Morning Headlines 1/29/13

Computer Programs and Systems, Inc. Announces Formation of TruBridge, LLC

CPSI announces the formation of TruBridge, LLC, a wholly owned subsidiary which will provide business services, consulting services, and contracted IT services.

Siemens Healthcare’s Q1 profits jump 38%

Siemens posted quarterly profits of $1.62 billion, or $1.89 per share, on sales of $24.15 billion.

Request for Information on Hospital and Vendor Readiness for Electronic Health Records Hospital Inpatient Quality Data Reporting

CHIME comments on CMS’s request for information on EHR-based quality reporting readiness, raising concerns over how discrete data should be extracted from narrative physician notes for reporting.

5 findings in ONC HIE research

ONC publishes new research highlighting the types of high-impact services that can sustain HIE organizations.

Health chief wants big telemedicine network across Georgia

Brenda Fitzgerald, MD, public health commissioner for Georgia, reports that every public health center across the state will be able to put patients in front of top specialists via telemedicine within three years, citing grant applications as the primary means of paying for the program.

Readers Write: In Defense of Copy-Forward

In Defense of Copy-Forward
By Lyle Berkowitz, MD

I’m part of the Association of Medical Directors of Clinical Information Systems (AMDIS), a group of 2,000+ physicians who are the experts in implementing and using EMRs. We have a pretty lively listserv discussion board, and I enjoy seeing what my colleagues are thinking, as well as posting my own thoughts. I especially enjoy posting when I feel like certain studies or comments by non-clinical researchers, administrators, or politicians make us start to question common sense.

One of my favorite topics recently came up — the fear and horror associated with actually reusing some of a previous note. This usually falls into the concept of "Copy-Forward" (when you copy forward the whole note and then edit for today’s visit), or "Copy-Paste" (when you select certain parts of a past note and just copy that part of it. I posted my reply and thought I’d share and expand a bit.

So as not to bury the lead, I think Copy-Forward of a note is a great tool and supports both efficiency and quality, when used appropriately. Turning it off is a classic throwing the baby out with the bathwater analogy. To clarify my biases, my thoughts and ideas are mainly from the perspective of an outpatient physician using Copy-Forward over the past decade, but much of this certainly can be applied to the inpatient world in various ways.

Also, the use of Copy-Paste has some similarities to Copy-Forward, but I agree Copy-Paste is not nearly as efficient and poses more quality issues since it does not have the automatic updating features you might see with Copy-Forward. Here are the points I would suggest we consider.

First, I am sick of these reports which say that things like, "We used plagiarism software to show that 60-80 percent of a doctor’s note is the same as their last one." Um, of course! Since when did progress notes become creative writing endeavors about coming up with different ways to document diabetes, hypertension, and obesity in the same patient visit after visit?

The creative parts of doctoring should involve being "House": figuring out the diagnosis, figuring out the best treatment plan, and artfully explaining it all to the patient. It should not be writing Edgar Allen Poe-like short stories to amuse our auditors or confuse our colleagues. Although, it could be fun, hmmm… what if I described a diabetic’s problems with hypoglycemia in Poe’s style: "Arousing from the most profound of slumbers (due to a glucose of 45), the patient states he feels as if he was in a gossamer web of some dream. Yet in a second afterward, so frail may that web have been, he claims to not remember that which he was dreaming."

Second, there are obvious efficiency benefits to Copy-Forward, but there are very real quality benefits as well. The most obvious is that this type of workflow makes it less likely that important diagnoses will be missed or forgotten over time. Additionally, many systems update certain pieces of data during the Copy-Forward process, so that you can see the most recent results (discussed more below). Obviously incorrect information can be duplicated, especially when a note is being authored by multiple providers over time, but this is where good training and leadership are needed to ensure every provider feels fully responsible for everything in their notes.

Third, getting rid of Copy-Forward or even Copy-Paste is certainly overkill, but we do need to use some common sense in designing technology, workflows, and processes that make it easy to do the right thing when documenting. In the ideal system, much of the critical data would either be updated automatically (e.g. the most recent lab would appear when a note is copied forward), or the system would date entries so it is clear what was done in the past versus today. To clarify, let me break down how an ideal progress note might look like when Copy-Forward is used:

Allergies, Meds, Problems

These update automatically, which is great, and means the note has the most recent data. I would hope all EMRs have this functionality already.

Past Histories (Social, Surgical, Family)

These copy forward and allow for easy editing in the note. Ideally, they could be managed in a widget external to the note and have them update from those profiles as well.

Physical Exam

Want to ideally be able to view old physical exams, and even reuse them when desired (except for vitals). In my current system, the full exam (sans vitals) does copy forward. So I usually just delete it and drop in a new macro and edit that. However, some patients have findings I want to compare from last time (e.g. size of a rash), or consistent findings (e.g. murmur) which I want to be reminded about

Labs/Studies

For labs (e.g. CBC, chem, chol profile) and certain studies (e.g. mammogram results, last ECG), we use macros which "auto-updatem" so when a note is copied forward, they update automatically to the most recent dates and values.

HPI/Impression/Plan

As some have heard me detail before, I use a form of "problem-oriented charting" in which I type out the history, impression, and plan for a diagnosis (e.g. diabetes) or system/problem area (e.g. "GI issues") all on one line. I also use a macro which includes the date of the entry and my initials.

• Example for a diabetic patient. "01/19/13(LLB): Stable on Metformin 500bid, CS 100-120s before meals, no med side effects or other complaints. Impr: Stable DM, PLAN: CPM, labs, rtc 4 mos". No flourish is needed. The result is that when copied forward I can see the last time I addressed the DM and if I made any changes. In the same "area" for the problem, I would also have a list of relevant meds, labs, and testing results (e.g. ECGs and ECHOs for hypertension). This way I can see everything I need about a problem all in once place – which means I can make quicker and more accurate decisions.
• Summarizing old entries over time. I will either retain the old entry, or can summarize over time (e.g. I might take four entries from 2012 and summarize into one line such as, "2012: Dx with DM 4/12, added Metformin 500qd, 6/12 incr to 500 bid and did well").
• Multiple issues. Since I often address multiple issues in a given visit, I created a line which reads, "Problems below not addressed this visit" so that I can clearly demarcate what I did and did not address on a certain day. I think this method is extremely efficient and higher quality than the method of trying to document all the HPI about multiple issues at the top of a note, and then separating out the Impr/Plan at the bottom.
• What is a SOAP note? Larry Weed, MD devised the concept of problem-oriented charting 50 years ago, but I think it’s fair to say we have over-complicated it over time. The SOAP note is supposed to be based around a problem. In other words, each problem should have a documentation area for Subjective, Objective, Assessment and Plan. Instead, we create one large SOAP note where we break away all the Subjectives into their own paragraph ("HPI"), thereby distancing your thinking about the complaint and what we are going to do about it. I hope we will soon see more EMRs going "back to the future" by embracing the true problem oriented charting philosophy.

Fourth, the outpatient world is different from inpatient, but there are similarities. I understand that inpatient notes can be more difficult to manage due to quickly changing problems, and especially multiple authors. Personally, I hope we put some more thought into the concept of an "Inpatient Wiki," a single type of inpatient note that can automatically pull in the relevant information for each specialty (e.g. different for medicine, OB, and various types of surgery). Then each author could see what they need to see – it would pull in the labs, tests, consult suggestions, or a nursing note – why make the doctor repeat this themselves every time?

The care provider would then be prompted to write what they are supposed to add, and the note would be a living document which flexes to the individual, but can be time-stamped for medico-legal purposes as well. It could have clear sections (similar to above), as well as an organ or system based areas (e.g. Cardiology issues, GI Issues, Neuro Issues, F/E/N issues) for documenting the SOAP note .

In summary, I would go as far as to say that we need to change our paradigm to "The Note is the Chart." The chart should no longer be a collection of distinct and incomplete notes, but rather the last note can really be the complete chart which contains everything a provider needs. If we do this, then we can reframe our expected workflow from, "You need to read every note ever written to understand the full patient" to, "You just need to read the last note".

The result: when a patient goes to the ER or sees another doc, those providers will find that the most recent note in the system will have all the info they need, so they won’t need to try and dig through 48 notes over 10 years (and let’s face it, they never do that anyway). Granted, the paper record allowed for a much easier way to flip thru past notes, but sooner or later we have to acknowledge that computerized systems have different attributes than paper. We can either keep trying to force the computer to act like paper, which never works out well, or we can start embracing the differences and truly take advantage of them.

Lyle Berkowitz, MD, FACP, FHIMSS is associate chief medical officer of innovation for Northwestern Memorial Hospital; medical director of IT and innovation for Northwestern Memorial Physicians Group; and co-founder and chairman of healthfinch.

Readers Write: New HIPAA Rule Overview

New HIPAA Rule Overview
By Brian Ahier

Four years ago, the HITECH Act introduced major revisions to HIPAA. Now everyone is all atwitter since the Office for Civil Rights (OCR) of the Department of Health and Human Services (HHS) has published the omnibus final rule modifying the HIPAA Privacy, Security, Breach and Enforcement Rules as well as additional changes required under the Genetic Information Nondiscrimination Act of 2008 (GINA).

"Much has changed in healthcare since HIPAA was enacted over 15 years ago," HHS Secretary Kathleen Sebelius said in a statement. "The new rule will help protect patient privacy and safeguard patients’ health information in an ever expanding digital age." This rule also creates a lot of work for healthcare organizations.

First off, organizations will need to amend notices of privacy practices and make sure the revised notices are properly posted and distributed. This means creating new forms and posters as well as allocating resources for legal review. There will likely be other forms, such as requests for access, that should also be updated or created. There will also be a need for workforce training to promote more ongoing awareness among staff. This is a good opportunity to take advantage of the safe harbor provision by encrypting PHI according to HHS guidance.

The rule has significantly expanded the scope and impact of the Privacy and Security Rules on business associates. Anyone providing services to a health plan or healthcare providers who receives or generates PHI may be subject to these expanded provisions. Previously, most business associates were subject to the Privacy and Security Rules only through a business associate agreement with the covered entity. Now, even if there is no BAA, if you are simply acting as a business associate, you are liable under HIPAA. The rule specifically identifies as business associates subcontractors, patient safety organizations, health information organizations (and similar organizations), e-prescribing gateways, and vendors of personal health records that provide services on behalf of a covered entity.

Another interesting development is that the rule revises the definition of a “breach,” which will serve to make breach notification much more likely. The HITECH Act requires covered entities and business associates to provide notification following discovery of a breach of unsecured PHI. Breach means the acquisition, access, use, or disclosure of PHI in a manner not permitted under the HIPAA privacy rule that “compromises the security or privacy” of the PHI unless an exception applies.

The rule amends the definition of breach to clarify that the impermissible acquisition, access, use, or disclosure of PHI is presumed to be a breach and breach notification is necessary unless a covered entity or business associate can demonstrate, through a documented risk assessment, that there is a low probability that the PHI has been compromised.

Previously under the interim final breach notification rule, the privacy or security of PHI was deemed to be compromised if there was a significant risk of financial, harm to reputation, or some other harm to the individual as a result of the impermissible use or disclosure of PHI (commonly referred to as the “harm standard”). In other words, if you could demonstrate no significant risk of harm, then the incident did not rise to a reportable breach.

The new rule replaces this "harm standard" with what HHS calls a more objective process for assessing whether PHI has been compromised. The new standard, however, still appears to leave covered entities and business associates with a lot of questions. The rule has deleted the definition of “compromises the privacy or security” of PHI (which was the harm threshold), and declined to adopt a clear standard requiring notification of all impermissible uses and disclosures without any assessment of risk.

The rule expands what uses and disclosures of PHI are considered marketing thus requiring an individual’s authorization; however, the new marketing restrictions do not impact a covered entity’s face-to-face communications with individuals. For example, prior to this new rule, an authorization would not be required for a hospital to send a brochure to its patients about a new imaging device being used by the hospital, even if the communication was paid for by the manufacturer of the imaging device.

Now the hospital would no longer be permitted to send communications about its new imaging device if the manufacturer of the device pays the hospital for the communications unless the hospital first gets authorizations from its patients. The rule provides an exception for communications about drugs that are currently is prescribed to an individual as long as any payment is reasonably related to the covered entity’s cost of making the communications. For example a drug manufacturer would be able to subsidize a physician’s cost for sending out refill reminders.

The rule has also implemented a new tiered penalty structure. Depending on the degree of knowledge that the covered entity had or should have had regarding the violation, penalties for each violation range between $100 (did not know or have reason to know) and $50,000 (willful neglect without correction), with a maximum penalty for a given year of $1,500,000 for any violations of the same requirement or prohibition. It will be very interesting to see how aggressive enforcement is over the next few years.

One of the significant changes in the rule is the expanded rights for patient access to electronically-stored PHI. The rule extends beyond those promulgated under Meaningful Use and provides the right to obtain an electronic copy of PHI stored electronically in a designated record set (e.g., medical records, billing records, and other records relied upon to make decisions about the individual) rather than simply and electronic health record.

If the covered entity can’t readily produce the form and format requested, then it must offer other electronic formats that it can provide. If the patient doesn’t agree to any alternate electronic formats offered by the covered entity, then the covered entity must provide a hard copy as an option to fulfill the access request. Also, if an individual requests that a copy of his or her PHI be sent via unencrypted email, then after advising the individual of the risks a covered entity is permitted to do so.

Another notable requirement is that  covered entities now have 30 days to fulfill a request with the possibility for a singular 30-day extension allowed. Electronic and hard copy PHI, no matter where the data are located, must be provided within the timeframe.

The rule also clarifies the fees that may be charged. For example rule adopts the proposed amendment at § 164.524(c)(4)(i) to identify separately the labor for copying protected health information, whether in paper or electronic form, as one factor that may be included in a reasonable cost-based fee. However fees associated with maintaining systems and recouping capital for data access, storage and infrastructure are not considered reasonable, cost-based fees, and are not permissible to include. The rule also  rule we clarifies that a covered entity may not charge a retrieval fee (whether it be a standard retrieval fee or one based on actual retrieval costs).

Even with some of the protections in the Affordable Care Act, the rule still provides that a covered entity must comply with an individual’s request to restrict disclosure to a health plan (or the plan’s business associate) of PHI that pertains solely to a health care item or service for which the health care provider has been paid out-of-pocket and in full. This right extends to situations where a family member or other person, including another health plan, pays for the service on behalf of the individual.

Last week I joined Deven McGraw and David Harlow for a Google Hangout where we discussed the new HIPAA rules. It was a lively discussion and is well worth taking the time to see, so grab some popcorn and watch the video for some great insights.

Brian Ahier is health IT evangelist at Mid-Columbia Medical Center of The Dalles, Oregon and president of Gorge Health Connect, Inc.

Curbside Consult with Dr. Jayne 1/28/13

I spent most of my week trying to help colleagues retool budgets, which is never a pleasant task. Everyone is being asked to do more with less. In healthcare, sometimes that’s extremely tricky.

I’m lucky in that my medical informatics group is a department of one. I don’t have to worry about our current hiring freeze or the potential of laying anyone off unless they decide they don’t need a CMIO any more. With the current climate in MU, that’s unlikely. We already had our travel and conference budgets slashed last year, so there are no surprises there. We’ve already figured out how to receive education and training for free — no surprises there either.

From an IT perspective, we’re cutting budgets for hardware and extending refresh cycles. No one can expect to see new devices on the scene any time soon. I’m glad lots of vendors are designing for the tablets and Apple platforms, but our teams won’t be able to take advantage of any of those new features. As much as feel like I’ll be missing out, I can live with it. We’ve been using the same hardware platforms for years and we’re used to them. I don’t think continuing to use a wheeled cart as my workstation is going to kill me. (on the other, hand it might – keep reading.)

The hospital where I work is fully committed to its brand spanking new Accountable Care Organization. It has announced that it’s putting all hands on deck to make sure we’re investing in care management, patient engagement, and marketing. We’re going to spend tens of thousands of dollars making sure patients don’t want to leave our organization so that we can achieve shared savings. We’re going to make sure that we’re their hospital of choice.

As a part of that effort, I’ve been asked to prepare a handwritten thank you note and deliver it personally to each patient I discharge from the emergency department. I’m also supposed to recite a fairly canned statement about how much I appreciate the patient choosing my hospital and thank them for the opportunity to deliver excellent customer service.

When I saw the memo this week, I was just speechless. As a physician who has to care for patients, I’m horrified by sinking so much effort into marketing and frivolity when we’re making cuts to the bone in frontline clinical service areas. What about delivering excellent care? Where did that go? Here are some chilling examples:

• After 5 p.m., we only have one housekeeper on duty for the entire ED and two floors of the hospital. Nursing staff and patient care techs are expected to clean all the emergency department rooms after patient discharge. Most of the time we don’t have a tech, so an RN (or sometimes the physician) is cleaning rooms. I know this is not a new phenomenon, but it’s still not right. This also means that if we have a situation where we need a “terminal clean” of an exam room (highly contagious disease, etc.) we have to shut down the room, often for hours, while we wait for housekeeping.
• Lack of housekeeping also means trash is overflowing in the exam rooms. But there’s more. To cut down on costs, staff has been asked to conserve on the use of trash can liners. I didn’t believe it until someone showed me the memo. This means that rather than pull up the plastic bag around the trash, seal it, and carry it to a larger waste receptacle, they are expected to wheel a larger receptacle into the exam room, heft the trash can into the air, and dump the trash into the larger can. Inevitably things wind up on the floor, not to mention the potential for infectious material to be flung into the air. This is also done with biohazard cans, although I haven’t seen a specific memo that says that the can liner recommendation applies to “red bags.” Leaving the liner in leaves the bacteria in. Whoever came up with that policy should be gifted with a trash can containing a used diaper.
• We no longer follow isolation protocols in the “low acuity” portion of the ED because our patients are “low risk.” Last time I checked vancomycin-resistant enterococcus didn’t play favorites.
• Exam rooms are often “turned” so quickly that registration brings new patients back before the room has been adequately cleaned.
• Non-clinical areas do not get cleaned at all. The floor of our work area in the ED is so dirty that staff places towels or drapes on the floor before depositing their tote bags (no, we don’t have lockers).
• IT hardware is no longer cleaned. That picture above is the keyboard I was greeted with last week. It is not fit for use by anyone. The worst part is that there was visible food on it, meaning someone touched it while also touching food.

It is in this circumstance that I am expected to write thank you notes. This is in between trying to see patients, providing decent quality care, getting all my documentation competed (including the mandatory sepsis screen we just added for all ED patients regardless of presenting problem), educating patients on not coming to the ED inappropriately, serving as my own social work staff, figuring out how to get patients to afford their $4 generic prescriptions, and convincing patients that plugging their iPhones in to the outlet above the bulging biohazard trash can so that the cord dangles into it is a bad idea.

You’re probably thinking right about now that I work in some third-world hospital. Not so much. We’re urban and safety net, but we’re decidedly first-world with an academic presence. We have the endowment to prove it.

You may also think I’m just complaining, but seriously, I love my job. I love the people I work with. I love my patients, even the ones who are handcuffed to the gurneys for the duration of their stays.

I apologize for the wait. I apologize for delays. I apologize that the police used a Taser on you and I ask you politely to stop spitting at us. I apologize to the other patients for having to witness your behavior. I thank patients for coming and wish them well even when they scream at me or when I have to call armed guards to help discharge them. But if the administrators want thank you notes, they’re going to have to hire Emily Post. Maybe she’ll bring a feather duster (or a blowtorch) to clean the computers.

Good luck with making our facility the destination of choice. Congrats to the marketing team that dreamed up the thank you note scheme. Maybe we should start with basic sanitation if we want patients to come back. It’s hard to understand how we’re going to be meaningful users of EHR technology when we can’t be meaningful users of sponges and mops.

Have a story of administrative ridiculousness? Can your gross pictures top mine? E-mail me.

E-mail Dr. Jayne.

Morning Headlines 1/28/13

Athenahealth to lay off 36 in Birmingham area

A spokesperson with the Alabama Department of Economic and Community Affair reports that athenahealth has filed notice to announce the layoffs of 36 Birmingham-based employees, effective March 6.

Compuware turns down Elliott offer, Covisint unit IPO still on

Compuware turns down hedge fund Elliot Management Corp’s proposal for a $2.3 billion buyout.

2 Chesco companies report combined 168 layoffs

MEDecision will lay off 83 workers effective February 1, representing more than 25 percent of its total workforce.

Hospital’s electronic records system goes off line after AT&T outage

New Hanover Regional Medical Center went to paper downtime procedures when a regional AT&T outage cut access to its Epic system.

Why Do Patients Derogate Physicians Who Use a Computer-Based Diagnostic Support System?

A survey focusing on why patients have a negative perception of physicians who use clinical decision support concludes that it may not be related to seeking the physician external advice, but rather that the physician is turning to a computer rather than a colleague.

Monday Morning Update 1/28/13

From Optumized: “Re: Optum’s acquisition of Humedica. Confirmed by Lazard Capital Markets.” I appreciate that the update from Steven Halper, managing director of equity research, credited HIStalk as the original source (as I, in turn, should thank Embers and another couple of readers who tipped me off). A Boston Business Journal article says the acquisition is valued by an insider in the hundreds of million dollars. I interviewed Humedica President and CEO Michael Weintraub a year ago. I notice that the Boston paper is getting credit for breaking the news with its Friday afternoon article even though I ran and confirmed it Tuesday evening with the help of readers.

From False Positive: “Re: Farzad’s rebuttal that talks about ‘cynical critics.’ Who are they? How does he know that they don’t like paper?” The cynical critics, at least those constantly seeking attention, are easy to spot because they sing only one loud and sustained note. When I read an emotional, overwrought restaurant review on Yelp, I always click that person’s profile to see if they have a mix of positive and negative reviews and ignore them if not. Likewise, I twit filter the monotonic EMR whiners and cheerleaders alike, placing a lot more value on the 80 percent who don’t flaunt their blinders publicly. Farzad was right about the RAND study – they said their original projections about EMR savings were wrong because EMR adoption was less than expected and payment incentives are still screwed up. The job of EMRs is to support reform, not to create it. He’s also right that those cynical critics haven’t written smug and pedantic articles extolling the virtues of paper medical records, so they’re leaving us to breathlessly anticipate their suggested alternative. And if they’re intentionally avoiding EMR-using doctors and hospitals for their own care, they aren’t blowing that horn either. What they should be criticizing is the healthcare system that created the current batch of EMRs that conform precisely to its ridiculousness.

From The PACS Designer: “Re: TPD’s List. The recent update of TPD’s List of iPhone Apps that added a HIStalk Sponsors section has created new interest amongst them to recognize their iPhone apps. Vitera informed us about an app (above) that provides healthcare providers access to their Intergy EHR solution enabling anytime, anywhere access to schedules, tasks, patient records, and e-prescribing. Humetrix alerted us to several iBlueButton apps they developed with HHS. These new apps will be added to the next TPD’s List update.”

From Ear-Ground Continuum: “Re: MEDecision. Huge downsizing – they let 83 people go last month with another round this week and next.” Unverified. Recent comments on Glassdoor are certainly interesting. UPDATE: Verified by a reader’s link.

From Nasty Parts: “Re: Greenway reseller iPractice Group. Closed its doors today. Sources say cash flow problems despite strong sales, so the board pulled the plug.” Unverified. I e-mailed the company but haven’t heard back.

Speaking of the RAND study, more readers think it was naïve rather than biased (and yes, RAND should be capitalized, at least if you buy the idea that it’s OK to make up acronyms solely to create a conveniently pronounceable word, in this case Research ANd Development.) Anyway, new poll to your right: if you had to buy a vendor’s stock, which of the five listed would you choose?

Several readers (me included) expressed an interest in hearing more from Robert D. Lafsky, MD, whose guest articles always contain an impressive mix of medical knowledge, wry cynicism, and grammatical excellence (he always e-mails me when he finds my mistakes, and the threat of incurring his gentle wrath caused me to double-check the spelling of RAND). He has agreed to elevation to regular contributor under the nameplate The Skeptical Convert, with his first installment running this weekend.

Here’s a new Spotify playlist of what I’m listening to: new Aaron Neville, The Cardigans, 4 Non Blondes, Alabama Shakes, Imperial Teen, and a few more.

Athenahealth files notice with the State of Alabama that it will lay off 36 employees at its Birmingham office on March 6. The company has not announced what types of workers are affected, although Birmingham was the location of Proxsys, the care coordination systems vendor athenahealth acquired in 2011 to boost its athenaCoordinator product.

Compuware turns down the $2.3 billion buyout offer of Elliott Management Corp and says it will instead spin off Covisint as originally planned.

Weird News Andy says this is better than die-alysis. A kidney patient in China who can’t afford dialysis treatments has lived for 13 years so far by dialyzing himself three times each week using a machine he built from kitchen tools and old medical equipment. He recently declined the Chinese government’s offer of free dialysis that was extended after his story was picked up worldwide, saying the hospitals are too far away and too crowded. He’s not worried that two of his friends died after trying a similar setup.

WNA also likes the RP-VITA iPad-controlled medical robot that just received FDA approval.

Farzad Mostashari can bask in the knowledge that he’s a big enough name to be featured in a CAP News parody (it’s like The Onion, but not as well done). I think they probably chose him randomly for the article Toilet Sizes Expand to Meet Needs of Obese Nation, quoting him in describing a new HHS standard called “Ass Cheek/Toilet Seat Ratio.”

Gartner says Big Data has reached the Trough of Disillusionment stage of its ingenious Hype Cycle, of which I’ve been a long-time fan. If the author is correct – and I would say she is – the previously Big Data-fawning press will start running negative articles, which is OK since once that negativity has been purged, it’s on to the Trough of Enlightenment, where organizations whose interest is more than fad-chasing start delivering results. A Wall Street Journal blog post on the Gartner item quotes Aurelia Boyer, CIO of New York Presbyterian Hospital, who says they’re using Hadoop with natural language processing to analyze millions of patient records to find, for example, how many of them have mentioned a gunshot wound.

A study looks at why patients may think doctors who use clinical decision support are less capable. Apparently patients worry more about doctors using non-human tools rather than having a doctor who seeks external advice.

New Hanover Regional Medical Center (NC) goes to paper downtime procedures for seven hours Thursday when its Epic system goes offline due to an AT&T regional outage.

An online publication HITECH article elicited interesting comments. Granted some of them veer into death panel nut job territory, but they’re still fun to read and some are insightful.

• “EMRs encourage doctors and nurses to cheat and lie. EMRs have made medical records inaccurate and unreliable. When I read medical records nowadays, I often can’t tell what the hell happened.”
• “In an EMR, every URI is an average URI.”
• On the use of surgical case templates: “… worked out with the hospital risk management department to describe what should happen, and entered in the EMR with one click of a mouse. What actually happened? No one can tell.”
• “The response calling this idiocy a step in the right direction apparently fails to get the point, which is that EMRs make crappy doctors look like decent ones by giving them the same well-written notes as the good ones.”
• “It seems to me that this isn’t exactly the unintended consequences of EMR; it’s the unintended consequences of the government incentivizing bad EMR by incentivizing the wrong things:  the ACA encourages rapid adoption of immature or awkward technologies without clear benefits; medicare, medicaid, ACA, and the employer-provided health insurance tax exemption incentivize egregious billing practices. EMR and provider companies respond to the incentives; the problem isn’t the software per se, but the incentives. There’s no inherent reason why an EMR system should require more data entry on the part of doctors, or why the data entry should take longer than updating a paper chart. Systems could be designed that work better and provide consumer benefits, but they aren’t appearing because the system incentives really aren’t designed to serve the customer.
• A physician on not customizing template-created notes: “I like to think most of us are pretty honest, and this doesn’t feel like a lie, more like the best that can be done with the time available and the limits of the EMR. I don’t know if I am only humoring myself about the honesty. I do know the job can’t be done except by the copy and paste method.”
• “This article misses a key point. If they’re fine falsifying electronic records, why wouldn’t they be comfortable falsifying written records? Moreover, electronic records are easier to falsify, but they’re also easier to catch.”
• “I think physician associations need to reemphasize that documentation by exception is not appropriate for physicians, perhaps even take it a step farther and officially declare it outside the standard of practice. The great potential benefit of EMR’s (along with the requirement that they be able to produce data in a standard format) is that medical charting will stop being primarily about stories and start being primarily about data. This will not only make treatment of patients more scientific, it will energize evidence-based medicine. Right now, about half of medical treatment is done despite no evidence of efficacy. Of course, if the data is unreliable, we have GIGO. So the use of charting by exception leading to bad data is a huge problem.”
• “EMR’s are the vehicle for corporate and government direction of medical care. I predict that within 5 years, it will be illegal to provide medical care to a patient unless it is through an Electronic Medical Record … this idea will be advanced as important to preventing waste, fraud and abuse.”
• “Simply put, doing a thing, and documenting the doing of a thing, are two separate, and not particularity related skills (I would figure that journalists would understand this better than anyone), and it is unlikely that a person who is good at the former is also good at the latter, and when we ask him to do both, this is what we get. Cheer up, we could get the people who do amazingly good documentation to do the surgery. I suspect that would be much worse.”

I’m scooping Weird News Andy on this story: a drunken Englishman is hospitalized after the paramedics he called found his frigid sexual partner dismembered in a snowy field. The partner was a snowman; the man’s injury involved frostbite of his manhood, which nearly required amputation.

It’s NextGen Part 3 from Vince this week as he covers Opus Healthcare Solutions.

Sponsor Updates

• SimplifyMD is running cartoons and videos looking at the humorous side of medical practice at “Easy Street Family Practice.”
• Nuance announces that the electronic medical records systems used by hospitals and clinics in the United Arab Emirates will be voice-enabled using Dragon Medical.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: The Idealistic HR Rep Is Wrong: IT Success Means Treating Your Stars Better Than Everyone Else

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in May 2008.

The Idealistic HR Rep Is Wrong: IT Success Means Treating Your Stars Better Than Everyone Else
By Mr. HIStalk

Healthcare IT is an industry of experts. Folks with highly specific skills are the hardest to find and keep.

You know them. They’ve developed battle-hardened expertise in the quirks of a particular vendor’s product, often as technical experts (aka programmers, system analysts, or application specialists). You, some other hospital, or a vendor raised them from sapling to stout oak. Unfortunately, others covet and sometimes steal them. Losing one can kill your project or your reputation with users quickly.

Job #1 for an executive is to keep these stars. Here’s the biggest secret for doing that: don’t treat everyone equally. The idealistic, chipper HR rep is dead wrong. You keep your stars by identifying them and treating them better than everyone else, proudly and loudly.

(My motto is this: keep the top 10 percent of employees deliriously happy, the middle 80 percent comfortable, and the bottom 10 percent miserable).

Stars are like attractive women – they know it. That means having options, one of which is leaving for greener pastures. Insecure managers who try to beat down excellence by applying by-the-book principles of democratic, feel-good management in which everyone is treated alike will be left with plodding conformists. The geniuses will be long gone. Unfortunately, one genius can outperform a handful or more of plodders, especially when you’re talking about programmers, DBAs, and the like.

Most of those stars don’t want to be managers, so the promotion carrot doesn’t work. They aren’t starving, so throwing money at them won’t buy their loyalty. The best strategy is to identify that top 10 percent, then break the rules for them (who doesn’t feel special when someone breaks rules for them?)

Make them attend only that 10 percent of meetings that are important. Managers have long detuned their outrage threshold and will happily sit through time-wasting sessions where no conclusions are reached and no assignments made, but technical folks would rather be accomplishing something.

Give them whatever technical toys they need and then some. Your best analysts should have a huge monitor, a mobile device of their choosing, and whatever software they think will look cool on the shelf. These may or may not improve productivity, but they serve as a badge of honor visible to all that they’re special (that motivates others to seek stardom, too). Compare the cost to that required to find and train a replacement – it’s nothing.

Feed them. Surprise pizza or an off-campus lunch is cheap.

Put your best people in the best workspaces. Windows motivate. So do fancy chairs. Working from home on occasion is a real perk. Airless, institutional cubicles that scream interchangeable galley slave aren’t for stars. Brad Pitt doesn’t share a dressing room with the extras.

Send a note of thanks to their significant other after a long stretch of heads-down work.

Let them wear whatever they want as long as they’re not meeting with outsiders. People do their best work when they’re comfortable. Only managers wore ties as toddlers.

Respect stars, even if you can’t do the same for everyone else. Everyone, right up to the big boss, should know their background, hobbies, family members, and favorite vacation spots.

Send them off to training. It’s a badge of honor for an employer to invest in training-related travel. If the training budget is limited, spend it on the stars instead of dividing it equally.

Let them screw around on the clock with technologies you may never use. Hospital stuff is sometimes outdated, so exposure to cutting edge technologies is a motivator.

Allow them to interact with users and executives and users if they want. It’s insulting to have a middle manager boss steal the limelight when things are going great, but hide behind a closed door the rest of the time (I know because I’ve done it).

Make it clear to managers that their primary focus is to keep their stars happy and productive, which often means butting out and not trying to artificially add value. Not all managers are stars, either.

If an assignment is too trivial to make it sound crucial even by stretching the truth, give it to someone else, not a star. And if it’s critical but probably impossible, give it to a star and tell them so, feigning surprise when it gets done in a blinding flash of genius.

All of this sounds simple, but have you formally identified your stars and intentionally treated them better than the non-stars? If not, you’d better do it before someone else does.

Collective Action 1/25/13

The views and opinions expressed are those of the author personally and are not necessarily representative of current or former employers.

Leader the Follow (Part 2) — Identity

Let’s see … where were we? Oh yes, talking about being a follower and the significance of that role. This is a follow up to the last Collective Action post on HIStalk.

Last time I asked for input from readers about what kind of leader you would follow. I received several responses and I will include some of them at the end of this article. Thank you to all who provided feedback — it was insightful and entertaining. 

The key to studying followers is similar to the key to studying leaders. It is not about characteristics of a leader or follower. To me, the key is identity. How you see yourself determines your effectiveness. 

I agree we need to talk about Meaningful Use, business intelligence, ACOs, and what the next great innovation in healthcare will be. But none of those things can happen without  a focus on both leaders and followers and teams they lead.

As I was researching this topic of identity, I came across an interesting term: “metaperceptions.”  This is not how you are perceived, but rather how you perceive others perceive you. The difference is slight, but profound. 

I have a great example of this from a recent presentation I gave. I was speaking to a crowd of about 100 people here at our hospital at a recent event. It was an EMR project-related event that we themed “Finish Strong,” where I and others presented concepts from Dan Green’s book Finish Strong. 

I consider myself a good communicator. I believe I have a gift that allows me to write and present well. As I was presenting, someone in the audience dozed off. I thought right then that her perception of me was that I was a lousy presenter. Instead of continuing as I should have, I got thrown off. I thought they had lost interest and I started rushing through the rest of the presentation, not giving some of the more impactful parts ample time. 

Afterwards, I spoke to her and asked her how she liked the event and presentation. She said that she loved it, but had a new baby and was very tired. She made some comments about what was said and how it impacted her. I was blown away. My metaperception was wrong, but that didn’t matter, it impacted my effectiveness.

The root of our identity is only partially based on what others think. It is mostly based on how we view and think about ourselves. Here are some interesting statistics regarding how we think about ourselves. 

According to Daniel Amen, MD, a renowned psychiatrist and brain imaging specialist, we have about 60,000 thoughts per day — one every second while we are awake. Ninety-five percent of those thoughts are the same ones we had yesterday (a broken record!) For the average person, 80 percent of those thoughts are negative. 

That is incredible. Every day, the average person working in your department or your hospital or living in your home has 45,000 negative thoughts. Whether you are a leader or a follower, whether or not you care about what others say about you, you can do enough damage to yourself to keep yourself from fulfilling your destiny.

How do we combat this? How do we help those around us combat this? If you don’t think this is true about yourself, then you are probably not average, but you know someone who is. While it may not directly impact you, it impacts you in some way.

Let me offer something to you that is a bit unorthodox, but that has literally changed my life. I got this from the late Zig Ziglar, who says that how you see yourself is everything. A part of his program, called Self Talk, includes a laundry list of positive attributes: honest, intelligent, organized, responsible, committed, teachable etc. He offers several paragraphs with affirmations and instructs everyone he works with to say this list of affirmations in the mirror, morning and night, for at least 30 days. 

When I first heard this, I thought it was ridiculous, much like what you are likely thinking now. When I tried it, I thought it was stupid and embarrassing. I would not tell my wife. I locked the bathroom door and went through it as fast as possible. 

A peculiar thing happened after a couple of weeks. First of all, I finally told my wife, but I also started to become less embarrassed. I started to see that I really was some of these things, and some of them all the time. Other characteristics were just seeds and needed watering. 

At the end of 30 days, although I did not count, I literally sensed the number of daily negative thoughts decreasing, being replaced with thoughts that were empowering. Dare I say, I started to believe that I was just scratching the surface of what I thought I could accomplish in life. There is a lot more to that story, but it is for another post.

Besides how we talk to ourselves, there are additional factors in our life that impact those 60,000 thoughts. In Darren Hardy’s book The Compound Effect, he dedicates a chapter to influences. He says that everyone is affected by three kinds of influences: input (what you feed your mind), associations (the people with whom you spend time), and environment (your surroundings). These external forces are very powerful and dramatically affect how we think and feel about ourselves, our choices, behaviors, and our habits. In this book, he offers suggestions on how you can govern these forces so they can support and not derail your journey towards success.

To help deal with this on a corporate level, we have been walking our team through a couple of things to help positively reinforce who they are and where they are going.

The first was we helped everyone on our team develop a brand statement for themselves and complete a professional bio. This exercise forced them to take a look inside and actually write down what they have accomplished and really who they are as a person and a professional. 

The second thing we did was have everyone complete Clifton’s Strengthsfinder assessment. The result of the assessment was a list of your top five strengths, which most everyone, including myself, has posted on their door or cubicle wall. 

We review these things in team meetings. We try to use them to better align teams. Although we have a long way to go to really perfect this, the attempt alone at trying to deal with this has had a positive effect in the department.

Follower or leader, both are important roles, and while healthcare goes through rapid transformation, we need the best and brightest operating in their gifts with full confidence. If you struggle with this or know someone who does, you can be a resource in their life, and in turn, in this industry. The answer to how to improve healthcare will come from the people within healthcare, and we need these people thinking they can affect change. 

While this topic may not seem relevant, I believe it is at the root of advancement. Whether leader or follower, even this little bit of knowledge about your identity and how you see yourself can help you and help you help others. This is your destiny!   

Responses

The first response came from a popular HIT blogger who reached out via Twitter (@SmyrnaGirl) and said, “I would follow a leader who wouldn’t be afraid to impart wisdom and one day let me lead in their place.” 

Not all followers share this sentiment. An anonymous person shared the following. “When my personal convictions are strong and clear, others may agree and choose to follow, but they do so on their own. On the other hand, if my convictions happen to align with those of others before me, then I may seem to be a follower, but in reality I am going my own way. Either way is fine with me. I will never follow or lead just because someone thinks I should, and I have no inherent desire to fill either role.” After a few more comments, he went on to answer the question directly. “For me, I would have to first decide if it was my battle. If so, then I’d follow the plans and directions of the one who seemed most aligned to my own thinking.”  

A practice administrator in Jacksonville, FL had this to say. “This organization thus  far has given me almost free reign on how and where I am taking our primary care network, with the expectation that I do it within cultural norms and corporate guidelines. After 10 months, I am happy to report that this is a comfortable position for me.” 

A quality management informatics analyst sent an e-mail saying, “One of the best leaders I had was a supervisor who openly said that he ‘had my back.’ When business events happened that threatened to undermine my authority or the scope of my work, he would respond by protecting me and promoting my interest in the situation. As a result, I felt a lot of loyalty and trust toward him and tried even more to meet his expectations.”  

The final comment came from a chief operating officer of an HIT vendor. He provided some great comments about leadership and following in general. We had an e-mail dialogue that really gave me some great insight into leadership. He said, “Inspirational leadership is great, but good execution combined with it is rare. Find a CEO or president who is a visionary and the matching CEO or COO who has the power of execution to make it happen. Typically, the inspirational people are not good at actual execution, but they need to let go to have others execute.” It sounds like he would be willing to follow someone who in addition to being able to recognize their strengths,they can recognize their weakness and bring someone in who can help bridge the gap.

Bill Rieger is chief information officer at Flagler Hospital of St. Augustine, FL.

The Skeptical Convert 1/25/13

APSO Fact and Fiction

I sit on an Epic implementation advisory committee for my hospital’s multi-hospital organization. From time to time, we are asked to make policy recommendations. One issue brought to our attention concerned the formatting of medical assessment notes, especially the part where the practitioner actually gets around to stating his or her actual opinion about what’s going on and what to do next. 

The issue had to do with whether that information would be placed at its usual seat of honor at the end of the report, or whether it should be placed up at the top. The shorthand for the formatting issue would be “SOAP vs. APSO”, where the four letters stand for “subjective, objective, assessment, plan.”  

In medical school, we are taught the traditional “history and physical” reporting format when evaluating a new patient or problem. The patient’s own story comes first– information considered “subjective” (yes, you can argue that the subjectivity is as much in the head of the practitioner as the patient, but a digression here). What followed traditionally was a detailed physical examination.  

In the mid-20th century, Lawrence Weed, MD coined the SOAP terminology, incorporating the reality that lab tests and imaging had become major factors in the medical workup. “Objective” became his bucket term for doctor- and system-generated information beyond the patient’s history.  

But whether you call the next section “impression”, “assessment” or “differential diagnosis”, the question it attempts to answer is the whole point of the exercise. What, doctor, is your opinion about what is going on here? What do you think is wrong, and if not that, what else might it be? The plan for what to do, of course, should follow logically from that.

The argument of APSO proponents is that they don’t really want to change this, but that EMR reports have become bloated by lots of templated and imported information. Someone reviewing them just wants to get to the conclusions and recommendations of the attending or consultant. So, put that at the top. Their position is that no matter how you format the information, the workflow and “thoughtflow” (a nickel to Dr. Bierstock) stay the same.

Is that true? I have trouble believing it. In fact, deep down I really dislike the APSO format, and I didn’t like it before any computerized reporting was developed. 

Many practitioners, especially medical subspecialists, dictate their consult notes that way. They’ll say they work in their heads down from the subjective / objective, but when they dictate, they do start with the conclusions. When I read down the page of an APSO consult, I often see gaps in basic structure and/or clinical information that may have been included if the author had stayed in order. From my own experience, dictating in traditional order, I do in fact sometimes revise my opinion or add additional diagnostic options by the time I get to the end.

But really, I can’t get that worked up about it (that’s why I dumped my original title:  “Let’s send APSO to Lhasa”). The reason is that APSO notes at least have some sort of thought-through assessment in them. Frankly I read a lot of notes that dutifully go through the motions of a history and physical, but then the conclusion — often compressed into some ghastly mutant section called the “Assessment/Plan” — blandly restates the available findings and problems and goes straight to the tests and consults that will be requested. If you have nothing to say, you might as well spit it out at the beginning. Saves time for me, anyway.

Will Epic straighten these problems out or exacerbate them? I’m out of space now, but Epic go-live is in two months. Stay tuned.  

Robert D. Lafsky, MD is a gastroenterologist and internist in Lansdowne, VA.

An HIT Moment with … Chuck Demaree, Access

An HIT Moment with ... is a quick interview with someone we find interesting. Chuck Demaree is CTO of Access of Sulphur Springs, TX.

What’s the continuing role of electronic forms as hospitals move to EHRs and other systems?

First, we have to establish a basic understanding about forms. A form is merely a structured tool to collect and organize data. Whether it is paper or electronic, its purpose remains the same.

Electronic forms can be placed in two categories. Online forms are primarily used for data acquisition. Managed output forms re-structure and automate the distribution of data in either a printed or electronic format. 

Hospitals need both types of forms going forward. The online, outward-facing forms collect data from sources that may not be connected to their hospital network, such as patient homes, clinics, and physician offices. Managed output forms organize data from the many disparate systems used in a hospital into a normalized format prior to routing forms into a document repository, or ECM/EDM system, as part of the EHR. This also becomes important if a Legal Health Record (LHR) ever needs to be produced for litigation purposes. 

What are some examples of workflow, productivity, and information needs that for most hospitals can be met only via the use of electronic forms?

Most health information and EHR systems — including those from Siemens, Meditech, Epic, McKesson, and Cerner – utilize some sort of workflow, but there is almost always another process or workflow that takes places even before the HIS or EHR is used. Today, that workflow is still a manual process that is either verbal or written. It is difficult to build a system that can address all the varied processes that exist. Electronic forms allow a hospital to address each process uniquely by designing a form or set of forms and custom workflow to address that process. 

Some examples are patient scheduling or pre-registration from home, feeding a registration or scheduling system. Automating acquisition of data from systems such as endoscopy, EKG, and perinatal and normalizing the structure of the data and routing and indexing the documents into the document repository. Adding electronic signatures and barcodes to existing forms and systems that do not currently provide that capability, such as discharge instructions or patient teaching documents. Business and back office functions, such as human capital management, purchasing processes, and accounting output such as checks or direct deposit notices.

If a hospital has already purchased an EHR, what would they do with your systems that would benefit patients?

Some EHRs have very nice patient portals to access the patient’s medical information, but not all patients are technically inclined or have access to the Internet. Some patients still prefer a physical document, and sometimes that is the only method for transferring data from one hospital’s EHR to another.

Our systems can provide outward-facing secure data acquisition across the Internet for patients and practitioners who are not on the hospital’s network. They can also easily control the format of data before it is printed or aggregated into an EHR. Controlling and normalizing the format of data makes it easier to read and find the information needed. This helps expedite care and reduce mistakes.

What is the role of electronic forms during system downtime and disaster recovery?

This goes back to the purpose of the form as a tool. During a downtime or business continuity episode, well-designed forms make it easier to continue to move patients through the clinical process and still capture data in a structured and familiar format. If these forms are barcoded with the form ID and the patient ID, then automatic indexing of this data into the document repository becomes much more efficient and less prone to error or misfiling.

Do hospitals intentionally use electronic forms as an alternative to entering data manually into a cumbersome online system?

I think there are a limited number of choices for hospitals to fine tune a system to make it easier for their staff and patients. We have many customers that use our output management products to automatically capture disparate medical device and clinical system data and redistribute it into an EHR or document repository. We have others who have chosen to not purchase employee or patient self-service systems and instead use our online forms solutions to create their own user-friendly front end for data acquisition.

Morning Headlines 1/24/13

Quality Systems, Inc. Reports Fiscal 2013 Third Quarter Results

Quality Systems, Inc, known to most as the parent company of NextGen, reports Q3 earnings, with revenue up two percent and EPS $0.26 vs. $0.36, missing analyst estimates for both.

Huron Consulting Group Bolsters Huron Healthcare with Strategy and Supply Chain Experts

Huron Consulting Group announces that Jim Agnew (Navigant Consulting) and Jeffrey McLaren (VHA) have joined the company as managing directors in its Huron Healthcare practice.

Vermont becomes first in nation to implement accountable care organization

Officials from Fletcher Allen and Dartmouth Hitchcock Medical Center announce the creation of the nation’s first statewide accountable care organization (ACO), called OneCare Vermont.

GE Healthcare Announces Centricity Practice Solution 11

GE Healthcare announces the release of the next Centricity Practice version, which provides enhancements to help facilitate ICD-10 transitions.

SB 1275 Medical data in an electronic or digital format; limitations on use, storage, sharing, & processing

Republican Senator Stephen H. Martin introduces a bill to the Virginia State Senate which mandates that providers cannot be penalized for refusing to implement an EHR, analytics cannot be performed across multiple patients to manage population health, and organizations are not permitted to participate the Nationwide Health Information Network.

News 1/25/13

Top News

Quality Systems (NextGen) reports Q3 results: revenue up two percent, EPS $0.26 vs. $0.36, missing analyst estimates on both. The company reported a 29 percent drop in system sales revenue as operating expenses rose six percent. The earnings call transcript is here. The results were announced before Thursday’s market open, with shares closing down only 0.16 percent by the market’s close.

Reader Comments

From Kojak: “Re: Intuit Health changes. Medfusion founder Steve Malik is retiring in June and Sanjiv Waghmare is taking over as Intuit Health’s new GM.” The e-mail announcement was attached. Malik (above) was named president of the Intuit Health Group when Intuit purchased Cary, NC-based portal vendor Medfusion for $91 million in 2010. Waghmare is a VP of product marketing.

From WHIMSSical: “Re: booth demo stations. PowerPoint or video? Should vendors use PPT since nobody can hear the video?” I say video and/or a live demo backed by a credible and engaging demonstrator, but perhaps also a fast-paced and highly graphical looping PowerPoint on a big projection screen as a billboard to grab attention as attendees streak by. Readers, what would get your attention?

From Doc Tari: “Re: Allina. Did know if you heard Allina having a bit of restructure. CMIO Shrift left to Cleveland and now CIO over all the IS areas.” 

From Carrie Prejean: “Re: HIStalkapalooza. What exactly does one wear to HIStalkapalooza this year? Bowling shoes? I want to come prepared because I am determined to win the ‘Inga Loves My Shoes’ contest!” When I first heard that this year’s bash was going to be in a (very cool) bowling alley, I was also perplexed on the proper attire. We are fine-tuning things, but suffice it to say that just about anything will go. We will once again have a red carpet, so arriving in stiletto heels and sequins will be totally acceptable. Alternatively, if you own a vintage bowling shirt, this could be the time to pull it out of the back of the closet. The shoe contest will include categories for those partial to high fashion as well as those who choose to adorn more functional bowling shoes. We will also be crowning a HIStalk King and Queen based on their total fashion package. Winners will be awarded amazing prizes, so don’t show up in your “straight off the exhibit floor” attire, especially if the look includes a company logo’d tee shirt.

From RFP: “Re: MD Anderson. Posts an EHR RFP.” The RFP strongly suggests that prospective bidders attend the pre-proposal conference on Wednesday, January 30 just in case you want to thrown your electronic hat into the ring.

From Slim: “Re: Optum. I read your update confirming that Humedica was bought by Optum. Wouldn’t it have to be announced since Optum is part of UnitedHealth Group, which is publicly traded?” I’m not an expert, but I believe SEC disclosure requirements cover only “material events,” meaning companies must file an 8-K form only if a merger, loss of a key customer, or policy change could reasonably be expected to impact share price in the company’s subjective judgment. UnitedHealth Group’s market cap of $58 billion and annual revenue of $111 billion would make all but a huge acquisition non-material.

From Bill O’Plenty: “Re: SB 1275. Crazy law introduced in Virginia.” Virginia State Senate Bill 1275, introduced January 14, would prohibit any organization that stores electronic medical information from (a) participating in the Nationwide Health Information Network; (b) performing analytics on multiple patient records for diagnosis, treatment, or population health management; and (c) processing medical data within Virginia if most of the patients represented live out of state. It also mandates that providers cannot be penalized for refusing to implement EHRs, that patient consent for electronically storing their information is valid only for healthcare coverage purposes, and that the state is prohibited from starting or operating an HIE. I e-mailed the office of the bill’s sponsor, Republican Senator Stephen H. Martin, to ask what he’s trying to accomplish with the bill, but I haven’t heard back. Senator Martin is running for lieutenant governor, which could ironically pit him against Democrat Aneesh Chopra, former White House CTO and advocate for all the items that the bill would prohibit, so perhaps he’s just trying to pick a fight.

From Wearing Dad’s Suit: “Re: Epic’s non-compete. Does it cover this?” Applicants for the head football coaching job posted on the University of Wisconsin’s HR website include a Walgreens pharmacist whose only relevant experience was as a season ticket holder, a Fedex driver who said he’d take $60K to lead the Badgers, and a financial analyst with Epic whose college athletics experience consists of having been a practice player for Tulane’s basketball team. I give our young Epic friend credit for trying even though he lost the $2 million job to a more experienced candidate who responded to the online posting, Utah State Coach Gary Andersen.

HIStalk Announcements and Requests

The latest highlights from HIStalk Practice include: Epocrates says its app has helped clinicians avoid more than 27 million adverse drug events. Farzad Mostashari, MD highlights some of the ONC’s 2012 achievements. Pharmaceutical companies and other businesses embrace advertising opportunities within cloud-based EMRs. E-visits may be as effective as in-person office visits for uncomplicated ailments. Dr. Gregg describes a day in the office in the Year 2063 (quite fun.) You know the drill: catch up on all the latest ambulatory HIT news, click on a few sponsor ads to find a goodie or two that might improve your life, and sign up for the e-mail updates. Thanks for reading.

On the Jobs Board: Cerner Experienced Providers, Product Marketing Manager, Healthcare Strategy Communications Specialist, Project Specialist.

Acquisitions, Funding, Business, and Stock

Healthcare social networking site iMedicor acquires iPenMD, which offers a digital pen solution to capture clinical data. iPenMD apparently bought the intellectual property of nextEMR this past July per a reader’s rumor report.

Merck Global Health provides $6 million in growth capital to eHealth Technologies, a provider of continuity of care solutions.

Praesidian Capital invests second lien debt capital in eTransmedia Technology to replace debt and fund growth.

Revenue cycle systems vendor Recondo Technology receives a $20 million growth investment from private equity firm Bregal Sagemount.

Healthcare Growth Partners releases its 2012 HIT Market and M&A review that summarizes capital markets, M&A, and capital raising activity for the healthcare IT and services sector.

Sales

Tampa General Hospital (FL) selects Merge’s CTMS for Investigators solution for enterprise management of clinical trials.

People

Huron Consulting Group adds Jim Agnew (Navigant Consulting) and Jeffrey McLaren (VHA, Inc.) as managing directors in its Huron Healthcare practice.

HIMSS promotes Thomas M. Leary to VP of government relations, taking the place of Dave Roberts, who was elected to the San Diego Board of Supervisors.

Iatric Systems promotes Frank Fortner from SVP of software solutions to  president.

The Northeast Business Group on Health honors Truven Health Analytics president and CEO Mike Boswood at its 18th Annual Tribute to Leadership.

Clinical data integration provider Apixio hires Jonathan Murray (Aetna) as chief business development officer.

Intellect Resources announces triple-digit growth in 2012 and announces several promotions and hires, including the promotion of Eileen Dick to VP of technology and Cindy Orr to VP of go-live services.

Robert Rowley, MD (Practice Fusion) is named medical advisor for personal health care vendor LifeNexus.

Announcements and Implementations

CareCloud and HealthTronics partner to combine CareCloud’s PM product with HealthTronics’ UroChart EHR and meridianEMR urology-specific EHR platforms.

Fletcher Allen and Dartmouth Hitchcock Medical Center (above) announce the creation of OneCareVermont, the nation’s first statewide ACO that includes 13 hospitals and hundreds of primary care physicians. We announced their plans in September.

Three Ontario hospitals go live on PatientKeeper Physician Portal, Mobile Clinical Results, and NoteWriter, including Alexandra Marine & General Hospital and two hospitals in the Huron Perth Alliance.

The RFID in Healthcare Consortium and Intelligent Hospital.org recognize six organizations for their advanced use of healthcare technology solutions.

GE Healthcare introduces Centricity Practice Solution 11.

Other

Winthrop Resources is conducting a survey on cloud solutions and bring-your-own-device practices. If you’d like to take about 10 minutes to help them out, the survey is here.

HIMSS finds yet another way to offer preferential treatment for its higher-ranking provider members whose purchasing influence makes its vendor members salivate. Healthcare Transformation Project offers “exclusive access” to services, meaning of course that someone has to be excluded (like the rest of us dues-paying members). For example, invitation-only HTPers get “up-front VIP seating at the HIMSS13 Keynote Address by President Bill Clinton” (I was going to insert a cigar joke, but decorum prevailed). The Transformers who are willing to spend $295 of their employer’s money to attend its annual forum at the HIMSS conference get to hear a bizarrely HIT-unrelated group of political speakers – former Florida Governor Jeb Bush, Democratic political strategist Donna Brazile, and former Nixon speechwriter Pat Buchanan. HIMSS says that “participants will make commitments that will translate goals into meaningful and measurable results in their own organization or community,” so we can all look forward to seeing how those work out for patients. Meanwhile, HIMSS offers vendors a bunch of expensive ways to get in or near those decision-making faces, with $50K buying you a podium speaking slot and free tickets for prospects who would be impressed by Pat Buchanan.

Cerner and Sporting KC take heat for failing to keep their promise to build a $35 million youth soccer complex in return for the $200 million in taxpayer-funded incentives they received to build their professional soccer stadium and Cerner office buildings. The youth fields were supposed to in use by now, but work hasn’t started.

Spain’s leading newspaper says it was duped when it ran a fake photo of Venezuelan President Hugo Chavez in his hospital bed, which the paper was told had been taken illicitly by a hospital nurse. The image, widely panned as unconvincing, turned out to be a screen shot of a YouTube surgery video from 2008 featuring an acromegaly patient being intubated.  

The local TV station covers the use by Georgetown University Hospital (DC) of the iPad-based patient data collection system from Tonic Health that replaces paper forms in the doctor’s office. The story says other Tonic users include Mayo, UCLA, the VA, and Kaiser. The company says the product integrates with EHRs via HL7 or can send a CCD record. It offers a free version with limited functionality. Founder and investment information is here.

As tweeted by @Cascadia: a Virginia medical practice charges patients for using its patient portal, billing $125 per year for Gold access to make appointments and refill requests, while the $250 per year Platinum plan adds three electronic visits. That’s the opposite of every other industry, where free online services encourage customers to do it themselves without tying up an expensive employee. This is like banks offering free teller service but charging for ATM access, or maybe McDonalds adding a drive-through surcharge.

A Texas judge orders the deposition of two partners of a CPA firm accused by a medical practice of failing to secure the accounting system it installed in the practice, which the practice says allowed an employee of the practice to embezzle $1 million over five years.

Weird News Andy says this man wears his nose on his sleeve, also wondering if he will pick his nose in public. British scientists are using a man’s own cells to grow a new nose to replace the one he lost to cancer. They have two noses underway (“just in case someone drops one,” the researcher said) and the patient will chose one of them to be implanted under the skin of his arm until it’s ready to transplant.

I had a feeling where WNA’s story was going when I saw his best-ever headline, “Nothing like having a cold one after work,” but I still nearly choked on my soda when I saw the story, in which a male hospital nurse is arrested on suspicion of having sex with the body of a deceased patient.

Sponsor Updates

• Nuesoft Technologies CEO Massoud Alibakhsh discusses data security and Nuesoft’s technology platform in the video above.
• Awarepoint celebrates its tenth anniversary and recaps key successes.
• GetWellNetwork Founder and CEO Michael O’Neil delivered Thursday’s keynote address on interactive patient care technologies at the IPC Symposium at Hasbro Children’s Hospital (RI).

EPtalk by Dr. Jayne

Your tax dollars at work. On Tuesday, the US Supreme Court rejected an attempt to reopen Medicare claims that are more than two decades old. The hospitals assert that CMS miscalculated payments between 1987 and 1994 that were intended to compensate their treating large numbers of low-income patients. Based on the fact that it took my local academic medical center over a year to settle the bill for a routine eye care visit, it doesn’t surprise me that it takes years for hospitals to figure out they’re missing money.

Attention vendors: Mayo Clinic releases a new list of the top reasons for visiting US health care providers. Maybe you should use this as a starting point for your primary care office visit templates rather than some of the bizarre things I sometimes see on your screens. Granted the data is from Olmsted County, MN, but it looks surprisingly similar to my clinic roster this week except for the absence of “flu” and “freaking out that spouse has the flu.”

I received my first HIMSS-related mailing today. It was so underwhelming I can’t even remember who it was from. When I went to dig it out of my recycling bin, I couldn’t find it – which means it was nondescript as well. Great job, marketing team!

A wise man once told me to always spend a small amount of time “looking for your next gig” because things are constantly shifting in the world of medicine. For those of you who think the same way, ONC is looking for a policy advisor “who knows meaningful use policy backwards and forwards.” I was curious, so I checked out the link and got the best laugh of the day. The low end of the salary range is $123,758. Leave it to the federal government to specify it down to a bizarre dollar amount.

I had lunch with four of the smartest women in the world today. Three have been my boss in the past while the fourth who taught me everything I know about billing. Here’s a shout out for leaders who not only know their fields but “get it” as far as motivating employees to excellence. Thanks for keeping me grounded and reminding me that although I currently work in chaos, I can always count on your listening ears. And your unbiased opinions when I text you pictures of shoes I’m thinking of buying. And your assistance with crafting the “Typhoon Jayne” cocktail for HIStalkapalooza. Salud!

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 1/24/13

All the Tools in the Toolbox: How ONC Delivered Value In 2012

Farzad Mostashari, MD responds to a Boston Globe article that characterizes the ONC as “an office whose primary role has been cheerleader” by publicly outlining how the ONC delivered value in 2012.

Prison Time for Health Data Theft

An emergency department registration clerk from a Florida hospital was sentenced to 12 months in federal prison for inappropriately accessing 760,000 electronic health records and then selling contact information of about 12,000 motor vehicle accident patients to a co-conspirator, who used the data to solicit legal and chiropractic business.

Medicare Program; Request for Information on Hospital and Vendor Readiness for Electronic Health Records Hospital Inpatient Quality Data Reporting; Extension of Comment Period

CMS has extended the deadline for public comments on EHR inpatient quality data reporting until February 1.

Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries

A JAMA study quantifies the result of implementing evidence-based post-discharge interventions and concludes that while hospital readmissions dropped six percent, so did hospital admissions, resulting in an unchanged percentage of readmissions among overall admissions.

Readers Write: Dueling Myths: Interoperability and Bending the Cost Curve 1/23/13

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

Dueling Myths: Interoperability and Bending the Cost Curve
By David Lareau

We’ve been hearing for so long about how interoperability is going to do wonderful things that we may have lost sight of the fact that it isn’t actually real yet.

Just look at the sharing of patient clinical information between systems. HHS has just come out with a press release in which they highlight that the penalty per incident for HIPAA violations can be as high as $1.5M. Healthcare executives are being told, “Make your system interoperable, but if you make a mistake, you’ll pay.” Is it any wonder vendors have put clinical data in silos with massive protections around it?

Maybe a bit of reality is getting through. At least they removed the requirement to process incoming clinical quality measure data from MU stage 2, although that seems like a moot point since no one is sending it out except to the government.

But even with these mixed messages in our industry, there is hope. Within the next year or so, new companies will enter the market with systems that are being designed from the ground up to share and distribute clinical information using some of the same methods as social networks. One of the key factors in getting to market quickly for these new entrants is that they don’t have to build upon 15 or more years of “already poured concrete.”

A front-page article in the Washington Post this week said that healthcare is driving job growth in the Washington, DC, area. Read a bit further and you get to these tidbits:

• “Northern Virginia’s Inova Health System added about 1,000 positions in 2012”
• “The growth at Inova last year was largely a result of a major initiative to overhaul its medical records program”

OK, I love it that people are gearing up to update their systems and that jobs are being created, but someone please tell me how that helps us bend the cost curve down? I’m not hearing much about clinician productivity increasing, and I seem to remember from Econ 101 that there is an inverse relationship between cost and productivity. Productivity goes down, cost goes up, and vice versa.

Meanwhile, we hear rumors about Meaningful Use Stage 4 when we’re trying to read the crystal ball about Stage 3 and gear up for ICD-10-CM. I must tell you, I don’t know about the cost curve bending down any time soon, but I sure can tell you that my anxiety curve is going up.

David Lareau is chief executive officer of Medicomp Systems of Chantilly, VA.

Readers Write: Mandating Physician Data Entry 1/23/13

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

Mandating Physician Data Entry

We constantly hear about how EMRs slow physicians down in clinic. I’m on the IT side, and while I agree that every EMR needs to work on usability, it seems that part of the problem is physicians have to use the computer in cases when they would hardly touch paper.

Example: the physician used to just dictate his note and tell his nurses about any tests he was ordering. The note goes to a transcriptionist, and later comes back and is filed to the paper chart. The nurses grab whatever paper forms were needed for the tests, which the MD signs so it can be faxed over.

An analogous workflow in the EMR would be: physician dictates his note (not using Dragon, still using a transcriptionist) and the note is interfaced back into the EMR to be signed. The nurses queue up the orders and the MD signs them (or the nurse just places the order and they’re sent to the MD for signing later). This is all technically possible in Epic and I imagine in other EMRs too.

This workflow seems ideal and maintains the original division of labor. Or you could even hire a scribe to write the note and queue up the orders instead of relying on transcription interfaces and forcing nurses to deal with order entry. But it seems that hospital leadership has an assumption that physicians’ hands need to be on the computer constantly. Is there a reason for this, besides health systems not wanting to pay for the extra staff?

In an ideal world I can see mandating that physicians enter data to ensure accuracy, but maybe that’s a goal for later when EMR usability improves.

The author has chosen to remain anonymous.

Readers Write: Vendor Lessons Learned 1/23/13

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

Vendor Lessons Learned

After 10+ years working for a few HIT vendors, here are a few lessons learned:

1. Stop trying to sell half-baked products: new products, upgrades, and old products remarketed. Litmus test: if you wouldn’t sell it to your mom or best friend, it ain’t ready. No amount of sales talent will overcome poor quality.
2. Hiring a strategy firm for a lengthy assignment is a red flag that shows a lack of confidence in the direction of the company. Litmus test: validating information or evaluating a new market is one thing, hiring someone to tell you how to run your business is another.
3. Buying a business at a premium and then inflating prices to customers and prospects to cover the cost of the acquisition is not wise. Litmus test: if your pricing strategy is based on creating value for you rather than your customer, you have it backwards.
4. The best sales talent in the world can’t fix bad products, bad service, and bad strategy. Those problems need to be first addressed at the top before anyone is going to sell anything of value over time. Litmus test: silver bullets don’t work despite the temptation to believe they do.
5. Stop establishing sales quotas that have no basis in reality. Spreadsheets don’t sell deals and prospects don’t care about your budgets, business plans, or quotas. Did you hear Nick Saban talk about winning? He doesn’t focus on results, he focuses on the keys that create the results. Litmus test: if you are not clear on exactly how you expect to generate the leads required to hit your sales targets and/or your plan is solely contingent upon your reps figuring this out you have a problem. Hope is not a strategy.
6. Companies that achieve consistent growth follow basic principles. At the core, they have passionate leaders who have a cause, are committed to being the best, and are dedicated to truly helping their customers (internal and external) win. This is much easier said than done. Litmus test: you know when you have something special. You cannot really explain it, but you have Mojo – Energy, Confidence, and Focus.

The author has chosen to remain anonymous.

CIO Unplugged 1/23/13

The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.

The Long View

I proposed to Julie on February 1, 1984. I was 19. I’m not sure I really knew what love meant, but I sure enjoyed being around her. I loved listening to her practice piano for recitals as I stole second glances.

Despite our young age, everyone was pretty stoked about our engagement except her parents. Looking back 27 years later, with my own daughter that age, I can’t really blame them.

Julie defined their marriage. She was the apple of their eyes. They wanted to delay giving her away for as long as they could. When they did, they hoped for a doctor or lawyer. At least those were the types they had over to dinner so Julie could meet them on weekends home from college.

I recall pulling into their driveway one Friday. My Chevy Vega with the duct-taped hood cowered next to their lacquered Mercedes. Wearing baggy sweats and tennis shoes with holes, I was the definition of poor. While I grunted away in the Army Reserve as a private, her dad stood tall as a retired WWII naval officer.

They were against the marriage from the get-go and withheld their support. Then came the final meeting, one last chance to talk us youngsters out of a commitment that had failed them both previously. They hired an investigator who reported everything about me from teenage indiscretions to bank withdrawals to employment history. There was nothing new to Julie. 

Out of exasperation came the final plea came. They offered me a handsome amount of money to walk away.

I had no hesitation. I’d already counted the cost. Despite the fast and easy reward, I took the long view. I’d never had that kind of cash, but I knew money wouldn’t make me happy. I immediately said no. They walked away.

We face many temptations in our careers. Most are not so stark, but others manifest themselves in many forms. We all know of colleagues who took bribes from vendors to influence purchasing decisions. Eventually they got caught and lost their careers and reputations. The short-term gain never pays long-term dividends.

Reviewing hundreds of resumes over the years taught me to spot trends where applicants constantly jumped from job to job, each time trying to bank a modest increase. Although a person might receive payola by making so many moves in a short period, they likely won’t land the big one. Who would hire someone whose trend suggests he or she might leave in a year? At some point, all the jumping catches up to you, especially at the highest levels. Think tortoise and the hare.

I do believe there are times you must go to grow. Other times you need to grind through challenges so your character can form and your leadership can blossom. I see too many people run at the first sight of trouble.

Boy, I’ve been tempted myself. I recall one year a while back showing up at a new employer where it was clear I was way in over my head. Way over. Everyone was nice and it was a stellar advancement opportunity, but my insecurities got the best of me. After a few months, I humbled myself and called my former employer, asking to return.

The COO, who had previously served as my mentor, said no. He explained that I needed to stick it out, learn, ask for help, adjust, and succeed. As much as he wanted me back, he knew if I went in reverse, I would never reach my ultimate goal of CIO. I followed his counsel, and today I am living my career dream. Had I taken the short view, I would likely still be working in the same position today.

My in-laws ultimately had a change of heart and helped us with the wedding expenses. I appreciated the fact they wanted to protect their daughter from making such a huge commitment at a young age, not yet even a junior in college. I would’ve handled it differently, but again, I understood the motivation.

We got married and worked our butts off to get through school and start our family. Today we are richly blessed, having taken the long view.

Whenever challenges hits me, I’m tempted by the short view. But one look at my family and my career reinforces the lesson. The long view pays off.

Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.