Morning Headlines 10/25/13

Cerner shares drop on revenue miss, outlook

Cerner reports Q3 results: EPS of $0.35 vs $0.30, revenue increased 7.6 percent but missed expectations leading to a three percent drop in share price after hours. Cerner shares are up 43 percent year-to-date.

The Wellness Network Acquires LOGICARE Corporation

The Wellness Network, a media company that owns several in-hospital TV channels, acquires patient instruction and education vendor Logicare.

Representatives Blackburn, Green, Gingrey, DeGette, Walden and Butterfield Introduce SOFTWARE Act

A bipartisan group of legislators have introduced the Sensible Oversight for Technology which Advances Regulatory Efficiency (SOFTWARE) Act, a bill written to clarify the role the FDA will take in regulating medical software, including mobile health apps and EHRs.

Boston Children’s Hospital Researchers Launch Start-up to Offer Enterprise-grade Software Solutions and Services Across the Digital Healthcare Ecosystem

Boston Children’s Hospital announces the launch of Wired Informatics, a spinoff startup that will market an NLP product to hospitals and other healthcare organizations.

Fighting Healthcare Fraud Using Whistleblower Statute Returns $20 For Every $1 Invested

A report by the Taxpayers Against Fraud Education Fund finds that for every dollar spent investigating and prosecuting government fraud, more than 20 dollars are recovered. Health care economist Jack Meyer notes “If all costs and benefits are accounted for, the benefit to cost ratio of False Claims Act law enforcement now exceeds 20:1. Civil health care fraud is one area where federal and state governments are recovering far more than they are spending."

News 10/25/13

Top News

Cerner reports Q3 numbers: revenue up 8 percent, adjusted EPS $0.35 vs. $0.30, falling short on revenue expectations. From the conference call:

• Domestic revenue was up 8 percent, while global revenue increased only 1 percent.
• The company sold its sixth French client and its first one in Brazil.
• Cerner says that by the end of the decade, the EMR will provide just one feed into a population health management system, and the company is already selling solutions and services to customers who don’t use a Cerner EMR.
• Cerner and Epic are distancing themselves further from their competitors, and Cerner says it is gaining momentum against Epic.
• Cerner says its clients have acquired hospitals at six times the rate of Epic’s, giving the company more potential users.
• Cerner has been approved by Apple as the only non-carrier company allowed to sell the iPhone, and it will offer an unlocked, no-plan iPhone for CareAware Connect, which can replace pagers and other communications devices.
• Cerner says its work with Intermountain Healthcare will disrupt the industry and accelerate clinical computing by a decade, reducing healthcare costs by up to 20 percent. Projects include using Intermountain’s Care Process Models as an EMR-agnostic “clinical navigation system” and blending content with the EMR to provide activity-based costing as a resource management system.
• EVP Jeff Townsend compared Epic to Kodak for its suggestion that Meaningful Use be delayed for five years, suggesting that both Epic and Kodak spent too much time selling profitable old technology and trying to delay the inevitably changing future.
• An analyst noted that “Intermountain has a history of chewing up and spitting out vendors” and asked how Cerner can keep them happy. Townsend said Cerner will do an accelerated Millennium implementation so they can get to the “fun stuff” more quickly.
• Cerner says it was chosen over Epic at Intermountain because of population health and the ability to influence cost, saying, “This is not a project. This is a decade, if not a two-decade-type relationship.”

Reader Comments

From Digital Bean Counter: “Re: million dollar question. Why hasn’t the government asked any of us health informaticists about fixing the Healthcare.gov website?” It’s not an informatics problem, so that would be pointless. Nobody in healthcare (nor in government contracting, apparently) has the experience needed to plan for the kind of scale Healthcare.gov needs and there’s nothing there at all related to informatics. It requires people who have built monster-sized e-commerce sites, the kind who live in the Silicon Valley instead of the beltway. It’s a shame that the site has turned into a political football – nobody seemed to mind when the VA, DoD, and HHS were burning through millions to billions of dollars in poorly planned and poorly managed IT projects and the website is only marginally related to Obamacare. Nobody can say anything about any topic these days without someone screaming about a perceived political agenda, and politics isn’t the same as the government, which is comfortingly inefficient and wasteful no matter which party is involved. I think I remember a stat that 50 percent of US government software projects are utter failures and a complete waste of taxpayer money and almost all of the rest don’t deliver the expected value.

From Alexis Nexis: “Re: expense reports gone wild. There’s no understanding of what someone on the road experiences:  a hotel room and bed, no ability to cook some eggs in the morning, no ability to pack a sandwich for lunch, doing laundry just on the weekend, etc. Not to mention the additional six to 25 non-billable hours of travel (above the commute between hotel and office) typically incurred every week by road warriors. I can assure you that there’s no road warrior getting rich off his meal expenses. I am quite surprised that snacks and coffee are being included. IRS guidelines view meal expenses as breakfast, lunch, and dinner. Shame on the commentator for not having negotiated a contract accordingly. And shame upon those contract administrators who insist upon receipts for when IRS guidelines don’t require them. To have to save my receipt for the toll on the highway or for my $7 of breakfast in the morning is ludicrous. It burdens everyone with additional unnecessary overhead. I routinely put into my contracts the IRS per diem rate for the locale. Perhaps we should wonder about what it is that makes healthcare in the United States the most expensive in the world without our getting the best return what we spend. I would suggest that it’s not the relatively incidental amounts being referred to. By the way, where could I sign up for that $200 an hour rate?” This is one of those “don’t sweat the small stuff” issues. Line item living expenses are annoying because you get into that pointless mental debate over whether a consultant who buys a $4 coffee on the way to the hospital every morning must be screwing you in other ways as well, and yet sometimes that same employer doesn’t give the consultant a clear picture of what work needs to be done or doesn’t have the required internal people lined up. At $200 per hour, that $4 coffee represents just over one minute of billable time, and I’ve seen consultants trying to find things to do for hours each day because they were just shown a cubicle and abandoned because nobody had the time to manage them.

From Bignurse: “Re: Yann Beaullan-Thong of Vindicet. You interviewed him a few weeks ago. The 2013 McKnight Technology Award in the Transitions category was awarded to a Vindicet client for implementing its patient management system. The organization says the system cut admission time to its skilled nursing settings to less than 1 hour.” Yann’s HIStalk interview from December 2012 is here. The company offers referral management and discharge managing systems.

From Boy Oneder: “Re: Epic’s Healthy Planet. It’s population health management and is robust – wellness, chronic disease registries, population outreach, high risk care management, and risk stratification algorithms.” I heard the term “Healthy Planet” and asked Boy Oneder what it was all about. Boy Oneder also says that Epic had documented clinical workflows in the Netherlands years ago in preparation for sales like the two that just happened to two large Amsterdam hospitals. I don’t think Epic is joking when it talks about world domination.

From Player: “Re: Epic hospital. You should interview a CFO, anonymously or otherwise, about how they looked at the cost justification for implementing Epic.” That would be fun. Volunteers?

From Boy Lee: “Re: innovative companies. You profiled some of them years ago.” I ran a series I called Innovator’s Showcase in 2011, which took a ton of work. I invited startups to apply to be profiled on HIStalk, but they had to have an original product, real customers, real revenue (although not too much of it), an a short time in business. I had three folks review their brief applications and we chose seven for the Innovator’s Showcase. We thought these had the best chance of success. None have failed as far as I can tell. They were:

Aventura (clinician computing experience)
Health Care DataWorks (analytics)
OptimizeHIT (which was connected to ImplementHIT in some way that confuses me to this day, which offers EHR training)
Caristix (HL7 and interfacing software)
Logical Progression (acquired by Bottomline Technologies – offered mobile documentation)
Trans World Health Services (benchmarking and analytics)
Health Nuts Media (learning games and educational material)

From DrLyle: “Re: your comments about physician-focused startups with no clue how to make solutions for doctors. I loved your answer. I just wanted to make sure the key word is ‘most’ and not ‘all.’ Some of us are actually making some good stuff that truly uses HIT to automate and delegate care, saving time for docs and improving quality for patients.” I was amused at the number of folks whose brains blocked all but the words they get emotional about, firing them up to argue about what they perceived as an anti-innovation rant. I very specifically mentioned only companies that don’t care about patients or providers and that are clueless, arrogant, insulting, and badly planned. If I were CEO of one of those I’d keep quiet, and if I was one of the better startups, I’d be happy that my unworthy competitors had been called out publicly. I’ve been the hospital IT guy who heard these pitches and I’m fairly certain most of my peers think similarly – don’t come knocking until you’ve done your homework. Hospitals may seem like local businesses that need help, but they are massive enterprises. Getting your fledgling product in the door means someone internal is going to have to go to bat for you, meaning their job is on the line if you can’t deliver. Do you have documentation, an implementation plan, around-the-clock support, and sound technology that isn’t dependent on your one Romanian programmer not finding a better contract?

I should mention that part of my rant came about is because I resent any company (big or small) that barges into healthcare without showing respect for patients and the people who have been involved in taking care of those patients all along. Healthcare is a vendor’s Vietnam, as Misys or Sage or any number of other half-hearted former dabblers can explain. They saw themselves swooping in from other industries with massive firepower and a hearts-and-mind campaign that would ensure a quick and painless surrender by the peaceful, primitive locals. A handful of years later, their thoroughly defeated and demoralized salespeople and executives were climbing over each other’s backs desperate to squeeze onto that last available helicopter ride to safety.

From Lazlo Hollyfeld: “Re: Healthcare.gov. At least the CD version is slated for a ‘16 release.” The Onion is brilliant as usual in its satire about Healthcare.gov.

HIStalk Announcements and Requests

Some goodies you may have missed this week on HIStalk Practice include: Practice Fusion defends its practice of emailing patients to request physician reviews. Parents want to email their pediatricians and they want it to be free. The Rothman Institute will implement White Plume ePASS. Female doctors provide better quality care than their male counterparts. A physician is charged with breaking and entering after she broke into an office, set up a temporary practice, and began seeing patients. Hayes Management Consulting VP Rob Drewniak outlines a process to prevent breaches with HIPAA compliance. Dr. Gregg offers a Top 10 and a Bottom 10 List on HIT adoption. Linda Fischer, EMR manager for Boulder Community Hospital Physician Clinics, discusses her Greenway Medical EMR implementation, including details on the selection process, EHR data migration, obtaining physician buy-in, and quality care initiatives. In lieu of sending Halloween candy, please treat me to your email address to subscribe to the latest HIStalk Practice updates. Thanks for reading.

Here are a couple of on-the-spot interviews Bonny and Catherine of Aventura conducted at ACEP13 in Seattle last week. They just turned on the video recorder and let the folks say whatever they wanted about IT.

From an ED physician:

Technology is struggling to match what physicians and other clinicians actually want to have happen. When people say all the time, “Is this a great system?” then yes, it’s a great system, but not in this particular setting. There’s many, many, many times a mismatch between what the clinicians want to have done and what the technology can do. There’s innocence on both sides. That’s what my experience has been with this technology. This innocence of mismatch, where the technical people are extremely good at what they do, the hospital people and clinicians are very good at what they do, but this matching of the two is really not working nearly as well as everybody thinks it is. As an example of why there’s this disconnect between documentation and clinicians is my assessment of a patient begins way before anybody thinks it does. It begins when I hear that patient screaming out of the corner of my eye as he’s brought in. I’m not documenting then. I’m not even seeing the patient yet, but that’s when my assessment begins. When I walk into the room, the smells and everything, that’s all part of my assessment, but many times that does not get documented.

From a resident:

I’m a fourth-year EM resident. Our workflow is that we will typically sign up for patients at the doctor’s station and go and see the patient, which takes about five to 10 minutes. Then come back, put our orders in, see other patients, and then we’ll frequently come back and either document or dictate in between patients. Aventura seems like a good application. Friendly, very fast. Sounds like it would be helpful.

Acquisitions, Funding, Business, and Stock

Microsoft turns in Q1 numbers: revenue up 16 percent, EPS $0.62 vs. $0.53, beating expectations.

McKesson files Q2 numbers: revenue up 10.7 percent, adjusted EPS $2.08 vs. $1.79, beating expectations on both. Technology Solutions revenue was up 7.7 percent although software revenue was down 9 percent. The company also announced that it will acquire a majority stake in Germany-based drug wholesaler Celesio for $8.3 billion “to form a global leader in healthcare services.” John Hammergren, asked about whether the company will keep the technology business, waffled by saying results are good and there are no plans to change the mix, but MCK isn’t married to any particular strategy and has a responsibility to revisit that decision constantly.

Covisint reports its first quarterly results after its recent IPO: revenue up 19 percent, adjusted EPS –$0.08 vs. –$0.15.

Hospital health information management provider IOD Incorporated acquires ApeniMED, a Minneapolis-based company offering healthcare interoperability solutions.

Accelera Innovations secures a $200 million equity investment agreement from Lambert Private Equity. I’ve never mentioned Accelera even once on HIStalk and I admit I’ve never heard of them. Their website looks like something kid with FrontPage might have created in 2002, playing annoying music (unless you’re an “Arrested Development” fan, in which case you’ll enjoy Europe’s “The Final Countdown” because it will remind you of a G.O.B. magic trick ) following someone loudly and pedantically reciting a company pitch. Frankly, I’m struggling to believe the accuracy of the story that someone invested $200 million in this operation.

Quality Systems reports Q2 results: revenue down four percent to $118 million, EPS $0.22 vs. $0.31, missing analyst estimates on both. CEO and President Steven T. Plochocki says the results are indicative that the reorganization plan put in place during fiscal 2013 is beginning to gain traction. He also notes that revenue, bookings, and system sales were up from the first quarter.

The Wellness Network acquires hospital patient education software company Logicare.

Cureatr, which offers secure messaging solutions for providers, secures $5.7 million in Series A financing.

Miami Children’s Hospital signs a deal to allow HealthFusion to offer South Florida pediatricians an MCH-specific version of the company’s iPad-based MediTouch EHR that will connect to the hospital’s systems.

Sales

Trinitas Regional Medical Center (NJ) selects EDCO Health Information Solutions to implement Solarity technology and indexing services for medical records scanned at patient discharge.

Elmwood at the Springs Healthcare Center (OH) selects VersaSuite for EHR/PM for its long term acute care facilities.

Rush Health (IL) endorses athenahealth’s EHR and PM services for its 300 affiliated private physician members.

The State of California Office of Health Information Integrity selects iBlueButton from Humetrix for its HIE pilot.

The Berlin Visiting Nurse Association (CT) will replace McKesson Homecare with Brightree’s home health platform.

Children’s Hospital of Philadelphia signs a five-year contract with OnPoint Medical Diagnostics for its MRI Quality Assurance software.

VA Midwest Health Care Network chooses Visage 7 Enterprise Imaging Platform enterprise viewer for regional diagnostic interpretation and image access throughout its 11 hospitals. The organization also chooses Medicalis for enterprise workflow and Acuo for its vendor-neutral archive.

People

Athenahealth names Amy Abernethy, MD, PhD (Duke University Medical Center) to its board.

Vermont IT Leaders elects Paul Harrington (Vermont Medical Society) chair of its board.

Announcements and Implementations

Care at Home (CA) deploys AtHoc’s Home Care Alerts emergency mobile solutions.

Spectrum Health (MI) automates the exchange of patient information via CCD between its HealthMEDX post-acute care EMR and its Cerner and Epic platforms.

HIMSS names Texas Health Resources a winner of the 2013 Enterprise HIMSS Davies Award of Excellence for its use of HIT. CIO Ed Marx is a regular contributor to HIStalk.

Boston Children’s Hospital launches Wired Informatics to provide enterprise-grade NLP solutions for hospitals and other healthcare entities and introduces its flagship product Invenio, which extracts and leverages knowledge contained in clinical notes.

Partners Healthcare’s Center for Connected Health launches Wellocracy, a clinically-based source of self-help technologies for consumers, including health and fitness trackers and mobile apps.

Government and Politics

Finally some good news from the government: every dollar invested to investigate and prosecute healthcare fraud returns at least $20, based on data collected from 2008 to 2012.

A bipartisan group of House lawmakers introduces the Sensible Oversight for Technology  which Advances Regulatory Efficiency (SOFTWARE) Act  that would clarify regulations for mobile medical apps, EHRs, and other HIT technologies. The legislation builds on the FDA’s final guidance on mobile healthcare apps.

Healthcare.gov contactors tell a Congressional panel that it’s not entirely their fault the site doesn’t work as well as hoped – the government should have supervised them better and tested more thoroughly before setting the go-live date. An SVP of Canada-based CGI stuck with the story that user volume was greater than expected and said it was CMS’s job to do end-to-end testing, not the company’s. Andy Slavitt of Optum, which owns contractor QSSI, said the government decided late in the game to require users to create an account before viewing insurance plans and the company’s function for that didn’t work well in the site’s first few days. Rep. Anna Eschoo (D-CA), who represents the Silicon Valley, said blaming user volume is a “lame excuse” that “really sticks in my craw,” adding that Amazon doesn’t crash the week before Christmas.

John Halamka’s conclusion about Healthcare.gov: “… Nine women cannot create a baby in a month. There is a minimum gestation period for IT projects and our policymakers should learn from the lessons of the Health Insurance Exchange and re-calibrate the timelines shown in the graphic above [the CMS reform timeline] so that everyone is successful.” Or as one of my hospital programmers always told me years ago when pressed to make a delivery date, “You can take the cake out of the oven any time you want, but don’t blame me when you don’t like it.” 

The VA’s Office of the Inspector General finds that three ED patients died at the Memphis VA after receiving substandard care, one because the doctor violated policy by hand-writing an order for a drug to which the patient was allergic, a situation that CPOE would undoubtedly have warned about.

Innovation and Research

The Merck | Heritage Provider Network Innovation Challenge offers $240,000 in total prizes for creating tools that help people with heart disease or diabetes follow their care plans. Submissions are due November 10, 2013.

A peHUB article called “Disrupting healthcare – on whose terms?” says that companies with no healthcare background who jump into healthcare IT investments have a big performance disadvantage. It concludes, “These data clearly show a massive advantage for firms with healthcare expertise when making healthcare investments. And why shouldn’t they? Don’t we assume, for instance, that energy investors do better at energy investments vs. those firms without any energy focus or experience? Healthcare is at least as complex and regulated an ecosystem as energy and yet it repeatedly experiences cycles of outsiders driving up investor frenzy.”

Technology

Verizon Enterprise Solutions releases Converged Health Management, a remote patient-monitoring platform that allows patients to use biometric devices to capture vital signs and automatically transmit details to their providers.

Other

Providers rely on telephone calls, letters, and face-to-face conversations more than any other method to communicate with patients, despite the increased use of newer technologies such as text messaging, social networking sites, portals, and emails.

HIMSS announces keynote speakers for the mHealth Summit in December: FDA Commissioner Margaret Hamburg, Qualcom CEO Paul Jacobs, Denmark’s Minister of Health, and Nobel Peace Prize Winner Muhammed Yunus. I’ll be reporting from the conference, as will Travis from HIStalk Connect. HIStalk will have a microscopic, sparsely furnished booth in the exhibit hall because they were nice enough to give us one, which will be capably manned (or womanned) by the fabulous Lorre.  She may have nobody to talk to since I’m not certain the mHealth Summit draws a lot HIStalk readers, but if you’re going, find our micro-booth (#1305, right beside a slightly larger booth and company called AT&T) and say hello. 

More on the summary of KLAS’s report on McKesson Paragon, which concluded that the product isn’t ready for big hospitals in important areas (like clinical functionality and an integrated ambulatory system) and has experienced a pretty big drop in KLAS scores since 2010, but customers seem satisfied to wait for the three-year roadmap to bring it up to their expectations. The graphic above shows that 32 large hospitals bought Horizon replacements in 2012, with 10 each choosing Cerner and Epic and 11 choosing Paragon, with cost being a big driver for the Paragon wins. Among smaller Horizon hospitals, Epic was the big winner, probably through acquisition if I had to guess since I doubt those hospitals could afford Epic otherwise except though an affiliate agreement. Allscripts, Meditech, and Siemens didn’t get a single Horizon replacement deal, with the most startling fact in that statement being the inability of Meditech to execute in what should be a receptive market.

Brian Stowe, the former Epic project manager charged with taking sexually explicit photos of passed out women (of whom six of the eight were his Epic co-workers,) pleads guilty to taking photos and video of a 17-year-old girl asleep in his bed and will be sentenced  in January to a minimum of 15 years in prison. He still faces 62 felony counts.

A thief breaks into the offices of AHMC Healthcare (CA), making off with two unencrypted laptops on which was stored the information of 729,000 patients. The hospital has expressed a sudden interest in encryption, which the near-certain $1.5 million fine might have covered. Apparently hospitals are unable to muster the technical expertise and financial motivation to encrypt computers until after they’ve been inevitably burned and fined, so it costs them even more. Police arrested a vagrant for the theft on Wednesday, but the laptops are still missing.

After reading Tweets and news stories about all the folks who have been able to find more affordable healthcare coverage options on the Healthcare.gov website, I decided to once again attempt the application process. Unfortunately I did not get farther than the second screen, which contained a lot of gibberish. I guess I’ll give Jeff Zients, Verizon, and all the newly recruited techies a bit more time to fix things.
Weird News Andy says he is singing “La Cucaracha” to himself as he enjoys this story: cockroach farming is booming in China as the country finds them both delectable as a culinary treat and miraculous as a a basis for drug development, with hospitals using them to treat burns and a pharmaceutical manufacturer claiming its cockroach syrup cures ulcers and TB.

Sponsor Updates

• NVoq announces the general availability of its SayIt 8.2 release.
• Strata Decision Technology hosts 400 attendees in Chicago this week at its annual summit.
• Wolters Kluwer Health introduces Lippincott’s CoursePoint, a digital course solution for nursing education.
• DocuTAP will integrate Wolters Kluwer Health’s Health Language applications into its EMR solutions for the urgent care environment.
• Intelligent InSites will hold its InSites Build 2013 conference October 29-30 in Fargo, ND.
• Greythorn will offer an October 29 webinar on Radiant implementation and optimization.

EPtalk by Dr. Jayne

Let’s face it, consultants are a fact of life in our industry. Most of us are trying to do more than we possibly can with the staff we have in place. We’re trying to cope with an ever-changing regulatory landscape. We’re feeling the squeeze between immovable deadlines and vendors who aren’t delivering required code as early as we want them to. Sometimes we can’t hire new FTEs quick enough or we may not have anyone with the skill sets needed to help us stay compliant. And so, we turn to consultants.

A reader mentioned last week that his or her company was not in favor of paying meal and incidental expenses for consultants and asserted that the consultant’s employer should pay those expenses since it is already charging a hefty per-hour fee. The comment sparked several replies, so I decided to reach out to some of my friends who are consultants to see what they think. I’ve been on both sides of the story as I’ve hired consultants and been one, but I’ll hold on my thoughts for now.

Most of the consultants I talked to this week feel that their clients have a skewed view of what consultants actually are paid. Even though a consulting firm or vendor may charge $200 or $300 an hour, it’s unlikely that the individual field consultants are taking home even a third of that. Although many senior consultants do quite well, many junior consultants spend up to 50 weeks a year away from home. Divide the pay by the hours away from home and family and the paycheck starts to look even less great.

Companies have to cover for the time that their consultants are engaged in non-billable activities such as training, staff development, continuing education, and maintaining competency with EHR vendor software. Increasingly clients are refusing to pay for consultant travel time (or imposing ridiculous travel caps that don’t even cover flying time) and that has to be covered as well. One consultant I’ve used repeatedly tells the story of going to a small town in a remote western state, where he had to take four flights (to stay under the client’s air fare cap) and then drive four hours to get there. The total travel day was close to 18 hours and then of course he had to get home. The client had a three-hour round trip travel cap. I’m pretty sure the client knows they’re a four-hour drive from the nearest airport.

One of my favorite niche firms works with a single EHR vendor and maintains a very small group of consultants. All of them are nurses and the CEO is a nurse as well. Most of them continue to maintain their licensure and attend CNE so they can stay current with clinical topics. It makes them extremely effective and I’m happy to pay a higher per-hour fee for them because I know I’m getting the quality input I need for projects that need both nursing or other clinical expertise and a high degree of vendor-specific knowledge. I’m also happy to pay more for a small firm that I know runs lean and has little administrative bloat because I know they pay their workers well.

Unfortunately, the health system I work for has what can only be described as Enron-style accounting and they are constantly late in paying the consulting invoices even when all supporting documentation is provided in a neat and timely package. I wish the accountants understood the value of these consultants – they are super busy and don’t need my business to stay afloat and I’m afraid eventually they’ll stop working for me because it is simply too much of a bother.

Due to the size and scope of some of our projects, I’ve had engagements with the 800-pound gorillas of the consulting world as well. Although there have been a handful of consultants that have tried to take advantage of expense policies, the majority have been fair in what they submit for reimbursement. For those who have been a little too cavalier with their spending, it’s been fairly easy to address it with management. I haven’t yet run across anyone operating like the George Clooney character in “Up in the Air” where he pushes his expense reports to maximize his airline mileage. If you’ve ever been a road warrior and haven’t seen the movie, I’d recommend it.

The best defense against ridiculous expense reports is negotiating a good contract with the consulting firm. Know what you are willing to pay for, but be fair. Know what typical hotel rates are in your area and make sure you are allowing your consultants to stay somewhere that you would consider staying yourself. I’ve heard horror stories (and seen pictures) of “client recommended” hotels that I can’t imagine a hospital administrator would expect his own family to accept. If you have a corporate discount, make sure consultants have the codes, and if there is a limit to the number of rooms that can be booked at the corporate rate, that they book well in advance.

As far as meal allowances, they seem fair for the companies I’ve worked with. I don’t begrudge my consultants the coffee and snacks they submit because they’re working their tails off for me. Some of them can deliver in a week what my IT department takes a month to deliver, so the expense is well worth it. One of our IT buildings is away from the main hospital campus and there aren’t any close restaurants. I always have lunch delivered for the consultants so they don’t have to waste time trying to find food and worry about their logistics. But when I negotiate engagements, that is taken into account and their maximum daily meal reimbursement is adjusted accordingly. If you don’t want to pay for alcohol because you’re a faith-based organization, write it into the contract or hire a consulting firm that doesn’t allow alcohol to be submitted.

As I’ve mentioned before, I did a fair amount of consulting while I was building my CMIO skills and still do a couple of jobs a year with the full permission of my hospital. Ethics and professionalism are what keep consultants from abusing the system. Having been in those shoes, if I find someone milking it, I’m going to send them packing. On the flip side, I’ve been abused by clients and it’s never pleasant. At one site where I was engaged for a couple of months, my “handler” would routinely book my schedule with 10-hour days containing back-to-back meetings that didn’t allow for restroom breaks, let alone lunch breaks. I would hit the local supermarket before going on site and stock up on granola bars, fruit, and drinks. The same client didn’t even have cups or utensils in the break room, so I had to travel with my own mess kit if I brought restaurant leftovers.

Another client scheduled a business dinner after a full work day. The agenda was for me to meet with providers and address their concerns regarding an upcoming implementation. It was at a fairly expensive celebrity chef restaurant and I was looking forward to it. However when the bill arrived, the client asked for separate checks and made me pay for my own. Needless to say that blew my expense account for the day (actually three days’ worth) and I had to cover it out of pocket. Had I been on my own that evening, I probably would have had a turkey sandwich and a handful of grapes. Maybe some chips if I was feeling wild and crazy. Most of would agree these examples are pretty extreme, but unfortunately I’m not the only one who has had those experiences.

If you’re looking to cut down on consulting expenses, look at whether you really need consultants on site. Those who work projects remotely don’t submit meal or travel expenses and often they are more productive when your staff isn’t interrupting them or trying to pick their brains on unrelated projects. One consultant friend keeps me laughing with stories of his prowess at slaying scope creep since his client’s analysts are hell-bent on involving him in work that has nothing to do with his engagement just because they know he has the skills. He could probably deliver his analytics build faster if he was working from his bachelor pad than sitting in your cube farm among squeaky chairs, gossipy employees, and those who bring colds and flu to the office.

That’s another thing – nice clients have a plan for when consultants get sick or have family emergencies. They are understanding. They don’t make you feel bad when your daughter breaks her arm and you have to accompany her to the operating room (true story from a former grad school roommate.) They may even offer to have a physician evaluate you and make sure you aren’t near death alone in your hotel room after you get food poisoning at a dinner they catered. I’ve written prescriptions (with appropriate examination and documentation, of course) to treat minor illnesses and helped consultants get care after sports injuries. Just because they’re consultants doesn’t mean they’re invincible.

If clients really have a problem with consultant expenses because they object to having to pass them on to patients, I recommend they look at their own policies as well as consulting policies. One hospital where I’m on staff provides a 64-ounce mug to each new employee, who can then fill it with free beverages throughout the work day. Although it was instituted as a staff perk, I can’t help but wonder what the patients think as they see staff slurping their way through the day from mugs that are less than clean. You can bet that’s being passed onto the patient bill, as are the employee health care expenses from obesity and diabetes since I rarely see people filling up with diet pop, that’s for sure. Then there’s the lost productivity for the trips to refill.

While we’re at it to cut costs and save healthcare, let’s cut out frivolous marketing, overkill signage, and anything having to do with “centers of excellence.” I bet we could lower some hospital bills right there. But let’s not take it out on consultants who are working hard on our behalf.

What do you think about consultants and their expenses? Email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

The Wellness Network Acquires Logicare

Patient instructions and teaching systems vendor Logicare announced this morning that it has been acquired by The Wellness Network, which owns an in-hospital TV network that it says is used by 2,000 hospitals.

According to Matthew Davidge, president of The Wellness Network, “Patient education is at the center of healthcare reform. With the acquisition of Logicare we will be able to measure and record both patient comprehension and consumption of patient ed materials for meaningful use and better patient outcomes.”

Logicare’s 25 employees will continue to work from the Eau Claire, WI office.

HIStalk Interviews Paul Brient, CEO, PatientKeeper

Paul Brient is president and CEO of PatientKeeper of Waltham, MA.

Tell me about yourself and the company.

I’ve been in the healthcare IT business for my entire career, which is now about 25 years. PatientKeeper has been around for about 14 years. I joined 11 years ago. Our focus has always been to create technology that would help automate the day and the life of a physician, in a way that the physicians would see as a benefit to their workflow. We’ve been fighting the good fight for the past 14 years.

When you and I talked in 2010, CPOE adoption rates were tiny, especially in community-based hospitals. Is that still the case?

Certainly if you go about it in the traditional way, it’s still the case. There’s not a lot that’s changed in terms of the approach of classic CPOE vendors. There are many hospitals out there that are really struggling to get to 60 percent CPOE adoption. You hear stories of them having to badger and cajole and threaten physicians to make them use CPOE.

The essence and the core of the problem is that legacy CPOE applications reduce physician productivity. They spend more time taking care of the same number of patients than they did before. If you’re in private practice as a physician, that’s pretty devastating. For the healthcare system overall, automating the most expensive asset, or the expensive worker in the healthcare system, and making them less productive is not a win. 

In our view, we need to have a different approach to physician-facing technology. We have approaches that make physicians more productive, more efficient, save them time, and ultimately help them practice better medicine in a way that is consistent with the way they think they should be practicing medicine.

Hospitals were making their captive doctors use CPOE 100 percent while assuming that usage by the community-based docs would be nearly zero. Are hospitals paying more attention to the productivity and the satisfaction of their doctors?

I think they are, but they’re really torn. Many hospitals are torn between going after Meaningful Use and that’s what they’ve been told to do and it’s the right thing to do, and make the physicians happy. In many situations, those are somewhat exclusive.

One CIO showed me a graphic, saying, “As we’ve increased technology available to our physicians, we’ve decreased physician satisfaction pretty much in these relationships.” I think that puts a lot of CIOs between the proverbial rock and hard place. But I think most organizations right now are very focused on Meaningful Use and are having to sacrifice physician satisfaction in the short term. That’s probably not a long-term, sustainable strategy.

Everybody talks about the reduced productivity with CPOE. Do you think it’s mostly due to the poor application design for physician usability or the requirements by government or others that doesn’t benefit patients all that much?

As it pertains to CPOE and even documentation, there’s not a lot of government regulation that makes it difficult to use. It may make it difficult to write the software and get it out there and everything, but not difficult for the physicians to use per se.

I think the historical problem is that CPOE to date, from the classic way of getting it, is through an HIS vendor. Those systems evolved out of the back-end infrastructure. The physician has to learn how to put in orders in the way that the back-end system wants to consume them. That is not the way physicians are trained. Doctors have to go to two, three, four, five days’ of training just to be able to use these systems because they’re having to re-conform the way they think about ordering and the way they do stuff to the way the back-end systems in the hospitals process orders. That’s a way of doing things; it’s not a way to create great productivity.

An alternative way, which is the way we have approached the system, is to start with the way doctors think about ordering and build a computer system that translates it and gets it into the form that allows that order to be processed. If you think about the difference between like a Windows PC and an iPad in terms of user manuals and configurability and all this stuff, you pick up the iPad and it’s intuitive to use it. When we put a CPOE system in front of a physician, they mostly can just use it. Maybe it takes them 5, 10, maybe 15 minutes of training to be fully proficient. 

It’s not usability in the classic computer science sense. It’s about having a system that is designed from the beginning to work the way that doctors work. Then you get to do a whole lot of work in the back end to make it work the way the hospital does, because if they can put the order in but it doesn’t go anywhere, that doesn’t do anyone any good. It’s not an easy task. It’s a very different approach than anyone else has taken to date. I hope that as we move forward in this industry people take a different approach and focus more on the physician workflow and try to get systems that do mirror the way physicians have been trained and the way they practice.

Who would make that change? It’s almost all Cerner and Epic in hospitals at this point, and I assume that in your mind, both have usability problems.

You mentioned Epic. It takes two days to learn how to use. Obviously there’s a ways to go in terms of easy use and usability just from that fact alone. 

In terms of the “who,” this depends a little bit on whether we’re committed to an open, interoperable world. The government or anyone else didn’t make the edict that every single piece of IT used in a hospital should come from one of two vendors and you only get to pick one of them. That’s a pretty closed view of the world. There are other views of the world that would allow people to create best-of-breed solutions, whether it’s for specialty, or for different kinds of people within a hospital, whether it’s a physician or a nurse or phlebotomist, or whatever. And be able to have those systems automate those people in a fabulous manner and have the data flow back into those core systems. 

Frankly, the Cerners and Epics and even the Meditechs of the world, they run your hospital really well. You don’t hear problems of the laboratory folks or the pharmacists complaining about their Epic system or their Meditech system or their Cerner system. They actually do a really good job. They’re much more mature, especially with Epic. Cerner started out as a lab organization, a lab automation company. These systems are very mature and work really well for these folks. The challenge has been the doctor and some of the other caregivers that we don’t address. Certainly nurses have a fair amount of frustration. Some of that really is because the regulations and the requirements that are being placed on them. 

I think the solution to this is to have innovation. If we just have to get all our software from two vendors, that’s not necessarily going to create the most innovative part of the world. If you look at what’s happened elsewhere, like Salesforce.com and their ecosystem they created for our vendors. We run that as our core CRM system, but we run applications from three or four other vendors because it does it better than Salesforce.com. Salesforce.com opens their APIs and helps you buy them and all kinds of stuff. Hopefully we’ll be able to get to a place where the HIT world is like that.

We as PatientKeeper are trying to find ways that we might be able to leverage our technology and our 14 years of R&D to make these systems open for others as well. I’m not quite sure exactly when and how we’re going to do that, but we’re very committed to seeing innovation happen.

The challenge is that hospitals wanted one neck to wring, as they say, and chose single-vendor solutions even if they had to give up some things. What would be the driving force for that innovation if the customers don’t seem to want it and the two remaining dominant vendors that are out there don’t seem to have much incentive to change?

Just what we were talking about with physicians, we’re going through this Meaningful Use march. You see a lot of organizations that are really struggling to get to full physician adoption. Having two workflows, even if you can check the boxes on Meaningful Use and get to your 30 and 60 percent for your lab and pharmacy orders, that’s not a way to run a hospital. You want to get to 90 something plus percent. If you’ve slowed down your physicians and your physicians are complaining, you’re going to be in a big world of hurt. 

Certainly while any new sales of hospitals are going to mainly Cerner and Epic, more than half the hospitals out there don’t run Cerner or Epic right now. I’m not sure that they’re going to all magically convert over in any short period of time. I think we still have a world where there a bunch of hospitals out there really struggling with what to do with stuff that’s even more challenging to use than those two vendors. So yes, it’s going to be very interesting to see of best-of-breed versus one system thing. It waxes and wanes. 

In the rest of the world of technology, the notion of a single, closed, proprietary system that doesn’t allow support an ecosystem or support inoperability is pretty much passé. Technology is so good to be able to exchange data and integrate data. I hope that healthcare will ultimately succeed. It’s hard to put a crystal ball and see exactly how, but I think there’s been a lot of forces and they’re at work here and hopefully they will converge to create both the technological ecosystems but also the market demand for better systems for doctors.

Meaningful Use threw that equation off where it pushed people to buy the same old systems today, and hospitals spent whatever money they’re going to have for a long time. Is that an environment that will allow or encourage change? Do you think the Meaningful Use has degraded the market from where it would have been otherwise?

It’s certainly had an impact on it. It’s hard to say. It’s almost like you want to have a parallel universe, one with Meaningful Use and one without, to see exactly what would have happened.

The good news on Meaningful Use is that it got everyone focused on doing CPOE. The challenging news for some, as you point out, is that when we went out to look, if you’re a hospital looking for what the options are, there are only a few options. It is what it is. 

As people are now getting to the more mature phases of Meaningful Use and starting to look beyond it, that that’s where the opportunities are going to get created. When you’re trying to, “ I have to get to Stage 2. I’m going to check these boxes,” a lot of people went out and did the short putt, or in many cases, just took what they had and said, can we make it work? What we’re seeing is a lot of organizations that did that — and might even be at 50 percent or 60 percent utilization — but they are now saying, look, this is too painful. This is not sustainable. We need to do something different. 

They’re looking for options. PatientKeeper’s one option. There are other options out there. There a lot of creative solutions out there that people are starting to try. I think that as that pain becomes more acute, that will create receptivity to more and more creative options other than taking the HIS system I have now and try to deploy it more and more.

The world has changed a lot since PatientKeeper was formed. I think it originally ran on a Palm, if I remember right. Do you think that the way clinicians are using and expecting to use mobile devices has changed more than even on the consumer side?

Your memory’s good. It’s really interesting if you look at the mobile device world and you take a snapshot in time. Even when the Palm first came out, people said, well, gee, finally. If you recall what happened before the Palm, there were about 50 startup companies that tried to build a pen-based PC and failed. It was like for a while, Palm was it. Then you could take a snapshot in time and say, BlackBerry was absolutely it — that was a solution for all things mobile. 

There’s a point in time, and I think that point in time is actually starting to pass, where the iPhone looked like it was the only solution and the end-all, be-all. That’s starting to change, too. The Android devices are arguably much more innovative and more creative. The Android tablets are pretty darned compelling and half the price of an iPad. Who knows? It’s very hard to forecast what’s going to happen.

I’m certain, though, that mobility will continue to play a very big role in everyone’s lives, including physicians’ lives. I think physicians in general are probably a little behind the curve, in part because many HIS systems don’t have good mobile options. They can’t do core workflows in using mobile devices. But that’s changing. Companies like PatientKeeper and others are coming out with all kinds of cool, great devices to help physicians, and there are a million apps out there for them. Mobility is going to continue to be really, really important for physician. 

Let’s also not forget the PC. You know, PCs are still important, even for those of us who are entirely mobile. I remember when the iPad came out, a lot of my friends were trying to become just the iPad and not use any other device. Most of those experiments have failed and they’ve gone back to using multiple devices. It is about the right device for the right place. We just have a lot more options than we had when it was either the Palm Pilot or a big desktop PC. Now we got everything that ranges from little thing in your pocket to a bigger thing in your pocket to a thing in your coat pocket, different slim levels of laptops all the way up.

It’s great to see all these different form factors and these different approaches. We continue to leverage them, and certainly that is a net win for physicians, because if they can have the form factor that works for them in their practice at the right place, that that makes it that much easier for them to become productive.

There is an irony to physicians demanding the latest mobile device to run 25-year-old software. Are you finding that the KLAS report that showed PatientKeeper well ahead of the core HIS vendors in usability is convincing people that to just run the vendor’s application on a mobile device isn’t really getting very far other than to make it theoretically portable?

Certainly things like the KLAS report that looked at usability of the PatientKeeper approach versus others is very helpful for kind of providing a third-party assertion of it. I’d like to think that when people look at running like a Meditech screen through Citrix on an iPad that they understand the difference between that and actually having a real-life application in terms of usability. I mean, it’s possible, but as you point out, pretty ironic to be running software that was written in an environment when there weren’t even laptops, much less iPads, and running them on your iPad. 

As we focus on usability and focus on physical productivity, you’ve got to get the right applications and the right devices. Character-based screens on your iPad is not the right application on the right device.

The KLAS report was unusual in that it almost touted PatientKeeper directly over the vendors that trailed behind. What has the result been?

We certainly got a tremendous amount of interest and excitement. People have been looking for an alternative to the problem that we’ve been talking about. Doctors are not excited about not getting benefits from CPOE in particular, and they’re being forced to use it. 

One of the reasons that compelled KLAS to look at this was, here’s a new thing. It’s very different. There aren’t a lot of vendors out there right now that have CPOE that sits on top of other HIS systems. The HIS vendors don’t offer their CPOE for other HIS vendors. It’s a pretty unique concept that we’ve spent a lot of time and a lot of money making work. Certainly I think it’s got a lot of folk’s attention, because it’s a solution to a problem that’s here today. We’re really excited to see the usability reports from physicians about CPOE being so high.

You mentioned the creation of an ecosystem of independent apps like in the Salesforce model. Where do you see PatientKeeper fitting into that or how do you exploit that if it happens?

We spent $100 million plus of R&D effort essentially making these HIS systems open, to us at least, with integration technology and a platform. We run our CPOE system on whatever HIS system is out there. There’s a lot of work that I won’t call proprietary, in the sense of it’s specific to a given HIS system. 

We are contemplating ways that we might make that technology available to the industry. Imagine another vendor that wants to build a really great system for a care manager in a hospital. They are faced with the same task that we just spent all this money doing, of having to integrate with all these different systems that are out there. We could make that available to them so they could do a bidirectional integration to the system and be able to spend all their energy on what they’re good at, which is understand the care management workflow at discharge time, and create a great application for them without having to do the work and break their picks on all the rocks that we did as we built that. 

Certainly it’s a concept that we’ve been contemplating. We haven’t done anything in terms of actually releasing it into the world. But to your earliest question about how do you create innovation, we need something like that to happen. Even if all the HIS vendors open theirs up, they’d open theirs up in a different way and you’d have a difficult and challenging problem. There’s real opportunity there, and I think it’s opportunity not just for one company, but for the industry overall.

If those vendors were threatened by your existence and your performance on the KLAS report, could they  shut off the data nozzle so that PatientKeeper couldn’t run?

It depends a little bit on what they would tell their customers about that. Technologically, there’s no reason why we can’t run nicely against their systems. Certainly there are things that people could do to make those things not work well. It’s not an environment that they would be very well-received by their customer base. Ultimately, this comes down to the customers. If the customers demand this enough, vendors will have to supply it. 

I actually believe, totally honestly, that this isn’t about us versus the HIS vendors. It’s about all of us trying to figure out how to automate the healthcare system in the most thoughtful manner possible. We don’t replace an HIS system, and in fact, we can’t run our software without an HIS system in place, because we don’t run hospitals. All we do is help the doctors interact with the hospitals in a more effective manner. 

We don’t even see the HIS vendors as competitors. We see them as very much complementary to what we do. And God bless them, I totally respect all the work they do to run hospitals and they do it very, very, very well. Hopefully they will respond accordingly and say, hey, look, here’s a great opportunity to make a bunch of doctors happy and make them more efficient and it doesn’t cost them a dime of revenue.

Any final thoughts?

It’s just great to get to catch up. It’s been almost three years since we last chatted, so I really appreciate the opportunity. And I really thank you for continuing to help keep the industry informed of all the great news. HIStalk is always the place that I go first thing in the morning as I drink a little tea and get going for the day, so thanks so much.

Morning Headlines 10/24/13

Parents want e-mail consults with doctors, but don’t want to pay for them

A study conducted by researchers at the University of Michigan Health System finds that 77 percent of parents would be likely to seek email advice for their children’s minor illness if that service were available, but 48 percent felt that an online consultations should be free.

Administration enlists former CEO to help fix HealthCare.gov

Jeff Zients, former CEO of the Advisory Board Company, has been tapped to lead the tech surge for Healthcare.gov.

Laptop thefts compromise 729,000 hospital patient files

San Gabriel Valley-based AHMC Healthcare (CA) is notifying 729,000 patients of a data breach following the theft of two unencrypted laptops from an administration building.

California HIE taps iBlueButton

California will implement Humetrix’s iBlueButton app as part of a San Diego-based HIE pilot program. The app will let residents review their medical records from all participating physicians.

Readers Write: ICD-10: The Race is On and the Clock is Ticking

ICD-10: The Race is On and the Clock is Ticking
By Honora Roberts

For providers, the reality of healthcare has changed greatly in the past couple of years. Practicing medicine now revolves around an electronic health record, clinical decision support, and analytics. Reality will soon change again with a new and expanded coding “formulary,” ICD-10.

It’s no secret that this coding change spreads across every facet of operations, from clinical care and administration to finance, IT, and more. The move from the ICD-9 code set that has been in place since 1979 to ICD-10 represents a five-fold increase in the number of codes to learn, know, and apply. ICD-10 consists of 69,000 diagnosis codes (up from 14,000) and 72,000 procedure codes (up from 4,000.) Administrators, physicians, allied health professionals, billing departments, coding professionals, IT departments, and more face a new reality. The time to begin embracing this new reality is now, but where do you begin?

This shift to ICD-10 is a lot like “The Amazing Race” TV show in which teams race across cities and continents to find clues to their next required destination. While providers know the destination, they face tough terrain and unexpected obstacles. Start by knowing your greatest exposures – physician education and documentation improvements; loss of reimbursement; coder education; computer system and payer readiness; and regulatory compliance. Then focus on a couple of critical areas to avoid getting lost in this amazing race toward ICD-10 compliance.

Prioritize the 141,000. Despite the spike in number of codes, reality is that providers often will use a small subset of codes. To compress the initial transformation, begin prioritizing the codes most relevant to your institutions, physicians, and specialists. Once these are prioritized, you can begin mapping ICD-9 codes to the new ICD-10 code set. In essence, you’re starting by building an initial cross-walk or critical path between the two coding standards.

Test and remediate. Make sure the technical upgrades perform and deliver as designed, then test and remediate before they are used in the real world. When testing, set up real people in real workflows. Include physicians and nurses, specialists, coders, and others who provide a broad view of the systems and workflows. This testing will allow you to pinpoint common errors so that the technology can be customized to catch errors that can harm patients.

Improve documentation. Physicians and clinicians don’t care about ICD-10. They do care about improving the quality of care and doing no harm. Emphasize documentation improvement and provide the education, tools and process improvements to achieve improved documentation that, by the way, also complies with ICD-10.

Pursue proficiency. Your people will make the difference in success. Making sure they succeed requires training. Be sure to target training programs to your personnel’s specific roles and usage of ICD-10 codes. Role-based learning will improve speed to proficiency, improved adoption rates, and overall sustainability of your organization. Once staff members gain confidence on routine tasks, they will quickly gain efficiency that is sustainable over time. Job aids and reusability of learning are tools that reinforce learning and confidence. Start with your coders, if you haven’t already. Track results — comprehensive adoption requires continuous oversight and measurement.

Optimize beyond the transition. Once you’ve met the deadline, perform a post-deadline assessment and chart review to begin a genuine clinical documentation improvement program. The baseline you established at the start of the process will help you identify problem areas and remediate.

Manage the risk. Knowing your current situation and associated risks is a great place to start. By knowing the risk, you can establish plans to lessen their impact such as:

• Adjust budgets and develop strategies for potential reimbursement reductions
• Plan for lower productivity during the transition, which might take up to a year beyond October 1, 2014
• Developing contingency plans for high-risk areas, such as high-volume departments or adoption concerns.
• Instituting a well-defined and well-communicated governance and escalation process for issues that arise

Lead the change. Acknowledge that this change isn’t a technology or systems integration project alone. It is a significant organizational change. It involves people, processes, workflows, and technologies that extend beyond walls and buildings. A change this large needs to be managed from the very top of the organization and employees need to hear frequent updates to let them know how the organization as a whole is doing.

Ultimately, most providers in the United States are scurrying to execute a plan to make the transition to ICD-10. You still have time, but the clock is ticking. Don’t get lost in the details; focus on the critical few areas that will make or break the transition for your organization. Through support from your internal team—and the expertise from quality vendors, consultants and other experts—compliance is achievable.

Honora Roberts is vice president of health provider services at Xerox.

Readers Write: ONC Mission Reflections

ONC Mission Reflections
By Helen Figge, CPHIMS, FHIMSS

The leadership at ONC will be shifting a bit as Farzad Mostashari and David Muntz return to the private sector, having given the industry another steep dose of healthcare leadership excellence. It has been appreciated for some time now that the Office of the National Coordinator for Health Information Technology (ONC) was meant to be a compass to support the adoption of various pieces of health information technology, to promote a unified health information exchange platform, and to improve health care for us all. But any compass needs great leaders to man the ship. Not only leaders with skills to lead, but character traits steeped in ethical and wisdom offering guidance. Farzad and David were those captains that moved us forward with the national healthcare IT efforts through their decency, ability to lead by example, and just a genuine sense of being a very nice person that anyone would want to follow or work side by side with.

Remembering the inception of ONC, where many of us hold this office with high regard and respect, hoping that policies created for our healthcare delivery will minimize medical errors while simultaneously aspiring healthcare stakeholders to share patient information all to improve patient care. Payer and the government had aspirations these ONC programs would save money by improving efficiency.

We can conclude however that not all healthcare providers have fully embraced these technologies, but many of the healthcare providers have indeed done so and successfully thanks to the leadership of the past ONC leaders but now recently these two respected individuals in healthcare IT today.

So as we see these two individuals depart ONC, their legacies have indeed culminated into an ongoing improvement in the delivery of healthcare and leaving their posts having helped and move forward the agenda for us all in healthcare reform.

Farzad, while intelligent was also extremely charismatic helping to catapult the acronym “EHRs” into our daily healthcare conversations. He talked about EHRs like the latest and greatest gadget we all needed to try. David will leave behind a legacy of true collaboration and mentoring others in the healthcare IT landscape where often times it was a language in and of itself. David made healthcare IT logical and worthy of conversation even to those not so tech savvy. David’s ability of being extremely diligent and insightful while creating the conversation around healthcare technology was welcomed by all the non-CIOs as well as his peers in the industry. That is a true leader.

Often times we hear the phrase “it takes a village” to accomplish something. And yes that is quite true, but a true leader of that village, listens, digests, analyzes, and then reacts to a situation. A true leader does not lead by intimidation or dictatorship, but though consensus and character traits of leaving a place better than how it was found. Farzad and David each had their own attributes, but together created a uniform approach to an otherwise confusing state of healthcare affairs. These two individuals leave legacies of offering leadership through example and while their physical presence will be missed, their polices and professional attributes that have created the current ONC landscape will move forward, with another group of leaders who we all hope have the same level of integrity and respect these two have had from the industry at large.

Remember, someone wise once said, “Tthe world is filled with 99 percent followers and 1 percent true leaders”. Farzad and David fit into the 1 percent group quite comfortably.

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

Morning Headlines 10/23/13

Paragon Customers Optimistic Despite Functionality Gaps

A new KLAS report finds that McKesson Paragon customers are optimistic about Paragon’s ability to compete in the large hospital market, despite current functionality gaps.

Healthgrades 2014 Hospital Quality Report Reveals Risk of Death and Complications Vary Widely Among Our Nation’s Hospitals

A new Healthgrades report finds that individuals are far more likely to die or suffer complications at hospitals receiving the lowest Healthgrades rating. For example, Healthgrades evaluated 33 hospitals in Atlanta and found that stroke mortality rates were 17 times higher in hospitals receiving one star versus hospitals receiving five stars.

Nearly 10,000 Physicians and Their Practices Are Transforming HIT Systems and Physician Leadership Skills with the Support of Grants Funded by The Physicians Foundation

The Physician Foundation, a non-profit working to help practice physicians, announces that it has issued $3 million in grants aimed at helping practices through the EHR selection and implementation process.

VMware Shares Rise After Third-Quarter Profit Tops Estimates

VMWare reports its Q3 results: EPS of $0.84, beating analysts $0.82 estimate and driving share prices up to 9.8 percent at closing.

News 10/23/13

Top News

The HIT Policy Committee may miss its end of year target date to deliver MU Stage 3 recommendations and begin work on Stage 4, according to the committee’s vice chair Paul Tang, MD. Eleven ONC committees and workgroups, including the Policy Committee, canceled meetings during the shutdown; Tang says his committee is shifting its schedule of deliverables out a month.

Reader Comments

From Friend of Bob: “Re: BOB EDIS. Physicians’ voices were heard again at ACEP. A record breaking number of ED physicians attended ACEP13, over 7,000 reported. Wellsoft noted that at this year’s Scientific Assembly most attendees had a deep knowledge of BOB EDIS functionality and integration capabilities. This echoes the KLAS Specialty Report EDIS 2013: Revealing the Physicians Voice issued earlier this year.”

Acquisitions, Funding, Business, and Stock

DMH International, parent company of Touch Medical Solutions, signs a definitive letter of intent to acquire 100 percent of Virtual Physician’s Network, a provider of an online scheduling platform for surgeons.

VMware reports Q3 numbers: revenue up 14 percent, adjusted EPS $0.84 vs. $0.70, beating analyst estimates of $0.82 and in line with revenue expectations.

CTG reports Q3 numbers: revenue down five percent, EPS $0.23 vs. $0.23. The company says its healthcare business declined from last year because “a number of hospital clients are holding off on system investments” due to sequestration-related reimbursement concerns.

Lexmark reports Q3 numbers: revenue down three percent, EPS $0.95 vs. $0.94. Revenue for Lexmark’s Perceptive Software segment grew 38 percent.

Sales

Rochester General Health System (NY) will replace its existing enterprise content management system with Perceptive Software’s Content and Perceptive Capture solutions across its hospitals, ambulatory care centers, and physician offices.

St. Joseph Hospital (CA) will implement secure texting and on-call scheduling solutions from Amcom Software.

FirstHealth of the Carolinas (NC) selects MModal’s front- and back-end speech recognition, transcription, coding, and clinical analytics for its EHR systems.

Boston Children’s Hospital (MA) selects Strata Decision Technology’s StrataJazz for decision support and cost accounting.

Johns Hopkins Medicine (MD) will integrate Vital Images’ Universal Viewer into Epic.

People

Availity names Stephanie Kovalick (GE Healthcare) VP of portfolio operations.

Navicure appoints Sheridan B. Johnson chief compliance and security officer.

Population health analytics provider Rise Health names Michael Previti (Merge Healthcare) EVP of sales.

Announcements and Implementations

Meditech and Vitera Healthcare Solutions connect to the Surescripts network to provide their users with Direct secure messaging capabilities integrated with their EHRs.

Confluence Health-Central Washington Hospital & Clinics implements Merge Hemo from Merge Healthcare to automate their cath lab processes.

Summit Health (PA) deploys Nuance’s Clintegrity 360 Computer Assisted Coding and Clinical Document Improvement solutions for ICD-10 readiness.

Center Point Counseling (WI) installs ForwardHealth Group’s PopulationManager technology.

Other

Most providers express optimism about McKesson Paragon’s ability to deliver in large hospital settings despite current functionality gaps, according to a KLAS report. In 2012, Paragon secured 11 of the 32 larger hospitals migrating from Horizon; 131 large Horizon hospitals have not yet selected a replacement platform.

Individuals are far more likely to die or suffer complications at hospitals receiving the lowest Healthgrades rating according to the report, Healthgrades American Hospital Quality Outcomes 2014: Report to the Nation.

The Physicians Foundation issues over $3 million in grants to medical society foundations and healthcare organizations to assist almost 10,000 physicians select and implement EHRs.

An Arizona woman says she is the victim of identity theft four months after a University of Arizona Medical Center-South employee posted a workplace photo on Facebook that inadvertently included a computer screen with the woman’s personal information. The photo was removed after 30 minutes when a manager noticed the violation. The hospital’s privacy officer was notified of the incident, as was the patient. The woman recently notified the police after someone used her personal information to apply for food stamps. She also retained a lawyer, saying the incident has “been a nightmare,” that she is afraid to be home, and her life is at stake. Not to diminish the seriousness of the violation, but I can probably think of one or two things more nightmarish and life threatening than a breach of my PHI.

Sponsor Updates

• RazorInsights’ ONE Ambulatory EHR achieves ONC certification and secures 2011 compliance as a Complete EHR.
• EDCO Health Information Solutions will present a session on point of care medical records scanning at next week’s AHIMA Product World meeting in Atlanta.
• T-System names six winners of its fourth annual T-System Client Excellence Awards, which recognize emergency care facilities and physician groups that effectively use T-System solutions to improve clinical, financial, and operational outcomes.
• Emdeon will add full-color printing capabilities for printed communications to its Payment Network during the first quarter of 2014.
• Clinicians at Georgetown Hospital System share how their use of Aventura has saved them time and increased productivity and job satisfaction.
• A local paper profiles Jones & Sciortino Orthopedics (MO) and its use of eClinicalWorks to achieve Meaningful Use.
• Clinicians with Mercy and HealthEast Care System (MN) share how the use of Humedica’s clinical analytics platform from Optum have provided their organizations with health insights to improve treatment outcomes, care coordination, and quality.
• Information analysis firm IHS ranks Perceptive Software’s Acuo VNA the world’s market share leader among independent software vendors with 42.3 percent of total studies managed.
• Chilmark Research recognizes Medicity as a top-tier HIE vendor in its 2013 evaluation of the HIE market.
• HIStalk sponsors earning a spot on Capterra’s Top EHR Software list include: eClinicalWorks, McKesson, Allscripts, e-MDs, NextGen, NueMD, Vitera, and ADP AdvancedMD.
• Beacon Partners hosts a webinar on the steps healthcare organizations should take to form a patient-centered medical home.
• Quantros demonstrates the QPrecision release of its safety event management solution at next week’s ASHRM Annual Conference in Austin, TX.
• VitalWare embeds Atigeo’s xPatterns Clinical Auto-Coding into its CDiDocuMint application.
• CommVault introduces a content-based retention solution that enables enterprises to reduce storage requirements by keeping only data that is important to the business.
• MModal releases the Fluency Flex Mobile app for iPhones, allowing doctors to record clinical notes during patient encounters for integration within EHRs.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 10/22/13

Obama: Health care website problems inexcusable

President Obama weighs in on the failed Healthcare.gov launch, calling it inexcusable and reporting that the nation’s best and brightest from both the public and private sectors have been reaching out and asking how they could get involved to help fix the problems. The same "best and brightest" promise was made in a Sunday blog posted by HHS. No details were provided by either on who these new staffers are, what the additional cost will be, or when the site is expected to be fully operational. Both the president and HHS took the opportunity to publish the most recent Healthcare.gov numbers: 19 million visitors and 500,000 insurance applications filed since its October 1 launch.

How ONC is getting back on track after gov’t shutdown

As ONC’s full staff returns to work, various workgroups are adjusting the due dates of expected deliverables to account for lost time. Paul Tang, MD, vice-chair of the HIT Policy Committee, says that his group would be shifting its schedule of deliverables out by a month, which includes finalizing MU Stage 3 recommendations.

Miami Children’s Hospital Enters Technology Venture With MediTouch EHR

Miami Children’s Hospital forms a strategic partnership with HealthFusion Inc., developers of the MediTouch ambulatory EHR, in which MCH will market a white-labeled, cloud-based, pediatric EHR that comes integrated with MCH’s existing EHR database. The EHR will be available for Southern Florida based pediatric practices.

Curbside Consult with Dr. Jayne 10/21/13

I mentioned a few weeks ago that I had been preparing to sit for the new Clinical Informatics subspecialty board certification exam. Now that the testing period is over, I can talk about my experience. The American Board of Preventive Medicine expressly forbids candidates from discussing the exam content or questions so I’m not going to get myself into trouble, although there have certainly been some pretty significant discussions about it via the virtual water cooler.

The core content outline for the clinical informatics exam includes fundamentals, clinical decision making, health information systems, and leadership/change management. I don’t think there’s anything in the outline that is unreasonable. A major problem in trying to test that fund of knowledge, however, is that clinical informatics is an evolving specialty. Very few of us who have been in the field for any length of time intentionally set out to become informaticists. Of course there are some younger colleagues who decided to pursue it during medical school and attended a masters programs or fellowship, but I don’t believe they make up the majority of the seasoned workforce. The fact of how our discipline has developed (and subsequently exploded during the era of Meaningful Use) means that our field is extremely heterogeneous. That makes any kind of standardized evaluation a daunting experience.

Just look at physician titles as an example: CMIO, medical informatics director, clinical informaticist, medical director of informatics, medical informatics specialist, medical director of EHR, and my favorite: process improvement consultant. All of those titles are held by close friends of mine who are essentially doing the same job. Others have the CMIO title, but do vastly different jobs. Some are almost exclusively administrative, where others are heads-down writing their own code. Most of us are somewhere in the middle. We may practice medicine or not (although to sit for the new exam you do have to be currently certified in another clinical specialty.)

Preparing for the test was a good exercise. learned some things I didn’t know and encountered a lot of minutiae that, although “fundamental,” has very little bearing on my daily work. The thing that struck me most about the actual exam was that depending on your work experience, the difficulty of the questions varied. Like most exams, there were many “which is the best” and “which is the most appropriate” type questions with multiple correct-appearing answers. If you were straight out of a fellowship with little real-world experience, these might be easier. For those of us who have encountered hundreds of different variations on the questions (depending on whether the setting is inpatient vs. outpatient, whether the physicians in question are independent or employed, whether we’re wearing our physician hat or CMIO hat, what kind of system we’re talking about, etc.) the subjective nature of the questions made them difficult. Some of the questions I’ve actually encountered in real life and the answers to them may have been different at different times in the same project lifecycle.

Whether or not I passed (and truly I have no idea because it’s a new test and hasn’t been normed yet) isn’t going to impact my skill as a CMIO or make me less knowledgeable about handling tough decisions in the real world. Preparing for the exam though was stressful and actually taking it was an exercise in lack of user friendliness when you consider the whole electronic test-taking process used a third-party vendor. I was herded into the exam room along with firefighters, real estate agents, aspiring graduate students, and a couple of people who almost got ejected because they wouldn’t cooperate. We had to turn our pockets inside out, lift our shirts to expose our waistlines, raise our sleeves above the elbow, take a palm scan, and pay hundreds of dollars for the privilege. It certainly wasn’t that bad at another facility where I took my primary board exam a few years ago, but I guess things change. They didn’t make me take my glasses off to ensure I wasn’t hiding a chip or camera in them though, but I bet they do next time given the emergence of Google Glass.

Once most people finish taking this kind of test (after several months of preparation and at least some measure of worry) there’s this letdown period where you don’t know what to do with yourself. I did my best to keep busy and not second guess myself, but there comes a point where you just start thinking about the questions and how if you were in charge of the test, you’d do it differently. I couldn’t help but think of all the questions that weren’t on the test. Let’s pose some sample test scenarios and see what HIStalk readers think. It may not be evidence-based, but it is certainly ripped from the pages of real-world experience.

Item 1: As a clinical informaticist, you must often put yourself in the place of your stakeholders and end users as you make complex decisions. Read the following scenario, then select the best response to the associated questions. You are the finance director of a large employed medical group. The IT Director has decided to go to Las Vegas for the bachelor party of one of the IT analysts. He “signs out” authority over the ambulatory EHR project to you while he is gone, because after all, you’re both directors. He does this via email after 5 p.m. on Friday night then turns his phone off.

What is the most appropriate step for your first course of action?

a) Call Human Resources because it’s completely inappropriate for a supervisor to go to a Las Vegas bachelor party with his subordinates.

b) Call the IT director’s supervising VP because you’re not even in the same vertical and it’s not appropriate for you to take responsibility for his IT portfolio.

c) Call the CMIO and the EHR application manager and make sure they have your back.

d) Proceed to the local supermarket, purchasing more vodka than cranberry juice.

The weekend passes smoothly and without incident. However at 4 a.m. Sunday, your cell phone rings. The CMIO’s name is on Caller ID. Which of the following best describes the scenario?

a) This is a bad thing.

b) The clammy sweat you just broke tells you this is a very, very bad thing.

c) Anytime the CMIO calls you in the middle of the night it is extremely ominous.

d) You are glad you went to bed early Saturday night, because you have the feeling it might be days before you sleep again.

The CMIO explains that some cowboy analysts decided to perform an unauthorized “data migration” on your ambulatory database last night. No one was aware of the proposed maneuver as it was absent from the weekly change control discussion. Additionally, contractors were involved and it may not have been tested fully before deployment. It appears there may be some patient charts which have been corrupted, so they called the CMIO for advice. What is the most appropriate next step?

a) Curse the IT director’s name then try to track him down in Las Vegas.

b) Try to stop shaking, and then eat an entire box of chalk to address the heartburn you know is coming.

c) Be glad the CMIO has extensive experience resuscitating patients and staying calm because her demeanor makes you feel like it’s going to be OK.

d) Start making coffee; you’re going to need it.

Item 2: Review the above scenario. You are now in the role of the CMIO. It is 4 a.m. and you have just called your colleague. You calm her down and explain that you’re not that worried about the corrupt data because the organization has a well-vetted backup strategy and the team should be able to restore the database from the nightly backup, then apply the transaction logs up until the point they forced users off the system and started the migration. The finance director approves your plan and you phone the DBA on call. What is the most appropriate information to provide first?

a) Loudly ask, “What were you thinking?” and why he allowed unauthorized access to the production system.

b) Tell him to wake up his boss “because there’s gonna be hell to pay.”

c) Remind the DBA of your no-fault policy for reporting errors. A root cause analysis will be performed later and systems will be evaluated to prevent this from happening in the future.

d) Recommend a good travel agent for a one way trip somewhere far, far away.

The DBA makes some vaguely disturbing comments, so you get all involved parties on a conference line. Using your best patient interview skills (gleaned from years of trying to get the truth from drug-seeking patients) you begin to piece together what actually happened before they called you. Of the following system failures that have occurred, which is the most significant?

a) The team started the untested migration during the nightly backup process.

b) Users were on the system documenting clinical encounters during the migration.

c) The DBA already tried to restore from the admittedly non-reliable backup and it’s been running for two hours, but he neglected to mention it or the fact that he’s not sure the transaction log shipping was running properly prior to the incident.

d) A Level I analyst decided to wait four and a half hours before calling the CMIO for help and only called her because he “didn’t know who else to call.”

You ask for a list of users who were on the system when the incident started in an attempt to determine what kind of documentation they might have been doing and how severe a data loss might be. Should there be an unrecoverable data loss, which user will provide the most severe tongue-lashing?

a) Chief medical officer.

b) Chief of surgery.

c) Self-described “EHR Hater” who will use this as an attempt to mothball the ambulatory EHR project.

d) Your partner, who doesn’t want to be named as actually using the system since he brags to everyone in the physician’s lounge how he refuses to use it.

You invoke downtime procedures and notify the lone urgent care site that will be opening in less than three hours that they should document on paper and use the read-only downtime server for critical patient information needs. You notify all users that the system is down and immediately disable remote login capability so that no one can access the system while you figure out the recovery strategy. What portion of your user base will claim they never received notification?

a) None, as your communication plan is thorough and multi-media with multiple layers of backup.

b) Less than 10 percent, because most users are diligent about checking emails.

c) 20 percent, but they will find the email notifications three months from now when they get caught up on email. They will not apologize for yelling at you, however.

d) 90 percent, because they will jump on the bandwagon and complain about anything EHR-related.

Item 3: Given all the facts above, calculate the odds that the system will be back up with full data integrity before patient care starts Monday morning. Show your work. Estimate the total length of downtime. Conclude by estimating the total cost (in resources, recovery, and lost productivity) of this change control misadventure.

Bonus question: Estimate the number of employees who will be reprimanded for the actions leading up and/or during to the incident.

If you answered “C” to the multiple choice questions, then you just might be a CMIO (or someone who does the job without the title). As for Item 3, the system was indeed back up and ready for business by Monday morning. The total cost of the event was TNTC – as they say under the microscope, “Too numerous to count.” Before it was all over, we had to involve multiple representatives from various vendors, including the regional HIE and other downstream entities that received corrupt information and also had to perform various rollback activities.

I’m not going to give the answer to the bonus question just yet. If you want to make a guess, use the comment feature below. I’ll provide the actual answer later this week. For those of you who sat for the exam, I hope this gave you a laugh because we need one while we wait for the results.

What did you think about the exam? Email me.

E-mail Dr. Jayne.

HIStalk Interviews Tom Gonser, Founder, DocuSign

Tom Gonser is founder and chief strategy officer of DocuSign of San Francisco, CA.

Give me an overview of the trajectory that electronic signatures have gone through.

I started DocuSign about 10 years ago to try to do electronic signatures the right way. Before we started DocuSign, the way that happened is you literally had to have a piece of software on your computer and understand complex things like digital certificates in order to actually do it. It wasn’t working very well for anybody. 

We decided that rather than having people encrypt files and then email them around the Internet, a better way to do it was to turn it inside out and store the files securely in the cloud and then have people authenticate in order to access the documents. What that allowed us to do was not require anybody to have any special software. We could hide the complexity of all the encryption and audit trail and all that in a server. You could sign just using a browser from any device. That is what allowed the market to take off. 

I would say for the first couple of years as we were rolling out this new way of working, we spent most of the time just working with the user interface and making sure it was familiar and easy for people to do. People got both the ability to do it in a way that was easy enough so you don’t have to learn anything new, but also the security and legality so that it would stand up in court if it was ever challenged. And I’d say the last three years, we’ve really started to see it take off pretty dramatically.

You mentioned the legality of signed documents. Was that a challenge that had to be made so that it wasn’t a question?

It’s interesting. In the US, there was an act that was passed, a federal act actually, the US E-Sign act. It basically said if you process an electronic signature using steps — then they described specific things that need to be true — then that signature will have the same legal effect as an ink signature. We had the pattern, we just needed to make it easy. That was really the trick.

Once we did that, in the early days there were still a lot of questions about, “How do you know this is legal?” We had to become experts in the E-Sign act and communicate that to folks that weren’t aware of the fact it has legal since 2000 to do it this way.

Now that said, not every country in the world is governed by the US E-Sign act, obviously. There’s really three main sets of laws that are out there on the planet that deal with what a legally binding electronic signature is. Luckily, most countries have something that is defining in electronic signature. There’s the US, which is similarly adopted in other common law countries. There’s an EU directive, which governs what an electronic signature is in the EU. And then there’s a UN-based electronic signature guideline which is used through the rest of the world. Our job and our role is to make sure that the DocuSign platform can conform to all three of those different types of electronic signature sort of jurisdictions, as it were.

Ink signatures are refutable. You could just say, "I didn’t sign this" and there’s no foolproof way to say you did or you didn’t. Is the electronic version more promising for legality?

Exactly. It’s actually kind of funny. Once you start using DocuSign, people will come back after a month or a year and say, “I can’t believe we were just accepting handwritten scribbles on paper from people we’ve never seen their signatures before. And the documents could obviously be changed. We had no idea.” 

In the DocuSign platform, the signature is tied to the identity of the person using any number of tools that we provide. The whole document is itself encrypted and stored, so that if any changes were made after it had been signed, you could detect it. The whole process is just much more efficient, but also much more believable when you’re done.

We’ve done two mock trials to see what it would be like to go to court, despite the fact we’ve done half a billion documents. We’ve only had eight chances to have customers say that they want to refute it. In all those cases, there’s just too much information about what actually occurred. But the depth of information about all the aspects of what happened during the signing process is all stored with that signature. It doesn’t happen in the paper world. The paper world, you literally have a scribble. A lot of times it’s faxed in. You’re just taking it on faith that it’s actually correct.

I saw the YouTube video in which you were speaking about going to a new doctor and being handed a stack of papers that needed to be signed in a bunch of places to then be keyed in someplace else. When you look at the healthcare market, what opportunities do you see there?

The healthcare market is probably the largest market for DocuSign. The DocuSign platform manages the data and form data and routes contracts around securely to different parties. You can imagine in the healthcare example … we’ve been working with a couple of companies in that space, something called DocuSign for Patient Engagement, which allows literally patient onboarding, with a partner of ours called Kryptiq. 

If your doctor’s office subscribes to this, patients can fill in all the paperwork they need to before they show up. Even make the payment through the DocuSign system before they show up. All the information doesn’t need to be re-keyed. You can verify that it’s accurate. If the patient waits until they get into the office, they can just grab an iPad and fill out the same information. 

You’re dramatically reducing the cost. There’s a statistic we saw the other day that one third of the cost of healthcare in this country is derived by the operational aspect, you know, paper and paper management, all that overhead. You’re looking at billions if not tens of billions of dollars of waste that can be corrected by using electronic signature management like DocuSign.

Is the company an electronic signature company or a workflow company?

Forrester started looking into something they call Smart Process Applications. They define Smart Process Applications as those applications that involve human beings interacting with data and documents and potentially interacting in and outside the firewall. What turns out is that most of the things that are behind the firewall back office, ERP and stuff that you never really see, is highly automated and digitally connected. The challenge is that when you start dealing with those transactions where human beings are involved, either filling out a form or responsible for signing it or sharing with somebody else or it’s going outside the firewall, as you would see if you’re a patient involved with a clinic or something. Those processes typically have not been automated, which is where the paper load comes from. 

What Smart Process Applications are is literally building an application to automate a process that involves people and documents and data that typically span more outside of an organization. DocuSign is a platform upon which companies are building Smart Process Applications. A perfect example of this would be Kryptiq, our partner that’s developed a patient onboarding system that is built on the DocuSign system, in order to make that entire process of getting a patient from pre-registration through to the doctor handled in an electronic form instead of a paper form.

There are obviously lots and lots and examples of these Smart Process Applications in healthcare, but also in real estate, in financial services, all the places where human beings are interacting in a transaction. Forrester looks at that market and says it’s a $34 billion market, so a big, huge opportunity.

Do you consider yourself to have any significant competitors?

If you look at that market, a lot of the competitors are the big iron providers where someone’s going to come in and hand code a process using the traditional IT processes. Those are big, expensive projects, not cloud-based. 

The challenge is, once you build a process like that … let’s say you create this workflow for onboarding a patient or creating a patient payment process or something like that. Then a rule changes – some government agency says you need to fill this form out before you fill that form out, or it needs to be reviewed by the financial team before this. Some change happens because it always does. With those traditional IT engagements, start the clock, you’re out of compliance. It’s going to take you six months or eight months before your IT team can get in and re-code and rewire that thing.

The DocuSign platform, on the other hand, separates the workflow and data and documents. We allow our customers to create what we call templates, which govern the entire process of a transaction, including documents. An administrator could go in and re-sequence the way a transaction happens, or change out a document, or add another one. All of the Smart Process Applications that rely on that particular template are immediately changed. There is no coding re-work to be done. It’s a very, very flexible implementation. It saves a lot of time, not only in getting it going in the first place, but in the whole lifecycle of an implementation. All the changes and tweaks that you know are going to have to be made are much, much easier. 

It’s a new way to do it. It’s all because we’re a cloud-based approach as opposed to the typical, heavy IT software approach.

It was a coincidence that a couple of weeks ago, I got a document that asked me to sign using DocuSign for the first time. It made me wonder then – does interest in the product spread virally as people get something to sign that doesn’t require emailing, printing, signing, scanning, and emailing again?

Absolutely. It’s amazing how viral it is. Typically when someone goes through that process, at the end they’re thinking, I didn’t even know you could do that. That was really cool. I could see a way I could use this in my business, or I’d like to sign all my documents that way. They could go to the Apple store, the Android store, the Windows store and get our mobile application that allows just consumers to DocuSign any document anybody might be able to email them. The ability for even consumers to use DocuSign for anything they want really starts to push the viral spread.

We’ve had a lot of business in real estate, for example. A lot of times, you’ll hear a story from somebody who’s buying a house or leasing a house or renting something. That does create business for us, because typically people who are doing that are employed somewhere and they can take DocuSign to their work.

What’s really exciting to us about the healthcare space is somebody buys a house once every nine years, but I think the number of times you visit a healthcare facility is like three times a year, maybe four times a year. The viral exposure that can be seen in DocuSign in the healthcare space is an order of magnitude stronger than it is in, say, real estate. It’s exciting to us because when you’re a consumer and you buy your house with DocuSign and then you go to the doctor and they use the same exact service, you can use your same signature. If you have an account, you can store all the same documents in the same place. It starts to get a lot of synergy just for that individual consumer.

Is further product development necessary that’s healthcare specific, or is it everything in place and you just need the uptake now?

There are two answers to that. One is that anybody could take the DocuSign platform and create these Smart Process Applications as they sit today to solve pretty much any sort of workflow problem in that market.

With that said, we want to help accelerate that. We’re strongly engaging in lots of partnerships in the industry to connect our DocuSign platform to the platforms that are already in place. We’ve only been really focused on the healthcare segment as a vertical that we really hire people into with domain expertise for about a year, maybe a little more than that. But so far we’ve got some good partnerships going with GE Centricity, NextGen, Allscripts, I mentioned Kryptiq, Greenway, Vitera.

There’s a number of partners, and we believe in this particular market, working with partners that have established of infrastructure in place that we can connect the DocuSign system to is really the best way to really get it to crank up and go. We also partnered with one of the bigger, actually I think it’s the only sort of identity provider for the smart pharmaceutical industry, SAFE-BioPharma. That’s sort of for clinical trials. If you wanted to put on a clinical trial, a lot of them would require that you use this credential from SAFE, and so you can now do that with the DocuSign platform that’s integrated in. It’s such a big market  and there’s so many different aspects to it that we think partnering with the key platforms is really important.

Any concluding thoughts?

The next time you go into the doctor’s office or the dentist or whoever it is and you find yourself filling those forms out over and over, you should stop off at the front desk and tell them there’s a better way.

Morning Headlines 10/21/13

The sad state of EMRs: How they are doing more harm than good

Val Jones, MD, a blogger and advocate for digital health, writes that EHRs have come to the point that they are doing more harm than good. She cites the “enormous time suck” that charting into an EHR has caused for physicians.

CMS planned for paper processing before Obamacare launch

Just days before the launch of Healthcare.gov, CMS extended its contract with UK-based Serco, who had been managing its paper insurance application process, leading many to speculate that CMS knew the insurance exchange enrollment site was going to fail.

Medical Identity Theft: Recommendations for the Age of Electronic Medical Records

The California Attorney General’s office publishes a report on medical identity theft and recommendations for health systems in the age of EHRs, adding that nearly half of medical identity theft cases are actually incidents in which someone loans their insurance card to an uninsured friend or relative to obtain treatment under their insurance.

AMC and VUmc conclude contract with Epic for new joint EPD

Two Amsterdam hospitals, American Medical Center and VUmc, sign up to implement Epic.

Monday Morning Update 10/21/13

From Across the Pond: “Re: Epic. Two large academic hospitals in Amsterdam, AMC and VUmc in The Netherlands, signed a contract with Epic last week.” Academic Medical Center has 7,000 employees, 2,300 medical students, 120 medical informatics students, and an annual volume of 26,000 admissions and 350,000 outpatient visits . VUmc, which cooperates closely with AMC, is affiliated with the other big university in Amsterdam. Wikipedia says The Netherlands has eight university medical centers and 10 large non-university hospitals.

From Jane Jetson: “Re: Weight Watchers. I received an email this morning owning to the fact that they had technical problems. Perhaps I should forward to Kathleen Sebelius so that Healthcare.gov could borrow the wording.” The problem with the government is that nobody is ever individually responsible for anything; the incompetence is collective. It would be unheard of to acknowledge that something isn’t working except for political gain, or to accept responsibility for anything but success. All of the professional bureaucrats are busy trying to hang onto jobs that must be pretty sweet given their ducking and covering to keep them.

From Kittanning: “Re: startups. Why don’t you cover more startups? That’s where the innovation will come from.” I cover startups that have interesting consumer-facing technology, but rarely those who are targeting hospitals. Reason: most of them think their great technology idea will offset the founders’ lack of knowledge (and lack of interest) about how hospitals and doctors work and who just want to cash in quickly rather than helping patients or providers. Newbies can’t come in guns blazing telling everyone in healthcare that they’ve figured it all out as a 30-year-old programmer turned self-proclaimed CEO, insulting those who have more years in healthcare than they’ve had breathing, and nobody in a position of enterprise IT responsibility is going to be impressed by swaggering overconfidence from unpolished newcomers who think they’re the next Steve Jobs just because they are as abrasive as he was. I’ve seen very few great startup ideas that have the potential to turn into anything more than a spare bedroom business, and of those, only a tiny percentage are being run by people on whom you’d make even a small bet as a customer or investor. Creating enterprise technology innovation, unlike writing cute iPhone apps, requires a lot more than a Foosball table and cases of Red Bull. I’ve seen company pitches, most of them naive and unskillfully prepared, and the commonalities are: (a) lack of money and of a realistic plan for profitability that will allow ever bringing their product to scale; (b) a low barrier to entry that virtually guarantees that any degree of success can quickly be replicated by competitors; (c) lack of realization that it takes a lot of skill, money, and time to connect your great idea to hospitals even willing to undertake a pilot, much less buy the product, and the lack of appreciation of just how long the hospital sales cycle is and how imitative their purchases are; (d) having no one on the team who has ever sold technology to hospitals or partnered with similar firms; and (e) lack of understanding that people bet on the jockey, not on the horse, and impressive developers usually don’t make impressive CEOs regardless of their level of hubris. Great ideas are  a dime a dozen; the hard work is the long, expensive slog trying to get traction with them, and if you are new to healthcare selling a product whose target customer is hospitals, it’s a near-certainty that you’re going to justifiably fail, with your only hope that a better company will buy yours before it splats to the ground. That’s not anti-innovation at work – it’s the reality that healthcare attracts a lot of flaky, poorly thought out startups that don’t deserve to succeed. Come back when you hit $1 million in annual revenue.

From The PACS Designer: “Re: Omate watch. Another watch, funded through Kickstarter, is now available for purchase starting at $249. The Omate TrueSmart Watch can be used as a phone with its Bluetooth capability while still being fully functional without the phone. This no-hands phone style of watch will surely be used in healthcare settings.”

From Expense Reports Gone Wild: “Re: consultants. I continue to get bothered by the number of submissions on the bills of consultants for coffee, snacks, lunch, dinner, beverages, protein bars, etc. Why is it that we as a customer are expected pay for all this sustenance? Is the $200+ hour not enough? I am fine with paying for folks to get from home to the location, but why has there been this tradition of paying for other than travel? I think it is time to begin to object to these costs. If we are going to be part of saving health care we can’t continue to exacerbate the issue with rampant unnecessary spending. I have heard all the arguments around inconvenience of travel and this to make up for that but then let the employer of that person eat the cost. The per diem fee doesn’t fly either — when I go to work, I have to pay for my food, just because work means getting on a plane doesn’t excuse one from that obligation. Convince me I am misguided.” I agree, but taking the counterpoint as a consultant might, I could make the same argument for buying $500K hospital CIOs cars, club memberships, travel of a questionably patient-valuable nature, and bonuses for doing the job they were already paid to do. I think the conclusion is that everybody gets to pass the literal buck down to the patient bill, and only recently did big hospitals worry about their inability to create enough charges to pass through the excessive costs.

The problems with Healthcare.gov are either due to (a) screwed-up government software bidding and contractor oversight , or (b) not unexpected for a rollout of that scope, say most poll respondents. New poll to your right: is the influence of private equity firms on healthcare IT positive or negative? Your answer doesn’t provide any context, so after you’ve voted, click the Comments link to explain.

Welcome to new HIStalk Platinum Sponsor Sentry Data Systems, which offers hospital pharmacy procurement, revenue cycle, and compliance solutions. Sentinel RCM manages financials, inventory, charge master, auditing, and order flow, allowing them to track drugs from the point of purchase all the way to billing. Sentrex helps hospitals manage their 340B contract pharmacy relationships to maintain compliance by using a proprietary rules-based engine to apply hospital policies and procedures, supporting both 340B and Own Use programs. These products run on the Datanex infrastructure platform that processes millions of transactions each day. Hospitals running a 340B drug program need specialized technology to avoid running afoul of a maze of regulatory and auditing challenges and Sentry is the company to call. Thanks to Sentry Data Systems for supporting HIStalk.

I cruised YouTube for more on Sentry Data Systems and found this pharmacy director testimonial.

AtHoc is a brand new HIStalk Gold Sponsor. Over 200 hospitals rely on AtHoc for critical communication and personnel safety, turning their IP network into a closed-loop, multi-modal notification and communication system. Examples: protecting home health nurses with a smartphone duress/panic button, communicating with clinicians during IT downtime, and automating shift availability and filling processes. Above is a video on Kaiser Permanente’s use of AtHoc for staffing. Thanks to AtHoc for supporting HIStalk.

Athenahealth turned in unimpressive numbers that fell short of expectations Thursday, some but not all of them related to its Epocrates acquisition, but that didn’t stop shares from going on a tear after the announcement. ATHN hit an all-time high Friday and closed up 24 percent on the day at $130.83, valuing the company at almost $5 billion. Investors apparently ignored the financial results and instead were encouraged by a growing client base and an extended contract with PSS World that will put more salespeople on the ground pushing athenahealth offerings. Above is the one-year chart of ATHN (blue) vs. the Nasdaq (red). Jonathan Bush holds $40 million worth. From the earnings call, which is always informative whether you care about ATHN or not because Bush is willing to say what others won’t:

• One large client, an ambulance company that was never named at that company’s request (but had to be Rural/Metro), went bankrupt even before going to pilot with athenahealth and “new leadership fired us.”
• Like everybody else, athenahealth talks about population health a lot.
• The company will roll out athenaKnowledge in 2014, which will provide financial and clinical decision support to physicians.
• AthenaClinicals  can automatically make a note in the chart when patient prescriptions are filled, although so far that works in only about 23 percent of orders.
• AthenaClinicals users who also use athenaCoordinator can exchange patient information via athenaNet with no additional interfaces or exchanges.
• When asked whether athenahealth would gain or lose hospital business through consolidation, Bush replied, “I don’t know, dude. I assume we’ll win. I mean — the for-profit sector is where most of these mergers are going on that you’re talking about, and it’s a very rational sector. Most of the headwind we face in the enterprise world is with institutions who don’t view their bottom line as all that important. And their reputation as the bringer of great new physicians into the world and their reputation as the provider of procedures that no one else can provide, trump their abilities, their interest in asset efficiency. Now as we’ve said in past calls, we believe that asset efficiency is going to rise in appeal to even the most theoretical of academic medical centers as the pressure builds.”
• According to Bush, “At some point, the idea of information being liquid across people who don’t own each other is a major trump card when you think of this tragic lemming march of acquisitions, doctors and hospitals marrying up in marriages of convenience, nothing wrong with doctors and hospitals marrying up in marriages of love, but this wave of kind of moony, large-scale marriages of convenience just to get information integrated when there is another way, to me, it’s sort of a profound megatrend to watch.”
• When asked about hospitals using athenahealth products to control physician behavior, Bush said, “Well, I’ll tell you every proposal to a new enterprise today include a Google Map of all of the doctors that have admitting privileges at their institutions that are already on athenaNet. And those Google Maps are getting more and more dotty, lots and lots of little dots around their blue H. And the fact that now we don’t say we can direct, but we say, ‘Listen, hospital, do you want to — speaking of manifestos, do you want to get compliance via force or do you want to get compliance via love?’ … be the most high-quality, easy-to-do business with receiver of patient referrals. Be big and successful and survive this drought that’s coming by being the best, and that means being the most integrated, the most available … we don’t even need the tipping point for that, right? We could just show up and say, hey, you’re going to do a go-to-market strategy with your subsidized EMR the way poor Long Island Jewish did with Allscripts banging away, giving it away at red lights, trying to get the windshield wiper guys to give it away. Here, you got thousands of doctors paying for it, wanting it, and all you’ve got to do is light up your logo inside of the order screen.
• On selling athenaClinicals to customers who already have an EMR, “I know the last time I looked, it was 40 percent of our clinical sales today were people throwing one out … you have a huge wave of folks who looked, went out and jammed the EMR thing because Obama told them to, and then they got to Meaningful Use day and they got nothing … Used properly, they’ll get you Meaningful Use. But doctors are not supposed to be using them properly. All they’re supposed to be doing is seeing patients … Nobody wants to go back to their Board of Directors or their Board of Doctor Owners and say, ‘Yes, so sorry but I convinced you spend thousands and at times, millions of dollars on something that I really want to throw out now.’ But it is what it is. It’s a cash-on-cash no brainer. You just have to go through the embarrassment.”

John Lynn did an ICD-10 Hangout on EMR & EHR Videos.

GE reports Q3 numbers: revenue down 1.5 percent, adjusted EPS $0.31 vs. $0.33, but train and plane sales along with aggressive cost-cutting helped the company exceed Wall Street’s expectations, sending shares to a five-year high. GE Healthcare’s sales were flat, but earnings rose 7 percent.

A series of Wisconsin Democratic Party focus group meetings identifies the two favored candidates for governor, one of whom is Judy Faulkner of Epic. The strengths the groups favored were a wealthy, politically outsider woman not from Dane or Milwaukee Counties with name recognition who hates everything about Republican Governor Scott Walker.  I don’t think I’d take the results too seriously since they seemed to favor celebrity status over political qualifications – the group’s other choice was just-retired Green Bay Packer and “Dancing with the Stars” winner Donald Driver.

Eric Topol, MD isn’t impressed with MD Anderson’s use if IBM’s Watson to undertake a “moon shot” aimed at eliminating cancer. He tweeted, “This ‘Ending Cancer stuff, while a laudable goal, is sending a wrong message to public.” He didn’t explain, but I assume he meant that cancer isn’t one disease and the likelihood of eliminating it, with or without Watson, is nearly nil. Prevention is more important than treatment, I conclude, but if MD Anderson thinks Watson can help eliminate cancer (or help it market itself to cancer patients, which bring it nearly $4 billion per year in revenue for treating cancer rather than preventing it), then it’s worth a shot, moon-worthy or otherwise, even if it does encourage minimally intellectual Americans to think that anything less than a cure is a failure.

Val Jones, MD (aka blogger Dr. Val) says that despite her previous support of digital data in medicine, EMRs are doing more harm than good. Her reason: data entry is “an enormous time-suck for physicians” that harms thoughtful interaction with patients that would allow a correct diagnosis and sensible treatment plan. She doesn’t like correcting offshore transcription, hospitals with large IT departments (“40 young tech support engineers were furiously working to keep the EMR from crashing on a daily basis”), and EMR-required data fields (she called out Allscripts, whose system requires the doctor to indicate for every discharge prescription whether the medication comes in a tablet or capsule, which the system knows full well but which has to be entered again to allow the inpatient EMR to accept the information). I think she might have aimed her wrath more precisely at the one hospital at which she apparently had a bad experience since what she describes is certainly not universal, but certainly some hospitals are exactly as she describes.

Peace River Center, a Florida non-profit psychiatric agency, is awarded a $30,000 United Way of Central Florida grant to implement technology that will allow its home case workers and clinicians to remotely connect to its EMR.

In Canada, Victoria County Memorial Hospital loses its telephone service and Internet connectivity when a construction vehicle severs cables, causing the hospital to cancel walk-in diagnostic and lab services.

Twitter’s just-announced November IPO may be tarnished by “Twitter quitters,” those who try the service but abandon it because they can’t figure it out or don’t find value in it. A new poll shows that 36 percent of those who sign up for Twitter don’t use it and 7 percent close their accounts, much worse numbers than for Facebook. According to an active Facebook user who stopped using Twitter, "I didn’t really get the point of it at all. Most of them were people I wasn’t interested in hearing what they had to say anyway.” Twitter is big, but then again so were Second Life and Myspace.

Madison, WI-based 11-employee Wellbe raises $1.4 million in funding. The company’s Patient Guidance System, which it describes as a GPS for health, sends patients emails and information before and after their surgeries.

HHS gave UK-based government contractor Serco, under investigation there for contract fraud, an $87 million contract extension to its existing $114 million CMS contract to handle paper insurance applications just five days before the launch of Healthcare.gov, leading to speculation that the government knew Healthcare.gov was going to fail and paid Serco to handle the inevitable flood of paper-based insurance applications. However, CMS suggests that the Congressional Budget Office had estimated that 20 million people would apply, with 6 million of those doing so on paper, and the 2,000 people Serco hired were necessary to process the paper applications. HHS gave Serco a $1.2 billion contract in July to manage paper insurance applications for 34 state insurance exchanges in its first-ever US healthcare project. The parent company has annual revenue of around $8 billion. Serco took over NHS’s largest hospital pathology laboratories in 2009 in a privatization joint venture worth $1.3 billion over 10 years and was involved in a series of admitted serious patient errors, including losing samples, incorrect computer flagging resulting in administration of inappropriate blood, a software problem that calculated kidney function incorrectly, and a section of blood chemistry equipment that had to be shut down for four days after a computer virus infection. The 1,000-employee JV, called GSTS Pathology, couldn’t control its costs, had to borrow money from the hospitals to continue its operations, and announced that it would need to pull out of certain markets. GSTS Pathology continues to bid on new UK business, hoping to capture 30 percent of the pathology market.

California Attorney General Kamala D. Harris issues “Medical Identity Theft – Recommendations for the Age of Electronic Medical Records.” It cites a recent report stating that nearly half of medical identify theft isn’t really that at all – it occurs when someone with insurance loans their card to someone who doesn’t have insurance. EHR-specific recommendations include:

• Implement role-based access controls.
• Embed a copy of a patient’s photo (but not a government-issued ID) into the EMR.
• Give patients clear instructions on how to get a copy of their information.
• Give patients a copy of Clinical Care Summary documents asking them to verify the information but warning them keep it confidential.
• Set up the EMR to flag suspicious issues (known a “red flags”), such as a patient refusing to show an ID (other than in the ED); presenting an ID whose photo doesn’t match their appearance; presenting an ID with a name or address that doesn’t match the EMR information; giving a Social Security number, address, or telephone number that is already assigned to another patient;  receiving returned, undeliverable mail from the patient’s address; receiving previous denial of payment for situations such as a second appendix removal; bills returned as undeliverable while new charges continue under that same address; patient interview information is inconsistent with the EMR information; observing that a patient is not aware of the information in their record; and finding information in the EMR that conflicts with other information or with the patient’s presentation.
• Develop a process for instantly reporting any of the red flags above to a team that will review all available records and place affected accounts on hold, looking for problems such as erroneous data entry or inappropriate medical records merge.
• Document findings and policies in the EHR where it can be seen.
• Create a database of identities that have been used fraudulently.
• Add a message to the patient portal encouraging patients to review their records regularly, also giving them instructions on how to report discrepancies.
• Audit EHRs for unauthorized access.
• Build demand for provider detection software, which the report says is offered by only a handful of unnamed vendors whose applications are too expensive for all but the largest health systems.
• Correct records as needed, either annotating them or moving them to a specific “medical identify theft” location and then starting a new record.
• Use the Continuity of Care Document to electronically notify business associates and other providers that the record has been corrected.
• Follow HIE rules for correcting information.
• Encourage development of technical standards that would allow Health Information Organizations to exchange red flag information, such as modifying the MPI to indicate the addition of a red flag by a member.
• ONC should include red flag recommendations in Meaningful Use Stage 3.

Weird News Andy titles this story GIGO, wondering, “Who, if anybody, tested this thing?” (answer: government contractors). Not only is Healthcare.gov failing to allow most would-be users to get into the system, it’s also sending erroneous data to insurance companies from those who do. Duplicate enrollments, spouses listed as children, and missing data have been reported.

WNA also files these reports from his Weird Newsroom. Doctors are unable to determine why a Tennessee man has been crying blood for seven years, an unnerving trait that has cost him every job he has held. A Denver woman whose arm was unnecessarily removed after an incorrect cancer diagnosis tries out a robotic arm, but her rare underlying condition remains – any bruise she gets turns to bone, which is gradually transforming her into a human statue who knows she will be fully immobile soon.

A hospital sues one of its patients who refuses to leave because she likes her bed there. The patient was discharged after a four-day stay for pneumonia, but intentionally had her state-provided hospital bed removed from her home so that she could argue that her discharge was unsafe. The hospital says the patient is abusive to staff and fellow patients, complains if her room is at any temperature other than 83 degrees, and repeatedly calls the police department, public health department, and the attorney general to complain about her stay. The hospital wants a temporary injunction to send her packing.

Vince continues his fascinating HIS-tory of McKesson, specifically HBO, with information he received directly from Walter Huff himself. It’s fascinating to read how many early HIT pioneers were hospital CFOs who did programming or other computer work for their hospitals, and how many vendor systems came out of those hospitals.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: My Can’t-Miss Entrepreneurial Brainstorm: Display Computer Data in the Handwriting of the Person Who Entered It

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 October 2009.

My Can’t-Miss Entrepreneurial Brainstorm: Display Computer Data in the Handwriting of the Person Who Entered It
By Mr. HIStalk

I don’t want to brag, but I’m a business genius, one of your classic serial entrepreneurs who is so full of hot ideas that I haven’t found the time to stop working as a hospital wage slave. Each idea is so much better than the one before it that I can’t decide on the best one to pursue, so I’m continuing my decades-long preparation of reading Forbes and MSN from the catbird’s seat, located deep in the bowels of an academic medical center.

(One of these days, maybe when I retire, the world will be shocked and awed by the torrent of pent-up business expertise that I’ll unleash, even more so since I’ve never actually been in business except for a short stint as a paperboy back before Craigslist drove all the newspapers out of business.)

You will no doubt value my latest brainstorm appropriately – healthcare IT data elements displayed in a font created from the handwriting of the person who entered the data. Boo-yah and ca-ching!

Everything needs a serious-sounding name for the newly created genre, like “social networking” (or “social not-working.”) I like to call this “Reverse Handwriting Optical Recognition” (RHOR) or “Character Recognition and Proxy Personalization” (CRAPP). You are hereby non-disclosed.

They say every successful product has to solve a customer’s problem (I’ll believe that when someone explains what purpose the TV show “The Bachelor” serves). So, here’s the one I’ve targeted: clearly wrong information looks believable when you see it on a computer screen or printed report.

My inspiration is the news that Cedars-Sinai overdosed CT scan patients for 18 months because none of the techs noticed that the screen defaults were wrong.

Hospital people usually seem blithely unconcerned when presented with hilariously incorrect computer information, like a pregnant male patient or an ED bill for $12 million. The neat and orderly computer output throws off their radar in the absence of a visual cue that would identify the blithering idiot who entered the information in the first place.

Here’s my technical architecture design. Each user’s security profile will include a handwriting sample that has been scanned to a font. When the computer displays or prints something entered by that person, it does so in their own handwriting.

Brilliant, right? The bad information won’t be so reassuring if it’s displayed in a child-like scrawl or a breezy note punctuated with that smiley thing that tip-seeking waitresses draw on your check. Your radar would say, "I don’t trust a thing that fool says."

Skeptics or cynical venture capitalists might ask me, "What about information that the computer creates, like drug schedules or co-pay amount?" I smirk knowingly as only a world-weary entrepreneur can do. Computers, although good at idiot savant tasks like spitting out lists or calling up historical information, are the dumbest pseudo-people in the room. I’ll display their primitive conclusions in the sloppy scrawl of a 14-year-old who was raised with a keyboard instead of a pen, or maybe as indecipherable teen-like text messages saying something like UR PT IS DED ROTFL .

No longer will doctors and nurses place undue confidence in information just because it looks official. Those worthless clinical observations entered by a co-worker you wouldn’t trust with your drive-through order? Visual elimination made easy by Mr. CRAPP (send me that royalty payment, please, Cedars).

Darn, now I’m getting one of those serial entrepreneur brainstorms that may cause me to skip CRAPP and just go on to CRAPP 2.0. We write an add-on software application that lets users rate each data element for accuracy and usefulness. If someone’s a real bonehead, you answer "Did you find this data element useful?" with “no.” If someone enters an incorrect allergy or creates a duplicate medical record that has to be merged later, you rate them low. When enough people do the same, the user gets anonymous feedback of scorn and ridicule.

I don’t watch “The Bachelor” or other reality TV (except “Shark Tank” and my fellow high-flying capitalists), but I’ve heard of a concept that I might use in CRAPP 2.0. If you enter enough bad information, your co-workers might vote you out of a job.

Morning Headlines 10/18/13

Sebelius Stands Firm Despite Calls to Resign

Secretary of Health and Human Services Kathleen Sebelius is refusing calls for her resignation after the failed launch of Healthcare.gov.

athenahealth, Inc : athenahealth, Inc. Reports Third Quarter Fiscal Year 2013 Results

Athenahealth reports Q3 results: revenue jumped to $151 million, up 43 percent from $105 million during Q3 2012. Epocrates accounted for $13 million of that total.

St. Luke’s expects to spend $200 million on electronic records system

Nine-facility St. Luke’s Health System will spend $200 million implementing Epic across all of its hospitals and clinics. The system is expected to be live across the network sometime after 2017.

HIMSS Analytics Essentials: Virtualization Software and Dictation with Speech Recognition Applications Positioned for Aggressive

Data visualization and speech recognition applications are predicted to see a surge in sales according to a recent HIMSS Analytics report.

News 10/18/13

Top News

HHS Secretary Kathleen Sebelius is reported to have no intention of quitting after Republican criticism of the Healthcare.gov online insurance exchange debacle. Sebelius has acknowledged the problems, but says fixes are being put in place and those who were unable to sign up should try again. Success rates for those attempting to enroll were less than 20 percent the week of its rollout on October 1 and under 13 percent the second week, although one researcher says fewer than 1 percent of those who tried to register were successful. Another report finds that the cost for the system ballooned from the original estimate of $94 million to $292 million, with those payments going to the US federal government division of Canada-based CGI. Other estimates peg the total cost of Healthcare.gov to be more than $500 million.

Reader Comments

From Dr. Travis: “Re: Color me pink. Breast cancer awareness month has jumped the shark this year.” Travis tells me he likes the innuendo of this poster’s message, which I believe was from the Twisted Taco restaurant in the Atlanta area. Thanks for the reminder to support breast cancer research, get screened regularly, and/or encourage your loved ones to be screened.

From Reader One: “Re: from a vendor-specific forum today. ‘We inadvertently assigned 5,000 accounts to a bad debt agency. Is there a way to mass cancel?’ Now that’s what I call exciting.”

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor Boston Software Systems. The company offers an error-free workflow automation platform that allows its healthcare customers and business partners to streamline their business processes and improve productivity. Boston WorkStation lets IT departments efficiently solve problems and eliminate performance gaps in existing IT systems – integrating third-party registrations, performing eligibility checks, integrating lab results, posting payments and collections notes, performing mass updates, creating backup databases, running and distributing reports, and managing dictionaries and tables. Existing systems can be enhanced by creating new business rules and workflows and providing real-time access to external applications. IT departments love Swiss Army knife-type solutions that be used to enhance systems without vendor involvement or ongoing labor requirements, such as the hospital that’s saving 125 hours per month using Boston WorkStation to automatically create a pre-registration account at the time of scheduling or another that saves $500K by automating their materials management system to load inventory purchases and manage price updates. The company also offers Cognauto, the next-generation automation platform. The company’s products are used by over 2,500 hospital customers running many IT systems. Thanks to Boston Software Systems for supporting HIStalk and for issuing a very cool press release announcing that fact.

 
 
Thanks to Bonny and Catherine from Aventura, self-proclaimed “HIStalk minions” who volunteered to report from the American College of Emergency Physicians Scientific Assembly (ACEP13) in Seattle this week. They conducted some ED doc interviews about IT that I’ll have up later, but here are some of Bonny’s observations:

• The topic of scribes performing EMR data entry split the group, with some ED physicians expressing satisfaction in offloading tasks to what is often a pre-med student, but others feel guilty about making scribes do what some would say is their work.
• The best-of breed EDIS vendors were there (Picis, T-System, MEDHOST) as were the big enterprise vendors with EDIS, with Epic notably being MIA.
• Education and discharge instructions vendors (Discharge 1-2-3, Elsevier ExitCare, Krames) were exhibiting.
• Bonny says MEDHOST stole the show with a patient throughput solution that pushes preemptive communication about patients from the ED or OR, such as when a patient is likely to be admitted but whose emergency care is still underway. It also offers real-time and forecasted financial operational metrics for executives.
• ACEP rented out the Space Needle, the Chihuly Museum, and the Experience Music Project for attendee events.
• In the all-important vendor swag category, Bonny lauds Interactive Health Massage Chairs, whose booth was across from Aventura’s such that Bonny and Catherine could perform their own first-hand research as well as watch attendees shed their stress and exit happy. Check out the photo above – who wouldn’t want to have a chair massage while covered lightly with a blanket right on the show floor?

Highlights from HIStalk Practice this week include: a local paper profiles two physicians with opposing views on EMRs. CMS pushes a PQRS reporting deadline back three days. A vendor speaks out against shortened exhibit hours at MGMA. Most medical practices are concerned that ACA insurance exchanges will lead to increased collection burdens and lower reimbursements. Epocrates adds a provider directory to help members identify clinicians for consults and referrals. Emdeon will pay its departing CEO $2.4 million over the next two years. Thanks for reading.

Acquisitions, Funding, Business, and Stock

Athenahealth announces Q3 results: revenue up 43 percent, adjusted EPS $0.29 vs. $0.30, missing analyst estimates on both.

IVantage Health Analytics acquires Professional Data Services, a provider of managed care analytics and benchmarking solutions for hospitals.

StartUp Health admits 14 new companies to its three-year development program for health technology startups. Lt. Dan profiles the companies on HIStalk Connect.

Medical practice technology vendor Waiting Room Solutions changes its name to WRS Health.

Sales

Medical Services of America (SC) chooses Allscripts Homecare for its 70 home care service locations.

Elmcroft Senior Living (MO) will install Cerner CareTracker at its 85 assisted living facilities.

The 30-bed Aspire Hospital (TX) will implement clinical and financial applications from Healthcare Management Systems and physician documentation from Patient Logic.

The VA and DoD award Systems Made Simple a re-compete of the iEHR system contract for systems integration and engineering support.

Saint Luke’s Health System selects PeriGen’s PeriCALM fetal surveillance system for seven birthing hospitals in northwest Missouri and northeast Kansas.

The VA awards Harris Corporation a $60 million, four-year contract to design, install, and support the wireless infrastructure at 112 VA medical centers.

Riverside Medical Group (VA) selects athenaCollector for billing and practice management for its 300+ physicians.

The Texas Health Services Authority chooses EHNAC to develop a state accreditation program for private and public HIEs operating in Texas.

Texas Health Physicians Group selects StrataJazz from Strata Decision Technology as its integrated financial platform.

St. Luke’s Health System (ID) will implement Epic at a cost of $200 million and will offer Epic ambulatory to independent practices through an affiliate program.  St. Luke’s, defending itself against antitrust claims for its purchase of Salzer Medical Group, says Epic is a superior system that will allow providers to share information with patients and with each other more easily.

People

Northwest Community Healthcare (IL) names Glen Malan (Cadence Health) VP/CIO.

OpenTempo names Jim Crook (IDX) chairman of the board, Walt Marti (GE Healthcare) chief administrative officer, and John Jordan (dbMotion) VP of sales and marketing.

Announcements and Implementations

Quantros releases IRIS 2.4, a configurable dashboard to view overall hospital performance and display trends, distribution, and variations in performance.

Government and Politics

A California state appellate court rules that providers do not necessarily have liability to patients when medical records are stolen or misappropriated unless they are accessed by a third party. The ruling stems from a 2011 incident in which a UCLA Health physician’s laptop containing medical records on 16,000 patients was stolen from his home. The provider could have been liable for up to $16 million as part of the  class action lawsuit, even though there was never any indication the data had been accessed. The suit was dismissed. Rebecca Fayed, associate general counsel and privacy officer at The Advisory Board Company, tells me the ruling only applies to California, which has its own statute governing the disclosure of medical information and allows affected individuals to sue for damages for certain violations. She adds:

Although the ruling would not apply nationwide at the federal level, other states with similar state laws may look to this case for reasoning and may analogize to it even if it has no precedential value in any state other than California.

The ONC Tweeters seem happy to be back at the keyboard after a 16-day furlough.

Innovation and Research

 

Children’s Hospital of Philadelphia (CHOP) offers Harvest, an NIH grant-funded open source software toolkit that allows biomedical researchers to explore large data sets, such as those from EHRs and genomic databases. Researchers from CHOP’s Center for Biomedical Informatics are testing Harvest against several data collections, including the Longitudinal Pediatric Data Resource that tracks data from children with conditions detected in newborn screenings.

Technology

Deloitte introduces PopulationMiner, a data analytics solution that draws clinical, financial, and operational data from Intermountain Healthcare’s warehouse to support patient-outcome analysis.

ArborMetrix integrates surgical video analysis capabilities into its reporting and analytics platform, enabling healthcare organizations to improve performance benchmarking of surgeons.

Ninety percent of surveyed nursing home physicians say their use of drug references on mobile devices prevented at least one adverse drug event the month before the survey.

Other

Virtualization software and dictation with speech recognition applications are emerging as top areas for growth potential in hospitals, according to a HIMSS Analytics report on the US hospital IT market. The demand for ambulatory EMRs and ambulatory PACS also appears to be growing.

Joint Commission issues a sentinel alert warning for objects left inside surgery patients, which it says has caused 16 deaths in the past eight years. Most of the recommended actions involve processes and communication, but consideration of “assistive technology” such as RFID-tagged counting systems are also recommended.

In Canada, information on 2,000 patients of Parkwood Hospital is exposed when an unencrypted laptop is stolen from the car of a McKesson Automation employee.

Weird News Andy notes that California’s insurance exchange, Covered California, pulled down its online provider directory just eight days after go-live when the California Medical Association noted that obstetricians were labeled as ophthalmologists and doctors were incorrectly identified as speaking foreign languages. CMA also observed that some doctors were listed as exchange providers who didn’t actually sign up since insurance companies were permitted to add their in-network doctors to the list without their permission unless the doctor specifically opted out.

Staff and patients of Unit 5, the children’s cancer floor of the University of Minnesota Amplatz Children’s Hospital, create a video titled “Brave.”

Sponsor Updates

• SRSsoft hosts about 300 customers at its User Summit this week in Greenwich, CT.
• Sunquest and the Association for Pathology Informatics will offer an October 24 webinar on the topic of IT-driven virtual autopsies.
• Clinovations celebrates its five-year anniversary and highlights a few of its awards and honors.
• E-MDs integrates PatientPay’s online bill pay solutions within its PM software. The company will also integrate Phreesia’s point-of-care check-in solution into its EHR .
• St. Elizabeth Hospital’s (WA) use of e-form solutions from Access and hosted services from Inland Northwest Health Services helped the hospital meet HIMSS Stage 7 paperless requirements while eliminating the need for dedicated on-site hardware.
• Greythorn conducts a market survey for HIT professionals to analyze compensation, benefits, job satisfaction, hiring trends, and industry participation. Greythorn will donate $1 to the Boys and Girls Clubs of Bellevue and Chicago for every submission by November 20.
• Ed Bayliss, executive director for ChartMaxx, participates in a panel discussion on data exchange across the continuum of care at the eHealth Initiative 2013 Data Exchange Summit October 30-31 in Washington, DC.
• Humedica publishes a case study detailing how Mayo Clinic Health System prepared for value contracting using Humedica MinedShare.
• ZeOmega will embed Health Language technology from Wolters Kluwer Health into its Jiva care management platform.
• The Drummond Group certifies SRS EHR as a 2014 Complete EHR.

EPtalk by Dr. Jayne

You can tell that fall has arrived when every coffee vendor (including the one in the hospital lobby) is pushing pumpkin spice latte. Unfortunately, it is also the time I start sweating the fact that I need to come up with an extremely creative Halloween costume and come up with it stat. One of my favorite former bosses throws a massive party and the price of admission is a great costume. I enjoy Halloween immensely and have a closet full of costume options, but this party is peopled with brilliant individuals from academia, healthcare, and health IT so throwing on the Princess Leia braids simply will not do.

Maybe I’ll print a bunch of completely random attributes (some of which relate to me and some that do not) and go as my LinkedIn profile. I always laugh when people endorse me for knowledge of vendors I have never even heard of. I know several of the attendees are faithful HIStalk readers. Maybe I can convince my date to adopt a couples costume and we can go as Inga and Mr. H. Of course I could always go as Dr. Jayne, but that might be a little obvious. I guarantee at least one attendee will be wearing a bowtie and a Farzad-worthy grin.

The lobby of our medical school has a wall with pictures of our staff who have won various Nobel prizes. I could always dress as one of them and see if anyone picks up on it. Getting someone to identify that choice might be a little dependent on how far after the start of the cocktail hour I arrive, though, so not entirely a safe bet. I’m leaning towards possibly a World War I nurse just to have an excuse to purchase an awesome vintage cape. In medicine (and nursing) we used to dress more formally and I miss that. I understand that the current culture of scrubs is all about comfort and practicality, but I can’t help but think that if we dressed more seriously our patients (and administrators) might take us more seriously.

I took a course recently that covered communication and corporate culture. We did several exercises looking at how appearance plays a role in group dynamics. Watching several videos, we scored the characters based on believability, authority, seniority, and a host of other factors. Regardless of the scenario, those characters who dressed in traditional business attire scored higher than those who dressed casually. Besides dress, there are a lot of other factors at play with power dynamics, including the position of the participants (same height vs. seated/standing), tone, demeanor, etc.

I had the opportunity to rotate through a hospital in the UK during the late 1990s and was struck by the formality of the nursing staff. They still wore traditional dress whites (with caps) and nursing trainees wore blue. Physicians wore the long white coat and neckties. There were very few female physicians who I interacted with during my rotation, so I can’t particularly remember what they wore.

I trained at an academic medical center with an extremely traditional surgery department. Surgeons were never to wear scrubs outside the operating room. Trainees were not allowed to consume food or drink in the hallways – not even a sip of coffee – and white coats were to be fully buttoned at all times. Conversely, the OB/GYN house staff wore scrubs and sneakers 24×7, which created more than a few resentments. I wonder though if the patients or other hospital staff really perceived the departments differently? Was it a factor of dress code or of other factors that the dress code exemplified, such as discipline, order, and precision?

Scrubs and casual dress have become a way of life for most hospitals and medical offices. My hospital requires care teams to wear certain colors of scrubs depending on employee roles. Nurses wear navy, respiratory therapy wears light blue, patient care technicians wear khaki, etc. This seems to better help patients understand who is caring for them and what to expect. Unfortunately, physicians run the gamut between coat and tie and whatever scrubs they put on at the last hospital they rounded at. Some are so casual it’s hard to take them seriously. In response to a number of male physicians going sockless in loafers, one local facility created a rule requiring that “hosiery be worn at all times.” I’d like to have been a fly on the wall at the medical staff meeting where that was discussed: readmission rates, surgical site infections, ventilator-associated pneumonia, and bare ankles.

In the ambulatory care setting, the proliferation of scrub styles is mind boggling. We see a lot of “hip” medical assistants and patient care techs in low rider scrubs with flare bottoms that drag the ground to the point where they fray. I hope they never have to run to a code or crouch down to provide CPR, and if they do, that they have their waistband firmly in hand. One pediatrician I know has hand painted lab coats for every holiday and season. She’s the only physician on staff who wears a blue coat, so it really stands out. I smile every time I see her in the elevator, but I’m not sure what some of the patients and visitors think.

Generally I think the offices where staff dresses in a more uniform manner appear more organized and professional, but again maybe the dress code is a side product of management rather than a causative factor. Many of our offices provide staff with practice-logo polo shirts to be worn with khaki pants. This can be useful to reinforce an office brand as well as to help patients identify staff members, especially in busy offices with many ancillary services. That might be a great costume idea – maybe I’ll borrow a polo and masquerade as a staffer for a competitor practice.

I didn’t set out to write a fashion review, but perhaps Inga has been a greater influence on my writing than I previously thought. I could write an entire column on sassy patent leather hospital clogs, but we’ll save that for another night. I’m off to the internet for costume ideas. Got a great one? Email me.

Contacts

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

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