HIStalk Interviews Alan Portela, CEO, AirStrip Technologies

Alan Portela is CEO of AirStrip Technologies of San Antonio, TX.

Tell me about yourself and the company.

I’m the CEO at AirStrip Technologies. I have about 20 years of experience in healthcare information technology. I came from the EMR side in the past. I have been on the board of AirStrip for about two years and have been the CEO for a little short of two years, since January 2011.

When I came to AirStrip, the core business was mobilizing medical devices — specifically in obstetrics — on the inpatient side. We were accessing fetal surveillance on mobile devices with 510(k) class II FDA clearance. We were the only company doing this with FDA clearance. We remain today the only company doing this with FDA clearance.

Since then, the company moved into mobilizing other medical devices in the inpatient care setting and adding applications for ambulatory care as well. We introduced a cardiology product, which is now deployed in about 60 medical centers. We also introduced a patient monitoring component for mobile devices. All of our medical device connectivity products are cleared with the same classification by the FDA.

Next, we’re moving into the home health space with a partnership we formed with Qualcomm Life to be able to take management of chronic diseases outside of the hospital walls into a patient / population-centric approach.

I interviewed Cameron Powell – the president, co-founder, and chief medical officer — in early 2010. He said that contrary to what people might think, AirStrip is not just a vendor of mobile waveform display applications, but instead is a mobile solution that can expose any data. How will that influence the direction of the company?

I’d like to talk a little bit about the industry trends, how we fit in, and how we evolved as a company to where we are today.

When I started at AirStrip, the comment I received from the members of the team is that AirStrip was viewed at that time — two years ago — as a nice-to-have tool. Mobility overall was viewed as the first technology that healthcare organizations were going to deploy as soon as they were finished with the implementation of their electronic medical records and electronic health records systems to comply with Meaningful Use requirements, at the time Stage 2 and moving to other stages in the future.

My comment coming from the EMR world to my team was, “Well, good luck, because it’s going to take a long time until the process of EMR and EHR deployment is ready. There’s always a new tool that is coming up and a new product that is coming out.” That was the market trend.

I stated to the team that there are a number of initiatives and challenges that we need to look at in the industry. One is the shortage of caregivers. We have known since the Leapfrog Report that there is a shortage of caregivers. Now as we’re going into an outcomes-based reimbursement model and a patient-centric care approach, everything is centered more around the specialists and the top chronic diseases – a cardiologist for heart disease, endocrinologist for diabetes, neurologist for stroke.

What we need to do is leverage mobile technology to bring the data to the specialists and the primary care physicians wherever they are, rather than bringing them to the data. Mobile technology has to become a mission-critical tool to be able to bring the clinically relevant data to those caregivers at the right time, so that they can make the right decisions.

We started looking at mobility throughout the continuum around chronic diseases. When we shifted our messaging to a patient-centric approach, we started experiencing significant growth. In 2011, we grew about 300% over 2010. We started signing contracts, developing partnerships with large healthcare organizations like HCA, Dignity, Vanguard, et cetera that clearly saw the importance of using mobile technology not only to attract patients to their facilities, but also to attract physicians to their systems by offering the right tools and improving their quality of life.

As we looked at this whole thing, we said if we are mobilizing one of the most important clinical data sources — medical devices — throughout the continuum, we need to make sure that we look at the other clinical data sources that are going to make the physician’s life much better. Immediately we looked at EMRs and EHRs. About three months ago, we acquired the intellectual property of a product that was developed at a healthcare organization by physicians on a very similar platform with a very similar approach as what we have done with medical devices. We acquired the IP for a mobile EMR extender.

This is where the other trend comes in. As you see more organizations creating ACOs to manage population health, you’re starting to see that a number of providers are expanding outside themselves by buying more hospitals or acquiring surgery centers, urgent care centers, imaging centers and the like. They’re adding to their systems. Mostly likely they are going to have multiple EMR vendors, even though primarily they were using one particular EMR or EHR vendor.

The moment you do that, it’s the same thing that we experienced on the medical device side. You’re going to have multiple vendors in different units. You need to have a seamless way of mobilizing all those devices into one view.

What we realized was that by buying the IP for this mobile EMR extender, we now needed to do the same thing we did with mobilizing medical devices — mobilize all EMRs and EHRs into one single view, being able to move data across the continuum and having physicians look at one view of their world, improving their workflow.

Of course, there are other things that we have to include. Later on, we’re going to look at imaging and at third-party components that we can apply on top of our platform. Then we will look into videoconferencing to be able to offer the complete solution.

I always talk about that announcement from Steve Jobs when he introduced the iPhone. He said, “It’s not a Web browser. It’s not a phone. It’s not an iPod. It’s everything in one.” That became a revolutionary announcement. What we are basically telling the industry now is, it’s not a medical device, it’s not an EMR/EHR, it’s not an imaging system. It’s all in one, fully integrated on a mobile device, bringing the data to the physicians in one view wherever they are. We create that whole concept of the virtual physician in a way we have all been trying to do for a long time.

The key is to be able to now support data standardization throughout the care continuum, looking at things like CCD — continuity of care documentation — as a standard, and also looking at how we can move HL7 data to create a true healthcare information exchange and take advantage of things that the government has made available to us. This includes NHIN Direct or NHIN Connect for routing, data warehousing and also for an enterprise master person index.

Today the company has evolved beyond medical device mobility. Now we’re mobilizing EMRs/EHRs in a seamless way for physicians. We are now working with the existing standards the same way we’ve been working with the FDA requirements. We’re looking at the standards for data standardization, nomenclature and healthcare information exchange to be able to support the care continuum.

I think that AirStrip now offers is equivalent to what Steve Jobs announced for the iPhone. I think that AirStrip is the next generation of healthcare transformation — being able to put everything into one view for caregivers.

The company is fairly new to have gotten this far with remote monitoring solutions and FDA approval. Are you concerned about what it will take to go after those goals you mentioned?

We all have to recognize that the transformation is necessary and we need to stick to the things that we know, that will be able to make a difference. Transformation will take place thanks to our mobile platform.

I always make the comparison of operating systems on your devices. On your PC, you have Microsoft, or on any Apple device, you have the O/S, the operating system. The true value that you bring to improve workflow in any industry comes from the ability to apply technologies or applications on top of those operating systems. For us, we have the same situation, but we not only have good applications in the mobile space, but we have a very solid platform that we view as becoming that platform or operating system in healthcare that is going to allow for us to bring not only our modules, but other third-party components on top of our platform to be able to solve the problems that we are discussing.

From a development standpoint, what we’re going to do is stick to our core. Today, our core is mobilizing medical devices, EMRs and EHRs. When it comes to imaging and videoconferencing, all we’re going to do is look at third-party packages, plug them into our platform, and then use standards to be able to support single sign-on, content management, and as I spoke about earlier, healthcare information exchange to move the data around.

The key for us, and we’re doing, is to pick those healthcare organizations that are the visionaries and partner with them to be able to move in baby steps toward implementing this huge transformation — but do it in a way that we start region by region — medical devices, EMRs, EHRs and then bring the tools to those regions to be able to replicate that model in other geographies. What we’re doing is carefully picking those healthcare organizations that have the right vision and have the right clinical level of expertise and the right intentions to improve outcomes while reducing cost. Then, working with them, we take things to the next level.

When I’m talking about the vision, I’m really explaining a vision that we’re planning to achieve in the next 12 months. Although the technology is ready today, the bigger challenge is continuity of care. It’s allowing all those systems that the hospitals have to be able to comply with the standards that already exist.

How big is the company today in terms of revenue and headcount and how large it will need to get in the near term?

As a privately held company, we don’t share our revenue figures, but I can tell you that when I came in about two years ago, we were probably about 20 people. We have over 100 already. We have offices in San Diego, Nashville, Chicago, and our headquarters is in San Antonio — that’s where the company started.

As I mentioned to you when I talked about the growth of last year, we added a lot of presence with some key customers. We introduced our cardiology solution officially about 10 months ago and we already have anywhere between 57 to 60 hospitals installed. We already have contracts with another 200 to go live over the next 12 months.

We definitely see a significant growth in the company, but where we are putting most of the emphasis is on what we call clinical / business transformation. We clearly identified that technology is just an enabler of transformation. Transformation happens as a result of aligning people and process as drivers, with technology as an enabler. We created a whole new team where we brought physicians from the top consulting firms to work with us to be able to partner with our customers –you’re going to see some announcements in this area coming out in the next few weeks – to partner with customers to deliver the value proposition.

I believe that technology moving forward is not going to be acquired unless the technology pays for itself, clearly proves out the value proposition on a daily basis and is aligned with the requirements for ACO and Meaningful Use. That’s also why one of the acquisitions we made about two weeks ago was a Meaningful Use tracker to be bundled with our EMR enhancer. We believe that the EMR enhancer on mobile devices is going to increase decision, adoption and utilization and that automatically creates the compliance with Meaningful Use, being able to go to Level 1 and Level 2 much faster.

You have an extensive background in selling systems to the federal government. Do you see that in AirStrip’s future?

Yes. As you know, I was part of the team that installed 60 medical centers at the Department of Defense and 30 at the VA. That is close to my heart. My biggest passion before coming to AirStrip was to help those wounded warriors. Today’s environments are more dramatic. You look today at shortening stent time, event-to-balloon time, for a patient that has a full blockage of the arteries. You look at the wounded warriors, you have to immediately react to patients that are injured in the battlefield and take them through several layers of care until you bring the right outcomes to those kids.

My goal is take this to the federal government and be able to learn from what they have done in areas like security. The federal government is doing security at a level that no one else is doing yet in the private sector. We’re going through that process as we speak because we want to bring that lesson to the private sector – security from the federal government. We also want to bring the experience that we have in the private sector to all the things that we’re doing in the military space. So, yes, it’s definitely an area that we’re planning for.

Do you anticipate further acquisitions or going public at some point?

At this point we are backed by Sequoia. We just closed our third funding round with the Wellcome Trust group, who are very close partners with Sequoia. Now we have a strong 18 to 24 month plan to be that game-changer in healthcare.

That’s our immediate goal. How can we make the transformation to the point that everybody will look back two years from now and say, “AirStrip recognized the importance of virtualizing the caregivers and supporting the patient / population-centric model.” Everybody will remember the types of discussions that we’re having, how we were able to do that by collaborating with large progressive health systems as partners but also large EMR/EHR vendors and medical device companies. We are talking to all of them. We are looking at all of those as partners in full collaboration.

The idea of IPO is not something that we are concentrating on right now. We are enjoying this incredible growth. Acquisitions of other products that will be synergistic to our vision … we are always open to that.

Any final thoughts?

The key moving forward is coming up with the right technological approach and partnering with the right people and the right processes to be able to transform healthcare. But when we talk about people, we have to recognize that that we are talking about the provider, the payers, the vendor community, the systems integrators, all working together and collaborating to be able to sustain the transformation.

We know that transformation is coming. The sense of urgency has been established. This is where you’re going to see more collaboration between all the sectors, more than you have ever seen before. The ones that do not collaborate are the ones that are going to be left out.

News 9/28/12

Top News

The American Hospital association agrees in a letter to HHS Secretary Kathleen Sebelius and the Attorney General Eric Holder that EMR-assisted cloning and upcoding should not be tolerated, but retorts that CMS has ignored its repeated recommendations to expand E/M (evaluation and management) codes to create a national standard for hospital ED and clinic services. My opinion: the election-sensitive, administration-friendly HHS’ers got blindsided by a Center for Public Integrity article that insinuated but didn’t prove that a shift to higher complexity codes means that EDs and physician practices are gaming the system to the tune of $11 billion, so given too little time between now and the November 6 election to actually do something useful (like identify and prosecute someone who’s actually guilty), HHS just went public with meaningless finger-wagging to make it appear that they’re on top of the situation. HHS keeps bragging on how great their fraud detection systems are (which they should be, given the hundreds of millions paid to fat cat contractors to develop them), yet they apparently trust journalists more than their own armies of bureaucrats to tell them they have a problem. The reimbursement system is even worse than the tax laws in being a confusing hodgepodge of rules that nobody, even CMS, really understands or can interpret consistently. Some providers are undoubtedly committing fraud and the 99% honest ones would love to see them shut down and punished. However, as with tax loopholes, there’s nothing illegal or immoral about taking the maximum benefit that the law allows. There’s a reason that crime syndicates are moving from drug dealing to Medicare fraud: payment is quick and rarely questioned, the money is great, and the risk of actually going to jail is almost zero.

Reader Comments

From High Roller: “Re: QuadraMed. Quantum is just the first QuadraMed domino to fall. Franciscan Partners isn’t interested in holding on to the rest of the company forever, so it won’t be long before the other pieces are sold off. QuadraMed has a large enough client base, so they could milk their revenue stream for awhile. More likely, Franciscan will look to sell what’s left to someone like Allscripts who’d be interested in having a larger client base to sell into.”

HIStalk Announcements and Requests

Highlights from the last week on HIStalk Practice: patients want more online access to their health records but most doctors don’t offer the option. Lack of staff impacts EHR adoption, especially in smaller practices. Tips for using an EHR as a marketing tool and to increase patient satisfaction. Parents are more likely to fill children’s e-prescribed prescriptions than paper ones. Physicians are working fewer hours and seeing fewer patients than they were four years ago. I am looking for some MGMA picks. Thanks for reading.

Welcome to new HIStalk Platinum Sponsor Emdat, which offers hybrid clinical documentation and transcription solutions that improve the productivity and satisfaction of EHR-using physicians. Instead of pointing and clicking, physicians continue to use the most efficient method of documenting patient encounters – dictation. Emdat’s DaRT system automatically tags sections of transcription content (chief complaint, medical history, etc.) and then seamlessly auto-populates discrete information directly into the EHR just as though the physician entered it directly using structured documentation. Its Emdat Mobile solution not only allows physicians to document encounters on the go, but provides a more patient-friendly way to document during an encounter. Loyola University Health System uses it with Epic and says the setup was simple, reducing transcription turnaround time by 50% and allowed doctors to continue dictation, which they say is faster and better for patient care. Thanks to Emdat for supporting HIStalk.

Mr. H took off a little early to treat Mrs. H to some fun, so today’s post is a bit shorter than usual.  He’ll be back to serve up a full course of the Monday Morning Update over the weekend.

Acquisitions, Funding, Business, and Stock

As reported earlier today, Nuance will acquire QuadraMed’s Quantim product line. You have to wonder if Nuance didn’t rush the announcement a bit following our Wednesday mention of the deal on Twitter and HIStalk: early Thursday morning Nuance posted these (now corrected) announcements referring to “QuadaMed” and “Quantrim.”

The Kentucky Economic Development Finance Authority approves a $150,000 grant for Health Catalyst, a business accelerator for companies creating health-related software, including life-sciences and HIT companies. Health Catalyst will nurture five startups a year by providing work space, mentoring, and seed funding.

Sales

Evergreen Health (WA) selects MEDSEEK’s ecoSmart Patient Precisioning solution for predictive analytics.

Adventist Health selects MedeAnalytics’ Patient Access Intelligence solution for point-of-service cash collection across its 16 hospitals.

People

Mark Burgess (Cerner) joins Allscripts as director of solutions management.

Fletcher Allen Health Care (VT) hires Adam P. Buckley, MD (Beth Israel Medical Center) to be the organization’s first CMIO.

Announcements and Implementations

Wake Forest Baptist Health (NC) goes live on Epic.

Wellcentive announces Advance Risk Manager, a predictive risk modeling system for population health management that allows providers to focus on patients with specific risk profiles.

The three largest health systems in St. Louis join the Missouri Health Connection HIE.

Government and Politics

Rep. Mike Honda (D-CA) will introduce a bill to set up an Office of Mobile Health at the FDA to provide recommendations on mobile health issues. The legislation also calls for the creation of a support program at the HHS to advise app developers on privacy regulations and for a low-interest loan program for physician offices to purchase new technology.

Technology

The West Health Institute is developing Sense4Baby, a wireless and portable fetal monitor for high-risk pregnancies in remote clinics. The system, which is being piloted in Mexico, sends the captured data over a cellular network to the patient’s physician.

Other

The Seattle Times covers Caradigm, the Microsoft-GE joint venture whose headquarters opened this week in Bellevue,WA. Positive comments from Providence about Amalga are included, along with less enthusiastic ones from Swedish CMIO Tom Wood, who says he’s not sure how they can add a layer on top of EMRs without a lot of cooperation.

UMass Memorial Health Care (MA) will eliminate 140 positions, some of them in IT, in seeking $80 million in cost reductions.

John Reynolds, the former CEO of Hospital for Special Surgery (NY), is arrested for racketeering, charged with soliciting kickbacks from prospective vendors and extorting $300,000 from a hospital employee in return for arranging an annual bonus.

Weird News Andy wonders how this is possible. A women who is “internally decapitated” when her skull is torn from her spine in a car accident not only survives, but is basically back to normal.

Here’s a new video from St. Jude Children’s Research Hospital, featuring patients, employees, and celebrities singing “Hey, Jude” to highlight National Childhood Cancer Awareness Month. Some of those featured are Jennifer Aniston, Betty White, Robin Williams, and Michael Jordan.

Two-thirds of CHIME members report staff shortages and are in most need of more specialists to implement and support clinical applications.

A study published in the Journal of the American Medical Informatics Association concludes that CPOE was the main challenge among hospitals failing to achieve MU in the program’s first year.

Sponsor Updates

• TELUS Health brings its TELUSHealth.com portal live to showcase its solutions that link Canadian patients to their providers.
• Elsevier unveils its EduCode Clinical Documentation Improvement eLearning curriculum for ICD-10 at next week’s AHIMA meeting.
• New York eHealth Collaborative spotlights five health IT champions at the NYeC gala October 15.
• Muhannad Samaan, MD of Aultman Inpatient Medicine discusses how Ingenious Med’s charge capture software improved patient hand-off and communications.
• Software Magazine ranks Macadamian #435 on its Software 500 list, which is based on revenues of the world’s largest software and services suppliers.
• Sandlot Solutions releases a report on using data and analytics to improve healthcare delivery.
• Skylight Healthcare Systems integrates its Service Recovery process with Vocera’s communication devices.
• Optum launches its Optum ICD-10 Core Education program.
• TI combines its DM8148 system on-a-chip with Imprivata OneSign to provide out-of-the-box strong user authentication into any software application.
• McKesson expands its Intelligent Coding portfolio to include observation services.
• First Databank executives Keith Fisher, MS and Patrick Lupinetti, JD  will present educational sessions at next month’s AMCP 2012 Educational Conference.
• Vitera Healthcare Solutions reports record attendance at this month’s VIBE conference in Orlando.
• 3M Health Information Systems adds 18 physician education modules to its Web-based curriculum to address ICD-10 readiness.

EPtalk by Dr. Jayne

Don’t forget — October 3 is the last day for Eligible Professionals to begin their 90-day reporting period for the Medicare EHR Incentive Program, aka Meaningful Use. One of my buddies in the consulting business has been sharing e-mails he is receiving from providers. Today’s special: “I would like to be Meaningful Use but do not know to begin. I need the money. Please send tips for me to start?” I guess that’s someone’s idea of a consulting RFP.

An American Medical News article lists common EHR blunders. I’ve seen all of these in various forms across practices from small to large. Topping the list: lack of infrastructure, lack of workflow assessment, lack of training, lack of buy-in, failure to communicate with patients about delays during the transition, and failure to appropriately integrate the computer into the patient-physician relationship.

News flash: Nearly one-third of US medical school students who initially planned to enter primary care ended up switching to a more lucrative specialty. Surveys of students in New York show that “medical students who anticipated high levels of debt upon graduation and placed a premium on high income were more likely to enter a high-paying medical specialty.” Really.

In similar news, the US medical schools that still don’t have Family Medicine departments are starting to get with the program. Some of these schools are big name and I know all too well what it’s like to attend one. Now we just need to get all medical schools to incorporate informatics into their programs. Let’s teach budding doctors (and nurses, and everyone else) how to leverage technology to better care for patients rather than fighting it or trying to undermine it. Although the new generation seems tech savvy, I see too many students trying to short-cut their documentation.

Mashable lists “10 Office Technologies on Their Way Out.” The list of items they predict will vanish in the next five years includes obvious items like fax machines, tape recorders, and the Rolodex. I’m not sure about desktop computers, cubicles, and standard working hours. There are a lot of entrenched management types out there who will resist. Although I won’t miss formal business attire, which includes pantyhose (#7), I’d like to lobby to keep fashionable shoes part of the equation. If I see one more pair of flip-flops in the office, I just might scream.

The Greater Atlanta area is a hotbed of health IT vendors, so I hope that none of you were recipients of the free kittens given away in the parking lot of the McDonough Walmart. Apparently they were rabid.

As Mr. H mentioned earlier this week, HIMSS registration is open and the room supplies are dwindling. I’m glad he gave me a reminder. I booked tonight, yet wasn’t able to get my preferred hotel or even my preferred dates. I’m leaving a day early, but that’s probably OK since I have to take vacation to attend this year. My hospital no longer has a conference budget or paid professional development days, so I’m not complaining about spending one less night in an overpriced hotel. Plus, I was able to snag a super-cheap plane ticket so I can afford some hot new shoes for Histalkapalooza.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Nuance To Acquire QuadraMed’s Quantim HIM Line

Nuance Communications announced this morning that it will acquire QuadraMed’s Quantim product line for health information management. Quantim includes applications for coding, compliance, computer-assisted coding, abstracting, clinical documentation integrity, record and document management, and workflow.

HIStalk reported Nuance as the buyer Wednesday on Twitter and on HIStalk following the filing of Federal Trade Commission documents. The announcement was reportedly originally scheduled for October 1, the first day of the AHIMA conference.

Readers Write 9/26/12

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.

Weaknesses Revealed:  Secrets Exposed by Data Integrity Summary Reports
By Beth Haenke Just

The data integrity summary report is one of the most powerful – yet underutilized – tools hospitals have at their disposal for maintaining the integrity of the data within their MPI. Digging deeper into the statistics provided in these reports reveals far more than the volume of overlaid or duplicate records within the system. It can also reveal areas of weaknesses that, left unchecked, could threaten the long-term integrity of the MPI, limit its usefulness in achieving quality and safety goals and Meaningful Use, and hamper participation in ACOs and HIEs.

In addition to pinpointing the root cause of data integrity issues, summary reports can identify specific areas upon which hospitals should focus corrective efforts. These may include improved education and training, policy clarification, enhanced communication, and other steps that result in fewer duplicates and overlays for a more accurate MPI and improved data integrity.

Regular reviews of summary reports can also reveal patterns of errors. For example, too many null or empty fields in certain records can signal problems with registration processes. Drilling down deeper, data integrity statistics can be used to track errors with greater specificity, such as identification of incorrect patients, transposed Social Security numbers, or non-compliance with naming conventions. Data integrity reports can even provide detailed insight into the specific types of errors that are happening most frequently within individual departments or facilities and even enterprise-wide.

Once patterns are identified, individual cases can be closely examined to pinpoint where additional training or policy refreshers might be required. Coupling the data integrity summary report with advanced analytics tools allows hospitals to determine precisely where errors are entering the system and the specific types of mistakes being made. This, in turn, allows education programs to be customized to strengthen specific areas of weakness.

For example, if the summary report reveals an unusually large number of registration errors being made within a short period of time, a hospital can drill down into the data to determine the department where the mistakes are originating, as well as who is making them, why, and how. Often the culprit is an individual who is unfamiliar with the registration process and who is attempting to save time by creating new records for every patient versus first searching the MPI for existing ones. Additional training and education will significantly reduce, and in some cases eliminate, these types of registration errors.

The integrity of patient identity data is critical to achieving care quality and safety goals and plays an integral role in the success of HIEs and ACOs. By taking advantage of the wealth of information found within summary reports, hospitals and health systems can ensure the long-term integrity of their data.

Beth Haenke Just, MBA, RHIA, FAHIMA is CEO and president of Just Associates of Centennial, CO.

Round Peg in a Square Hole: Behavioral Health and EMRs
By Kathy Krypel

Implementing an EMR for behavioral health is like putting a round peg in a square hole. Yes, you read that right: a round peg in a square hole (the opposite of the traditional analogy). The EMR (round peg) can fit, but unless certain steps are taken, it won’t fill the behavioral health (square hole) need entirely. Those steps that need to be taken include:collecting the appropriate data and offering the behavioral specific tools and care plans for optimal diagnosis and care delivery.

Why does it matter? Since many large hospital systems offer behavioral health services as part of their continuum of care, it is important to fill in the gaps and variances around the EMR. The following are just a few examples of why it is important to offer behavioral care services that are supported by a robust EMR:

• One in eight (or nearly 12 million) ER visits in the US are due to mental health and/or substance use problems in adults.¹ This is the most costly venue for care delivery.
• Major depression is considered equivalent, in terms of its burden on society, to blindness or paraplegia. Schizophrenia is equivalent to quadriplegia.²

What are these behavioral healthcare EMR gaps and variances?

1. Providers. Most behavioral health providers are not MDs. In fact, primary care physicians spend limited time with patients and are often hesitant to diagnose and treat behavioral concerns. Most behavioral health providers are clinicians with Masters or Doctorate degrees who have been licensed by their state(s) to diagnose and treat behavioral health disorders.
2. The diagnostic process and tools. Behavioral health disorders are the only serious, chronic illnesses that are diagnosed based solely on self report. The tools used to assess the behavioral health patient’s mental status and substance abuse patterns are very different than the traditional medical diagnostic tools of imaging and lab work. Behavioral health diagnostic tools are most often elaborate question and answer tools that are can be both clinician-administered and self-administered. Behavioral health clinicians use tools such as the Beck Depression Inventory (BDI), Generalized Anxiety Disorder scale (GAD 7), and the Diagnostic and Statistical Manual (DSM IV). These tools need to be incorporated into the data capture and workflow built into an EMR. Additionally, behavioral health providers are required to develop elaborate treatment plans with the patient’s participation. Non-behaviorally focused EMRs typically don’t have tools built in for this and must be built (or ignored). If ignored, the EMR becomes nothing more than a word processor.
3. Customization will always be required. While there are multiple behavioral health specific EMR vendors in the marketplace and enterprise-wide EMRs that can be configured to cover behavioral health, customization will be required to meet multiple state-specific mandates, practitioner specialty requirements, and federal privacy rules that apply to behavioral health.

Although there are challenges, successes are growing. The following recommendations help to ensure a positive implementation outcome:

• Create a small but specific implementation team that aligns with your behavioral health leadership during the build and test period, so all build and testing work is completed in a collaborative manner.
• Build using the most commonly used diagnoses and their DSM IV criteria into the EMR to make it easy for providers and therapists to use drop-down lists to create the diagnostic picture of the patient.
• Build using ASAM criteria, so chemical dependency staffs can more easily complete treatment planning.
• Design within the “tighter than HIPAA” federal constraints that govern confidentiality of patient information for patients receiving chemical dependency treatment (i.e., CFR 42).
• Involve trainers and testers in the workflow discussions.

In order to avoid putting a round peg in a square hole, it’s essential to understand the variances in the behavioral health setting and address them in workflow, data capture, information exchange, provider engagement, and administrative requirements and incorporate them into the EMR project plan, design, and implementation.

Sources:

1. Mental Disorders and/or Substance Abuse Related to One of Every Eight Emergency Department Cases. AHRQ News and Numbers, July 8, 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/nn/nn070810.htm

2. Disability Adjusted Life Year, DALY, Daly 2004

Kathy Krypel is master advisor at Aspen Advisors of Pittsburgh, PA.

Data Virtualization Best Practices Accelerate Time to Value
By Richard Cramer

Data virtualization offers a value proposition that quickly excites business leaders and technologists alike. Business executives are enthusiastic because data virtualization enables IT departments to more quickly respond to new requirements – often in days or weeks rather than months or quarters. Information technologists are similarly excited about being able to get more done, more quickly, and deliver higher value to their business customers.

However, unless we’re careful, this same enthusiasm can lead to organizations trying to use data visualization where it’s not appropriate and results in a classic “square peg in a round hole” situation. It is important to keep in mind that while data virtualization is an important part of the data management tool kit, it is not the right tool for every purpose, and doesn’t eliminate the need for a traditional data warehouse.

Successful deployments of data virtualization share some common characteristics. First is that data virtualization is most successful when it complements a mature data management infrastructure, development standards, and implementation processes. Best practice in these organizations is to use data virtualization as a part of an overall data management life-cycle where data mapping logic that had been built in the virtual solution is seamlessly reused in the physicalized data integration solution.

Second, there are specific use cases where data virtualization is most appropriate. Best practice is to vet candidate uses of data virtualization against these use cases. Just because data virtualization can be used does not mean it should be used.

This is particularly true in the early stages of adopting data virtualization technology, since missteps in using data virtualization for inappropriate use cases in the first project or two can give the technology a black eye that is hard to overcome later.

Good use cases for data virtualization share the following characteristics: (a) data needs are of a short duration; (b) business requirements are unclear or evolving; and (c) situations where quickly prototyping a view of integrated data is required.

Situations where data virtualization is not a good fit include: (a) complex join logic is required; (b) high performance query response is a driving requirement; or (c) source system availability is unreliable or unpredictable.

In this context of best practices, it is exciting to see the healthcare industry providing many opportunities where data virtualization can be a key enabler of organizations looking to maximize their return on data. There are a large number of healthcare organizations with traditional enterprise data warehouse solutions in place, and that can most benefit from the addition of data virtualization to their architecture.

There are also many examples of use cases that are appropriate for data virtualization and can quickly deliver high value. For example, data virtualization can be used to accelerate drug research by providing scientists with integrated views of internal and external information to aid in the drug discovery process. The unpredictable nature of discovery can be enabled by virtualized data integration solutions—quickly combining lesser-known external data with well-known internal data speeds up the decision-making process and ultimately reduces the time to bring new drugs to market.

For healthcare providers, the ability to respond to ambiguous and frequently changing data requirements in a rapidly changing regulatory and business environment is a must. The rapid prototyping enabled by data virtualization can be invaluable in meeting fleeting reporting and data needs today that may be gone or completely different tomorrow. 

Richard Cramer is chief healthcare strategist of Informatica Corporation of Redwood City, CA.

Coordinating Physician and Nursing Care
By David Lareau

Historically, physician and nursing systems and workflow have often been parallel, but independent of each other. Physicians and nurses must be able to share information to provide coordination of care.

For example, physicians must comply with standards such as ICD-10, ICD-9, SNOMED CT, RxNorm, LOINC, DSM-IV, and CPT, while nurses employ terminology like NANDA, NIC, NOC, ICNP, PNDS, and CCC. With so many different standards in place, creating an integrated picture of patient care can be difficult at best.

Fortunately, all of these standards have already been mapped to link physician and nursing information. The capability now exists to integrate physician and nursing documentation and care capabilities as well as provide links between a patient’s clinical diagnoses and nursing care.

To create this functionality, all existing nursing standards were evaluated to identify the best candidate for use at the point of care in computerized systems. The Clinical Care Classification (CCC) system was selected and 182 CCC Nursing Diagnoses were linked to the more than 55,000 clinical diagnoses. Linking the CCC and clinical diagnoses makes it possible for all members of the care team to generate a list of nursing diagnoses based on the physician’s clinical diagnoses for that patient.

In addition, CCC Nursing Diagnoses are linked to CCC Nursing Interventions and to more than 1,760 specific nursing actions. Also, a starter set of customizable documentation protocols has been developed for each of the nursing actions.

One of the most significant aspects of this work is that the same concepts in the nursing protocols are linked to the physician content where appropriate. Coordination of care has arrived.

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

HIStalk Interviews Paul Taylor MD, CMIO and Co-Founder, Wellcentive

Paul Taylor, MD is CMIO and co-founder of Wellcentive of Roswell, GA.

Tell me about yourself and the company.

I’m an internal medicine physician. I practice clinic-based internal medicine about half time. I see patients five days a week. I also chair the clinical integration committee for our PHO. Our committee oversees all the different quality work.

We’re part of the Trinity Health System. We’re in the process of forming a tiered network and just signed up as an ACO. That along with the experience as a practicing physician and chief medical information officer for Wellcentive … it’s been such a lot of fun to put those three different things together.

Wellcentive is a population health management company. We provide population health management solutions that help physicians and their organization across the entire spectrum of population health management, including point of care, care gap analysis, outcomes reporting, automated patient outreach, predictive modeling, risk assessment, care management, and care coordination.

We’re taking a broad view of what population health management means and providing tools developed by a physician for physicians and their organizations. We also focus on aggregating and normalizing data from a variety of sources to make the solution as useful as possible.

The concept of providers being responsible for population health management got thrown into their laps without much warning. Do you get the sense that they are ready to take that on?

I would say most of them are not ready. This is a whole new set of tasks and responsibilities that physicians are being called upon to execute, and lot of the time, don’t really understand. They also have a hard time changing. Most physicians are set in their ways. For us to practice medicine in a different way than we’ve done for potentially decades is a tall order.

The conversation around improving outcomes, cutting costs, and to a certain extent the payment reform of accountable care is going much faster than most physicians can keep up with.

Providers are always suspicious of payers and insurance companies, and those payers have been aggressively investing in analytics and population health management technologies for a long time. Do you think that providers are at a disadvantage against companies that have made analytics a core competency?

I would say that they are. There are some gun-shy physicians as well when it comes to technology. I don’t think that electronic medical records have been as well received by physicians as they could have been. Some physicians are frustrated by the interruption to their workflow.  

Using a population health management solution is really different than an EMR that would be just one more thing. Some physicians are reluctant to dip their toes in that water. Payment reform is going to push them hard in that direction, though.

There weren’t many incentives for physicians to implement technology, but now they’re going to need the information from systems that contain their data. Will this need for analytics drive technology adoption, specifically of electronic medical records?

The need for the data and for the reporting — but also the need for the ability to proactively make improvements in your clinical outcomes and financial outcomes for your patients — is really going to drive that technology adoption. It’s not enough to be looking backwards. 

Analytics are knowing where you’ve been, but it’s having the tools, processes, and programs in place in your office to look forward, know where you want to go, and put the programs in place to get there. That’s where we are and should be going.

EMRs can be helpful in some regard to that end. The amount of actionable data that you need to have good insight and to how you’re doing — that predictive, forward-looking analytics to know where your patient may be over the next year — that type of technology is a lot different than a traditional EMR ,though.

Let’s say you’re a health system with a large hospital, a couple of smaller ones, and perhaps some owned and affiliated practices that use several different EMRs and exchange information through an HIE. What technology pieces are you missing that you’ll need under this new paradigm?

One of the important components is an interfacing platform that can aggregate and normalize data from EMR systems, practice management systems, e-prescribing solutions, local and national labs, health information exchanges, payers, and a variety of other different data sources. That’s a core competency and a core need. 

Data analytics is important to be able to do flexible outcomes reporting, so that you can tailor the reporting that you do for your organization to your specific organizational goals and metrics. Having some sort of outreach tools where you can communicate with patients and help close the gaps in care is important. For organizations that are working with risk-based contracting, risk assessment tools and predictive modeling to give them a good idea of their financial risk and patient panel so that they can properly negotiate with payers and employers.

The one big concept that’s important to understand is that if you look at an accountable care organization, they have to take into consideration the whole landscape in their communities. They have to tie all of that together with their different EMR systems, different practice management systems, different e-prescribing tools, and so on. They need a tool that can do that to help with their different business and clinical objectives, too.

EMRs are driving an unintended consequence in causing small practices and hospitals to align with bigger and more technology-astute providers, such as practices either selling out to hospitals or turning their IT management over to them. Will the need to manage populations provide another push for small organizations to align with larger ones?

I do think so. The likelihood is that the development of accountable care organizations and tiered networks with their more community-based reporting requirements are going to drive alignment of physicians with healthcare systems and their specific overarching umbrella technologies in ways that are probably a little different than with EMRs.

EMRs dictate workflow in physician offices to a certain extent. Because of that, there’s a lot of personal preference for which physicians like this EMR system, or which like another. Having an EMR that a health system offers can be helpful, but it also can be polarizing. Whereas if you have a population health management solution that‘s just a core business function for your accountable care organization, all the physicians are going to be engaged with it, using it, and have their outcomes reported through it. I do think that’s a phenomenon we’re going to see again.

After all the time and money that hospitals and practices have spent implementing EMRs, do you think they will be able to implement these new tools?

I do. We work with physician groups and organizations that have EMRs and some who don’t. The value a population health management solution brings is significant, even for those offices that have an EMR system.

The way that the systems are used in an EMR office is different than the way it is in a paper-based office. In a paper-based office, it does tend to be more point-of-care, hands-on use — looking at clinical decision support tools and doing medication reconciliation directly in the tool as opposed to through an interface with an EMR. With an electronic medical record, we tend to rely a little more on electronic communication between the population health management tool and the EMR, so there is not a duplication of the workflow and effort.

If I’m the typical hospital or practice with an EMR, what’s the bang for the buck in looking for additional technologies to move toward with managing populations?

You are going to need a population health management tool — one that can help you with the reporting, one that can help collect actionable data from a variety of different sources in your community to help make the reporting that you get out of it meaningful to help make the identification of high-risk patients accurate.

For example, if you’re implementing a case management program, having a strong population health management toolset that’s highly integrated with the pertinent data sources within your community is really probably the next step.

Do you see an overlap between what EMR vendors offer and the more specialized tools you provide, and is it hard to convince providers that they need those tools?

It’s beyond just simple functionality. You can have a rules engine that does analytics, but if the data that you’re running the analytics on isn’t accurate, it’s not up to date, it’s not complete, then the reporting that you’re going to get out of it is not going to be very meaningful. The physicians aren’t going to trust it. They’re not going to pay attention to it. They won’t get engaged.

EMR vendors generally are not focusing on integration and interfacing of actionable data across a community. That’s an easy argument, and a very valid argument to make.

Some of the toolsets that you find in a solution that’s geared towards population health management are beyond what most EMR vendors do. For example, predictive modeling and risk assessment, using vetted algorithms to help identify patients that are high risk of poor outcomes, using different types of tools that way so that you can enroll them in case management programs, or help you in your conversations with payers through case mix adjustment, that sort of thing. Those technologies are a little beyond EMRs.

Being able to track the cost and utilization of healthcare across a population of patients is something that’s really valuable information for physicians, especially ACO-type organizations. That’s also something that you really don’t see in EMRs.

We generally don’t think of a population health management solution as being in competition with an EMR. We see them as different types of workflow, parallel technology tracks with some overlap in the uses of the systems. But the goal of the population health management solution is primarily improving the clinical outcomes for a whole population, and also improving the cost of the healthcare delivered to them at the same time.

I see population health management solutions shining in community-wide implementations, which is a distinct and parallel technology track with respect to EMR implementations. Population health management and EMR solutions are complementary, and I don’t see them as being in competition with each other. Their clinical and business purposes are very different.

If I’m a patient now being covered by your tools through my provider organization, what changes in my care will I see?

You might find that you get some automated outreach to you, maybe on a quarterly basis. You get a phone call telling you all the different things that you’re due for, like a diabetic foot exam, mammogram, colonoscopy, that type of thing. The information that’s given to you on that phone call is more likely to be accurate.

You will also probably find that your physician is little more engaged with population health, in that they might be more likely to have care management work that’s being done in their office, a care team that’s involved with helping with your care. You may find that there are other people inside the office who, at a visit or between visits, are using the solution to help improve your care. That’s something that patients generally notice.

As hospitals acquire or align with medical practices, what information do they need to manage that relationship?

Without the appropriate toolset, it’s difficult for health systems or physician organizations to have a good feel for the quality of care that their physicians are providing. If they want to have more insight into that, they need the core set of data — the patient demographic information, accurate information about what’s the patient’s medical history is, what their diagnosis is, what medication they take, what sort of procedures or tests have been performed, and what immunizations have been given and what should not be given.

It’s also important in today’s environment to have an understanding of which payer those patients have. Also, to be able to use a benchmarking tool to help see how an individual physicians stacks up against his or her peers within the office, their specialty, or within their region. A lot of times we see health systems or physician organizations proactively working with those physicians whose performance rates are not as good, trying to help bring them along. Which is, of course, good for everybody.

What changes would you expect the average hospital or physician practice to see in the next five years in terms of the things we’ve talked about, and what should be their priorities in doing something now to be ready?

We’re going to see a lot more collaboration. We’re going to see much tighter relationships between hospitals and the physicians around quality, cost, and outcomes. We’re going to see the business structures of those relationships change significantly, and I would imagine fairly quickly, over that time frame, such that there’s less, “Well, that’s the hospital and this is my clinic here,” more of a feeling like, “We’re all on the same team trying to work together to take care of patients.” 

I believe that the financial incentives are going to be rewarding a community of physicians to help improve those outcomes. The only way you can really do that is by care collaboration through communication, through being proactive, looking forward, and doing things that require a care team to accomplish, like case management, care management programs, that sort of thing. I think we’re going to see a lot of changes over the next five years.

Any concluding thoughts?

Wearing my physician hat, I look at all the technology in this conversation around solutions, data, and interfacing. In my mind, the technology is just enabling. It won’t get the job done for you, but it’s going to help you get there if you choose to put the effort in.

I’m a firm believer that this kind of quality improvement work needs to be led by physicians and managed by physicians. Patients don’t want to be taken care of by some stranger at the case management program. They want their doctor to take care of them.

I also think that it’s important for physicians to roll up their sleeves in their offices and change the way that they’re doing things, so that they utilize the staff that they have in different ways to help drive outcomes and put together an office-based clinical quality improvement program centered around trying to take care of all patients, not just the ones who were in the office that day.

I see all that technology helping to enable, that but it’s just critical that the physicians are leading the charge.

News 9/26/12

Top News

HHS Secretary Kathleen Sebelius and US Attorney General Eric Holder warn AHA and other hospital organizations that the government will take appropriate steps to pursue healthcare providers who misuse EHRs to defraud Medicare, specifically calling out upcoding and cloning of medical records.

Reader Comments

From Wicked Fun: “Re: HIStalkapalooza planning. I just moved from the vendor side to a provider organization. As much as I am loving my brand new job, I miss the ‘fray’ of the world of HIT. The first comment from one of my MD friends  was, ‘What if you don’t go to HIMSS? We always go to the HIStalk party together!’’” The lesson here for the HIStalkapalooza faithful is to add our annual event as a mandatory condition of employment in your contract negotiations. If you like planning ahead, the 2013 version of HIStalkapalooza is scheduled for Monday, March 4, with registration opening sometime in January.

From Plinker: “Re: Northwestern in Chicago. Going Epic.” I don’t recall if I’ve mentioned that previously.

From Squint Eastwood: “Re: Vermont. Not a rumor, but interesting.” Fletcher Allen Health Care and Dartmouth-Hitchcock Medical Center submit an ACO plan that would create the for-profit OneCare Vermont LLC, which would include 13 of the state’s 14 hospitals (Porter Medical Center passed), 58 medical practices, two FQHCs, and other organizations. If approved in October, OneCare would be up and running by January 1, serving most of the state’s 105,000 Medicare beneficiaries. Fletcher Allen SVP Todd Moore, who will be CEO of OneCare if it’s approved, says access to data was a driver. “This is really an access to information revolution as much as it is anything else for us. This gives us access to the full claims set for the first time to Medicare beneficiaries that we treat … to understand how they seek care, how often they go to (the doctor) — whether it be at Fletcher Allen or at Northwestern Medical Center or in Florida.”

From Adam: “Re: Tampa General Hospital. Saw they’re going with RelayHealth for HIE. Aren’t they an Epic shop?” They are indeed.

From HereWeGo: “Re: MCK acquisition of MedVentive. The fat, spoiled kitty found a new toy to bat around and destroy until the next shiny object captures its attention.” Usually the fat cat in a given deal is the seller, so at least some of MCK’s cash trickled down to the MedVentive owners. I should clarify that the rumored MCK acquisition that I mentioned last week isn’t MedVentive, so another announcement could be coming if the rumor turns out to be accurate.

From Bobby D: “Re: MCK acquisition of MedVentive. This is the second company that Nancy Brown has been involved with that McKesson bought, the first being Abaton.com. She has two to go to catch Mike Myers of CliniCom history, who has sold them four companies.” Mike’s at QuadraMed now, I’m told, so he could bag “one for the thumb” if MCK happens to buy QuadraMed’s Quantim line, if indeed the rumor is true that it’s about to be sold (and even if it is, MCK hasn’t been mentioned as a player.) UPDATE: per Federal Trade Commission filings, Nuance will be the acquirer of Quantim.

From Moak: “Re: upcoding. How did you miss this one?” I get at least one e-mail per day (including this one) with a link to a big news story that I’ve already covered, so skimmers are missing out. Still, I appreciate the notice just in case I really did miss something, and Moak brings up an interesting point: the feds gave Faxton St. Luke’s Healthcare (NY) as an example of an ED whose higher levels of treatment jumped 43 percent in 2009, the same year it implemented EHRs. He says the hospital only has 22 days’ cash on hand and therefore is not stealing from anyone. I wouldn’t necessary make that assumption since poverty usually encourages rather than discourages criminality, but I think his point is that the hospital was struggling financially and may have simply cracked down on sloppy billing practices. One might assume that the feds would do some audits before slamming the entire healthcare provider universe with unproven fraud innuendo, but given its poor track record in uncovering even widespread fraud (see: South Florida), maybe the only arrow in its quiver is to bluff. If they have found even one case of EHR-abetted fraud and wanted to deliver an effective message, they should have had a photo op with someone in handcuffs.

HIStalk Announcements and Requests

A big thanks to all the readers who sent me notes bragging that they had already gotten their iPhone 5s after little or no wait at their local Apple store. My phone will arrive from China on Thursday. I loved the lightweight feel of a friend’s iPhone and had fun taking a few panoramic photos. My friend claims it is much faster than the iPhone 4, but she is not yet convinced the battery life is dramatically improved.

Welcome to new HIStalk Platinum Sponsor VersaSuite. The Austin, TX company offers an integrated system for medical enterprises (hospitals, clinics, surgery centers) that includes a hospital information system (including CPOE and eMAR), inventory management, RIS/PACS, laboratory information system, pharmacy management system, accounting, and HR. It’s all built on a single Windows-based stack running on a single database, standardizing the user experience across inpatient, outpatient, and ED. The company says it holds the largest number of CCHIT certifications of any single product, including CCHIT’s enterprise certification, giving healthcare systems one product that is MU certified for both EPs and hospitals. VersaSuite’s EHR includes specialty-specific templates for 24 disciplines, keyboard-free data entry, dashboards, tablet support, and a four-click assessment/plan for outpatients that takes only 5-10 seconds vs. up to two minutes in competing EHRs. The company is a member of IHE and its products support interoperability standards such as HL7 and DICOM and are compliant with HIPAA 5010 and ICD-10. Thanks to VersaSuite for supporting HIStalk.  

I booked my HIMSS room this week and suggest you don’t wait too long. I got my first choice, but the supply for close-in rooms is dwindling. HIMSS usually opens up more hotels later, but they’re usually a long shuttle bus ride to BFE.

Acquisitions, Funding, Business, and Stock

Cancer support site Navigating Cancer raises $2.3 million to hire developers and integrate its patient portal into EMR applications.

McKesson announces that it will acquire MedVentive, which offers population and risk management tools.

Sales

Wentworth-Douglass Hospital (NH) selects the Siemens perioperative management system by SIS.

The Upper Peninsula HIE (MI) will implement ICA’s CareAlign CareExchange platform.

Tampa General Hospital (FL) selects RelayHealth Enterprise HIE for CCD data exchange.

Johns Hopkins Hospital and Health System (MD) selects 3M’s 360 Encompass System for automated coding and clinical documentation.

Health plan service provider Magnacare (NY) will offer online appointment scheduling services from DocASAP, a startup competitor to ZocDoc.

Methodist Dallas Medical Center (TX) selects ProVation Order Sets from Wolters Kluwer Health.

Amcon’s Australian division announces the launch of its Messenger clinical alerting middleware at the 848-bed St. Vincent’s Hospital Melbourne.

People

M*Modal hires Mike Etue (OptumInsight, Allscripts) as EVP of sales, replacing Michael Clark.

Former PatientKeeper VP Michael Bertrand joins home health software provider HealthWyse as VP of development.

RemitDATA appoints John Stanton (Beacon Partners, above) as VP of consulting and Phillip McClure (MedeAnalytics) as VP of sales.

Beacon Partners promotes Christopher Kondrat from principal to VP of professional services.

Phillip Madden (Cerner) is named director of client sales at Orion Health.

Yuma Regional Medical Center names Robert Budman, MD (Catholic Healthcare East) as CMIO.

Besler Consulting appoints Edward J. Niewiadomski, MD (Southern Ocean Medical Center) as senior medical advisor.

Quality Systems, Inc. appoints Daniel J. Morefield (LEADS360) as EVP/COO.

Announcements and Implementations

Munson Healthcare (MI) implements VPLEX Metro virtual storage from EMC and private cloud technology from EMC and VMware.

SCIOinspire Corp. changes its name to SCIO Health Analytics.

Prognosis adds a configurable template engine and a physician rounding tool to its ChartNotes EHR.

In the UK, CSC admits that it will sunset the former iSOFT physician systems, including Synergy, Premiere, and Ganymede, that are used by about six percent of England’s practices. It denied the rumor of the impending retirement until Monday’s announcement.

PerfectServe adds a patient-centered rounding feature to its communications system, allowing clinicians to contact the appropriate physician for each patient.

Cleveland Clinic is implementing software from its new spinoff iVHR, which will present information from its Epic system to doctors in a visual form. The software will create maps patient locations with indicators of patient condition that link to all the background data from Epic, displaying it visually to help doctors see the big picture.

Government and Politics

The FCC’s mHealth Task Force recommends that wireless health and e-Care technologies be incorporated as best practices for medical care by 2017. Example technologies are remote monitoring devices, apps, body sensors, implanted microstimulation devices, medical device data systems, provider apps for remote image viewing, patient portals, clinical decision support tools, and a broadband-enabled HIT infrastructure. Some of its specific recommendations to the FCC include: (a) fill the open position for an FCC healthcare director; (b) provide education and outreach; (c) work more closely with ONC and CMS, specifically helping ONC with secure health messaging and communications standards; and (d) open up more of the communications spectrum for mobile broadband.

UC Davis Health System signs a 16-month, $17.5 million agreement to take over the state’s struggling HIE, formerly run by Cal eConnect. The project has been renamed the California Health eQuality Program (CHeQ) and will be led by Ken Kizer, MD MPH of UC Davis, who was previously CEO of the VA healthcare system, Medsphere, and the National Quality Forum. The project is halfway through its four-year, $39 million grant. They claim they are confident they’ll seamlessly move to a post-grant revenue model when the federal breast runs dry in 2014, which will make them one of almost none if they actually pull it off.

NPR posts the audio and transcript from Tuesday’s “The Diane Rehm Show,” featuring Farzad Mostashari and others on “The Pluses and Minuses of Electronic Medical Records” (but not Diane Rehm, who was on vacation, and not Farzad for the second half because he had to leave). The substitute host led an inordinate amount of the discussion toward upcoding, which made it a lot less interesting. What Farzad said: (a) maybe the EHR just captured the charges correctly; (b) the current system pays doctors more for recording what they actually do, so why wouldn’t they?; (c) EHR or not, fraud is illegal, and in fact the audit trails of EHRs can make it easier to detect. A former healthcare CIO and practice manager named Jim called in to say that his docs always intentionally downcoded with paper records because they were afraid insurance companies would challenge their recordkeeping, but were more confident that electronic records made it safe to bill accurately.

Other

OIG finds that Essentia Health (MN) overbilled Medicare by $865,000, or $3.18 for every $1.00 it was owed. Essentia blames its billing system, which it says it has replaced.

Avado CEO Dave Chase opines in a Forbes article that New York is “the epicenter of healthcare’s reinvention.” He cites as examples health accelerators, Medicaid HMOs, WebMD, the New York eHealth Collaborative, the state HIE, IBM, and Farzad Mostashari.

Weird News Andy finds an article from the physician author of Bad Pharma stating what everybody knows: drug companies selectively publish studies that make their drugs look good, using tricks such as small-numbers studies and statistical tricks that exaggerate questionable benefits. Less-flattering studies get shelved. Industry-funded drug trials were positive 85 percent of the time, while only 50 percent of government-funded studies were. Industry-sponsored studies of statin drugs were 20 times more likely to favor the test drugs. From the book’s description, “We like to imagine that doctors are familiar with the research literature surrounding a drug, when in reality much of the research is hidden from them by drug companies. We like to imagine that doctors are impartially educated, when in reality much of their education is funded by industry. We like to imagine that regulators let only effective drugs onto the market, when in reality they approve hopeless drugs, with data on side effects casually withheld from doctors and patients.”

Another WNA find, which he labels “workaholic”: the New York Post digs through public records to find city-employed psychiatrists who make multiples of their base salaries by claiming extensive overtime for ED coverage. One psychiatrist boosted his $173K base pay to $481K by claiming he worked 80 hours per week. The same doctor made $689K in 2009 by turning in 3,820 hours of overtime, including one non-stop stretch of 96 hours. The physicians are also allowed to operate private practices.

Here’s the latest cartoon from Imprivata.

Sponsor Updates

• eClinicalWorks releases the agenda for its October 25-28 National Users Conference.
• DrFirst creates an infographic called “Key Dates You Need to Know to Maximize Meaningful Use Incentive Payments.”
• Lifepoint Informatics announces its Gold Level sponsorship of the G2 Lab Institute Conference in Alexandria, VA October 10-12.
• MED3OOO VP Steven Stout discusses the risk and rewards of contracting for global risk in an October 3 Webinar.
• McKesson hosts a September 27 Webinar on strategies for driving reimbursement.
• A survey by commissioned by simplifyMD finds that EMR vendors often convince practices to replace their practice management system when implementing their EMR, but practices often experienced problems with cash flow and employee productivity as a result.
• MedVentive offers demos of its Population Manager and Risk Manager products during next week’s AMGA Institute for Quality Leadership Annual Meeting.
• Benefis Health System (MT) realizes a $4.9 million increase in appropriate hospital charges, a $3.5 million increase in reimbursement, and a $2.3 million reduction in uncompensated care within four months of implementing the first phase of its RCM initiative with MedAssets.
• MedAptus releases its Mobile Schedule application for Apple iOS.
• An Imprivata-sponsored survey finds that 72 percent of hospital IT decision makers believe pagers will be replaced by secure text messaging within three years.
• iSirona releases a white paper on device integration.
• Wellsoft will participate in the 2012 ACEP Scientific Assembly next month in Denver.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 9/24/12

As a primary care physician, I think the concept of health information exchange is exciting. I’m tired of seeing patients who forget to bring their medication lists. Don’t get me started on those who really have no idea about their health history. I’d love to be able to exchange with other practices in my community, but for now I have to settle with downloading their medication list from Surescripts and digging through hospital charts and scanned records.

Several groups are trying to get private exchanges going in my area. Our state is woefully behind in the exchange game, so it’s not surprising that people are stepping up to fill the gap. The technology is there, the desire is there, but unfortunately the governance is not there. Small, medium, and large-ish independent groups are in active discussion about sharing information, but are woefully undereducated about data ownership, participation agreements, and patient consent.

A colleague of mine was involved in one of these exchanges several years ago. It ultimately folded due to lack of agreement among the four participating practices. There were no arrangements for determining “source of truth” for patient information and the database quickly became corrupt and ultimately unusable. It was a shame, because initial participation yielded outcomes that were published in peer-reviewed journals and looked truly promising.

I was excited earlier this summer when ONC issued a Request for Information on Governance of the Nationwide Health Information Network. The RFI asked for input on how to make patients and providers confident about information exchange. As someone who has had to counsel patients on why they should share their data, the idea of a national standard was enticing. I’ve also had to hold the hands of providers as well – making them understand that having “somebody else’s stuff” in their charts is not necessarily a bad thing.

The other shoe dropped earlier this month when ONC announced that it will not “continue with the formal rulemaking process at this time, and instead implement an approach that provides a means for defining and implementing nationwide trusted exchange with higher agility, and lower likelihood of regret.”

I sympathize with all the statements that Farzad Mostashari made on his blog – that there are voluntary governance bodies, that regulation may slow trusted exchange, etc. ONC hopes to “identify and shine the light on good practices” and “provide a framework of enduring principles to guide emerging governance models.” I’m afraid, though, that for some nascent exchanges, it will be too little, too late.

Who is going to shine the light on the private exchange that is sharing patient data without their consent? The providers think it’s just fine because “the patients signed the HIPAA form,” not understanding that HIPAA consents typically cover treatment, payment, and operations. A standard form may not cover the fact that all the patient’s data just got populated into a private HIE which has no provisions for filtering sensitive information or tracking patient authorization. It may not have restrictions on who can access the data or who monitors data consumption. The providers can’t even articulate whether they’re practicing in an opt-in or an opt-out state.

Some of you may think this is a fable, but it’s the reality of a practice where I was a patient last week. After figuring out what was going on, I should have billed the practice for the free consulting I gave them explaining that in their state they simply can’t just choose to populate patient data to a health information exchange without consent.

I hate over-regulation as much as anyone, but the private HIEs that are popping up are starting to feel a little too “wild, wild west.” Voluntary bodies aren’t going to help them if they’re not even aware the voluntary bodies exist.

What do you think about private health information exchanges? E-mail me.

E-mail Dr. Jayne.

HIStalk Advisory Panel: Increasing Physician Involvement

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

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

This month’s question: What successful actions have you taken to improve the involvement and satisfaction of physicians with IT projects and services?

• We ask physicians what kind of IT solutions they believe would be beneficial to our service, quality, and affordability objectives. Physicians help us evaluate proposed solutions. Project teams are partly staffed by physicians, and in some roles, we pay them for their subject matter expertise. CIO meets directly with CMIO to ensure alignment on priorities and clarity regarding improvement opportunities.
• We strive to find ways to use HIT to make it easy for our physicians to do the right thing. We obsess over how many clicks each action takes, and whether someone else on the team should be doing it instead of the doctor. We are not perfect, but we’ve stumbled into a few things based on these principles which are unique ways to use our EMR, but which result in improved efficiency and quality.
• We formed a physician group called the PIT (Physician Information Technology) group that meets every other week. We do this so frequently because we are in the middle of a large EMR project. We run all decisions impacting docs through this group, from order sets to clinical notes design. Another thing we have done is launched a physician portal that has a blog manned by our CMIO and CIO, but I will have to tell you it does not get much traffic.
• The single most important tool for physician engagement has been shoe leather (OK, shoe rubber?) Getting out and making face-to-face contact with them in the hospital and in the clinics. Asking what works and what we can do better. Optimizing the EMR is an ongoing task and the first step is to convince them that we’re committed to it. Also, recognizing that one size does not fit all, whether it is the interface or the device or the software tools, has been critically important. Be flexible wherever possible about the tools we provide.
• I think this follows the classical thought process today: First, have a physician in a key leadership area seen as the owner of the project. I like to have a VPMA or Medical Director leading the charge depending on the scope of the project. (IMO, depending on this roles relationships with physicians and the physician model of the organization, this may or may not have any impact on the project.) Another key is having the right type of person in a Physician/IT role (CMIO, Med Dir of Informatics, etc.) Someone that can earn the trust and respect of the other Docs, translate clinical needs between IT and business workflow, and "prep the battlefield" for major decisions by meeting with groups or individuals off-line. Having key physician champions attend discussions with other clinical areas is a must. This is where workflows overlapping various areas (physicians and nursing, for example) come to a head. For ongoing support, maintenance, and optimization, having IT topics on MEC, division meetings, physician steering/champion groups, etc is a key strategy. And as a last resort, free meals are always appreciated. 
• We’ve taken a new approach to engaging physicians with our EMR via an online collaboration / community. Our "MyEMR" secure intranet site is unique and now has almost 500 physician members. Physician IT champions moderate discussion forums, answer questions for their peers. Education ‘tips and tricks’ videos. Design drafts are posted for review on new content and development items. New information (e.g., Stage 2 Meaningful Use information) also posted for review and education. Project status documents posted so that all can see progress on important efforts. This site was conceived by our physicians and now co-managed with them.
• Defining specific roles for physicians and using physicians to recruit other physicians has been a successful approach that I have used. Whether it is software implementation work or ICD-10 implementation or anything in between, physicians need to have clarify on the expectations and time commitments that they will be signing up for.
• We created a steering committee for them that reports to the medical staff executive committee. The only person from the hospital who is there routinely is the IT director (no CIO here). It is their chance to blow off steam about issues, and they do. If they gripe to the hospital administration about IT, they’re told that they have a channel for those complaints, and they are asked to use it. Once they recognized that we do listen and that within the strictures of the software and legalities, we’ll accommodate them if we know there are problems, they started using the committee. Now, it is more about moving forward than about fighting the battles of the last 20 years.
• With any change, you need executive leadership support (administration and physician), evidence-based metrics, peer-to-peer pressure, and a system’s level continuous process improvement culture that is combined with a comprehensive, multi-pronged communication plan that reaches all levels of your organization. You have to include physicians (champions and high-volume user representatives) at the table from the very beginning and recognize that they are key stakeholders, and not just barriers to IT implementation. Physicians, like us all, are slow to adopt new, disruptive technologies. Active involvement and an active communication plan are critical to getting them involved.  If they feel like they are part of the solution, then it will work. The solutions themselves also have to be designed for the user (the physician). They need to here "what is in it for them." Perhaps it is a reduction in time, errors, callbacks, etc. The more specific the better.
• We created a CITAC (Clinical Informatics Technology Advisory Council) made up of physicians representing most of the sections of the hospital(s) and we take them all of the new things we look at, get their input, get advice as to how to communicate with the entire medical staff, or to introduce new systems or technologies, etc. They also bring us suggestions from their respective sections on order sets, CPOE screens, prompts, core measure attributes to build in, etc. It’s really been helpful. In addition to the docs, we also include some nursing staff, my IT clinical informatics staff, and our vendor representative. We air some dirty laundry, and deal with some turf issues, some of which can be awkward but the end result is pretty positive. In addition to this, we have made trips to each of the major provider clinics to meet with those physicians to discuss issues and desires related to CPOE screens, prompts, processes, etc. But, one of the biggest things that I feel contributes to better adoption of new technologies, is that we use a lot of hospitalists in our organization, and once we get them to use technology and make some changes based on their feedback, we’re finding the other physicians are more prone to try it (since they see the hospitalists using it).
• We’ve worked very hard to partner with and develop Physician Champions. Physicians in this role are more in tune with current projects and services, and enjoy being involved in the decision making process. For many of our physician champions, we have regularly scheduled meetings with them and their Practice Administrators to prioritize projects and discuss options, which is beneficial for all of us. We are expecting to roll out a full Physician Governance program this next year.
• Physician IT committee, physician champion for certain projects, specific physician IT ‘helpline’ to facilitate quick resolution of their issues.
• The key to physician satisfaction and engagement in health IT efforts is definitely having them involved. It is not enough for them to just be invited to receive information about the project. They need a seat at the decision making table and a voice that is heard and listened to. The level of their involvement in decision making and governance can vary depending on the project/program at hand, but having as many thought and action leaders from the medical staff in active roles in the project/program as feasible pays dividends with the entire medical staff. The opposite situation (zero physician involvement) yields highly negative results in terms of medical staff satisfaction, engagement, and adoption. However, it is also absolutely vital to choose wisely those physicians that are selected for involvement. We naturally want to involve those who have "connectedness" with their peers and thus high influence, but we also must select for traits such as "collaborativeness", ability to understand and explain the "vision" and rationale of what we are doing to peers, and flexibility (as plans necessarily change while in progress more often than not).
• Most success has been to not just involve the docs, but have them lead initiatives. For example, we have three MDs that have had tasks and expanding roles in our Epic project. In addition, when you can have the docs be decision makers in projects, and those docs have the respect of most of the medical staff, per se, then things seem to go better. Having docs sit on a committee and updating them or asking for opinion is clearly not enough. They have to be like the pig at a breakfast of bacon, sausage, and eggs. Not like the chicken. 
• When we went through the process of choosing an EMR we intentionally set up a steering committee made up largely of our physicians. We had representatives from all of our clinic types and almost one from each clinic. These docs were an integral part of the process. Once our selection process was down to three, we did demonstrations of several days with each vendor and asked all of our clinicians docs and staff to sit in. We required a survey upon exiting even if it was just a check mark on a few basic questions. After demos, site visits, and analysis was completed, the only folks who voted were the physicians. We have tweaked the system we purchased to make it as useful to the docs as we can. When we have a live date planned, we make sure the physician has someone within hearing distance to answer all questions and concerns. It is all about the support.
• This is a long story, but something for which we are proud.  Many years ago (1993, in fact) we created a Clinical Systems Advisory Committee. It came to be because there was significant dissatisfaction among members of the user agreement. It started as a very small group of physicians who would meet with us weekly, then ultimately bi-weekly, to discuss our work. We provided dinner and (cheap) wine. We would always meeting in the evening; we would always make it a comfortable, and somewhat informal meeting. Over the years, it grew, and grew, and grew. And now, we meet monthly. The room is full with doctors, nurses and IT professionals. There are often more than 50 people in the room. Sometimes there are 75 or 80 people in the room. It is open to anyone who wishes to attend, although there is a membership list. Lots of great folks participate, and we all genuinely look forward to the meeting. It’s a social event as well as a work event. Lots of time to network and catch up. The meeting typically lasts for about two hours, but many folks stick around late into the evening. We serve great dessert. We have learned so much, made important decisions, and used the output as a way to advise our executive team. It has been a real joy. Additionally, now that we have embraced Epic as our enterprise-wide solution, we have added a Physician Council and a Nursing Council. In this case, we have ensured that we have a representative from every department or division. It is equally effective, equally active, much more focused and a bit more formal.
• Use of "Tech Rounds" at one of our hospitals, conducted by the local CMIO; done monthly and showing latest technology applications, use of system, etc.
• We have a mature CPOE implementation and a lot of community docs and contracted hospitalists (in many disciplines). It has been challenging to maintain physician involvement and enthusiasm for continuous improvement of order sets, decision support, etc. On the satisfaction front, hiring a CMIO (me) has been very helpful, and having a crew of dedicated physician educators / support specialists has been essential. Most of our physicians don’t bother with the IT Help Desk any more.
• Lots of one on one discussion; open conversations with physicians in various meeting formats, informal lunches, working  to provide prebuilt documentation screens by specialty, demonstrating the improvements in outcomes using computer associated protocols agreed to by provider groups.
• As part of our Epic implementation, we formed a Physician Advisory Group chaired by our CMIO consisting of physicians representing every discipline across our health system. This group has been key to driving significantly increased engagement by physicians in the requirements, design, implementation, testing, training, go-live, and ongoing improvement of our new EMR. The core advisory group has been meeting weekly for a year and has been very successful. We also invite other physicians, outside the core group, to participate in requirements and design sessions when needed, which extends our reach further into the community. These, and other supporting, actions have been effective in improving involvement and satisfaction of our physicians with IT projects and services. 

McKesson To Acquire MedVentive

McKesson announced this morning that it will acquire MedVentive, which offers population and risk management solutions. Terms were not disclosed.

MedVentive, based in Waltham, MA, was founded in 2005 by Jonathan Niloff, MD. Its solutions include MedVentive Risk Manager and MedVentive Population Manager. McKesson will add its offerings to its McKesson Enterprise Intelligence suite.

Time Capsule: Sutter’s $150 Million Turned $500 Million Clinical Systems Project: Where Seldom was Heard a Discouraging Word, Apparently

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 November 2007.

Sutter’s $150 Million Turned $500 Million Clinical Systems Project: Where Seldom was Heard a Discouraging Word, Apparently
By Mr. HIStalk

Sutter Health didn’t seem embarrassed when the local newspaper recently reported that its 26-hospital Epic clinical systems project will end up costing around $500 million. In fact, Sutter’s COO even hinted that the tab could run higher, saying that EMR projects rarely meet budget and timeline projections. He didn’t sound concerned.

Or, maybe it was gallows humor. Sutter’s original project budget was $150 million. Being off by over 230 percent is scandalous, at least when someone other than Uncle Sam is involved. Luckily, Sutter can afford a gaffe of a few hundred million.

Wildly faulty project budgets and timelines are not uncommon. Project complexity goes up much faster than being simply linearly related to bed size or headcount. It’s closer to geometric: doubling the bed size quadruples the effort (and therefore the cost). It’s anti-economy of scale. Little hospitals have it easy, other than they’re broke.

That’s no excuse for a bad estimate. Complex projects demand sophisticated planning and risk mitigation. Socking a lot of cash in a contingency fund is poor substitute for planning well in the first place.

The main reason for underestimation may be more psychological than numeric. Project costs are often underestimated and riddled with unlikely assumptions because that’s what people want to hear. This is similar to groupthink, in which members of a group are so reluctant to disrupt group harmony that they avoid viewpoints that are contradictory or critical.

Those executives who collectively decide to plunk down hundreds of millions of dollars for software may not be all that enthusiastic about the idea individually and off the record. Everybody else seems to like the idea, so it’s easiest to avoid arguing with peers by just going along as a passive rubber-stamper, especially if the boss clearly favors doing it.

After all, everybody else is hot to get going, too. Consultants urge action, especially when they smell an opportunity to get new engagements. Affected departments love anything new and fun, at least initially, so their appointed representatives can’t wait to get started. Journals, HIMSS conferences, and vendor salespeople encourage action because the industry (and therefore their place in it) depends on churn.

The CIO, being nurtured in an IT advocacy mindset, often naively believes that IT fixes problems, even when available solutions are dysfunctional and collective experiences suggest otherwise. If the other VPs are willing to do it, the reasoning goes, why not get a chance to shine, beef up the resume a little, and move up on the staff-and-budget yardstick they measure each other against?

Many of these big-ticket projects will never even come close to being worth what they cost. Does anybody go back to the people who made the “go/no go” decision and either ask for an explanation or fire them for bad judgment? Not usually. The project’s once-broad circle shrinks to a grim core of IT people stuck with the unenviable task of trying to reconcile unreasonable expectations with the ugly product limitations and internal processes at hand. What started out as a noble collective mission becomes a never-ending IT ground war that no one wants to talk about.

It goes without saying that IT people shouldn’t be initiating or leading projects other than those involving IT infrastructure. What may need to be said, however, is that the process and choice of people involved in making huge IT project decisions may be flawed as well. Seldom is heard a discouraging word when project-friendly allies sit around a conference room table breathing each other’s air.

If hospitals really wanted to make an informed decision, they’d bring in patient advocates, safety experts, physicians, risk managers, finance experts, and process engineers. That’s pointless if the pre-ordained executive answer to the “should we do this” question is already “yes.”

Monday Morning Update 9/24/12

From Eddie T. Head: “Re: Forbes 400. They’re pulling Judy Faulkner’s net worth out of the air, seeming to make up their numbers based on an alternate reality where Epic is publicly traded and the stock price is based on the nonsensical P/E ratios of companies like Cerner (35) or athenahealth (195). For comparison, Google and Apple have P/E of 21 and 16.” My first thought on seeing that Forbes estimated Judy’s net worth at $1.7 billion: they couldn’t possibly know what she’s worth since none of her assets, including Epic’s ownership structure, have been publicly reported. Epic has previously corrected reporters who referred to Judy as a billionaire – they say she’s not. Cerner’s market capitalization is five times revenue, and by that formula, Epic would be worth about $6 billion if (and it’s a huge “if”) it went public and was able to earn stock market credibility as Cerner does without screwing up the operation. Judy supposedly owns 40% of the company, so that would value her stake in the theoretically publicly traded Epic at $2 billion. That doesn’t mean she has $2 billion in the bank, but it’s safe to assume that she’s not overdrawing regularly.

From Milkshake: “Re: Forbes 400. Now I know why Judy and Neal are always smiling. I wonder how long they will keep their smiles once Grassley catches wind of the ubiquitous up-coding scams their instruments facilitate.” I don’t think they have a lot to worry about from Chuck since, despite the high expectations I had for him, seems to excel only at writing stern letters and then moving on to whatever headline grabs his attention next. Someone intent on scamming Uncle Sam in any fashion (medical or other) would probably find it more efficient to use a computer, but that’s hardly a good reason to ban computers. I’m somewhat anti-gun, but I still laugh at the folks at the anti-gun rallies who carry signs saying “Spoons made me fat.” In other words, the problem is people, not their choice of inanimate objects.

From Thinking Ahead: “Re: Epic. What’s their succession plan? Judy is almost 70, few people on the planet could afford to buy her out, and she doesn’t have much appetite for going public. Employee-owned models are nice in theory, but few if any have really worked, and to my knowledge Judy doesn’t have family engaged who could take over. The succession plan is important to a hospital that has paid tens or hundreds of millions for a product with a shelf life of decades.” I’ve talked to people who have seen the succession plan and they are comfortable with it. Epic would certainly change without the presence of the visionary and sole public face of the company who is personally involved with even the most trivial company decisions. However, I said the same about Apple and Steve Jobs and they seem to be doing just fine without him, although it’s been just a year since he died.

From The PACS Designer: “Re:Information Week 500. This year’s InformationWeek 500 finds Beth Israel Deaconess Medical Center at the #1 position. TPD salutes CIO John Halamka, MD for guiding his institution to the top of the IT world with innovative solutions, such as their search tool called Clinical Query which can be emulated and used by other healthcare organizations to improve processes.”

From Looking Deeper: “Re: HIStalk Advisory Panel on patient-facing technologies. I’m loving it. Finally we get some honest opinions on a topic that hasn’t been discussed to death like EHRs.” I agree — it was interesting information. EHRs get 90% of the attention these days, but they don’t address every problem. I’ve really enjoyed hearing what the Advisory Panel has to say. I send them a topic or two once a month, so you can look forward to more frontline reports. Thanks to those panel members who take the time to provide thoughtful answers – the industry benefits.

From Cache’ Jedi: “Re: Epic, MUMPS, and Cache’. VC and software guru Paul Graham describes a kind of momentum like Epic has now in this article.” The 2001 article describes why a less-popular programming language might actually be a “secret weapon” that stymies competitors because — geek arousal factor aside — it might allow companies to develop software better and faster. “In business, there is nothing more valuable than a technical advantage your competitors don’t understand … the people who understood our technology best were the customers. They didn’t care what language Viaweb was written in either, but they noticed it worked really well … the only programmers in a position to see all the differences in power between the various languages are those who understand the most powerful one … they’re satisfied with whatever language they happen to use, because it dictates the way they think about programs … the median language, meaning whatever language the median programmer uses, moves as slow as an iceberg …the more of an IT flavor the job descriptions had, the less dangerous the company was. The safest kind were the ones that wanted Oracle experience. You never had to worry about those.”

Most of us haven’t requested and reviewed copies of our EHR information. New poll to your right: McKesson announced Better Health 2020 in December 2011. Since then, how has its position in healthcare IT changed?

Rumor from a couple of readers is that McKesson has closed on the acquisition that I mentioned several weeks ago. I won’t run the target’s name since MCK is publicly traded, but above is a graphical hint.

Condolences to Intermountain Healthcare VP/CIO Marc Probst, whose daughter Heather died of leukemia last week. She was 16.

St. Rita’s Medical Center (OH) eliminates 60 jobs, some of them transcription positions that are no longer needed after its Epic implementation.

The finance minister of Ontario, Canada proposes legislation that would cap the salaries of public sector employees at around $400K per year. Most of the 150 employees who would be affected are hospital executives. Ontario Hospital Association is “deeply disappointed” since it says hospital leaders manage half of Ontario’s annual budget and therefore should be the most skilled and experienced leaders instead of those willing to work in “an arbitrary compensation environment which bears no relation to the job market.” I thought we were the only country where non-profit hospitals and high-profile charities pay on par with publicly traded companies in competing for the apparently immense talents of the altruism-free executive hired guns who are available only to the highest bidder.

Cerner speeds up construction of its new campus in Kansas City, KS, deciding to start immediately on the second nine-story tower instead of waiting until later. Construction will be completed 18 months earlier than originally planned, with the first tower opening next year and the entire campus finished by mid-2014.

Georgia Tech and Emory University are developing Remotoscope, an otoscope-like iPhone attachment that allows parents to take a picture or video of their child’s eardrum and send it to a doctor for review instead of heading off for the ED to be checked for an ear infection.

New River Medical Center (MN) is looking for a buyer after financial problems following a spat with a large physician group. The doctors took there business to a competitor hospital, with one of their stated reasons being that the other hospital used the same EMR they use and OMC recently chose a different product.

The New York Times publishes another story insinuating that EMRs inflate hospital and medical practice Medicare bills through up-coding. It includes vague references to fraud and OIG’s complaints that EMRs make it easy to bill for work not performed. Nobody seems to blame a screwy, code-driven payment system, the lack of CMS vigilance, and the strong possibility that providers are submitting accurate bills that just happen to inconvenience payers who have structured their operations around perpetually under-billing providers who are now armed with better tools. Fraud is fraud regardless of the tools used and haven’t seen CMS prosecute anybody or change its hopelessly complex payment rules. This would be like the IRS complaining that tax collections are down because taxpayers are using TurboTax to file more accurate returns. Instead, the IRS audits tax returns electronically, goes after cheats, and hopes that the majority of taxpayers it won’t audit will stay honest for fear of incurring its wrath. Some folks are raising an out-of-the-box question: why aren’t doctors paid by the hour instead of by the procedure? They could inflate their time spent, but that wouldn’t be as hard to detect. Are those Chicago-area pathologists really worth $2 million a year in taxpayer money just because they oversee big labs?

A Johns Hopkins surgeon and author starts out his Wall Street Journal opinion piece on hospital errors with the tired “jumbo jets full of patients harmed” cliché, but gets quickly to some interesting transparency measures that could improve safety. Specifically, hospitals should: (a) post dashboards of infections, readmissions, surgical complications, “never events,” and patient satisfaction; (b) post the results of anonymous safety and teamwork surveys of their employees; (c) record video of procedures and other process to review for quality improvement opportunities and as a permanent record if questions arise later; (d) use “open notes” where patients see what is written about them and correct any mistakes or add their comments; and (e) eliminate the use of gag orders that prevent patients from speaking about negative experiences and malpractice lawsuit settlements.

Wood River Health Services (RI) goes live on NextGen’s EMR. The Federally Qualified Community Health Center was already live on patient billing and dental services.

The surgery waiting room of the replacement Kaiser Permanente Fontana Medical Center (CA) that opens in May will have a computer bar where visitors can use their technology and the hospital’s WiFi network.

The board of Olympic Medical Center (WA) approves a $1.5 million hardware budget request for its Epic implementation, which the board approved two weeks ago in a $7.6 million agreement with Providence Health and Services. Epic will replace five OMC systems. The hospital hopes to earn $7.2 million in HITECH payouts over four years and chose to affiliate with Providence’s Swedish Medical Center because it needed help with its implementation.

Intelligent InSites mentions that its RTLS software is one of the technologies mentioned by a local TV station mentioned in covering last week’s opening of the new 50-bed Texas Health Resources hospital in Fort Worth. Intelligent InSites will integrate with Epic, Cen Trak, LodgeNet, Rauland-Borg, Siemens, TeleTracking, and Vocera. You would think that with all the emphasis on hospitality that THR would have chosen a more patient-friendly name than Texas Health Harris Methodist Hospital Alliance. Quick, shut your eyes and say the name you just read. See? Even the apparent shortcut name – Texas Health Alliance – doesn’t actually include “hospital” in its name, and sounds more like a vaguely threatening lobbying group instead of a place of healing.

Strange: a physician’s former office manager (also her landlord) sues him for sexual harassment, claiming he made her take an Internet sex test, sent her obscene text messages, offered her a watch in return for sex, and asked her to hand him a “Happy Birthday” teddy bear from his children to cover his face while he watched live sex on a webcam via Skype. She says he fired 40 percent of his employees and then fired her when she complained about not being paid overtime to cover. The doctor collected $5.3 million in 2008 as a Medicare fraud whistleblower after turning in University Hospital for using unlicensed beds to treat addiction payments.

More on QuadraMed in this week’s HIS-tory from Vince, with help from alumnus Frank Pecaitis.

E-mail Mr. H.

News 9/21/12

Top News

 

The Forbes 400 list of richest Americans includes Epic’s Judy Faulkner (#285 with a net worth of $1.7 billion) and Cerner’s Neal Patterson (#391 at $1.12 billion).

Reader Comments

From HIStalk Fan: “Re: EHR experience reporting. The IOM recommendations could improve outcomes and safety. It remains puzzling that ONC is against robust vetting for safety and efficacy.” ONC asked the IOM to suggest ways to collect and report EHR user experiences, particularly those involving problems with patient safety. IOM’s just-published paper lays out ways that could be done. Possibilities include (a) testing vendor products against use cases; (b) placing a “report a problem here” button on EHR screens to allow users to quickly report problems; (c) have EHRs collect information such as number of clicks or the number of screen views and mine that data to look for problems; (d) conduct user surveys; and (e) develop a formal reporting program. The article recommends posting the collected information on a website that would rate individual functions vendor by vendor using a star-type rating system.

From Misys_Ex: “Re: QuadraMed. Not all to be sold, only the HIM/Quantim line. Sale to close in a week. Spending and hiring freeze in effect. MModal is the rumored buyer.” Unverified. An all-company call has been scheduled for October 1, rumor has it, which would logically place the announcement on the first day of the AHIMA conference.

From Dale Sanders: "Re: odd iPad requirement. The Colorado Department of Health Care Policy and Financing is re-competing its Medicare and Medicaid Information System contract. The draft RFP requires each vendor to submit their response on seven iPads, one for each member of the selection committee.” The rationale is that the iPad saves printing and shipping cost, although you could do a lot of printing for the $3,500 or so. The state says vendors like the idea and the iPads are more secure than paper, ensuring that documents don’t fall into the hands of competitors and thereby force an expensive re-bid and/or legal challenge for the $100 million project. None of that would seem to preclude returning the iPads given that the state plans to erase and reuse them anyway.

From Laura: “Re: Practice Fusion. Another cloud downtime.” Only for a few minutes, apparently, but judging from the comments, I bet that Like button didn’t get much action while the users killed time waiting to get back on.

From Writing My Resume: “Re: McKesson’s Better Health 2020. Will go down as the largest mistake in the history of HIT. Customers like Providence, Southwest Washington, Ohiohealth, John Muir, Valley Health, WellStar, HealthEast, and Resurrection are moving from Horizon to Epic. The new Paragon customers are small community hospitals and it will take 10-15 of them to replace one Horizon customer. Rumors of another layoff coming.” Unverified. I interviewed MPT President Dave Souerwine when the program was announced in December 2011. Better Health 2020 was a series of commitments to (a) invest $1 billion in R&D over the following two years, a good bit of that in enhancing Paragon over a 30-month development cycle; (b) sunset no products, but shift resources away from Horizon clinical applications to Paragon; (c) stop the development of Horizon Enterprise Revenue Management and lay off 174 employees immediately; and (d) continue to support Horizon customers through Meaningful Use and ICD-10.

HIStalk Announcements and Requests

Are you current on all the latest ambulatory HIT news? Here are some highlights from HIStalk Practice over the last week: RAC auditing of physicians begins in 15 states, focusing on higher-level E/M codes. The state of Colorado reports that Medicaid medical homes are reducing hospital inpatient stays and ER visits. EHR adoption at community health center grows to 74 percent, thanks to HITECH funding. eClinicalWorks predicts a 23 percent increase in revenues for 2012. Implementation costs and low patient adoption are big barriers for practices wanting to add patient portals. A physician weighs in on the impact of the ACA, incentives, and EHR. Nuesoft Technologies’ Blake LeGate offers tips for preparing for ICD-10. Dr. Gregg thinks (a lot) about going back to paper. Some days, especially those when Mr. H is especially busy at his day job, the only way I know I am appreciated is to see that someone new has subscribed to HIStalk Practice. When you check out these stories, show me the love and sign up for the e-mail updates. Thanks for reading.

Working anonymously is good in some ways, bad in others. On the “bad” side, Inga, Dr. Jayne, and I labor in our otherwise empty rooms with no human contact, meaning our little HIStalk world will evaporate the moment we quit or get hit by that proverbial bus. It’s up to you to write our electronic epitaph in advance, as follows: (a) connect with us and Like us (note to Mark Z — a Love button would be better) on the usual ego-feeding social not-working sites; (b) sign up for our spam-free electronic updates; (c) show your appreciation for the companies that keep our caustic keyboards clacking by reviewing the gallery-quality ads to your left and impulsively clicking those that pique your interest; (d) inspect the more detailed sponsor information housed in the Resource Center and consider using the Consulting RFI Blaster to effortlessly contact several consulting firms at once about your needs; (e) send us news, rumors, photos, ideas, or anything else that interests you and therefore would probably interest the rest of the HIStalk universe; and (f) look into the nearest reflective surface and give yourself a jaunty thumbs-up on our behalf for being discerning enough to recognize that despite its amateurish presentation, occasionally inappropriate content, and intentionally ironic pipe-smoking logo character, HIStalk does a mostly OK job in keeping you informed as well as a guy with a full-time hospital job can do.

My inbox is bulging and I have a lot of catching up to do this weekend. That’s the best I can do, unfortunately. Re-sending your e-mail doesn’t really help solve my problem of needing to sleep five hours or so, which is about all the time I have left at the end of the day. I promise I have not forgotten you.

Welcome to new HIStalk Platinum Sponsor TeraRecon of Foster City, CA. The company is a global leader in enterprise image management solutions, especially with regard to advanced imaging procedures. Its zero-footprint iNtuition EMV (Enterprise Medical Viewer) can deliver interactive images to any Web browser for even the largest and most complex CT exam, even interactive 3D. Instead of a peering at static JPGs in the EMR or a generic 2D viewer short on useful tools, physicians get a rich viewer with contextual tools and viewing configurations that are automatically set based on image type. Specialists in particular get real value from 3D images. The flagship iNtuition solution integrates with any vendor-neutral archive, so it works with a wide variety of systems including PACS from any vendor. TeraRecon created the concept of advanced visualization and iNtuition is the leader in enterprise-wide, thin-client server-based visualization with over 4,500 installations all over the world. Thanks to TeraRecon for supporting HIStalk.

I admit that imaging solutions aren’t my strong suit, so hopefully this TeraRecon overview video that I found on YouTube will make up for any deficiencies that I shamelessly exposed in my introduction above.

Acquisitions, Funding, Business, and Stock

Skylight Healthcare Systems, a provider of interactive patient systems, raises $5 million in Series D financing.

Sales

The New York eHealth Collaborative selects MedAllies to operate its Direct Solution on the Statewide HIN of NY.

CMS awards HP a $43 million task order to continue providing IT services for the EHR incentive program and for maintaining the CMS Integrated Data Repository database.

Loma Linda University Medical Center (CA) selects Nuvon to provide medical device connectivity and interoperability as it migrates its OR, ICU, and dialysis center to Epic.

The VA awards Systems Made Simple (SMS) a $27 million renewal contract to support the Veterans Service Network program and Benefits Gateway System development project.

People

Bill Conroy joins Kareo’s board, a position he also holds for Prognosis Health Information Systems and Phreesia.

Ben-Tzion Karsh, a University of Wisconsin-Madison professor of engineering and one of the authors of the IOM article on EHR experience reporting that I mentioned above, died last month at 40.

Announcements and Implementations

INTEGRIS Health (OK) implements PatientSecure by HT Systems for biometric palm scanning.

Intelligent Medical Objects announces a search engine appliance to deliver just-in-time secure terminology services at the point of care.

Elsevier releases a version of its ClinicalKey reference system aimed at individual clinicians, which features information from 900 textbooks and 500 medical journals covering 41 specialties.

In Canada, three-employee Clinisys launches its first product, a cloud-based EMR.

New in the AMA’s CPT 2013 data file: consumer-friendly descriptors of each CPT code for patients and caregivers.

Santa Fe-based Seamless Medical Systems launches an iPad app for physician waiting rooms that allows patients to complete their forms online, review educational material, take notes during the visit and e-mail them to themselves, and play games.

Government and Politics

Sen. John Kerry (D-MA) introduces MITECH, a bill that expands the MU program to include safety net clinics that don’t necessarily qualify under the Medicaid incentive program. Kerry’s legislation would allow providers to qualify for incentives if at least 30 percent of their patient volume comes from lower-income patients.

ONC posts the vendors who signed up for the Blue Button Pledge (Alere Wellogic, Allscripts, athenahealth, AZZLY, Cerner, eClinicalWorks, Greenway, Intellicure, NextGen, and SOAPware) and invites other vendors to tweet their #VDTnow pledge to be added. Above is Farzad Mostashari’s welcome to the Consumer Health IT Summit where the companies were announced.

The US Army tests real-time medical communication software that uses mobile devices and 4G networks to support battlefield medics treating severely wounded solders. Portable physiologic monitors are used to to send streaming video, voice, and photos, along with treatment records, to surgeons that in real-life situations would be located in remote hospitals.

Innovation and Research

Mobile health apps that help manage medications and blood glucose are linked to improved diabetes management in socially disadvantaged populations.

Other

The board of directors of the Kansas HIE votes to transfer its duties to the Kansas Department of Health and Environment by October, 2013, which will save $350,000 a year.

The Joint Commission designates 620 hospitals as top performers on 45 evidence-based care processes closely linked to positive outcomes.

Joe Goedert of Health Data Management wrote a rebuttal to the Soumerai and Koppel editorial that ran in The Wall Street Journal this week called A Major Glitch for Digitized Health-Care Records. Joe mentioned some of the same points I did in my criticism of the editorial and the studies it selectively cited, but added quite a few more in Bad Research Shouldn’t Affect Good Policy. I respect the opinions of the authors and I’m as cynical as the next guy, but the editorial had just enough citations to possibly fool someone into thinking that it was new research (or that the old research mentioned was actually well done, which it wasn’t.) My criteria for assessing the objectivity of articles on almost any contentious topic (religion, politics, sports, or healthcare IT) is this: if the authors never give credibility to anything that doesn’t match their own beliefs, then I simply don’t bother reading because I already know what they’re going to say. I should note, though, that Ross Koppel was one of the authors of the IOM report on EHR problem reporting that I mentioned above and that’s a nice credit.

Job postings for healthcare professionals with EHR skills have jumped 31 percent over the last year.

Georgia Tech is offering a free, online Health Informatics in the Cloud class taught by Mark Braunstein MD, who has more relevant experience than anyone I can think of. Students don’t need a technical background – just five to seven hours per week for 10 weeks. The class is offered via Coursera, an online education startup that has already enrolled 1.5 million students in its “massive open online courses.” Its partners include Brown, Columbia, Stanford, Penn, and other topnotch schools that aren’t ordinarily interested in giving away their courses for free. This looks really good, especially for folks who don’t have a lot of formal healthcare IT education on their resume.

The family of a man who died in the ED of Beebe Medical Center (DE) files suit against the hospital and the ED staffing company it uses. The patient was discharged from the ED after being seen for chest pain, but he made it no further than a chair in the lobby before dying of a heart attack while waiting for a ride. Nobody noticed until hours later.

People who have eaten in Epic’s cafeteria will enjoy this profile of Executive Chef Eric Rupert (not celebrity French chef Eric Ripert, although I’m sure Epic could afford him if they wanted). The chef says Judy is a serious foodie — the only non-chef he’ll talk to about food — and she insists that Epic’s employees and visitors be fed well. He leads a staff of 78 Epic employees and describes the company environment: “There really is very little hierarchy here. You’re either a team member or a team leader, and the team leaders do everything that team members do, and then they also manage people. It’s not considered a promotion to go from a team member to a team leader; it’s just additional responsibilities.” He says Epic is different from its Silicon Valley counterparts in that employees pay the cost of ingredients for their meals instead of getting them for free, and everything is made in-house, even the baked goods. But like Google and other high-tech companies, Epic uses their food as a recruiting tool and has a diverse group of employees to feed, representing 55 countries.

Inga masquerades as Weird News Andy in finding this story. A Colorado man sues several food companies for “popcorn lung,” claiming that he ate microwave popcorn for years and the artificial butter fumes damaged his lungs. The jury, who apparently didn’t find his years of exposure to carpet-cleaning chemicals to be contributory, awards him $7 million. Inga adds that she hopes he gets his money in a Jiffy.

Epic UGM Report
By David Miller

Dave Miller, vice chancellor and CIO of University of Arkansas for Medical Sciences, e-mailed me privately about Epic’s UGM. I asked him if I could run his comments on HIStalk since non-Epic customers are always mystified by the company’s cult-like following. If you were one of the 8,000 UGM customer attendees and would care to share your thoughts about why it’s different than other user group meetings you’ve attended, I’d like to hear from you.

I have been to a number of UGMs at Epic, though it has been about three years since my last one. I am always amazed at the creativity of the Epic staff and the almost flawless way in which they execute the logistics to handle almost 8,000 users.

It continues to be primarily a user-driven event, from the advisory councils to the UGM sessions and even to the entertainment. The sessions themselves demonstrate the excitement that their users feel with what they have been able to do with one of the top healthcare IT products.

At the end of the day, it really comes down to Epic’s ability to instill their culture in each and every employee. Their simple focus on customer service was demonstrated by every employee I encountered. They had people stationed everywhere on campus to give directions, to drive golf carts to your destination, or just about anything else you needed.

I actually did not see a lot of Judy, but when she was present, she cheerfully took pictures with about anyone who would ask. Pretty amazing for a CEO of that stature. In my experience, most individuals in her position are self-absorbed and would never mingle like she does. I’ve also known Carl Dvorak for about 15 years, and he is about the most down-to-earth individual you would ever want to meet.

Judy creates an atmosphere for her employees that encourages and enables them to be at their creative best. The end result is a really good set of tools to manage the complexity of issues that healthcare organizations deal with every single day. Yes, there are imperfections, but they are so outweighed by the positives that they become irrelevant.

They used to say that no CFO ever got fired for hiring a Big 8 firm. Short of having someone completely inept in that role, I think I would say the same thing about a CIO.

Sponsor Updates

• ChartWise Medical Systems profiles Jennie Stuart Medical Center (KY) and its use of ChartWise:CDI to improve documentation an reporting.
• SuccessEHS reports that more than 10 percent of its EHR and PM client are now using its RCM services.
• Health Care DataWorks offers a September 25 webinar on CMS’s Value-Based Purchasing program.
• DrFirst offers Meaningful Use webinars over the next three weeks covering avoiding penalties, data exchange, the EHR as a clinical tool, and clinical quality measures.
• Orion Health’s portal solution for Alberta Netcare reaches 100 million views since its 2006 implementation.
• Versus features Northwest Michigan Surgery Center in its October 17 Webinar on maximizing patient flow with RTLS.
• TELUS Health Solutions and Sun Life Financial launch an eClaims solution for extended care providers across Canada.
• The Web Marketing Association recognizes CareTech Solutions as Outstanding Website Developer for winning nine WebAwards in 2012.
• CommVault joins The Association of Certified E-Discovery Specialists as an affiliate member.
• Awarepoint integrates its awareED module with Rauland Responder’s nurse call system.
• CDN Channel Elite recognizes NexJ Systems with gold awards for best cloud computing and best mobile solutions.
• MEDSEEK hosts roundtable discussions on marketing’s role in MU at this week’s Society for Healthcare Strategy and Market Development conference.
• Greenway hosts a Webinar series addressing the trends of electronification, consumerism, and improving population health.  
• Lifepoint Informatics will sponsor the Pathology Informatics 2012 conference in Chicago October 9-12.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Interviews Matt Sappern, CEO, PeriGen

Matthew Sappern is CEO of PeriGen of Princeton, NJ.

Tell me about yourself and the company.

I joined PeriGen in January of this year. I came over from Allscripts and Eclipsys, where I had been for about eight years in various capacities. I headed up a big chunk of our development organization at one time, ran our remote hosting business, ran our services business for awhile, and then after the merger, ran all of our client sales for a year-plus. I joined PeriGen in January and now getting my arms around labor and delivery.

What’s the size and scope of the company?

We’re about 100 folks. We’ve got offices in Tel Aviv, Princeton, and Montreal. We are the combination of two firms that merged in 2009. We’ve got more than 150 customers right now, including Banner, MedStar, Maimonides, and Albert Einstein. It’s a good cross-section of teaching hospitals as well as community hospitals. Our solution flexes pretty well across the entire gamut of hospitals.

How have fetal surveillance systems changed the way that obstetricians had practiced over the years?

The interesting part about fetal surveillance systems is that they really haven’t changed much at all for a number of years. That’s what attracted me to PeriGen. It was the first time that I saw that any vendor was applying some new technology and starting to innovate.

Surveillance systems, archiving, and annotation on the strip have been around a long time. Everybody does it, right? Philips, OBIX, GE, WatchChild, and PeriGen … we all do it pretty well, to be honest with you. PeriGen takes a different approach in applying evidence-based medicine to detect when there’s risk in labor. I’m hoping that we’re ushering in a whole new age of applying systems to healthcare. That’s really what drove me here.

That must be a different driver than at Allscripts, where you had to convince doctors to use CPOE or EMRs because someone else wanted them to even though the benefit might not necessarily accrue to them personally. I assume obstetricians want or demand PeriGen’s products.

When I was at Allscripts, Meaningful Use happened and hospitals were getting behind EMRs. It is a great feeling when we show our product. Clinicians’ eyes really light up, because it is just a bit different from everything else that’s out there.

It does everything that what I term “commodity systems” need to do, but our ability to apply technology to what has been a subjective part of labor and delivery is important. Probably 80% of medical malpractice comes back to bad interpretation of the fetal monitoring strip. We’ve figured out a way to apply technology to help interpret that strip.

Docs and nurses … their eyes tend to light up when they see this stuff. I think as with every new disruptive technology, it takes a little bit of time for people to understand why it’s so much better than what’s out there, particularly as budgets are tight.

What malpractice benefits have obstetricians seen from using the product?

There’s a bunch. Banner Health Systems has seen a precipitous drop, on the order of millions, in their malpractice expense.

Not only are we a great hedge on the downside of malpractice, but it’s my contention that we actually can help hospitals categorize when there are complications with labor, and potentially get greater reimbursement for that work. Even Medicaid provides higher reimbursement for vaginal delivery with complications as opposed to vaginal delivery without, but a lot of times that goes unchecked because there’s no simple system to categorically and systematically define or determine whether there have been complications in labor.

Most of the physician documentation begins with the moment of birth. Our ability to show that there were complications in the labor portion, we think, is going to allow hospitals to correctly charge and code their DRGs and establish some top-line revenue growth as well.

As unfortunate as it is when there’s any kind of patient harm that could have been avoided, everybody is very sensitive to anything involving newborns or peds. When you look at those malpractice-driven events, are they usually because of lack of following procedures or failure to detect complications?

Those go hand in hand sometimes. A lot of times there’s a subjective interpretation around whether the fetal monitoring strip is showing complications or not. What we’ve tried to do is firmly establish a tool that helps us determine that case. In fact, the NIH has licensed our tool to go back and take a retrospective view of thousands of strips from problematic births to determine if there’s any way to change the protocol.

Many companies are trying to develop software to analyze incoming data streams from patient monitoring systems. What have you learned as an early adopter in applying evidence to physiologic monitoring data?

You’re only as good as the evidence. We’ve put an awful lot of research into the 19 patents that we have. We have about 6,500 OB-specific protocols that we use. We’re continuously vetting that.

We’ve got some great clients. They work very closely with us in helping to shape our product as we go forward. Sometimes they say, “This protocol might be a little bit outdated,” or, “We had a case in here that your system really doesn’t contend with, and here’s how we think the workflow ought to go” and they help write new protocols. I think vigilance is part of that.

You’re applying accepted knowledge, but it sounds as though you’re also using the information you collect to develop what may become the next standard.

Yes. Standards evolve. Part of evidence-based medicine is when you get the evidence of something evolving, you got to take advantage of it. We’re constantly working with our clients to evolve our solution set. It’s really worked out well for us and for them.

Everybody’s spending a lot of their time and money working to implement electronic medical records, but the solutions market seems solid for high-acuity specialty areas like surgery, labor and delivery, and the ICU. Is it hard to earn a place at the table when those hospitals have made their big investments and you’re offering them a system they may not have thought about?

I think the rush towards Meaningful Use and deploying EMRs in as fast a manner as possible definitely eats up resources on the hospital side that they would otherwise deploy against programs like ours. But I think you’re absolutely right that there are specific areas in the hospital and labor and delivery, perinatal is probably the highest-risk service line in most hospitals. There is just so much nuance that I don’t think any of the larger EMRs can develop. I’d like to think that most of the clinicians understand the need for a specialty solution like ours.

You mentioned that your competitors do a good job. How do you differentiate PeriGen from them?

We’re the only ones who have gone well beyond that commodity solution set of surveillance, annotation, and archiving. To us, that’s great, but it’s an old application of technology. We are truly the only ones who are certainly doing that, but also applying our systems to deliver clinical decision support, to essentially say, “Hey, doc or hey, nurse — you’ve got a problem here. You need to look at this” and allowing that clinician to intervene.

None of the other systems do that.  In a way, I don’t feel like we have any competition because no other systems are doing that. Everybody is doing the commodity stuff. Nobody is doing what we do.

Where do you take it from here? Companies usually branch out into something unrelated or add functionality to what they have.

There’s a number of different directions. If you look at the number of obstetricians that are going through school, you see a downward trend in terms of available obstetrical talent. Careers are running a little bit shorter. It’s hard work being an OB, getting up in the middle of the night all the time. 

Our solution set lends itself to a service line around the remote OB hospitalist, an intriguing direction that we’re looking at. There are a number of areas that our technology is well suited for because it is so visual and it’s doing a lot of the heavy lifting for the clinician. I think we’re far more suited for that kind of a solution set than anyone else in the space.

At the heart of it, though, we also have an engine that can be abstracted away from labor and delivery content and populated with content from other departments as well. The concept of applying clinical decision support engines at the bedside in real or near-real time is one that can grow pretty significantly into other service lines.

I hadn’t heard of remote OB hospitalists. How is your product used remotely compared to products like AirStrip?

We’re published via Citrix. There’s a number of physicians using mobile applications now without using AirStrip. The last time I was at Banner, I was speaking to a doctor and he was sitting there on his iPad looking at tracings and actually entering some orders. Mobility is something that we feel pretty confident that there’s a solution set around for us and that a lot of our clients are already employing our solution in a mobile fashion.

The remote OB is a different concept. If you are in a hospital somewhere where you’re having trouble getting access to OBs, like any number of community hospitals around the country, perhaps there is a service that provides a consulting physician or that uses our system as an alerting system, like an ADP in home security.

None of these are productized now, but your question was where our application goes. Our application allows immediate visual recognition of a problem, so therefore lends itself to a number of services that don’t exist today.

In a small town, obstetricians spend a lot of time waiting on labor to progress. Is it easier for hospitals to attract and use those obstetricians efficiently when they’ve got a tool like yours?

Yes. There is no doubt that both nurses and docs have a more efficient workflow when they’re using our tools. Nurses can come in, check on patterns, and see it right away over a two-hour trend line whether there are problematic decelerations or not in the labor. It’s a lot more relevant clinical information, and a lot quicker than having to stare at the strip or unroll the strip out on the bed and see what’s going on.

How do you think obstetric services and obstetricians will fare under the Affordable Care Act?

I’m more worried about the number of obstetricians, frankly. I think they’re going to be fine. As you look at where hospitals are going with accountable care organizations, I think tools like ours are going to become more and more important.

If there’s a baby that’s born with a birth defect – heaven forbid, but we all know it happens — that child is in that system for, in many cases, the perpetuity of its life. Any tool like ours that employs systems to manage risk is going to be quite important in accountable care organizations going forward. 

Ultimately, I think that the practice of obstetrics is changing. We’re going to continue to see a higher demand, as there’s less OBs delivering babies. Systems like ours can help make those OBs and the nurses on staff a bit more productive, which is what we see a lot of excitement around.

From your time at Allscripts, what lessons did you learn that you will and won’t apply at PeriGen?

There’s a lot of things that we can do, being a much smaller organization than Allscripts and having a much tighter focus. We’ve got the freedom, agility, and speed to do things that they maybe can’t do quite as well. There are organizational tenets that I am taking a slightly different approach than we ever did at Allscripts relative to how I’m organizing our development and product teams. Stuff that the size and scope of Allscripts just wouldn’t allow.

Any concluding thoughts?

When I saw this application at work, I had been up for the job and I wasn’t sure if I was going to take it. I wanted to go see the application at work in one of our client hospitals. There was a woman having some complications and decelerations in labor, which are a bad thing. I’m not a doc, so that’s about as medical as I’m going to get. 

Our system helped detect what was going on. They were able to do an emergency C-section. Everything came out great. At that point, i saw more than ever in my career how technology can change the course of healthcare on a patient-by-patient basis.  

I feel like we’re bringing innovation where there has been little to date. We’re applying technology to one of the most problematic and subjective areas, which is interpreting the fetal monitoring strip. It’s a great proving ground for clinical decision support overall.

HIStalk Advisory Panel: Patient-Facing Technologies

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

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

This month’s question: What patient-facing technologies (portals, PHRs, kiosks, patient education, etc.) have you implemented that have had the most positive impact on patient satisfaction?

Patient Portal

• We’re in the early stages of a portal deployment. Too early to tell what kind of impact it will have on patients, although our CEO sees it as a Kaiser killer. I’m not so certain.  
• We are in transition with our Epic implementation. We have an existing patient portal and also a failed attempt to use kiosks. With Epic, we have already signed up 20,000 new users to MyChart and the reviews have been very positive. In addition, we will most likely move away from kiosks as they just don’t seem to generate much interest in spite of widespread adoption in banking (ATMs) and airlines.
• Patient access to their health records has had the most positive impact on patient satisfaction so they can access their own information or schedule on their own time.
• None, and "therein lies the rub!” Some doctors in my group have tried Phytel, but not with a lot of enthusiasm, and I did not hear that they had an earth-shattering experience. I chose instead to test drive on my patient population the actual need and demand for such tools before I invested time and staff effort into a technology that may as well go nowhere because my older patients are simply not ready for it. All of that while the company as a whole was looking for a more integrated solution/EMR that would offer a patient portal along with practice management and other tools all in one as opposed to having a piecemeal approach.We did find one after a long and arduous process and I hope that it will prove to be worth the wait. However the patient’s response and demand for such technology remains to be seen as many of them are not computer savvy, nor do they even have a computer.
• Nothing yet. We are still trying to get the Stage 1 criteria met for Meaningful Use, but I’m very much looking forward to the patient portal. We’re among the last facilities in our state to allow our employees to look at their own records within our hospital information system. I want to get them moved over to the portal as soon as we can so we can close that loophole!
• Undoubtedly it is the patient portal that has had the most impact on satisfaction. People who want to take individual control of their health appreciate and utilize the opportunities to review their test results, communicate with their caregivers, and make their own appointments, among other things. Promotion of this kind of ownership over one’s health is also a key to improving health outcomes for patients and a critical component of realizing the kinds of outcomes that will help determine our payments in the near future.
• Many of our physicians indicate that access to a patient portal has been the most significant change in terms of patient satisfaction that they have seen in a dozen-plus years of medical practice. A physician example: for the first six months, about a third of the messages I received were just to say, "Thanks for this new system – it’s awesome." Now I have good stories to tell — the case of an elderly heart failure patient that we have interacted with regularly (via daughter and home care) using the patient portal. She was in the hospital or ED every 2-6 weeks for the year prior to the portal and (knock wood) has not been admitted in >6 months since our more frequent touch points and monitoring.
• I have yet to work at an organization where we’ve implemented any of these with a verifiable increase in patient satisfaction. Not saying that the technologies aren’t useful, just that there was not a reliable way to verify the impact. As a side note, the implementations with the greatest impact are those where patients wait less and answer questions the fewest number of times. Implementing portals and kiosks can help support this experience, but only if the organization changes workflows to support activities such as pre-registration.
• Most successful patient-facing tool has been Epic’s MyChart, especially on the primary care side. They have been very diligent about getting patients signed up while they are in the office using cheap netbooks. Adoption has been very strong and feedback has been very positive. The key was to go live with a fairly robust set of features enabled on day one rather than trying to ramp up over time.
• We’re still working on implementing the patient-facing technologies. Previously as a patient, I was thrilled about patient portal. One of the cool things we’re working with our EHR vendor on is a tool that will help us proactively reach out to patients to remind them of wellness activities specific to them.
• The area of patient portals has been a problem area for me. I struggle with how a patient should engage with a community hospital directly as opposed to a primary care physician. The fact that MU is driving both hospitals and physicians to have portals is going to create a larger issue in my opinion. This opinion is shared by patients in a recent focus group we did. Two patients in the group had recently connected to their PCPs athena portal. Their question for me and my hospital colleagues was, "What would I go to you if I have this with my PCP?" Because of MU S2, we will be implementing a patient portal and spending close to $400k to do so. This to me is another example of how MU is gone awry. A Patient Portal in an IDN make sense. In a community setting with an independent hospital and small independent providers, a portal aggregation strategy makes more sense – a single sign-on to the hospital, PCP, and specialists in a community but three separate systems. I wish such a solution existed, but we have not found one (but still looking).
• Patient Portal. We are a large group which has over 60 percent of our patients signed up, giving patients what they want and need – actionable transactions (e.g. messaging the office or doctor, refill requests, appointment requests), not fluffy marketing material or even PHR info. We will add in more PHR info over time, but we have seen the demand for actionable items be what drives their use of the system. They LOVE it, and most of our docs now love it also, as it is an easy way to communicate in a non-synchronous manner, which allows for better explanations and web links, as well as better documentation for the chart.
• Portals work very well. We use MyChart and have hundreds of thousands of patients using it for lab result lookup, appointment scheduling, bill review and payment, after visit summaries, etc. Public PHRs have gotten no traction. Kiosks we haven’t deployed due to ADA concerns.

Kiosks

• Patient check-in kiosks associated with patient portals, allowing the patient or caregiver to fill out visit information in advance of office visit and/or in waiting area of office.
• Kiosks. If done well, can facilitate the registration process, which starts the whole care process on a positive note.

Interactive Patient Systems

• GREAT question.. Not sure any of them have really “delighted” our patients. If I had to pick one technology that seems to be pleasing SOME of our patients, I would suggest the kiosk, in the ambulatory environment, seems to be perceived as a good thing. We also recently developed an application that runs on our interactive television system. It allows a patient (or a family member) to view photos of all members of their care team. In a large academic medical center, this can be important. A member of the clinical team is added to the system if they order something or view something in the patient’s record. When they interact with the system, their photo, their name, and their title are added to the patient’s profile. The patient can then view the entire care team. A photo and name stay active on the profile for four days and drop off if no interaction. It’s very new, but patients seem to like it.

WiFi Access

• The single patient satisfier most raved about by our patients was WiFi in the waiting rooms. It took many patients asking for it and some persuading of the clinical and admin folks. We had to assure them that this would not affect any of our patient care systems. We did have to add a disclaimer page that there was no support and that folks should not be going to certain sites — all of the legal jargon that admin wanted. From a technical side, we carved out some bandwidth that always uses a lessor priority and will reduce itself to almost nothing if the bandwidth is needed for patient care. We impressed on our patients that once called to an exam room, all electronics were to be powered down and turned off. We have about the same acceptance rate as the airlines or your local movie theater. Some of our more technical folks (like me) make use of any spare time to keep up on emails and issues. We got a lot of positive feedback.

Social Media

• I think the jury is still out on our patient-facing technologies and their impact on patient satisfaction. However, it is well worth noting that our endeavors with social media (Twitter and Facebook, particularly), even though our efforts are in their infancies and perhaps relatively minor when compared to others, have yielded great increase in patient and community engagement and affinity for our health system.

Patient Messaging

• Delivering engaging communications via text messaging (confirming appointments, medication refills, etc). They like this proactive approach versus the passive communications on the portal. My internal medicine physician practices in a fairly large group affiliated with an academic medical center. Getting anyone on the phone is a miracle. It is like they are in the Get Smart cone of silence. However, they have finally implemented a secure messaging system (they use an old flavor of Allscripts) and I recently had a positive experience using it to have a prescription refilled. Worked nicely. They do not, however, have online scheduling and I don’t think I could actually "talk" to my physician
  on line.

Printed Patient Documentation

• In general, we are not there yet. Still getting physicians implemented on EMRs. However, we have had some very positive comments from patients who receive their clinical visit summaries at the end of their office visit. They love having their visit information printed out for them so they can share with families. This coming year, we will be implementing Patient Portal and integrating Healthwise Patient Education with eClinicalWorks.
• So far Thomson Reuters CareNotes for patient education has had an huge impact on our patient satisfaction. The patients really appreciate have clear documentation they can take home. However, we are in the process of implementing a patient portal that I think will really increase our patient satisfaction scores.

News 9/19/12

Top News

Massachusetts Eye and Ear Infirmary and its physician group will pay HHS $1.5 million to settle potential HIPAA violations following the theft of an unencrypted laptop containing electronic PHI of patients and research subjects.

Reader Comments

From Honky Cat: “Re: Waiting in line at Apple. Don’t wait in line for your iPhone upgrade. Go to this link and pre-order your phone. They will ship it to you in two to three weeks. Surely you can wait that long for it.” I considered setting my alarm to be one of the first people to go online last Friday and place an order. Instead, I slept in and waited until 6:00 am to get online. By that time Apple had stopped taking orders to reserve the iPhone 5s for pick up at the local Apple store, so I’ll wait for mine to be delivered in a couple of weeks. Apple, by the way, sold two million iPhone 5s in the first 24 hours of pre-orders, more than double the previous record set in 2011.

From The PACS Designer: “Re: mobile image viewing. TPD congratulates Aycan Medical Systems for being one of the first to gain FDA approval for its Aycan Mobile for the iPad. Now that the FDA is involved with mobile solutions, we’ll see more teleradiology mobile solution approvals for other vendors.“

From Steve: “Re: QuadraMed. To be sold in the next 7-10 days.” Unverified.

From Pointer: “Re: EHRs. A vendor-agnostic viewpoint on how they don’t change the cost curve.” It may be vendor-agnostic, but this particular article is a clearly labeled opinion piece written by authors who have been historically negative toward EMRs, EMR vendors, and government. They are entitled to their opinions, but recognize them as such despite the bait-and-switch newspaper headline trumpeting “A Major Glitch.” Their editorial conclusion is accurate, though – most studies have failed to prove that EMRs save money (I haven’t seen any studies that convinced me that paper records save money or improve outcomes either, of course.) That’s not to say they don’t, only that it’s tough to prove since nothing in healthcare stays unchanged long enough to get a baseline. It’s also true that expecting technology alone to create savings without changing incentives is unreasonable. I agree with the authors that blowing taxpayer billions to get providers to buy software they weren’t willing to spend their own money on was illogical, but no amount of Monday morning quarterbacking will bring that cash back or cause providers to toss their EMRs out the nearest window. It’s time to move on, realize that healthcare IT is here to stay, and constructively make it better instead of hand-wringing. Like everything else, the industry has 10% cheerleaders, 10% naysayers, and 80% rational people who don’t need the self-proclaimed experts on either end of the spectrum to tell them what to think or do. If you’re a provider, choose EMR or paper as you desire, do something innovative with it that improves outcomes and reduces costs, and then write your own article. That’s the one I’d rather read.

From Looking Deeper: “Re: patient portals and self-scheduling. I install patient portals for a living, including scheduling. There really aren’t technical challenges any more. Providing convenient, immediate online scheduling is a solved problem even in healthcare, especially in primary care. The problem is in people’s heads. Whenever online scheduling comes up, physicians and clinic staff will tell you that their patients can’t possibly handle it – they’ll schedule the wrong kind of visit (office visit vs. physical) or create some other vague problem. I dutifully inform them that online scheduling is working fine in clinics and practices across the nation. ‘Other clinics find that their patients can handle this,’ I always say. They usually say, ‘Not our patients.’ Interestingly, clinics serving less-affluent areas and the indigent tend to be more in favor of such patient-centric services. ‘Our patients are an especially incompetent group’ is a pretty negative view to hold of the people you’re trying to care for. If we could just get past this attitude, pretty much all primary care visits could be scheduled online. In the rare case where something needs to change, the clinic can call or e-mail the patient and reschedule, but that’s less than 5 percent of appointments scheduled online. Specialty and procedure visits are a different beast and need some careful analysis before they are opened up to online scheduling, but online scheduling for primary care is a solved problem.”

HIStalk Announcements and Requests

I have newfound respect for anyone working with insurance companies to secure payments. I had mentioned a few months ago that I had a minor medical procedure that resulted in some complications, lots of doctor office visits, and about 20 different medical claims. I was lucky enough to have both primary and secondary coverage in place since the claims were in the thousands. I also thought I was lucky because both policies were from the same very big insurance company. Unfortunately, the insurance company has spent the last four months trying to decide internally which policy should be primary, and so far no claims coordination has occurred. After several weeks of hour-long phone calls, yesterday I finally turned “not nice” and demanded to speak to a supervisor. I explained that I didn’t give a (expletive) which policy was primary or secondary, it was all one insurance company, and the (expletive) claims needed to be paid. I actually believe the claims will finally be processed correctly. The moral of this story is that if you work in a hospital or practice, take a moment to say thanks to your billing and collection staff. And bring them chocolate on a regular basis.

I don’t know about you, but I’ve been busy turning off all my Facebook and Twitter connections to folks who keep preaching politics. Has anybody ever convinced someone to change their political beliefs by proudly posting a Facebook link to the latest nut-job partisan article? Actually, they sometimes almost convince me to vote the other way out of annoyance.

Thanks to Healthcare Quality Catalyst supporting HIStalk as a Platinum Sponsor. The Salt Lake City company offers a practical clinical data warehouse solution that combine technology and clinical improvement methodologies to improve care. The information needed to answer a clinical improvement question is scattered in most hospitals (satisfaction surveys, Epic Clarity transactions, and lab and prescription information, for example) and HQC puts it together in its Adaptive Data Warehouse and subject-specific data marts (such as women and newborns) to support continuous, evidence-based care improvements. HQC offers more than just the tools, supplying clinical improvement methodologies such as role definitions and process templates to create effective improvement teams. If you’ve been around the industry for some time, you surely know some of their folks: Todd Cozzens, Larry Grandia, Dale Sanders, Bruce Turkstra, and David Burton, MD were some of those I immediately recognized. I interviewed co-founder and CIO Steve Barlow a year ago and got a good background on the company. Thanks to Healthcare Quality Catalyst for supporting HIStalk.

I naturally cruised over to YouTube and found this video that introduces Healthcare Quality Catalyst better than I did.

Acquisitions, Funding, Business, and Stock

PE firm ABRY Partners makes a “significant” investment in SourceMedical Solutions, a provider of software and services for ASCs and rehab centers.

In England, a company that commercializes university research invests in an Oxford spinoff whose software that can monitor pulse, respiration, and oxygen saturation using only a webcam.

Also in England, eHealth Insider reports that CSC will stop selling iSoft GP systems to NHS markets, in which it has 582 practice customers. CSC denies the report.

Vipaar, which sells surgery proctoring software based on technology developed at the University of Alabama at Birmingham medical school, raises half of its $1.2 million funding goal.

Sales

Community Medical Center (NE) selects BridgeHead Software’s Healthcare Data Management Solution for backup and archiving.

CommUnity Care (TX) will deploy NextGen RCM Services throughout its 22 clinics.

Pemiscot Memorial Health Systems will expand its deployment of Prognosis Health Information System by implementing its financial system and its laboratory information system powered by Orchard.

Community Hospital Grand Junction (CO) chooses the perioperative system of Surgical Information Systems.

People

Zotec Partners hires Kristy Floyd (American Society of Anesthesiologists) as director of anesthesia business development.

The Medical College of Wisconsin appoints David C. Hotchkiss (University of Texas Health Science Center) VP/CIO.

Healthland names Patrick Spangler (Epocrates) CFO.

Douglas Billian, founder of Billian Publishing, died September 15 at 84.

Announcements and Implementations

HIMSS Analytics recognizes Fort HealthCare (WI) with its Stage 7 Award for EMR adoption.

Providence Medford Medical Center and Asante Rogue Regional Medical Center (OR) will complete their hospital and clinic implementations of Epic in April.

Nuance will purchase Ditech Networks, a provider of voice technologies and voice-to-text services, for $22.5 million.

AMA releases the 2013 CPT code set, which goes into effect for claims filed as of January 1, 2013.

Certify Data Systems announces the general availability of its HealthLogix HIE platform, which it says is the first to deliver an aggregated patient view from all community health encounters regardless of EHR.

Cincinnati Children’s Hospital Medical Center (OH) implements Passport Health’s PatientSimple and Smart Statement online billing solutions.

eClinicalWorks launches its $10 million open, secure collaboration platform that works with any EHR or even paper-based practices. The NHIN Direct-compatible network allows members to transmit electronic referrals and patient records with attachments.

Government and Politics

ONC posts the second wave of draft test procedures for the 2014 Edition EHR certification criteria.

I don’t think Farzad ever followed through on his promise to name the EMR vendors who took his #VDTnow pledge to allow patients to view, download, and transmit their medical information. Claudia Williams of ONC tweeted her list, which I assume is complete: Allscripts, NextGen, AlereWellogic, Intellicure, eClinicalWorks, Greenway, SOAPware, athenahealth, Azzly, and Cerner. Conspicuously but not surprisingly missing is Epic, which doesn’t even have a Twitter account as far as I know. Maybe they already offer the capability as some have suggested, but if so, all they had to do was tweet out their already-met pledge. Judy’s on ONC’s Health IT Policy Committee, after all.

Innovation and Research

The National Library of Medicine awards The Ohio State University College of Medicine’s Department of Biomedical Informatics $1.3 million to develop a system that uses EHRs to identify potential patients for clinical trials.

Other

Wider use of EHRs over the last decade may be contributing to a growing up-coding trend that has added $11 billion to healthcare costs. Physicians argue the higher codes are justified because care of seniors has become more complex and technology allows them to code more accurately. Critics say the findings suggest billing abuse and fraud. I I were still selling EMRs, I’d be handing this study to doctors and touting it as proof that technology is helping physicians bill and be paid for the actual care provided. Meanwhile, naysayers like Mr. H will probably dig deeper and suggest objections to such hasty conclusions.

Hell hath no fury: a Washington dermatologist wins a $600,000 settlement and a rare apology from state health officials who had investigated him for drug abuse and medical fraud. An anonymous tipster had reported that the doctor was falsifying drug records, using cocaine, and running in-office orgies among his staff, patients, and prostitutes. In a separate lawsuit, the doctor was award more than $100,000 from his former wife, who turned out to be the anonymous tipster who had filed the complaint late in the couple’s bitter divorce proceedings.

The folks from Arizona Associated Surgeons sent over their video for the Western Users Group meeting at ACE (the Allscripts user meeting) last month.

Want to rub elbows with sexy celebrities on your hospital employer’s dime? CHIME’s Fall CIO Forum will feature Olympic beach volleyball gold medalists Misty May-Treanor and Kerri Walsh Jennings, mostly known for leaping around nearly naked in prime time reminiscent of the much-beloved “Girls on Trampolines” segment of The Man Show except with smaller bikinis. Misty and Kerri (or was that Misti and Kerry?) will discuss Meaningful Use Stage 2 and … no, wait, they’ll pose with star-struck CIOs, sign autographs, and collect a big non-amateur payday courtesy of patients who pay $5 for an aspirin.

A group of 30+ physicians labeling themselves as “Doccupy” complain to Contra Costa, CA county supervisors about the $45 million implementation of Epic at its hospitals. They said 10 percent of ED patients are leaving without seeing a doctor, a number that increased after the hospital’s July 1 go-live as the average time in the ED increased from three hours to four. Patient loads were cut in half to prepare for the implementation, but the doctors claim that several of their peers still quit because of stress, saying, “We were not ready for Epic and Epic was not ready for us.” An ED physician going off shift said she still had documentation to complete for 16 patients, adding, “It’s going to implode.” Some doctors spoke up about the advantages of Epic, and all agreed that it’s important to have an integrated electronic record. Detention facility nurses had complained about Epic to the supervisors last month.

The Cure JM Foundation (juvenile myositis) is in the running for a $250K research grant that will go to the charity with the highest number of Facebook votes. Information and voting links are here. Several HIT folks I’ve heard from have children with JM and I’m sure they would appreciate your vote.

Patients storm Charlton Memorial Hospital (GA) after a contracted collection company incorrectly manipulates the hospital-provided data file, sending patients collection notices for bills they don’t owe.

Of the seven highest-earning non-profit CEOs in the country, four run hospitals, according to the Chronicle of Philanthropy. I think they’ve missed a few since I’ve seen several hospital tax forms with CEO salaries above these figures.

Bloomberg Businessweek profiles Terry Ragon, founder of the Boston-based InterSystems, which sells the Cache’ database that runs Epic, Meditech, and quite a few other MUMPS-based healthcare systems. The article calls Ragon a “Hidden Software Billionaire,” estimating the value of the company he directly owns at $2 billion.

Here’s a fun coincidence. Dave Miller, vice chancellor and CIO of the University of Arkansas for Medical Sciences, sent over the above video of him doing a nice cover of “Mustang Sally” at Epic’s UGM (his wife had the camera 90 degrees off kilter for a few seconds, but his singing was fine). The day they got back home, he impulsively bought some raffle tickets from a charity fundraiser. He won the prize, which was made in 1967, the same year Wilson Pickett released “Mustang Sally” on an album – a classic Ford Mustang.

Sponsor Updates

• SuccessEHR grows its RCM services business 92 percent over the last year.
• First Databank hosts its 2012 FDB Customer Seminar this week in San Diego.
• T-System offers Webinars this week on  improving ED throughput.
• Melanie Pita JD, EVP of product management at Prognosis Health Information Systems, presented a session on EHRs and Meaningful Use at the Georgia Rural Health Association conference this week at Callaway Gardens.
• TeraRecon is exhibiting its advanced visualization solutions for medical imaging this week at CIRSE 2012 in Lisbon, Portugal.
• Michigan Health Connect HIE and Greenway Medical will provide data exchange between Greenway’s PrimeSUITE customers and hospitals on the Michigan Health Connect platform.   
• MedPlus offers a three-part Webinar series hosted by Steven Waldren, MD, director of the AAFP’s Center for Health IT.
• White Plume releases a white paper discussing practical considerations to minimize losses while migrating to ICD-10.
• ChartWise Medical Systems unveils its ChartWise:CDI software at this month’s AHIMA convention in Chicago.
• Orion Health opens an office in Singapore for development and technical support employees.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

EHR Design Talk with Dr. Rick 9/17/12

A Single-Screen EHR Design for the Patient Encounter

The benchmark . . . for all navigation techniques should be the saccadic [rapid] eye movement. This allows us to acquire a new set of informative visual objects in 100-200 [milliseconds]. Moreover, information acquired in this way will be integrated readily with other information that we have recently acquired from the same space. Thus, the ideal visualization is one in which all the information for visualization is available on a single high-resolution screen. – Colin Ware, Information Visualization: Perception for Design

I would like to bring together some of the user interface designs we have been considering and propose for discussion a single-screen EHR design for a patient encounter. Before presenting the design itself, it is useful to recall the design concepts covered in previous posts:

• The human visual system is very good at organizing data spatially (Why T-Sheets Work; Pane Management – Part 2).
• We excel at grasping patterns and seeing relationships among data elements when they are presented in a single view, but have limited capacity to remember these elements when they are distributed across multiple screens (Humans Have Limited Working Memory).
• The most efficient way to navigate visual space is by using rapid (saccadic) eye movements (Fitts’ Law).
• Using a large, high-resolution screen supports navigation by saccadic eye movement (Pane Management – Part 1).
• When we do need to navigate using a mouse or other input device, we can reduce the cognitive costs by making the targets large and reasonably close (Fitts’ Law).
• It is often easier to grasp patterns visually than mathematically or verbally (Computer-Centered versus User-Centered Design).
• It’s easier to find patterns and solve problems with data presented compactly and grouped visually – using columns, rows, and formatting – than with data presented as free text (Pane Management – Part 1).
• Using vertical and horizontal scrollbars to navigate small panes requires cognitive effort and doesn’t solve the working memory problem (The Problem with Scrolling). It is preferable to display an overview of the data and use mouse hovers or clicks to display details as needed (Overview with Details on Demand).

The Design

A large single screen with high resolution, for instance 1920 x 1080 pixels (full HD), is used to display all the categories of data for a patient encounter on a particular date. Each category of data is assigned to a pane of fixed size and location on the screen:

Because humans are able retain about nine spatial locations in visual working memory (although we can only remember simple visual objects or patterns contained in about three to five of them), a set of nine panes arranged in a 3×3 grid was chosen for the high-level design.

The figure below shows this same screen design populated with data from a patient encounter:

Click on the thumbnail below to see the design at higher (but not full) resolution:

The figure below shows the Problem List pane:

A marker (for instance, an asterisk) indicates that more detail is available for a data field. Detail can be displayed by hovering or clicking, as shown below for Diabetes Mellitus:

and for transient ischemic attack (TIA):

The same high-level design is used for all panes, as in the Exam pane below (size slightly reduced):

Again, hovering over or clicking on a line with an asterisk brings up more detail for that data field:

The design allows default or normal findings to be summarized:

while still making the full default text available on demand:

Expanded Panes:

As an alternative to expanding individual data fields, all the data fields within a pane can be simultaneously expanded by hovering or clicking on the pane’s title bar, as shown below for the Problem List:

An expanded pane will necessarily obscure adjacent panes, as below:

Even in this case, context is at least partially preserved because of the large high-resolution screen.

Design Considerations

Expanded data fields:

• In order to maintain as much context as possible, data fields within an individual pane expand only to the minimum size required.
• More than one data field within a pane can be expanded at the same time, provided that the expanded fields don’t overlap.

Expanded panes:

• In order to maintain as much context as possible, panes expand only to the minimum size required.
• More than one pane can be expanded at the same time, provided that the expanded panes don’t overlap.
• The same single-screen design is used both for data entry and subsequent data review. Any pane can expand for data entry and then contract to its original size.

I would propose that this kind of single-screen design for a patient encounter, with all its interactive capability both within panes and among panes, should be thought of as the chart note. In this design, there is no separate text-based or PDF "completed note," except as needed for use outside the EHR.

The design above is a sketch – a design being considered, reformulated, and reworked. I tried to design it based on an understanding of how the human brain best takes in, processes, and organizes information. Its purpose is to generate discussion and debate. I look forward to your comments and suggestions.

Finally, there is a major caveat that comes along with the single-screen design presented here. A patient’s electronic health record is a longitudinal record, while the design above represents a snapshot in time. More on this in coming posts.

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.

Curbside Consult with Dr. Jayne 9/17/12

There’s been a lot of talk lately about the perils of cloned documentation. I had several readers forward me the recent notification from Medicare administrative contractor National Government Services that states that it will deny payments for encounters whose documentation appears cloned.

Let’s face it. Many of us have been creating what could be construed as cloned documentation since our residency days. Back when the average length of stay was a little longer (especially on a teaching service), we were encouraged to completely recap the contents of the previous day’s note, which often led to copying.

With 15 or 20 patients on our rosters, it was often impossible to remember subtleties about each patient, so you just copied what you had from the previous day, updated the lab values, any new complaints, etc. It was a lot like using copy forward / update technology in EHRs today, except a pen with a drug company logo and some truly horrific penmanship was involved.

When dictating discharge summaries, the vast majority of patients had strikingly similar exams since patients had to have largely normalized to go home: Heart regular rate and rhythm; no murmurs, rubs or gallops; lungs clear to auscultation bilaterally; and so on. When confronted with a stack of discharge summaries to dictate (which lazy attending physicians had kindly “flipped” our way) on patients we had maybe seen once, they all started to sound remarkably alike in other ways as well.

I remember being on service at a pediatric hospital, where in a single call night I personally admitted 17 patients for asthma exacerbation. The other interns on the team had at least five or 10 asthma patients each as well. Since there were three interns on a team, the senior resident was covering nearly 50 patients – and more than 30 of them had similar chief complaints and presentations. We had strict criteria for who was admitted (thanks to evidence-based medicine), so their presentations were actually very similar, and all had failed identical interventions in the emergency department before admission. You can bet those senior resident notes didn’t have any new or different information than what was presented in ours.

Ditto on Labor and Delivery during residency, where I trained at one of the highest volume birthing hospitals in the region. Since a normal uncomplicated childbirth really isn’t an illness, the documentation was routine and nearly identical. It would have been difficult to find truly unique information to write about some of the patients. I supposed we could have put in frivolous information like, “This blonde Caucasian mother of the adorable blue-eyed infant has no complaints,” but we were tasked with rounding, not writing beautiful, flowing prose.

My problem with the entire issue of cloned notes is that no one really has defined what they consider cloned, making this just another arbitrary way for payers to deny reimbursement. One contractor defines it as, “Documentation that repeats language from previous entries on that patient or from other patients with similar conditions.” I dare anyone to find a note written in the last two decades that doesn’t repeat language in some way, shape, or form.

Prior to EHR, I used a homegrown paper template documentation system that created remarkably uniform notes. On the positive side, it also created remarkably high-quality visits. Clinical decision support was baked into the documentation forms for various chief complaints. We often took materials provided by various professional organizations (AAFP, AAP, ACOG, CDC, etc.) and customized it to meet local and payer guidelines. For uncomplicated illness (strep throat, sinusitis, urinary tract infection, etc.) the notes would be strikingly similar from patient to patient.

Why is it bad thing for the physician to document exactly the appropriate information to substantiate level of care and quality? Should extraneous information be required for payment so that the note appears individualized just for the sake of being individualized?

I can easily avoid the appearance of cloned documentation across patients by including nuance information in the history of present illness. I have no problems doing so if it is relevant to the patient’s story and his or her care.

Another issue entirely is that of cloned documentation within a single patient chart. Regulators and anti-EHR voices are after those of us who like to “drag and drop” previous visits into today’s note, then update it. Note that I said “update.” I didn’t say drag, drop, and depart. Who among us who actually cares for patients does not have at least a few dozen “Groundhog Day” patients, those where every single visit is the same? I’m talking about patients like the noncompliant hypertensive diabetic who refuses to follow the instructions from the previous visit. Every single assessment and plan looks something like this:

1) Diabetes: Reviewed blood sugar log. Counseled patient to take medications as directed and continue 1,800-calorie ADA diet. Patient to exercise 30 minutes daily and check blood sugars daily, bringing meter to next visit for download.

2) Hypertension: Counseled again regarding sodium intake and packaged foods. Exercise as above, continue medications.

3) Obesity: Discussed diet and exercise as above. Refer to nutritionist. Discussed consequences of continued noncompliance including worsening of chronic health conditions, heart disease, and potentially premature death.

Really, what else do I need to say here? Maybe I should start adding incremental data like, “Counseled patient for the 15th time” to make it more individualized. Or I could document specific details of the data in the blood sugar log, but that would be redundant and also introduce a potential source of error as I manually key numbers into my note.

The bottom line is this. Why should I not be able to pull this data forward, then update or add to it? It’s clear, it’s complete, and it accurately documents what I stated in the visit. I shouldn’t have to add extraneous information just to satisfy an auditor.

A friend of mine has a collection of hilarious patient visit notes (of course, with any patient identifiers carefully redacted with a broad-tip Sharpie) from both the paper and EHR realms. One of my favorite pages in his scrapbook is the ultimate healthcare haiku, written before the days of E&M Coding:

Boil-Lanced.

And that, dear readers, is a thing of beauty.

Have a great example of patient documentation to share? E-mail me.

E-mail Dr. Jayne.