Advisory Panel: PHI on Mobile Devices

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

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

This question this time: What policies, practices, and tools are you using to control the use of PHI on mobile devices and apps?

Policies titled “Data Encryption” and “Mobile Device Safeguards” provide the basis for protection regarding mobile devices, emphasizing the requirements for encryption (storage and transmission), not saving PHI to mobile devices unless necessary, deleting the PHI when finished, and basic physical protections. Tools utilized are various methods of VPN, McAfee EMM and ActiveSync, native and container encryption methods, whole disk encryption, complex passwords, training and publications, Citrix, VM View, and custom applications that provide connectivity without storage or print.

We require any device that connects to our mail server to be encrypted.  If the device isn’t encrypted, the server won’t allow a connection.  We’re still working on a secure communication system with our non-employed providers, since they want us to send SMS messages rather than emails. 

We use Good Technology to provide secured access to our corporate email, contacts, and calendar on mobile devices.  Our policies limit the users who can have access by role. My perspective is that we use Good to mitigate our risks, but it has not increased satisfaction among our users.

We force a password protection on mobile devices and enforce a "10 attempts" wipe policy.

The health system adopted an encryption policy as a  CYA effort. We officially prohibit the use of personal computers for health system business, but I can’t see any way that we can control or even police this activity. Employees have external hard drives at home that they use to backup their laptops, at least they should have some backup mechanism. Therefore, when any of these home-based devices is stolen, the health system does not have to report the event, but the patients’ data are still compromised.

Likely not a surprise with all the recent news around this subject, we recently are about to launch the following: (1) Automatically encrypting all outgoing emails which contain PHI (based on whatever detection system the IT team is using). I hope ours is accurate and does not create a painful process in non-PHI circumstances;  (2) Automatically enforcing that any smart phones syncing to the system for emails/calendar have a four-digit device PIN, an inactivity timeout under 15 minutes, and remote wipe ability if device lost or stolen – I did not realize they could do all this automatically (but hopefully most of us do all this already!)

We have a policy that prohibits storage of PHI on mobile devices. We use a mobile device management software tool (MDM) that enables us to securely deliver e-mail, calendar, and contacts from our Exchange environment to iPhones and Android smart phones.

Must enforce passcodes, that is blocking and tackling/101 stuff. All too often you’ll see misconfigured policies for iOS / Android / BlackBerry that are missing that simple setting. Then you must encrypt. We are using a cloud service MaaS360 that segments the device into a personal and a business side. The solution has device encryption and very nice GUIs for policy management. You can deploy your own applications through the solution and it’s been stable. Cheaper solution compared to other MDMs.

DLP for flash drives and any data moved to a mobile device or external drive. The use of computers as kiosks in all patient care areas. These are locked down so that no data can be downloaded. Encryption on phones though this is a self-reporting/self-enrollment process at the present. By policy we require all portable devices to be encrypted. This is difficult to enforce on non-organizationally owned devices.

Currently only supporting Epic apps (Haiku) and don’t require UDID management. Rather we control by security (if you’re a provider, you can use). We just force 5 minute logouts and logout immediately upon exit. We are looking at bringing up policies for mobile management of any device that wants to connect to our Exchange as well. Should be live by end of year. BlackBerry Enterprise server offers these controls.

In the process of implementing an MDM solution, and evaluating DLP solutions.

If employees choose to store PHI on their mobile devices, the device must be protected by encryption and strong passwords; they must fall under central device management, which means we can erase the device, remotely and enforce password policies; and they must agree to declare a "lost PHI device" incident within 1 hour of first realizing the device was lost. Interestingly, we experienced one of these incidents recently. A physician reported his device lost, as required, and we erased it– everything on it. Later, he found it and was angry that we had erased his personal pictures and address book.

We are in process of rolling out a mobile device management strategy utilizing Airwatch. In addition, we limit the individuals and roles that can access particular information already (even a bit more granular/more tightly controlled than the typical role based access) with regard to mobile devices/apps.

Morning Headlines 9/12/13

ONC Launches Patient Matching Initiative

ONC launches a collaborative initiative that will focus on developing highly reliable patient matching techniques for use in health exchanges to ensure that patient records can be correctly identified across disparate systems.

Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With Electronic Health Records

A study published in the Journal of the American Medical Association finds that pay-for-performance programs implemented in EHR-enabled small practices modestly improve care for cardiovascular patients, compared to care received at EHR-enabled fee-for-service small practices. The study was conducted between 2009-2010 and spans only a year of trended outcomes, which resulted in researchers noting that longer-term studies would need to be done to determine whether the changes increased or decreased over a longer timeline.

Electronic Medical Records Hold Clues to Suicide Risk

The VA is researching the use of natural language processing, in conjunction with its EHR system, to automate a risk profiling program designed to alert for potential suicide risk. The NLP-based program searches non-structured clinical narrative in a patients record for key signs that would indicate that the patient is at risk.

SAIC Outlines Business Objectives For Leidos, A National Security, Health & Engineering Solutions Leader

SAIC leadership presents the strategic objectives of Leidos, SAIC’s healthcare and national security spinoff business. The mission of the health sector of the business will be to "optimize the use of electronic health records, apply data analytics and behavioral health research to help enable customers to improve healthcare quality and patient outcomes, detect and prevent diseases, enhance scientific discovery, and reduce costs to the healthcare system."

HIStalk Interviews Anna Turman, CIO/COO, Chadron Community Hospital

Anna Turman is CIO/COO of Chadron Community Hospital of Chadron, NE.

Tell me about yourself and the hospital.

I’m the CIO as well as the COO of Chadron Community Hospital. We’re a small, critical access 25-bed hospital. Not for profit, of course.

As the CIO and the COO, a good explanation is having to do more with less. I am the more with less. I do have to run both roles. I find that very complicated a lot of the time. I don’t have enough time in the day for it.

We do trauma, we do babies, we do lab, we do surgeries. We have just about everything. I think we are exceptional for a critical access hospital. The next closest hospital to us, which is another critical access hospital, is 53 miles. The next what we call hub hospital or larger hospital is 100 miles north or 100 miles south. The one north is in South Dakota and that’s where we ship a lot of our patients. We usually stabilize and ship, so like hearts or other big traumas, we stabilize and ship.

You were a graphic designer, which is probably the least likely background to get into either CIO or COO roles, much less both. How did you transition into what you’re doing today?

I used to live in the city, got married, and my husband wanted to move back to this town of 500 people that he was from. There’s not a lot of graphic design necessary here, and so I had to reinvent myself and go back and get some education. I’m a highly motivated Type A personality, so it is what it is.

How is your job different from those of other CIOs, especially those from larger facilities?

On the governance level, it’s quite a bit different. We have our strategic plans and run our IT strategic plans off the business strategic plans, but we’re so much smaller that our communication seems a lot easier than having to deal with the complicated governance that you can see in some larger facilities. Our governance is much more simplified in communicating. I think that’s huge.

I took on the COO role and wasn’t able to give up the CIO role because I guess I did well enough at it that he didn’t really feel that it was necessary for me to give it up. I do balance that. It is difficult to balance. The responsibilities are just the same as any other hospital. I’m in charge of the business office and medical records.

What makes it nice is that I can see every aspect of the business. I can help from the IT perspective as well enable those parts of that business to get somewhere, be more efficient, or find the goals that they need to. I think that helps. It ties in. It’s a beautiful tie-in, actually. It helps me communicate better. I don’t have that “one more person” that I need to communicate with to find out what we need to do to enable other goals because I already know everybody’s goals.

What systems do you run?

I run NTT, complete NTT. We did a full-blown, big bang, six-month complete implementation everywhere from HR to financials to clinicals to pharmacy to radiology. Everything is NTT.

Are you doing OK with Meaningful Use, ICD-10, and everything else that’s coming down road?

Yes. I think we’re an exceptional facility. We have an exceptional group of people who are hardworking, pioneer-type people. We are a small facility, small area, small community, so they’re pioneers, they are hard workers. They do more with less. It’s just natural ability.

Because of that we, have been very blessed to have the capability of meeting Meaningful Use Stage 1. We are going to attest to Stage 1 year one and we are working on Stage 2 right now.

We won “Most Wired.” For a small-town, 25-bed critical access hospital, we really are exceptional. That is me patting them on the back, not myself.

How is your IT team structured?

I have one clinical informaticist. He’s a pharmacist. I have a data manager. He runs data, can help us with any reporting, helps us get everybody’s reports out for our data mining and all that stuff. It’s all one database, so that helps tremendously. We have the network manager and he runs all the networks. I have the clinical manager, who runs the clinical informaticist and updates all the systems. He’s also the applications manager.

What IT accomplishments are you most proud of?

It was probably “Most Wired.” That is pretty hard for anybody, let alone a small facility.

How are the IT needs of critical access hospitals different from the average 300- to 400-bed community hospital?

They aren’t. It simply comes down to, we just have to figure out how to do more with less. We have the HIPAA security laws. We have to encrypt all of our emails going in and out. We have to encrypt this, we have to encrypt that. We have to do all the same security. We have single sign-on. We have thin clients at the bedside, med administration at the bedside. Technically, to keep up with everybody else to have Meaningful Use, meet Meaningful Use, and to get Most Wired, we have to have the same needs.

For a while there, our biggest issue was Internet and speed and fiber. Rural Nebraska Healthcare Network is made up of eight or nine hospitals. Eight of them are critical access hospitals. One of them is Regional West Medical Center, which is the one that is 100 miles south of us. We have through grants been able to put redundant fiber into those smaller hospitals. We’re able to coordinate and collaborate backups to each other. Three of them have the same electronic health record, Healthland. They back up to each other’s offsite location and we use the fiber for that. There is a lot of business continuity we can work out through that fiber.

That was probably the biggest thing that was different in the bigger facilities. We didn’t have that access to high speed broadband or anything like that. Now that we do, it’s been a lot better. I can transfer my radiology results to and from. We can do our radiology here. We send them to our radiologists, who are actually in Denver, and we can use our fiber for that. We get quicker response for that because mammograms, for example, take a lot of bandwidth. We couldn’t do it with the T1s we were using originally, so then I had to buy 10 megs of fiber. That still wasn’t enough for the mammograms. When we got this grant that we can have redundant fiber, it’s a gig throughout all of our hospitals. We were capable of doing the mammograms and now we can do digital mammograms. It has to do with me being so much more rural more so than the technology that’s different.

Do you think Meaningful Use set the direction that’s best for patients or would you have done anything differently had that not been the carrot that was in front of you at that moment?

Oh, boy, you’re going to ask for my soapbox, aren’t you? [laughs]

I don’t know. I think there could have been some better ways to go around it. For example, I’ll give you my soapbox.

Everybody is throwing out this patient portal. There is not a lot of collaboration. People are trying, don’t give me wrong, but there are still clinics everywhere like ENT clinics or hospitals who are competitors and things like that. We are trying to communicate and share the data. We do that with our Rural Nebraska Health Network. I have an ENT clinic appointment up in Rapid and they give me a patient portal to access their information and do things there. Now I have their patient portal with a user name and password. I log in and help them meet their Meaningful Use.

When I go to the ER across the state in Lincoln because I was watching the football game and I ended up in the ER by breaking my arm, they get me on the patient portal, give me a user name and password, and now I have that one. Then if I go and visit over here, I have to go to a dermatologist or something, I have their patient portal and their user name and password. Then they come to this hospital where the actual physician is and their clinic here. I have their clinic and the hospital’s patient portal.

How many patient portals does that patient have to have? How many user names and passwords do they have to have? It really does come down to that exchange of information. That is going to be a key player.

What have you done that’s innovative?

I like that we use our televideo for mental health. We really do push because we are so rural. For our home health and hospice, they really do travel a 100-mile radius to reach those patients. We’re trying to push our televideo now to start doing the home health and hospice that way as well. But we do use it for mental health. We use it for dialysis patients so they can see their dialysis nephrologists through the televideo. We used it once when the baby was sent to another facility and they had to stay here because the baby was in danger — we used it so they could see the baby.

We use the televideo quite a bit. That’s a key feature for us rural people. It’s important. Innovative? I don’t know if we’re able to be as innovative and on the brink of things, but we really do try to.

Did you ever look at a big hospital and either wish you there or be glad that you aren’t?

No. I usually try not to see “grass is greener” anywhere else. I usually just try to be happy where I’m at. [laughs]

Communications in bigger facilities is so much more complicated for them. I am very happy that we have the communications that we have here and that we work so well together and work hard to get things done as a team. I think it’s a lot harder to do that in a larger facility. We see each other face to face so much more than anybody else would.

What opportunities and challenges do you see from an IT perspective of keeping up with reimbursement and regulatory changes?

To be honest with you, that is probably one of our biggest sticky points in a small facility. Larger facilities will have a HIPAA privacy officer. Well, I’m the HIPAA privacy officer. A larger facility will have a HIPAA security officer. Well, I’m also the HIPAA security officer. Having to know everything, know it well, and be very successful at it is very hard because so many roles get put under one person. Right when you think you’ve got it down and you could do it well, they change it again.

It does make it very complicated. Right now, I’m just cleaning up the Omnibus. Omnibus came out, changed out the privacy stuff, so I had to go and make sure we got all that taken care of. Every time they make a change, whether it’s technologically or patient privacy, it’s complicated for us because we have to know everything. One person has to know so much more and wear so many hats than a larger facility. It’s hard to keep up. It really is.

Do you think that economy of scale will lead more hospitals to acquire each other because they can’t go it alone?

The survival rate of the critical access hospitals is hard now. As we move more towards the future, it’s going to get harder. I don’t see it getting easier.

That is probably not typical of my perspective. I tried to look at everything from positive perspective, but no, it’s not getting any easier. The sequester makes it harder. Things like that just make it harder to survive as a small hospital. Even in Nebraska, governmentally they are looking at how to get rid of some of those critical access hospitals.

For a CIO who wants to do as you have in becoming a COO, what would surprise them most about what it’s like?

It makes being CIO a little bit easier except for the “more work” part. [laughs] You get a glance at the business goals and you can align the strategic plan so much easier. But that’s because I play dual roles, so I don’t know. That is kind of difficult.

For me, it was easier because I can see everybody else’s plans and I can coordinate with them and collaborate a lot better. I’m trying to think what the biggest surprise is. To be honest with you, CIOs are less just technology and more business structured anyway, so it was a fitting role to move into the COO position. I think CIOs have been moving away from just technology for some time. They have to understand the business strategy. They have to be a business person.

Most CIOs see it differently, but other people may see CIOs as just a technologically knowledge base. In reality, we are also a business knowledge base. It’s a good transition to go from CIO to COO.

Any final thoughts?

I should say a little bit about ICD-10. As small as we are, we only have a few coders, so the training is a little easier. But then again when ICD-10 does switch around, the bulk of the problems are going to come down on just a couple of people. If it all is smooth, great, but we have to have expectations for the worst. We don’t have that many people, so resources, when it comes down to going live, will be a little different for us.

Morning Headlines 9/11/13

Nashville’s HealthStream buys Pensacola health care consultants

Nashville-based HealthStream, an software-as-a-service vendor focused on delivering professional development and educational tools to hospital employees, pays $8.5 million to acquire Baptist Leadership Group, a healthcare consulting firm offering programs aimed at increasing patient satisfaction, employee engagement, and quality outcomes.

Implementation of an Outpatient Electronic Health Record and Emergency Department Visits, Hospitalizations, and Office Visits Among Patients With Diabetes

A study published in the Journal of the American Medical Association following the implementation of EHRs across outpatient clinics between 2005 and 2008 found a small but statistically significant drop in ED visits and hospitalizations after EHRs were introduced.

Six Reasons Why Nuance Needs To Put Icahn On Its Board Now

Forbes covers Carl Icahn’s increasing shareholder position in Nuance, arguing for why the company would be better off adding him to their board than continuing with their poison pill defense.

Certification Guidance for EHR Technology Developers Serving Health Care Providers Ineligible for Medicare and Medicaid EHR Incentive Payments

ONC publishes an integration guide for EHR developers building applications for clinical environments that fall outside the scope of Meaningful Use.

News 9/11/13

Top News

Healthcare learning and performance improvement systems vendor HealthStream acquires Baptist Leadership Group, a consulting practice owned by Baptist Health Care in Pensacola, FL, for $8.5 million. The company also announced that the health system will use its talent management software.

Reader Comments

From Warrior: “Re: telling clients about unethical sales tactics after quitting a vendor job. The answer to the question is an easy one. Take the severance package and agree to keep the pie-hole closed. Any unethical sales techniques will eventually reveal themselves. A couple of years ago I was a victim of senior management lies and deceit, to say nothing of what was being done to clients. I quit without calling customers or the competition regarding the egregious business practices. Three months after I resigned, several of the morally bankrupt executives were shown the door with very generous golden parachutes. Blood money – what goes around, comes around. My hands are clean!” My take: unless a former employer was doing something illegal as opposed to something unethical, keep the dirty secrets to yourself. If you were one of the “good guys,” your departure will make enough of a statement.

From More Cow Bells: “Re: Sutter EHR downtime. The spokesperson cited the uptime percentage as 99.4. It bothers me that the systems handling the clinical and financial information of our hospitals are estimated to be unavailable for more than 52 hours per year. I’m not sure any other industry that deals with public safety and well-being would tolerate being down an hour a week (air traffic control?) What about striving for the old standard of five nines?”

From Dirk Diggler: “Re: Sutter EHR downtime. You mentioned news articles whose come-on headlines don’t deliver anything but an advertiser click. Here’s one.” A HIMSS-owned publication lures readers in with the cutesy and eventually misleading headline above. The article it sits astride contains nothing but shallow information extracted from old press releases about Sutter’s Epic (actually Citrix) downtime. When you finally read down through an extra click to Page 2 (banking an extra click to impress advertisers), the healthcare IT expert cited is the hospital’s nursing union rep, who offered three suggestions: (a) train people on downtime procedures; (b) communicate well; and (c) get nurses involved in system design. You can decide whether the advice is more insulting to the healthcare IT experts targeted by the publication than the article itself. At least the headline didn’t start with a number (“Eight Reasons Apple is Really Cool”) or require clicking an idiotic slideshow of unrelated photos lifted from other sites. I don’t like getting fooled and I hate wasting time, so I stop reading sites that promise more useful information than they deliver.

From Not Intuit: “Re: Intuit Health. Fifty percent staff cuts today, including me. All seniors leaders except for the product development lead gone.” Unverified, but the source is not anonymous. The former Medfusion’s name is still Intuit Health temporarily, but it’s a private company again after being bought back by founder Steve Malik a couple of weeks ago. My August 27 interview with him is here.

HIStalk Announcements and Requests

 

Welcome to new HIStalk Platinum Sponsor PatientSafe Solutions. The San Diego-based company offers smart point-of-care mobile solutions for the future of accountable care, delivering measurable safety and quality improvements that fit into care team workflows. The company’s flagship PatientTouch system, with 70 implementations, offers iPhone-powered software solutions to eliminate harm, reduce waste, and improve productivity. New York-Presbyterian Hospital chose PatientTouch a few months ago and Parkview Medical Center (CO) recently extended its use and integrated it with Meditech 6.0. Thanks to PatientSafe Solutions for supporting HIStalk.

I found this YouTube video on PatientSafe’s PatientTouch.

Upcoming HIStalk Webinars:

The Transition to ICD-10: Building the Bridge as You Walk on It (Thursday, September 12, 2:00 Eastern)
Using Infrastructure and Application Monitoring to Assure an Optimal User Experience  (Thursday, September 19, 1:00 Eastern)

Acquisitions, Funding, Business, and Stock

Disclosure management services company MRO Corp. acquires the assets of MTT Enterprises, a release-of-information service provider.

Santa Rosa Consulting completes its acquisition of IT security company EGIS Systems and renames it Fortified Health Solutions.

ZappRx, a developer of a mobile e-prescribing platform, raises $1 million in seed funding lead by Atlas Venture and Life Sciences Angel Network. 

Scotland-based Craneware says its revenue and EPS were up for the year despite not hitting its target of 1-2 big-hospital sales that can be worth up to $20 million each.

A Forbes editorial urges Nuance to put Carl Icahn on its board instead of fighting him off with a poison pill provision. Reasons: (a) financial results and management guidance have been poor; (b) Nuance shareholders should want Icahn involved given his past performance; (c) it can’t hurt; (d) Nuance doesn’t seem to have a strategy other than acquiring other companies; (e) CEO Paul Ricci is overpaid, having made $78 million in the past three years; and (f) the company should break up into separate business to make its Siri-type voice offerings more attractive, or as the article says, “If I’m Apple, I don’t want a medical transcription company with a bunch of transcription workers in India, but I’d be very interested in just the mobile speech piece.”

Sales

Sentara Williamsburg Regional Medical Center (VA) selects Versus Advantages Asset Tracking and Fleet Management.

Kmart will offer LDM Group’s PharmacistCare and CarePoints messaging solutions to pharmacists and patients to improve medication adherence.

People

Healthcare consulting firm Decision Resources Groups hires Courtney Morris (Truven Health Analytics) as EVP of solutions.

Geeta Nayyar, MD (AT&T) is named CMIO of PatientPoint.

Clarity Health Services names Karlynn Billings (McKesson Specialty Health) VP of business development.

Announcements and Implementations

Children’s Hospital Colorado will extend its use of T-System’s ED facility coding solution to two new locations that will open in 2014.

A total of 101 Ohio hospitals are participating in the Medicity-powered CliniSync HIE.

JIT Healthcare Marketing launches to offer ad-hoc marketing, PR, and design services with a simplified payment process.

Mediware will invest $2.8 million on enhancements to its rehabilitation and respiratory care electronic documentation solutions.

Memorial Health Hermann Health System (TX) takes almost 600 providers live on eClinicalWorks EHR and adds an additional 200 user licenses.

Infor announces GA of Infor Implementation Accelerator for Healthcare for the management of financials, human capital, and supply chain processes. Infor also releases Infor EMS Integrated Healthcare suite, which provides a real-time exchange of data between EMS and hospitals.

ImageTrend releases Version 3 of its patient registry system.

Liaison Healthcare announces the launch of EMR-Link, which allows clinicians to view lab and rad results reported through its hub on any smartphone.

Corepoint Health adds Direct Project protocol support to the latest version of its integration engine, giving customers a simpler way to exchange information with external organizations.

ICA announces its SmartAlerts service, which identifies high-risk patients in real time to reduce readmissions.

Government and Politics

The Meaningful Use Workgroup of ONC’s Health IT Policy Committee plans functionality goals for MU Stage 3.

ONC releases “Certification Guidance for EHR Technology Developers Serving Health Care Providers Ineligible for Medicare and Medicaid EHR Incentive Payments,” designed to help developers of EHRs for providers who don’t usually fall under HITECH (mental and behavioral health, non-acute care settings) design systems that are interoperable with HITECH-influenced EHRs.

Innovation and Research

A study published in JAMA finds that implementation of EHRs  Kaiser Permanente Northern California in 2004-2009 was associated with a slight but statistically significant reduction in ED visits (519 vs. 490 visits per 1,000 patients) and hospitalizations (251 vs. 239 per 1,000 patients) for diabetic patients. Office visit rates exhibited no association.  Another JAMA published study finds that EHR-powered small practices produced slightly better outcomes working under a pay-for-performance program.

Mike Wasser creates the very cool BloomAPI v 0.1.0, a free self-hostable API that queries the automatically updated latest version of the National Provider Identifier database. It also supports simple and complex online queries. You’ll be interested if you want to look up doctors in real time by name, ZIP Code, address, or NPI.

Brian Norris (@Geek_Nurse) follows up his Tableau-powered MU attestation slicer and dicer with one on data breaches. He seems to enjoy tearing into large, publicly available data sets to provide new insights and the results are cool, so he might accept suggestions (that’s where the breach idea came from).

A keyword-based search of online help wanted ads finds that healthcare IT-related job postings have increased by 86 percent since HITECH passed.

Southern Polytechnic State University in Atlanta will host the CDC Health Game Jam September 20-22, challenging entrants to quickly produce games that address CDC’s health priorities, such as disease prevention and healthy lifestyles.

Technology

The European Patent Office will grant PeriGen a patent that covers specialized techniques for displaying patient data to help OBs recognize trends and deviations from normal conditions.

Streamline Health Solutions releases its dual coding enhancement for the eCAC and eAbstract applications that allows users to assign ICD-9 and ICD-10 codes simultaneously.

Other

A HIMSS Analytics survey on clinical and business intelligence finds that only 9 percent of respondents plan to buy a dedicated solution that integrates with their EHR, but among those who do, Truven, Elsevier, and Cognos, all of which significantly trail buying whatever their EHR vendor offers.  

A debt collection agency that previously worked for the University of Chicago Physicians Group announces that an incorrect security setting on its Web server opened up information about 1,344 still-active claims to anyone who happened to find it. The problem was reported by a debtor who noticed that they could see the information of other debtors.

Hospital bond ratings may suffer from the costs and problems introduced by an Epic implementation, but the bonds of Dane County, WI (home of Epic) enjoy a AA+ rating from Fitch because of Epic’s employee growth.

Speaking of Fitch bond ratings, Mary Washington Healthcare (VA) gets a low rating and downgrade after a $28 million profitability hit in FY2012 due to a billing systems conversion and another $2 million drain due to CPOE implementation, causing the hospital to write off $25 million. I believe both systems are Siemens Soarian.

Weird News Andy wonders what the funniest or most interesting things providers have experienced from their patients as in this story, where a man coming out from surgical anesthesia notices a woman next to his bed and says, “Man, you are eye candy. Whoa. You may be the prettiest woman I’ve ever seen. Are you a model?” When reminded that the eye candy in question was in fact his wife of six years, he exclaimed, “"Oh my God, I hit the jackpot.”

Sponsor Updates

• Capario announces it is ready to begin ICD-10 testing and offers customers an online ICD-10 submitter testing tool at no charge.
• Aprima Medical integrates NoteSwift into its EHR system.
• A Forbes article on the use of IT to advance the delivery of healthcare highlights QPID Health, which it calls a “promising startup software development firm.”
• Convergent Revenue Cycle Management will offer RCM solutions to Siemens customers.
• HIMSS Analytics reports that Imprivata OneSign is the most widely selected SSO solution among hospitals using EpicCare.
• ZirMed will offer tools to help providers transition to ICD-10.
• ATT offers a white paper discussing how providers can use a collaborative care approach to earn incentives and prepare for accountable care.
• Sumit K. Nagpal, president and CEO of Alere Accountable Care Solutions, shares his thoughts on how the use of technology can improve patient outcomes.
• Etransmedia CEO Vikram Agrawal discusses the lack of access to qualified programmers.
• Greenway Medical adopts the EHR Developer Code of Conduct issued by the HIMSS EHR Association.
• Divurgent posts tips for go-live personnel on how to make the most of relationships with recruiters.
• HIStalk sponsors listed on the 2013 InformationWeek Top 500 include: ATT, CommVault, Emdeon, Informatica, InterSystems, McKesson, MModal, NTT Data,  TriZetto and Xerox.
• The CSI Companies acquires IT staffing firm Anteo Group.
• The GE Foundation awards The Guideline Advantage an $880,000 grant to provide 12 FQHCs with quality improvement technology from Forward Health.
• Billian’s HealthDATA hosts an #HITchicks tweet chat September 19 to discuss four gender-related HIT topics.
• Nuance partners with Hyland Software to enable eCopy ShareScan to scan directly into Hyland’s OnBase EMC system.
• Benson Area Medical Center (NC) reports that it has reduced IT costs and improved security of patient data by utilizing the e-MDs EHR software within the ClearDATA HealthDATA cloud platform.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 9/10/13

Quality Systems, Inc. Acquires Mirth Corporation

Quality Systems, Inc., parent company of NextGen, announces its acquisition of Mirth Corporation, which offers interoperability solutions that include the open source Mirth Connect integration engine. The acquisition was pursued to provide NextGen customers with improved data exchange capabilities.

Aprima and NoteSwift Announce Partnership and Distribution Agreement

Ambulatory systems vendor Aprima announces a partnership with NoteSwift that will bring voice recognition and natural language processing to the Aprima customer base. NoteSwift claims to reduce pointing and clicking by 75 percent and ensures that electronic documentation features will work while moving toward a narrative-based documentation model.

ONC’s goals for MU stage 3 in 6 charts

ONC’s primary goals for Stage 3 Meaningful Use are outlined. The theme for Stage 3 seems to be focused on squeezing improved outcomes out of the EHR and HIE infrastructures that Stage 1 and 2 established.

Medical Practices Move Health IT To Cloud

A market analysis surveying 8,000 CIOs, CFOs, and administrative support staff at US hospitals and practices finds that 87 percent plan to replace components of their core practice management solution within 12 months. Practices are turning to cloud-based options at a significantly higher rate to avoid upfront investments in licensing and hardware.

Readers Write: Big Data – The Next HIT/EMR Boondoggle?

Big Data – The Next HIT/EMR Boondoggle?
By Frank Poggio

Here we are on the back side of the HITECH wave. EMR vendors can see that the government-sponsored manna will soon end, so IT marketers have been prospecting for the next gold mine. They found it and it’s called “Big Data and Analytics.”

It really makes perfect sense. After they install the deca-million dollar EMR systems that capture and track mountains of healthcare operational data and send it to the government, what else are can they do with it? Analyze it! Analysis for clinical and administrative purposes, analysis for planning, analysis for diagnosis, for prognosis, for best practices, for financial management, growth strategies, market penetration, and more. To paraphrase an old cliché, “There’s got to be a pony in all that data somewhere.”

It is often repeated and rarely challenged that healthcare providers are a decade behind commercial industry when it comes to IT tools and implementation. That clearly is the case when we look at Big Data (BD). But before healthcare jumps into this numerical ocean, maybe we can learn something from commercial industry and bypass many of the hurdles and errors private industry hit during its initial foray into the world of analytics.

First, a little history. Today it’s called Big Data and Analytics, but in the 1960s it was called Operations Research, Management Science, or Quantitative Analysis. Operations research was actually an outgrowth of World War II. The Defense Department asked mathematicians to identify more effective and efficient methods for bombing the enemy. The British used modeling and data analysis to improve submarine warfare.

After the war, these sophisticated mathematical tools were applied to volumes of operational data captured by many business transaction systems of the 1970s. The focus was on optimizing production and improving forecasting in order to reduce the risk embedded in strategic decision making. The former used mathematical models such as linear programming and queuing theory aimed at maximizing throughput and minimizing costs. The latter was typically done with regression analysis, probabilistic models, and Monte Carlo simulation to assess and minimize risk. In the 1980s and 1990s, more sophisticated tools such as random walks, chaos theory, and fuzzy logic were developed and applied to financial and other business problems.

Today the thinking in healthcare is that with our ever-expanding sea of Big Data, we should start applying these same tools to help address the healthcare cost crisis. Not at a bad idea. But before we spend billions searching for our “pony,” we should at least learn something from the sins of our brothers in the commercial world.

During the ’70s and ‘80s, commercial industry spent billions trying to apply these concepts with only marginal benefit. It has only been in the last 10 or 15 years that analytics in commercial industry has really paid off with leaps in improved logistics and productivity, while the jury is still out on management, strategic, and predictive applications. It took decades for commercial industry to see measurable benefits from BD. Here are two of the reasons and their implications for healthcare.

Bad or insufficient data. Thirty years ago when commercial firms crunched big wads of financial data, they found that there were significant problems correlating econometric data with accounting data, and more so with tax and government data. Earlier in my career I worked for GE in one of their OR groups. We found that merging or correlating the data originally captured for the different audiences rendered unusable results. Much time and effort had to be spent reclassifying financial data to make it sync properly with econometric and government data. In addition, we came to realize that volume and statistical data not captured at the source was fraught with errors and misclassifications. Thousands of hours were spent normalizing, scrubbing, and disaggregating data before we could make reliable correlations for decision making.

Healthcare has some very similar challenges. The issue with accounting data versus econometric data is the same, but the disparities between reimbursement data (tax) and business operation or econometric data is far greater. As an example, commercial industry had to invest billions in sophisticated product/service costing systems, while today in healthcare, many institutions still rely on Medicare cost analyses, which any financial manager would classify as nothing better than gross approximations.

Many of the BD analytics will incorporate and be driven by cost comparisons. Medicare cost analysis is a long way from a true product/service cost accounting system.

Merging clinical data and financial data is currently the rage, but another big hole will be using billing documents, charges, or RVUs as a basis for analysis. Provider charges are not related to service cost because they have been warped by decades of government policy and payment nuances. They are as far from financial reality as we are from the sun. In addition, the coding and classifications embedded in billing documents have been twisted to meet the objectives of payors and payment rules. Everybody agrees that ICD-9 coding is inadequate if not inaccurate, yet no doubt it will be a core element in many of the BD analytics clinical  / financial models.

Reality versus the “model.” After several decades, commercial firms came to realize that many of the mathematical models they employed only loosely fit the real world. Models are far simpler representations of the real world and typically model builders fill in the blanks and more complex parts with assumptions.

The real world keeps changing. Yet many of the predictive tools we use such as regression analysis are based heavily on past performance and have limited ability to reflect change. Medicine is in constant change. Hardly a week goes by without a new research report that retires an old protocol and replaces it with a new one, while new drugs, modalities, and technologies are introduced almost every day.

The practice of medicine is both science and art. It is difficult to properly model the science part, let alone the art component. The same can be said for management: science or art? It took decades and millions of dollars before commercial industry realized the limitation of many of the predictive models they applied and how sensitive the predictions were to the underlying assumptions. Correctly modeling the subjective judgment component of management and medical decision making will be a very expensive task.

Clearly the old GIGO rule applies to Big Data as much as it applies to our day-to-day EMR transaction systems. The significant difference will be in the investment needed for BD just to get past level one GIGO. When we implement a transaction system we can see if it works effectively or has bugs in a matter of days. With Big Data and Analytics measuring the efficacy and impact can take years, be very expensive, and a financial boondoggle for vendors.

Next up: five things to check before diving into the Big Data ocean.

Frank Poggio is president of The Kelzon Group.

Readers Write: Seize the Opportunity: Making Your Meaningful Use Meaningful

Seize the Opportunity: Making Your Meaningful Use Meaningful
By Linda Lockwood, RN, MBA

In recent weeks, countless stories have appeared in healthcare-industry publications touting the complexities of Meaningful Use (MU) Stage 2 and the challenges ahead. While MU Stage 2 is no walk in the park, turning these challenges into an opportunity to establish the proper foundation at the outset goes a long way to setting up an organization for continuing success throughout the course of the EHR Incentive Program.

A strong MU program is also the basis for long-term quality and performance improvement that goes far beyond MU compliance. Viewed as strategically foundational, it can help health systems survive and thrive in today’s shift from volume- to value-based care delivery and reimbursement models.

Successfully meeting Meaningful Use requires more than just taking on another IT project, checking off boxes, and receiving incentive payments. Rather, a compelling case can be made for adopting a strategic and programmatic approach to enable ultimate success over progressive MU stages. It requires implementing a program with consideration of standardization, improved workflows, documentation at the point of care, interoperability, eCQMs as defined by multiple quality programs, and an auditable defense portfolio that provides evidence of the provider’s compliance and intent.

A full lifecycle looks beyond the initial incentive payments. It employs a comprehensive approach that closes the loop on every aspect of the program. It also establishes the culture and business plans that support improved patient care outcomes and efficiencies necessary to survive in the new, fee-for-value healthcare world.

Taking a programmatic approach to achieving meaningful use can provide foundational benefits in the long run. As we look back at the journey already traveled and ahead to MU Stage 2 and beyond, it is clear that the organizational approach to MU directly impacts future success. Organizations that chose the “easy way out” as a path to financial gain are now facing Stage 2 with increased thresholds, a focus on sharing data and engaging patients, increased emphasis on eCQMs, and realizing that they have significant work ahead.

Organizations that “seized the opportunity” at the outset and invested the time, money, and resources to set the proper foundation for value-based performance improvement are now in the lead with regard to successfully meeting the MU Stage 2 requirements.

If your MU approach was not robust enough, is all lost? Absolutely not. At the heart of every successful MU journey is an organization with a commitment from the top to view MU as a foundational strategy to improve quality and support the goals laid out by CMS. Much has been said about the transitions of care, patient engagement, and quality reporting issues, but what many don’t often talk about is how to position an organization for success. Some key points to consider include:

• Identify and act upon lessons learned
• Embrace a big vision; leverage the MU effort
• Understand the scope and level of effort required; don’t underestimate Stage 2 challenges – thresholds, interoperability, and patient portal and engagement
• Include all stakeholders; align with quality and performance improvement
• Develop program management and governance
• Focus on adoption and change management
• Understand vendor approach; challenge and verify
• Create an auditable defense portfolio and an audit plan
• Budget for upgrades, software and services; understand how this will affect the timeline
• Establish a comprehensive portal plan to include security, access, outreach, content, policies and procedures
• Pay special attention to the Summary of Care – the complexities and the content to include physician documentation for care planning.

Meaningful Use is truly a journey that must be embraced beyond the IT department. To be successful, organizations must employ proactive executive sponsorship that supports the long-term, value-based, performance-improvement vision. Realization of the vision depends on developing and delivering a well-structured program. Organizations that adopt this approach will be aligned for success; they will be the frontrunners in this new world of value-based payment and performance improvement.

Linda Lockwood, RN, MBA is the partner of advisory services at Encore Health Resources of Houston, TX

Curbside Consult with Dr. Jayne 9/9/13

Before landing my current job, I had a brief sojourn in the consulting world. At my first placement, the director who hired me said this: “A consultant is someone who knows the same things you do but comes from more than 50 miles away and has a nicer briefcase, so people will listen and follow directions even though you’ve told them the exact same thing.” I giggled a little at the time because she had a Chanel tote and I had a Samsonite on wheels, but we had a successful engagement nevertheless.

In looking for other definitions of the consultant role, Urban Dictionary describes it as:

A self-proclaimed expert that extorts inflated fees from a host company in return for vague and predominantly incorrect business advice. The successful consultant detaches from its host at the exact moment its parasitic qualities are discovered by upper management …

I’ve certainly come across that type before. One of the first consultants I ever encountered could have been the reason that the “buzzword bingo” game was created. I remember sitting across the conference table thinking, “Who is this woman and who does she think she’s kidding?” as I tried to weed through the barrage of words that had very little meaning. Luckily our leadership quickly determined she was all fluff and no stuff and showed her the door. Unfortunately there are some people who are so dazzled they don’t see through the hype until long after the consultant has flown the coop.

There are many reasons why organizations hire consultants and there are many different types of consulting offerings in the healthcare IT world. Even with the best consultants, though, it’s important to manage them and understand exactly what they are supposed to be doing and the role they should play in the organization. How consultants are managed depends on the reason they are hired.

Consultants can be leveraged to backfill skill sets that are lacking in an organization. These are often well-defined, one-time projects such as constructing an interface, mapping a lab crosswalk, or installing hardware. In this situations, it’s fine to have a “once and done” philosophy and let the consultants get in and get out.

For other backfill situations such as training users prior to go-live or supporting them after, it’s important to ensure knowledge transfer. A forward-thinking organization will include time in the proposal to allow the consultant to train existing team members in the target skill set and proctor the team until it is able to function independently.

In the first situation (once and done), organizations can get away with minimal management – ensuring timelines are met and deliverables are high quality with sufficient documentation. The second situation requires more active management to ensure that training is occurring and that the team is absorbing in a manner that they can later assume the role played by the consultant. It also requires appropriate instruction to the team so that they can understand what is expected of them and that they are to adopt the methodology agreed on by the leadership and the consultant.

Another reason to use consultants is workforce augmentation – when an organization has a skill set but is involved in a project that requires more resources than they can allocate. Consultants in this role may work better remotely. I’ve seen consultants quickly lose productivity when brought on site because of constant distractions. It’s tempting to try to pull an expert resource into other initiatives and difficult for the consultant to combat scope creep. When staff augmentation occurs on site, expectations regarding time and attendance should be made clear at the beginning of the engagement. Some attention should be paid to the team dynamic so that existing staff doesn’t feel intimidated.

On the other hand, I’ve used consultants in the past simply because I needed someone to BE intimidating. I’ve leveraged our vendor to play “bad cop” to our internal “good cop.” In other situations, I’ve been asked to be the bad cop myself. The key to this strategy is making sure the consultant understands the end game. It’s never polite to knowingly make someone a punching bag, especially when you may have to work with them again down the road.

Consultants are also used for strategic planning efforts. This is where some bad consultants take advantage. The Urban Dictionary definition continues that, “the consultant preys upon upper management’s lack of job expertise and unrealistic dreams of grandeur.” This is more likely to occur when there is a lack of leadership or vision, making it easier for flimflam artists to thrive.

I’ve been in situations where management really has no idea what is going on. They don’t know exactly what they want a consultant to do or what they hope to accomplish, other than wanting someone to “just fix this.” A skilled consultant will sit down with the client and explain that there is no magic wand to be waved. He or she will then work with the client to develop realistic and actionable goals for the organization.

Too many managers assume that because a consultant is on the scene, they can be on autopilot. It’s important to understand that the consultant isn’t always part of the management structure. Unless the engagement is set up in a certain way, consultants can’t force employees to do their jobs or take action when sloppy work is done. They must work with the existing reporting structure to deal with problem people, processes, and policies.

We’ve all had our experiences with consultants run amok as well as with those that pushed us to excel. Send yours my way and I’ll share the best of the best (and the worst of the worst) with HIStalk readers.

E-mail Dr. Jayne.

Quality Systems/NextGen Acquires Mirth

Quality Systems announced this morning that it has acquired Mirth Corporation, which offers the Mirth Connect open source integration engine and related tools. QSI says the acquisition will allow its NextGen Healthcare subsidiary to offer better data exchange capabilities, including participation in HIEs.

In the announcement, QSI President Steven Plochocki was quoted as saying, “The acquisition of Mirth will further strengthen QSI’s capabilities across the board, based on the new level of data integration and migration functionality it brings us. We intend to expand our client base and position the company for continued growth, particularly within both the connectivity and EHR replacement markets, as we work to meet the needs of hospitals and physicians as well as their patients. Mirth’s solutions, coupled with the depth of our current portfolio, will enable us to emerge as one of the most connected solutions in the industry. This will help accelerate our ACO strategy, support our rapid expansion into the interoperability market and give us the opportunity to cross-sell Mirth’s solutions."

The company says the Mirth brand, team, and offices will remain unchanged.

Morning Headlines 9/9/13

Aetna Once Offered To Buy NY Startup ZocDoc For More Than $300 Million And The Founders Walked Awa

A Business Insider article reveals that in 2011 insurance company Aetna offered to buy ZocDoc for more than $300 million but ZocDoc’s founders walked away. Insiders at the company, now valued at north of $700 million, say that ZocDoc is pursuing a public offering rather than a buyout.

Will An App A Day Keep The Doctor Away? The Coming Health Revolution

A Forbes article explores the market drivers that are contributing to meteoric growth in the mobile health market, citing VC and serial entrepreneur Vinod Khosla, who predicts that algorithms will one day be capable of replacing 80 percent of doctors.

Baylor Health Care System Wins 2013 Tech Titans Award for Successful Needs-Based Customizations to Allscripts EHR

Baylor Health Care System receives the 2013 Tech Titans Technology Adopter Award, an award issued annually by the largest technology trade association in Texas, for enhancements developed to improve its Allscripts CPOE and physician documentation solutions.

MyMedicalRecords Wins Appeal, Will Proceed With $30 Million Claim Against SCM

MMRGlobal is moving forward with a $30 million breach of contract suit against CA-based Surgery Center Management, LLC, a company that provides outsourced business services, including IT, to surgical centers in the region. The company signed a settlement with MMRGlobal in 2011 agreeing to pay $5 million per year in patent licensing fees but has since stopped paying.

Monday Morning Update 9/9/13

From The PACS Designer: “Re: Apple’s fingerprint reader. With Apple possibly launching several products next week, TPD thought it would be good to give you a glimpse of what’s coming next. The fingerprint reader, if introduced, brings an interesting security solution for healthcare in that lost devices will be unusable as long as the security lock remains active.” Above is a leaked photo of a new iPhone start button with what appears to be a built-in fingerprint reader, from Sonny Dickson.

From IT Guy Turned Patient: “Re: Apple and healthcare. Interesting perspective. I could still argue persuasively for the Windows model. but what I know about the healthcare system could be inscribed on the top of a pin and still leave room there for me to ice skate. From my perspective as a recent user of healthcare, what seems to be the driving factor is simply referrals. I go to a primary healthcare provider who by most standards would be considered way better than average. I am listened to regarding symptoms, then referred to a specialist to whom I give the same answers to regarding symptoms, I am tested, receive boilerplate textbook treatment, and ushered out the door as I hear a receptionist behind me say, ‘Next.’ Meanwhile, five months later, nothing has changed. I am in exactly the same boat as I was pre-visit to either facility except about $1.800 lighter. I’ve never been called to be asked, “How are you? How did we do?” There’s no warranty. No one really seems to care once you’re out the door, which is interesting since the industry that I work in routinely makes that call. Why do people not howl at the moon over piss-poor healthcare the way they do over even mediocre or worse car care or home remodeling? I don’t know what it would take. I don’t know whether the Apple model or the PC model would work better, but from my point of view the entire experience seems so institutionalized and insulated from capitalism and the rest of the world. Something needs to change, but getting government more involved rather than less won’t accomplish that. One thing I know for certain is that we live in the United States of Unintended Consequences.” I’ll say again as I always do — you get what you pay for. More precisely, you get what insurance companies and the government pay for, and that’s patient and procedure volume. Unfortunately for now, nobody’s paid very much to care about how you like it.

From Caveat Emptor: “Re: ethics. Is a sales employee who feels their former employer engaged in unethical sales practices obligated to inform customers instead of accepting a generous severance package that prevents disclosure of those practices” I’ll open it up to readers for comments, but my answer is no. It’s not appropriate (much less an obligation) for a company’s former employee to start calling customers making accusations about company ethics. If the sales practices were all that bad, customers will find out and make their own complaints (possibly legal ones) that would carry more weight than those of someone who didn’t speak up while drawing a paycheck from that company, but suddenly feels moved to do so after quitting. I don’t have specifics about the practices mentioned here, but I’ll ask readers to weigh in anonymously on that issue as well – what are some really abhorrent sales techniques you’ve seen used?

Half of poll respondents attend the HIMSS conference because they want to see other attendees, while only 15 percent are primarily drawn there by the educational sessions (which is probably a good thing based on my perception of the slide in quality of the education track). New poll to your right: which of John Halamka’s five CIO challenges will be most important?

George Giorgianni, who has worked for HBOC, SIS, DocusSys, and Unibased in his 35 years in healthcare IT, will retire on October 4.

Cornerstone Advisors names John McGuinness, MD (Meditech) to the newly created position of CMIO.

Baylor Health Care System wins a local technology trade association’s innovation work for its development of add-on modules for Allscripts Sunrise Clinical Manager, including a physician documentation tool.

Jimmy Weeks posted on Twitter this photo of the Bridgeport Hospital appointment conversion team beginning the move to Epic. They’re part of Yale New Haven Health.

A business site says that Aetna once offered to buy physician appointment scheduling app vendor ZocDoc for $300 million, but the founders turned the deal down, probably wisely since the company is valued at a lot more than that now.

Vince’s HIS-tory Part 4 on Cerner looks at the company in its early LIS-centric days in the form of a customer’s system search.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: WWJD: What Would (Steve) Jobs Do If He Worked in Healthcare IT Instead of Apple?

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 June 2009.

WWJD: What Would (Steve) Jobs Do If He Worked in Healthcare IT Instead of Apple?
By Mr. HIStalk

I’m having an identity crisis. After working exclusively with Windows PCs for decades, I bought a Mac for a family member.

The MacBook is easy to use, sleek, and full of eye candy. Its lit-up Apple logo exudes barely contained and self-aware hipness. I’m not fully convinced that it’s not just “different” instead of “way better” than the usual PC clones running Windoze, but I admire Apple for using its advantage as a proprietary hardware/software vendor to package cool design, thoughtful engineering, and a boffo user experience into a machine that ends up doing pretty much the same stuff you can do on a PC, only making you feel smug while doing it.

All the Mac people I’ve known were artsy types. I figured them to be right-brainers who were too preoccupied with social protests and making vegan brownies to handle manly computer tasks like using Regedit or spending a pleasant afternoon reinstalling WinXP after running out of options to fix one corruption or another. And, Steve Jobs in his jeans and turtleneck was one beret short of being a full-on artiste, while Microsoft gave us the hyper-annoying loudmouth Steve Ballmer as the cartoonish, kill-our-enemies capitalist pig who was ideally cast for the political climate of that time.

I’m convinced there’s a fortune to be made for someone to create the healthcare IT equivalent of Apple.

The industry is a lot more like Windows than Mac. Systems were clearly designed with user experience and brilliant design way down on the list, which is pathetic given that busy doctors and nurses are supposed to use them happily and constantly while not killing patients. Instead of Apple-like control over the entire ecosystem, customers just buy whatever systems they want, throw them in the same data center, and then fuss when the end result isn’t exactly seamless.

Systems break a lot, they disappoint their owners, and they are a long way from being cool. Fanatic loyalty to a product or company is unheard of, not too surprising considering that vendors titrate their effort (and quarterly expense) to a customer satisfaction level that’s only very slightly above the “let’s kick these guys out and start over” level.

Epic is kind of Apple-like. They have a quirky CEO who has an unwavering agenda, a funky campus, products that carry a premium price and never get de-installed, and tight control over their ecosystem. They hire easily influenced kids instead of other vendor’s retreads. Their customer list is relatively small but cult-like, jostling for space at the annual Verona gathering like Apple-heads annually migrating to California.

Epic does shun one of Apple’s core competencies, however: slick marketing that intentionally creates a world-against-us mystique. People still talk today about that shocking and downright arrogant 1984 Super Bowl commercial that declared war between an Macintosh-empowered creative class and oppressive Big Brother mainframers portrayed as storm troopers (which was really more of a minor skirmish since Apple wasn’t exactly a force to be reckoned with back then).

On the physician EMR side, you’ve got companies that have some Apple characteristics as brash giant-killers: eClinicalWorks, athenahealth, e-MDs, and a few others. Big companies have bought some of the potential Apples, although it’s hard to simultaneously bring them into the corporate fold while not screwing up what made them interesting in the first place. (What would you get if GE bought Apple? GE.)

So here’s my business advice (understandably highly valued and sought after since I’m a wage slave in a non-profit hospital who knows nothing about business): now’s the time to start up a physician systems company using Apple as the model. The market is fragmented, some of the major players and their technologies are stuck in the 1980s, Uncle Sam is throwing money around like only someone with a currency printing press can, and the number of doctors doing “none of the above” on an electronic system is 80 percent. Getting even 5 percent of that market would be a fantastic business.

And here’s my highly secret strategy that nobody would think of: hire a few people from Apple to show you how to do it. The reason HIT products and companies look alike is because the same people were involved, floating from one job to another and bringing their same preconceived notions along for the ride.

You’ll know when you’ve succeeded: users will clamor to have your lit-up logo on their laptops to show everyone how cool they are.

Morning Headlines 9/6/13

Health IT Czar on Making Meaningful Use ‘Meaningful’

Outgoing ONC Chief Farzad Mostashari, MD, offers advice to clinicians during an interview with Medscape Editor-in-Chief Eric Topol, MD.

Health IT Policy Committee Summary

The HIT Policy Committee hears final recommendations from the FDA Safety and Innovation Act Workgroup, concluding that for the most part HIT should not be subject to FDA premarket requirements unless the product qualifies as a medical device. The group agrees that post-market surveillance should include reporting and implementation testing.

NextGen Healthcare, Clinical Decision Support Consortium and WVP Health Authority Join to Launch Clinical Decision Support Pilot

NextGen announces that it has created an interface to Partners Healthcare Systems’ clinical decision support tool so that physicians using NextGen will be able to send a CCD to the tool and then immediately receive an evidence-based set of recommendations appropriate for that patient.

3D Printing Is a Matter of Life and Death

A surgeon at the University of Michigan prints a lung splint with a 3D printer, saving an infant with a collapsed trachea.

News 9/6/13

Top News

The HIT Policy Committee approves multiple recommendations presented by the FDA Safety and Innovation Act (FDASIA) Workgroup, including:

• HIT should not be subject to FDA premarket requirements except when it constitutes medical device accessories or involves certain forms of high-risk CDS, such as computer-aided diagnostics. EHRs, decision support algorithms, and HIE software may be subject to regulation.
• Vendors should be required to list products that are considered to represent potential risk.
• Post-market surveillance of HIT should include reporting from users and vendors and also include post-implementation testing.

The committee also called for adoption of existing standards and creating new standards to address specific areas, including HIE. The recommendations now go to the FDA, ONC, and FCC, which are expected to release a proposal for public comment early next year.

Reader Comments

From Dr. Loredana: “Re: male vs. female physician compensation. A study found that women docs spend more time with patients. Therefore, they see fewer patients and thus make less money. Physicians’ time should be valued and addressed just like any other resource in healthcare. It is finite and scarce and we only have 24 hours in the day like anybody else.” A quick Google search uncovered a number of studies indicating that female physicians spend an average of 10 to 50 percent more time with patients than their male counterparts. Now I am curious if there are any studies tying outcomes with time spent per patient encounter.

From Tallman Letters: “Re: consulting firms and vendors. I’m turning to you, our most trusted source! Which healthcare consulting firms or vendors are most qualified to (a) provide technical consulting to providers about what technical architecture they should use; (b) build a healthcare data model; and (c) implement the tech architecture for full EDW/BI? Keep up the great and amusing work you do for us all!” I’m turn to my most trusted source – readers. Please leave a comment with your thoughts for TL.

HIStalk Announcements and Requests

Some of this week’s highlights from HIStalk Practice include: athenahealth reveals development plans for its recently purchased Arsenal complex, including walking and biking paths, an incubator for HIT startups, and a beer garden. Minnesota State Fair visitors are given coupons for free healthcare e-visits. More than half of all medical students use tablets as part of their medical training. The IT administrator at an orthopedic practice accesses a physician’s electronic signature to forge prescriptions. Dr. Gregg discusses the darker side of vendor-provider relationships, including Practice Fusion’s opt-out policy for sending patients emails that appear to come from providers (I also share my view.) Thanks for reading.

On the Jobs Board: Healthcare Customer Advocate, Clinical Applications Consultant, Project Manager.

Acquisitions, Funding, Business, and Stock

Agilum Healthcare raises $1.43 million in a debt offering.

Teladoc acquires fellow telemedicine services provider Consult A Doctor for an undisclosed amount.

SAIC announces Q2 results: revenue down 12 percent, EPS $0.13 vs. $0.32, missing expectations and cutting its 2014 outlook. Its health an engineering segment did better, but only because of the recently acquired maxIT Healthcare. SAIC plans to split itself into two companies, with its national security, health, and engineering operations to be moved to a new company called Leidos, with headquarters in Reston, VA. Healthcare is the smallest of the three operations with 6,000 employees.

Sales

Tenet’s Saint Louis University Hospital selects iSirona’s device connectivity solution.

Pekin Hospital (IL) selects Interbit Data’s NetSafe business continuance and downtime protection software.

The VA awards AMC Health a five-year, $28.8 million contract to provide telehealth solutions and services.

Mt. Washington Pediatric Hospital (MD) contracts with HealthCare Anytime for its Enterprise Patient Portal Suite.

Community Medical Centers (CA) selects Infor Cloverleaf.

People

Cerner promotes Zane Burke from EVP of the company’s client organization to president. Neal Patterson, who covered the president role since former President Trace Devanny left in 2010, will retain the titles of chairman and CEO. Cerner says that Burke’s promotion does not represent a formal succession plan announcement.

HIT consulting firm Meditology Services names Michael Flynt (Workday) VP of sales.

Patient engagement portal provide Omedix appoints Shay Pausa (ChiKiiTV/Magnet) CEO.

Caradigm appoints Joel Ratnasothy, MD (Fujitsu) as medical director for Europe, the Middle East, and Africa.

Anil Chakravarthy (Symantec) joins Informatica as EVP/chief product officer.

Diane Cecchettini, RN, president and CEO of MultiCare Health System (WA), announces her retirement next year. She served as a flight nurse in Vietnam, was a troop commander in Desert Storm, was president of the Washington State Hospital Association from 2005 to 2007, and won several IT awards.

Marc Donovan (World Wide Technologies) joins Nexus as sales director for the company’s connected healthcare practice.

Announcements and Implementations

Virginia Hospital Center will invest five to $10 million to consolidate its 100-plus employed physicians into one multi-specialty group and migrate the currently separate practices to eClinicalWorks.

Cerner will integrate Elsevier’s CPM CarePoints and InOrder evidence-based content solutions into its PowerChart EHR.

Artemis Health Group will add Health Language’s clinical language management tools from Wolters Kluwer Health into the Artemis OB/GYN EHR, PM, and patient engagement solutions.

Carolinas HealthCare System will use aggregated claims and clinical data from Verisk Health to analyze and manage population health.

Castle Medical Center and Hawaii Pacific Healthcare will join Health eNet, Hawaii’s statewide HIE.

A new KLAS report on enterprise patient access finds that best-of-breed solutions are common, with the most important functions to users being calculation of estimated patient responsibility, eligibility verification, and preauthorization.

HealthTech’s YourCareCommunity.Com v1 earns ONC-ACB certification as a modular EHR.

Intelligent InSites adds integration with HyGreen’s hand hygiene monitoring system to warn workers who haven’t washed their hands.

The UHC alliance announces plans for an automated program that will extract clinical and administrative information from the IT systems of its members and transfer it to UHC for benchmarking. NYU Langone Medical Center and Cleveland Clinic will be the first adopters, with the system expected to be available to all UHC members by the end of 2013.

NextGen Healthcare client Willamette Valley Providers Health Authority (OR) deploys a clinical decision support tool developed by the Clinical Decision Support Consortium that takes a request for CDS from NextGen Ambulatory EHR, delivers it to an enterprise clinical rules service at Partners HealthCare for analysis, and immediately returns recommendations within the NextGen application. The “cool” factor here: community-based physicians can access CDS data from a large academic medical center across the county and retrieve recommendations at the point of care. The Consortium aims to establish nationwide consistencies for CDS recommendations and is comprised of members from provider organizations and EHR vendors, including Partners and NextGen.

Government and Politics

Brian Norris of Social Health Insights LLC  created a cool visualization page for Meaningful Use attestation data using tools from Tableau Software.

Innovation and Research

GE, Under Armour, and the National Football League launch the GE NFL Health Health Challenge, which will award prizes of up to $10 million for concussion-related solutions that can include technologies to detect and measure brain injury.

Palomar Health expands its Google Glass incubator Glassomics to include smart watch technology in healthcare. For some background on the smart watch market, see Lt. Dan’s post on HIStalk Connect, “A Primer on the Up-and-Coming Smartwatch Market and What It Means for Healthcare.”

A Mayo Clinic study finds that data from the Fitbit activity tracker can help predict the mobility of post-op patients and help clinicians customize their care plans.

Research by the Pennsylvania Patient Safety Authority finds that EHR default values cause quite a few errors in drug doses and times, although nearly none of the errors caused patient harm.

Other

John Halamka’s five biggest CIO challenges for the next few months:

1. IT requirements driven by mergers and acquisitions
2. Regulatory uncertainty related to ICD-10, HIPAA Omnibus, and Meaningful Use Stage 2
3. Meaningful Use Stage 2 requirements, particularly at shops like BIDMC that build their own applications
4. The ability of provider organizations to keep the doors open while trying to meet all the regulatory requirements as revenue declines and risk-based reimbursement increases
5. Leading in real time

I am ashamed to admit that I found this story just a teeny bit amusing, though so pathetically wrong. A patient files a civil lawsuit against Torrance Memorial Medical Center (CA) after discovering that an anesthesiologist had decorated her face with stickers while she was unconscious during surgery. A nurse’s aide snapped a photo of the patient, who was freshly adorned with a black mustache and teardrops. The anesthesiologist and other involved employees were disciplined but not fired.

Three UK doctors face a loss of their medical licenses after allegations that they copied material from a book to create an iPhone app that helps evaluate clinical evidence. One of them faces an additional charge of posting a positive review of the app on the App Store without disclosing that he has a financial interest in it.

A Forbes article wonders if Cleveland Clinic can save its home city with its $6.2 billion in revenue, $300 million in operating income, $10.5 billion in assets, 42,000 employees, its own 141-trooper division of the state police, and now its plans to spin off for-profit companies and jump start the local economy with the Global Center for Health Innovation, scheduled to open next month with HIMSS as its largest tenant. Cleveland’s population has dropped 10 percent in the last decade and median income fell 60 percent, with its only economic bright spot being healthcare.

Anybody see a HIPAA problem with this pre-med student’s Google Docs-based patient tracking solution?

Cardiologist Eric Topol, MD, who is also editor-in-chief of Medscape as of February 2013, interviews Farzad Mostashari, MD. It’s good. Some snippets and factoids:

• Mostashari came to the US from Iran at 14, then went to Harvard and Yale.
• “Ninety percent, probably, of what happens in healthcare today has no basis in evidence. At the very least, I think what we owe ourselves and our patients, what we really want to do is: If we have variation, if we make a decision that is not based on the general guideline, it should be studied so that we learn something from that variation.”
• “The dream is that with every encounter, you know everything about the patient. You know everything about any medical knowledge that has ever been generated and you know everything about what is happening right now in the community where we are. Because the treatment for a sore throat is going to be different in January with the flu epidemic than it is going to be in September when asthma is peaking. So you have to bring in the 10 to the 6th power, the 10 to the 3rd power, and the 10 to the zero in that encounter. Whatever you do generates and goes back to teaching everybody else what is going on in the community, what is going on in medicine, and contributes to this patient’s knowledge. Right now my visit doesn’t even contribute to my next visit.”
• On $37 billion in HITECH incentives: “I think doctors would say that they earn it. No one gives out anything.”
• Mostashari and US CTO Todd Park roomed together when they moved to Washington, DC four years ago in July, sharing a small apartment with no air conditioning.
• On the jokes that ONC stands for “Office of No Christmas” because of the push to get the work done. “That is what it felt like — that there is this incredible urgency. You have a day, a week, a month, and pretty soon the opportunity to make a difference is gone.”
• “Meaningful Use, it is a tool. Take that certification, take that decision support, take that quality measurement. Don’t have quality measurement done to you or say, ‘I am going to be paid and judged based on quality. I can’t control that.’ What you can do is make it meaningful; take the tools and make them meaningful. Help your staff make the tools meaningful.”
• “We are going to solve this path that we have been on towards unsustainable cost growth. One out of every $5 spent in this country is being spent on healthcare. It is just amazing, and it is not sustainable. It is not sustainable for people, for families, for businesses, for state governments, for federal governments. It is not sustainable for anybody. We are going to solve that. I think we are going to solve it not by cutting people back, not by saying ‘You can’t get that,’ but by delivering better care. I really believe that.”

Weird News Andy thinks it’s cool that a University of Michigan 3D-printed lung splint saved a child’s life. The surgeon says he hand-carves such devices when necessary, but he can’t match the accuracy or speed of the computer.

Sponsor Updates

• Forrester Research names Ping Identity a leader in its identity and access management report.
• EDCO creates  a video explaining its point-of-care medical records scanning process.
• Truven Health Analytics releases ActionOI Practice Insights, which allows hospitals and practices to compare productivity, costs, and utilization.
• ZirMed partners with EHR Integration Services to provide Allscripts PM and GE Centricity Group Management customers integration with ZirMed’s RCM, clinical communications, and analytics solutions.
• Kareo tops Black Book’s list of Top 20 Seamless Software Vendors for EHR, Practice Management, and RCM.
• NYC REACH, the REC for New York City, assigns Aprima the Medical Meaningful Use Champion status in its vendor recognition program.
• Medseek reports that 10 healthcare organizations are using its Empower enterprise patient portal and another 11 will go live in the next six months.
• Paul Taylor, MD, CMIO of Wellcentive, outlines the performance and improvement part of the Health Care Network Maturity Model.
• Vitera hosts a September 25 webinar on preparing for the PCMH transformation.
• An SiS blog post lists the “Top 6 Things Anesthesia Providers Should Know When Evaluating AIMS.”
• GetWellNetwork shares data from its healthcare system customers that demonstrate the relationship between patient engagement and improvements in patient satisfaction, quality and safety, and finance and operations.

EPtalk by Dr. Jayne

I wrote last week about a Wall Street Journal Health Blog piece. It referenced a survey about what motivates doctors as they make care decisions. More than half felt physicians want to do what’s best for the patient, where the choices of “fear of lawsuit” and “business / financial considerations” each received 21 percent of the response.

Since I covered fear of lawsuits already, let’s talk a little bit more about financial considerations. It’s easy to see a response of “business / financial considerations” and assume that means “what’s in the provider’s best financial interest.” I don’t think the vast majority of clinicians think that way. If we were constructing this survey, we’d have more granular choices. One of the main things I think about (after discussing the clinical appropriateness of a proposed procedure, treatment, or test) is whether there is a way to pay for the test. It was bad enough when all I had to worry about was whether the patient had insurance that would cover it, but today it’s so much more complicated. It doesn’t do any good to recommend a treatment if there is no way the patient can receive it due to financial constraints.

First, we have to think about whether the patient even has insurance coverage or not. If they do, is this symptom or condition related to anything pre-existing that may or may not be covered? If not, do I need to contact the payer for an authorization? How difficult is it to obtain the authorization? Are there tests, documents, or examples of trials of therapies that have to be provided for a medical review board to determine coverage? Does the payer have arcane rules that have been grandfathered into the plan regardless of recent legislation to ensure services are covered?

Should the authorization be obtained, are there limits on where I can send the patient? Does the patient have geographic or transportation issues that would make it more feasible (economically or otherwise) to do it at one facility over another? Does the patient have religious preferences that are in conflict with the mission of the preferred facility? Do I have to write a letter to explain the distress it would cause if allowances can’t be made for a non-preferred facility?

The next consideration is that even though the patient may have insurance and the procedure may be authorized, the out of pocket cost for the patient may be more than he or she can bear. Those under high-deductible plans are electing to defer care to the end of the year in hopes that they will meet their deductibles by then. If it’s a preventive service, we may have the opposite time shift: some plans have yearly aggregate limits on preventive services, so if they’ve already met the limit for the year, they may elect to push it to the next calendar year. Regardless of the kind of coverage, we have to know whether the patient can afford the patient portion of the cost, whether it’s a deductible, co-pay, co-insurance, or something else.

Let’s say the patient does not have insurance coverage. We have to think through whether the patient qualifies for any public assistance programs and if so, how long it would take to become enrolled vs. how acute the need for the test / treatment / procedure might be. If they don’t qualify for public assistance, are there any grant programs? Are there public health resources? Is there a hospital or imaging center doing a free outreach program? If not, do I have any colleagues in my hip pocket who would be willing to perform the procedure with a payment plan or under other medical hardship arrangements? Does the facility make allowances for self-pay patients and do they allow them to negotiate price? If so, what is a reasonable price? Where can the patient get more information?

Once we get through figuring out if we can proceed and how we’re going to pay for it, can the patient afford to take off work to have surgery, complete treatment, etc.? Is he or she covered by the Family and Medical Leave Act? Does he or she have to wait until they are eligible for coverage? Is there a short-term disability policy in place, and if not, does the patient have enough vacation time or other resources to be able to be off work? Or does he or she have to take the time off unpaid? Are there other family dynamics or barriers to care, such as who will take care of small children while the patient is in treatment? (Remember assessing barriers to care is part of being a patient-centered medical home and participating in pay-for-performance and accountable care initiatives. Believe it or not, worrying about the patient’s childcare arrangements has become our problem.)

If you’re not a provider, are you exhausted just reading this? I know I am. The absolute last thing to cross my mind in these situations is whether my practice will make any money ordering the intervention. Looking at the costs in the office for clerks, paper pushing and administrative shenanigans, multiple phone calls, faxes, the patient’s time, and my time to work through all of this, we’ve already lost money before the order even leaves the EHR. When you think about it this way, I’m surprised that business and financial considerations didn’t rank higher in the survey because it seems they’ve become part of nearly every clinical decision we make.

Maybe elements like this roll up under the attempt to do the right thing for the patient. Or maybe the average person taking the survey didn’t think about all these different factors. This wasn’t really a scientific survey, but I bet if you wanted to create one, the qualitative researchers would have a field day. I’d enjoy seeing the comparison between a survey of the general population vs. a survey of healthcare providers.

What do you think motivates doctors as they make care decisions? Email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 9/5/13

Cerner names new president

Cerner promotes Zane Burke to president, replacing Chairman and CEO Neal Patterson, who temporarily added the President title when Trace Devanny left the company in July 2010. Burke has been with Cerner since 1996 and most recently served as executive vice president of the client services organization.

Mostashari leaves policy designers final thoughts

National Coordinator for Health IT Farzad Mostashari, MD attends his final HIT Policy Committee Meeting, discussing the goals of MU3 and the challenges the industry will likely face on the road ahead. He also took the opportunity to thank the committee members for their work.

Your Heartbeat Is Your New Password

Developers at Bionym have created a bracelet that authenticates users based on the unique peaks and valleys of their heart’s rhythm. Users place their fingertip on a sensor embedded in the bracelet for a few seconds while an ECG is captured and compared to a stored version to confirm the wearer’s identity and authenticate that user to a host of devices.

Readers Write: Be the One

Be the One
By Daniel Coate

Amidst all the paperless aspects of our world, last year I subscribed to the New York Times Sunday edition on paper. I really enjoy the old-school nature of waking up Sunday morning, walking down my driveway to pick up the paper, and spending a couple of hours with a cup of tea or coffee reading the in-depth analysis of the week’s news.

I was taken by an article in the December 8, 2012 edition of the paper entitled, “Billion-Dollar Flop: Air Force Stumbles on Software Plan.” I’ve had it on the corner of my desk since and am just now thinking I should write about it.

The bottom line is that the Air Force is canceling a six-year modernization effort of its logistics systems and processes. On the technology front, they were attempting to convert from custom legacy logistics systems developed in the 1970s to an Oracle ERP system. The six-year track of the project cost “them” $1 billion (oh, and when I say “them”, I really mean “us”). By the time the Air Force canceled the project, it had realized it would cost an additional $1 billion just to achieve one-quarter of the capabilities originally planned. As a reminder, one billion is a big number – if you were to start counting right now at a rate of one number per second, you’d get to 1 billion in 2045 (32 years).

In analyzing the reasons for this colossal failure, many contributing factors were identified, such as starting with a big bang approach that tried to put every possible requirement into the program, making it very large and very complex.

However, the main reason identified was, “…a failure to meet a basic requirement for successful implementation: having ‘a single accountable leader’ who ‘has the authority and willingness to exercise the authority to enforce all necessary changes to the business required for successful fielding of the software.’”

As we all know, there are a number of exciting developments and converging forces changing the healthcare industry right now. With these converging forces, healthcare organizations are under tremendous pressure to address a number of priorities simultaneously:

• Reduce operating costs while driving value
• Implement and realize the full benefit of electronic health records
• Transition from volume to value and plan for the accountable future
• Harness the power of data and analytics to drive a data driven culture
• Enable the connected community across the care continuum
• Achieve Meaningful Use and complete ICD-10

While it seems like a tidal wave, these initiatives are aimed at paramount goals: better care, better health, and lower per capita costs. It’s essential that we as an industry heed lessons learned like this example from the Air Force to avoid similar stumbles or flops. While it’s never a comfortable position to be that single accountable leader, I think it’s important that as we all do our day-to-day work, we look for ways where we can either assume that leadership or recommend that a specific person assume that position. It is a key way to drive value from investments in information technology, operations and process improvement, and change leadership.

Daniel Coate is principal and co-founder of Aspen Advisors of Pittsburgh, PA.