Readers Write: The Sequester’s Impact on Healthcare: Dangerous Unintended Consequences

The Sequester’s Impact on Healthcare: Dangerous Unintended Consequences
By Rich Temple

It has been three months since the sequester hit the healthcare industry, and the effects are more profound than they might seem. What’s most troubling is that the budget cuts in many cases will wind up costing the government more money and will have a particularly negative impact on cancer patients and those living in rural areas.

Cost of Caring for Unemployed

Across the healthcare spectrum, providers can anticipate about $11 billion in cuts. A joint study by the American Medical Association and the American Hospital Association estimates the loss of 330,127 healthcare jobs and 496,000 indirect job losses by 2021. Victims of job losses tend to require extra care to sustain their health and well-being while out of work, and the cost of these interventions may wipe out the perceived benefits of the sequester’s capricious cost-cutting.

Another Hit for Providers: Cuts in Medicare Reimbursement

For individual healthcare providers, the 2 percent across-the-board Medicare reimbursement cut will exacerbate challenges for providers who are already struggling to adapt to value-based purchasing and other mandated reimbursement cuts. Mercifully, Medicaid was exempted from this cut, but even Medicare Meaningful Use incentives will sustain the 2 percent reduction.

Particularly hard-hit will be rural hospitals, which according to a study by iVantage Health Analytics are twice as likely to be thrown into the red as a result of these cuts. That’s because rural hospitals treat older, poorer, and less-insured patients and are thus directly dependent on Medicare for their economic sustainability. This financial damage will ripple down to the communities they serve since these organizations tend to be among the largest employers and are likely to be a key focal point of much of the activity in their local economies.

Cuts Disproportionately Affect Community-Based Cancer Clinics

Cancer care is the area most profoundly impacted by the sequester. Reimbursement cuts are making it financially untenable for community-based cancer clinics — one of the more cost-effective treatment sites — to continue to serve many patients, thereby forcing them to either seek care in a more expensive hospital setting or not seek care at all.

Historically, Medicare reimbursement for cancer drugs has been the average price of the drugs, plus a 6 percent administrative fee to cover the cost of providing care. The sequester reduces that fee to 4.3 percent for both drugs and services, which in essence translates to a 28 percent cut in actual reimbursement.

According to a study conducted by the actuarial firm Milliman, the sequester is already resulting in layoffs, closings, cutbacks, and is driving patients into hospital settings. The study also says that the government could pay an average of $6,500 more per year for cancer patients in a hospital versus a community clinic.

Cuts to Cancer Research Means Fewer Clinical Trials

Another area where cancer patients are hard hit involves cuts to research funding. Besides the estimated loss of 20,500 research jobs, NIH research indicates that every $1 invested in cancer research yields over $2 in incremental economic activity. This translates to a $3 billion direct negative hit on overall economic activity.

Significant cuts to cancer research mean that fewer clinical trials will be available to help identify better treatments and thus, more protracted, costly, and painful care for patients will continue.

Most Vulnerable are Hardest Hit

In summary, the sequester’s effects are causing great pain on many levels to some of the most vulnerable segments of our population. And the perceived cost-reduction benefits are actually not likely to be realized since the unintended consequences of the sequester look like they will cost even more than the mandated cuts. These consequences could take the form of:

• More expensive, less efficient care due to patients losing access to primary care physicians
• Incremental unemployment insurance for those who have lost their jobs
• Protracted inpatient stays due to less readily available preventative research
• Other forms of public assistance these individuals will require

The effects of the sequester on healthcare have not been discussed extensively of late in the media. However, it should be noted that there are unintended consequences that we will most likely pay for in the coming years ahead.

Rich Temple is national practice director for IT strategy at Beacon Partners.

Curbside Consult with Dr. Jayne 7/22/13

I mentioned last week that I would be attending our quarterly “All Provider” meeting and had been hoping that Accountable Care would continue to be the focus of physician anger rather than EHR. Although it continued to draw a large amount of complaints (along with ICD-10 and Pay for Performance) EHR was once again in the spotlight. The current issue revolved around system availability.

In a nutshell, providers don’t ever want the system (or any part of the system) to be down. They expect upgrades and patches to be magically applied with no disruption. I don’t blame them – no one wants to be without the information they need to safely (and efficiently) care for patients. We do have to remember, though, that we’re dealing with machines and networks and the people who install, program, and maintain them. Downtime can be minimized but it is not completely avoidable.

One of my providers is really fond of using statements like, “How come you can’t just patch this thing like Microsoft does?” Being a long-time user of Microsoft products, I think that shows a remarkable lack of insight. I don’t think Microsoft is particularly adept at making user-friendly patches.

The average end user typically has no idea what is in them and has to just accept them through the auto-update process without thought and frequently without concerns for timing. I love rebooting after batches – when the system is trying to shut down and it warns you not to unplug, touch, or look funny at the device because “Windows is configuring updates.” There is no estimate of how long it will take or what it’s really doing.

Our department painstakingly combs through vendor release notes to make sure we fully understand everything we’re installing and how it will impact the end user experience. We communicate, re-communicate, and over communicate using a variety of media and strategies and yet it seems to never be enough. Many of our maintenance tasks can be done with users on the system. However, there is one item that has to be done with all users logged off. We typically do this once a month after midnight and it takes about 10 minutes. You’d think that we were asking people to give up an organ they way they respond to this.

People cannot possibly be without the record! There might be an emergency! The sky might fall! I’m not talking about a hospital system here – I’m talking about an ambulatory EHR in a large group that’s about 60 percent primary care. In my experience with having colleagues contacted through the after-hours exchange in the wee hours of the morning, it takes more than 10 minutes for them to respond to texts or calls. One would think that if those 10 minutes were critical, they’d be answering instantaneously and not making the emergency department secretary chat with voice mail. Even better, perhaps they should consider taking in-house call.

Once upon a time in a land far, far away, we managed patients from home without the chart. We used the data we had (patient, nurse, ER physician, resident, intern, exchange, partners, pharmacy, etc.) to give the best advice we could. Certainly there are benefits of having home access to charts, but being without them occasionally is not the end of the world. Patients did well the vast majority of the time. We used things like clinical judgment to treat the patient in front of us, not numbers.

Of course, scheduled downtime and unplanned “events” are two different things. However, with a solid business continuity plan, they should have very little impact to clinicians. Some of my colleagues can access their disaster recovery servers directly. Others have “mini-charts” sent to a network drive every night. Some colleagues have no plan and can’t tell me the last time they actually tested a backup to see if it could be used to perform a system restore.

Despite the crucial nature of clinical data systems, we are at risk of outages and it’s time to be prepared. If you don’t know what your disaster plan is, find out. If you do know your plan, then good for you. If you’re like some of the colleagues I dealt with today who think that clinical systems are the only ones that ever go down, I offer the same challenge I gave at our meeting: take a week and see how many “issues” you have with non-clinical systems. By issue, I mean an instance where the system doesn’t perform perfectly. I think you’ll be surprised at how often they happen and how often we simply move past them and get on with our work.

How do your end users cope with downtime? Do you have processes in place to maximize availability? E-mail me.

E-mail Dr. Jayne.

Morning Headlines 7/22/13

Quality Systems, Inc. 8-K filed 7/17/2013

Quality Systems, Inc., parent company of NextGen, files an SEC 8-K form that includes language suggesting that it may be looking to be acquired.

athenahealth Management Discusses Q2 2013 Results – Earnings Call Transcript

Jonathan Bush discusses athenahealth’s poor Q2 performance on an earnings call held Friday.

New Medicaid computer system doesn’t end errors

New Hampshire’s new $90 million Medicaid computer system has bogged down reimbursement processing significantly, resulting 40 percent of claims being suspended pending further analysis. Meanwhile, some providers say they aren’t getting paid properly.

Veterans in Data Breach Suit Suffered No Harm, Government Argues

In a class action lawsuit filed against Department of Veterans Affairs over a stolen laptop containing sensitive patient information, the federal government is defending itself by arguing that since there is no proof that the thieves ever accessed the data, there is ultimately no proof that an improper disclosure actually took place.

Monday Morning Update 7/22/13

Half of survey respondents say the ongoing DoD-VA EHR discussions haven’t changed their perception of those organizations, while a third day they’ve gone negative as a result. New poll to your right, as suggested by a reader: what’s your opinion of VC-backed companies? The answers are a little bit tricky to tease out the opinions of providers vs. vendors. As always, feel free to follow up your all-important vote by leaving a comment on the poll.

I have a lot of HIStalk Webinars scheduled and could use another person to serve as moderator. If you have healthcare IT Webinar presentation experience, have good speaking skills, and are available weekday afternoons Eastern time, tell me why I’d be stupid not to hire you.

Quality Systems hints in a comment buried in an SEC filing from last week that it may be considering selling itself. The filing describes the company’s acquiescence to dissident shareholder Clinton Group, whereby Quality Systems will bring on the three Clinton Group board nominees to avoid a threatened proxy fight. Clinton Group has successfully used the same threat with other companies.

Microsoft writes down $900 million after its Surface RT tablet flops and the company cuts the price of the 32 GB model from $499 to $349 hoping for potential buyers who have resisted only because of price.

Four college students in Uganda design a smartphone app that connects to a fingertip sensor to allow instant diagnosis of malaria without repeated needle sticks.

Vitera Healthcare Solutions names Jeremy Muench (McKesson) as SVP of client operations.

From athenahealth’s Q2 earnings call, following the announcement of poor results that sent the stock retreating:

• Jonathan Bush proclaims that the company is “very much in the big show” with its Epocrates acquisition and enhancements to athenaClinicals.
• The Ascension Health contract was highlighted.
• Bush claimed that athenahealth is the only vendor that can financially guarantee its customers a smooth transition to ICD-10 and MU Stage 2.
• The move to having recipients of information via athenaClinicals pay for its use rather than just licensing it to an organization is “a hard slog” and has extended the sales cycle and increased sales costs.
• Both athenaCoordinator and athenaClinicals revenues are falling short.
• Bush apologized for comments he had made previously about Epic, saying, “I made some unfavorable comments about Epic, which was a mistake. Epic is a fine company, one for which we have tremendous respect and we are proud to be working alongside of in terms of clinical integration. Soon, any Epic client should be able to connect with athenaNet with a very minor instruction and authentication process.”
• $17 million of increased Q2 revenue came from Epocrates revenue and tenant rent from the Arsenal office complex the company purchased.
• Sales and marketing expense jumped 50 percent in the quarter, while R&D cost was up 66 percent.
• Bush said he thought Ascension went with athenahealth because it sees itself as a national clinical with doctors it doesn’t control.
• Bush sees Epocrates as being enabled with secure provider-to-provider messaging and being given the capability to update non-athena systems with information. “If a doctor is on Epocrates and is chatting on and sharing patient information on athenaClinicals, even though the hospital they’re on maybe on Cerner or Epic, they would love to be able to order prescriptions and then say, ‘Now athena, you deal with updating my Cerner system because I don’t like logging into it or my Epic or my — pick your favorite A Flock of Seagulls system.’”
• More athenaClinicals transactions are being automated, or as Bush says, “Now athenaClinicals with no fax server and no 1,000 people data entering clinical results in India is a very different profit profile than the one we have today.”
• Demand for athenaClarity is so high outside of its Massachusetts origins that Bush says the company can’t keep up.

Mediware will announce Monday its acquisition of home infusion and specialty pharmacy systems vendor CPR+ of Westerville, OH.

The federal government, requesting dismissal of a data breach lawsuit involving a missing VA laptop, argues that no proof exists that anyone has seen the patient information it contained and no identify theft has occurred.

New Hampshire’s new $90 million Medicaid computer system, development of which was contracted to Xerox’s ACS, is causing payment problems due insufficient rules testing according to the CFO of Concord Hospital, which has a $5 million payment backlog. An orthopedics practice reimbursement specialist, noticing wild overpayments, asks for a billing manual and is told it is still being worked on. The HHS commissioner admits that payment of 40 percent of claims has been suspended pending further analysis.

ONC offers a 10-step plan for protecting PHI.

In England, East Kent Hospitals University NHS Foundation Trust blames its just-installed GE Healthcare radiology information system for delayed appointments and results.

The Mount Sinai Medical Center (NY) announces that it will use technology from Real Time Medical to implement teleradiology services in several imaging clinics. I’m curious (and annoyed) as to why the company’s name appears everywhere as Real Time (two words) except in its logo, where it’s one word.

Inga does her best Weird News Andy impression by sending me a link to this story. A British vacationer returning from Peru thought she was imagining the scratching sounds inside her head until doctors found maggots living inside a hole in her ear canal, hatched from eggs depositing there by a fly.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 7/19/13

Athenahealth Slips To Loss In Q2; Backs FY13 Outlook

Athenahealth reports a $12.4 million net loss, or -$0.34 per share in its Q2 results. Despite the poor performance, the company stands by its year end-forecast.

Data show electronic health records empower patients and equip doctors

CMS releases a report touting standout metrics of the EHR incentive program. It says EHRs have sent 190 million prescriptions and 13 million patient reminders electronically.

Bill sets timeline for health records sharing

Sen. Bill Nelson (D-FL) proposes a bill that would set concrete milestones and a firm timeline for the VA/DoD EHR project.

Hospital Denied Access to Its Own Records

Milwaukee Health Service is suing Atlanta-based Business Computer Applications, demanding that the company restore access to its electronic medical records. Milwaukee Health scrapped BCA’s Pearl EMR and migrated to GE Centricity, but BCA says it has not been fully paid.

News 7/19/13

Top News

Athenahealth reports Q2 results: revenue up 44 percent, non-GAAP EPS -$.08 vs. $0.24, beating revenue estimates but missing consensus earnings expectations of $0.22. The company says it stands by previous FY13 guidance.

Reader Comments

From Keen Observer:“Re: Senate Finance Committee on Health IT hearing Wednesday. Here are my notes.” Thanks. Video is here and the transcript of Farzad’s testimony is here. I’m including your notes below.

Farzad and Patrick Conway from CMS fielded a lot of questions about the Meaningful Use program’s benefits and the adoption rate, especially among rural providers. Farzad’s bow tie also took a number of shots, including one from Sen. Pat Roberts advising him not to wear it in Dodge City, KS. Both Senators Baucus and Roberts urged Farzad to get out into rural America and see what the conditions are like before assuming that all rural hospitals and providers should be held accountable to the same IT standards as their urban counterparts.

They asked Farzad about his thoughts on a delay to Stage 2 and he said he didn’t think it would be beneficial to slow the momentum. Senator Thune asked about what Stage 3 will look like and if there will be more stages beyond that. Both witnesses ignored the second part of that question. They also talked a lot about interoperability and evolving standards. Some asked if the bar was too low for interoperability. Senator Enzi really hammered Dr. Conway about the physician drop out rate that was reported for docs who achieved Stage 1 MU.

Next week the Finance Committee will hold another hearing with with Janet Marchibroda from the Bipartisan Policy Center, John Glaser from Siemens Healthcare, Marty Fattig from Nemaha County Hospital which is a critical access hospital and Colin Banas from Virginia Commonwealth University Medical Center.

HIStalk Announcements and Requests

This week on HIStalk Practice: CareCloud introduces an update to its Charts EHR that I believe includes Medicomp Quippe functionality. TransforMED selects 90 primary care practices for a three-year patient-centered medical neighborhood pilot project. CMS highlights key 2014 deadlines for the EHR incentive and other eHealth programs. Physicians in larger states, ER specialists, and pathologist historically experience higher levels of PQRS success. Dr. Gregg shares a scary tale of EMR demos, UXs, and UIs. Join the fun, take a read, and check out the offerings of a few HIStalk Practice sponsors. Thanks for reading.

Acquisitions, Funding, Business, and Stock

Quality Systems reaches an agreement with Clifton Group, an investor that had called for the replacement of the company’s board. Quality Systems will add three Clifton Group nominees to its board.

UnitedHealth Group reports Q2 results: revenue up 12 percent, EPS $1.40 vs. $1.27, falling short on revenue expectations but beating handily on earnings. The company’s Optum segment turned in revenue of $8.8 billion with earnings from operations of $536 million, which contributed significantly to the bottom line. The insurer’s quarterly profit was $1.44 billion.

Sales

Care New England Health System selects Infor Healthcare’s business process automation solutions.

Jefferson Radiology (CT) contracts with McKesson Business Performance Services for revenue cycle management.

St. Joseph’s Hospital Health Center (NY) selects ProVation Care Plans from Wolters Kluwer Health.

Pilgrim Hospital (UK) chooses MetaVision from iMDsoft for its ICU.

People

Extension names Brian McAlpine (Emergin) VP of product management and marketing and Johnathan Salyer (Capsule) director of strategic accounts.

CompuGroup Medical promotes Norbert Fischl to CEO of CGM USA.

HealthAlliance (MA) names Chris Walden, RN, BSN (Flagler Hospital) as CIO.

Former Florida Governor Jeb Bush joins the board of Alpharetta, GA-based healthcare staffing company Jackson Healthcare LLC.

Cleveland-based analytics vendor Socrates Analytics names Jim Evans (McKesson) as CEO.

Industry long-timer Jim Klein, who worked for CompuCare, QuadraMed, InterSystems, Advisory Board, and Gartner, died of prostate cancer Wednesday, July 17 at his home in Great Falls, VA. He was 65.

Announcements and Implementations

ProHealth Care (WI) implements Omnicell’s G4 Unity medication management platform.

The Ottawa Hospital launches Wolters Kluwer Health’s UpToDate Anywhere.

Southeast Hospital (MO) implements Access e-forms barcoding to manage registration packets, order sets, and home health documents.

Navicure reports that it increased revenues 27 percent in the second quarter and added 316 medical practices.

Government and Politics

CMS releases information suggesting that EHR use is helping providers manage patient care and provide more information securely. CMS notes that since 2011, providers have used EHRs to send more than 190 million prescriptions electronically, send 4.6 million patients an electronic copy of their health information, forward more than 13 million patient reminders, check drug and medication interactions over 40 million times, and share more than 4.3 million care summaries with other providers.

During a Senate Finance Committee hearing, ONC head Farzad Mostashari, MD says that pausing the MU program to evaluate whether the bar has been set too low would “stall the progress that has been hard fought (and) take momentum away from progress.”  Incidentally, even senators aren’t immune to Mostashari’s dapper bowties: Sen. Orrin Hatch apparently took a moment to call Mostashari’s cravat “a beauty.”

Sen. Bill Nelson (D-FL) introduces a bill that would impose specific deadlines for the Department of Defense and the VA to exchange electronic health information. The Service Members’ Electronic Health Records Act would require the DoD and VA to use standardized forms within six months of enactment; to exchange real-time information and use a common UI within a year; and to offer service members with electronic copies of their information by June 30, 2015. According to the Senator, “For 15 years, we have tried to fix this problem. In the past five years, the departments have spent around $1 billion, but we are not there yet.”

Innovation and Research

Seamless Medical Systems is awarded a $50,000 grant from the Venture Acceleration Fund of Los Alamos National Security, LLC. The company will use the money to further develop its SNAP Practice patient engagement platform.

Technology

Connexin Software will use Health Language applications from Wolters Kluwer Health to normalize data into standard terminologies within its pediatric EHR solutions.

Tech writers are stalking executives of Apple, hoping to see visual evidence of the wearable body sensors or related devices that the company is rumored to be studying.

Children’s Hospital Foundation (DC) passes on Microsoft SharePoint for its Intranet because of complexity and staffing requirements, instead choosing Igloo.

Tech Crunch profiles ElationEMR, a San Francisco-based startup founded by a Stanford economics professor who says she and her brother “had no prior experience building anything of the sort. And my brother happened to have a knack for design and I kind of had a bit of a knack for engineering and learning quickly to pull things together.” The EMR costs $149 per month, which includes support, e-prescribing, lab interfaces, training, and a patient portal. An ElationEMR user can see all the practices that have seen their patient. Signup for a test account is free.

Other

A majority of surveyed EHR consultants expects the majority of EHR vendors to involved in merger, acquisition, or closure within five years, most often due to delaying usability problems in favor of meeting MU requirements. Do we blame the fallout on opportunistic vendors taking advantage of a hot market, or the government and MU for managing their development priorities? Probably a bit of both. The study concludes that well-funded smaller vendors serving niche sectors may do better than some larger vendors who have failed to resolve “fundamental flaws caused by being all things to all physicians.”

The National Football League says it’s on track to roll out an iPad-based sideline concussion assessment tool next season. The results will be printed and placed in a paper chart, but eight teams will be piloting a program to send the information directly to the patient’s electronic medical record.  The league’s 2011 collective bargaining agreement called for deploying a full EMR this year that would allow medical records to follow a traded player. Safeguards are being put in place to prevent viewing of the records by competing teams, the league itself, and teams for which the player is trying out but is not yet signed. The NFL signed a 10-year agreement with eClinicalWorks in November 2012 to provide its EMR.

Milwaukee Health Services, a Federally Qualified Health Center,  says Atlanta-based Business Computer Applications is endangering 40,000 people by remotely locking the organization out of its own data servers in a billing dispute. Milwaukee Health Services has done business with BCA for 24 years, but says it paid the vendor $3 million to develop an EMR called Pearl EMR that still doesn’t work and isn’t HIPAA compliant. The hospital moved to GE Centricity, claiming BCA promised to give it a copy of its database, but later reneged. It’s suing under the Computer Fraud and Abuse Act. BCA claims to be the largest minority-owned software company in the world and claims it developed the first EMR in the US outside of the Department of Defense. It still sells Pearl EMR, which is certified by CCHIT as a Complete EHR for ambulatory.

Weird News Andy says if you have to be shot, there’s no better place. A patient is superficially wounded by a bullet shot through the window of her room in Crozer-Chester Medical Center (PA).

WNA says this woman doesn’t have a leg to stand on. A Utah woman who says she has wanted to be disabled since she was four years old seeks a doctor who will cut her perfectly healthy sciatic and femoral nerves to paralyze her legs. She suffers from Body Integrity Disorder, which causes her to believe her legs aren’t her own. The woman has tried to paralyze herself by intentionally causing accidents and now hopes that aggressive skiing might do the trick since she can’t afford to pay a doctor to cripple her.

Sponsor Updates

• Allscripts will offer its ambulatory clients LDM Group’s ScriptGuide patient education solutions.
• Sandlot Solutions offers an August 14 Webinar, “Real-time, Clinical & Claims Data at the Point of Care: Reshaping the Way You Deliver Healthcare.”
• Aprima reports that over 1,000 Allscripts MyWay customers have switched to Aprima PRM since October, when Allscripts announced that it would not provide MU or ICD-10 enhancements to MyWay.
• The TrustHCS Academy graduates its class of coding students.
• Ecfirst validates Imprivata Cortext as HIPAA compliant and will perform ongoing audits.
• GetWellNetwork will add patient-education content from ASCO’s Cancer.net patient Website.
• An API Healthcare-sponsored study finds that hospital and health system executives are prioritizing workforce management-related issues to achieve long term fiscal sustainability.
• A Beacon Partners-CHIME survey of  healthcare CIOs examines Meaningful Use progress and challenges.
• Ingenious Med announces impower Mobile 2.0.
• HealthMEDX forms a physician medical advisory board.
• Carl Fleming, principal advisor with Impact Advisors, discusses the evolution of tablets and how they are helping physicians.
• Wellcentive introduces a Network Maturity Model to evaluate the maturity of healthcare organizations.
• Clinical Architecture is recognized as a 2013 Indiana Company to Watch award.
• Sandlot Solutions Director Rosalind Bell discusses information as healthcare’s ultimate business partner.
• Intellect Resources publishes an infographic depicting the use of social media in healthcare.
• ICSA Labs’ Jack Walsh discusses the vulnerability of Android devices.
• Chicago Crain’s Business profiles Care Team Connect Founder and CEO Ben Albert.
• Ping Identity CEO Andre Durand discusses the setting of reachable goals in a New York Times interview.

EPtalk by Dr. Jayne

ONC releases a new “ONC Certified HIT Certification and Design Mark” along with a nine-page guide on how it is (and is not) to be used. I’d show it to you, but that in itself would be a violation of the terms of use, so you’ll just have to check it out for yourself. I did provide a hint above. I’m less worried about the Pantone graphics people coming after me than a hit squad from ONC.

A reader sent me this slide show from a Medscape physician lifestyle report. I’m sad to see that both my primary and secondary specialties are in the top three for burnout. Check out Slide 8, which lists physicians’ favorite pastimes. Non-medical writing ranks at the bottom, but I’d personally put it at the top. Some weeks it seems like being part of the HIStalk crew is the only thing keeping me sane.

From Checklist Diva: “Re: checklists. I was reading your post about checklists and it warmed my heart. Personally, I love checklists. I write things on my lists just so I can cross them off, items like ‘eat lunch.’” I put a block on my calendar every day not only to remind myself to eat lunch, but also in the hopes that someone will show a little humanity and not schedule a lunch meeting. It works a good part of the time, probably because I put humorous titles on the appointments to make it look like I have important meetings. My admin occasionally gets into the spirit and changes the locations or adds ridiculous attachments that make me laugh. He provides support to several of us and I’m pretty sure I’m his favorite because I have a sense of humor.

Speaking of humor, I might not have much left after next week. It’s our regularly scheduled “All Provider” meeting, which usually turns into a freeform complaint session because the (very young) president of the medical group has a hard time moderating his more senior peers. Some of the physicians get pretty far out of control and the audience gets completely restless with audible sighs, vigorous paper shuffling, slamming chairs around, and the occasional demonstrative hand gesture. For years EHR has been the designated punching bag, but we seem to have been elbowed aside by Accountable Care as the villain of the day. Some meetings though I feel like we should be dressed for roller derby instead of the board room.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 7/18/13

Quality Systems to Nominate New Directors to Board

Quality Systems, Inc. parent company of NextGen, has announced that it will add three new directors to its board to avoid a proxy fight initiated by activist investor Clifton Group. The deal will send Clifton Group nominees James C. Malone, Peter M. Neupert, and Morris Panner to the board. In exchange, the Clifton Group will withdraw both its call for the current board to be replaced as well as its series of bylaw proposals that would have been up for vote at the next shareholder meeting on August 15.

EHR Industry Insiders Predict the Demise of Hundreds of Competitors in Black Book Replacement Market Survey

An EHR replacement trends report predicts a 50 percent reduction in the crowded field of EHR vendors by 2017 or the implementation Meaningful Use Stage 3. The study polled 880 EHR consultants, analysts, managers, and support team members on the state of affairs in what it calls the "Year of the Great EHR Switch."

Sen. Hatch calls for pausing meaningful use program

In a finance oversight meeting with Farzad Mostashari, MD, Senator Orrin Hatch proposed a pause to the Meaningful Use program to evaluate whether the program may have "set the bar too low." He says the program should be judged not by how much incentive money has been spent, but on demonstrable improvements in patient care.

PeaceHealth making cuts to close $130 million budget gap

Vancouver, WA-based PeaceHealth is targeting $130 million in spending cuts to account for reduced reimbursement rates and a planned $350 million EHR implementation that will take place across its health system over the next few years. Cost-saving strategies will include voluntary furloughs, early retirement, reduced travel, leaving vacant positions unfilled, and consolidating the number of contractors.

HIStalk Interviews Andrew Farquharson, Managing Director, VentureHealth

Andrew Farquharson is managing director and co-founder of VentureHealth.

Tell me about yourself and VentureHealth.

I’m a venture capital investor and entrepreneur focused on healthcare investing and company building. I began my career in life science when I graduated with a BA from UC Berkeley, and went right into the research side of Genentech. After Genentech, I went to Harvard Business School and founded my first company there. I returned invested capital back to investors. I didn’t make a killing, but learned a lot.

After that, a friend and I took over a company called Operon that makes synthetic DNA and built it up into the world’s number one provider of DNA. At Operon, I ended up running the entire demand side of the business: sales, marketing, customer support. My friend Nathan Hamilton ran operations, R&D, and reinvented the way they make DNA. We ended up selling that company for a $150 million in June 2000 without taking any venture money.

After that, I became an angel. As an angel, I realized that one of the challenges is getting access to the very best deals; getting access to venture-quality deals. I joined a small venture fund and then I met my current partner Mir Imran. Mir is one of these rock star innovators in the biomedical space. He’s founded about 24 companies and has returned billions to investors. He invented the implantable defibrillator, among many other things, which has generated over $200 billion in revenues. Not bad. Mir is one of these guys where 80 percent of the things that he does return money for investors. He’s very good at what he does.

VentureHealth was not an idea that came out of nowhere. When we were raising our second venture firm, a number of folks wanted to co-invest with us because of our previous successes. Mir had lots of success. There are many healthcare professionals who would like to get involved in healthcare startups, but don’t know how to do it. Those are the folks who initially began reaching out to us.

Our initial response was really kind of uncertain. Investing is very risky, and we didn’t want to encourage people to partake in investments they didn’t understand. But as we kept chatting with high net worth individuals, we realized that there’s a large pool of financially sophisticated folks who want access to venture capital deal quality deals in healthcare, but who don’t know how to do it and don’t have a time to figure it out. We help them get access to venture quality deals in ways that were consistent with SEC guidelines.

Then the JOBS act came along. The future is going to become very interesting. The future is going to allow groups like ours to expand our investor base and publicly disclose when we’re raising capital. We can’t do that yet. The SEC is being thoughtful and measured in how it goes about regulating the JOBS Act. 

For right now, everything we’re doing is within the confines of the current law and the current regulations, which is why we’re doing what we’re doing with accredited investors we personally vet who really understand the risk. But if and when the SEC begins to actually implement the JOBS Act, we’re watching that carefully and we plan to respond appropriately once the doors are wider open.

Could you provide a quick summary of the JOBS Act and what it means for angels, accredited investors, and the general public?

The JOBS act will allow potentially hundreds or thousands of investors to invest, a true crowd of individuals who have much less money to write much smaller checks and get involved in a venture capital deal or any kind of startup deal.

But we’re not there yet. The SEC is still ironing out the details. It’s something that the SEC wants to move slowly towards that because they really want to make sure folks who invest know about what companies are doing and they understand the risks of investing capital. The SEC particularly wants to protect individuals against fraud, which we agree with.

For VentureHealth, we see the JOBS Act having an immediate impact on high net worth individuals as soon as  the next 12 or 18 months. We’re going to be thoughtful about how we begin to open up to a true crowd.

Right now, VentureHealth is only focused on accredited investors?

Exactly. Healthcare equity crowd-funding is very new. There are companies mushrooming up trying to make equity crowd-funding platforms real. One of the most successful that’s focused on the consumer space is called CircleUp. If you’re an entrepreneur raising money yourself, you should probably have a look at CircleUp’s model just to understand what they’re doing. They’re venture backed. They’re doing deals every month. Like us, they’re focused on accredited investors for now, but are trying to open up to the general public when it becomes legal.

You’re not taking any cash from the startup.

That’s right. The VentureHealth portal takes no cash from startups. That approach may be attractive for entrepreneurs, but does not necessarily make sense from an investor’s perspective.

This can be counterintuitive until you think through the incentives. We’re compensated along with the investors like any venture firm. In the case of VentureHealth, the individual investors make the decisions. The money flows from them. They’re the ones who own the equity through a fund structure. If the company returns cash to investors, we participate as members of the general partner. 

In contrast, if you’re a broker-dealer, you make money every time cash flows into a startup, so your incentive is to drive as many transactions as you can regardless of quality. Whereas for us, the incentive is to only take deals if we’re going to ultimately make money for investors. We’re aligning with the investors to try to find companies that are going to have successful outcomes as opposed to just driving a whole bunch of deals.

What separates VentureHealth from AngelList?

AngelList is a successful, creative approach to crowd-funding at high volume. AngelList has allowed lots of startups to put their wares up on the website and allowed lots of individual investors to look at those deals. It enables connection between the investors and startups. AngelList does not have a model, as far as I know, where it makes money by charging the startups or the investors.

I think they’re providing a really valuable service to everyone. As an angel myself, I appreciate what they do. I think they’re a great company and they’re well off. But what we do is very different. We curate our deals and only select investment opportunities that meet our criteria. As our exits this year reflect, our approach seems relatively robust. We curate our deals and will post far fewer than AngelList.

Conversely, AngelList does not try to protect investors from bad deals, just like Kickstarter doesn’t either. It’s really up to the investor. Investor beware, which is the case with many robust marketplaces. In the case of healthcare investing, however, investors often don’t have the clinical, regulatory, and business perspectives to bring an opportunity into the proper focus. 

I think that there’s a lot of value in their model, but the model does require a lot of understanding on the part of the investors. That does not always translate well into healthcare.

Our model is simple. We do our best to protect our investors, unlike AngelList and Kickstarter and most of the other equity crowd-funding platforms. Another way of saying this is we try to find the most attractive opportunities run by the best entrepreneurs. Our assumption is that, over time, this will prove successful for everyone.

What stops you from taking all of the best deals for yourself?

We manage about $72 million right now, which is really small money in the big picture of things. Our fund is not going to be able to fund all healthcare innovation. Far from it. We sit back a little bit and think about what’s happening in healthcare.

A lot of life sciences venture funds have been failing. The supply of venture capital dollars for life sciences innovation is, shall we say, challenged and at the same time there’s a strong demand from accredited investors who are not traditional angels and don’t know how to source or invest in these deals.

You’ve mentioned life sciences explicitly a few times. Is VentureHealth only focused on life sciences such as pharmaceutical and biotech or are you also looking at software, hardware, services, wellness, PRM, and medical devices?

For us it all begins with clinical outcomes. If we can see a way to really dramatically impact clinical outcomes, then we begin to get excited. That said, our history has been medical devices, and we have recently been moving assertively into biopharmaceuticals.

How big is the team curating deals?

The answer is a little complicated. There are three of us who are co-founders of the portal — Mir Imran, Talat, and me. We all had a lot of experience making and curating deals. But there are another 30-plus people inside InCube Labs — who are great friends of ours  — who actively work in forming companies and doing research. In a sense, we get a free ride from a much larger group of people, primarily PhDs. They’re from pharmacology, engineering, protein science, material science, implantable sensors, Wi-Fi technology, and even guys in social media and web development.

Morning Headlines 7/17/13

Effect of Electronic Health Records on Health Care Costs: Longitudinal Comparative Evidence From Community Practices

A study funded by the Massachusetts eHealth Collaborative and published in the Annals of Internal Medicine finds that EHR adoption does not lead to cost savings. However, using ambulatory EHRs in community practices did modestly slow cost growth.

Pioneer Accountable Care Organizations succeed in improving care, lowering costs

CMS has released quality and cost performance data on the Pioneer ACO program which, it says saw quality improvements across the board and cost reductions at a majority of participating organizations. Still, seven organizations have announced that they will switch to the Medicare Shared Savings ACO program and an additional two sites have confirmed that they will leave the ACO model altogether.

U.S. News names its ‘Best Hospitals’ list

Johns Hopkins Hospital reclaims the top spot on the Best Hospitals list after its 21-year streak at number one was broken last year by Massachusetts General Hospital.

Electronic Medical Records: Friend or Foe?

A union nurse working at McLaren Macomb Hospital (MI) criticizes the usability of EHRs, McKesson’s Paragon in particular. She says the value of EHR systems is clear to the union, but hospital administration has a responsibility to provide an EHR sophisticated enough to handle both the legal compliance needs and the needs of the clinicians and patients.

News 7/17/13

Top News

A Massachusetts eHealth Collaborative-sponsored study finds that EHR adoption by doctors in three communities generated no statistically significant per-member, per-month cost savings, although EHR usage appeared to be associated with less-rapid cost increases. Participating communities were chosen as having the highest likelihood of EHR success by MAeHC, which also paid most of their system and implementation costs. The most commonly used systems were from Allscripts, GE Healthcare, eClinicalWorks, and NextGen. Insurance cost information from 2005-2009 was used.

Reader Comments

From Jessica: “Re: speakers. I love HIStalk and am an avid reader. Can you recommend speakers that you’ve seen and liked?” I haven’t heard many lately, so I will defer to readers. Who stood out?

HIStalk Announcements and Requests

HIStalk’s seven millionth visit was logged Tuesday morning. Thanks for contributing to that number.

Welcome to new HIStalk Platinum Sponsor CareWire. The Excelsior, MN-based company’s mobile solution improves outcomes and loyalty by engaging patients in timely communication that is tailored, thoughtful, and relevant. It sends mobile messages that are encounter-specific, personalized, and perfectly timed: patient instructions, arrival information, and links to services or provider-specific content. The result for providers is a reduction in the cost of no-shows, fewer manual interventions, and improved outcomes and reduced risk. According to the executive director of an outpatient surgery center, “CareWire is like air traffic control for my patients.” The SaaS-based solution requires minimal interfacing – just send it a daily flat file and it’s happy. CareWire’s proprietary rules engine identifies the patients and their mobile numbers, determines the appropriate messages to send, and allows authorized users to send their own messages directly to patients. Templates are provided for appointments, procedures, and case-based episodes that span visits and procedures. Thanks to CareWire for supporting HIStalk.

I’m really enjoying Pepperland, a fun novel about music, anarchy, computers and sexual freedom in the 1970s. The Amazon reviews include a quick one I wrote that compares its detail, in-jokes, and pop culture to something Stephen King would have written without his bloated excess and often ridiculous supernatural themes. The author is the amazing Barry Wightman, writer, musician, voiceover guy, and VP of marketing for Forward Health Group. I hardly ever read fiction because it usually annoys me and I have a microscopic attention span, but Pepperland is a blast.

I usually notice when a company is proud enough of sponsoring HIStalk that they say so on their Web page. The iHT² folks do and I appreciate it. I keep thinking I’ll attend one of their Summits since readers have told me good things about them.

Acquisitions, Funding, Business, and Stock

Healthcare analytics provider ArborMetrix closes $7 million in Series B financing.

Ping Identity closes a $44 million investment round.

Caremerge, a developer of communication and care coordination apps for seniors, raises $2.1 million in Series A funding.

Reed Elsevier Group will move  Elsevier/MEDai to its LexisNexis Risk Solutions business unit, where it will join the acquired EDIWatch as a fraud and abuse solution.

NPR profiles Cerner in an EHR series it’s running, pointing out its HITECH-fueled employment boom in which 3,000 employees were hired in the past two years.

Sales

Winthrop-University Hospital (NY) chooses PeriGen’s PeriCALM Plus charting and fetal monitoring system.

Celebration Orthopaedic & Sports Medicine Institute (FL) selects simplifyMD’s EHR/PM system for its 10 providers.

Pacific Alliance Medical Center (CA) will implement Summit Healthcare’s Express Connect interface engine.

Wishard-Eskenazi Health (IN) selects eClinicalWorks PM for 385 providers across eight locations.

Harris Corporation will use Symedical Server from Clinical Architecture to enhance terminology management, interoperability, and data normalization in its HIE and clinical integration solutions.

The Scarborough Hospital (Ontario) selects SIS.

Canada’s Fortius Sport & Health will implement EMR and PHR technologies from Telus.

Georgia Regents Health System (GA) signs a 15-year, $300 million contract with Philips Healthcare for consulting services, medical technologies, and operational performance, planning, and maintenance services.

People

Anthelio appoints Asif Ahmad (McKesson Specialty Health, Duke University Health System) CEO, replacing co-founder Rick Kneipper, who will remain as chief strategy and innovation officer and chair of the company’s healthcare innovation council.

Bruce Brandes (AirStrip) joins Valence Health as EVP for growth and innovation. David Kirshner (Boston Children’s Hospital) also joins the company as VP of corporate and business development.

PathCentral, which offers a online information exchange and digital consultation forum for pathologists, names David Frishberg, MD chief medical advisor. He will continue in his pathology roles with Cedars-Sinai Medical Center.

Announcements and Implementations

Michigan Health Connect becomes the state’s first HIE to transfer infectious disease lab reports from hospitals to the state health department.

HIMSS introduces the HIMSS Health IT Value Suite, a knowledge repository that classifies, quantifies, and articulates the clinical, financial, and business impact of HIT investments. In reading the press release and details on the HIMSS Website, it appears that HIMSS is positioning it as an industry resource as opposed to a product or service available for purchase.

MModal rebrands its Philippines-based medical transcription provider MxSecure to MModal Global Services.

Southern Health NHS Foundation Trust deploys SEIM and content security technology from Trustwave.

Open Door Center for Change (WI) installs Forward Health Group’s PopulationManager.

NCH Healthcare System (FL) completes its implementation of Cerner this week.

Deep Domain releases Version 3.0 of its EHR reporting software. It charges $78 per provider per month for a reports subscription.

AHIMA and CHIME announce plans to join forces in conducting HIM/HIT research, presenting sponsored Webinars, co-presenting sessions at CHIME’s Fall CIO Forum, and working together on advocacy issues.

Government and Politics

Only 18 of the 32 first-year Pioneer ACOs reduced Medicare costs in their first year, though all improved their quality measures. Seven of those that did not produce savings say they will switch to the Medicare Shared Savings Program, while two others will leave the program entirely. While the Pioneer program rewards providers for shared savings, the majority of a provider’s patients are likely still covered by traditional fee-for-service contracts.

National Coordinator Farzad Mostashari, MD, interviewed by NPR: “Paper works just fine if you want to deliver healthcare the way you sell shoes. If you want to wait in your office for the door to open and say, jingle, jingle, and you say, can I help you, and pull a chart and deliver care, and then when you close that chart, that information is dead, paper works just fine. If you want to coordinate care with other providers, if you want to share information with the patient and engage them as partners in their own care, paper doesn’t work just fine.”

Innovation and Research

A video by Vonlay’s Steve Knurr, Google Glass Explorer, records cycle racing using the device. He plans to help develop a heads-up cycling display that will include bike telemetry, biometrics, and race information.

It’s not all Google Glass in the computing eyewear field. Italy-based GlassUp, running its launch campaign on Indiegogo, will offer a camera-free and more stylish alternative that will cost only $399 ($299 as a Indiegogo donation, or $1,500 for 10 pairs right off the first production run.) They will also offer a prescription version for those who already wear glasses.

Other

A Wolters Kluwer Health survey finds that changing reimbursement, financial challenges, and finding time to spend with patients are the top challenges facing doctors.

The healthcare business intelligence market lacks a clearly perceived leader, according to a KLAS report. Large BI vendors such as IBM, SAP, Microsoft, and Oracle command the largest mindshare, but the lack of sufficient healthcare focus leaves most providers with unmet needs.

US News & World Report releases its annual hospital rankings. Johns Hopkins (above) reclaimed the top spot, followed by Mass General, Mayo Clinic, Cleveland Clinic, UCLA Medical Center, Northwestern, New York-Presbyterian, UCSF, Brigham and Women’s, UPMC, HUP, Duke, Cedars-Sinai, NYU, Barnes-Jewish, IU Health, Thomas Jefferson, and University Hospitals Case Medical Center.

The top administrator of a Georgia cancer treatment center files a whistleblower lawsuit claiming its health system owner overcharged the government by upcoding claims. It also charges that Columbus Regional Healthcare System essentially pre-paid a referral kickback by intentionally overpaying for a local cancer center it bought for $10.5 million; that its medical director modified the medical record to justify higher charges because he was upset at a potential income loss caused by regulatory changes; and an insurance company executive who sat on the hospital’s board threatened to withdraw his financial donations to the hospital if the medical director were to leave in a contract dispute.

A Wall Street Journal article covers hospitals that use big data, specifically The Advisory Board Company’s Crimson platform, to encourage higher-quality, lower-cost physician behavior by showing doctors how they compare to their peers. 

A labor publication editorial written by a union-represented RN complains that EMRs “are getting in the way of the fundamental work nurses do.” She says that the union understands benefits of EMRs, but doesn’t want nurses “to become lost in the land of acronyms, drop-down menus, non-existing options, and endless grey pages in which endless boxes must be clicked.” She concludes that her employer needs to replace McKesson Paragon with a system that “fulfills both the legal compliance needs and the needs of the patients who are hospitalized for competent, attentive, and effective nursing care” The author has previously argued that nurses should work for independent agencies rather than directly for hospitals.

The Judy Maple Foundation will hold a charity golf tournament on July 27 in East Springfield, OH hoping to raise money for the Charity Hospice of Wintersville to replace outdated computers for use with its EMR.

Sponsor Updates

• Aventura is named as one of 10 Denver startups with cool offices, complete with pinball machines, a gym, and healthy food. 
• Beacon Partners hosts a July 26 Webinar on optimizing clinical systems.
• IHE USA and ICSA Labs certify eight HIT products under its pilot certification program to test security and interoperability in the IHE Patient Care Device or IHE IT infrastructure domains.
• InstaMed announces the availability of its InstaMed Network, which allows providers to accept electronic payer and patient payments.
• Levi, Ray & Shoup finalizes its purchase of Capella Technologies.
• Kareo outlines five ways it can help users prevent denials.
• Emdeon will integrate the Simplicity Settlement Services by ECHO into the Emdeon Payment Network. The company also introduces Virtual Card Services, an electronic payment option to reduce payment distribution costs and payment processes.
• KLAS Research adds MModal Fluency Direct to its customer rankings.
• BayCare Health System CIO Tim Thompson shares his organization’s experience implementing Medicity’s HIE platform.
• The Nashville Business Journal profiles Shareable Ink CEO Laurie McGraw.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 7/16/13

Personal health record vendor MyMedicalRecord announces that it is on the verge of securing a patent for what is essentially e-prescribing technology. The patent describes "providing a user with the ability to access and manage prescriptions online by providing features that include sending prescriptions to a pharmacy, accessing prescriptions from a pharmacy, scheduling prescription refills, sending reminders regarding prescription refills including by text or email, and identifying adverse drug interactions by analyzing prescription medications."

Readers Write: The Enterprise Content Management Adoption Model

The Enterprise Content Management Adoption Model
By Eric Merchant

There have been numerous publications recently about the amount of unstructured content that exists (80 percent of all content) in a non-discrete format outside of the electronic medical record. This unstructured content exists as digital photos, scanned documents, clinical images, and faxes and e-mails.

The challenge of capturing this information as close to the source as possible — managing it effectively and ultimately delivering it to the necessary physician, nurse, or other provider in a timely manner at the point of need — is a continuous uphill battle. There are varying degrees of being able to manage unstructured content and make it available to decision makers in a meaningful way to improve patient care, drive operational efficiencies, and improve financial performance in the healthcare market.

In developing a content strategy, the challenge is greater than simply buying a software suite and thinking your problems are over. As content grows in volume and complexity, the strategic plan needs to be flexible to be able to grow and adapt accordingly.

To do this, a reference is needed to determine where we were, where we are now and where we want to be. I began creating an Enterprise Content Management (ECM) adoption model as an internal point of reference, but also as a strategic guide for the industry. In practice, it would function similarly to the seven stages of the EMR adoption created by HIMSS Analytics.

ECM Adoption Model

This adoption model can serve the healthcare industry well by allowing us to keep focused on the outcomes we want to achieve and the systems that would provide them. The adoption model also intertwines patient care initiatives (capture content and deliver within the EMR), operational efficiencies we need to achieve (federated search and analytics) and outcomes that will directly benefit healthcare organizations’ financial performance (intelligent capture, VNA and Image Lifecycle management).

In addition, this strategy also delivers on the commitment to support Meaningful Use and IHE data-sharing initiatives with the ability to share and publish unstructured content to information exchanges.

EMR systems have received the bulk of the attention the past few years due to the value they bring and the public policy and reimbursement implications of getting them successfully implemented. However, as the healthcare market becomes more electronically mature, we cannot lose focus on the larger picture and the bigger challenge and ultimately the patient. This picture is incomplete without bringing together both the unstructured content created outside the EMR and the discrete information within the EMR.

To do this, the ECM adoption model, in conjunction with the EMR adoption model, must both be used as a roadmap to reach that goal. ECM vendors must take the same approach that EMR vendors have taken and work hand in hand with healthcare organizations to provide the solutions to achieve Stage 10 of the ECM adoption model and ultimately move closer to a complete patient record, which subsequently creates better health outcomes delivered efficiently and in a financially solvent manner.

Eric Merchant is director of application services, health information technology, for NorthShore University HealthSystem of Skokie, IL.

Readers Write: Requirements Versus User Experience: The MU Design Impact on Today’s EHR Applications

Requirements Versus User Experience: The MU Design Impact on Today’s EHR Applications
By Tom Giannulli, MD, MS

Since the first electronic health record (EHR) applications, the federal government has been looking for ways to leverage EHR technology to improve the quality and cost of healthcare delivery. A decade ago, President George W. Bush declared that every American should have an electronic health record within 10 years. While we’ve come a long way, almost half of all medical providers are currently searching for an EHR, installing one now, or looking to switch out the one they have in place.

This is an eye-opening situation given the investment of billions of dollars in EHR technology by healthcare providers, technology suppliers, and the government via incentive programs. Why is this? One contributing factor is that the government incentive programs have excessively focused on features over user experience and outcomes.

When the current EHR incentive programs emerged in 2009, EHR suppliers with existing products were faced with the challenge of meeting Meaningful Use (MU) requirements. It’s not easy to retrofit new functional requirements into an existing product, and it’s commonly understood many suppliers had to focus on achieving functionality requirements however possible given the potential impact of government incentives. The time-bound goal was simply to get X feature programmed in Y weeks so that version update or hot fix could be applied to meet customer certification timelines.

Function ruled over form, often resulting in degraded user experience and sub-optimized workflows. In hindsight, it may have been better to have fewer incentive program requirements with broader definitions and simpler tests to validate compliance.

For example, assume a general requirement for physicians to be able to share standardized clinical documents with basic tests of compliance. With this more general goal, technology suppliers would have greater freedom around how to solve the requirement resulting in a greater range of solutions—some of which likely would have superior usability. The market would then reward the company that best met both the requirement and the associated usability and user satisfaction.

The overall goals of MU are sound; it’s simply that in practice the extent and specificity of the requirements often overemphasize feature content and prescribed usage at the expense of user experience and the innovation that comes with flexibility. A doctor on HIStalk a few weeks ago highlighted this reality:

“When you’re used to using very clean designs—a MacBook, an iPhone, Twitter, Facebook—and you sit down on an EMR (electronic medical record system), it’s like stepping back in time 15 or 20 years.”

I had the opportunity to build an EHR after MU Stage 1 had been established. This allowed us to take a more comprehensive approach in terms of meeting our overall design goals, including usability, as well as MU requirements. We wanted to make it possible for the physician to use the application to chart patient visits and the required data and reporting were generated as an by-product of normal use.

Now, we are facing changes for MU Stage 2, integrating those into an existing product, tying them to user needs in a way that makes sense. We have developed a process that uses a lot of user feedback and testing and we try to iterate quickly with releases at least monthly.

But the fact is that the specificity of MU and the rigorous testing don’t provide for the best user experience. Ironically, these really specific requirements—a number of which dictate the user experience to a large degree—are supposed to be creating improved usability when in fact they are detracting from user-friendless and improved workflow.

I believe that without MU, many EHR features would be similar, but there would be notable differences resulting from the focus on user feedback versus government direction. As a physician and an EHR designer, I would still want to track health maintenance and have tools to manage people’s care. The big change would be the ability to focus on some market-driven elements that we haven’t been able to spend as much time on because they aren’t MU requirements.

We would be spending more time looking at how we could use the practice data to highlight workflow problems or areas where the practice isn’t using best practices. By leveraging our large pool of operational and clinical data, we could generate more recommendations for practice optimization and patient care. These are very high level concepts that we are exploring, but are at a lower priority given the resources required to implement MU2 in a way that is well integrated and results in a positive user experience.

In a perfect world, current MU2 requirements would be replaced with just few high-impact goals related to interoperation and communication. Current MU2 requirements have added little new incremental value while creating a significant burden for vendors and end users. This situation is even more challenging in that the requirements are becoming more specific and dictate user interaction in some cases. The structure is in place to capture discrete data, measure quality, and communicate standardized data.

At this point, I believe the market should drive the process of advancing features and expand-on the valued features outlined by the MU requirements.

Tom Giannulli, MD, MS is chief medical information officer at Kareo.

Curbside Consult with Dr. Jayne 7/15/13

A Tale of Two Lists

I’ve been a big fan of making lists even before people like Atul Gawande raised the collective consciousness with The Checklist Manifesto. One of my former co-workers used to make fun of those of us who were “list-makers” and said that we lacked spontaneity and a certain sense of fun due to our fondness for lists. Personally, making lists has kept me sane.

There’s too much going on in most of the working world today and especially in healthcare. Everyone is trying to do much more (remember Meaningful Use?) with the same level of staffing or even less. People are overworked, under-inspired, and fatigued. These are factors that allow near-misses (or actual misses) for patients. Making lists helps one ensure nothing is forgotten and that every precaution was taken to ensure care was delivered as intended.

Checklists aren’t just for the front lines of patient care. I use one when I’m wearing my IT hat as well. They can be simple – I have a checklist I use before presentations to make sure I have e-mail, instant messenger, and other applications shut down so they’re not distracting. I make sure my desktop background is neutral and my screen resolution is adjusted.

They can be complex and multi-faceted. We use checklists extensively in our EHR implementation framework. They ensure that every user in every specialty and every practice setting receives consistent training. Signing the completed checklists after training documents the users’ receipt of training and has reduced the incidence of “nobody every showed me that” complaints to near zero.

I had a chance to revisit our training checklists today when one of our implementation specialists went out on family leave earlier than expected. With it in front of me, I was able to deliver solid training to a couple of specialists even though it’s been several months since I’ve covered their particular discipline. After the session, I made sure to compliment the implementation manager on ensuring that the lists are kept current and used consistently by everyone on her team.

She joked back at me that the training lists are the only ones that seem to be working for her right now. She’s in a bad cycle of making lists for implementation projects that continually get put on hold by the leadership. Once providers figure out that their pet projects are on hold, they raise a political ruckus and the projects are reactivated. She pulls up the lists and updates project plans, only to be put on hold again when the projects are not funded.

It’s a vicious cycle and to the point where she’s not even updating them anymore, just changing the date in the header. I don’t blame her. The best list in the world can’t be successful if no one is able to activate it and carry it through to completion. I think the leadership needs a better checklist to ensure projects are funded before trying to get them up and running. Or maybe they need a checklist for when they try to put them on hold, making sure they are not political hot potatoes before they are placed on hold.

How does your organization view checklists? E-mail me.

E-mail Dr. Jayne.

Morning Headlines 7/15/13

Practice Fusion raising $60M, sources say

Ambulatory EHR freeware vendor Practice Fusion is rumored to be within days of announcing $60 million in new funding from an undisclosed New York-based investment firm.

Sutter’s New Electronic System Causes Serious Disruptions to Safe Patient Care at E. Bay Hospitals

Nurses with the California Nurses Association working at Alta Bates Summit Medical Center (CA) have gone on strike, citing patient safety concerns with the hospital’s newly implemented Epic system. Alta Bates, a Sutter Health facility, becomes the third health system to fall victim to an EHR-related nursing strike in the past few months after Affinity’s nurses hit the pavement in June over what they called a "hurried" Cerner implementation and Martin General Hospital (CA) nurses went on strike in May to delay a upcoming McKesson implementation. Sutter Health is reportedly spending $1 billion on a system-wide Epic implementation.

Athenahealth soars on Ascension deal

Athenahealth stock rose 20 percent Friday after the company announced a deal with Ascension Health Network worth as much as $42 million. Athena will implement its practice management solution to more than 4,000 Ascension providers.

Do Clinical Trials Work?

An op-ed in the New York Times questions the validity of clinical trials for new medications.The use of Avastin to slow the development of aggressive brain tumors is discussed. Researchers have not been able to link Avastin to improved survival rates through clinical trials despite growing anecdotal evidence that suggests a relationship does exist.

Monday Morning Update 7/15/13

From Flyswatter: “Re: Practice Fusion. Running out of money, expanding, or both?” Free, ad-supported EMR vendor (are you a vendor if your product doesn’t cost anything?) Practice Fusion is rumored to be raising another $60 million after a $34 million round held less than a year ago.

Three-quarters of respondents say healthcare organizations should continue with their plans to buy software in preparation for Affordable Care Act-related changes even though the future of the ACA is uncertain. New poll to your right: how has the DoD/VA discussion about a shared EHR changed your perception of those organizations?

I mentioned last week that it would be fun to hear from folks who have been reading HIStalk since the beginning 10 years ago. Some replies:

• ”I know I’ve been reading your stuff since the beginning for sure. I think a friend of mine referred the site to me, but I can’t remember who and/or exactly when… all I know is that now you can’t get rid of me.”
• “I count you as one of my celebrity acquaintances.” [this tongue-in-cheek comment came from someone who knows me]
• “I found HIStalk while searching for a primary source of unbiased information about the healthcare IT world. I found HIStalk to be one of the few outlets at the time willing to publish all things healthcare IT (good, bad and the ugly) and provide value to sponsors and readers alike. It’s been wonderful watching HIStalk grow with the healthcare IT industry. Congratulations!”
• “In 2003 I worked for Eclipsys, and one of our sales reps asked if I read HIStalk. He said it was the best blog about the industry he had ever read, and that if I wanted to be in the know and feel hip at the same time, I should check it out.  And so I did. And stayed. Congratulations!”

HIStalk Webinar Monday, July 29

Jonathan Teich MD, PhD of Elsevier will present “Clinical Decision Support: The Promise, Pitfalls, and Practicalities” on Monday, July 29 from 2:00 to 2:45 p.m. Eastern. He will provide practical insights into the key success factors for selection, design, management and rollout of CDS interventions and will describe 10 types of CDS and how to apply them. My CIO reviewers who provided feedback on the rehearsal gave this Webinar rave reviews, with one of them saying he was so engrossed by the CDS examples that he wished it had lasted 30-45 minutes longer (when’s the last time you heard that about a Webinar?) I thought it was really well done myself. You can register here.

Also upcoming: “Five Steps to an Enterprise Imaging Strategy,” presented by Merge Healthcare, on Wednesday, July 24 from 3:00 to 3:45 p.m. Eastern.

These Webinars meet HIStalk’s standards for quality, clarity, and attendee value. They have been critiqued by experts and are moderated by folks who work with me.

Six people lose their jobs for inappropriately viewing electronic patient records at Cedars-Sinai Medical Center, possibly those of Kim Kardashian. Four employees of community physician practices were found to have been using the login credentials of their physician employer and were dismissed, along with a medical assistant and an unpaid student research assistant. The journalistically rigorous TMZ decided that a phony quote and Photoshopped picture were the perfect way to illustrate its uncredited rumor, which was repeated by traditionally privacy-indifferent press anxious to jump on the celebrity gossip bandwagon without appearing to be pandering to intellectual lightweights.

Another nurse union uses an EMR implementation to publicly criticize a health system. The California Nurses Association cites 100 reports from RNs claiming Sutter Health’s $1 billion implementation endangers patients of Alta Bates Summit Medical Center. The nurses say the system requires too much nursing time, delays care, and isn’t clinician friendly. The union wasn’t nearly as concerned about patient safety eight weeks ago when it ordered its nurses to walk off the job for seven days in those same Sutter East Bay facilities to protest a reduction in their health benefits.

Intermountain Healthcare says it has developed an EHR module that allows state death certificates to be completed automatically.

A Silicon Valley business newspaper profiles former professional quarterback Steve Young, now a private equity deal-maker for HGGC (formerly Huntsman Gay Global Capitalist). The article says he was involved in that private equity firm’s investment in Sunquest, which it later sold to Roper Industries.  

A dozen employees from the Raleigh, NC offices of Allscripts volunteered to help clean up tornado damage in Moore, OK and presented the local hospital with a check for $50,000. Allscripts covered all of their expenses and paid their full salaries.

Ivo Nelson’s Next Wave Health advisory and investment firm will announce Monday that former Steward Health Care CIO Drexel DeFord has joined the company as a principal advisor.

Shares of athenahealth jumped 20 percent on Friday after the company filed SEC documents disclosing a June 30 deal with Ascension Health Network’s physician segment, which will deploy the company’s system to its 4,000 providers and affiliates. Athenahealth’s market cap is now $4 billion, with Jonathan Bush holding shares worth $33 million. A $10,000 investment in ATHN shares on this day three years ago would be worth $48,000 today.

Also earning a spot on the Nasdaq’s top percentage gainers for Friday were WebMD (up 25 percent on its sales outlook) and Quality Systems (up 12 percent on an analyst’s upgrade).

Showing his HIStalk colors at the top of Mt. Bachelor in Oregon is Dean Sitting, PhD, professor of biomedical informatics at UT Health Science Center in Houston.

Maybe it’s just me: every time I get an e-mail survey from HIMSS, I dutifully start completing it, but then bail out in annoyance just a few questions in. Every HIMSS survey is way too long, has endless answer choices but often not the one I need, and uses a stiff and authoritarian tone that makes me feel like I’m dealing with IRS instead of an organization to which I voluntarily pay dues out of my own pocket.

Blue Cross Blue Shield of North Carolina is called out for sending out live patient data to software developer DST Systems for testing its systems. Cigna went on record saying it would never do that, while Aetna said it shares data in similar situations.

Brown University researchers create software that can analyze the cries of an infant, hoping that the 80 auditory parameters can detect developmental problems.

An interesting New York Times opinion piece questions whether clinical drug trials work, wondering if disease and response is so individualized that mass testing creates more frustration than usable knowledge. It says drug companies are just playing the lottery in testing drugs they don’t expect to be effective, hoping for a statistical miracle. It also says that nearly every study is biased from the outset because drug companies pay for them, turning them into a “straw-man comparator” of drug vs. placebo instead of a real quest for finding the best treatments. The healthcare IT connection: genomics, which could effectively match patients with drugs likely to benefit them.

Vince starts his history of Siemens in this week’s HIS-tory. He is trying to find the lost history of the IBM SHAS (Shared Hospital Accounting System), so if you know more than what’s on Vince’s slides, he would enjoy hearing from you. Vince loves this stuff and his enthusiasm and fun memories come through loud and clear in his HIS-tories.

Sponsor Updates

• Intelligent InSites will host a July 25 Webinar, “The Hospitality Environment” – Improving the Patient Experience with Innovative Technology.”
• O’Reilly’s Strata Rx Conference, “Data Makes a Difference,” offers HIStalk readers a 20 percent discount on registration through August 15. It will be in Boston September 25-27 and feature speakers from athenahealth, Valence Health, HHS, and Humedica.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: Healthcare Transparency 2.0: Using RHIOs to Rate, Criticize, and Publicly Rat Out Idiot Patients Wasting Everybody Else’s Healthcare Money

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 2009.

Healthcare Transparency 2.0: Using RHIOs to Rate, Criticize, and Publicly Rat Out Idiot Patients Wasting Everybody Else’s Healthcare Money
By Mr. HIStalk

I’ve always made fun of those “Get a Free Medical (wink, wink) Scooter” commercials that run during the fake judge TV shows that are watched religiously by homebound, unemployed, and intentionally deadbeat people while the rest of us are at work. I see them occasionally while getting my oil changed, waiting to have labs drawn, or getting a haircut. I feel like I’m peering into a sociology experiment gone horribly wrong.

The scooters don’t really look all that fun, but apparently “free” makes them a blast, at least to that latter category of people (since so many of us are joining the “unemployed” category involuntarily, I’ll focus on the intentional deadbeats). “When did you realize your mobility was impaired, Mr. Jones?” “Why, when I saw that sweet scooter model that looked like an ATV with a beer can holder and a ‘Free with Medicare’ sign on it, sir.”) I suspect it’s the same people who borrow someone else’s handicapped sticker to get the best parking place.

Apparently that “intentionally deadbeat” demographic is a rich vein to be mined by semi-scrupulous companies who know that “Jerry Springer” moves some medical iron while “Meet the Press” doesn’t. Now comes mesothelioma time, valiant ambulance chasers channeling Robin Hood by taking money away from anyone who has it and redistributing it (minus the 90 percent legal fees) to the daytime TV audience not quite up to the subtle nuances of General Hospital.

My solution is either simply brilliant or brilliantly simple (I can’t decide). Use RHIOs to turn healthcare professionals into a constantly communicating network of fraud- and sleaze-sniffers and pay them for turning people in (the government is terrible at detecting Medicare fraud, yet is puzzlingly world class at snooping on citizens). Everybody wants transparency, so let’s make it work both ways. Patients ought to have some skin in the game.

Anybody can rate doctors and hospitals anonymously, even to the point of adding vicious, unsubstantiated comments. If Mr. Smith rips Dr. Jones on a public doctor rating site, Dr. Jones should be able to, as on eBay, add a blistering response, such as, “This lard-butt patient smokes, ignores my advice, has sued three doctors so far, and has never paid a dime of what he owes me.”

RHIOs could be the interoperability platform for exchanging information about those crackpots who ruin the system. Doctors, nurses, pharmacists, and dentists could flag patients who stiff them on co-pays even though they drive Jags, who use someone else’s insurance card, or who are just plain nasty. Let the doctor check their credit report, criminal record, IQ, and work history while they’re at it. They’re the ones who will be facing them naked (the patient, not the doctor) in an exam room, so it shouldn’t be Mystery Date in there. Like the stockbrokers say, “Know your customer.”

Patients who have filed more than one malpractice suit would get tagged so other doctors can avoid them. It would be like the NFL: patients get one medical challenge with no hard feelings, but frequent malpractice flyers get marked as trouble, as do drug-seekers and scooter-wanters.

Forget evidence-based medicine. If you really want to save healthcare dollars, give doctors the tools to identify and avoid those who seek to use them dishonestly and irresponsibly. That fruit is abundant and low-hanging. Plus, it’s not like the RHIOs are really doing anything anyway.

Post the information publicly and let’s put some shame back into dishonesty, criminal behavior, and irresponsibility. It could even be made cost-neutral by charging the public to peek at the postings. I bet people who make “Cops” or “Dog the Bounty Hunter” could figure out how to monetize it.

Now if you’ll excuse me, I think I’m coming down with a touch of mesothelioma, so I’ve got a scooter to order while they’re still free.