Morning Headlines 1/21/13

EDs with HIE more likely to avoid repeat imaging

One of the first large-scale studies on the links between HIE participation and imaging in hospital emergency departments finds that redundant CT scans, x-rays, and ultrasounds decreased significantly, with savings in the millions of dollars, at hospitals connected to an HIE.

How Data Analytics Helped Spark a $36.5M Turnaround at Boston Medical Center

Boston Medical Center President and CEO Kathleen Walsh attributes a data analytics project to the hospital’s financial turnaround in which it went from a $32 million loss to a $4 million surplus in two years.

Survey says: EHR incentive program is on track

National Coordinator Karen DeSalvo, MD outlines the progress made thus far under the EHR incentive program.

St. John embraces digital records

A local paper covers St. Johns Medical Center’s (WA) Epic go-live. St John’s is Part of PeaceHealth’s system-wide Epic install.

Curbside Consult with Dr. Jayne 1/20/14

Last week, Mr. H polled his HIStalk Advisory Panel regarding their top priorities and concerns for 2014. I laughed out loud at the response above. Not only is it extremely direct, but in the case of my hospital, it’s entirely true.

Like many facilities, we spend a lot of time going through various exercises to define the various projects we need to work on during the year. We also expend a great deal of effort reviewing our personnel and their capabilities while we determine the overall capacity for work.

I looked back at our timekeeping system, and during 2013, I spent nearly 100 hours in various project evaluation and prioritization efforts. That doesn’t include the time spent looking at team members and whether or not they can take on additional projects. At most of those meetings, there were between six and 12 attendees, so that means we spent close to half a person-year trying to figure out what we need to work on and in what order.

We have over 100 prioritized projects on our ‘to do’ list. Being “prioritized” means that a project fits certain business criteria. For example, it might be in support of our Accountable Care or patient outreach efforts. It might be a process improvement project which requires modification of existing systems or addition of a new system. It might even be something that enhances the user experience or the overall usability of an application. Bring prioritized, however, does not mean that a project is funded.

There are a lot of things on the list that the requestors believe we need to do, but are not willing to commit funds to actually accomplishing. They want us to find funding out of some nebulous IT pot of gold which simply doesn’t exist. Because these projects aren’t funded it means they languish on the prioritization list, which adds to everyone’s frustration. The IT department feels like it can’t ever move things off the list and our departmental customers feel like the IT department doesn’t do anything.

When a project is actually funded, we can knock them out pretty quickly. For example, one of our outreach clinics recently applied for and received grant money for a very specific clinical reporting project. The requested a suite of reports and a dashboard for monitoring. We created a proposal and they approved it. The IT chargeback item was opened and the scope document created and finalized. We had their dashboard live in beta in under 30 days and in production a week or two after that. We probably could have done it faster, but there were some delays with accounting and paperwork and we’ve learned the hard way not to start anything until all the paperwork is in place.

Looking at the actual IT discretionary budget that we have to work with, it’s going to be nearly impossible for us to do anything that isn’t MU-2 or ICD-10 related. If it’s not regulatory, it’s not going to happen unless D.B. Cooper drops a mysterious bag of cash from the sky. We have enough in the budget to handle various hardware and infrastructure upgrades so we can stay ahead of the vendor requirements game.

Like many other hospitals, we’re struggling with the fact that our vendors aren’t delivering the MU-2 and ICD-10 software as quickly as we want it. I hope what we ultimately receive is high quality because we can’t afford endless rounds of testing or delays when what we receive requires patch upon patch. We need to get the MU software in so we can free up the environments for ICD-10 testing. If there are delays, we can’t afford to stand up extra testing environments to handle what the vendors should have taken care of during beta testing.

At least our ambulatory vendor has delivered its software package, which includes both MU-2 and ICD-10. We’ve got it in testing and it looks pretty solid, but there are a couple of fixes we’re waiting for that are fairly specific to our environment. We should have them in the next week and then the real fun will begin. Our physicians are very nervous about the ICD-10 transition and we’re using a third-party vendor to augment the mapping provided by our vendor, but that’s one more thing we’ll have to test.

We’re only a couple of weeks into the year, but I already need a vacation. We plan to attest for MU-2 in the third quarter so we can coast towards ICD-10, but I doubt it will be a smooth ride. In the mean time, we’ll be on-boarding new practices and adding several dozen physicians to existing practices. I think I’m going to need roller skates. If you’re a CMIO what are your priorities for the year? Email me.

Email Dr. Jayne.

HIStalk Interviews Adam Cheriff, MD, CMIO, Weill Cornell Physicians

Adam Cheriff, MD, is chief medical information officer of Weill Cornell Physicians of New York, NY.

Tell me about yourself and the organization.

I am the chief medical information officer for Weill Cornell Physicians. I’m a part-time internist, the rest of the time responsible for the clinical health information technology and clinical operations for our physician organization. Weill Cornell Physicians is 950 multi-specialty faculty physicians associated with New York-Presbyterian Hospital.

You recently went live with Epic. How’s that going and what are the most important lessons that you’ve learned so far?

We have been an Epic ambulatory customer for many, many years, since 2001. We have a great deal of experience with ambulatory clinicals. What we did most recently was convert our legacy practice management system, which had been GE-IDX, to Epic. We’re very happy with how that’s gone.

We gave it a lot of careful consideration as to what the motivations were for doing it. For us, it was really about trying to consolidate onto a single platform for our administrative and clinical systems; the patient experience and improving it via self service; and lowering the training burden for our staff and faculty. We had an eye towards the future, where we knew we were going to have to do more advanced analytics, and being able to seamlessly move between the clinical and the administrative was a big deal. We had a hope that in doing this that we would lower some of our long-term operating costs.

We went into it with what we thought was good justification. I thought we were thoughtful in terms of how we restructured organizationally from an administrative business unit standpoint in order to support the implementation. That really was a lot of matrixing of the IT and clinical staff that knew the Epic clinicals and knew how to manage that relationship, the business office that were the core revenue cycle domain experts, and our finance office. I think that matrixing really helped a great deal.

Some organizations, particularly on the hospital side, have struggled with the conversion to Epic from a revenue cycle standpoint. What’s been your impact?

We feel very fortunate, obviously. I think the press seems to have a little bit of a selection bias in terms of seizing on, unfortunately, the missteps. I can completely see how these things would happen. They’re extremely complicated projects.

We have felt very, very fortunate about how things have gone. I should say that our implementation methodology may have predicted some of our success. Despite the fact that Epic would like to see organizations do this big bang — and I think that there are reasons for that in terms of not necessarily bleeding this out and being trapped in two worlds — we did this in a series of pilots leading up into a big bang. That gave us just enough experience with the new tools, so that with each phase of it, we got stronger.

The high-level summary of our financials is that for one cohort, we’re about six months into this. For the two-thirds of our business, we’re about three months, or one quarter, into this. We are 10 percent year to date increased in our receipts. Now it’s unfair to attribute that all to Epic, because obviously we have a lot of other growth initiatives. But if you look at it from the standpoint of what we budgeted in terms of anticipating that growth, we’re still three percent up, which you can fairly attribute to the Epic effect.

The main efficiencies that we’ve gained is that Epic is great in terms of transparency and accountability, for working charge edits and claim edits, and really has a great task management system to do that. Our pre-AR, we’re working much more aggressively than we were pre-Epic.

When you converged onto the single Epic platform, what goals and metrics did you hope for as an outcome?

We looked at the classic revenue cycle metrics. Those are all important. Days in AR , and this might be somewhat Epic-speak, but days in pre-AR as well, claim edits, denials.

Epic does a fairly good job of being prescribed and doing a fair bit of hand-holding with tools to be able to look at those metrics as you’re making the transition, even including some of the legacy practice management statistics as you make that implementation. We are also very interested not exclusively in the revenue cycle side, but also on the access and front-end side — registration quality, patient duplicates, the number of patients that make online appointments, our access metrics in terms of how long people have to wait to get appointments, and so forth.

When you mentioned patient self-service, were you primarily referring to self-scheduling?

Yes. Self-scheduling and online bill payment were the two features of MyChart that we were able to unlock with the conversion to practice management.

What kind of feedback do you get from patients?

It’s a little early for us to have amassed a lot of formal feedback. Anecdotally, we think that patients love it and that it is definitely helping our brand. Although I will say that given our marketplace in New York City, we have to keep up in that. Many of the other big academic centers are using similar if not identical platforms. Patients really like the convenience that is afforded in sectors other than healthcare. 

Culturally, from a physician organization standpoint, we still have a ways to go. While the consumer is definitely demanding it and the patients want it, the physicians are a little bit slow and guarded about the degree to which they’ll give open access to scheduling. But I think we will evolve.

You mentioned that Epic is part of your brand just as it was for Kaiser Permanente, who named their implementation HealthConnect. Do you see that as a competitive advantage and a way to enhance your brand with patients?

Yes. We did something similar right down to the name in that we branded MyChart as Weill Cornell Connect. The patient engagement strategy is so important. From a regulatory standpoint, it’s become increasingly important in terms of all the Meaningful Use objectives around engagement and how you need to communicate with the patient.

From a branding standpoint, the patients really do feel connected. Part of it is the transparency and the visibility of the record, which, of course is something else that the physicians slowly have to wrap their heads around.

But it’s really the interactivity. It’s the ability to, in an asynchronous way, reach out to the practice for all the things that people need to reach the office for. Not being on these endless phone queues is a real patient satisfier.

You mentioned that having both sides of the house on Epic gives you some new opportunities. What are you doing or what will you be doing in terms of analytics and population health management?

We are pretty energized about this. Clearly we’re moving from the phase where it’s less about the adoption of the technology, even to some extent less about optimization, although that is going to occur forever. It’s more about now that we have had critical massive adoption, what do we do with all this great data that we have been collecting? We, like most Epic clients, rely heavily on the relational model of Epic’s data, which is Clarity. We have pretty sophisticated report writers and business intelligence tools, including both Business Objects and Cognos, that sit on top of that. 

We are very eager to see where Epic continues to develop in this arena. They have done a good job of recognizing that in order for us to effectively manage populations, we’re going to need more than just the data that’s within Epic. The Epic data warehouse that they’re building towards that will allow us to take in outside claims data and patient satisfaction data is very intriguing to us.

Have you gained insights from having all that data available?

We engage in the same kinds of clinical outcomes and chronic disease management metrics that most large institutions engage in. We understand how our diabetics are being managed and our CHF patients and COPD and the chronic disease markers. 

We have struggled, like many organizations, to drill into that from a utilization and cost containment standpoint. That’s why it will be critical for us to start to marry those clinical data, which have become ubiquitous in our system, with the claims data that will be generating now that we have the practice management system.

How do you see practices changing both in terms of the changes prescribed by the healthcare environment and the availability of the technology like you’ve implemented?

Oh, boy, that’s a good one. The technology absolutely changes our culture and our practice patterns. I can give concrete examples over our life cycle. 

The first thing that the electronic health record did is it made us function more as a group model. We are a group. We’re a federated group of clinical departments. But sharing the single patient record with the focus changing from the provider’s record to the patient’s record was a real paradigm shift in the way that you can’t help but promote communication. That has promoted better outcomes. 

The next major paradigm shift was the rise of the patient portal, that level of transparency and really getting providers to understand that in many ways the patient owns the data and being as transparent with the results. The self-service model and the online scheduling. Even the rumblings of the OpenNotes project, where people will expose their clinical documentation. 

These are all things that are going to be profound drivers of the way we practice and probably will predict better outcomes because you’ll have a class of patients that’s much more engaged in their care.

Are you implementing more evidence-based medicine and standardized care protocols along the way?

We have. We have made use of fairly standard decision support tools that are available in Epic, particularly around Health Maintenance Rules. For certain populations of patients or certain chronic diseases, making sure that we have the data-driven schedule of what should be done for those patients. We use decision support alerts to support that. I think it’s been very effective, actually. We probably have, at this point, dozens of rules that are keeping track of that information.

Is there more interest, or could there be more interest, in patients taking a more active role in their healthcare and their health than they have previously?

Yes, because it’s more accessible. If you go back even just a few years pre-portal, it’s pretty difficult for patients to really access their information. What they’re left with is what they can absorb in a hurried clinical interaction, which is often exceedingly difficult for patients. As the word says, a portal is a window into what’s going on with them. 

The fact that we’ve been able to embed patient-friendly education that directs people to do further learning about their conditions, I really do. Where Epic is developing some of the tools that we’ve implemented is that for chronic diseases, that there are tools for patients to engage. Whether that’s blood glucose monitoring for the diabetic or blood pressure monitoring for the hypertensive, that’s a way for them to engage in their health and to promote that communication back with the provider.

If you look ahead two or three years, where do you see the most important IT-related priorities that will impact your organization?

It may have become a cliché at this point, but the past couple of years have really been about keeping up with regulation. Unfortunately I don’t see that necessarily dying down. Meaningful Use, ICD-10, and all these things that we really have to do. A lot of good that has come out of it, but in many ways, it has stifled innovation. 

The next couple of years are going to be about usability and trying to refine these user interfaces. Clearly interoperability is where we’re headed. The goals of some of this regulation is consistent with promoting the this interoperability, but many of us at the ground level have not seen that realized. T think that’s going to be incredibly important.

Locally, and this is true of many organizations like us, growth is going to be a big driver. The fact that we’re probably going to extend into a larger provider network to take care of larger populations, we’re going to have to find ways to spread our technology and to be reasonably agile about that.

Morning Headlines 1/20/14

GE Healthcare revenue flat, earnings up 4%

GE Healthcare reports Q4 earnings, revenue declined one percent to $5.12 billion, but profits were up four percent.

Netherlands hospital staff visits St. Rita’s Medical Center

Epic appears to be expanding its presence in Europe as nine members of St Jansdal Hospital, located 40 miles from Amsterdam in the Netherlands, go on a site visit to St. Rita’s Medical Center in Lima, OH.

Girish Navani, on Why Titles Don’t Matter

Girish Navanti, CEO of eClinicalWorks, is interviewed by the New York Times on his leadership style. Navanti hires directly from college, and does not believe in firing people. He enjoys an 80 percent approval rating on employee review website Glassdoor.com, higher than the CEO’s of Greenway, Allscripts, or Epic.

Royal Berkshire Hospital booking system ‘still flawed’

In England, the new CEO of Royal Berkshire Hospital addresses employee concerns over the hospital’s $47 million Cerner Millennium system which went live in 2012.

Monday Morning Update 1/20/14

From Big Kahuna: “Re: Advisory Panel question about ‘2014 will be the year of …’ Patient Access! Of the 10 hospital CEOs we heard speak at last week’s J.P. Morgan conference in San Francisco, eight mentioned patient access as a chief concern or initiative.”

“Jeopardy” winner or not, readers aren’t impressed with the healthcare potential of IBM’s Watson. New poll to your right, as requested by a reader: are HIT vendors laying off more people than 1-2 years ago? You can click the poll’s Comments link after voting to explain.

Lorre is finishing up work on HIStalkU, a new site that will showcase our completed, recorded HIStalk webinars to give them more long-tail visibility. We included the capability to include outside webinars, white papers, and videos as well, so if you are interested, contact Lorre. We have plans for adding more purely educational content such as lectures and slide sets (thus the name.)

Welcome to new HIStalk Platinum Sponsor Arcadia Healthcare Solutions of Burlington, MA. The 12-year-old, 200-employee company has worked with 7,500 providers, 150 PCMH practices, and five pioneer ACOs to improve healthcare quality and reduce cost via EHR outsourcing and consulting, vendor-agnostic data integration and population analytics, provider retention, and practice transformation and coaching. The company can improve key ambulatory network measures 15-30 percent in six months by bringing together EHR and claims data and helping providers use it. Some of its EHR optimization accomplishments include reducing log-in time by 50 percent, improving system performance by 27 percent, and increasing physician satisfaction by 20 percent. Arcadia provides expert advisors rather than, as it says, “high-priced management consultants who leave nothing behind but PowerPoint.” You probably know some of Arcadia’s industry long-timer leaders: Sean Carroll (Nuance); Sam Adams (Lawson, Picis); and Chris Couch (Health Dialog). Thanks to Arcadia Healthcare Solutions for supporting HIStalk.

Cerner launches what will be the largest corporate campus in Missouri at an eventual 4.1 million square feet. Cerner says its $4.3 billion complex will house up to 1,500 new employees within three years.

Meanwhile in England, the interim CEO of Royal Berkshire Hospital says its $47 million Cerner Millennium system is still not working right, adding, “It was particularly bad the year before, but it’s still not good enough. We’re in the process of moving with a new strategy with what the information system should be in future.”

The local newspaper covers a site visit to St. Rita’s Medical Center (OH) by a nine-member delegation from an Epic prospect hospital in the Netherlands.

DreamIt Health Baltimore launches and adds Kaiser Permanente to its list of strategic partners that includes Johns Hopkins and Northrop Grumman. Startups chosen for the four-month boot camp, many of which don’t even have websites that I could find, are:

• Aegle. Wearable biometrics.
• Avhana. EHR clinical decision support.
• Cognuse. Game-based stroke rehab.
• EMOCHA. Medication data capture.
• Protenus. Patient consent management.
• Respi. Smartphone-based spirometry.
• Patient Feed. Inpatient collaboration.
• Phobious. Augmented reality treatment of behavioral health issues.
• The Smartphone Physical. Smartphone diagnostic tools.

Beverly Bell (Health Care DataWorks) is named VP of consulting at Siemens Healthcare. 

Connie McGee (AirSrip) joins Pershing Yoakley & Associates as a principal.

Actor Dennis Quaid is back on the patient safety bandwagon again years after after his high-profile legal crusade against medication errors went on hiatus. Quaid, whose newborn twins were given 10,000 unit/ml of the blood-thinning drug heparin as an IV flush rather than 10 units/ml at Cedars-Sinai in 2008 without permanent harm, is urging Californians to support the Pack Patient Safety Act that would require doctors to look up their patients in the state’s CURES prescription dispensing database before prescribing narcotics. The proposed act, which will appear on the November ballot if it gets enough signatures, would also adjust California’s $250,000 medical malpractice cap for inflation to $1.1 million, require physicians to be randomly tested for drugs and alcohol, and would require doctors to report their peers if they witness substance abuse or medical negligence. Bob Pack’s two children were killed in 2003 when a doctor-shopping drug addict ran over them, after which he found that multiple Kaiser Permanente doctors were prescribing narcotics for the woman without realizing it. Pack, the founder of NetZero, developed the CURES system that few doctors use ( including those of Kaiser) and that doctors say is user-unfriendly. Quaid sued everybody in sight after the medication error involving his twins (including the drug’s manufacturer and distributor, who had nothing to do with the nurse’s mistake) and shamed Cedars into spending $100 million for medication barcoding. HIMSS put him on as a conference keynoter in 2009. He merged his patient safety foundation with another group the next year and hasn’t had much to say about patient safety since.

NextGen, like Greenway and Allscripts before it, will integrate analytics from Inovalon (which changed its name from MedAssurant last year.)

A Wall Street Journal blog entry mentions an Amazon patent for “anticipatory shipping,” where the company it will use its customer information to reduce the delays between ordering and shipping that “may dissuade customers from buying items from online merchants.” Nobody seems to interpret the possibilities as I do in reading between the lines: the company could ship items “on approval” for opt-in customers with return postage paid, allowing the company to put appealing merchandize into the hands of qualified customers with the confidence that many will keep it. Amazon would be putting a lot of trust in the information it owns, but imagine the possibilities of customers voluntarily buying items they didn’t order, just like making impulse purchases in a store’s checkout lane. Amazon has blurred the line between bricks-and-mortar stores and online purchases with its Prime program, fast shipping, digital downloads, superb product recommendations and reviews, and the possibility of drone-delivered packages. I can see this as its next step in world domination. Imagine the mess if hospitals and practices used their patient data to automatically schedule tests or issue prescriptions and you’ll see why Amazon is a lot smarter.

GE Healthcare announces 2013 financial results, with sales down slightly but profits up 4.4 percent.

The local paper says the formerly high-flying transplant program at University of Arizona Medical Center has been temporarily shut down after a dispute with the program’s chief surgeon, who was fired in September 2013 when the hospital accused him of falsifying the electronic records of unsuccessful surgeries. The surgeon claims he was let go after criticizing the dean of the university’s medical school.  

Girish Navani, CEO of eClinicalWorks, is interviewed by the New York Times on his management style. Some highlights: (a) he doesn’t believe in titles because they create “title warfare”; (b) he doesn’t fire people, he just tells them to take three months to find something else they want to do or be prepared to change how they work; (c) the company hires straight out of college, saying, “We don’t hire free agents, we draft players.” I like this idea:

There’s a big, oval table outside my office, with eight chairs around it, and I spend a lot of time working there. It gives an opportunity to anybody to come up to me, ask questions, discuss an idea and brainstorm on a big whiteboard. Some people will join a conversation just because they want to learn. You never ask the question, “Why are you sitting at this table?”

Weird News Andy says she’s on pins and needles. New England Journal of Medicine reports the case of a woman with resistant knee pain who was found by doctors performing X-rays to have knees filled with hundreds of acupuncture needles, apparently left there intentionally for ongoing benefit by her acupuncturist.

Vince’s HIS-tory of McKesson Paragon is bittersweet because it’s the last episode in his series that has been running on HIStalk for years. Industry long-timers have enjoyed some fond (and not-so-fond) memories of companies, products, and people in the past, while newer folks have developed new appreciation for the origins of the industry in which they work.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: Dark Side on Line One: If Cash Really is King, Now’s the Time to Leave That Hospital Job

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 February 2010.

Dark Side on Line One: If Cash Really is King, Now’s the Time to Leave That Hospital Job
By Mr. HIStalk

These days, more and more industry people are using Willie Sutton’s famous answer to why he robbed banks. “Because that’s where the money is,” they say. The current form of the question is this: “Why are you leaving your hospital job to work for a vendor or consulting company?”

I’ll be honest … I thought self-serving university people were full of it when they predicted big shortages of healthcare IT people. The sky is falling, they cried, but it sounded like a lame pitch to boost enrollment in their informatics degree programs. ARRA or not, it just didn’t seem likely that implementers and project people would suddenly be in big demand.

The anecdotal evidence I used to support that belief was this: many of the best people who work for the vendors my hospital uses have been laid off. Experience = higher salary = first to go, at least in the minds of dimwitted vendor VPs whose own ill-informed revenue projections fail to pan out, meaning he or she gets the elevator while the worker bees get the shaft.

I figured there must be lots of talent available, considering vendors are still cutting people loose. Plus, I didn’t (and still don’t) think federal handouts are going to provide enough lipstick for the pig that most doctors visualize EMRs as being (it’s not EMRs they are resisting – it’s USING the EMRs. Sounds the same, but isn’t.)

I guess my lesson learned is to never bet against the money. Cash will presumably get doctors to use EMRs they don’t really want. It’s also working to pull several hospital CIOs and other IT people to (or back to) the vendor dark side.

One non-profit CEO asked me if I thought he should continue working in his current role, which is good for society but not necessarily so great for his wallet. As altruistic as I can sometimes be, I gave him the classic answer from MBA economics: take the better-paying job and donate more to charity. Buy carbon credits for selling out. The window is wide open and this opportunity may never repeat.

Vendors and consulting companies are loading up. The talent they can most easily afford comes from hospitals. From there come the fresh troops, getting their call like a minor league baseball player being offered the chance to move up to The Show.

For those with short memories, though, vendors are just as quick (quicker, actually) to unload FTEs when conditions slip. If you have a loving, loyal hospital spouse who makes you happy and puts up with your idiosyncrasies, then think carefully before running off with the tarted up, drug-seeking vendor stripper who is whispering in your ear to throw it all away to run off to Las Vegas with her to gamble. It’s not nearly as fun as it looks.

The hospital IT people I know are in two camps. Some have worked for a vendor and wouldn’t go back at gunpoint, or have enough roots and loyalty to resist the siren song. You’ll see the second group at HIMSS – former colleagues who suddenly show up in a vendor both wearing shiny new Koolaid-stained suits, so flush with newfound enthusiasm that you would be jealous if you didn’t know the odds of eventual disappointment.

It’s like when low-paid civil service employees quit public service to work for fat cat contractors. It’s a shame, but nobody can really blame you for taking advantage of the cards you were dealt. There’s no unattractive scar even if you did just sell your soul.

I’m not even slightly tempted. I don’t like suits, travel, lumbering bureaucracy, and strategies developed by bean counters who don’t understand healthcare. The second happiest day of my work life was when I was hired by a vendor; the happiest was the day I quit. The years in between are a vaguely unpleasant blur.

But if your hospital job isn’t so great, if the economy has killed the hope retirement, or if you just want a change of scenery, the time is now to do something strictly for the money. The great thing about hospitals is that they won’t hold a grudge if you have to come crawling back in a couple of years.

Advisory Panel: Recent Vendor Experiences

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

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

This question this time: Can you describe a particularly good or bad experience you’ve with an IT-related vendor lately?

Explorys has been great to work with as we focus on connecting our community physicians

I have been very pleased with the responsiveness of our consultants and vendors to lower their fees in order to help us meet our budgetary needs around our $100 million plus implementation. It has become clear to me which vendors can be relied upon to become true partners in which are only in it for themselves.

We’ve had a very tough time with Voalte. Call quality has been pretty awful and Voalte hasn’t been able to delve an app that addresses the problem. They keep telling us that the iOS7 version of their app will correct the problems, but they do not recommend that we deploy that version. Hmmm. 

I’ve actually mentioned this vendor before, but they continue to provide major benefit to me. Virtual Procurement Services.  (VPS). They have saved our organization millions of dollars in capital and operating expenditures. It’s an interesting model, actually, probably worth one of your interviews.

I continue to me amazed at the poor state our vendors are in as we prepare for MU Stage 2. They blame CMS and ONC and say the certification process is broken and that the regulations come out too late and are not fully baked, but the fact is they are sending us code that doesn’t work and isn’t ready for testing. Many of us are in jeopardy of not meeting MU S2 since we will have to wait until Q4 leaving no room for error. The vendors must do a better job getting us a product we can use as we face the challenges of implementing the processes and workflow changes that are required once the software works.

A CDS vendor with a good presentation of a great product, concentrating on our EHR and our issues. They are Dutch, so they already know about ICD-10. I guess that identifies the company.

Predixion Software, good experience related to analytics, supporting our clinical staff in better management of readmission rates.

None of late. Still ramping up in the new gig and the only net new I have hired is the Advisory Board for ICD-10 help. We just started (I know, I know – this is way late but clearly one of the reasons I got hired!)

On the good side, a vendor sent me a holiday gift card that could only be used for donation to a provided list of charities. You could donate on behalf of yourself, your organization, or anyone else. On the bad side, any and all vendors that send you half of something expecting that you will meet with them to get the other half of something that as a whole you couldn’t and wouldn’t accept in the first place.

I was just discussing a system upgrade with a manager. The upgrade turns out to be a reimplementation. The ballpark cost provided by the sales guy/gal, that we budgeted, has now tripled. While I’m obviously not opposed to a vendor improving their product, I think they should be assuming some of the additional expense. While they are changing the system’s infrastructure to something “better” there is no acknowledgement that their previous infrastructure may have been somewhat lacking.

Unfortunately all seemingly middle of the road/mediocre.

I work for a vendor now, but when I worked in a hospital, I found Iatric to be the most responsive vendor we dealt with. They were professional and very quick in all responses. If we had a problem they would have their people work through the night to fix it. Literally every dealing I have ever had with anyone in that company has been positive.

A general experience growing with vendors who really do not take time to know or understand customer needs. Let’s stop cold calling and cold emailing in health IT.

Advisory Panel: 2014 Will Be the “Year of the …”

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

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

This question this time: In your opinion, 2014 will be the "Year of …"

2014 will be the year of population management. Not really, but those two words will be used a lot.

Informaticist. I think all healthcare organizations will be focused on how to turn data into information, whether through business intelligence, clinical or biomedical informatics, retrospective / real-time / predictive analytics. These efforts will take on new meaning as we continue to build accountable care organizations and networks

Cuts to the budget.

The year the Federal Government went too far trying to ‘fix’ healthcare.

2014 will be the year of the HIE. Many words will be sprayed onto computer screens and into throw-away journals regarding connectivity and data availability, but there will be few objective studies, and I still will not be able to see the actual Xrays of the patient that was just transferred from another downtown hospital.

Data analytics.

I hope it will be the year of the non-buzzword, meaning that if one has not figured it out by now, whatever the buzz is about, rarely helps you in accomplishing the tasks at hand for your organization. Of course, we will hear ICD-10 and MU, but I would not call that buzz, it is just work that has to be done.

"Year of the Hospital Financial Losses." I think there will be more hospitals showing financial deficits than at any other time in history.

2014 will be the Year of the EMR App. We will see more and more apps which integrate nicely with EMRs and fill a special niche via content and/or workflow, which the giant and slow moving EMR vendors can’t do themselves. 

EHR Equivocation. Until the vendors solve or at least do a better job on usability, understand their OWN product completely, and enlist the help of clinicians in design, we will see significant slowing in EHR adoption. We’ve seen most of the adopters that were able to provide the resources required for an enterprise wide EHR implementation already take the leap… in the end, the cost of an EHR still significantly outweighs the penalties for the foreseeable future.

Year of patient engagement and ICD-10 chaos.

For healthcare in general, Year of the Merger & Acquisition. For Healthcare IT, Year of the CIO turnover.

I think it will be the year when interoperability and big data will continue to be little more than buzzwords. The difference between the two is that one day, in a somewhat distant future, interoperability will actually come to pass and make a difference. Big Data will never be more than a buzzword. Like smart watches, Google Glass will prove to be useful in some applications in healthcare, but will not be a game changer. The leadership of a few HIT companies will continue to watch with glass-eyed wonder at how the American taxpayer continues to fund the exponential growth of their personal bank accounts while the products they provide in exchange for those funds reach new heights of mediocrity. And those whose mortgages are paid by selling these mediocre systems will continue to defend to the last breath the promise that these systems will one day deliver on if we only give them another decade or two to work their magic because the years and years they have been given to prove their value so far just aren’t enough. At the same time, any impartial studies done on the ROI of these systems that cost the taxpayers billions will show little to no benefit to that oft intentionally forgotten constituent of the healthcare system- the patient. (Man, am I a cynic or what?) On a more optimistic note, I think the health insurance exchanges will actually start to show some positive ROI for the oft forgotten constituent.

2014 will be the Year of EMR Optimization. Now that most IDNs are finished or far along with EMR implementation, they will turn increased attention and resources to making EMRs work more effectively to support critical business imperatives related to healthcare reform and the numerous changes we’re undergoing in response to industry pressures.

2014 will be the year of a major data breach (hopefully not here). Most of the breaches I’ve heard about have been from lost/stolen computers or an organization doing something stupid, not an intentional penetration. Perhaps I’m just overreacting to the Target hack and in reality there is no interest in healthcare data. On the other hand, nobody that I’m aware of in health care has NSA-quality protection and I think it would be pretty easy.

Regulatory mandate dictating the IT vision/budget

Year of the “search for value in analytics.”

Wearable.

Morning Headlines 1/17/14

Streamline Health Signs Definitive Agreement To Acquire Unibased Systems Architecture, Inc.

Streamline Health Solutions, which offers a variety of health information management and revenue cycle solutions, will acquire the St. Louis-based Unibased Systems Architecture, vendor of the ForSite2020 enterprise scheduling and surgery systems. Terms were not disclosed.

ONC Releases SAFER Guides

ONC releases the Safety Assurance Factors for EHR Resilience (SAFER) Guides, which include checklists and recommended practices to help providers assess and optimize the safety and safe use of EHRs.

Doctors sue NC over Medicaid billing system

Several North Carolina doctors sue the state and its software vendors and consultants for Medicaid payment delays caused by its $484 million NC Tracks system that was rolled out on July 1. The doctors, who have stopped accepting new Medicaid patients, said in the lawsuit, “The proof of CSC’s wrongdoing was the disastrous state of the software upon go-live.” The system has been criticized by the state auditor, but the Department of Health and Human Services says it outperforms its 35-year-old predecessor and issues are being addressed.

U.S. Hospitals Show EMR Growth Opportunities for Patient Portals, Clinical Data Warehousing and Radiology Barcoding Applications

A HIMSS Analytics report shows that among applications that support its EMR Adoption Model, those with the most five-year promise due to first-time purchases are patient portals, clinical data warehouses, and radiology barcoding applications. It also predicts high replacement sales of laboratory barcoding systems, pharmacy management systems, and radiology and laboratory department solutions.

News 1/17/14

Top News

Streamline Health will acquire St. Louis-based patient scheduling and surgery systems vendor Unibased Systems Architecture.

Reader Comments

From Salient Point: “Re: vendor layoffs. I’ve never had so many colleagues (most of them older), including high-performing salespeople, being let go. Seems like more than the usual Q4 pruning. Are you seeing this?” I will defer to readers. It does seems as though companies are cutting back, maybe because the HITECH boom is pretty much over unless you are Epic, Cerner, or a consulting company.  The EMR dance partners have largely been chosen, other than the likely ambulatory rip-and-replace caused by unmet expectations and acquisitions.

From Eclipsys Gal: “Re: Chad Eckes, chief strategy officer at Cancer Treatment Centers of America. Replacing Sheila Sanders as CIO at Wake Forest Baptist University Medial Center (NC).” Unverified. Sanders resigned after four years at WFBUMC in May 2013 following a disastrous Epic rollout, although the hospital said her departure was unrelated.

HIStalk Announcements and Requests

A few highlights from HIStalk Practice over the last week include: CareCloud reports the addition of 520 new clients in 2013, including the 20-provider Urology Austin (TX). The PCMH model leads to lower cost, better access to care, higher patient satisfaction, and fewer avoidable or unnecessary services. Practice Fusion achieves 2014 Complete EHR certification in time to beat its December 31 “guarantee” deadline. More than half of providers say they have not yet estimated the impact of ICD-10 on their cash flow. Doximity claims it has more physician members (250,000) than the AMA. SureScripts adds almost two dozen vendors to its clinical network for secure HIE. A dozen HIT vendors share opinions on the biggest challenges facing physicians and physicians practices in 2014 in part one of a three-part series. Thanks for reading.

Welcome to new HIStalk Platinum Sponsor MBA HealthGroup of South Burlington, VT. The company’s consulting services include Epic, Allscripts, ICD-10, EHR optimization, Meaningful Use, and RCM. They’ve trained and supported more than 5,000 physicians on Allscripts EHR, trained 3,000 users on Epic 2012, and provided RCM services to 400 physicians in 38 states. Fletcher Allen CIO Chuck Podesta mentioned using the company’s Epic 2012 upgrade services when I interviewed him earlier this week (the case study is here.) I noticed a new company blog post on the benefits and pitfalls of personalizing Epic that contains good nuts-and-bolts advice. Thanks to MBA HealthGroup for supporting HIStalk.

Listening: The Neighbourhood, a new California-based five-piece that skillfully blends alternative music with R&B. The singer is 22, which must be the coolest thing ever.

HIStalkapalooza and HIMSS

HIStalkapalooza registration will continue for several days. Everybody who wants an invitation has to register individually (that includes Inga and me, so don’t expect sympathy after the fact if you didn’t bother). We would love to invite everyone, but that’s not possible given that we had more than 750 requests in the first few hours, so watch your inbox for invitations on February 4 or so and follow #HIStalkapalooza14 on Twitter. Imprivata is doing an amazing job to make it the best event possible, as you’ll see if you score an invitation. It’s hard to comprehend that this will be the seventh version, going all the way back to Orlando in 2008 when it was 200 or so people in a Peabody Hotel conference room. I was thrilled because I was secretly hoping for 100 but expecting 25.

HIStalk sponsors: let Lorre know if you’ll be attending our sponsor-only networking reception on Sunday evening, February 23 at the HIMSS conference. It’s going to be pretty cool and a nice way to finish to the pre-conference weekend. Contact Inga if you haven’t sent your information for our HIMSS guide.

Acquisitions, Funding, Business, and Stock

The price of Allscripts shares climbed nine percent Wednesday following the company’s prediction of five to eight percent adjusted revenue growth per year from 2014 to 2016. Analysts were expecting five percent growth in 2014. Above is the one-year chart with MDRX in blue and the Nasdaq in red, with shares rising 60 percent.

Valence Health reports revenue growth of 35 percent for 2013 and a 65 percent increase in bookings.

Craneware says its first half earnings are expected to be up five percent over last year.

Mercom Capital Group issues its healthcare mergers and acquisitions report for 2013, reporting $2.2 billion and 571 deals in 2013 vs. $1.2 billion and 163 deals in 2012. The top five VC-funded companies for the year were Evolent Health ($100 million), Practice Fusion ($85 million), Fitbit ($73 million), MedSynergies ($65 million), and Proteus Digital Health ($45 million). Above are the largest M&A transactions of the year. The full report costs $599.

Sales

Center for Diagnostic Imaging (MN) extends its use of Merge Healthcare solutions to include the iConnect Network interoperability platform.

Long-term care provider Grace Healthcare (TN) selects the Daylight IQ disease management system from COMS Interactive.

NorthBay Healthcare (CA) selects Health Catalyst’s Late-Binding Data Warehouse and Analytics platform.

WakeMed Health & Hospitals (NC) will implement population health and final risk management solutions from Evolent Health.

Kaiser Permanente (CA) renews a multi-year agreement with MedAssets for strategic sourcing and spend analytics solutions and to serve as Kaiser’s exclusive GPO for its nationwide facilities.

People

ISalus Healthcare hires Jason McDonald (Kareo) as chief sales officer.

HIMSS names its former board chair Willa Fields (San Diego State University) the winner of the 2013 HIMSS Nursing Informatics Leadership Award.

Rick Roycroft (MedAssets) joins Huron Consulting Group as managing director of the company’s healthcare practice.

Cureatr names Vik Shah (Medidata Solutions) as EVP of client services and operations.

Announcements and Implementations

Johns Hopkins HealthCare (MD) and BlueRush Media Group will co-develop an online portal that provides information for employers and their employees who are undergoing or have gone through cancer treatment.

The City of New Orleans EMS integrates its EMS Service Bridge electronic patient care reporting system from ImageTrend with the Greater New Orleans HIE.

In Canada, Cerner completes deployments of its ambulatory EMR  at three Ontario ambulatory clinics, supported by Canada Health Infoway.

Compass Oncology (OR) pilots My Care Plus, a patient portal designed specifically for cancer patients by McKesson Specialty Health.

The VA deploys Health Level’s critical case management platform for all its VA National Teleradiology Program medical centers.

The Ministry of Health of the Kingdom of Saudi Arabia launches nationwide open access to Wolters Kluwer Health’s UpToDate for the country’s 80,000 physicians and nurses.

Lincoln Hospital (WA) and Community Wellness (WA) use the INHS TeleHealth system to offer diabetes and pre-diabetes education to rural communities in northern Idaho and eastern Washington.

Government and Politics

ONC releases the Safety Assurance Factors for EHR Resilience (SAFER) Guides, which include checklists and recommended practices to help providers assess and optimize the safety and safe use of EHRs. The set of nine guides are High Priority Practice, Organizational Responsibilities, Contingency Planning, System Configuration, System Interfaces, Patient Identification, CPOE with Decision Support, Test Results Report and Follow-Up, and Clinician Communication. Each starts with a checklist of recommended practices for optimizing EHR safety. The guides were developed by Joan Ash, PhD (OHSU), Hardeep Singh, MD (Houston VA, Baylor), and Dean Sitting, PhD (UT Health Science Center). This is some really good work.

ONC announces the beginning of a 30-day period for organizations to submit requests for ONC-Approved Accreditor status, which is valid for up to three years. This the organization that accredits EHR certification organizations, with ANSI as the incumbent since the role was first defined in 2011.

CMS and ONC select McKesson and Meditech as its first designated “Test EHRs.” In order to meet the transition of care objective in Stage 2, EPs, EHs, and CAHs must successfully exchange an electronic summary of care document with a CMS-designated test EHR or with an EHR technology different that the provider’s EHR technology.

Several North Carolina doctors file a class action lawsuit against the state for delayed Medicaid payments, claiming that the the state’s Department of Health and Human Services and its contractors — CSC, Maximus Consulting, and SLI Gobal Solutions — were negligent in their rollout of the state’s $484 million NCTracks payment system.

Brian Ahier provided this audio of Karen DeSalvo’s introduction of herself to the HIT Policy Committee earlier this week. She sounds kind of fun, but for some reason her voice goes up in tone at the end of some sentences like she’s asking a question when she isn’t.

Other

A HIMSS Analytics report predicts accelerated growth for patient portals, clinical data warehousing and data mining, and radiology barcoding applications. The number of patient portal vendors rose from 28 in 2009 to 62 today.

CTG will add 300 jobs in its home city of Buffalo, NY in a medical informatics partnership with University of Buffalo’s Center for Computational Research in a genomics and big data initiative. The company helped create UB’s Institute for Healthcare Informatics in 2010 and contributed funds for Roswell Park Cancer Institute’s Center for Personalized Medicine.

A California highway patrol officer stops a California software developer for speeding, also citing her for wearing Google Glass. He considered the device to be covered under the same laws that prohibit playing video in the driver’s field of vision.

Texas and the city of Austin offer athenahealth $5.7 million in incentives to open an R&D center that would create 607 jobs with a capital investment of $13 million. The company is also considering locations in California, Massachusetts, and Georgia, the latter two of which have previously provided athenahealth with similar incentives.  

BIDMC CIO John Halamka says he has written two books, one a reflection on his blog writings and other a fictional thriller. He’ll be signing the former at HIMSS. He really is a Renaissance man now that he’s turned into a gentleman farmer (I’m hooked on his “Building Unity Farm” series.) I just can’t understand how he finds the time to get so involved in so much, maybe because I’m lazy.

The governor of Guam signs a bill approving a $25 million loan to Guam Memorial Hospital to help it repay its previous bailout loan and to pay the support fees of NTT Data, which threatened to cut the hospital off from software support.

Michael Gilbert, MD, a family medicine physician with St. Joseph Health (CA), writes a good ONC post for practices called “How to Use a Patient Portal.” As an Allscripts Enterprise user, he says the company pushed him to use Jardogs FollowMyHealth after they bought that company, resulting in a 40 percent drop in registrants from their previous portal (presumably Intuit Health). Current problems include the large number of pending registrations that never become active (which throws off the MU Stage 2 denominator), the requirement for users to install the Microsoft Silverlight graphics browser plugin (which hangs up my browser regularly, so I can understand that), and  the need for providers to motivate patients to participate. Interestingly, the practice bought a software development company and will build its own portal and HIE (!!!), but in the meantime seems fairly happy with the Allscripts product:

[providers] participate in secure online clinical communication, schedule appointments, refill medications, and answer routine questions with and for patients. The new portal automatically uploads all results within minutes of being verified by the provider and patients can directly schedule into providers schedules, ask for medication renewals and pay bills. The portal also offers a computer, iPad and iPhone application with all of the above functionality to patients. We have over 30,000 patients registered, and have achieved 10 percent penetration of all registered patients across both medical groups. Some providers have almost half of their patients registered. Our physicians encourage their patients to message them via the portal.

Weird News Andy appropriately finds this story sad. An ambulance takes 18 minutes to arrive at the scene of a shooting in a mall parking deck, unable to enter the facility because of the low ceilings. The crew had to roll the gurney up the ramp to get to the male victim, who had refused to hand over his keys to four carjacking assailants, who then shot him as his wife sat beside him in the car. He died.

An Iowa state prison psychiatric hospital employee is fired for downloading patient photos from the hospital’s computer, Photoshopping them, and emailing them to co-workers, who often responded with additional requests (some of those folks were also fired, apparently.) One of his works involved patient faces superimposed on a “Star Wars” poster whose title he changed to “Tard Wars.” He was also found to have used work PCs to visit adult site including “Heavy Hotties.” The man said his job mostly involved playing cards or Wii with patients, which enabled him to “Photoshop at the same time I am changing lives. It’s called multi-tasking.”

Sponsor Updates

• The coreANALYTICS health system performance improvement system from Encore Health Resources earn ONC 2014 certification as an EHR module. Catholic Health Initiatives is using it.
• Allscripts announces that its KLAS scores are on the rise, with Allscripts Enterprise EHR up 11 percent for the 12-month period ending December 2013 and Sunrise Clinical Manager up four percent.
• Coastal Healthcare Consulting introduces Convergence, a patient identity management solution that uses NextGate’s Enterprise MPI.
• NextGen will map its EHR directly to the IRIS eye disease registry.
• Josh Byrd, Patientco’s director of marketing, shares his perspective on why the patient experience matters.
• Joseph Petro, SVP of healthcare R&D for Nuance, explains how clinical language understanding is critical for helping providers drive productivity while remaining focused on patient care. 
• TriZetto’s Provider Solutions Business unit introduces the Top Codes Report, which allows providers to chart their most frequently billed procedure and diagnosis code pairs in preparation for ICD-10.

EPtalk by Dr. Jayne

ONC releases SAFER Guides to aid providers in safe use of health information technology. The Safety Assurance Factors for EHR Resilience Guides contain best practices for EHR use and include checklists for practice assessment. ONC Chief Medical Officer Jacob Reider discusses the nine guides on his “Health IT Buzz” blog.

There was a lot of discussion in the physicians’ lounge this morning regarding the suggestion that medical school could be reduced to three years. Certainly the idea of saving a year’s worth of tuition and living expenses might be attractive to those who already know what residency they want to pursue. Several of the programs currently in place reduce electives and require summer classes in order to meet required educational standards.

My medical school’s fourth year curriculum was all elective, and in hindsight, I’m glad I had it. Being at an urban academic medical center allowed me to see things I wouldn’t have been exposed to in residency and also allowed me to practice my clinical skills with less focus on competing against my peers. Coupling reduced medical school experiences with resident work hour limits could create a rocky start for some physicians entering practice.

The other hot topic in the lounge has been the recent New York Times article on scribes. After reading the article, several of my colleagues now think scribes are the be-all, end-all answer to their EHR problems. I enjoy moonlighting at a local emergency department that uses scribes, but physicians need to understand the limitations of the scribe model. Although they’re very popular for episodic care (emergency, urgent care) there are challenges in office-based medicine. One of the major issues is that using a scribe doesn’t relieve the physician of the need to learn the EHR. He or she will need to be able to access the system to view data and to handle after-hours patient contacts such as hospital admissions, phone calls, cross-coverage, etc.

Scribes hired from third-party agencies are expensive – up to $28 per hour in my market. It’s hard for physicians to cover that expense in primary care. The alternative chosen by many physicians is to train a medical assistant to scribe. That approach can be effective as long as the medical assistant is relieved of their other daily responsibilities. It is extremely difficult to try to play both roles in a busy primary care practice. The article says physicians using scribes can see up to four extra patients per day. That’s not been the experience of physicians in our community, who are lucky to see one or two extra patients per day. Scribes may not be as helpful with telephone messages, provider-to-provider communication, and other administrative burdens that impact physicians.

Physicians also need to spend time reviewing the scribe’s notes for accuracy. At my site, there is a pool of scribes and we may work with three or four during a single shift. Although the overall quality of their work is acceptable, the work of some is much stronger than others. Their work requires careful review, especially when they are new. Scribe training programs may be only a few weeks long. If you get lucky and have one who is a pre-med student or a nursing student, it can be a lot of fun since you can do some teaching along the way and they are generally very motivated to do a good job in the hopes they will be able to ask for a recommendation. If you get unlucky and have a scribe who has been up late the night before cramming for exams, it can be a challenge.

Speaking of challenges, today HIMSS invited me to attend a focus group. How could I resist their opening line: “Are you a CIO with a bed size of 150-400 or an IT Director/Manager with a bed size above 300 and not a practicing physician?” Why do they keep demographic files on members if they aren’t going to use them? Between that and the overall lack of HIMSS social invites, I’m starting to wonder whether this meeting is going to be more work than play. I’m confident, however, that with Inga’s vast social network, things will turn around. What are your HIMSS social plans? Email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Advisory Panel: Top 2014 Priorities and Concerns

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

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

This question this time: What are your organization’s top three IT priorities for 2014 and the concerns you have about executing them?

(1) ICD-10.
(2) Data center relocation to a CoLo.
(3) Complete enterprise EHR rollout.

The only one I’m really concerned about is ICD-10. There are just so many uncertainties around how the providers and the payers will make the transition.

Our top three IT priorities for 2014 all revolve around our Epic platform.

(1) We need to finish our enterprise-wide Epic implementation.
(2) Once we survive our go-live, we will enter into an extended period of optimization of the system, which I anticipate will take at least three to four months.
(3) Subsequent to that, we will begin to develop the capabilities within IT to begin to extend our Epic platform to other entities across our state.

My biggest concern for all of these is the ability to maintain my current resource levels as well as adding new resources in order to address the organizational strategic outreach initiatives.

(1) We are determining whether to stay on our current EMR platform or to switch.
(2) ICD-10 is looming.
(3) We are also focused on getting our remaining hospitals to Stage 7.

(1) ICD-10. Significant work needs to be completed on all facets of this mandate. Vendor testing and validation, staff education (HIM, physicians, and billing), reporting requirements, and many more. Payors are not ready, IS vendors are not ready, and our staffs are stretched thin, so it remains my greatest concern in 2014.
(2) MU Stage 2. So much is still not known. How will we meet the patient engagement goals (absurd for a community hospital with independent medical staff that also must meet the portal goal)? What will the CQMs require for new data collection? How will the medical staff deal with electronic medication reconciliation and the requirements of the Transitions in Care electronic documentation at the hospital while also dealing with a different system and set of requirements in their office? These questions remain and the vendors will not be ready until the last quarter leaving no room for error.
(3) Pending affiliation. During all of this, we are entering into an affiliation that will dramatically change our organization and will, at some point in the near future, require a conversion to a new ERP system and EHR.

After the massive expense of our EHR and in the face of ongoing financial financial struggles (real or perceived), there will be great pressure to hold down costs, perhaps even to find a revenue-generating activity for IT. The concern is that needed education and training will be shortchanged and clinician workflows that should be corrected promptly will be allowed to calcify, requiring even more resources in the future. Many of these workarounds reflect inadequate technical support (I never knew it could do that!) or training (I never knew it could do that!)

(1) Ensuring readiness for regulatory items like ICD-10 and Stage 2 Meaningful Use).
(2) Continuing to optimize our EMR investment via new high-value clinical decision support projects. 
(3) Implementing new enterprise-wide revenue cycle solution.

(1) ICD-10. 
(2) Operational cost reductions (both IT and non-IT).
(3) Growth through acquisition.

(1) ICD-10.
(2) MU Stage 2.
(3) Financial resource management (conservation).

The three are not compatible. I’ll need resources for both of the first two while being asked to use less at the same time. 

(1) Our top IT priority is moving from Cerner to Epic, with the obvious concerns about data migration and workflow changes slowing us down initially.
(2) Appropriately using analytics (from identifying high-risk patients for outreach, to looking for otherwise hard to find adverse events), with the dual concerns of (a) not having enough report writers, and (b) not having enough people to execute on what we find. 
(3) Figuring out telehealth at our organization, with the concerns of (a) finding a technical model that works efficiently, and (2) finding a business model that makes sense (who will pay for it!)

(1) Epic optimization. Hiring and retaining qualified Epic analysts is becoming very challenging in our region. Standard now is  work from home and significant yearly salary increases due to the local competition from institutions out of build phase so analysts are free to jump ship.
(2) Windows XP support (lack thereof). The March 2014 move to Windows 7 has us very nervous – Epic and scores of integrated applications cannot be tested enough to quell the unease.
(3) ICD-10. Ouch… how am I going to get providers that don’t document well to do an even better job next October? We discovered quite quickly that Epic support is still just nudging up their own learning curve.

(1) MU Stage 2. 
(2) ICD-10. 
(3) Integrated financial and clinical systems.

(1) ICD-10. Since ICD-10 success is based on physician documentation, it’s a wildcard as to how well you will do regardless of the education effort. 
(2) MU Stage 2. MU Stage 2 criteria related to transitions of care will be particularly difficult since there are three components (i.e. 50 percent of discharges, 10 percent using CDA format, and a transaction to a different EHR.) Items 1 and 3 are easily achievable but 10 percent using CDA format could be difficult depending on where your patients transition (both inpatients and ambulatory). Many post-acute settings, for example, do not have an EHR capable of receiving this format.
(3) Privacy and security. Privacy and security is just a matter of keeping up with the regulations. Competing for resources is difficult since this area doesn’t  get enough attention until you have a problem. With the final Omnibus rule in place, fines have increased, as will audits. Business associates will be particularly vulnerable, as well they should be. There are a considerable amount of other priorities for 2014 (e.g. ACO IT, EHR optimization) but these may have to wait.

(1) Government regulations compliance.
(2) M&A integration.
(3) Growth initiatives.

My main concern is having too many top priorities competing for finite resources, both in IT and operations.

I’d be very surprised if anybody answers anything but:

(1) MU2.
(2) ICD-10.
(3) Keeping the place running.

(1) MU Stage 2. Vendor delays, expectation of patient engagement.
(2) ICD-10. Inability of vendors to deliver on time; excessive fees (CAC).
(3) Volume to value mandates (reporting, data exchange, etc.), a market mess.

(1) Meaningful Use Stage 2 and 3. Concern about areas where we don’t have full control.
(2) Expanding use of mobile and connected care connecting our enterprise and our community through mobile devices.
(3) Maintaining security in a rapidly changing environment. Expecting more and more security breaches.

Morning Headlines 1/16/14

Surgical Information Systems Acquires Healthcare Software Leader AmkaiSolutions

Surgical Information Systems, a perioperative specialty EHR vendor, acquires AmkaiSolutions, an ambulatory EHR vendor that provides software for ambulatory surgery centers. The partnership extends SIS’s reach into the ambulatory space within its niche EHR market segment.

Allscripts rises after giving 2014-16 outlook

Allscripts reports that it expects five to eight percent annual growth per year through 2016, while analysts were expecting the company to report a flat five percent growth rate. The aggressive forecast drove Allscripts’ share prices up seven percent by the end of the trading day Wednesday.

HHS makes progress on Health IT Safety Plan with release of the SAFER Guides

The ONC releases a set of guides and tools to help healthcare providers and organizations assess and optimize EHRs for improved safety. The guides represent a part of the Health IT Patient Safety Action and Surveillance Plan, which was published in July of 2013 to address EHR safety concerns.

HIStalkapalooza 2014, Sponsored by Imprivata

HIStalkalooza 2014, sponsored by Imprivata, will be held Monday, February 24, 2014 from 7 p.m. until 11 p.m. at the House of Blues Orlando (Downtown Disney) during the HIMSS Annual Conference & Expo.

Clay Ritchey, Imprivata’s chief marketing officer, said in a company announcement, “HIStalkapalooza is perhaps the most high-profile, premier social event in healthcare IT, and Imprivata is proud to be this year’s sponsor. We plan to uphold the annual traditions that attendees expect at HIStalkaplaooza as well as add some new, exciting surprises that will make this one of the most memorable events yet.”

Attendance is by invitation only since the facility capacity is limited and demand is always high. Those interested in attending complete an online form. Invitees will receive an emailed invitation around February 4. 

The seventh annual HIStalkapalooza, dubbed “Healthcare’s Night Out,” will include the usual events such as the “Inga Loves My Shoes” contest, crowning of the HIStalk King and Queen, and presentation of the annual HISsies awards. Other activities include:

• A live band
• Cartoon artist, magician, and other fun activities and entertainment
• Great food and an open bar

Transportation between the Orange County Convention Center and the House of Blues will be provided.

HIStalk and Imprivata will provide more details as the event draws closer. Keep up on Twitter using #HIStalkapalooza14.

Imprivata is a leading provider of authentication and access management solutions for the healthcare industry that enable fast, secure and more efficient access to healthcare information technology systems to address multiple security and productivity challenges. For more information, please visit www.imprivata.com.

Readers Write: Next Steps at ONC

Next Steps at ONC
By Helen Figge

The new leader, Karen DeSalvo, MD, has been appointed at ONC. It is anticipated that ONC is set to continue  the creation of an interoperable, private, and secure nationwide health information system  with the ultimate goal of supporting widespread distribution of data. More importantly, widespread implementation of Meaningful Use of healthcare technology.  

Many, however, still struggle to gauge what ultimately will be developed to facilitate the electronic exchange of health information. How will we launch the system, maintaining high quality along with security so that patient records are impenetrable to tampering?

The nirvana of the ONC program was to improve healthcare delivery alongside reducing healthcare costs.  But with uncertainty of where Obamacare eventually will land, and with all the other moving pieces like ICD-10, additional worries play into the overall scheme of just what the final healthcare landscape will look like. Not only to the healthcare providers, but to the consumer of healthcare, like you and me.

Besides the obvious conversations that we all hear centered around Meaningful Use, ONC has many opportunities to improve healthcare globally, most notably stressing and promoting early detection, prevention, and management of chronic diseases, which account for most of the healthcare expenditures we see today.

As we continue to see ONC evolve, let’s hope that the emphasis will not only zero in on Meaningful Use,  but also be energized for promoting such things as staying well through good health habits – wellness – in the various stages of our life cycles. Regardless of the technologies in play or the governmental regulations already set in motion, the key to the healthcare game is for consumers to stay healthier longer and be rewarded for maintaining a healthy state versus dealing with the aftermath of illness. 

This plays well into the ONC mission of eliminating health disparities among different populations and ensuring best practices regardless of geographic confines as well. There is a lot on the ONC table to continue to execute. Hopefully ONC will also affirm the need to have promotional campaigns for promoting early detection and prevention more effectively in the marketplace. This seems still to be void or at least not very noticeable from some vantage points.

Let’s not forget the ONC charge of establishing a governance for the Nationwide Health Information Network (now coined the eHealth Exchange), which when successfully executed, would be a Web-services based series of specifications designed to securely exchange healthcare related data.  

Independent of the leaders named at ONC, the arduous task of moving healthcare to the next level of quality will be at the forefront. A big sigh and a long pause will be needed to start the conversations with enthusiasm for sure, but in the end it will be just another day in the life of a CIO and the technology teams along with all of the healthcare providers in this era of Obamacare.

Helen Figge, CPHIMS, FHIMSS is is VP of clinical integration for Alere ACS.

Readers Write: Alerts versus Alarms – Not Just Semantics

Alerts versus Alarms – Not Just Semantics
By Brian McAlpine

We often hear references to “alerts” in the context of clinicians experiencing overload or becoming fatigued. For example, alert fatigue is a well-known problem whereby clinicians are constantly bombarded with multiple types of alerts, each designed to get their attention.

Alerts can come from many different sources, including the EMR/EHR, lab systems, CPOE, medication administration software, imaging systems, nurse call systems, and many other sources. Almost any system in the clinical environment can generate an alert.

For the purposes of limiting the scope of this discussion, let’s limit the definition of “alerts” to the patient care environment and direct patient care. Using this working definition, I would also say that a nurse’s phone that receives alerts or can process text messages can also generate alerts (i.e. via a beep or vibrate) that let the nurse know when a new message has arrived.

Recently there has been increasing industry discussion and focus on “alarms” and the problem of alarm fatigue. The Joint Commission’s NPSG06.01.01 has raised the awareness of this problem and now hospitals must start to pay close attention to which medical devices and corresponding alarms are contributors to alarm fatigue. 

Both alerts and alarms interrupt the clinician and can be a source of distraction that leads to critical errors, so what’s the difference? There is a big difference, especially when provider organizations attempt to get their arms around these problems.

This is really a problem where healthcare as an industry needs to focus and prioritize what is most critical. When you look at the key differences between alerts and alarms, you can further appreciate why the Joint Commission has taken action for the second time in the last 10 years, the first time being here with the National Patient Safety goal for managing audible alarms.

Alarms are typically derived from medical devices and often communicate an immediate life-threatening patient condition. Think a v-fib or asystole alarm from a patient monitor. Alarms are always more time sensitive and a delay of a few seconds may matter to the safety of the patient. Another key characteristic of alarms is that they are almost always intended for nurses or respiratory therapists (i.e. non-physicians). Physicians do not deal with alarm response – that is for nursing to handle. Finally, alarms are always regulated by the FDA from both the medical device side (alarm generation) and from the perspective of an alarm management middleware. The FDA regulates the alarm management middleware vendors through the 510k process. As a result, only a few vendors can offer an alarm notification capability because of strict FDA 510k regulations.

But what about alerts and vendors that integrate alerts? Shouldn’t these be regulated just like alarms? The answer lies in the definition of alerts and the key differences as compared to alarms. Alerts are usually not associated with medical devices and are not immediately life threatening, but could be very serious. A big difference is that alerts are not always immediately time sensitive — a delay of 30 seconds or even several minutes often does not matter like it does with a patient monitoring alarm. In terms of who typically receives alerts, these can be intended for any clinician, and often physicians receive alerts generated by systems such as the EMR. Another major difference is that alerts are generally not regulated by the FDA like medical device alarms are.

Because of these differences, many vendors can (and do) offer an “alerting” capability. The barriers to developing an alerting or alert notification feature are simply a lot lower when compared to developing alarm management middleware. But what does this mean in practical terms to a hospital looking at the diverse set of vendors that blend alarms and alerts all together into one confusing message about what their solution is really capable of? One key way to cut through all the hype is to follow the Joint Commission’s lead and focus on medical device alarms as a key starting point.

The Joint Commission just recently released its R3 Rationale report in response to its NPSG.06.01.01 for alarm system safety. A key statement in this report outlines clinical alarms as being more critical and a higher threat to patient safety as compared to “alerts”. In fact, the report explicitly states that the NPSG does not address “items such as nurse call systems, alerts from computerized provider order entry (CPOE), or other information technology (IT) systems.” It is obvious that the Joint Commission thinks the best starting point is with an evaluation of medical device alarms.

This is clearly only the starting point because we have to go back to the bigger problem as stated at the beginning of this post . Alerts and alarms interrupt the nurse and increase potential for errors in the care environment. You have to start somewhere, and by starting with alarms, you can get a handle on addressing a very key issue. This will lead to a foundation and framework that will enable you to more effectively address the alerting problem in the future.

What do you think? Are alarms the right place to start?

Brian McAlpine is VP of product management and marketing at Extension Healthcare.

HIStalk Interviews Laurie McGraw, CEO, Shareable Ink

Laurie McGraw is president and CEO of Shareable Ink of Nashville, TN.

Tell me about yourself and the company.

I’ve been in healthcare for 20 years. I started way back when at IDX in Burlington, Vermont. In the late ‘90s, they broke off a subsidiary called Channel Health. I was running development at the time. That got bought by Allscripts. I was part of the Allscripts team from 2000 up until the time that I left in January of last year. 

When I started at Allscripts, we had five customers doing the EMR. It was called EMR back then. When I left, it was a $1.5 billion company that was pretty large. Those 12 years were a blast, just an absolute blast for me. 

This past summer, I joined Shareable Ink. I am the CEO of Shareable Ink today. It is a young and vibrant company that was founded by a brilliant innovator named Steve Hau who took a common sense approach to doing clinical documentation.

Shareable Ink does clinical documentation and we do it really, really fast. We take existing paper forms, tag them, digitize them, and preserve workflows for physicians to document, Again, very efficiently, very fast. We have these analytic tools where people can get great insights from the data that they’ve put in and drive financial outcomes and quality improvements.

Part of the appeal of the digital ink option for data input was that CPOE adoption was pathetic and electronic physician documentation wasn’t common two or three years ago. Usage of those has improved. Is there still a need for an alternative form of input?

I think so. I’ve worked with physicians all these 20-plus years. I’ve been in front of hundreds of physicians, physician audiences from physician groups to hospitals to whatever. What I know is, physicians don’t hate technology. They don’t. They love technology.

But what they hate is they hate being slow. Everyone appreciates getting quality data at the point of care. They want all that information. They just hate being slow. 

With Shareable Ink, we can extend the investment that’s already been made in electronic health records, or we can just simply replace paper that still exists in lots of different places in the healthcare system. Just making that physician fast, it’s very valuable. People have already made significant investments in clinical technology, but when physicians are slow, there are a lot of things that need to be done to improve that for them.

Part of your value proposition is the concept of clinically rich documentation. Does the typical electronic medical record product support that?

Fundamentally, the answer is yes. Electronic health records — and I’ve worked on them for all 20 years — are good products. Whether it was ones that I had worked on previously or other companies who are putting out electronic health records, they’re fundamentally good products.

Where the electronic health record falls short for physicians, in terms of what I’ve seen, is where they start to slow the physician down. It doesn’t mirror workflows that previously worked, either in the paper world or in the newly adopted electronic world. That’s where I see the need to either augment or go back to workflows that were previously really fast.

I know I keep saying fast, fast, fast as a theme here. I say that because all of the benefits of electronic health records, everybody still wants them. Many, many organizations are achieving them. But they’re still falling short. Everything in healthcare is driving towards more need for data at the point of care. That’s where we’re focused.

Is it common for hospitals that have successfully implemented CPOE and clinical documentation for physicians to add a product like Shareable Ink or do they usually use it before they are ready to adopt those EMR tools?

It’s pretty rare that an organization is completely on paper. Usually Shareable Ink is in a place that is supplementing some already automated clinical workflows. We’re either extending an EHR investment that’s already been made by some specific workflows in a particular specialty or we’re replacing some existing paper forms that are still being used because those particular paper forms capture all the data in a really efficient manner for the clinician. 

For example, we do a lot of work in the area of anesthesia, where a lot of paper still exists. We’re replacing the paper. But in many other places, we are replacing paper where clinical technology already exists.

I made the observation when I interviewed Steve Hau four years ago that the higher you go up the specialization chain of physicians, the more reliant they are on very specific forms rather than the general documentation that an internist might us. What areas of the hospital are most reliant on those specialized forms that don’t translate well to an EMR?

A couple of years ago, I would have said specifically areas like cardiology or orthopedics or something of that nature. The discussions that I’m having today, it’s back to areas — surprisingly to me — like primary care, where, quite frankly, there’s a lot of documentation needs, but organizations are still needing to supplement what their primary care physicians are doing because the speed at which they need to document in the electronic health record isn’t fast enough because of the tools that they’re using. They’re going back to things like paper to supplement it and scanning it in, or they’re looking at hiring scribes to help those physicians meet their productivity objectives. 

The premise of “the more specialized you are, the more likely that there are paper forms to supplement that” … it’s not that that is not true, it’s just that there are more general areas like primary care where there still is a lot of paper because of the productivity needs of those clinicians.

Hospitals put in systems, find them to be a burden to productivity, and then come to you for an alternative?

Absolutely. There’s opportunity to extend that electronic health record. The investment has been made and everybody is driving their quality programs based on what they can get out of their electronic health records, but they have to also meet certain productivity objectives within their organization because the volumes for these physicians and clinicians are increasing. 

Shareable Ink can help expand an electronic health record in those areas where you hear of physician dissatisfaction with their electronic health records. That’s a pretty common complaint. The reason is rarely because they don’t believe in the electronic health record. It’s always because of the speed issues and the productivity issues or how they’re encumbered because of using the technology. They just feel it slows them down. I’ve heard this directly for such a long period of time.

Most of the new hospital EMR sales are by either Cerner or Epic. What are some examples of integrating the Shareable Ink offering into those products?

We can integrate through interfaces so we can provide data into those systems, whether they’re Cerner or Epic, in the hospital. We have partnerships with vendors like Allscripts, like Greenway, where we use their open APIs to send discrete data into the electronic health record. 

Those are ways that we can extend the electronic health record investments organizations have made with those vendors. We’ll be looking to do more extensions like that in the coming year.

For a company like Epic that hasn’t offered too many hooks into their application, what would be a functional view of an Epic hospital implementing Shareable Ink?

We’re exploring those workflows now. Shareable Ink is a young company, but where we’ve implemented today is in specific areas where we’re replacing paper forms that already exist. They go into a McKesson system, a Cerner system, through a document viewer within that other system. Shareable Ink preserves the view of the form that has been filled out as well as all of the discrete data that is under the covers of that paper form.

There’s a lot of richness involved with what you can write on a piece of paper, even including the way you write it, where you write it, or what you draw as a picture. Are people realizing that that sterility of a set of fields that are extracted into an electronic medical record may lose some of the patient context?

I think that is a problem. I think that is an issue. I believe Shareable Ink can help solve some of that by bringing some of that richness back.

I’ve seen the discussions and been in the discussions with physicians who feel like they’re looking at a SOAP note or a clinician note that may be complete, but it’s so sterile they’ve blocked all the nuances of the care that was provided to the patient. Can Shareable Ink help in that regard? Sure, it can help — but not necessarily in the same ways as speech – through different pictures or notations or things of that nature. But I don’t want to pretend for a second that getting to that specific discrete data is still incredibly important for all of the quality metrics and everything else that an organization’s trying to drive toward.

Can you hand forms that have been turned into Shareable Ink to someone with no training and turn them loose?

You can. It is a stretch to say no training. There is some training required, but it is simple training. 

With Shareable Ink, when clinicians adopt it, they are not clearing their schedules. They’re not reducing their patient volumes to then adopt this additional clinical technology. What they’re doing is taking some additional time. The paper metaphor or what they’re used to with a form — that’s the workflow that’s preserved. 

It’s already a workflow that they’re familiar with. Now they’re just doing it on an iPad, or that same form on an iPad, or they’re doing it with a digital pen.

How is Meaningful Use affecting your business?

I’m hoping that it will increase the need for tools from Shareable Ink because Meaningful Use means a whole lot of additional data is required at the point of care. Just simply voice recognition into blobs of text is not going to be enough in terms of all the data that’s required for Meaningful Use. 

Shareable Ink can provide that additional rich data at the point of care while still keeping that clinician very, very fast. I’m expecting Shareable Ink to again be a great addition in complement to the EHRs that are out there.

Do you have any final thoughts?

I’ve spent 20 years in healthcare. While it has been awesome in terms of paving the clinical information highway, today what I see is that we spend a lot of time on all of the challenges that are out there: adoption, physicians being slow, needing better data, the challenges of Meaningful Use and ICD 10. What all that points to is really the need for better data at the point of care. 

I am optimistic that what we’re doing at Shareable Ink in terms of providing that rich data at the point of care and by doing clinical documentation in a way that is fast and efficient for the physician that we’ll be able to deliver on the promise of data-driven healthcare.

Morning Headlines 1/15/14

NantHealth Unveiled at J.P. Morgan 32nd Annual Healthcare Conference

Healthcare billionaire Patrick Soon-Shiong, MD, launches his long awaited healthcare IT startup NantHealth. Soon-Shiong spent $800 million on 60 acquisitions in preparation for the launch. His company will focus on population health management, cancer care coordination, care transition management, in–home monitoring, and personalized wellness.

Navicure Announces Key Findings from Second ICD-10 Readiness Survey

A new ICD-10 readiness survey of physician practices finds that 74 percent have not started their ICD-10 preparations, with 27 reporting that they are unsure of how or where to start preparing for the transition.

Providers seeking more strategic integration of CDS tools

KLAS evaluates clinical decision support systems which survey respondents reported are not integrated enough with core EMR systems to deliver the kind of strategic direction providers are looking for.

New Peer-Reviewed Study Shows Mixed Results in ACO Medication Readiness To Achieve Quality, Cost Goals

A new study published by the Journal of Managed Care Pharmacy questions whether ACOs are ready to be held accountable for medication prescribing and adherence, as the report finds that most ACOs do not have policies in place to prevent duplicate medications from being prescribed, and do not have the ability to notify physicians once prescriptions have been filled.