “respond as appropriate.”

Epic and service provider NNIT win a big EHR deal for all of eastern Denmark, beating out Cerner and IBM/Systematic. According to a press release translated from Danish, “We have chosen Epic and NNIT’s offer as the economically most viable. All three bids included good, professional suggestions for the healthcare platform but in the end we chose the offer that scored the highest on the parameters we had defined for the bid in advance. Now we look forward to seeing the positive effect for our professional users and not least the patients.” The project for Regions Zealand and Hovedstaden, which will involve 40,000 users, is valued at $180 million. The Denmark-based Systematic was probably the pre-decision favorite. NNIT, oddly enough, is owned by drug manufacturer Novo Nordisk and, not so oddly, is also headquartered in Denmark.

From the Allscripts earnings call Friday:

• CEO Paul Black blamed missed revenue numbers on the transition to subscription pricing. Not to be cynical, but surely this is the longest streak of quarterly reports in which a company blames its own voluntarily chosen strategy for causing disappointing results.
• Most of the discussion revolved around population health and 40 percent of the Q3 bookings came from it.
• The company talked up its electronic referral network and homecare solutions.
• Black said 90 percent of Sunrise clients will commit to the 6.1 upgrade by the end of the year.
• Both system sales revenue and professional services revenue were down, causing non-GAAP revenue to drop by 7 percent year over year.
• Black confirmed that SVP Jim Hewitt, former Jardogs CEO and CIO of Springfield Clinic, will replace Cliff Meltzer as the head of development, although didn’t really answer the directly asked question of why the replacement was necessary.
• Ambulatory solutions were hardly discussed except in the context of forming a network to connect all Allscripts users.

According to a tweet by former National Coordinator Farzad Mostashari, MD, the HIMSS EHR Association “can’t just say, ‘we don’t want FDA regulation.’ Have to work hard to make the (ONC) alternative work.”

The PR company that manges ONC’s “Health IT Buzz Blog” wins a PR society award for their efforts. You might be surprised (but probably not) by how many company blogs are ghostwritten or edited by freelance writers and PR flacks, aimed at promoting rather than informing. HHS/ONC awarded Ketchum a $25.8 million public relations contract in 2010  because of its track record in gaining public acceptance for unpopular projects, placing provider EHR adoption and patient privacy concerns in that category. The government has a history with Ketchum: the GAO said that a 2004-2005 series of Ketchum-produced prepackaged “news” reports sent to local TV stations to run as their own, complete with actors pretending to be journalists reporting from Washington, were actually “covert propaganda” that failed to disclose that the government paid for them.

ONC names the winners of its recent patient empowerment codeathon. In the Blue Button category: Edge Interns (patient health evaluations), Light Hearts (discharge CHF workflow), and Patient Watch (wearable device data tracking). In the financial category, WTF! Denied (redesign EOB and surely the most interesting name among the participants), MintMD (patient cost presentation), and Archimedes (ranks personalized insurance plans from California’s insurance exchange).

The CEO of University Hospital (GA) says hospitals will probably have to join in regional alliances to survive because of EHR costs and the Patient Protection and Affordable Care Act. CEO Jim Davis, whose hospital spent $50 million on Epic and is facing another $30 million in upgrades, is considering signing a shared services contract with Novant Health, saying he can’t compete with that organization’s 20-hospital economy of scale. “When Novant, which has 20 hospitals, does an upgrade on their Epic system, which takes a lot of work, they spread that cost over 20 hospitals.  When I do that same upgrade, I spread it over one. If I can be the 21st hospital that (cost) gets spread over, then everybody’s costs goes down.” He’s worried about PPACA because Georgia opted out of Medicaid expansion and even those who buy insurance will probably buy the cheapest plans with high deductibles and lower provider reimbursement.

Weird News Andy isn’t impressed with the excuse of a Florida doctor caught on surveillance video stealing a framed bird picture from Naples Community Hospital by slipping it under his white coat after hours: the doctor claims he was just borrowing it.  

The city of Washington, DC seeks guardianship of its most frequent 911 caller, with its Department of Behavioral Health filing a court petition claiming that the 58-year-old woman (who was named in the report and in the newspaper story) has psychiatric disorders and insufficient mental capacity to make medical decisions for herself. The woman started calling 911 for fainting spells in 1997 and hasn’t stopped, racking up 226 calls and 117 ambulance transfers in the past year alone.

Monday is Veterans Day in the US, set aside to honor everyone (living and dead) who has served in the military. If you served, thank you. If you didn’t, thank them. Use hashtag #HonoringVets on Monday.

A reader asked me to re-run my 2007 list of EMR rollout rules. Here you go.

Mr. HIStalk’s Universal Rules for Big EMR Rollouts (From 2007)

1. Your hospital will pledge to make major process changes, vowing to “do it right” unlike all those rube hospitals that preceded you, but the executive-driven urgency to recoup the massive costs means the noble goals will change to just bringing the damn thing up fast, hopefully without killing patients in the process.

2. The project and/or system must be anointed with an incredibly dopey and user-embarrassing name, preferably chosen from user submissions and with the offer of crappy vendor paraphernalia or lame IT junk as a prize, and also preferably made up of a far-fetched phrase whose contrived acronym spells out a medically related word or female name. Instead of inspiring the expected collegial chumminess among users, it will serve as a bitter reminder of the innocent, naive days between RFP and go-live before it got ugly.

3. Doctors won’t use it like you think, if at all, because hospitals are one of few organizations left that doctors can say ‘no’ to.

4. You’ll spend a fortune on mobile devices and carts that will sit parked in a corral due to the short life of their $100 battery and a dysfunctional but not yet fully depreciated wireless network, the keystone arches to the entire project.

5. All the executives who promised undying support to firmly hold the tiller through the inevitable choppy waters and who overrode all the clinician preferences in a frenzy of inflated self esteem will vanish without a trace at the first sign of trouble, like when scarce nurses or pharmacists threaten to leave or when the extent of the vendor’s exaggeration first sees the harsh light of day in some analyst’s cubicle.

6. It will take three times as long and twice the cost of your worst-case estimate.

7. You’ll pay a vendor millions for a software package consisting of standardized business rules, then argue bitterly that all of them need to be rewritten because your hospital is extra-special and has figured out the secrets that have eluded the vendor’s 100 similar customers. The end result, if the vendor capitulates, will be a system that looks exactly like the one you kicked out to buy theirs.

8. You’ll loudly demand that the vendor ship regular software upgrades to fix all the bug issues you submit, but then you’ll refused to apply them because you’re scared of screwing something up with the skeleton maintenance staff you can afford, given that millions were spent on systems with nothing left for additional IT support staff or training.

9. All those metrics you planned to collect to show how quickly the EMR would pay for itself instead show the situation unchanged or getting worse, so factors beyond your control will be blamed (like a ridiculously long implementation time that changed all the assumptions and external conditions) and ROI will not be brought up again in polite company.

10. No matter how unimpressive the final result toward patient care or cost, the EMR will be lauded far and wide as wonderful since the vitality of the HIT industry (vendors, CIOs, consultants, magazines, HIMSS, bloggers) requires an unwavering belief that IT spending alone will directly influence quality, even when nothing else changes.

Vince continues his fascinating HIS-tory of McKesson, this time covering its acquisition of IBAX. He’s looking as always for fun stories, photos, and memories from folks who were there and his contact information is on the last slide.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: My Simple Solution to Privacy and Security: Publish Everybody’s Electronic Medical Records on the Internet

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in December 2009.

My Simple Solution to Privacy and Security: Publish Everybody’s Electronic Medical Records on the Internet
By Mr. HIStalk

Before I knew better, I worked for a crappy and perpetually money-losing hospital software vendor. A key to our non-competitiveness was an unbroken string of clueless executives (is that redundant?) who were either first-time managers or bottom-feeders.

One of those manglers (as we wittily and privately called them in pathetically insignificant resistance to their tyranny) decided that it made perfect sense that we support center people would pick up each other’s voice mails.

That particular mangler’s underdeveloped brain had reasoned thusly: customers might call an analyst’s extension directly (despite company rules specifically forbidding that practice) and leave an important message (like, “Our entire system just crashed and patients are dying as a result, so I thought I’d leave this personal voice mail message on your unlisted extension rather than calling the 800 number”).

(Spoiler: weeks later, an equally uninspired analyst, in a rare burst of analytical skill, asked the obvious question: couldn’t we just change our voice mail message with instructions for clients to call the 800 number? The mangler furrowed her brow for several minutes and finally acknowledged that this innovative practice might indeed be worthy of a trial project.)

So the mangler decided each of us would pair up with a phone buddy (I wish I was making this up, but I’m not) and we would share our voice mail codes and listen to each other’s messages, thereby helping customers who were loathe to follow our rules about not leaving them in the first place.

It would have happened except for the strenuous objections of one analyst, who was agitated that those messages might include medically related ones (probably depression-related since all of us were on shaky employment ground with our nose-diving employer).

I still think about that ridiculous episode today, primarily trying to answer this question: why are we so protective of our medical records? We’re all subject to the same human frailties, so anything you have that’s dysfunctional, too big, too little, oozing, or wrinkled makes you one of a large number of people having that same characteristic.

In 30 seconds of hard analysis, I drew this conclusion: it’s an animal reflex to hide weaknesses from predators (such as company back-stabbers, stalkers, and insurance companies).

Because of those fears, privacy and security concerns threaten to derail EMR adoption and data exchange. It costs a bundle to encrypt, decrypt, lock, track, and manage electronic health information. Hackers rise to the challenge regularly.

I have a solution. It draws inspiration from those cold-weather socialists in Norway who recently decided to place all tax records online. Anybody can look up anybody else’s income and net worth (“tax porn,” the wags call it). The Norwegians believe that universal access to that knowledge will apply constructive pressure for equality.

My can’t-miss proposal is this: we declare that all medical records and insurance files are immediately and forever placed in the public domain.

I think this flash of insight makes me a thought leader since nobody else has recommended it. Once the initial outrage wears off, we’ll get used to the concept that if society is taking care of everybody, then society gets to see the result. I see many advantages:

• We could immediately stop worrying about breaches of privacy since there isn’t anything to breach. And since there will be no privacy, we also won’t need security.
• Lame RHIOs and HIEs wouldn’t need to keep pretending they have any chance of success that doesn’t involve government welfare since providers can get clinical information directly.
• Providers have no excuse for not checking allergies, meds, and past surgeries since it’s as easy as Googling “Tiger Woods mistress”.
• It adds a much-needed layer of personal accountability to those having their healthcare costs paid for by someone else (which is almost everybody, since patients are appalled at the idea of spending their own money for their health and well-being). Say, neighbor, I happened to run across your medical records and maybe you want to drop a few pounds and cut back on the prescription narcotic use, eh?
• It connects the life sciences industry to potential clinical trials subjects. I noticed that thing growing on your lung – do you want in on our multi-billion dollar drug study in return for a Chili’s gift certificate?
• It would make everybody feel better about their medical condition since they can easily find people who are worse off than they are.

My plan, unlike all those stimulus-happy privacy projects, is revenue-positive. Google and Microsoft are failing miserably to convince people they need personal health records, so the federal government will offer them the chance to outbid each other for the right to host the records and charge for access (or and splatter context-aware text ads on every page). They can charge whatever they want, but Uncle Sam gets his 80 percent cut off the top.

Then we use that money to buy EMRs (which will improve since vendors won’t be wasting their time on privacy and security functions) and to start paying down the crushing national debt.

I couldn’t possibly accept any kind of recognition or compensation for this significant contribution to humankind. Well, maybe just one thing: I get to keep all the ad revenue generated from page views of medical information involving celebrities and politicians.

Morning Headlines 11/8/13

Allscripts Healthcare Posts Q3 Loss

Allscripts reports Q3 results: revenue dropped to $330 million, compared to $360 million a year ago. EPS $0.05 vs $0.23, missing analysts estimates.The company also announced that it has fired  Cliff Meltzer, EVP of solutions development.

Data Analytics Update: Health IT Policy Committee Meeting

CMS has paid $16.5 billion in EHR incentive payments thus far. Meditech, Cerner, and Epic customers account for almost half of Stage 1 hospital attestations. Epic, Allscripts, eClinicalWorks, and NextGen represent almost half of Stage 1 EP attestations.

HIMSS Offers Guidance to HHS on FDA Regulation of Health IT

In a letter to HHS Secretary Kathleen Sebelius, HIMSS argues against FDA regulation of EHRs as a medical device, instead proposing "a new risk-based oversight framework that takes into account factors such as risk relative to intended use and cost/benefit of any proposed oversight."

Results From Survey on Health Data Exchange

eHealth Initiative’s 10th annual health data exchange study consolidates survey responses from representatives at 200 HIEs across the country. Respondents report that large scale interoperability is still too difficult and expensive for most to sustain on revenue alone. Currently, only 25 percent of respondents report that they are earning enough to operate independently.

News 11/8/13

Top News

Allscripts reports Q3 results: revenue down 8 percent, adjusted EPS $0.05 vs. $0.23, missing estimates on both. By GAAP standards, the company lost $48.9 million in the quarter. The company also announced that it has fired Cliff Meltzer, EVP of solutions development since July 2011, and will pay him severance that includes his expected one-year salary and bonus totaling $900,000. A reader’s rumor suggests that former Jardogs CEO Jim Hewitt, named Allscripts SVP of development after the the company acquired Jardogs in March 2013, will replace Meltzer. I interviewed Hewitt in June 2012.

Reader Comments

From HerkyHawk: “Shoes. A Symantec representative was wearing these shoes at the Virginia HIMSS meeting. They serve a dual function: conversation starter and castrator for when she gets angry.” Readers often send me photos of fun shoes, for which I am thankful. This shoe earned a rare mention on HIStalk because its owner clearly understands that shoes offer so much more than foot protection.

HIStalk Announcements and Requests

A few goodies you may have missed from HIStalk Practice this week include: the implementation of HIT in practices reduces the demand for physicians. CMS says it’s not appropriate to charge patients a fee to access their records online. A reader worries about ZocDoc and HIPAA compliance. Lawmakers consider phasing out fee-for-service billing in favor of rewards-based models. The government shutdown delays the release of the 2014 Medicare physician fee schedule. Jaffer Traish of Culbert Healthcare Solutions discusses EHR clinician adoption and change management. Dr. Gregg shares a post-Halloween nightmare. Julie McGovern of Practice Wise offers advice for providers seeking a replacement EMR product. Micky Tripathi’s “Pretzel Logic” post is called Have Sympathy for Your Vendor. Thanks for reading.

HIStalkapalooza planning has begun for the February 24 event at the HIMSS conference in Orlando. It’s too early to announce the sponsor, venue, and other details (registration won’t start until right after New Year’s) but I always get requests from companies asking about co-sponsoring it along with the primary sponsor. The previous sponsors have always declined to share the limelight, but this one is OK with the idea and has a plan for providing exposure and recognition at the event because it’s going to be really big and impressive. Let me know if your company is interested.

Acquisitions, Funding, Business, and Stock

Verisk Analytics reports Q3 results: revenues up 10 percent, adjusted EPS of $0.62 vs. $0.54, missing analyst estimates on both measures. The company noted that its “healthcare business delivered growth that was below” plan, but it remains “enthusiastic” about the longer-term outlook.

Midwest grocery chain Schnucks follows its competitor Walgreens by opening its first 6,500 square foot IV infusion center, offering patients free Internet access, a TV, a snack bar, and evening and weekend appointments. The center’s pharmacist and two nurses can either infuse the medications on site or prepare them for home administration.

Sales

In England, BT selects Harris Corporation to supply clinical portal solutions for health and social care organizations across the NHS.

The California Office of Health Information Integrity awards contracts to Humetrix, UC San Diego Department of Emergency Medicine, and the Santa Cruz HIE to participate in a PHR demonstration project.

Huntsville Memorial Hospital (TX) selects StrataJazz from Strata Decision Technology for cost accounting, operating budgeting, long-range financial planning, and capital planning.

Mammoth Hospital (CA) chooses the MEDHOST emergency department information system.

People

Coker Group hires Jeffrey T. Gorke (Castle Gate Management) as SVP of practice management.

VA’s acting CIO Stephen Warren is named executive in charge of the office of information and technology and CIO.

Capsule names Didier Argenton (Siemens Healthcare) as VP of international sales.

Patricia Sengstack, DNP, RN, formerly deputy CIO of NIH and currently president of the American Nursing Informatics Association, is hired as chief nursing informatics officer of Bon Secours Health System (MD). 

Announcements and Implementations

Software Testing Solutions will provide automated testing services for Sysmex WAM decision support software for the clinical laboratory, validating the system’s rules, application settings, and workflow practices.

Surescripts adds 12 Epic health systems to its national clinical network, including Swedish, UCSD, UCSF, and Community Health Network.

pMD expands its charge capture secure messaging feature with real-time alerts and direct text messaging.

Government and Politics

CMS CIO Tony Trenkle will leave the agency, according to an internal email sent to CMS employees.Trenkle oversaw $2 billion in annual IT products and services, including the development of the healthcare.gov website. Dave Nelson, the current director of the office of enterprise management, will serve as acting CIO.

CMS paid $16.5 billion in EHR incentive payments to over 325,000 EPs and hospitals through the end of September. Customers of Meditech, Cerner, and Epic account for almost half of all hospitals that have attested for Stage 1 MU; customers of Epic, Allscripts, eClinicalWorks, and NextGen represent almost half of all EPs that have attested for Stage 1.

USO CEO Sloan Gibson, the President’s nominee for the VA’s deputy director position, says in his nomination hearing that he will focus on the agency’s disability claims backlog and the integrated EHR (i-EHR) project of the VA and Department of Defense.

The Military Retirement and Compensation Modernization Commission, reviewing the failure of the VA and Department of Defense to create a single EHR, floats the idea of combining the entire health systems of the VA and DoD into a single organization, with former Senator Bob Kerry stating, “If [VA and DoD] can’t work together, put one of them in charge. Pick your poison, I don’t care which one. Create a unified command with DoD or put VA in charge.” Former Indiana Congressman Stephen Buyer agreed by saying, “If you had one chief information officer in charge of budget and line items for both, this problem and many others would not be an issue.”

I signed up on Healthcare.gov this week just to see what all the fuss was about. I have to say it was a pleasant experience – the much-criticized identification system worked great and the entire process to get quotes took maybe five minutes. Once I saw the prices I’m glad I have hospital-subsidized medical insurance. I  wasn’t as pleased with the site when I logged back in later – it seemed to be confused that I had requested quotes without buying insurance, and I kept getting warnings about pending messages when there weren’t any. Trying again just now, all I got was a blank screen with no options, and clicking the “Get Insurance” tab just took me back to the default page.

Other

Jackson Health System (FL), planning how it will spend the $830 million it will get from a just-passed property tax referendum, says it will upgrade rather than replace Cerner with the $130 million that is intended for EMR-related improvements.

An investigative report finds that financially struggling Lifespan (RI) paid its now-retired CEO $8 million in 2011, raising his 14-year total compensation with the organization to $39 million.

HIMSS, trying to ensure that FDA doesn’t regulate EHRs as medical devices, proposes to HHS a “risk-based oversight framework” that would consider the risk when used as intended and the cost vs. benefit of oversight. It makes sense – HIMSS points out that non-clinical IT that has no patient safety implications doesn’t oversight. They also don’t want vendors to be solely responsible, with surveillance and reporting responsibilities to be shared among vendors, providers, and government. They suggest that vendor responsibility ends once their control of their product ends, such as when users customize it.

Weird News Andy is at a loss for all but one word: unbelievable. A man claims that city police in Deming, NM pulled him over for rolling through a stop sign at Walmart, then decided from his posture and previous behavior that he was hiding drugs in his anal cavity. A judge issued a cavity search warrant but the local ED doc refused to do it, saying it was unethical. The man was then taken to Gila Regional Medical Center, which obliged by performing two sets of x-rays, two rectal probes, three enemas, and a colonoscopy, all without the man’s consent and with no drugs were found. The hospital is adding its own version of anal intrusion to the story by not only billing the man, but threatening to turn his debt over to collectors.

Sponsor Updates

• Informatica achieves top marks for customer loyalty, overall quality of products, and product reliability in the 2013 Data Integration Customer Satisfaction survey.
• Halim Cho, director of product marketing for Covisint, will discusses the importance of cloud identity and access management at the November 20 Gartner Identity and Access Management Summit in Los Angeles.
• Intelligent InSites VP Marcus Ruark presents on the value of operational intelligence at this week’s Data Intelligence for Health Care Conference.
• QuadraMed will add Health Language terminology management solutions to its QCPR platform.
• Bottomline Technologies hosts its second annual Healthcare Customer Insights Exchange this week in Del Mar, CA.
• Airwatch secures additional office space for its UK facility to accommodate recent growth.
• Verisk Health publishes its schedule of events through the end of the year.
• Vocera’s chief medical officer Bridget Duffy offers ideas for improving patient satisfaction scores.
• eClinicalWorks CEO Girish Navani predicts that patient engagement and population health management will become essential components of EHRs.
• Predixion Software publishes a white paper on embedding predictive analytics into software.
• PGA Championship winner Jason Dufner gives Greenway employees a putting clinic.
• Hayes Management Consulting provides details on its monthly webinar series.
• HIStalk sponsors named to the Thomson Reuters 2013 Top 100 Global Innovator list include 3M, AT&T, Fujifilm, GE, NTT, and Xerox.
• PeriGen hosts a November 13 webinar on labor progress as part of its inaugural webinar series on excellence in perinatal care.
• ZirMed’s Betty Gomez discusses risk mitigation strategies for ICD-10 at next week’s WEDI 2013 Fall Conference in Maryland.

EPtalk by Dr. Jayne

News flash: CMS requests public comments on potential Clinical Quality Measures for Stage 3. The measure specifications are published on the CMS website for your review. If you don’t have any exciting social plans for the weekend, I’m sure it will be a good read. The comment period closes on November 25.

You know you’re a clinical informatics propeller head when you find a quote like this one funny. It’s gone somewhat viral in the health care IT universe since being shared on Twitter last week. I have a medical student working with me this month and he almost spit his coffee when I turned my laptop so he could read it. It’s true, though – lots of people are talking about doing it, but the realities of actually doing it are very different.

My own health system has a vision of big data. They’re spending loads of money building various analysis platforms since they never met a homegrown application they didn’t like. There is a herd of project managers and marketing types that has embarked on a road show to extol the virtues of big data. It’s exciting to hear them talk to groups of physicians about the vision for the future, when they will bring together data from our EHR with payer and community data and use it to change the world.

Call me cynical, but rather than pin all our hopes for the future on a project that is just getting started, perhaps it would be a good idea to go ahead and use what we already have to start changing how we practice. We’re fortunate to have selected an ambulatory EHR that has robust reporting capability. It also can automatically send patient-specific tasks to the care team when test results are overdue, when preventive services need to be scheduled, or when clinical values are out of range. A couple of years ago we bought additional hardware to be able to run over 250 clinical reports and tasks from them, but the servers are largely sitting idle.

Why is this happening? My theory is this. Unlike a certain baseball field in Iowa, if you build it, they may not come. Our physicians are deathly afraid of these reports and what they represent. They’re worried about liability – specifically, the liability of having these patient care tasks and not having the staff to work them. They’ve been told that having a report that they don’t take action on is riskier than having no report, so they have not allowed us to enable them for their practices. They feel trapped in a Catch-22 — if they can demonstrate higher clinical quality they hope to negotiate better reimbursement for their services, but they can’t demonstrate quality because they can’t afford the staff to drive it.

It’s easy to say that physicians should cut their take-home pay and hire more staff, but it’s not realistic. In our group, primary care physicians make less than half of what their subspecialty peers make and typically work longer hours in the office and hospital. The bulk of our primary care growth has been with younger physicians who are still paying off student loans debt that is higher than the mortgage on a McMansion. Our starting salary for most new primary care physicians is barely more than IT managers make.

This brings me to the point of why I have a medical student working with me. He’s in his fourth year and is a smart cookie, but is no longer sure he actually wants to be a physician. He sees the long hours that his faculty preceptors put in and the sacrifices their families have made and doesn’t feel it’s worth it any more. So, with over $180,000 in student loan debt, he’s looking for a way to leverage his clinical knowledge and critical thinking skills in the healthcare field. Unfortunately, learning about the complexities of the Meaningful Use program, the transition to ICD-10, billing requirements, documentation standards, the plethora of audits that we face, and the overall anarchy found in the healthcare system may be driving him out of medicine altogether.

One of the more challenging aspects of working with him has been trying to help him make sense of everything. Much of what we deal with defies logic and pushes the bounds of reason. When I delivered his mid-rotation evaluation, I asked what part of our time together he enjoyed most and he said it was the more IT-focused meetings we’ve had. We’ve been through some highly technical discussions the last few weeks about server virtualization, hardware and operating system upgrades, backups, redundancy, and off-site storage. I asked him what he found appealing about that and he said it was the fact that it was logical and made sense.

I’ve got another two weeks with him, so there’s hope, but it’s been interesting to see his reaction to the things that CMIOs deal with every day. At best I want to convince him to complete an internship so he can be fully licensed and will have more options than if he decides not to pursue additional clinical training. But in the mean time, I’m sure I can come up with plenty of sticky hardware and infrastructure issues to keep him occupied.

Do you work with medical students? What do they think about healthcare IT? Email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 11/7/13

Healthcare.gov casualty: CMS CIO steps down

Centers for Medicare & Medicaid Services CIO Tony Trenkle will step down from his position effective November 15 according to an internal email sent by CMS COO Michelle Snyder. Trenkle joined CMS in 2005, directing the Office of E-Health Standards and Services before becoming CIO and overseeing the agency’s $2 billion IT budget.

NSA allegations prompt NIST to review data encryption processes

The National Institute of Standards and Technology announces that it will have its data encryption standards independently reviewed after leaked documents reveal that the NSA has cracked the encryption standard. NIST encryption is the de facto standard for healthcare information security.

Surescripts Network Gains Momentum, Adds 12 Health Systems to Connect Providers across Care Communities

Surescripts adds 12 Epic health systems to its growing health information exchange network.

Disability claims backlog, EHR efforts top VA nominee’s priorities

Sloan Gibson, current USO CEO and presidential nominee to be the next VA deputy director reported that he would tackle the longstanding backlog of disability claims and will work to find common ground with the Defense Department on a new strategy for a joint electronic-health records system.

Readers Write: Big Data: Enabling the Future of Healthcare

Big Data: Enabling the Future of Healthcare
By Anthony Jones, MD

Everyone’s talking about the importance of big data in healthcare. Yet as the data piles up – most of it still in different silos – health systems are struggling to turn big data from just a concept into a reality. Here’s how I see big data having the biggest impact on the health of populations, both today and tomorrow.

Most healthcare organizations today are using two sets of data: retrospective (basic event-based information collected from medical records or insurance claims) and real-time clinical (the information captured and presented at the point of care  — imaging, blood pressure, oxygen saturation , heart rate, etc.). For example, if a diabetic patient enters the hospital complaining about numbness in their toes, instead of immediately assuming the cause is their diabetes, the clinician could monitor their blood flow and oxygen saturation and potentially determine if there’s something more threatening — like an aneurism or stroke — around the corner.

Where real pioneering technologies have succeeded is putting these two data pieces together in a way that clinicians can grasp the relevant information and use it to identify trends that will impact the future of healthcare – predictive analytics. So for example, if more diabetic patients start to present a similar trend of numbness in their toes, the coupling of real-time and retrospective data can potentially help doctors analyze how treatments will work on a particular population. This gives hospitals a much stronger ability to develop preventative and longer-term services customized for their patients.

Now what if we take data a step further and introduce gene sequencing into the picture? Today, gene sequencing is used primarily to determine the course of treatment for cancer patients. As we reach an inflection point in the cost of gene sequencing, this data will be routinely added to a patient’s health record. Imagine the kind of impact this data will have on treating infectious diseases, where hours and even minutes matter. The next time there’s a disease outbreak, we could potentially know the genome of the infectious organism, the susceptibility of the organism to various antibiotic therapies, and determine the correct course of action without wasting precious resources in trial and error.

Undoubtedly, we have yet to determine the most practical, cost effective way to manage this kind of data. To put it into perspective, the human body contains nearly 150 trillion gigabytes of information. Imagine collecting that kind of data for an entire population.

There’s no doubt this is a mammoth task, and while we might not be there yet, we are certainly getting closer. There are still challenges ahead: organizations are learning lessons from the early adopters and trying to determine the best ways to cooperate and share data. Undoubtedly the amount of investment required to make big data technologies work is more than what a single segment of the market can afford. That means all stakeholders, including pharma, will have to work toward a common vision. But with Accountable Care Organizations paving the path for payers and providers to work more closely together, we are heading toward success, and more importantly, better patient care.

Anthony Jones, MD is chief marketing officer, patient care and clinical informatics, for Philips Healthcare.

Readers Write: Epic Concerns

Epic Concerns
By Long-Time Epic Customer

Wake Forest Baptist is just the tip of the iceberg for Epic clients struggling with revenue, based on conversations I’d had with various contacts at UGM. There was quite the buzz about a large number of customers with revenue concerns who are not hitting the news. Yet.

We installed Epic years ago, but have seen a vast difference between our prior experience and a recent rollout of newer products. The method where time was taken to help us build our own system has been replaced by a rushed, prefab Model system installed by staff where even the advisers and escalation points at Epic have little knowledge of their applications. Epic has always had newer people, but it was much more common to have advisers during the install who did have experience to watch for pitfalls.

Though today’s economy is certainly a large factor in any revenue struggles, I am unsurprised by stories like Wake Forest or Maine and believe Epic should have seen some of it coming. We had enough experience with Epic to spot trouble with new products. New clients likely don’t have that built up yet, and they probably rolled off the cliff with nothing but green lights on Epic’s reviews of their install progress from newbies who didn’t know any better.

It feels like Epic tossed a winning formula in favor of a faster, cheaper install. What many of us are getting ends up being cheaper, indeed. That is a tough contrast to reconcile at UGM. After getting my ears blown out at an expensive, new, rarely-used auditorium that was just built to replace a barely older, rarely-used auditorium, Judy spoke at length about how the campus was cost-efficient and made employees more productive. Many of us are developing an alternative thesis, which is that productivity has been getting squeezed (and compromised) to support the costs of the campus.

I want to keep loving Epic. They are still good, but their services are declining.  The campus strikes a nerve with many clients who justifiably wonder whether our vendor is investing in the things that made them great when we’re getting answers, solutions, fixes, and reports slower than ever.