HIStalk Interviews Don Menendez, President, White Plume Technologies

Don Menendez is president of White Plume Technologies of Birmingham, AL.

Tell me about yourself and the company.

I began my career with IBM. I’ve been in software for a long time. I got into healthcare in the late 1980s. I joined a company that had a billing operation, a Unix-based PM system, and an RCM element. The real interesting thing was that we had a shared resource, a large IBM mainframe that we were selling time on. Clients didn’t incur technological or cost risk — they paid on a monthly basis. We didn’t even know it, but we had an ASP before we knew what it was.

That’s how I got to the healthcare side of it. We sold that company to a publicly-held company and then I was looking for a problem to solve. I believe software should solve real problems in a simple way.

I looked at  two things. There were two big gaps in the workflow in the physician offices that I saw. One was, back in 1999, clearly the EMR gap. I felt from a timing perspective and the amount of disruption that it would cause for physicians the timing didn’t make sense at all.

There was another one that was kind of interesting. It was what we ultimately got into. It was the automating of the front end of a revenue cycle management process.

It had been the same for quarter of a century. I’d always known that the first time you automate a manual repetitive, complex, confusing process, that’s when you get to ring the bell financially for your costumers, as opposed to what version 10.1 does for him. That was what this area was. A lot had been done on the back end, but very little on the front end. We felt that if we could push the process use technologies and know-how at the front end without negatively impacting the doctor, we had a real winning solution for him.

Why would practices that already have a PM/EMR system need your products?

It’s really interesting because probably in the last 18 months, the great majority of our new clients are exactly that – people who have an EMR already installed and a PM system. 

I think what happens is this. We approach a number of these practices when they’re in an EMR evaluation stage. Many of them feel like they’re going to be able to achieve the results that are provided by the kind of solutions that we provide once the EMR is implemented. What a  lot of them seemed to find out was that for any number of reasons, they’re all different. The EMR solution is working well, but they’re not satisfied with the results they were able to get as it related to the automated charge capture and coding process.

Sometimes these physicians find the charge capture process too time-consuming and they won’t do it, or it just doesn’t work for them. Other times it doesn’t match the workflow within the practice of how to do what we call post-encounter coding, taking that encounter and adding all the additional things to it necessary for it to get paid correctly. It’s not all done by the physician, and so there are some real workflow issues.

Other times, what ends up happening is they come to us because they’ve figured out that to solve this problem, they’ve had to hire additional administrative people just to do additional work to get the charges in correctly now because they’re starting with physicians than a different manner they started before.

While they took a step forward in the clinical process, it seems like they either made no progress on the RCM side, or worse yet, they took a step backwards. It’s been really interesting that most of our new business is coming from those folks. I would not have predicted that, to be honest, three or four or five years ago, but that’s really what happened.

Do you think it’s a surprise to physicians that when they finally get a PM or an EMR system, much of the benefit accrues to someone else?

My personal opinion is it’s all across the board. For some of them, they predicted that forever. They were very skeptical in the beginning and it was borne out. For others, they were skeptical and it’s borne out differently. They’ve really gotten some value out of it.

In our particular area, the niche that we serve, and what we’re trying to accomplish — quite frankly, the functionality that we provide is an afterthought for both the physician practice and the vendors that are trying to sell the EMR product. Automated charge capture and coding is an afterthought. Many times is an afterthought in the design process, during the sales process, and during the implementation process.

For what we do, they really haven’t thought much about it during the evaluation and implementation process. But when they get down to the point where they’ve rationalized all that technology and are starting to move forward, we find the administrative people say, “We’ve taken a step backwards” or “We made no progress on this at all, and we didn’t realize that there were something out there that could solve some of these problems.”

Describe how your system works differently from the PM and EMR.

Our whole approach was that you can’t slow the physician down for an administrative task or process. It just didn’t make sense. It was counterintuitive to do that. Everything that we’ve done has been designed around that. The part of the process that starts with the physician needs to help them with their productivity, or certainly not slow them down.

This is an odd thing. It sounds counterintuitive, but when we started this business 13 years ago, the great majority of physicians out there — I’ll bet 90 to 95 percent of physicians — were marking encounters on a paper encounter form. They would spend somewhere between three to 10 seconds with that form. That would be enough information to start the process so they can get reimbursed with that encounter. That’s a pretty high standard against which to take an electronic system and try to make that work. 

We’ve focused on the charge capture device, whatever that is, to be productive for the physicians. We’re agnostic towards that. We don’t care. We’ve always had a real open attitude. The best way to get a charge into the system is whichever way is the best for the individual doctor. It could be an iPad. It could be another tablet device. It could be an iPhone, an Android, or other mobile devices. It could be EMRs, keyboards, and lab systems. It could be paper. Regardless of the tool used to capture that data, it should complement and leverage the process and the workflow of the practice. That’s what’s important.

Like most software companies, we learn on the back of our customers. We’ve been doing this same very focused process for 13 years. They’ve taught us a bunch about how it works. It’s not slowing the physician down.  It’s not pushing administrative tasks to the physician. It’s leveraging productivity and accuracy on the front end of the process as opposed to the back end of the process where most of that’s been.

How does it integrate with the PM/EMR?

We originally integrated with PM systems because EMR adaption was so minimal that it just wasn’t an issue for most of our clients. We probably have upwards of 30+ different interfaces that have been in place for quite some time now. Over the last three or four or five years, we have been doing many more EMR interfaces, so that once the doctor is finished with the patient encounter from an EMR basis, they will send us the important bits of data that we need for the charge encounter.We’ll run it through our automated workflow and coding system and then electronically send it to the PM system as if it had been keyed in by the PM system itself.

Obviously, there’s a real benefit there when you got an environment where there’s one PM system and a different vendor for the EMR system. We provide a nice middleware bridge for them just to pass the data, but when we pass it, we clean it up.

I notice you just brought AccelaMOBILE for mobile capture of physician hospital charges. Explain how physicians bill for the hospital services they provide.

It’s really interesting. In the ambulatory setting when they’re in clinic, the administrative personnel will put all sorts of procedures and processes in place around the physician to make sure they get the information they need to get an encounter paid. But when those physicians go out to the hospital, they’re on their own. 

It’s almost like the Wild West out there. It’s every way possible you could think about it. Some are doing along 3×5 card. Some of them get a rounding list printed off from their PM system and they jot those things down. I’ve seen physicians jot it down on their scrubs. They run into a colleague in the hall and they do a consult that nobody knows about and they forget do it. They go to the football game or the music recital right from the hospital and they lose their charges.

One of the big problems with mobile charge capture is just getting decent good data back to the billing staff so they can clean it up. That’s the real allure of mobile charge capture and the concept of AccelaMOBILE. It’s always been about getting the form factor and a technology used by the physicians. 

We looked at doing this 10 or 12 years ago, but the technology just wasn’t there. But now, with physicians being 10 years younger than they were, they’re accustomed to the form factors of smartphones and iPads and those kinds of things. We can now at least solve that first part of the problem — we can get the data back to their billing office in a legible manner that’s complete about what they were doing in the hospital. That’s what the real excitement of the mobile product is.

The second piece is that once you get the data in, it does need to be cleaned up and appropriately done so that you get paid for it. The mobile product is the front end for remote charge entry by the physician. That is complimented by our back-end suites of products that do the workflow and the coding on it.

For some companies, it’s a whole different ballgame to develop their first mobile application and do it right. What did you learned in bringing out AccelaMOBILE and seeing how physicians are using it?

I’ll sound like a broken record, but we’re dealing with high-knowledge professionals that are extremely busy. They were trained to see one, do one, and teach one. That’s the way we try to do the user interface. It has to be simple, it has to be quick, it has to have very few clicks, it has to provide them shortcuts necessary so that they can get into the technology and get out of it very quickly. That’s a continually improving process, and frankly, our physicians are the ones that teach us the most about that. But the simpler the better for them.

How hard is it to make a business case for a practice that may have stretched themselves to buy another new system and now you’re offering them a different one still?

A big issue for everybody is the bandwidth of the practice. Intellectual bandwidth, time to do another project, certainly finance is a commitment, that kind of thing. That is a big issue for us in the marketplace at this juncture, but we try to do things to minimize that. Our whole approach is focused on minimizing that.

We believe that if you’re seriously looking to improve your automated charge capture and coding process on the front end, you can take a look at what’s out there in the marketplace. You can evaluate the systems. You can evaluate what’s available and how it’ll work, probably within a week or two if you could devote a little bit of time to it. 

For us, implementations are typically three days. We’re in and we’re out. It’s a pretty quick process, so it’s pretty light as it relates to the staff itself, but the bigger issue is just the idea that you’d even think about looking at something there.

On your website, it says that HITECH has skewed the EMR market and the vendor accountability to customers with what was described as a checkbook and a gun. How do you see the EMR/PM market evolving over the next several years?

I’m bullish about that, for two reasons, primarily. We believe that once Meaningful Use settles down a bit, the same market forces that have been in place for years will be refocused on, and that’s downward pressure in reimbursement — we don’t see that changing – and increasing complexity and cost associated with physicians figuring out how to get that reimbursement. We expect the focus to shift back to operational efficiency in the ambulatory setting.

I may be wrong about this, but it seems as if none of the current incentive programs are really incenting operating efficiency for the practice. What they’re about is about driving data. Once that moves a bit, I think we’ll play really well, and that as they start to turn towards maximizing efficiency again.

The other piece, the wild card that everybody’s talking about and knows about, is ICD-10. It’s a huge, huge threat to physician productivity and to revenue cycle performance. That’s not about driving data — although for the government it is about driving data — but to practices just trying to see their patients and do what they need to do, it’s a huge threat to both those areas. That’s where we focus. We hope that it doesn’t get pushed out. It’s a distraction. We understand the importance long term about it, but we think it’s an unfortunate distraction.

We think that once all that quiets down a bit, it will return to some of the basic issues. Frankly, they’re going to be harder. The economics are going to be different in an acute setting than it is the ambulatory. The hospitals are buying up all these practices. As they move out of that acquisitive mode and they start to try to rationalize their acquisitions, I think there’s going to be more focus on maximizing operational efficiencies. They’re going to look for help in the ambulatory setting with revenue cycle systems and that kind of thing without having staffs.

Any concluding thoughts?

I’m grateful for the great team we have here. I started this because I thought that business is a part of the fabric of life. You can do both. You can have a great team, you can compete effectively, you can be profitable, but you can have a place where people can live balanced work lives. I’ve been fortunate that the folks that decided to work here really care about our customers and find ways to solve problems. I’m grateful for that. 

I’m grateful for that and I’m grateful for our customers. We have learned so much from them about the challenges that they face and how to make our product a better result of that. Software companies learn on the backs of their customers. I’ve been in the software business since I got out of college and they never get credit for teaching us, but they do teach us. I’m grateful for that.

This is a great time to be in the business. I don’t know what’s going to happen, but as long as physicians wake in the morning, see patients, and hope to get paid for what they do, they’re going to need to get encounter data to the payer and we seem to know how to do that pretty well. There are lots of different ways of making that happen, so we think that means that there’s going to be an opportunity for us. Even as a small player, we’re bullish on what the next three to five years might look like for us.

Morning Headlines 12/7/12

Athenahealth to buy Watertown complex for $169M

Athenahealth completes a deal with Harvard University to buy a 760,000 square foot Watertown, MA campus for $168.5 million.

Ninety-Four Percent of Hospitals Surveyed Suffered Data Breaches; Estimated Cost to Healthcare Industry Averages $7 Billion

Survey results from the Ponemon Institute reveal that 94 percent of hospitals experience data breaches in the last 12 months, with 45 percent reporting more than five breaches over the past two years.

T-Systems Wins Major IT Outsourcing Agreement in US Health Industry

T-Systems expands its presence in HIT as it closes a “pay-as-you-go” IT outsourcing for Presbyterian Healthcare Services.

Reuters – Thoma Bravo, Francisco, THL Final Suitors for Merge

Thoma Bravo LLC, Francisco Partners and Thomas H. Lee Partners have submitted revised takeover offers to Merge Healthcare.

SAIC Announces Financial Results for Third Quarter of Fiscal Year 2013

SAIC announces Q3 results: revenue up 3 percent, EPS $0.33, missing on expectations of $0.35. The company reported that it had signed over $100 million in consulting contracts through its Vitalize and MaxIT acquisitions.

News 12/7/12

Top News

Reuters reports that PE firms Thoma Bravo LLC, Thomas H. Lee Partners LP, and Francisco Partners have submitted revised takeover offers for Merge Healthcare and are awaiting a decision from the company.

Reader Comments

From Nasty Parts: “Re: MedeAnalytics. Oracle backed out of a deal to buy the company, so they’re re-orging and putting a number of folks on the street.” Unverified.

From Spamalot: “Re: funny vendor spam. The ridiculous image and hilariously misspelled text caught my eye before I could hit the delete key.” Could it be that the company has decided to offend as many of the senses as possible, with your delayed “delete” validating their cunning premise of turning your head like a gruesome car wreck? Surely it was not a native English speaker who composed the pitch for business “coninuity” and referred to network security as a “new sexy term.” The company’s two addresses appear to be mail drops, and the Facebook link in the spam goes to a marketing person’s personal page that features family photos and cutesy kitty porn. I’ll hazard a guess that their incoming lines won’t be overwhelmed by clamoring prospects.

HIStalk Announcements and Requests

In case you have missed any HIStalk Practice posts in the last week, here are some highlights. Most physicians who e-prescribe believe it reduces prescription fraud and facilitates decision-making. Vermont’s eight FQHCs go live on five different EMRs. OIG finds that physicians who protest the denial of Medicare claims win their cases 61 percent of the time. Spring Medical Systems will offer its EHR clients an analytics solution from Clinigence. The AMA argues that pre-payment MU audits would be too burdensome for physicians. None of this news can be found on HIStalk, so if you are interested in the ambulatory HIT world, make sure to sign up for the HIStalk Practice e-mail updates. Thanks for reading.

On the Jobs Board: Director of Reimbursement, Cerner Activation Consultant, Director of Marketing, Marketing Programs Manager.

I’m not really interested in two front teeth for Christmas since I don’t have a spot for them, but I could use some holly jolly reader gifts that cost nothing: (a) take 10 seconds max to sign up for spam-free e-mail updates from HIStalk, HIStalk Practice, and HIStalk Connect; (b) sleuth us out on Facebook, LinkedIn, Twitter and make the electronic connection; (c) support the companies that pay the bills by checking out their ads to your left, reviewing their offerings in the Resource Center, and sending out an effortless request for consulting information via the RFI Blaster; and (d) graduate from spectator to player by sending me news, rumors, and guest posts. I note that Dann’s HIStalk Fan Club on LinkedIn now has 2,881 members, all of whom get extra attention when requesting something because I’m reassured that they aren’t ashamed of reading HIStalk. A reminder: we’ve got the top headlines each weekday morning on HIStalk, courtesy of the newest crew member, Lt. Dan. You won’t get an e-mail blast to remind you since I figured that would be really annoying, so just head over to the main page and you’ll see what’s new before you head out for work (like I do).

Acquisitions, Funding, Business, and Stock

Toronto-based Constellation Software purchases 100 percent of the fully diluted shares of Salar from Transcend Services, a division of Nuance. Transcend purchased physician documentation and charge capture systems vendor Salar in July of 2011 for $11 million, followed by Nuance’s acquisition of Transcend for $300 million in March 2012. We ran an accurate reader rumor report of the then-unannounced sale on November 30.

EMR vendor Modernizing Medicine raises $12 million in Series B financing to expand into the orthopedic and ENT markets.

SAIC announces Q3 results: revenue up 3 percent, EPS $0.33 vs. –$0.28, missing on expectations of $0.35. The company said it signed over $100 million in contracts from its recent acquisitions, maxIT Healthcare and Vitalize Consulting Solutions. SAIC also announced that it will cut 700 jobs in advance of possible fiscal cliff federal spending cuts that would decrease defense spending. Shares that were at $20 in early 2010 closed Thursday at $11.26, valuing the company at just under $4 billion.

Sales

Presbyterian Healthcare Services (NM) signs a multi-year agreement with IT service provider T-Systems to manage the health system’s data center operations.

Martin’s Point Health Care (ME/NH) selects athenahealth to provide EHR, billing, PM, and care coordination services for its 90 providers.

Catholic Health Initiatives will partner with Encore Health Resources to create a suite of electronic healthcare intelligence solutions focused on quality, performance, and risk analytics.

Indiana University Health selects Healthcare Quality Catalyst’s data warehouse platform for reporting and analytics.

Mercy Medical Center (IA) will implement iSirona’s device connectivity software to automate the flow of patient data from more than 150 devices into Epic.

Abington Health System (PA) selects the Surgical Information Systems perioperative IT solution for its two hospitals.

WellSpan Health (PA) subscribes to the CapSite Database to improve its purchasing processes.

Maury Regional Health System (TN) selects Medseek’s patient portal solution.

Ophthalmic Consultants (MA) adopts the Professional Charge Capture solution from MedAptus.

People

Interoperability software provider Compressus names Joe Lavelle (Results First Consulting) as COO.

Clinithink hires Fiona Lodge, PhD (Microsoft) as director of technical operations and Nathan Skorick (Altos Solutions) as business development executive.

Huntzinger Management Group VP William Reed (above) joins the company’s board of directors, along with Richard Sorensen (US Health Holdings.)

Emdeon adds former Allscripts Chairman Philip Pead and former Harris Corp. CEO Howard Lance to its board.

Hospitalist Fred Chan, MD is named to the newly created position of CMIO for GBMC HealthCare System (MD).

Jardogs names Ken Mikesh (MyHealthDIRECT, above) as SVP of strategy and business development and Brenda Stewart (Merge Healthcare) as SVP of marketing.

Homer Warner, a cardiologist and medical informatics pioneer, died November 30. He started developing clinical software at University of Utah and Intermountain Healthcare in the mid-1950s and wrote Intermountain’s ground-breaking and still-used HELP system in the 1970s, one of the first electronic medical records and clinical decision support systems. He was chair of University of Utah’s Department of Medical Informatics, the first such program offered by a medical school. Intermountain opened the Homer Warner Center for Informatics Research at Intermountain Medical Center in 2011. He remained active, vital, and humorous until his death at age 90, as evidenced by this video interview conducted a few weeks ago.

Announcements and Implementations

Vitera closes its hardware support business unit through a partnership with DecisionOne, which will hire Vitera’s field technicians. Vitera notes that it has added more than 270 employees this year and anticipates filling another 200 positions.

The University of Texas at Austin launches the country’s first HIE laboratory, which is funded by ICA, Orion Health, eClinicalWorks, and e-MDs.

DrFirst announces Akario, a free secure clinical messaging system.

GE Healthcare launches its Centricity Business 5.1 RCM solution.

Allscripts releases Sunrise Financial Manager, a revenue cycle solution designed for accountable and value-based care payment models.

The HIEs of West Virginia and Alabama, both customers of Truven Health Analytics, earn federal recognition for reaching milestones for full query-based and directed information exchange.

MModal opens a medical transcription center in Mysore (India), where the company plans to create 100 jobs over the next two years.

Cisco Systems is providing video calls with Santa to patients at 31 children’s hospitals (including Children’s of Alabama in a photo from Tuesday, above) via its Santa Connection Program, which runs through December 21 .

Government and Politics

The IRS releases a final rule subjecting the sale of medical devices to a 2.3 percent tax beginning in 2013, which is expected raise $29 billion in tax revenue through 2022.

Innovation and Research

Independence Blue Cross, Penn Medicine, and DreamIt Ventures create Philadelphia-based DreamIt Health, yet another digital healthcare accelerator. It offers $50,000, a four-month boot camp, office space, mentoring, and a demo day. It gets 8 percent of the equity in return.

Other

Athenahealth will buy the 29-acre, 11-building, 760,000 square foot Arsenal on the Charles complex in Watertown, MA from Harvard University for $169 million. The company was already leasing 330,000 of space in the complex for its headquarters.

A CapSite survey finds that one-third of US hospitals have adopted a vendor-neutral archive, while another 19 percent plan to do so.

Kaiser Permanente will open a new IT center in the Denver, Colorado area and will hire 500 IT employees by 2015.

A survey finds that 94 percent of healthcare organizations suffered at least one data breach in the last year. Other findings: (a) 69 percent don’t secure PHI-containing medical devices such as insulin pumps, and (b) almost all of them use cloud-based solutions and allow employees to use their own medical devices even though half of the organizations question the security of those technologies.

The CDC reports that 40 percent of office-based physicians now use an EHR with a basic level of functions, up from 34 percent a year ago.

At a dermatologist appointment this week, I noticed signs on the window urging patience, as the one-doc practice had just changed EMR systems. I asked the doctor and got an earful in return. He had already attested for Meaningful Use Stage 1, but was convinced by a salesperson to trash his EMR and move to GE Centricity. He said it’s the worst business decision he has ever made, not because Centricity is bad, but because he spent a lot of money, he’s being hit constantly with additional upgrade and maintenance fees, and to top it all off, he now realizes that he has no chance of collecting Stage 2 money because the bar is set too high for his practice. Not to mention that as a specialist, the EMR is not providing much patient value. He says he’s hoping to hold on for the 2-3 years it will take to get his practice back on its feet again, as the EMR is now his single largest expense. I can only describe his behavior as ashamed, followed by relieved as he realized from our discussion that he’s not the only one struggling to pay for something that he probably should never have bought in the first place. Needless to say, he’s not exactly thrilled with the HITECH program. It’s an eye-opener to realize that these little practices are cash-strapped businesses run by folks who may be excellent clinicians, but who are also marginal, accidental businesspeople just trying to keep the doors open and their employees paid. Derms are usually well paid and minimally stressed thanks to acne and Botox, so I can only imagine what it’s like for a primary care practice.

In Canada, Vancouver Coastal Health fires a long-time clerical employee for looking up the electronic records of five local media personalities out of curiosity.

Hello, Doc, Internet porn is free: a female employee of a doctor’s practice notices a red light glowing behind supplies in the restroom. She finds a video camera pointed at the toilet. The doctor finds his career potentially in that same toilet, as police executing a search warrant find the camera-controlling software on his computer. Maybe he should claim that the restroom doubles as a telemedicine station.

A privacy “weakest link” example. MC and Mel, a couple of morning zoo-type deejays from Australia sporting the worst fake British accents in history, call up the London hospital treating the Duchess of Cambridge for morning sickness, doing hilariously unskilled and giggling impersonations of Queen Elizabeth II, Prince Charles, and barking Corgi dogs. They get through to a nurse who provides a full update on the former Kate Middleton’s condition, learning that Kate “hasn’t had any retching with me.” The hospital is evaluating its privacy practices. UPDATE: in a not-so-funny ending to the story, the nurse who took the prank call has apparently committed suicide.

Sponsor Updates

• Billian sponsored the December 4 Health IT Leadership Summit at the Fox Theater in Atlanta, which attracted 600 attendees. Above are Ellen McDermott (University of West Georgia), Jennifer Dennard (Billian Inc.), David Hartnett (Metro Atlanta Chamber of Commerce), and Cynthia Porter (Porter Research).
• AT&T adds a remote interactive patient monitoring solution from Ericsson to its ForHealth remote patient monitoring platform.
• Mercy Regional Hospital (KS) implements a paperless employee time off request process using Access Evolution.
• Healthcare Clinical Informatics offers ten tips for realizing the value of EHR.
• Shareable Ink will exhibit at next month’s ASA Conference on Practice Management in Las Vegas.
• Beacon Partners and its employees donate over $9,500 in support of the Red Cross’s Hurricane Sandy relief efforts.
• ChartWise Medical Systems will integrate TruCode’s grouper, pricer, and editing Web Services into its ChartWise:CDI software.
• Imprivata publishes a white paper highlighting best practices for realizing care team collaboration and productivity benefits using HIPAA-compliant texting.
• CPU Medical Management Systems, a MED3OOO company, partners with RISARC Consulting to provide CPU customers an option for secure electronic document exchange.

EPtalk by Dr. Jayne

ONC holds its annual meeting on Wednesday, December 12 in Washington, DC and also accessible by webcast. It will include sessions on HIE and interoperability, patient engagement, and of course Meaningful Use.

A study in the December issue of Pediatrics lists five key features needed for pediatric EHRs: well visit tracking, support of growth chart analysis, immunization tracking, immunization forecasting, and weight-based drug dosing. Although the article notes that “it’s nearly impossible to find an EHR that meets those standards,” I guess I’m lucky because my system supports all of these. One of my friends is looking to replace her system and I’m attending a demo with her over the holidays. We’ll have to see how that vendor stacks up.

Over on HIStalk practice, Inga mentioned a survey on e-prescribing. Although I’m optimistic about its potential, I’m skeptical about the ability of pharmacies to keep up. Case in point: e-prescribing of controlled substances. Although the DEA finally approved this and several vendors piloted it in a handful of states, there is still a lack of awareness. I happened to stop by the pharmacy at a local supermarket chain and ask if they’re ready to receive such scripts (because I’m more than ready to start transmitting them) and received a stern lecture from the pharmacist about how he’s been told it’s illegal to do so.

Weird news story of the week: A New Orleans ambulance crew finds their vehicle immobilized with a parking boot, applied while they were on the scene with a patient.

I previously mentioned Scanadu, the startup that hopes to make a Star Trek-style medical scanner a reality. The company unveiled its SCOUT product, which is headed to the FDA for approval as a home diagnostic device. If it really delivers what it says – five vital sign results in 10 seconds with 99 percent accuracy – I think they’re missing a major market. For physician practices where rooming patients quickly is essential, this would be a killer app.

One of my favorite Tweeps is @MeetingBoy. Since I shared my holiday party recipes, I’ll share his piece on Eight Reasons Why I’m Skipping the Office Christmas Party.  I’ve never been to a real-life office Christmas party – we don’t have those in non-profit land. The closest we have is the holiday potluck. I’d love to live vicariously through HIStalk readers and of course promise to keep you anonymous. Bonus points for anyone who has received a corporate logo holiday gift worse than what I received one year: jumper cables.

Flu season has arrived early. If you haven’t received the vaccine, there’s still time. Whether you’re vaccinated or not, please keep covering those coughs, stay home when you’re sick, and keep washing those hands. And in case you wondered, paper towels spread fewer germs than drying your hands with a blower.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Mobile.

Morning Headlines 12/6/12

ONC, CMS revise EHR Stage 2 rules

ONC and CMS revise several stage 2 rules, publishing an interim final rule with a 60-day comment period.

Allscripts Releases Sunrise Revenue Cycle Management Solution

Allscripts announces a newly developed revenue cycle management solution designed to track costs across the enterprise and support value based care models.

Truven Health Analytics HIE Advantage Customers Receive National Recognition for Achieving Health Information Exchange Milestones

West Virginia and Alabama, both running HIE infrastructures put in place by Truven Health Analytics, receive federal recognition for reaching full query based, and directional information exchange.

Vitera Healthcare Solutions Partners with DecisionOne Corporation to Deliver Superior Hardware Services and Support to EHR/PM Customer Base

Vitera closes its hardware support business unit through a partnership with DecisionOne. All affected Vitera employees will be absorbed by DecisionOne, which will take over support functions for Vitera starting in 2013.

Readers Write 12/5/12

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!

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

Hey Healthcare, ‘I Dare You to Do Better’
By Nick van Terheyden, MD

I was reading “Dream Big, Start Small: NYU Startups Disrupt Big Industries” when a quote from Mana Health caught my attention: “We want to make the job as easy as possible for doctors … We want to be Apple in [the] health industry.”

This quote got me thinking about the role of simplicity in healthcare. Part of what makes Apple unique is its simple approach to consumer technology. While bells and whistles are buried beneath the surface, what the user experiences is the ability to pick up a piece of Apple technology and interact with it without reading a verbose manual or watching a “How-To” YouTube video.

Clearly, a team has already taken the time to anticipate how people will use this technology, what questions they might have, where they might get hung up, and what’s really going to “wow” consumers and keep them engaged. There’s something mystical and awe-inspiring about this type of simplicity, particularly if you compare it to what clinicians have to do in order to get up to speed on the most basic healthcare technologies.

Maybe it’s because The Official Star Trek Convention was recently held in San Francisco, or the fact that I just recently heard that a nine-minute teaser for the latest Star Trek movie, “Star Trek Into Darkness” will be available in 3D IMAX theaters on December 14, but in addition to “simplicity,” I’ve also been thinking a great deal about how advancements in technology can help the healthcare industry “boldly go where no one has gone before.” And more importantly, to get “there” without asking clinicians to fight Klingons.

Over the past year, there has been an array of studies and stories pointing to frustrations associated with electronic health records and Meaningful Use. This is compounded by additional pressures putting the heat on the healthcare industry — a looming physician shortage, an aging population with increased care demands, and changes in the reimbursement model.

Still, for every problem, there’s a solution. What keeps me up at night, though, is the fact that all too often we try to slap a new coat of paint on a problem in an effort to mask the issue as quickly and efficiently as we can. More often than not, we approach problems — especially in healthcare — with a fast and furious desire to make things right in the moment instead of aiming to make things right for the long term.

The fast fix in healthcare is often not the real solution to the problem. Take the transition to ICD-10, for example. At first, some healthcare providers wanted to keep doctors as far from the transition as possible. And at first glance, I can understand why. No one wants to take the focus off of the patient. Still, the transition to ICD-10 can’t be simplified without having doctors on board as part of this massive personnel and technological overhaul.

See, the problem with simplicity is that to get to that type of Apple approach in healthcare, you have to take into consideration the myriad of players that will be affected. You have to take the time to test and tweak, test and tweak in an iterative process that while challenging and time intensive, will ultimately be rewarding. In other words, to get to “simple,” you have to trudge through the difficult for quite some time.

As we head into the holiday season and take a look back at the accomplishments and failures from the past year, let’s agree to remain focused on integrating a new sense of simplicity into the complexity of all things healthcare in 2013 – whether it’s technology, health insurance, or patient communication. One particular “Star Trek” quote mapping back to the simplicity theme that seems like a fitting request for all healthcare players in the coming year is this: I dare you to do better.

Nick van Terheyden, MD is chief medical information officer at Nuance of Burlington, MA

Humble Suggestions from an Allscripts Pro Client to Ease Transition Pain for MyWay Clients
By Cathy Boyle, RN, BSN

By now, I’m sure everyone who uses Allscripts MyWay is aware that the company is transitioning customers to the Professional Suite. You’re probably overwhelmed sorting through options as you decide whether to upgrade to the new product or to jump ship and start over with another EHR company. 

Starting over with another company may be painful, but it’s also somewhat vindicating. On the other hand, agreeing to upgrade to the Professional product may be the easier road because you’re exhausted and don’t want to start over with someone new. 

Let me offer a little perspective …

Three years ago, our practice learned Misys was merging with Allscripts and we would need to move to the Allscripts product. No choice.

We were miffed, to say the least, and jumped ship to a competing product. Within three months, we realized it was a serious mistake. We ate a little crow and made the decision to return to Allscripts. 

We implemented the Allscripts Pro EHR/PM system and came to the conclusion that even though not all of our experiences with Allscripts have been perfect, it was the right choice. Like it or not, Allscripts is the leader in the EHR world for a reason. They haven’t always gotten it right. Unfortunately, no one does. 

I will not pretend to understand how any of you feel as a MyWay client. The only thing I can offer is my perspective from moving to another product and realizing the grass is not always greener on the other side. 

My suggestions are threefold:

1. If you haven’t already, sign up for Allscripts Client Connect and check out the resources available for people upgrading to the Pro EHR and for those considering other options. You’ll find links to webinars, product demos. and lots of other info. Can’t hurt, right?
2. Go to the Pro ARUG (Allscripts Regional User Group) page for your state and start asking questions of Pro users in your area. They’ll answer you honestly. They are not paid by Allscripts and have real-life, in-the-trenches perspectives on the Pro product.
3. Find out who in your local community has the Pro product and go take a look at it. See it for yourself firsthand as you make the best decision for your practice.  

Then, if you don’t like what you see and hear, feel free to explore other options.

I wish you the best in this world of healthcare changes – I really do!  But if you come to realize, as we did, that the Pro solution is right, I would personally like to welcome you to the Pro family! We will help you, support you, cry with you, teach you, bang our heads (at times) with you, and celebrate the victories that come with finding a system and a family of users from which you can benefit. It’s not always easy going, but you will be heard and you will not be alone.

I am not paid by Allscripts and do not reap any personal benefit from writing this post. Just concerned with what is happening to fellow clinicians in the Allscripts community. Feel free to contact me directly if you have questions. I will not mince words and am happy to help in any way I can. 

Cathy Boyle, RN, BSN  is clinical director at Heiskell King Burns & Tallman Surgical Associates, Inc. of Morgantown, WV.

OCR’s Guidance for De-Identifying Health Data
By Deborah Peel, MD

The federal Office of Civil Rights (OCR), charged with protecting the privacy of nation’s health data, has released guidance for “de-identifying” health data. Government agencies and corporations want to de-identify, release, and sell health data for many uses. There are no penalties for not following the guidance.

Releasing large data bases with the de-identified health data of thousands or millions of people could enable breakthrough research to improve health, lower costs, and improve quality of care — if de-identification actually protected our privacy so no one knows it’s our personal data. But it doesn’t. 

The guidance allows easy re-identification of health data. Publicly available databases of other personal information can be quickly compared electronically with de-identified health data bases to reattach names, creating valuable, identifiable health data sets.

The de-identification methods OCR has proposed are:

• The HIPAA Safe Harbor method. If 18 specific identifiers are removed (such as name, address, and age), data can be released without patient consent. Still, 0.04 percent of the data can still be re-identified.
• Certification by a statistical expert that the re-identification risk is small allows release of databases without patient consent. There are no requirements to being called an expert. There is no definition of small risk.

Inadequate de-identification of health data makes it a big target for re-identification. Health data is so valuable because it can be used for job and credit discrimination and for targeted product marketing of drugs and expensive treatment. The collection and sale of intimately detailed profiles of every person in the US is a major model for online businesses.

The OCR guidance ignores computer science, which has demonstrated that de-identification methods can’t prevent re-identification. No single method or approach can work because more and more personally identifiable information is becoming publicly available, making it easier and easier to re-identify health data. See Myths and Fallacies of Personally Identifiable Information by Narayanan and Shmatikov, June 2010. Key quotes from the article:

• “Powerful re-identification algorithms demonstrate not just a flaw in a specific anonymization technique(s), but the fundamental inadequacy of the entire privacy protection paradigm based on ‘de-identifying’ the data.”
• “Any information that distinguishes one person from another can be used for re-identifying data.”
• “Privacy protection has to be built and reasoned about on a case-by-case basis.”  

OCR should have recommended what Shmatikov and Narayanan proposed: case-by-case “adversarial testing” in which a de-identified health database is compared to multiple publicly available databases to determine which data fields must be removed to prevent re-identification. See PPR’s paper on adversarial testing.

Simplest, cheapest, and best of all would be to use the stimulus billions to build electronic systems so patients can electronically consent to data use for research and other uses they approve of. Complex, expensive contracts and difficult workarounds (like adversarial testing) are needed to protect patient privacy because institutions — not patients — control who can use health data. This is not what the public expects and prevents us from exercising our individual rights to decide who can see and use personal health information.

Deborah C. Peel, MD is founder and chair of Patient Privacy Rights Foundation of Austin, TX.

Evolution in your Data Center
By Axel Wirth

The change of a biological organism through a combination of mutation and natural selection over a number of generations was first articulated as the Theory of Evolution by Charles Darwin. In short (and with my apologies to the great scientist), if a change occurs and the next generation is more successful, it will have a higher probability of passing on its characteristics to future generations.

Survival of the fittest, survival of the smartest, or plainly a strategy to adapt to a changing environment. Whichever way you look at it, it has enabled the human race to populate the earth from our origins in Africa to the icy north.

But evolution works in both directions. Think, for example, of the problems caused by antibiotic-resistant infections like MRSA. We can also apply a similar thought model outside of biology. Let’s have a look at the scary and complex world of computer viruses and malware.

A recent example. In mid-2009, W32.Changeup, a polymorphic worm written in Visual Basic, was first discovered, but was not really anything special. It wasn’t harmless, but in general, it was classified as a medium damage, medium distribution, and easy to contain worm.

But then evolution came to play (granted, this was not evolution by mutation, but evolution by design). As of recently, we have seen over 1,000 variants of W32.Changeup, some of which much more aggressive and successful than the original. Some variants recently showed an increase in activity of over 3,000 percent in a single week.

What is even more concerning is that based on some of the characteristics of this worm, it is especially dangerous for the typical healthcare infrastructure. We have already seen several hospitals hit hard over the past weeks.

Why now and not back in 2009? Just like MRSA, W32.Changeup evolved and became more resistant and dangerous.

There are a number of malware threats which, due to the way there are designed, are affecting healthcare IT more than others. Downadup, also known as Conficker, was one of them. It looks like Changeup is joining the club. Here is why:

• It spreads through removable drives. Devices and subnets which are perceived to be protected through isolation and may not have sufficient malware protection and resilience are at risk.
• It infects old and new versions of Windows on workstation and server platforms. Certain devices on hospital networks with older or unpatched operating systems (e.g. medical devices, dedicated workstations, and servers) may be especially vulnerable.
• It uses multiple propagation methods through removable drives and shared network drives. Once a system is compromised, Changeup’s main purpose is to download various additional malware. Among it is a Downloader Trojan, which in turn will download even more malware.
• Changeup is polymorphic in nature. As it copies itself to other devices, it maintains its function, but changes it look. This makes it difficult to detect with traditional signature-based antivirus software. Modern anti-malware software provides more functionality than signature-based protection, but proper configuration of your endpoint protection combined with a layered security approach are required to detect and protect against a sophisticated worm like Changeup.
• Changeup copies itself to removable and mapped drives by taking advantage of the AutoRun feature in Windows, which should therefore be prevented for all users and devices, including network shares.

This brings us back to the initial point made about evolution. We now have diseases which are resistant to a single antibiotic and require a complex, multi-pronged approach. Similarly, with computer malware like Changeup, a single approach (e.g. relying on signature-based antivirus alone) is not sufficient any more. At a time where we are seeing well over 10 new viruses and variants being created per second, we need to take a strategic “defense in depth” approach.

Of course, traditional and signature-based antivirus is still part of that picture, but it needs to be complemented by system and network intrusion detection, peripheral security (firewalls), system configuration and controls, security event monitoring, and URL filtering to prevent connection to known C&C (command and control) URLs.

Axel Wirth is national healthcare architect for Symantec Corp. of Mountain View, CA.

Collective Action 12/5/12

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

Engagement

I failed, and I mean big time. Like “I was surprised I kept my job” type failure. Fortunately there were circumstances around me that moved the attention off the failure, but it still happened.  

I was 31. It was my first director-level job. I was, in many ways, woefully unprepared. I walked into this IT director position at a 100-bed behavioral health hospital at a time where they were selecting a vendor for their EMR project.

Even before I officially started there, I had to fly out to sit through vendor demos. My second day on the job I was in a meeting with the CFO, CEO, controller, CMO, and a hired consultant and was asked which system I thought we should go with. I didn’t even know where the restrooms were and had hardly logged on to my computer. It was a real “drink from the fire hose” experience.  

We eventually made a decision and started to progress through the project. I leaned on the consultant a lot, as I was learning healthcare terminology and at the same time trying to implement an EMR. It was crazy.  

Ultimately, the project failed. We never got it off the ground. Right about the time it failed, the company was bought by another company and the focus shifted away.

As I reflect on that project, I realize that the biggest piece that was missing was what I now refer to as engagement. We set up meetings and the CMO would not show up. The nursing director was too busy to help document workflows and processes. None of the physicians or nurses ever thought it would really happen — they were all seemingly waiting for it to fail. The CEO was a verbal champion for it, but could not quite get the CMO and nursing leaders to engage appropriately.  

I learned a tremendous amount from that failure. I carry many of those lessons with me today.  

The greatest lesson I learned is the power of engagement. In this example, it was lack of clinical leadership engagement that was the primary reason for failure. That project and experiences since that project have collectively heightened my sensitivity to and awareness of engagement. I now understand that engagement encompasses much more than I originally thought.

I want to provide a few examples of how we at Flagler Hospital are trying to engage with leadership, staff, and physicians.

The first example relates specifically to the IS team. Within my first six months of employment here, I floated the idea of what we now call the Clinical Experience program to the newly formed IS leadership team. The idea is rooted in the fact that we are not here for IT purposes — we are all here to support and improve patient care. How can you sit in a cube and make decisions that impact patient care without understanding what it means to provide patient care?

We implemented a program with the assistance of clinical leadership where every member of the IS team is required to spend eight hours per quarter on a clinical unit or combination of units. This time is documented and included in the employee’s quarterly performance review.

Some people have responded very well to this and have become even more engaged in what they are doing. Some just go through the motions and don’t see the value. They may not see the value, but that does not mean there is no value. The real impact came in one of our team meetings when we reviewed a network incident that took the ED down hard. Everyone there had a clear understanding of what that meant because they had all spent time in the ED, at least briefly, witnessing its dependence on IT services.

The next example of engagement is at the organizational level. We are in the middle of an EMR implementation at our hospital, but of course we have not always been in the middle. There was a beginning! The beginning for us was January 2011, and it was launched with an organization-wide event planned mostly by the marketing team (who else should be planning these things?)

They did a great job of putting a theme together that tied our corporate theme of iCARE (Compassionate, Always listening, Responsive, and Empowered) with the project. This ended up with the project name of iCAREiConnect.

Before the event took place, the marketing department went around with a video camera to each department in the hospital and recorded departmental dance routines to Stereo MC’s song “Connected.” The video they put together kicked off the event.

There were Xbox iConnect stations as well as other game stations around the room. Our vendor, Allscripts, was there performing product demos and handing out marketing items. Overall, it was a very successful event that got the whole organization, including physicians, engaged. If you watch the video, you will see that we are all in. That level of engagement and buy-in has been evident throughout this implementation and is something that we rely on daily to progress forward.

The final example is also project related. We are mostly completed with the build of our Allscripts environment and are looking forward to testing and training phases of the project. As you can imagine, stress levels are high and people are getting worn down. We wanted to ceremoniously mark the completion of build and shift of focus to testing and training, so we decided to have a “Project Reboot” event. The theme of the event would be Finish Strong, based on the book Finish Strong by Dan Green.  

Again, marketing planned and coordinated the event. It included a photo shoot, video shoot, a few speakers, and a formal ceremony. The whole IS department was present, as well as clinical leadership and SMEs, vendor partners, and hospital administration. The CEO spoke, the CMIO spoke, and because Dan Green could not make it to talk about the principles associated with Finish Strong, I took his place and wrapped up the speaker portion of the event.  

The final portion involved two significant ceremonies. The first one was the book. We purchased copies of Finish Strong for everyone present. For four weeks prior to the event, I worked with nursing leadership (engaging nursing leadership) to get each book signed by a patient. When we distributed them at the event, we talked about how a patient signed each book and how we told the patients what we were up to (engaging the community.) People were really touched by this — it suddenly got personal.  

We ended the event by handing out Finish Strong bracelets to everyone and asked them all to wear them at all times until we go live with the new system. We’ve done bracelet checks periodically since the event and most are still wearing them. I sent a book and bracelet to the CEO of Allscripts and asked Glen to wear it, as he is as much a part of this process as we are.

There are so many more examples of engagement. Our CMIO is doing a fantastic job engaging the physicians with the PIT Crew. We are going through every single order set in the hospital and will have consolidated, evidence-based order sets when we go live.

This kind of stuff doesn’t just happen. It must be intentional. It must be authentic. You have to actually believe that without engagement from everyone, you will fail. You can believe it or not, but that does not make it any less true.  

As I wrap this up, I want to encourage you to see where you are engaging others in the organization. Ask other leaders if they feel involved in what you are doing. We have not done this perfectly and are receiving feedback about where we are lacking. We listen to that feedback and try to engage others in different ways. This is not an IT project. It is a clinical transformation that requires the engagement of all areas of the hospital.

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

An HIT Moment with … Marc Andiel, CEO, Accent on Integration

An HIT Moment with ... is a quick interview with someone we find interesting. Marc C. Andiel is co-founder, president, and CEO of Accent on Integration of Murphy, TX.

What integration-related parts of Meaningful Use Stage 2 will the average hospital struggle to meet?

With Meaningful Use Stage 2, hospitals and providers are under more pressure than ever to demonstrate the use of CPOE, record and chart vital signs changes, and effectively leverage clinical decision support. In this environment, it’s imperative that healthcare organizations make the automatic acquisition of device data a reality. It saves significant time, streamlines documentation processes, facilitates valid and accurate orders, ensures clinicians have the most recent and relevant patient data, and reduces errors.

In fact, we’re seeing that clinicians are outright demanding this automation. But because patient care device interfacing requires considerable time, effort, and resources, many providers simply cannot support the effort.

One significant struggle is that in most hospitals, medical devices have historically been completely separated from the information technology group. They may reside on proprietary networks, as well as closed, non-interoperable deployments. Breaking medical device data out of these silos is imperative to meeting the integration-related Meaningful Use Stage 2 core measures.

Manufacturers began addressing this problem by providing modality-specific solutions. This model worked at first, but it resulted in many one-off projects that didn’t benefit the organization as a whole. But with the onset of Meaningful Use, providers made it a priority to take a more enterprise approach. We’re seeing that more than ever, provider organizations are refusing vendor-specific integration offerings and instead demanding enterprise-wide, vendor-neutral solutions like our Accelero Connect integration platform to interconnect a multitude of disparate technology systems.

Organizations will continue to struggle with integration projects unless they deploy solutions that are architected to facilitate the convergence of medical device technology and information technology. Additionally, caregivers, IT, biomedical / clinical engineering, and vendors must come together and take a patient-centric approach to fully unite people, processes and technology.

How many hospitals have integrated their medical devices with their clinical IT systems and what lessons have they learned in doing so?

From our experience, basic level vital signs device integration with clinical IT systems is the exception, not the rule. Far more hospitals have this on their roadmap than the number of facilities that have already completed basic vital signs integration.

It’s important to note that there is a huge gap when it comes to full medical device integration with clinical IT systems like monitors, smart pumps, ventilators, glucometers, and smart beds. Hospitals that have integrated medical and patient care devices with their clinical systems are finding that many devices beyond monitors will send clinical parameters that are not supported by their clinical systems. 

Because basic vital signs integration for monitors — bedside, continuous feed, low acuity — is still uncommon for most hospitals, the real challenge that lies ahead is connecting more complex devices that will require clinical support of several more parameters.

Quite a few companies offer medical device integration products and services. How is Accent on Integration different?

Our software-only solution has zero requirements to be at the point of care. Another difference is that we don’t see ourselves as simply a product company. We will always function as both a services and a product company because we believe this will result in the most benefit for our customers. This is extremely important to us because the services component of our business allows us to be very in tune with what device manufacturers are doing now and with their product roadmaps.

It also means that we stay well informed of the current capabilities of consuming systems — like EHR, BI/CDS, EDIS, etc. — and most important, we remain in touch with clinical workflow and everyday clinician realities and challenges. To us, without an intimate knowledge of the devices, the IT systems, and the end-users’ needs, it is highly unlikely that a product alone can meet its envisioned purpose.

In addition, we routinely work for the big healthcare IT and medical device vendors to integrate their systems. We feel that the breadth of our knowledge of the different systems available in the market today and how they work is unsurpassed by any competitor. Lastly, we have extensive experience working for and with provider organizations, clinical IT vendors, RHIOs, HIEs, and technology companies.

Your leadership team all worked for Baylor. What made you decide to start a company and what’s good and bad about working for yourselves?

Jeff McGeath and I started AOI in 2006 with a simple vision that there has to be an easier way for healthcare organizations to connect their disparate systems. We reflected on our expertise and recognized that although we were very proficient in the IT system integration space, the future of healthcare relied on connecting disparate devices that housed an incredible amount of clinically critical information. Additionally, it was becoming more and more necessary for providers to be able to exchange information outside of the walls of their organization.

There was so much change and flux at the time that we weren’t completely certain the industry would go in the direction we predicted. As with most startups, things didn’t come together overnight. However, eventually we were providing services for device manufacturers as well as for one of the first HIE vendors.

Eventually it became clear that our early predictions and focus areas were growing into very important healthcare verticals. We are proud to have been a key player in steering the path of integration for the last six-plus years. Because we forged early roots in this space, today we are able to say that AOI can provide services from the device to the connected community and everything in between. We can offer expert services to providers, hospitals, and vendors alike.

While we always knew we wanted to be both a services and products company, we absolutely wanted to make sure there was a need. A benefit of working without outside influences like investors and private equity is that you have complete control of the focus of the company. You can be much more nimble. Certainly there is the early, day-to-day struggle of bootstrapping the organization. However, seven years later, we are much better for it and have been able to take the needed time to evaluate the market.

As we built our organization’s capabilities and grew our services offerings, we were able to keep a keen eye on where there were market gaps we were interested in. We were able to easily work toward filling those gaps.

One of the hard parts about working for ourselves has been building our team so that we can provide the level of professional capabilities we offer today. Finding exceptional people is hard and very time-consuming work. In our previous jobs, we were fortunate to work with great individuals who were already in place, but when we started Accent on Integration, we had to start from scratch and build a team of professionals that we knew would contribute to the company’s success.

Everyone has a core group of people that they have worked with in the past that, if given the chance, they would want them by their side again. You pointed out that our leadership team all has previous ties, and Jeff and I would have it no other way. We did everything we could to bring those folks on board, and it is a continuous process to add to our team of all-stars. Our employees are our greatest asset.

What new integration needs do you see developing for hospitals in the future?

Full waveform integration is definitely a hot topic with hospitals today. Every customer we meet with has questions about the best way to get waveform data out of their ancillary systems and into the hospital EHR in a format that can be viewed natively. Today, this is sometimes accomplished by attaching documents or scanning strip images. But what we’re seeing is that hospitals are pushing the EMR vendors toward native support of this rich data.

The market has matured to the point that basic HL7 interchange is not really a challenge for hospitals and vendors using a variety of tools. Richer content — such as waveforms and CCDA — and the orchestration of multi-step technical workflows to support clinical workflows are the integration needs we see the industry heading toward. The standards organizations like HL7 and IHE are already a few years into that stage of integration readiness, with one example being IHE’s Waveform Content Management (WCM) profile.

We also expect to see EHRs supporting a richer set of parameters from devices so a greater amount of device data can be integrated. As more data is available in real-time, alerting will continue to mature, which will greatly improve patient care and safety and has the potential to significantly improve overall operations.

In addition, we see HIEs and ACOs having community-based offerings that leverage device data not only from the hospital, but also from any location including the home.

Lastly, the interface engine market appears to be experiencing some redistribution, and there will be provider organizations that will need people skilled in both product X and product Y to do a good migration of interfaces.

Morning Headlines 12/5/12

Nuance Communications Acquires Accentus

Nuance acquires medical transcription, document imaging and remote coding vendor Accentus of Ottowa, CA for an undisclosed sum.

Children’s Hospital Central California Selects Athenahealth To Help Achieve Higher-Quality, Comprehensive Patient Care

Children’s Hospital of Central California will implement Athenahealth’s cloud-based EHR across its 127-provider system.

VA Taps GetWellNetwork To Provide Patient Engagement Platform to Transform Care for Veterans

The VA choses GetWellNetwork to implement enhanced patient education and patient communication tools across 21 VA medical centers.

Imprivata Cortext Sets Pace as the Fastest Growing HIPAA Compliant Text Messaging Solution with More Than 250 Healthcare Organizations Enrolled within 60 Days of General Availability

Imprivata signs 250 organizations up for its HIPAA-compliant text messaging system, which ranges in price from free to $5 per user/month.

News 12/5/12

Top News

The Atlanta newspaper covers the case of an internist whose stolen identity was used to apply for a National Provider Identification number, then used to incorporate a fictitious Buckhead medical clinic using a UPS Store mail box as an address with “Olga Teplukhina” named as the clinic’s CEO. The paper then did its own investigation, finding 131 CMS-registered medical providers that used an Atlanta UPS Store as their practice location, resulting in OIG looking into at least two dozen of them. One UPS Store-based company was found to have billed Medicare for $1.2 million in fraudulent injections, but is still in business because companies that are barred from billing Medicare can still bill private insurance. Despite the fact that the newspaper created the list of 131 practices using minimal effort and desktop software, CMS says it doesn’t have the technology to recognize private mailboxes since they carry a regular street address. The article says CMS pays claims that it really should deny under existing regulations because it worries that legitimate provider mistakes would unduly delay payments. One doctor complained to CMS that his name was being used to bill Medicare fraudulently, but two years later, the phony provider still has an active NPI that uses the doctor’s name.

Reader Comments

From Diminutive Avian: “Re: Epic. Most people don’t know that Epic has one final implementation check. Judy has to personally give the go-ahead. If she doesn’t like what she sees, she tells the customer she’s pulling out and gives them their money back. That’s another reason why the company has only successful implementations. Unlike publicly traded vendors, Epic is more than willing to walk away if the client is botching the install and ignoring Epic’s recommendations.” I’ve been told that at least two big academic medical centers are in precisely this predicament as we speak. From what I’ve heard, Judy gives the client two choices: (a) agree to let Epic send in a SWAT team to take over the project, or (b) find themselves another vendor.

From BubbaLove: “Re: Duke University. Heard they’re being sued by Deloitte for breach of contract due to mismanagement of the Epic implementation.” Unverified. Perhaps HITEsq or another attorney reader can scour the legal databases and report back. UPDATE: two well-placed sources and one even better second-hand source contacted me to say there’s no truth to this rumor. I’ve also had no volunteers tell me they’ve turned up any legal documents. I’m concluding that the reader’s report report, which they admitted was second hand, is inaccurate –the Duke and Deloitte working relationship hasn’t changed as the project continues.

From Current Epic Employee: “Re: Epic’s employee ages. In the November staff meeting it was announced that Epic’s #2 Carl Dvorak has worked for Epic for 25 years. He showed a slide saying that 42 percent of the current employees weren’t born then — i.e. are under 25 — and 78 percent are under 31.” People get nervous at the idea of fresh graduates telling major medical centers how to run their business, but it seems to work and it’s brilliant on Epic’s part. You take new graduates whose career prospects are negligible, plant them in Wisconsin where there aren’t many other jobs, and pay them more than they would make otherwise but less than everybody else pays their more senior HIT people. You train them in skills with minimal value elsewhere, like MUMPS programming, and give them job perks that make them feel like they’re working for Google. The young folks don’t complain much, they don’t bring in all the bad habits they learned working for less successful vendors, and by following the formula they almost always get the job done. That makes Epic almost infinitely scalable unless Midwestern universities stop graduating liberal arts majors with high GPAs. Nobody seems to mind except the experienced people who Epic won’t hire.

From UKnowMe: “Re: IBM. Seems like several high-ranking healthcare people are getting very connected on LinkedIn lately. A sign of change to come?” I don’t know, but I think your observation has business merit for LinkedIn. They could sell the names of companies that have a large percentage of current employees updating their profiles (preparing to bail) or companies newly added to a lot of profiles (on a hiring binge).

From HC IT Advisor: “Re: AeroScout, recently acquired by Stanley Black and Decker. Has issued a cease and desist order to Centrak and will be filing a patent infringement suit. Apparently Centrak is using the patented CCA capability in their new WiFi tags.” Unverified. Calling HITEsq again, either that or I need to sign up for one of the lawsuit databases like PACER so I can look these up myself.

Acquisitions, Funding, Business, and Stock

Health analytics and research company Decision Resources Group acquires the UK-based Abacus, a health economics consulting firm.

Talent management software provider HealthcareSource acquires NetLearning, which makes learning management software for the healthcare industry.

Nuance acquires Accentus, an Ontario-based transcription, documenting imaging, and remote coding technology vendor.

An article in the San Antonio newspaper questions whether Gene Powell, chairman of the University of Texas Board of Regents and co-founder of AirStrip Technologies, should have disclosed that Vanguard Health Systems, which the board chose to launch a new $350 million children’s hospital in San Antonio, had a pending business deal with AirStrip at the time. Powell did not vote on the issue, did not recommend Vanguard, and was not legally required to make any disclosure since he owns no Vanguard stock and is not a Vanguard employee, so perhaps it was a slow news day.

The former Big Five accounting firm Arthur Andersen, driven out of business in 2002 for its role as Enron’s auditor, is ordered to pay an additional and final $9.5 million for its similar auditing involvement in the 1999 merger of McKesson and HBOC. Andersen agreed to pay $73 million to settle McKesson HBOC-related class action claims in 2006, with the possibility of contingent payment claims.

Sales

Children’s Hospital of Central California will implement athenaClinicals, athenaCollector, and athenaCommunicator across its 127-provider system.

Marietta Memorial Hospital (OH) extends its IT services contract with CareTech Solutions for an additional three years.

Twenty-one VA medical centers will implement GetWellNetwork’s interactive patient care solution, including the new Interactive Patient Whiteboard.

Memorial Health System (IL) purchases the Omni-Patient enterprise master data application and the WebFOCUS BI platform from Information Builders.

MemorialCare Health System (CA) renews and expands its relationship with MedAssets to include GPO services for supplies and purchased services and MedAssets Capital and Construction solutions.

Huntsman Cancer Institute at the University of Utah selects Wolters Kluwer Health’s ProVation MultiCaregiver EHR.

Contract resource organization NCGS selects Merge’s eClinical OS and clinical trial management solution.

Consulting firm AmpliPHY will provide Wellcentive’s data analytics platform to primary care practices.

Managed care company Amerigroup Corporation chooses McKesson Clear Coverage for point-of-care utilization management, coverage determination, and network compliance.

Michigan Health Information Network Shared Services signs with HIPAAT International for technology that allows patients to control the sharing of their PHI and allow them to view an audit log of who has viewed it.

People

Qualis Health hires David Chamberlain (Cardiac Science and Criticare Systems) as CIO.

Saint Francis Hospital and Medical Center (CT) names Sudeep Bansal, MD as the organization’s first CMIO. 

Todd Johnson, former president and CEO of Salar and SVP of Transcend Services/Nuance after Salar’s acquisition, is named CEO of HealthLoop.

Michael Waldrum, whose roles at the UAB Health System included a five-year stint as CIO through 2004, is named CEO of University of Arizona Health Network.

Charlie Baxter, AVP of Iatric Systems and former Army captain, died Friday at 48. The guest book is here.

Announcements and Implementations

Allscripts EHR customer Primary Physician Partners (CO) becomes the first practice to connects to the CORHIO.

The Indiana HIE says that more than 750 physicians and 174 practice sites have agreed to publicly post their clinical quality measure scores on the Quality Health First Program’s public reporting website.

Imprivata announces that more than 250 healthcare organizations enrolled in its Cortext HIPAA-compliant, pager-replacing text messaging solution its first 60 days of release. Pricing ranges from free (unlimited users, unlimited messaging, unlimited photo messages, standard support, 30 days’ archiving) to $5 per user per month (upgraded support and archiving).

Elsevier integrates its ExitCare library of discharge instructions and patient education with Meditech’s EHR.

ICSA Labs and IHE USA unveil a certification program to test and certify the security and interoperability of HIT, with three tiers of certification: conformance to IHE profiles, demonstrated interoperability among disparate systems, and validated implementations of deployed certified technologies. Participants in January’s 2013 NA Connectathon in Chicago can register for testing at the event.

Montrue Technologies releases a free version of its Sparrow EDIS iPad-based emergency department information system. I interviewed Co-Founder and CEO Brian Phelps, MD earlier this year.

Government and Politics

Recovery auditors collected $2.2 billion in overpayments in fiscal year 2012 and gave providers $109 million in underpayments. Net 2012 corrections were $2.4 billion, compared to 2011’s $939 million.

Congressman Mike Honda (D-CA) introduces the Healthcare Innovation and Marketplace Technologies Act to foster more healthcare innovation through the development of marketplace incentives, challenge grants, and increased workforce retraining. The bill would also establish an Office of Wireless Health at the FDA.

Innovation and Research

A Microsoft Research documentary shows the organization’s work in using technology to fight tuberculosis in India, including development of a biometric monitoring system to make sure patients keep their healthcare appointments and systems that trigger an SMS message to a manager when a patient misses scheduled medication doses. Treatment is effective and straightforward, but requires more than 40 clinic visits in six months. Non-compliance causes TB spread, drug resistance, and nearly 1,000 deaths per day in India.

UCLA engineering school researchers create BigFoot, a software package that allows people with chronic foot problems to track their conditions using a PC and flatbed scanner.

Other

Streamline Health, which acquired Atlanta-based Interpoint Partners a year ago, will move its corporate headquarters from Cincinnati to Atlanta. The company will continue to operate the Cincinnati and New York City offices.

Cerner analyst Staci Klinginsmith is crowned Miss Kansas USA.

University of Virginia Medical Center warns patients that a mobile device used by on-call IV pharmacists in its home health agency is missing and contains patient information, including diagnoses, medications, and Social Security numbers used as health insurance ID numbers.

HIMSS, responding to OIG’s recommendation that the bar for Meaningful Use payments should be raised via pre-payment reviews, improved EHR MU reporting, and improved EHR reporting certification, supports CMS developing guidelines that will help providers prepare and retain audit-related documentation. In other words, like CMS, HIMSS isn’t a fan of pre-payment reviews.

I’ve spent a considerable amount of money and energy on programming workarounds required to make HIStalk work on the incredibly buggy and standards-breaking Internet Explorer, but I’ve noticed its gradual improvement. I’m encouraged that Microsoft gets the lack of browser love it receives and can even poke fun at itself with a fun “it sucks less” video (above) and a new site, www.browseryoulovetohate.com. I’m checking it out in Firefox, of course, since I’m not that forgiving of IE’s past transgressions, but I may download the IE10 beta just to see what all the fuss is about.

A new JAMA article finds that the average dentist now out-earns the average physician, with pharmacists not too far behind.

Lyle Berkowitz, MD (Northwestern University) and Chris McCarthy, MPH, MBA (Kaiser Permanente Innovation Consultancy) are editors of the newly published Innovation with Information Technologies in Healthcare. DrLyle says it tells the stories of 20 organizations who are HIT innovators in improving care quality and value, with details that he describes as “a big cookbook of recipes on how to innovate with HIT” divided into sections covering electronic medical records, telehealth, and advanced technology. I took a quick skim over a couple of the sample chapters he sent over and it’s meaty, without the usual fluff that makes some HIT books seem like a handful of good ideas and thoughts that were shamelessly padded to justify an author credit and a higher selling price. The book is $74.14 on Amazon and you can use the Look Inside! option to try before you buy.

A Colorado Public Radio article covers EMR adoption, showcasing a five-physician practice that expected its new EMR to increase patient capacity by 25% and get its bills out more quickly. That turned out to be wishful thinking on the salesperson’s part. They never got back up to more than 80 percent of their pre-EMR workload, they found that their Medicare patient volume was too low to qualify for incentive payments, one doctor quit over frustration with the EMR, and the remaining four partners were on the hook for the $200,000 they had borrowed to buy it. The end result: they had to sell their practice.

Use of mobile technology to view patient information and to access non-protected health information is on the rise, according to a HIMSS mobile technology survey. Key uses include collection of data at the bedside, bar code reading, monitoring data from medical devices, and capturing visual representation of patient data. Funding and security concerns are the top barriers to mobile technology adoption.

Athenahealth’s Jonathan Bush channels Dr. Mostashari on Fox Business wearing a holiday-red bowtie and pitching healthcare technology.

A local paper shares the story of a clerical supervisor in a British Columbia hospital who was conducting training on the Vocera communication system when the device issued a Code Orange, warning of an impending flood. Clinical staff moved patients to safety just before a wall collapsed in a flood of water, while the supervisor scrambled to save paper charts and the hospital’s stockpile of 75 Vocera badges.

Weird News Andy is really fired up about use of the Liverpool Care Pathway for palliative care in the UK. An audit of records from 178 NHS hospitals finds that nearly half of the dying patients who had life-saving treatment (drugs, fluids, food) withdrawn via the protocol weren’t told that fact, 22 percent had no documented evidence that their care and comfort was maintained, and a third of the families didn’t receive literature explaining the process. A proposal is on the table to require consulting with the patient or family before initiating the pathway, which leads to patient death in an average of 29 hours.

WNA could contribute only a “sheesh” to this article, which finds that Dallas mothers and daughters are bonding over cosmetic surgery procedures, often motivated by reality TV shows that make that practice seem normal.

A former Microsoft manager takes advantage of newly legalized marijuana in Washington by opening a “premium marijuana” retail business, expressing his desire to position his brand of weed like fine brandy or cigars to high-income baby boomers. He says, “Think of us as the Neiman Marcus of marijuana … the buzz is in the air.” He says he came up with the plan while high and will name the business after his marijuana-farming great-grandfather.

In Brazil, an apparently computer-savvy thief robs an ATM by replacing its USB security camera with a Plug and Play keyboard and a USB stick, then restarts the machine and keys commands to withdraw all its cash. He was caught. The article mentions the recent discovery of several ATMs at Inova Fairfax Hospital (VA) that were rigged with “ATM skimmers” that fit over the card slot, capturing the card’s number and in some cases using video recording to capture the user’s PIN.

Sponsor Updates

• Aspen Advisors hosted 62 associates at its annual retreat in Fort Lauderdale, which included a run fun that raised $1,000 for the University of Miami Health System.
• Besler Consulting representatives will present at upcoming New Jersey and Metropolitan Philadelphia HFMA seminars.
• Santa Rosa Consulting announces E2E Activation Support, a service line that will provide elbow-to-elbow EMR go-live support.
• The Black Book Rankings names DrFirst the top vendor for e-prescribing and recognizes Emdeon for outstanding developments in clinical exchange solutions. Other HIStalk sponsors earning honors include Allscripts, e-MDs, Vitera, Aprima, SRS, Quest MedPlus Care 360, and McKesson.
• A local paper profiles eClinicalWorks CEO Girish Kumar Navani and the success of his company.
• AT&T names its top five healthcare trends for 2013, which emphasize growth in mobile apps and telehealth.
• Sacred Heart Health Systems (FL/AL) shares how Iatric Systems’ Security Audit Manager has aided privacy compliance by capturing audit log data from its Siemens, McKesson, and Picis systems. 
• Three Informatica customers win Ventana Research Leadership Awards, including HMS Holdings (IT Leadership Award for Analytics and Overall IT Leader); Moffitt Cancer Center (Business Technology Award for Big Data); and  Ochsner Health System (IT Leadership Award for Information Management.) Informatica’s PowerCenter Big Data Edition also won the Ventana Research Technology Innovation Award.
• Mark Van Kooy, Myra Aubuchon, and Dawn Mitchell of Aspen Advisors present a December 5 Webinar on addressing EMR value with a hospital board.
• 3M Health Information Systems offers a Webcast featuring 3M CMIO Sandeep Wadhwa’s presentation on improving ACO efficiency and outcomes.
• Cumberland Consulting promotes Charles Taylor to principal and Jose Gonzalez to executive consultant.
• The Advisory Board Company’s Southwind program recognizes Dignity Health (CA), Adirondack Region Medical Home Pilot (NY), and Lancaster General Health (PA) for successful physician partnerships.
• Covisint releases a white paper that outlines the evolution, growth, and future of HIEs.
• Beacon Partners employees assemble 108 care packages for troops during the company’s annual meeting.
• Wellcentive’s VP of Product Strategy Mason Beard discusses interface strategies for population health management in a blog post. 

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 12/4/12

AMA calls pre-pay meaningful use audits a ‘burden’ on docs

AMA and CMS raise concerns with an OIG recommendation to implement pre-pay audits as part of the Meaningful Use payment program.

University of Missouri Health Care touts success in implementing electronic medical records

A local newspaper reports that that the Ellis Fischel Cancer Center, Missouri Orthopedic Institute, Missouri Psychiatric Center, Women’s and Children’s Hospital and University Hospital have all achieved HIMSS Stage 7.

Efficacy of a Clinical Decision-Support System in an HIV Practice: A Randomized Trial

A newly published study ties improved patient outcomes to increased sophistication and design of clinical decision alerts.

For Second Opinion, Consult a Computer

The New York Times covers the Watson in Healthcare project, an IBM initiative aimed at increasing the clinical potential of computers, by highlighting some of medicine’s most brilliant diagnosticians.

Curbside Consult with Dr. Jayne 12/3/12

There’s been a lot of chatter (via Twitter and other social media) about the hospital battle going on in Boise, Idaho. More than half of the physicians in town are employed by St. Luke’s Health System or a competitor. Independent physicians have shared allegations of skewed referrals, rising patient costs, and other unfair practices.

I’ve never been to Idaho, but after reading several articles about the situation, I find it not much different than what I’m seeing in my own market. Certainly there is some degree of this going on just about everywhere, regardless of whether health systems are non-profit or for-profit. Some control over referrals stems from value-based care initiatives and contracts where providers and their sponsoring institutions assume financial risk. Other moves seem to be merely profit-motivated.

In addition to demanding referrals, health systems are demanding that their member physicians refer exclusively to hospital-owned laboratory and ancillary services unless the patient refuses. Patients are left holding the bag, as they may have separate co-pays and/or deductibles for hospital-based (as opposed to reference lab) services.

I’ve personally had issues with hospital-based radiology departments whose cumbersome processes take complex registration and billing inefficiencies to a new level when they try to merge the hospital way of doing things with an ambulatory patient’s expectations. The hospital where I am on staff charges a screening mammogram at more than three times the charge of the freestanding radiologist-owned imaging center (which also provides private waiting areas and on-site immediate results as well as being a bargain). Since I’m on an insurance plan where I have a fixed amount of money to spend on preventive services, guess where I’m headed?

Let’s also talk about provider-based billing, where the hospital assumes control of a practice, names it a “hospital outpatient clinic,” and starts billing a facility fee in addition to the fee for provider services. I experienced this recently when a minor dermatology procedure (for which my ambulatory practices charge about $100) showed up on my bill as several hundred dollars because it was performed by a member of the medical school faculty. Practically speaking, her practice is no more a “hospital department” than mine is – despite the hospital’s assertion that Joint Commission accreditation and being part of a monstrous bureaucracy merit a different charge structure.

Unfortunately, overcharging individual procedures and services is just the tip of the iceberg. CBS ran a story this weekend on Health Management Associates. The story alleges coercion of emergency department physicians to admit patients who didn’t require admission. An interesting component includes the use of a software program to order extensive panels of tests on patients based largely on their ages rather than their presenting complaints or histories. It’s a fair bet that other organizations could be accused of the same thing.

Although my hospital’s emergency department intake process contains numerous wasteful components (like performing suicide screening on every patient who walks through the door – even a three-year-old needing stitches from tripping into a coffee table) I’ve never been pressured to increase admissions. Frankly, I’m not sure where we’d put them, as we’re constantly waiting for beds upstairs and end up boarding patients in the ED hallways. In my opinion, our major source of waste is the practice of defensive medicine, which results in overuse of tests and imaging because physicians are afraid they’ll be sued if they miss something.

Earlier in my career when I was in full-time primary care practice, I experienced a lot of pressure. The first few years it was personality-driven: the chief of staff complained I wasn’t referring enough to him. In fact, I was referring to one of his junior partners who started at the hospital at the same time I did and with whom I had better rapport. The hospital continued to reinforce that they wanted to earn our business and our referrals, even to the point of purchasing a high-quality competitor specialty practice to whom most of our primary care practices referred. Once they were in the corporate fold, however, referrals were expected and even demanded.

Back in the day, we knew our hospital tracked referrals for imaging services. A couple of times, I received cards thanking me for my referrals when my volumes had increased. I didn’t mind that so much, but now our hospital sends detailed reports to providers comparing their referral volumes to that of their peers. I find that extremely distasteful. The provider group’s administrators also mine data in the EHR and distribute referral reports that highlight which providers are referring out of the system and which are “loyal.”

No matter how recently we completed training, this certainly isn’t what any of us signed up for. I’m not delusional enough to think that Marcus Welby is still out there somewhere, but there has to be something better than this.

Have a story about a health system that earns its referral business rather than demanding it? E-mail me.

E-mail Dr. Jayne.

EHR Design Talk with Dr. Rick 12/3/12

The Snapshot-in-Time Design

There are two basic EHR designs for presenting the patient information that accumulates over time (see my last post).

By far, the most common EHR design solution is to display a summary screen of the patient’s current health information, organized by category (Problem List, Past Medical History, Medications, and so forth). Past information is available in date-sorted lists or indicated by start and stop dates.

The other design solution is to display a series of snapshots that capture the state of the patient’s health at successive points in time. While this design was at the core of paper-based charting (see Why T-Sheets Work), it is an uncommon EHR design.

In my opinion, the snapshot-in-time design has three advantages:

• It supports our notion of causality – we see how earlier events affect subsequent ones.
• The patient’s story is presented as a narrative that gradually unfolds. Humans excel at using narrative to organize and make sense of complex data.
• Perhaps most importantly, a series of visual snapshots allows us to makes sense of abstract data by organizing it in visual space.

The following EHR screen mockups display a patient’s story as snapshots in time. While these illustrations are for an ambulatory EHR, the design works equally well for hospital-based systems.

To see the mockups, click on the PowerPoint link below. Once PowerPoint is open, expand the view by clicking on the full screen button in the lower right corner (indicated by arrow).

Rick Weinhaus MD practices clinical ophthalmology in the Boston area. He trained at Harvard Medical School, The Massachusetts Eye and Ear Infirmary, and the Neuroscience Unit of the Schepens Eye Research Institute. He writes on how to design simple, powerful, elegant user interfaces for electronic health records (EHRs) by applying our understanding of human perception and cognition. He welcomes your comments and thoughts on this post and on EHR usability issues. E-mail Dr. Rick.

Morning Headlines 12/03/12

Exclusive: Blackstone in lead for Allscripts, deal uncertain

Blackstone Group looks to be the front runner for the Allscripts acquisition after the second-round bidding ended. However, insiders at Blackstone report that a deal is still uncertain because of unreasonable premium demands by Allscripts.

”60 Minutes” says HMA set admission quotas

“60 Minutes” airs a piece on Sunday reporting that HMA, the nations fourth-largest for-profit hospital chain, set patient admission quotas for its emergency room physicians, which resulted in unnecessary patient admissions and costs.

CDC link will let Kansas network track health threats in real time

The Kansas Health Information Network has become the nation’s first HIE to connect with the CDC to report clinical information as part of the CDC’s BioSense program, which tracks public health data in an effort to preempt outbreaks.

CareFusion And Cerner Implement Integrated Solution To Help Improve Patient Safety, Streamline IV Medication Management

Cerner customer Children’s Hospitals and Clinics of Minnesota has implemented a new IV medication administration process that interfaces physician ordering data from the Cerner EMR to the IV infusion pump through a wireless connection.

Monday Morning Update 12/3/12

From NoNamesPls: “Re: MD Anderson. They will replace not only their in-house developed EMR, but also commercial systems for pharmacy, lab, RIS/PACS, and ADT/Scheduling. Epic and Cerner are the frontrunners.” Another reader forwarded me the internal e-mail from the deputy CIO and the CMIO, which says MDACC spends $20-$30 million per year on its homegrown ClinicStation but still can’t keep up with federal regulations. The RFP goes out in January. It’s interesting that the e-mail suggests that they’re happy with the patient benefits of their existing system, but will spend hundreds of millions of dollars to replace it for non-patient reasons. Somehow you have to wonder if that’s really a good thing.

From Upon Further Review: “Re: three hospitals of Dignity Health (formerly CHW). Scrapping their Meditech 6.0 and Medhost implementation that was supposed to start going live last week and moving to Cerner. Go-live required by January 1, 2014.” Above is part of Friday’s letter sent to employees by Chuck Cova, president and CEO of Marian Regional Medical Center, which says, “We are not confident in the Medhost and Meditech system’s meaningful use and ability to perform at a high level for optimal use.” It went down to the wire: Medhost was to supposed to be brought live starting November 26, but the project was delayed on November 13 and then killed on November 30.

DZA MD replied to my Time Capsule editorial from 2008 in which I suggested that patient encounters be recorded on video now that multimedia storage is cheap (security cameras are running everywhere, after all, and your encounters with Las Vegas card dealers are recorded in multi-angle splendor). Here’s what DZA MD had to say:

Imagine how well behaved everyone would suddenly be! Patients and caregivers. Both are in need of civility IMHO.

Though certainly not the first, I proposed this solution to patient care documentation to interested academics at my institution  round the millennium. It was not taken seriously and was viscerally scary in a dot.gov sort of way, but the time has arrived. Some consequences (positive):

• Documentation. Real-time video and audio. Obvious. Supplement with dictated or keyed notes into the EMR, capturing decision-making and care coordination / consults. Even online research pertinent to the visit (can sarcoidosis cause GI symptoms?) could be incorporated into the record (browser history), supporting decision making and due diligence. These AVI files are completely portable without need for interface language.
• Billing. How about simply paying an hourly rate for time spent, like lawyers? Time stamps on audio and video, post-visit data entry and online patient care research would serve as indisputable evidence of billable time.
• Legal. ‘Nuff said. Patients who opt in to AV documentation assent to legal arbitration. And benefit from reduced insurance costs associated with this documentation product. Patients who opt out must use the traditional tort pathway, but are exposed to the added expense of that course of action.
• Patient education and self care. An electronic copy (edited or not) of the visit can be provided to the patient. Presumably the interaction involves patient education elements from the clinician.
• QA. NLP can sort through audio files for key words related to quality metrics. AV files can be used for clinician feedback for both physical exam skills as well as interpersonal behavioral skills.
• Cost.  Memory is cheap. AVI files are portable, searchable, and easily indexed and archived. Insurers could develop pilot programs using this technology to study cost impacts in preparation for wide release if promising.

I hand-picked this week’s Spotify playlist with music sharing only one attribute: I like everything I included. On it: Pond, RPWL, The Killers, Band of Horses, Marina and the Diamonds, Turtle Giant, and a searing live version of “Little Wing” from Clapton/Winwood. Here’s a trivia throw-down: what movie (one of my favorites) opens with Tune #13 as buses drive by in the night? If you want to play along at home, I also created this empty playlist to which you can add your song du jour — I’ll listen to them and choose some for next week’s playlist (it’s like a clinical inbox for music referrals).

Welcome to new HIStalk Platinum Sponsor Fujifilm, which offers the Synapse product line (RIS, PACS, 3D suite, virtualization, managed services, and teleradiology RIS). The Web-based Synapse radiology management solution provides hospitals and outpatient imaging facilities such capabilities as integrated dictation, a referring physician portal, electronic dashboards, mammography reporting, peer review that meets ACR guidelines, and critical result notification, all included at no extra cost. Users can craft their own workflows via built-in tools for instant messaging, automated e-mail notification, and digital forms creation. They can also use drawable consent forms, inventory tracking, and real-time eligibility checking. The RIS integrates with every PACS on the market, including of course Synapse PACS. It even includes teleradiology capabilities. You can choose Synapse RIS as a turnkey system that includes software, hardware, hosting, system management, upgrades, and optional disaster recovery services and off-site archiving. Customers pay by exam volume rather than per user or per site, which makes it affordable for facilities ranging from small imaging centers to multi-facility enterprises. Thanks to Fujifilm for supporting HIStalk.

Here’s an overview of Fujifilm’s Synapse RIS that I found on YouTube.

Thanks to the following sponsors, new and renewing, that have recently supported HIStalk, HIStalk Connect, and HIStalk Practice. Click a logo for more information. 

The vast majority of survey respondents believe that transcription is a commodity service differentiated primarily on price. New poll to your right: should the government require more upfront proof of attaining Meaningful Use before before sending payments?

Few people buy traditional software (i.e. PC programs in a box instead of apps in a Web store) these days, and those who do are rarely delighted. I’m happy to report an exception. I bought the just-released Dragon Naturally Speaking 12 and it’s amazing. The accuracy approaches 100 percent and it’s quite fast. I bought the premium version from Amazon for $126, which also includes the ability to transcribe pre-recorded dictation, sort of like Nuance’s eScription server-based speech recognition (the Home Version is only $50). You can speak at least three times faster than you can type, not to mention saving your wrists. I’ve used previous versions as well as the Windows 7 speech recognition and Siri and there’s no comparison. (Disclosure: Nuance is a sponsor and has offered me free copies several times, but I paid out of my own pocket so I wouldn’t feel bad about saying I hated DNS if that was the case). DNS 12 is one of the most amazing things I’ve ever seen run on a PC, although as critics always point out, you can’t use it with an EMR since that requires the more expensive medical version. But if you want to feel like Bill Shatner sprawling back in a chair on the Enterprise bridge and barking out orders for the computer to obey, you need it. It must be a miracle for people with handicaps who can’t use computers in traditional ways.

Scanadu, the 20-employee company whose tagline is “Sending your Smartphone to Med School,” announces that it will release three consumer tools by the end of 2013. The $150 Scanadu Scout is held to the temple and in less than 10 seconds, checks pulse, heart activity, temperature, and pulse oximetry and sends the results via Bluetooth to its smartphone app. Project ScanaFlo is a disposable cartridge that turns a smartphone into a urine analysis reader (pregnancy complications, gestational diabetes, kidney failure, or UTI). Project ScanaFlu is a saliva tester that detects cold symptoms by checking for strep, influenza, adenovirus,and RSV. Scanadu is best known for working on a tricorder-like health assessment device and these modules are the first components of it. Above is a Friday interview with the co-founder and CEO, who seems to be at a loss of how to explain medical principles to the sing-songy twenty-something interviewer who nods intently while saying “sort of “ and “you know” a lot while clearly not understanding most of what he’s saying.

It appears that Blackstone Group has become the frontrunner to acquire Allscripts, although the company is rumored to be holding out for more money than Blackstone thinks it’s worth. Shares dropped 11 percent Friday, having lost most of the gains that occurred after rumors of the company’s sale slipped out in late September. The other bidders were claimed to be Carlyle Group LP and TPG Capital Management LP. I don’t understand SEC rules, but this business of running newspaper stories quoting insiders about who’s making offers and at what price sure seems to open the door for cheating, like intentionally leaking out news that will move the share price up or down in a way that will benefit the leaker.

CareFusion announces that Children’s Hospitals and Clinics of Minnesota has gone live on wireless connectivity between its Alaris smart IV pumps and Cerner Millennium.

Health Management Associates warns investors that a “60 Minutes” report is expected to claim that the for-profit hospital operator’s contracted ED doctors were pressured to admit patients who didn’t need to be hospitalized. Both HMA and Community Health Systems have disclosed in SEC filings that several government agencies are following up on whistle-blower allegations by requesting admissions information. HMA says it thinks authorities want to know how more about its vendor-provided ED software and whether it was programmed to admit patients unnecessarily. Tenet Healthcare had accused competitor CHS in early 2011 of using ProMed Clinical Systems software to boost its admissions in a lawsuit, but a judge dismissed the claim. HMA is also a user of ProMed’s Web-based vEDIS software, which is ONC-ATCB certified. I seriously doubt that ProMed makes admission decisions that the ED docs can’t override, so if there’s a smoking gun, I’d expect to find it in internal e-mails, meeting minutes, or in interviews conducted with the actual ED docs.

Kansas Health Information Network becomes the first HIE to connect directly to the CDC’s BioSense outbreak tracker, allowing hospitals to quickly share information about threats and report them to CDC to investigate possible outbreaks.

Advanced Data Processing announces that it has fired an employee who admitted stealing data from an ambulance billing system it runs and selling it to a criminal group suspected of using the information to file fraudulent tax returns to collect refunds. The information came from Cape Fear Valley Hospital Health System (NC). The same scam has led to the arrest of three people in Florida, at least one of them an employee of Florida Hospital Tampa, who used hospital patient billing information to collect $1.5 million in IRS tax refunds.

Why can’t American healthcare strikers be this much fun? Public health workers in Spain protest government spending cuts and healthcare privatization by performing a flash mob dance outside La Paz Hospital in Madrid.

GE CEO Jeff Immelt says, “The next holy grail is about decision support and analytics.”

A rare Weird News Andy weekend update: in France, a man is awarded $250,000 in his lawsuit against GSK, maker of the Parkinson’s drug that he claims caused him to become addicted to gay sex and gambling. The suggestion that gay sex is a shameful addiction that requires compensation is kind of insulting, but apparently the jury bought it.

Bizarre: a pharmacist pleads guilty to planting mercury in areas of Albany Medical Center Hospital (NY) in the hopes that the ensuing panic would drive patients away. Police searching the home of the man, who was upset that the had hospital billed him for treatment, found child pornography, Nazi memorabilia, and a stockpile of guns and ammunition.

Also bizarre: a Washington veterinarian and aspiring EMT is charged with animal abuse after former employees claim he punched and choked animals under his care. He had already admitted to stealing and using drugs from his practice. The owner of one animal that was allegedly mistreated summarized, “Well, I wouldn’t want him to be my first responder. Golly.” The doctor’s Facebook blames disgruntled former employees and lawyers trying to change the state’s veterinary malpractice laws, which limit plaintiffs to recovering the “market value” of their animal with no pain and suffering award available for the lawyers to skim their 33 percent of.

Vince covers the fascinating HIS-tory of CPSI this time around, getting some help from Troy Rosser, SVP of sales there.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg.

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: I’ll Alert the Media: Why Not Use Cheap, Easy Multimedia to Store Patient Information?

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

I wrote this piece in February 2008.

I’ll Alert the Media: Why Not Use Cheap, Easy Multimedia to Store Patient Information?
By Mr. HIStalk

Clinical systems vendors don’t seem to have noticed that it’s now easy and cheap to record and store photos, audio, and video on computers. Everybody’s snapping a digital photo, recording MP3 audio, or using a cheap camcorder, camera, or cell phone to make a video recording that, while not exactly “Lawrence of Arabia” quality, is plenty good for nearly every other purpose. Storage isn’t a problem, either, now that you can dash into Best Buy and leave with a terabyte of external disk under your arm for $229.99, according this week’s ad.

Maybe doctors haven’t noticed either. Otherwise, why wouldn’t they be retooling their practices to take advantage of cheap media? A picture is easily worth a thousand words, especially at today’s transcription rates. Doctors will peer endlessly and intently at diagnostic images and try to describe them in great detail with words, but are happy to read another doctor’s description of a wound or surgical procedure instead of demanding to see the actual photo or video of it.

Having something more than a mountainous chart (most likely paper, but possibly either electronic or an ugly hybrid of both) would sure be an advantage in trying to remember what the patient said two visits ago, what their infected eye really looked like, or what their exact words were in describing their chest pain.

Instead, doctors jot down a few illegible notes, taking time away from the patient to perform that secretarial work they complain bitterly about when it’s CPOE or e-prescribing.

Medical schools must be training them wrong. They’re documenting care and interventions like it was 1908. If this was Playboy, there would be no centerfold, just a wordy description to go along with the World Peace interview.

It would sure be nice to have the patient’s information captured in the EMR in something other than black letters on a white background. “Nice” is being too kind. It’s just ridiculous that our supposedly savvy move from paper to computer means only that the screen looks just like the paper.

I could rattle off hundreds of clinical benefits, but instead, I’ll play my most convincing trump card first and save us both the time: lawsuits.

Lawsuits are always “he said, she said.” The patient claims they weren’t warned, or the doctor says they weren’t told, or the surgeon swears he removed the sponge that somehow stayed inside the patient. Healthcare volumes are so high that no one remembers accurately, if they even remember at all.

That guy with the infected toe that the ED doc saw for 90 seconds comes back without the toe, but with a lawyer. There’s just no way for the doctor to look good trying to decipher a ratty pile of badly written paper in front of a puzzled jury and a mad-dog ambulance chaser.

Imagine if every exam room had a constantly running camera recording audio and video. Everything the patient says, everything they are told, every action that was performed – all recorded perfectly. At the patient’s next visit, it would take seconds to call up a fast-forward version, prepping the doc to impress the patient by noticing that her hair has been attractively cut or his wedding ring is now an untanned finger line.

If the lawyer is in tow (no pun intended), there is no gray area. Every scrap of information is right there in low-res video and audio, plenty good to stop most lawsuits cold (unless the doc is a quack, in which case the cameras and microphones should be avoided like the plague).

It’s as easy and cheap as having multiple security cameras in an office building or a Nanny-Cam. Privacy issues would need to be worked out, but those relating to technology and cost are done deals.

Today’s media can capture every nuance of physical fact, verbal cues, and the dynamics of a particular interaction, all permanently, cheaply, and easily retrievable. For that reason, it seems ideal for the practice of medicine, nursing, and other healthcare delivery, not to mention the educational and performance aspects. Maybe everybody’s just too busy to have noticed.

An HIT Moment with … Patricia Stewart, Principal, Innovative Healthcare Solutions

An HIT Moment with ... is a quick interview with someone we find interesting. Pat Stewart is a principal with Innovative Healthcare Solutions of Punta Gorda, FL.

What kinds of projects are clients looking for help to complete these days?

Many clients are struggling simply to meet such basic IT objectives as maintaining and increasing IT services to support the organization’s business and clinical strategic goals, optimizing investments in IT so the organization receives maximum value for their investments, and mitigating risks to business processes and patient care associated with IT. All while pushing to meet Meaningful Use requirements, dealing with the impact of healthcare reform, and understanding the developments in the purchaser and payer arena. These are broad initiatives and there is pressure to move forward in all of them concurrently.

Organizations are being bombarded with a host of industry changes — accountable care and medical home models, Meaningful Use and health information exchanges, ICD-10, and the call for business intelligence. Now more than ever, healthcare organizations need solid IT strategies. Typically, however, there are limited IT resources to support these strategies. This has created many opportunities for our consulting services.

The majority of our engagements fall into three main categories. Engagements to help clients implement one or more of McKesson’s Horizon suite of products with the goal of reaching MU. Engagements to help clients implement a new system, such as Epic or Paragon. Engagements to help clients transition and support their legacy McKesson applications while they convert to a new vendor, such as Epic or Paragon. We are also seeing more requests for assistance in system and workflow optimization and analytics projects.

What are some innovative implementation ideas you’ve used or seen?

It’s still not common to manage a project from start to finish according to an overall business strategy. Or for IT groups to collaborate with stakeholders to understand their needs and challenges. These practices create innovation and success.

One of our clients created co-management arrangements with each physician service line that included quality of care, patient satisfaction, value analysis studies, and EMR adoption. They established strong teams with lean experts to develop implementation approaches for issues that affect physicians directly, such as CPOE, bedside barcoding, and medication reconciliation. The teams design the implementation approach, success factors, and metric-driven financial rewards for physicians.

Clients have created dedicated teams for testing and identifying build and process issues. They have pulled operations people into a workflow and process team to identify gaps between current and future state, to make decisions about process changes, and to provide go-live support. Some clients have cut back on classroom training and instead allocated those resources for "at the elbow" user support during go-live, which also makes financial sense since these resources can be cheaper than the cost of implementation specialists. 

The company has been around for several years. During that time, the Epic business has taken a big swing up and lots of people have formed small consulting companies to take advantage of the demand. How do you see that market and your competition changing in the next few years?

Our management team has been working in the HIT environment for many years and we have never seen the kind of market growth we’re seeing now. This demand has led to a rush of people entering the consulting profession, and — as you mentioned — a lot of new consulting companies. While we’ve seen more people choosing to become consultants, we haven’t seen a corresponding increase in the experience and skill levels these individuals bring to the table.

Unfortunately, financial opportunities instead of missions, goals, and aptitude are leading people to the market. We think it is inevitable that the market will slow down, and when it does, there will be consulting companies that drop out of the market. Few are built for long-term survival.

We credit our success to a corporate mission, culture, and identity based on simple core values: do the right thing for our clients, do the right thing for our consultants, and never forget there is a patient at the end of what we do. 

What are the best jobs in healthcare IT right now, and which ones would you advise industry newcomers to prepare for?

System and process optimization. Implementations over the last few years have occurred under stressful conditions with short timelines and limited resources. System implementations have not aligned with an organizational strategy. For organizations to be successful, they must understand how their systems impact business operations. Organizations must answer the questions: what value are we getting from the systems and how are they supporting our strategic goals? What processes must change to maximize our investments and achieve our goals?

One way facilities can meet system optimization resource needs is by creating transitional programs that take strong clinical experts and train them in application support roles. With shrinking inpatient census and greater focus on clinical quality and readmission initiatives, organizations can put clinical experts with IT aptitude on a path to IT knowledge. Facilities can grow bench strength from within. It is a long-term strategy and requires investment, but we believe it’s better than searching for talent – expensive talent – that isn’t part of the organization’s culture.

Jobs that leverage data to manage patient populations and outcomes. These jobs require an understanding of the system design so the right information is captured. Their roles and responsibilities will include using predictive analytics to proactively manage outcomes and maintain reimbursement.

What subtle industry trends are you seeing now that will become important down the road?

Systems and IT resources must support initiatives that allow healthcare to transition into community settings. We must focus on managing population health and creating effective support systems to transition patients into community care settings

The emergence of the Chief Clinical Information Officer. The melding of CMIO and CNIO for a less siloed approach.

Increased ability to adopt and manage change. With the implementation of so many complex systems, healthcare organizations and providers now have a wealth of data. With it comes a greater responsibility to respond quickly to conditions that affect patient outcomes, positively or negatively. To meet that responsibility, healthcare organizations and providers must be more nimble than ever. They must adapt efficiently and effectively to changing conditions. Having years or even months to implement changes and gain adoption will not be an option.

Morning Headlines 11/30/12

Medicare Is Faulted on Shift to Electronic Records

A review by the Office of the Inspector General finds that Medicare is not adequately overseeing the Meaningful Use program, leaving it vulnerable to paying incentives to Eligible Providers and hospitals that have inaccurately claimed their compliance.

After All the Time and Money is Invested, Will e-Health Ever Deliver on its Promise?

A Toronto newspaper reviews Canada’s ambitious and expensive e-health program that still leaves it behind much of the industrial world, with 80 percent of physician practices still using paper charts.

MIT Media Spin-Out Ginger.io raises $6.5 Million Series A Round

The startup, which summarizes its smartphone-based population management tool as a “check engine” light for humans, raises its investment total to $8.2 million in a round led by Khosla Ventures.

Guidance Regarding Methods for De-identification of Protected Health Information in Accordance with the Health Insurance Portability and Accountability Act (HIPAA ) Privacy Rule

HHS issues a guide describing acceptable method for de-identifying patient information to comply with HIPAA’s privacy rule.

Hospitals Get New Grades on Safety

Leapfrog Group issues its second set of hospital grades on patient safety, with a significant number of hospitals moving two letter grades up or down due to new data and an adjusted methodology. One of the 25 hospitals that earned an F is Ronald Reagan UCLA Medical Center, while Cleveland Clinic’s grade slipped from a C to a D.