Time Capsule: Think Today’s Healthcare System is Bad? Imagine if Doctors Followed Only Their Own Best Interests

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 May 2009.

Think Today’s Healthcare System is Bad? Imagine if Doctors Followed Only Their Own Best Interests
By Mr. HIStalk

Everybody gripes about the US healthcare system’s high cost and low value. Rightly so, but it could be a lot worse. Here’s a thought I had today:

Imagine how bad it would be if doctors weren’t willing to follow the Hippocratic Oath.

I see doctors as falling into two camps. Some went to state medical schools at taxpayer expense. I figure those docs owe the rest of us, kind of like military academy students who have to repay their debt by serving in uniform once they graduate.

However, bunches of new MDs and DOs went to private med schools. They don’t owe us a thing.

Imagine the strain that doctors could place on the healthcare system if they took the course of action that benefits them the most, no different than a lawyer or accountant would do. They might refuse to:

• Treat patients who can’t pay cash upfront.
• Work for free serving on hospital committees or taking ED call.
• Work nights and weekends.
• Use someone else’s information systems, like CPOE.
• Use EMRs and interoperability technologies just because someone else wishes they would.

Doctors should be able to do whatever they damn well please and not feel guilty about it. If a doctor doesn’t want to take Medicare because it’s a money-losing pain, then blame Medicare, not doctor. If they shun using an EMR because it cuts their productivity, blame the vendor. If a hospital can’t survive without free doctor labor, then maybe it should fail or maybe the system is flawed.

If I were a cynical doctor watching my income drop, I would ditch the niceties and do whatever benefits me the most. I wouldn’t hurt patients, but I would focus on the activities that provided the most income or satisfaction, no different than most other professionals. Why not take advantage of the system that everyone plays in?

I’d start a boutique practice, cherry-pick the cash patients, and tell the insurance companies to stick it. I’d work 9 to 5 and tell patients to call the ED if they have an off-hours problem. I would get some humorless MBA to figure out how to run my practice like a factory, identifying those particular widgets that are the most profitable, then crank those out efficiently and soullessly. In any other field, this would be considered admirable and efficient.

Most importantly to this discussion, I would look at technology the same way a big company looks like plant equipment: it better pay for itself fast. Why else would I want it?

That sounds crass and cold, doesn’t it? So what? Doctors shouldn’t be expected to make sacrifices that other professionals don’t. Rightly or wrongly, we don’t have a charity-based healthcare system – it’s a business. Companies in business choose their means of production carefully. That’s why there’s a free market (or at least was until EMRs were mandated).

Doctors are soon going to be punished for using the technologies that provide them benefit if they’re not the ones Uncle Sam says are best. Next thing you know, professors will be fired for using overhead projectors instead of PowerPoint, accountants will be fined for doing calculations by hand, and lawyers will have to select only government-certified suits.

Thank goodness doctors haven’t wised up to the fact that they hold astonishing power over whether the healthcare system fails or keeps limping dysfunctionally along. Better hope the labor unions don’t whisper in their ear.

This Week in HIT 8/30/13

Tales from Encrypt: Big Breaches to Fill

Facts and Background

Major data breaches were reported this week at Advocate Medical Group (IL) and UTPhysicians (TX), both involving the theft of unencrypted computers from their premises.

Opinion

Both incidents involved somewhat unusual circumstances: Advocate’s stolen devices were desktops rather than laptops, while the stolen laptop of UTPhysicians was attached directly to a medical device and therefore not something IT would necessarily support. The bottom line of this cautionary tale: if there’s a hard drive, encrypt it.

Musings

• Computer security is only as good as physical security unless encryption is installed.
• Computers attached to medical devices may not even be on the network, making them discoverable only by physical inspection.
• It’s interesting that anyone even bothers to steal computers given their low black market value compared to cell phones or iPads. Perhaps they are intentionally stolen for more sinister purposes, such as intending to sell the medical data they may contain or holding them for ransom, but the thieves realized too late that they’re not really bright enough to pull that off.
• Government agencies like HHS and the IRS like to choose an occasional rule-breaker and flog them publicly to keep everybody else in line. Being that poster child is going to cost AMG millions in fines, investigation costs, and remediation.

Hospital EMRs: Epic and Cerner are Kicking Sand in Everybody Else’s Faces

Facts and Background

A KLAS report finds that Epic and Cerner are about the only systems being bought by 200+ bed hospitals and health systems, while Meditech and McKesson Paragon dominate small-hospital sales.

Opinion

The Epic-Cerner domination was obvious, but the staggering declines by conglomerate vendors McKesson, Siemens, and GE Healthcare may not have been.

Musings

• It has always been true that the best and best-selling products in healthcare IT are sold by companies that aren’t distracted by unrelated business lines. The worst and worst-selling products have always been marketed by international conglomerates.
• Cerner is a rare exception to another rule: publicly traded companies usually far worse in product quality and sales.
• KLAS says Cerner is narrowing the previously lopsided five-to-one sales advantage Epic has had.
• McKesson’s only potential bright spot is Paragon. If it wasn’t for that product, they would be better off just selling off their creaky legacy products (Star, Series, Horizon, etc.) and getting out of healthcare IT altogether as big companies often do once the novelty has worn off.
• Most of the laggards came with low expectations, but the zero wins and three losses for Allscripts explain why the company is suddenly steering all conversations toward population health management and away from both inpatient and ambulatory EHRs.
• The only real unanswered question, which KLAS points out, is who the Horizon and Meditech Magic customers will choose once they realize the Meaningful Use drawbacks of sticking with an also-ran EMR.
• Epic and Cerner aren’t cheap. As hospitals feel the budget pinch and swallow hard when writing their monthly maintenance fee checks, will the lower cost of Meditech and Paragon lure them in despite more limited functionality?
• Meditech should have been a better contender, but 6.0 seems to have killed its momentum just when it seemed poised to seize the opportunity to move into the Big Three of big-hospital products.
• As the hospital whales consume the smaller fish, Epic and Cerner will gain more hospitals by attrition as the incumbent vendors get the boot.

Attention Doctor Shoppers: The Database Knows You’re Hooked 

Facts and Background

New York State prescribers must check the I-STOP statewide database of filled narcotics prescriptions before issuing new narcotics prescriptions as of this week.

Opinion

It’s a good first step in identifying drug-seeking patients, but not a very elegant solution in in requiring prescribers to manually look up patients on a secure Web page.

Musings

• Pharmacists aren’t required to check the database when dispensing prescriptions, but they are required to enter their filled narcotics prescriptions into it immediately.
• The database should really be a national one, although state-specific laws always impose maddeningly archaic limitations on any kind of national effort (state-by-state medical licensure, for example).
• It would be nice if the database had the capability to integrate with EHRs to save doctors a lot of fumbling around while they’re in the room with the patient.
• What happens when a patient is identified as a doctor shopper? Most likely nothing except they walk out without a new prescription and buy their drugs on the street instead.
• While some prescription drug abusers pay cash to avoid detection, surely insurance company records (and especially Medicaid records) would already have allowed these patients to be easily identified.
• Use of the database is likely to increase drug dealer profits and drug abuser crime as the reduced drug supply pushes prices up.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 8/30/13

Regulators to investigate Advocate data breach

HHS and the Illinois attorney general announce that they will investigate Advocate Medical Group’s four million patient data breach, the second largest in HHS history.

July 2012: EHR Incentive Program

CMS releases the latest EHR Incentive Program results in which 4,051 hospitals have been paid to date, which accounts for 80 percent of eligible hospitals. Payments have reached $15.8 billion since the start of the program.

Carl Icahn Increases Nuance Stake, May Seek Board Seat

Carl Icahn increases his stake in Nuance to 16.9 and reports that he may seek to put a representative on the company’s board of directors.

Despite backlogs, VA disability claims processors get bonuses

An investigative report calls out the VA for issuing $5.5 million in bonuses to its employees in 2011 for "excellent" performances despite a 155 percent increase in the disability claims backlog. Two-thirds of the VA’s claims processors took home bonuses that year.

News 8/30/13

Top News

HHS and the Illinois attorney general announce that they will investigate the July 15 theft of four unencrypted Advocate Medical Group desktop computers that contained the medical information of 4 million patients, announced last week. An HHS spokesperson signaled the financial exposure the medical group is facing in describing the “high-profile actions that have sent clear messages to the industry that we expect full compliance with privacy and security rules.” Advocate admits that the information should never have been stored on the hard drives. Obviously encryption technology would be throwing off some impressive ROI right about now, which might be something to consider if your organization hasn’t implemented it.

Reader Comments

HIStalk Announcements and Requests

Highlights from HIStalk Practice this week include: Physicians are split when it comes to publicly sharing Medicare payment data. New York physicians are required to consult an electronic prescription database before writing scripts for controlled substances. The benefits of a practice’s ACO participation reach beyond the patients covered by the ACO. MGMA offers online scheduling tools for its annual conference. More than 90 percent of office-based physicians accept new Medicare patients, which is about the same percentage that accept new privately insured patients. The AMA urges CMS to prohibit insurers from paying physicians less than contracted amounts when reimbursing providers with plastic or virtual credit cards. Doximity says it has more physician members than Sermo. I look at the Stage 2 dilemma, highlighting the recommendations of various professional organizations and offering my opinions, namely that CMS should keep the January 2, 12014 start date but extend the deadline for meeting Stage 2 requirements. You won’t find any of these stories – and others – on HIStalk so keep reading HIStalk Practice if you like staying current with happenings in the ambulatory HIT world. Thanks for reading.

Welcome to new HIStalk Platinum Sponsor InterSystems. The company is a global leader in software for connected care. Its products empower healthcare professionals with the information they need to make the best clinical and business decisions. HealthShare is a strategic platform for healthcare informatics, enabling information exchange and active analytics across a hospital network, community, region or nation. Cáche is the world’s most widely used database system in healthcare applications. Ensemble is a platform for rapid integration and the development of connectable applications. InterSystems has more than 35 years of experience as a trusted partner serving thousands of physicians, hospitals, and health systems around the world, including Johns Hopkins, Kaiser Permanente and Memorial Care; five statewide HIEs; and the national health systems of Sweden and Scotland. The company’s technology is also used by over 100 leading healthcare software vendors in their solutions, including 3M Health Information Systems, Epic, and GE Healthcare. Thanks to InterSystems for supporting HIStalk.

A YouTube cruise turned up this video about InterSystems. I thought I knew the company pretty well, but I learned a lot about them.

On the Jobs Board: Staff Engineer (Java), Clinical Applications Consultant, Project Manager.

HIStalk Webinars

CareTech Solutions will present “Using Infrastructure and Application Monitoring to Assure an Optimal User Experience” on Thursday, September 19, 2013 at 1:00 p.m. Eastern. The presenter will be John Kaiser, senior director of the Pulse IT monitoring service. The abstract:

It’s time for hospital IT monitoring to mature – from reactive to predictive. Supporting the highly-complex healthcare technology environment with only individual monitoring tools or relying on an application vendor to identify system degradation is not the most effective means to providing users with a reliable, optimal IT experience. A comprehensive monitoring solution includes eyes on servers, network, application performance, and real user monitoring. CareTech Solutions will discuss an integrated approach to comprehensive monitoring of both the infrastructure and applications, with an emphasis on delivering a consistent solution based the hospital’s IT maturity level. The target audience is CIOs, CMIOs, CNO, IT directors, and IT analysts.

Acquisitions, Funding, Business, and Stock

The healthcare IT business unit of Tennessee-based Parallon Business Solutions, itself a subsidiary of Hospital Corporation of America (HCA), merges with Vision Consulting to form Parallon Technology Solutions, with Vision President Tim Unger taking the CEO role. Parallon Business Solutions has 24,000 employees and provides services to 1,400 hospitals and 11,000 non-acute care providers.

Carl Icahn boosts his stake in Nuance to 16.9 percent of the outstanding shares, according to an SEC filing Tuesday, saying he may want to talk to the company about adding his slate of nominees to the board. Above is the one-year NUAN share price in blue vs. the Nasdaq in red.

Sales

Blessing Physician Services will deploy Phytel’s population health management suite.

Rideout Health (CA) will roll out Perceptive Software’s Enterprise Content Management solution integrated with its McKesson Paragon HIS.

People

McKesson Specialty Health and the US Oncology Network appoints Michael V. Seiden, MD (Fox Chase Cancer Center) CMO.

Physician RCM provider MedData promotes Ann Barnes from president to CEO.

Announcements and Implementations

Australia’s Noarlunga Hospital activates Allscripts Sunrise Clinical Manager.

Novant Health (NC) reports that 343 of its physician clinics are now live on Epic’s PM platform and 316 are live on EHR. The five-year project was completed three years ahead of schedule and under budget.

Humana and Centene join Verisk Health as founding members of its pooled data initiative, which uses Verisk’s database of cross-payer information and analytics to identify illicit billing practices.

Hawaii Advanced Imaging Institute upgrades to RamSoft’s PowerServer RIS/PACS/MU radiology workflow application.

Home device manufacturer Bosch Healthcare and health content vendor Remedy Health Media announce a partnership to develop and sell products for remote patient monitoring.

Government and Politics

ONC opens the Behavioral Health Patient Empowerment Challenge to highlight existing technologies to help patients manage their mental health or substance use disorders.

A Washington Post article says that the Department of Veterans Affairs was paying bonuses to its disability claims employees despite a mammoth backlog, thereby encouraging them to game the system by pushing the tough claims aside to boost their numbers. It does point out that employees were handling high claims volumes even though the number of claims made the backlog grow.

Other

Skyline Exhibits provides trade show stats that vendors might use to justify for exhibiting: (a) 81 percent of trade show attendees have buying authority; (b) the top reason for attending is to see new products; and (c) building brand awareness is the highest marketing priority for most exhibitors. Marketing execs may very well need to look for justification considering that a 10×10 booth at HIMSS costs about $4,000. Tack on drayage, shipping, travel, trinkets, and personnel and you’re at $20K in no time.

Coming to a baby shower near you: a smart sock from Owlet Baby Care that monitors a baby’s vitals and sleep position and includes a four-sensors pulse oximeter, an accelerometer, a thermometer, and a transmitter to send data to a smartphone or computer. The company’s cofounder says the device does not require FDA clearance, though a version that includes an alarm system for oxygen levels will. Owlet is seeking $100K in crowdfunding.

Here’s a story of interest to anyone in charge of their organization’s encryption efforts. UT Physicians (TX), the medical group practice of the UTHealth Medical School, notifies 600 patients of a potential data breach after the theft of an unencrypted laptop. Unlike similar thefts at other organizations, UTHealth has a comprehensive encryption policy that covers more than 5,000 laptops. The stolen laptop was overlooked, however, possibly because it was attached to an electromyography machine in the orthopedics department and is considered more of a medical device than a standard computer. The laptop included patient names, birth dates, and medical record numbers, but no financial information.

Researchers in Canada find that the use of RFID badges raised the handwashing compliance of nurses from 33 percent to 69 percent. Their study appears in the current issue of CIN (Computers, Informatics, Nursing). I wasn’t familiar with that journal even though it’s been around in various forms since 1983, but it looks decent.

Fourteen-hospital Baptist Memorial Health Care Corp. lays off 61 employees, including pharmacists and nurses, but urges them to reapply for 500 open positions, many of those newly created to support its Epic rollout.

If you’re a fan of evidence-based medicine or Coldplay, you’ll like this video, which was tweeted by Farzad Mostashari.

Spectrum Health (MI) fires several employees after one of them takes a picture of an ED patient’s rear and posts it to Facebook with a caption of, “I like what I like.” The health system fired the employee who took the picture and all of those who gave it a Facebook Like, including an ED doctor.

Marin General Hospital (CA) asks the FBI to investigate a possible scam that shut down the phones in labor and delivery and the ED last week.

Liviam announces its Facebook-like site for long-term hospital patients, which offers the CareStream timeline, a dashboard from which the patient can request help, a blogging tool, and an events calendar.

New York prescribers issuing prescriptions for pain meds must first check an online registry of pharmacy-reported filled narcotics prescriptions as of this past Tuesday, implemented to help curb the abuse of addictive drugs.

Sponsor Updates

• Truven Health Analytics offers free access to Micromedex iPhone apps for customers outside the US and Canada. Truven also announces enhancements to its Unify Population Health Management solution, which is deployed in partnership with CareEvolution.
• Iatric Systems announces that its Meaningful Use Manager and Public Health Syndromic Surveillance products have earned 2014 ONC HIT certification.
• IHS names Merge Healthcare the leading provider of vendor-neutral archive solutions in the world and in the Americas.
• iSirona adds Singapore-based telehealth services provider myHealth Sentinel as a reseller.
• The Massachusetts eHealth Institute awards Aprima Medical a $101,000 grant to advance the interoperability of EHRs with the state’s HIE.
• Besler Consulting releases a review of the FY2014 Hospital Inpatient Prospective System final rule.
• InstaMed achieves Phase III CAQH CORE certification.
• EClinicalWorks names HealthNet (IN) the winner of its Improving Healthcare Together video contest. Auburn Medical Group (GA) and Open Door Family Medical Centers (NY) took second and third places.
• Aspen Advisors shares details of the ICD-10 preparation services it delivered to East Jefferson General Hospital (LA).
• Dearborn Advisors discusses the need for healthcare organizations to optimize their EHRs in order to thrive in today’s regulatory climate.
• API Healthcare highlights the importance of meeting the needs of an aging workforce.
• pMD announces that its mobile charge capture solution will support iOS 7, which has a possible September 10 general availability.
• Visualutions will resell Wellcentive’s Advance to FQHCs.
• RazorInsights will showcase its ONE Enterprise HIS solution at the 15th Annual HIS Pros Buyer’s Seminar next month in Rosemont, IL.
• Medicomp hosts its annual strategy update webinar September 18 and 19 and opens registration for MEDCIN U sessions November 3-5 in Reston, VA.

EPtalk  by Dr. Jayne

It’s quite a challenge to try to keep up with Mr. H and Inga in finding newsworthy items each week for EP talk. Between our day jobs and our staggered publishing schedules, it’s easy to be scooped by another member of the HIStalk crew. In the spirit of mixing things up, we’ll be taking EPtalk in some new directions. I may write up an interesting product, discuss a recent journal article, or respond to something I’ve seen in social media. Since EPtalk runs with the news each week with a slightly different audience than Curbside Consult, I may do some multi-part pieces to allow reader responses to influence the next week’s piece.

Yesterday, @ONC_HealthIT tweeted a recent Wall Street Journal Health Blog piece that asked readers what doctors use as the basis for care decisions: business or financial considerations, fear of lawsuits, or doing what is best for patients. I was gratified that with over 1100 votes, 56 percent of respondents believe we want to do right by patients. The other two options tied at 21 percent.

I’ve spent a good part of my career working in emergency departments and urgent care situations. I have to agree that fear of lawsuits can be an important driver. Financial considerations are also important, but there are many nuances other than what this survey can capture. Case in point: at one of the hospital-owned urgent care centers where I moonlight, the leadership issues a monthly report that looks at our utilization. On the surface, this aims to encourage us to provide more cognitive medicine and perform less defensive medicine.

Although thoughtful practice is a nice goal, I’d be kidding myself if I thought the report was aimed at encouraging us to use our brains rather than tests. The fact of the matter is that our population is largely uninsured, with Medicaid and Medicare closely behind. The hospital has been hemorrhaging money for the last decade despite extremely good management. It’s largely due to payer mix and other external economic factors in the community. Across our department, the Family Medicine physicians have much lower service utilization than do the Emergency Medicine physicians, and I think it’s partly due to the way we see the patient population

As a family doc, I’m used to seeing patients quickly in the office, treating their self-limited problems, and moving on. There’s a relationship between the patient and the physician. We tend to think that if the patient is becoming worse or not improving, they’ll be back. We don’t feel that pressure to try to cover all eventualities while they are in front of us, although it’s become that way with the advent of the Patient-Centered Medical Home, Accountable Care, and other initiatives where every visit has become a preventive/full-service visit as we try to cram as much as humanly possible into each encounter.

I really try not to order tests if I can make the diagnosis based on clinical history and physical examination. Not just for cost reasons, but also because tests are not without risk. Even a simple urinalysis can give false positives that lead to unnecessary follow-up, including not only financial cost but the burden of patient anxiety.

I’m also not afraid to play the bad guy with patients when it’s indicated. I don’t care if your husband’s primary doc gave him antibiotics for his viral illness. Just because you came to the urgent care and have the same symptoms, you’re not going to get them from me. I don’t care if your copay was $50, it’s not the right thing to do. It’s likely you’ll mark me down on your patient satisfaction survey, but I’ve reached a point in my career where I simply care less about satisfaction scores than I do about quality care and antibiotic resistance. You’ll get my empathy, sympathy, and some symptomatic treatment, but no Z-pack for you.

My peers that trained in emergency residency programs tend to order more X-rays for vehicular trauma even if the clinical story isn’t that impressive. Maybe it’s fear of being sued or maybe it’s just the way they’ve been habituated from working in higher acuity and trauma centers rather than the ambulatory office. Maybe because there was that one case where they missed something and it came back at them later. It’s definitely harder to try to help a patient understand why decision support rules say it’s OK to not order an x-ray than it is to just shoot a film, and sometimes I order those films too. None of us is perfect and medicine still has some art to go along with the science.

The most interesting thing about the utilization reports, though, is that over the last year, they have done very little to drive any of physicians at the high end of the test ordering spectrum into a lower bracket. Right now, the only “incentive” provided is seeing your name on the report and where you fall against your peers. Some docs may consider these reports the way I see the physician satisfaction numbers – as something that’s not on the top of their list for the many things we have to worry about when we’re seeing patients. Others may need education or potentially something more tangible before their behavior will change.

The bottom line, though, is that defensive medicine is alive and well regardless of steps towards tort reform, provider education, and other interventions. I’ve been doing some thinking about the other 21 percent as well. I’d liked to have seen the “financial considerations” choice expanded to include other options but you’ll have to tune in to the next post for those thoughts.

I’ll still throw in the occasionally newsy tidbit especially if it involves both shoes and technology. A new CT scan technology by CurveBeam called pedCAT shows what the foot and ankle actually look like when weight bearing. I was fascinated by the YouTube clip from the Royal National Orthopaedic Hospital. Since I was hobbling around this afternoon due to a loose heel on my favorite pair of pointy-toed mules, it’s a sure bet that my scan would have more than one ICD-10 code associated with it. I’m leaning toward “Unspecified soft tissue disorder related to use, overuse and pressure” and “Grief reaction” since I ultimately had to pronounce said mules dead at 6:59 p.m.

Contacts

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

More news: HIStalk Practice, HIStalk Connect

Morning Headlines 8/29/18

Telstra Buys DCA’s Healthcare Division

Australian telecom giant Telstra has acquired Database Consultant Australia’s healthcare division, which makes the Communicare EHR solution and markets a secure messaging platform for healthcare.

Announcing the Behavioral Health Patient Empowerment Challenge

ONC announces the Behavioral Health Patient Empowerment challenge, which is seeking entries from existing behavioral health apps that help patients manage mental health and substance abuse.

Novant Health Completes Rollout of Electronic Health Record at Physician Clinics

Novant Health (NC) has completed its rollout of Epic in 240 clinics under budget and three years ahead of schedule.

Aprima Medical Software Receives Grant to Advance and Accelerate Health Information Exchange in Massachusetts

The Massachusetts eHealth Institute awards a $1.3 million in grants to Aprima Medical to fund projects that increase interoperability between electronic health records and the state’s health information exchange.

HIStalk Interviews Heather Sobko, President and CEO, IVR Care Transition Systems

Heather Sobko, PhD, RN is president and CEO of IVR Care Transition Systems, Inc. of Birmingham, AL.

Tell me about yourself and the company.

I started out in psychology and sociology. I got advanced degrees in those and I decided that I really did not want to be a psychologist. I went into nursing and ended up getting my doctorate degree in nursing, with a focus on comparative effectiveness and outcomes research.

I lean towards geriatric populations just because I’m enchanted by geriatric patients. I think they’re delightful and I enjoy working with them. Adults with chronic illness became a passion of mine.

After working in clinical settings, both in acute care and then in long-term care, I realized that wow, we can do a much better job helping folks transition. This was long before bundled payment rules came out or before Affordable Care Act was implemented with penalties for readmissions.

Looking at what patients faced going through care transitions, I realized there is a lot that we can do. Using technological tools, we can do a way better job. It doesn’t have to be expensive. It doesn’t have to be difficult.

That’s where the idea for IVR Care Transition Systems came from. Intentionally, we chose a phone-based system. Alabama is very rural. We have patients who live in sections of our state that just don’t have Internet access. We’re just not there.

We decided to use something really low tech — the telephone. Everybody knows how to use one and everyone has one. It doesn’t require any special training or any special equipment to be able to participate.

The technology folks get excited about smartphone apps, but only a small percentage of patients will ever use them, mostly those who were already motivated anyway. Do you think IVR systems get overlooked because they’re not as cool sounding as an app?

Apps are very trendy. I think that right now there are about 12,000 different health apps available. People download the apps, they use it a couple of times, and then they realize it’s a lot of work to keep up with them and they don’t want to do that. That one falls by the wayside and they’ll just download another one and try that for a couple of weeks. That’s just a pattern, a trend.

There is no research that shows a link between long-term successful outcomes and the use of any of these apps. There are so many available it’s almost like what we go through in the inpatient setting with alert fatigue. I get the sense that there is a trend coming down the pipe that is app fatigue. There is just so much available.

IVR is unique and especially helpful for individuals who are older, who aren’t tech savvy, from a previous generation. Therein lies my passion for geriatric patients. Patients like to get a phone call. Our system is not a computerized voice — it’s a real person’s voice. It’s me, actually, because I’m a real nurse. Who else should talk to a patient than a real nurse?

Because we schedule calls when the patient likes to be called, in pilot testing with 540 patients, we had an 86 percent response rate for patients completing 28 different surveys getting them through that 30-day critical period for risk for readmission and emergency department visits. They like the system. They like it. They look forward to talking to the system or getting feedback from the system. The system’s name is CATHE — your care transition helper.

Did people push back like they might against PBX or telemarketing? How did you get them to participate in a survey that’s delivered by telephone?

Patients know the call is coming. We ask for the patient. We have the patient list for CATHE to address them when she calls. For example, you might like to be called Tim. When CATHE calls, she will say, “Hello, this is CATHE, your care transition helper. I’m calling to speak with Tim,” but it’s Tim voice the way you recorded it.

The person knows who it is. There is caller ID that identifies it that it is part of the healthcare plan you’re participating in, so it’s the hospital or the clinic calling to check up to see how you’re doing. I think that does make a difference.

The system also has built-in empathy. If someone says they’re feeling worse, the system says, “I’m sorry you’re feeling worse today. These next few questions will help me learn more about that.”

We really try to keep it focused on what is meaningful from a clinical perspective. Cold calling patients and having a conversation with them — first of all, it’s hit or miss. You might catch them on a great day, and if you’re lucky you catch them on a day they’re having some problems, you can do some problem solving and a help guide the patients to appropriate steps. But chances are it’s hit or miss. Even if you catch them within one week post discharge, if they’re not having the problem, you’ve lost an opportunity to do an early intervention when it arises.

The CATHE calls less lasts less than four minutes each. They’re all logic-based, so if a patient reports they’re not having a symptom, we don’t ask any more questions about that symptom. We go to another topic. That keeps it fresh.

The questions are not the same every day. Patients learn very, very quickly that a real person is behind this looking at a very comprehensive dashboard. If red flags are triggered, someone in person follows up to help you with your medicines, to help you make that follow-up appointment with your community provider, or to help you with diet and exercise or symptom recognition before it becomes an urgent situation.

If you gained 2.5 pounds in 24 hours as a heart failure patient, for example, that’s an early sign that you’re holding fluid. A quick adjustment in the medication can fix that, and then you can monitor. But if it becomes five pounds, 10 pounds, 15 pounds, which can happen so quickly, now you’re forced to go to the hospital and have an IV drug administered so you can get rid of that extra fluid.

The biggest value of this system in general is that it captures patient-provided data. We’ve spoken to numerous payers. The bundled payment all cause readmissions is really not a very good measure. As a clinician, I could have zero patients readmitted to the hospital, and on paper, I look like superstar. But in reality, what if all my patients died? That’s not a very good measure.

The data does belong to each hospital that uses the system. It’s their patients, so it’s their data, not ours. They can trend and track what’s going on. If a patient on Day 17 needs to come back to the hospital, now they have a whole database full of information that says, here’s what happened with this patient each day. Here’s how we responded, and then it became important that we brought the patient back. We believe, based on this data, that you should reevaluate and perhaps reimburse us even though it’s within 30 days. Insurance companies are saying, well, if you have data, OK then — we’re willing to take a look.

That’s very, very meaningful. Hopefully, over time, we may be able to change that policy and make it a little bit more appropriate, a better measure for what’s really happening with these patients so they’re not all put into the same box for all cause readmission. Some readmissions are appropriate and necessary, and right now, hospitals and doctors and nurses are being penalized for doing the right thing. That’s just the wrong incentive.

Most technologies don’t scale up to the number of patients that need to be monitored. Some just try to predict readmissions or provide analysis after the fact without involving the patient.

Correct. We were gearing up towards looking at Meaningful Use Stage 3, which is going to require patient-provided data. It’s very important that the patient is engaged. Engaged patients, regardless of their level of illness or number of co-morbid condition, simply do better, period. If you have an engaged patient, you can already anticipate that that patient is going to do better. This system is just a tool that allows the patient to engage with you.

The other thing is that it overcomes the barriers to external providers. Within the system, there are automatic links to every external provider that that patient is involved with. It’s a whole team approach. If you have a patient who is triggering red flags and you would like to share that information with a community provider, you can click on a link. The system automatically sends them a message that says, please log on to the system and review patient XYZ for changes.

Now that communication takes place automatically with a click of a button. You never have to log out of the system and go searching for information. Most patients have five, six different providers. You can keep everybody in the loop through one strategy. They have a read-only view and they can look at the information and participate in figuring out what is the best thing for the patient. That’s also very, very beneficial.

Many of our older patients that live in rural communities also have very low levels of literacy, many of them only sixth-grade education. Having something talk with them rather than have them have to read something is also advantageous.

Patients can get a call at five in the morning or eleven o’clock at night. It doesn’t matter. Whatever they want can happen. We’re available through the system 24/7. We don’t have someone sitting and making a telephone call and trying to reach a patient. If the patient would like to be called at six in the morning, it automatically calls at six in the morning and they are ready for that call.

It does leave a nice message if it misses you and will call back in 30 minutes. After two tries of that, it will leave a message saying, “I’m so sorry I missed you today. I’ll try again tomorrow.” A patient who doesn’t respond in three days will automatically trigger a red flag that something is amiss and we can call a family member and find out is everything OK.

But the main thing is lots of patients don’t understand the difference between side effects of their medications and symptoms of their illness. By engaging with a patient over a 30-day time period, you capture the opportunity to teach them and to help arm them with tools to be their own advocates. For example, asking a patient, “What will you say when you call the doctor?”

Shortness of breath is a good example. Patients may believe the main symptom is, “I can’t sleep at night.” They’re going to tell the receptionist at the doctor’s office, “I can’t sleep at night.” That person, who is not a clinician, is going to take down a note: Mrs. Johnson is having trouble sleeping.

That’s not a triage. That’s a priority. Someone eventually will get to that phone call and may recommend a sleeping medication. What the patient probably should have said is, “I’m a heart patient. I’m sleeping with four pillows and I can’t breathe and therefore I can’t sleep.” That’s a whole different scenario.

We try to teach patients how to communicate with their providers to really speak to them about what’s very, very important. We coach them, “This is what you need to say. Let’s practice” and then we follow up with them and see how it went after they make that call.
We don’t intervene. It’s not a rescue system. It’s really designed to help the patients engage and learn how to better manage for themselves, because there’s not enough of us to go around and patients really appreciate the fact that we’re reaching out.

It also doesn’t matter what kind of insurance the patient has. They could have terrific primary and secondary insurance or no insurance. All patients get the same quality of follow-up regardless. That has meaning in and of itself because it’s leveling the playing field. We are very proud of that component –that all patients, regardless of what kind of insurance they have, are going to get the same high quality follow-up care.

As a PhD nurse, informatics expert, and researcher, it’s clear that you get excited about patients, while most of the companies out there are more excited about the technology or the business aspects of what you do. Are enough nurses working in healthcare IT or using the approach that your company is taking?

We have several nurses on our team. Believe or not, the TIGER Initiative and HIMSS and the American Medical Informatics Association — particularly the Nursing Informatics working group — the Association of Nurse Executives, everyone is really starting to catch on to the value of informatics in general. It can never take the place of clinical expertise, but there are tools that can help us do a better job and help us measure what we’re doing so that we have some evidence that shows what’s working, what’s not working, and what are the very best practices.

If we’re not measuring our outcomes, then we’re just playing a guessing game. Informatics is critically important to being able to capture and measure and evaluate what we’re trying to improve with the patient.

Do you have any concluding thoughts?

Our team is very, very diverse. I never, ever could have put something together like this all by myself. There is 40 of us — engineers and business people, lawyers and IT specialists, and physicians and surgeons and social workers. Everyone has something very valuable to contribute. That’s how we put the whole system together — lots and lots of different types of data specialists.

I am sitting in a happy seat that I get to be surrounded by these stellar individuals. But really, this group of people … I just can’t even begin to describe how fortunate I am to work with these folks. It’s just remarkable to me and it’s very synergistic. We don’t have room for egos. There is no chip on the shoulder. There is none of that.

We have a corporate philosophy. We have all read Guy Kawasaki’s book Enchantment and decided that that would be our mantra. In everything we do, we try really, really hard to be enchanting. That’s our core philosophy of how we conduct ourselves among the team and with our potential customers and collaborators — that we want to be enchanting.

Morning Headlines 8/28/13

The Gap between EMR Vendor Market Share Widens

KLAS releases a new report on large hospital EMR market share changes during 2012. Cerner and Epic took 75 percent of new business in the 200+ bed market. McKesson lost the most customers during the year after announcing their decision to sunset the Horizon platform. Of all vendors evaluated, Epic was the only vendor to retain 100 percent of their customer base for the whole year.

Sutter’s $1 Billion Boondoggle-New Electronic Records System Goes Dark

Another nurses union is publically questioning the safety of its EHR system, this time 24-facility Sutter Health’s Epic system, which went down Monday after a system upgrade.

Deadline looming for state’s patient record exchange

Two competing pay-to-play health information exchanges operating in Kansas have until September 30 to connect their networks or they risk losing $1 million in grants promised to them. The two agencies have successfully tested network connections, but have been at an impasse since May over security policies designed to control for inappropriate secondary use of shared data.

Scoring system could help reduce adverse drug events in hospital patients

University of Florida College of Pharmacy researchers are developing algorithms to help hospitals determine the best pharmacist staffing numbers to prevent adverse drug events and improve patient safety.

News 8/28/13

Top News

Two Kansas HIEs, one covering Kansas City and the other serving the rest of the state, risk losing their federal grant money if they can’t agree on data exchange terms by the state-imposed deadline of September 30 (already extended from July 30). LACIE and KHIN could be forced to shut down by the end of the year if they haven’t worked out their differences by then. KHIN doesn’t want the network to share data with insurance companies that aren’t KHIN members, while LACIE says the agreement would prohibit organizations that are connected to an ACO from accessing the network’s data. At issue is aggregated information that could be used for non-patient care purposes. The Kansas HIE board voted to shut itself down in September 2012 and let the Kansas Department of Health and Environment take over its duties, which means the state is in charge. Kansas has no secondary data use policy.

Reader Comments

From Joyce: “Re: Mission Hospital, Asheville, NC. Laying off 70 workers, which is big news in a small town where healthcare supports the local economy.” The 730-bed hospital will cut the CEO’s salary by 26 percent, slash management salaries from 13 to 20 percent, eliminate merit increases, implement a three-month PTO freeze where time off is not accrued for worked hours, reduce its 403(b) matching, and reduce the employee wellness incentive. The hospital’s CEO made $480K in 2010, while the CIO was paid $349K. That’s the problem with hospitals – they provide growth to their local economy, but much of that is paid for by federal taxpayers in the form of unsustainably rising national healthcare costs. Building an economy based on healthcare won’t work, which politicians seem reluctant to admit since hospitals employ a lot of people and write nice political donation checks.

From HealthPlans: “Re: WellPoint. AJ Lang is no longer with the company, an internal employee tells me.” A WellPoint spokesperson confirms that Andrew J. Lang, senior VP of application development since December 2008, is no longer with the company.

From Mennonite Rockstar: “Re: BIDMC IT security after the Boston bombing. I had the impression they rearranged the setup of their homegrown application’s security from reading the Fast Company article. Perhaps Mr. HIStalk can get Halamka to clarify?” John says that his IT shop made no changes to their applications, but did tweak their audit log reports to allow the hospital’s compliance department to monitor the specific situation.

Acquisitions, Funding, Business, and Stock

Group purchasing organization Premier Inc., owned by 181 hospitals, health systems, and other healthcare organizations, files plans for an IPO of up to $100 million in common stock. Premier had $869 million in net revenue for the fiscal year that ended June 30, up 13 percent from the prior year.

Merge Healthcare Chairman Michael Ferro, Jr. resigns and is replaced by board member Dennis Bell. Ferro, Merge’s top shareholder, has indicated that he may eventually explore ways to boost shareholder value, including taking the company private. MRGE shares were unchanged on the news.

Federal HIT provider Systems Made Simple projects 2013 income of $260 million, up from $167 million in 2012.

The strategic venture arm of Canada’s TELUS makes an unspecified investment in Rockville, MD-based Get Real Health, which offers the InstantPHR personal health record. Three of the company’s seven executives came from US Web, while two were Microsoft HealthVault developers.

Sales

Southern Prairie Community Care ACO (MN) will deploy technology from Sandlot Solutions to manage patient health information and give providers access to data  at the point of care.

HealthproMed (PR) selects eClinicalWorks EHR for its two-location FQHC.

Greenway Medical will develop an HIE for more than 500 physician members of the Denver-area Rose Medical Group, Rose Medical Center, and their patients.

Grady Health System (GA) selects Strata Decision Technology’s StrataJazz for cost accounting, operating budgeting, and capital planning.

PinnacleHealth will use Care Team Connect’s integration and rules engine to integrate biometric data from Honeywell monitoring devices with other patient health data.

Palmetto Health (SC) chooses 3M 360 Encompass System for automated coding, clinical documentation improvement, and performance monitoring.

The National Football League signs a 10-year agreement for the ININITT Smart-NET PACS, which will allow the medical images of players to be viewed remotely or from mobile devices on the sidelines.

People

QHR Corporation, a Canada-based HIT company, names Owen Haley (Allscripts) chief commercial officer.

Tony Scott (Microsoft) joins VMware as CIO.

Cumberland Consulting Group adds Joseph Serpente (McKesson) as director of business development.

Announcements and Implementations

PeaceHealth’s Peace Island Medical Center (WA) goes live on Epic September 1.

Emdeon launches a self-service testing exchange solution for ICD-10, allowing providers and channel partners to submit ICD-10 test claims and receive claim status feedback. The Emdeon Testing Exchange for ICD-10, which Emdeon purports is the first of its kind in the industry, requires no additional software and is a free service to Emdeon providers, channel partners, and payer customers. Sounds like a great service that would be even more valuable if more payers were ready and if providers already had ICD-10-ready software updates from their vendors.

Greenway presents Innovation Awards to Boulder Community Hospital Physician Clinics (CO), Regional Obstetrical Consultants (TN), and Albuquerque Health Care for the Homeless (NM) at its PrimeLEADER user conference in Washington, DC.

Sonora Regional Medical Center (CA) goes live on Cerner September 4.

Vocera announces enhancements to its secure messaging platform that include on-call scheduling, new smartphone clients, an improved Web console, and server enhancements.

I came across this tweet today. Ah, athenahealth, I don’t think you can convince me that switching EHRs is as easy as switching from Time Warner to AT&T U-verse.

Innovation and Research

University of Florida researchers are developing a scoring model that will use hospital EHR information to identify inpatients most likely to experience an adverse drug event, allowing those patients to be more aggressively monitored. The result will be rolled out to 13 hospitals for validation in the study’s second year.

Technology

An Ohio surgeon wearing Google Glass during a surgery broadcasts the procedure over the campus network, also using it to consult with a colleague.

Other

Apple is rumored to be planning a trade-in program for iPhones in an attempt to increase the percentage of units it sells directly. What Apple is really trying to do is get  more people like me to walk into their retail stores and spontaneously drop $50 on the latest, greatest cool Apple accessory. The speculation is that Apple will tie the trade-in value to the cost of an upgraded iPhone and offer an amount less than the open market value or what third-party companies like Gazelle would pay. I’m not due for a discounted upgrade any time soon, but my 16GB iPhone 5 is almost filled up. Maybe I’ll be one of the nerdy folks queuing up in line at the Apple store the first day the newest iPhone is released, supposedly in late September.

Cerner and Epic are winning three-fourths of all new large-hospital EMR deals, according to a new KLAS report on clinical market share. Cerner and Epic dominate in community hospitals, though McKesson Paragon and Meditech are gaining some traction. Biggest net customer losers for 2012 were McKesson and Siemens, while Epic was the only vendor that didn’t lose any customers. Allscripts, GE Healthcare, and QuadraMed had no wins at all.

HIMSS opens registration for its annual conference February 23-27 in Orlando. Aetna CEO Mark Bertolini will deliver the keynote address bright and early Monday, while Wednesday afternoon’s keynote speaker is still TBA. The Thursday afternoon keynote is “world class blind adventurer” Erik Weihenmayer, who unfortunately may not be enough of a draw to prevent weary crowds from making a mass exodus Thursday morning.

A California Nurses Association press release claims that Sutter Health’s Epic system went down Monday at its Northern California hospitals following an eight-hour upgrade-related downtime on Friday. A union spokesperson was quoted as saying, “This incident is especially worrisome. It is a reminder of the false promise of information technology in medical care. No access to medication orders, patient allergies and other information puts patients at serious risk. These systems should never be relied upon for protecting patients or assuring the delivery of the safest care.” While the union did not issue an equally passionate press release extolling the virtues of paper charts, it did throw in unrelated shots at management for urging nurses to enter patient charges correctly, apparently preferring that Sutter not bill what it’s owed even though those funds allow it to generously pay unionized nurses.

The Gainesville, FL newspaper profiles 12-employee RegisterPatient (now using the name Ingage Patient)and its CEO Jana Jones, who was formerly CEO of BCBS of Tennessee subsidiary Shared Health. According to the company’s site, the product offers appointment scheduling, alerts, registration, secure messaging, check-in, health education, a PHR, care plan integration, renewal requests, and electronic referrals.

This photo by @Nurse_Rachel_ is surely embarrassing Sinai Hospital of Baltimore as it lights up Twitter. Nobody should be surprised that hospitals and doctors do whatever pays them the most; to expect otherwise is naive.

Weird News Andy says, “Nurse, doctor, what’s the difference?” A draft VA policy would eliminate the requirement that advanced practice nurses, including nurse anesthetists, be supervised by physicians. Take a wild guess at how the American Society of Anesthesiologists feels about that.

WNA also notes an AARP report warning  that 20 years from now, aging baby boomers won’t have enough family members to take care of them because of increased longevity, fewer children, and a high divorce rate. Family care is worth an unpaid $450 billion per year

Technical problems with the site Sunday and early Monday forced me (for reasons too hard to explain) to remove Vince’s HIS-tory of Cerner in the Monday Morning Update and simply link to it instead. Here it is again. Meanwhile, the site is now running on a supercharged new server that will better handle the readership growth. I’ll probably appreciate that more after I’ve caught up for all the sleep I lost over the weekend as the web hosting people fixed the inevitable problems.

Sponsor Updates

• Imprivata introduces OneSign ProveID Embedded for use within virtual desktop environments.
• GetWellNetwork announces the call for presentations for its seventh annual user conference June 3-5, 2014 in Chicago.
• Frost & Sullivan recognizes Merge Healthcare with the 2013 North America Award for Product Leadership in Interoperability Solutions for its iConnect Enterprise Clinical platform.
• Wakely Consulting Group will process data from Truven Health MarketScan Research Databases through its Wakely Risk Assessment Model to help health plans meet HHS requirements for risk adjustment and reinsurance.
• Jason Fortin, senior advisor at Impact Advisors, discusses MU deadlines.
• The HCI Group is named to the Inc. 5000, coming in at #3 with 24,545 percent revenue growth in the past three years.

Contacts

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

More news: HIStalk Practice, HIStalk Connect

HIStalk Interviews Steve Malik, Founder and CEO, Medfusion/Intuit Health

Stephen Malik of Cary, NC founded patient portal vendor Medfusion, sold it to Intuit in 2010 to create Intuit Health where he served as president until June 2013 , and announced last week that he has purchased his former company back.

You’ve said you were looking for healthcare IT investments and decided that your former business was the best one. Having looked around, what other kinds of business in healthcare IT did you find that really were or really weren’t appealing?

I’m a limited partner in multiple funds. I’ve got an opportunity to look at both entry-level, growth stage, and a little more advanced than that. Of course, a number of these VCs are looking to do more in health IT. As you know, it’s a hot area these days. About time, right? Especially around here. Pharma has been so hot, so it’s nice to have HIT take the lead flag.

I’ve looked at a lot of them and had some support from analysts. It’s been great. Inevitably in these meetings 30 minutes in, they all want to start talking about patient engagement strategy, how critical that is to Obamacare working and ACOs, etc. I agree with them that it’s critical and the next wave of opportunity to help improve people’s health and reduce cost.

At the same time, their traction was in most cases 13-14 years behind where we were with Intuit Health. I’ve been on that journey. I know how hard it is to change behavior, both for the staff of the physician’s practice and also for patients.

Having developed a secret sauce over a long period of time that’s working well here, I was concerned for them, in many cases, that both gaining adoption as well as the challenges of selling in the medical space, even though there’s a lot of consolidation these days with hospitals buying practices … You’ve been in the space a long time. You know there’s still an awful lot of five-doc and under practices that require a huge effort to get them to adopt IT in terms of the initial sales and marketing efforts you have to put into it. Distribution has been the biggest challenge for most of them.

That’s why for me, being able to get the old Medfusion — currently Intuit Health — back and take advantage of 8 million-plus patients and 100,000 secure communications a day plus … that engine that’s already going is a great distribution channel to use startup-type methodologies to put solutions on our platform and see how the market responds to them, to build an agnostic solution that goes beyond just the tethered portals that are mostly the checkbox that a lot of folks in the industry are choosing right now. I get that. It’s an easy answer. It comes with their EHR/PM.

But frankly, when we look forward, as we look at the larger community type plays that are becoming more and more predominant, all of them have multiple IT systems. Being able to have an agnostic solution that can work across various ambulatory, acute, pharma, lab, etc. solutions in places where a consumer actually wants their data, and being able to leverage on top of that applications and innovation that is teeming in the space right now. Then pick the winners and go in a little deeper with them in terms of what’s available with integration. We think that’s a winning strategy.

To answer your question, if I was going to put X millions of dollars into some startup, to be able to build a platform that’s robust enough to allow them to have distribution seemed like a really good opportunity for me to apply the relationships I’ve built over all these years in the space. Also to invest, but to make a broader bet than just individual potentials that could turn into something.

Usually when someone buys their old business back from an acquirer, it signifies some difference in opinion of how the acquirer ran the business and often involves paying a fire-sale price to restore it to its former glory after the big business has decided it wants to move on to something else. What are your thoughts on the business moving from Medfusion to Intuit and now back to you?

I have nothing but praise for Intuit. I learned a tremendous amount being involved with a Silicon Valley software giant. It’s plenty of hard work and process that goes into making their products delightful. Anyone who’s used TurboTax, Quicken, or QuickBooks knows it works great for them. They get the value of out of there and they solve problems. To be able to add that knowledge and experience base to my previous history, I’m thankful for that, thankful for the contacts, thankful for the training, and thankful for the investment.

They put a tremendous amount of money into our product to focus on scalability, reliability, privacy and security. It’s the kind of investment you make when you own TurboTax because you can’t afford to have problems in that arena with a smaller BU. All of that puts us in a great position to move forward.

Surely there are some parts of the larger organization that don’t move as quickly. Even my first week back, I’m reveling in the ability to make decisions a little more quickly without bringing in as many people. Thankfully I think that what they did was give is a great platform to move forward. We’ll be a lot more entrepreneurial and focus on innovation moving forward. I’m looking forward to that.

I’m happy not to be flying to California at the rate I was and participating as a corporate officer. Certainly running a BU requires some participation in corporation events that while important to the team you’re playing on, don’t allow you to spend as much focus on your own business unit. I’m glad to be freed of those responsibilities.

All in all, I think they set us up well for success moving forward.

Intuit wrote down $46 million when Allscripts bought Jardogs. What could Medfusion or Intuit Health done to be less reliant on a single customer that was large enough to at any point buy or build their own portal product and finally did?

They acquired someone, so yes, versus building it. I wouldn’t say we’re as reliant on Allscripts as people would like to think. We’ve done very well in other segments.

There are a number of EHRs that have more flexibility and openness in being able to write to their APIs or to integrate with them. Look at Jardogs. They were successful without Allscripts’ help in doing a guerrilla-type integration. Our ability to execute in the marketplace, while Allscripts continues to be a good partner … as of the moment, we’re officially their preferred solution. We have a tremendous number of doctors that are mutual clients. We’re very strong in the areas where they’re very strong. I don’t see that necessarily going away all that quickly. They have such a large base, it’s going to take many, many years for them to bring those solutions up to speed and be able to handle those kinds of volumes.

A big part of our experience is that when we started to put a lot of utilization through the system. That’s where the kind of investment that Intuit made really benefitted us. Keeping up a multi-tenant, SaaS-based solution that has tremendous volumes going through it is an engineering challenge that goes beyond having snazzy features.

I think it’s a good business move for PMs and EHRs to have their own solution, but the large market trends are definitely in favor of an agnostic solution. When we go out and look at larger communities — the ones that are doing the acquiring and growing and eventually the ones that will be ACOs — on average, they have over 45 different IT systems. I’m willing to bet, obviously, that patients don’t want to go to 50 different portals. To be able to provide a consolidated, easy-to-use experience for the patient across any doctor that they go to, I think plays a different role than just a tethered solution to an ambulatory answer, for instance.

What do you see as the long-term future for patient portals?

Obviously I’m making my bet on the fact that I think the community is going to want to have their website with their brand that they’re able to consolidate and allow a patient and family … most families have one person who manages the healthcare for the family. If they’re a nuclear family, they’d like their kids, their spouse, and any other care they’re doing all consolidated. I think the future is all about “do it for me.” One of the big challenges with the solutions that only work for one doctor is that you’re still entering information a lot. In today’s rapidly more and more digitized world, it makes a huge difference for a patient to be able to get a chart summary, to have all of their history there, and then be able to consolidate that across all their doctors.

You asked me about interesting companies that I looked at. There are a plethora of very interesting solutions around discharge management, care coordination, disease management, etc. I think they’re part of that future. I think what’s going to happen is that innovation is going to come into our space like it has in financial services and others that have digitized before us, and I believe the consumer is going to want one place to go for all their health information. They’ll want it portable. They’ll want to leverage the trusted relationship they have with their doctor. I think docs are going to say, OK, you have diabetes, this is my preferred diabetes app. I’d like to essentially prescribe that app.

From a “do it for me” perspective, folks like us will add value to those applications with one place you log in, tying into sensors and other kind of data that’s going, and then consolidating that information and sending the pertinent information with alerts back to the providers on the back end. We’ve seen that kind of innovation in other spaces. To be frank with you, I don’t know if that’s 2020 or 2016, but what I’m going to try to do is make that happen sooner rather than later.

Are you going to use the Medfusion name?

We’re having a contest with our employees and with customers. We’re going to evaluate the right name for the direction that we’re heading into. I’ve said a couple of times that I love the name Medfusion, and for all I know it may be the one that bubbles to the top, but I’m going to use this opportunity to make sure we’re appropriately branding ourselves for the direction we’re heading. I’d love to have an answer for you right this minute. You were right, I’m not really answering. [laughs]

Any final thoughts?

I gave you such verbose answers I probably answered one or two of the questions you were going to ask [laughs]. I appreciate the opportunity to talk to you. You’ve got a site that everybody in our space looks at. You’ve done a great job with that. It’s certainly one I check out on a pretty regular basis.

I think we’re going to have more news for you. I wouldn’t have come back to do something little. I’m intending to really try to accelerate the business and stay ahead of some of the trends that are out there.

Morning Headlines 8/27/13

Q&A: OSEHRA CEO Seong Mun on iEHR, future of open source

Leading up to the 3rd annual OSHERA summit, CEO Seong Mun answers questions on unifying VistA under a standard codebase and the odds of VistA coming out on top in the DoD EHR vendor search.

Data Triage for the Boston Bombing: How Beth Israel Deaconess Protected Patient Records From Hackers, Journalists, and Curious Doctors

FastCompany interviews John Halamka, MD, CIO of Beth Israel Deaconess on the IT security protocols used to thwart hackers and journalists from accessing victim’s medical records in the post-marathon bombing hours while its staff treated both bombing victims, and then later that week bombing suspect Dzhokhar Tsarnaev.

Tony Abbott eager to overhaul e-health system

Leading up to federal elections in Australia, Opposition leader Tony Abbott vows to overhaul the struggling patient-controlled electronic health record program if elected. The PCEHR program has been widely criticized due to cost overruns and dismal patient engagement.

Readers Write: Natural Language Processing: Putting Big Data to Work to Drive Efficiencies and Improve Patient Outcomes

Natural Language Processing: Putting Big Data to Work to Drive Efficiencies and Improve Patient Outcomes
By Dan Riskin, MD

Natural language processing (NLP) is increasingly discussed in healthcare, but often in reference to different technologies such as speech recognition, computer-assisted coding (CAC), and analytics. NLP is an enabling technology that allows computers to derive meaning from human, or natural language input.

For example, a physician’s note may state that a patient “has poorly controlled diabetes complicated by peripheral neuropathy.” When notes are analyzed through an NLP system, coded features are returned that can:

• Suggest codes such as ICD-9 or ICD-10 that may feed a CAC billing application;
• Classify a patient according to applicable quality measures such as poorly controlled diabetes mellitus, to support a reporting tool;
• Populate a data warehouse;
• Feed analytics applications to support descriptive or predictive modeling, such as the likelihood of a patient being readmitted to a hospital within 30 days of discharge.

Healthcare is data intensive from both clinical and business perspectives. While the industry’s transition to electronic data collection and storage in recent years has increased significantly, this has not actually forced physicians to code the majority of meaningful content. Eighty percent of meaningful clinical data remains within the unstructured text, as it does in most industries. This means that it remains in a format that cannot be easily searched or accessed electronically.

NLP can be leveraged to drive improvements in financial, clinical, and operational aspects of healthcare workflow:

For financial processes, automating data extraction for claims, financial auditing, and revenue cycle analytics can impact the top line. NLP can automatically extract underlying data, making claims more efficient and offering the potential for revenue analytics.

For clinical processes, automatically extracting key quality measures can support downstream systems for reporting and analytics. NLP can infer whether a patient meets a quality measure rather than requiring individuals to manually document each measure for each patient.

For operational processes, descriptive and predictive modeling can support more effective and efficient operations. NLP can extract hundreds of data elements per patient rather than the 2-4 codes listed in claims, producing better models and supporting business insight and diversion of resources to high risk patients.

So, NLP is a powerful enabling technology, but it is not an end user application. It is not speech recognition or revenue cycle management or analytics. It can, however, enable all of these.

There is a battle underway that is increasingly recognized in the healthcare space. Individual hospital divisions seek turnkey solutions and frequently purchase NLP-enabled products. But at a broader level, health systems as a whole do not want to pay repeatedly for similar technology. They seek best-of-breed infrastructure, wanting a combination of electronic health records, data warehouses, NLP, and analytics.

This battle will increasingly highlight best-of-breed data warehouses, data integration vendors, and natural language processing technologies as health systems search for a scalable, affordable, and flexible healthcare infrastructure to feed a suite of clinical, operational, and financial applications.

Dan Riskin, MD is CEO of Health Fidelity of Palo Alto, CA.

Readers Write: Bridging the Divide: Can Clinicians and CFOs Speak the Same Language?

Bridging the Divide: Can Clinicians and CFOs Speak the Same Language?
By Nick van Terheyden, MBBS

Pity poor Henry the VIII. Historians still argue over his medical records. Though his was the most scrupulously documented medical history of his age, burning questions remain. Did he suffer from syphilis as believed for centuries? More likely he had familial diabetes, which better explains his symptoms – including his well-documented inability to heal from wounds.

Imagine if Henry’s physicians were also tasked with assigning codes and complying with the clinical documentation requirements of today. The Tudor dynasty might have had some reimbursement issues. Heads would have rolled.

Sure, bloodletting is no longer an accepted therapeutic modality. But have we really come that far in bridging the divide between the clinician’s responsibility for care and the CFO’s responsibility for financial performance? Or do finance and quality continue to be involved in a forced marriage of sorts?

Clinicians are focused on their patients. While they understand the importance of billing, they need to put their energies into diagnosing and treating patients to ensure positive outcomes. And they’re overwhelmed with data – patient test results, clinical studies, guidelines, protocols – much of which they have to sift through to find relevant, critical information. Add to that, they have the burden of learning the new coding requirements under ICD-10, with the deadline approaching around the corner.

CFOs, of course, are also focused on quality but, at the same time, must juggle that priority with issues related to reimbursement, their bottom-line and ever-changing and expanding compliance requirements. They’re continually seeking out and analyzing solutions that may be able to improve both patient health and revenue performance. At the same time, they also recognize that without physician buy-in, they cannot meet any of these goals; therefore, they are looking for meaningful ways to bring them along, without disrupting their workflows.

Information that’s deemed crucial for the clinician may not be deemed useful by the CFO, and vice-versa.

Yet finding ways to break through this language barrier between the clinical and financial perspectives will be a critical success factor for healthcare organizations in the years ahead. It’s more than just a communications issue. It’s a strategic imperative aimed at translating the narrative of care into an actionable piece of information that aids in care coordination, while also ensuring appropriate reimbursement and minimizing the potential revenue leakages that keep most hospital CFOs up at night.

Clinical documentation is at the heart of plugging these revenue leakages while also meeting quality standards. Instead of finding one-stop solutions to prevent leakages across the revenue cycle, it is much easier to build accuracy from the start rather than trying to fix the problem after the train has left the station and the process is in motion.

Regardless of the tools used, clinical documentation addresses the most important concern for both physicians and CFOs: ensuring that the most useful information is captured accurately and is made readily accessible to the decision makers (and systems) who need it. At the end of the day, we all know that quality leads to a win for all.

Nick van Terheyden, MBBS is CMIO of Nuance.

Curbside Consult with Dr. Jayne 8/26/13

Mr. HIStalk ran a Time Capsule piece about electronic timekeeping systems earlier this week. Due to being on staff at several hospitals as well as working as a consultant and as a CMIO, I’ve been through more time and attendance projects than I can count. And definitely more than I’d like to remember.

Most hospitals I’ve worked at embrace two different flavors of timekeeping systems. The first type is the time, attendance and payroll system, used to track time worked for hourly employees as well as vacation, sick, and other time off for both hourly and salaried employees. The second type is the project-based time system, which allows for tracking time spent on various initiatives. Some IT organizations use this type of system for charge-backs to the departments utilizing IT services as well.

Our nurses complain bitterly about the rules that have been implemented around time and attendance tracking. They’re expected to clock in early enough to make it to their work area on time, but not too early or they will be penalized. When the emergency department nurses have to work through their designated lunch break (which happens more often than anyone would like) the procedures they have to go through to clock a “no lunch” and avoid having a break automatically deducted are akin to hopping on one foot while turning in circles and whistling the score from “Les Miserables.”

It’s so complicated that even though the system allows for nurses to bid on days off based on a request queue that looks at their seniority, work status, and previous holiday and weekend work schedules, many of the charge nurses schedule on paper because they have difficulty “seeing” the schedule and how it’s going to work out. Maybe it’s the user interface, maybe it was the training, or maybe it’s just the product in general, but either way people dislike and distrust the system.

Our department has a mix of salaried and hourly employees. We all use the same system, although our department isn’t configured with the capability to request days off. We still have to fill out a paper form and obtain a wet signature from our supervisor. Our shared administrative assistant keys in our time off once it’s approved. Even though I’m a salaried employee, I have to electronically approve my 40 hours each week and submit it to the administrative assistant to approve. I’d love to be able to go in and modify it to reflect the hours I actually work, but unfortunately that functionality would be an enhancement.

As if dealing with the time and attendance system isn’t bad enough, many of us have to work in project tracking systems as well. One hospital for which I did some consulting work tried to interface the project system to the payroll and attendance system. I’m glad I was not an employee (and also that I was not on that project) because it was a disaster. It was pretty easy to tell that whatever user validation testing was done was inadequate or nonexistent. The project system was only configured to track billable time and when employees didn’t have 40 hours on their project card, it automatically deducted the difference as vacation.

Apparently no one noticed that the project system didn’t have categories for the rest of the things that happen in a hospital IT department – drafting proposals, responding to customer inquiries, reading general emails, team meetings, collaboration at the water cooler, etc. Although it was easily fixed by adding all those tracking categories, the rollout left the teams with a bad taste that took more than a year to erase.

Whether time is billable or not, there is a great deal of data in project accounting systems. Many managers don’t know how to leverage it to determine if their teams are productive or not. It’s rare that I see managers compare hours among team members working the same projects or even spend time thinking about whether the time clocked is reasonable based on the nature of the project. It seems like people don’t realize their teams aren’t working as efficiently as needed until the overall project metrics show that staffing is over budget.

I’ve worked with a couple of managers who are really good at this, though. The best was an inpatient pharmacy project manager dealing with a large and complex build. She looked not only at how much time people were spending on comparable tasks, but was able to reference it to their weekly status reports and determine that some team members had as much as 50 percent more throughput than others. After doing some one-on-one assessments to make sure everyone was adequately trained and had the same level of competency (as manifested by error rates) she called the team together.

I was able to watch as the meeting unfolded because she asked me to be the neutral facilitator. Knowing what she had planned, I think it was also so she could have a witness in case the team tried to go over the table at her. She started innocently enough asking them to come up with a consensus response for a variety of questions about how long it takes to do various build tasks. Everyone was very open in the discussion. She took her time waiting for them to all agree on what was reasonable.

What they didn’t realize that she had all the project time and productivity numbers pre-built on a spreadsheet which she modified as she started asking the questions. By the end of the meeting, she had some interesting data that painted a pretty damning picture of how some team members were performing compared to what they all had just agreed was reasonable. At the same time, she had also created a road map for the rest of the project and let the team know she’d be holding them to the productivity parameters they had just defined themselves. Needless to say, they were speechless. They never saw it coming.

I kept a close eye on her team the rest of the build. Fortunately they handled themselves as professionals and I didn’t hear a lot of complaining or see a change in error rates. Maybe they were either embarrassed that they had just been caught sandbagging or were motivated to meet the goals set by the team – we’ll never know. They’ve been live for quite some time and they still use those same time estimates when scoping upgrades and revisions to the pharmacy database.

I have to admit I pirated her approach. I’ve used it to help novice physician leaders who have been told by their tech teams that it will take too long to build customizations that would make the physicians’ lives easier. The physicians can work through the average time needed to do x, y, and z tasks and compare it to the time that would be saved for end users or the quantifiable improvement in patient safety. I’ve used it with tech managers who are being held hostage by programmers who don’t want to exert themselves. I’ve also used it in the clinical office prior to doing time and motion studies.

I’m always interested in ways to better use the data at hand rather than having to implement new systems or use manual processes. Do you have creative uses for data from your time tracking systems? Email me.

E-mail Dr. Jayne.

Morning Headlines 8/26/13

The CIO: Healthcare’s New Million Dollar Man

SSi Search surveys 178 healthcare CIOs on changes to their roles and responsibilities post-HITECH and compares that with associated salary increases. 23 percent of respondents reported a 50 – 75 percent increase in responsibility since HITECH was passed, but reported receiving less a 10 percent salary increase over the same period.

Kaiser Permanente Opens New Information Technology Center in Greenwood Village

Kaiser Permanente opens a five-story, 350-person IT office in Greenwood Village, CO which it estimates will house 700 employees by 2015.

NYC Macroscope Puts Data at the Fingertips of City Officials

New York City public health workers are developing a big-data surveillance program that promises real-time population health monitoring of the city. The program will rely on EHR data aggregated into a surveillance tool that will drive public health decisions.

Class 2 Recall Picis EDIS PulseCheck

Picis recalls its PulseCheck EDIS due to problems with prescription comments being dropped from electronic prescriptions when filed or printed.

Monday Morning Update 8/26/13

From Todd: “Re: FDA security guidance. FDA has published radio frequency guidance for wireless medical devices that includes information about authentication and encryption to prevent hackers from gaining control. FDA has a draft out for comment that includes a requirement that vendors develop a plan to apply operating system updates and patches to address security flaws.” It’s strange (or typical government efficiency) that a document that went to draft in January 2007 finally gets published years afterward. The cybersecurity draft came out in June.

From Digital Bean Counter: “Re: Optimity Advisors. Anyone have experience working with them?”

From Keith: “Re: EHRs. If they aren’t medical devices, why is the vendor reporting to the FDA and recalling its care controlling system?” Picis announces a Class 2 recall of its ED PulseCheck emergency department information system due to a problem printing entered notes along with prescriptions. My guess is that Picis (part of OptumInsight) commendably reports through FDA even though they aren’t required to since I’ve seen their entries in the MAUDE database over the years. Demands for FDA oversight would be reduced to almost nothing if vendors reported and tracked software defects with the same enthusiasm as they do unpaid invoices.

Most poll respondents don’t think the FDASIA report will improve IT-related patient safety since it limits its scope to a user reporting mechanism and other forms of post-marketing surveillance. New poll to your right: when a vendor requires you to register before downloading a white paper you want to see, what do you do? I will, as the poll maker, unprofessionally expose my bias in stating that I think hiding advertising material behind a lead-gathering signup form is both stupid and insulting. We hospital people are smart enough to figure out how to contact you if your material inspires us to further action; we aren’t fans of being cold called as punishment for being willing to give your material a look. Do the sales and marketing people a favor and ignore their faulty advice. I always sign up with phony information, inserting the vendor’s own phone number in the required slot.

I  ran a reader’s question in Friday’s news asking for hospitals that have switched from Cerner to Epic. Readers provided these: Aurora, Legacy Health Portland, Children’s Dallas, University of Utah (underway), Rex Healthcare, Loma Linda, and Lucile Packard (underway). I appreciate the information, which then led me to another question as it often does: have any hospitals voluntarily switched from Epic to Cerner?

XIFIN, which offers revenue cycle solutions for laboratories, radiology,  and pain management, acquires PathCentral, a vendor of cloud-based digital anatomic pathology vendor with big-name customers such as Johns Hopkins, Mass General, and University of Southern California.

A medical assistant / IT administrator at an orthopedics practice is arrested for stealing a pre-signed blank prescription form from the the practice’s EMR and writing himself a prescription for Percocet.

The Washington Post profiles Altruista Health, a 75-employee Reston, VA company that offers predictive algorithms that identify a provider’s highest-risk patients. I ran a Readers Write article by CEO Ashish Kachru in December 2012.

URAC and the Leapfrog Group announce the second annual Hospital Website Transparency Awards, which recognizes websites that portray quality measures honestly and contain information that’s actually useful instead of the far more common marketing BS (stock photo photogenic doctors, community chest-puffing, and unsubstantiated claims that locals are incredibly lucky to have a world-renowned medical facility in a town too small to even have a mall.)

Wisconsin Statewide Health Information Network says it will go live soon, running on the Medicity platform.

A 178-respondent CIO survey performed by SSi-SEARCH finds that the average CIO makes $286K, but despite greatly increasing workload and responsibility, receives single-digit annual salary increases. Still, almost 60 percent of respondents say their pay is satisfactory. They report that people- and team-related issues are both their biggest challenge and their biggest accomplishment. Only 11 percent of the CIOs aspire to a non-IT role, but those who do are interested in a COO position despite responses indicating that it’s tough for a CIO to be recognized as a strategic leader outside the IT realm.

An Allscripts promotional video filmed at Sarasota Memorial Hospital (FL) celebrates the hospital’s 15 years on Sunrise and features VP/CIO Denis Baker.

New York City is piloting NYC Macroscope, which aggregates EHR data into a public health surveillance database that will allow city officials to monitor the health of the population in near real time. Their only concern is that its data is, by definition, limited to those patients who receive medical care, so the city will still need to conduct traditional survey-based surveillance. Data exchange has been established with 3,200 providers in the NYC Primary Care Information Project, which uses eClinicalWorks and distributes queries through the Hub Population Health System.

Advocate Medical Group (IL) announces that four unencrypted desktop computers were stolen in a July 15 burglary that contained basic patient information and Social Security numbers on 4 million patients.

Bats Global Markets, the nation’s third-largest stock exchange with $101 million in 2012 earnings, is discussing a merger with another exchange that would make it larger than Nasdaq. Bats was started by former Cerner employee Dave Cummings in 2005 as an electronic trading company. The company was supposed to go public in 2012 by being listed on its own exchange, but a software bug froze its systems seconds after its executives rang the trading bell, causing Bats to cancel its IPO as the word spread and underwriters feared a steep share selloff. Cummings may have learned email etiquette from his former boss Neal Patterson as he immediately sent a scathing ready-fire-aim internal email cancelling all bonuses.

Texas Health Resources names Luis Saldaña, MD as CMIO of the 25-hospital system.

Two executives of Eastern Connecticut Health Network, including VP/CIO Charlie Covin, leave the organization abruptly as it prepares to sell itself to for-profit Vanguard Health Systems.

Kaiser Permanente opens an IT center in Greenwood Village, CO, with the current 350 employees working there expected to double by 2015.

The accounting department of University of Mississippi Medical Center accidentally sends an email to 190 students Wednesday evening with an attached worksheet containing the Social Security numbers, GPAs, and other personal information of all 2,300 of its students. It frantically tried to recall and then purge the message, but 115 of the students had already opened it and three had forwarded it to an external email address.

The Roanoke newspaper reports that the former president and CEO of Carilion Clinic (VA) received $6.2 million in final compensation when he left in 2011.  Another Carilion CEO who retired in 2001 received a $7.4 million lump sum payout that was only one of two installments he earned for honoring his non-compete agreement.

A former employee of MedCentral Health System (OH) files a lawsuit against his former employer, claiming that he was unjustly fired after complaining that Open Systems, a Cleveland-based technology vendor, was bribing the hospital’s IT department to buy its overpriced computer equipment with travel, sports tickets, and food. The employee says he complained to the former IT director, who told him he would be running the department some day and should just mind his own business.

Microsoft CEO Steve Ballmer announces his retirement as CEO, causing shares to jump 7 percent Friday, ironically raising Ballmer’s personal fortune of $15 billion by another $800 million by his own departure. A Reuters article summarizes his many mistakes with a quote: “That is the most expensive phone in the world and it doesn’t appeal to business customers,” Ballmer laughed in a TV interview after the launch of Apple’s iPhone in 2007. Five years later, iPhone sales alone were greater than Microsoft’s overall revenue.” The article also mentioned the infamous “Monkey Boy” video, in which Ballmer leaps and screams all over a sales meeting stage hoping to generate enthusiasm that the company’s performance couldn’t.

Vince Ciotti says this device might entice older doctors to use an EMR.

Robert Wood Johnson Foundation says the use of patient-shared medical visit notes (OpenNotes) is spreading, with Beth Israel Deaconess Medical Center rolling it out now with similar plans by the VA, Group Health Cooperative, Geisinger, Cleveland Clinic, and Mayo Clinic. RWJF will issue a $2.1 million grant to share lessons learned and to help health systems implement it.

Weird News Andy perhaps inevitably title this article “Sh*t for Brains.” California’s Department of Public Health fines three UC Davis Medical Center doctors who injected fecal bacteria into the brains of three cancer patients as an experiment, hoping to kill tumor cells. Instead, the resulting infections trigger septicemia-induced seizures, with one patient dying shortly after. The doctors admitted that they had no plan to address problems that might have developed and couldn’t explain why they chose those particular patients.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: Time Won’t Let Me: Everybody Hates Filling Out Timesheets, But It Beats Being Laid Off

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 May 2009.

Time Won’t Let Me: Everybody Hates Filling Out Timesheets, But It Beats Being Laid Off
By Mr. HIStalk

One of the least-popular yet most useful things I’ve done in IT management was to implement an electronic timesheet system. I thought it would add a defensible layer of transparency and accountability to our otherwise black hole of IT projects and maintenance activities (it did), but I didn’t expect the staff to resist (they did).

It was for their benefit, after all. Executives were complaining about IT costs because they had no idea what we were working on (coddling those same PC-illiterate honchos armed with the highest-powered laptops and cool PDAs that never got used except to mess them up was a lot of what we did). They couldn’t figure out why we kept needing more people (forgetting all the cool new applications they went out and bought without allocating operating funds to keep them running). They figured we must be screwing around since we rarely emerged from our IT hole to encroach on the rarefied air of their windowed, couched, and conference tabled offices (because we were trying to keep outdated servers and applications running on a shoestring instead of chatting on our couches).

I pictured the day when, under snotty cost pressure from the bean counters, I would triumphantly wave a slickly printed labor allocation pie chart and proclaim, “Sure, we can cut IT costs. Which of your financial applications would you like to shut down?” (it actually did kind of work out that way).
Employees still resented the “getting into my business” aspect of accounting for their time. They made it clear with eye-rolling and begrudged compliance that the whole timesheet thing was invading their personal, company-paid space.

I’ve done this twice. The arguments are always the same:

• I’m too busy to track everything I do (suck-ups)
• I multi-task, so it’s impossible to record time accurately (excuse-makers)
• I don’t want to have to drop everything just to record a two-minute phone call (whiners)
• I would need at least 200 time codes to fully represent my broad contributions to the enterprise (opportunistic night shift computer operators)

Here’s a given. At the meeting where the timesheet idea is first floated (carefully masked under the working title “effort tracking,” which fools no one) and employee resistance first rears its ugly head, someone who considers themselves a master of cynical wit will invariably say, “How do I record the time it takes to record my time?” Ha ha, that never ceases to amuse even after hearing it 100 times.

Everybody hates recording their time. Software is often old and clunky (I see somebody has modified Twitter into a timekeeping system – you Tweet when you change activities and it records the elapsed time. That must really tear at the soul of Twittering geeks who still hate having their time tracked).

But the thing is, it works beautifully. Even given the inevitable fudging and one-upmanship involved (did you really work 112 hours this week?), it’s amazing to find out where employees really spend their time. You find out how long it takes to upgrade the payroll system, develop a new CPOE order set, and apply the latest server patches. You can then plan for next time.

The faint Big Brother overtones help, too. Folks who don’t mind goofing off but are too honest to lie on a timesheet might work a little harder rather than perjuring themselves.

And at least it’s not the Soviet-inspired problem tracking system, which forces employees to stop co-workers mid-sentence to announce, “I can’t talk to you until you open a ticket.”

This Week in HIT 8/23/13

Nuance Recognizes Icahn’s Voice as Hostile

Facts and Background

The board of speech recognition giant Nuance Communications, alarmed by the rapid accumulation of its shares by billionaire investor and corporate raider Carl Icahn, adopted Tuesday a shareholder rights plan (aka “poison pill”) that prevents any outside investor from holding more than 20 percent of the company’s shares.

Opinion

With Nuance shares up only 22 percent in five years and considerably lagging the Nasdaq after some company stumbles this year, are Nuance’s board members protecting the interests of shareholders or their own?

Musings

• It’s at least flattering to attract Icahn’s financial interest. At the moment he’s pursing Dell and his August 13 announcement that he’s buying Apple stock sent shares up 5 percent.
• Icahn owns 16 percent of the outstanding shares of NUAN.
• Ican is worth $20 billion, mostly made by buying downtrodden companies and selling them off in pieces.
• Healthcare (Dragon, eScription, transcription services) is Nuance’s bread and butter at about 50 percent of revenue, even though the company is mostly known outside of the industry as providing the technology behind Apple’s Siri and voice-powered appliances.
• Icahn’s tactics after he gains control of a company involve replacing the board, then breaking the company up if the share price doesn’t respond.
• Historically, shareholders receive significant benefit if the companies Icahn controls either are taken private or are acquired, but suffer if they remain independent.

We’re Not Intuit Any More: Medfusion’s Founder Buys it Back

Facts and Background

Steve Malik, who founded patient portal vendor Medfusion in 2000 and sold it to Intuit in 2010 for $91 million, confirmed Tuesday that he has bought his former company back.

Opinion

Intuit joins Misys and Sage as examples of why nobody benefits when financial software firms decide to dabble in industries they know nothing about, especially ones involving patients.

Musings

• Cary, NC-based Medfusion had taken in only $2.2 million in outside investment when Intuit bought it, so Malik must have made a fortune back in 2000.
• Malik bought Intuit Health back at an unannounced price, likely a lot less than $91 million since its revenue was declining despite increasing physician adoption.
• Malik says he hasn’t decided whether to revive the Medfusion name.
• Intuit announced that it was seeking a buyer on August 1, when it announced unimpressive quarterly results.
• Intuit wrote down an astounding $46 million in May 2013 after Allscripts, its biggest customer, bought portal vendor Jardogs in March 2013 after years of being stuck with its earlier (dumb) decision to market rather than build a patient portal to complement its EHRs.

Greenway’s Subscription Wasn’t Delivered in Q4

Facts and Background

Greenway announced a wider than expected loss and decreased revenue in its earnings report Monday, blaming its shift toward a recurring revenue model.

Opinion

Competition, the HITECH slowdown, and regulatory development costs are making it tough to meet lofty expectations in the ambulatory EHR world.

Musings

• Like all software companies, Greenway is trying to wean itself off sales-driven revenue and move toward a recurring revenue model involving maintenance fees, training fees, and add-on services such as revenue cycle management. Like most software companies, they aren’t finding it easy, especially while doing it under the watchful eyes of Wall Street.
• Sales to Walgreens boosted revenue, but at reduced margins.
• The company says it expects system sales to drop 50-60 percent as it moves to subscription pricing.
• Tee Green said in the earnings call that Meaningful Use Stage1 created market “carnage” that will benefit the company in the form of more astute prospects.
• GWAY shares are up slightly on the week.
• The report wasn’t great overall, but GWAY is a work in progress having gone public only 18 months ago and share price unchanged since.

More Parking Lots for Neal to Watch: Cerner Plans a $4 Billion Campus

Facts and Background

Cerner’s planned development of a 251-acre abandoned mall site will be the biggest office development in Kansas City history, eventually housing 15,000 employees.

Opinion

Campus projects are a good indicator of company optimism, and even though taxpayers will be on the hook to give Cerner $1.2 billion in tax incentives for a 70-30 private-public split, a capital project of this magnitude indicates a lot of confidence about the future for a company whose market cap is $16 billion.

Musings

• Cerner will put $8 million into a fund intended to improve the seed neighborhood that surrounds the abandoned mall.
• Cerner employs 9,000 in the Kansas City area.
• Cerner will buy 221 acres of the property from co-founders Neal Patterson and Cliff Illig.
• The former Bannister Mall closed in 2007 due to suburban flight and rising neighborhood crime drove customers away. It was torn down in 2009.
• The site is near Cerner’s Innovation Campus.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.