Readers Write 8/15/12

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.

A Letter from Michael Stearns, MD

As many of you know, I was until recently the president and CEO of e-MDs, Inc. an ambulatory EHR vendor. I joined e-MDs in 2006 as their CMO and was promoted to president and then president and CEO in 2007 and 2008. Through 2011, my tenure at e-MDs was marked by significant increases in revenue.

On July 2, 2012, I was abruptly removed from my position with e-MDs for reasons undisclosed, other than a vague inference to company policy violations. e-MDs has refused several requests to disclose the details of these alleged infractions or the names of those involved, making it impossible to respond or to provide essential information that would allow me to clear my name. 

Unfortunately, e-MDs took the unusual step of publishing a press release that contained information based on false allegations that have not been subject to basic tenets of due process. The rationale for taking such action is difficult to discern. Regardless, I will be relentless in my pursuit of the facts. I remain confident that information will eventually emerge that will exonerate me completely. 

Due to a very unfortunate situation that occurred while I was a Navy medical officer roughly two decades ago, I have learned to be particularly sensitive to my conduct in the workplace. In summary, I found myself caught up in the fallout from the Tailhook scandal of 1991 that resulted in hundreds of naval officers having their careers damaged or destroyed, as detailed in this Duke Law Journal article.

Staffing shortages in the Navy resulted in a lack of available female chaperones, and female patients made a number of complaints. One of my patients, a female seeking disability for unexplained loss of genito-rectal sensation, bladder dysfunction, and lower extremity weakness, complained that my examinations had been overly detailed on two separate occasions. An investigation of my conduct with female patients over a four-year period led to two other complaints emerging, but the overwhelming majority of patients reported that I was “one of the most caring and thorough physicians they had ever known.” 

During the investigation, a number of facts emerged that shed doubt on the validity of the claims made by these individuals. Given the post-Tailhook atmosphere, there was a great deal of pressure on the commanding officer not to demonstrate leniency in any matter of this nature. I was given the option of either fighting the allegations in court or submitting my resignation in lieu of charges. However, under a subsequent threat of media attention, they reneged on the resignation offer and filed indecent assault changes.

My military counsel, after a cursory fact-finding effort, informed me that given the hysterical climate created by Tailhook — regardless of my guilt or innocence — I would be found guilty and could spend up to 15 years in prison. I was told my only realistic option was to accept a time-sensitive plea offer that reduced the charges to the misdemeanor equivalents of simple assault and battery. In return, I would also be found formally not guilty of the indecent assault charges, including any reference to inappropriate sexual touching. I was also informed by my attorney that the plea bargain would not result in a loss of my medical license, based on direct communication she had with the Maryland Board of Physician Quality Assurance (MBPQA).

A MBPQA review body recommended that my license be suspended for six months and the suspension stayed. However, after a protracted and acrimonious process, the MBPQA removed my license to practice medicine for a minimum of one year. Perhaps most disappointing to me, especially in light of the fallout from the Tailhook scandal, was that, despite my pleadings, the MBPQA did not perform an independent investigation that would have revealed a number of exculpatory findings of fact. Making matters worse, the published MBPQA order contains false information that has never been corrected. I was found formally not guilty of indecent assault and all language to that effect was removed from the guilty pleas. Despite this, the MBPQA order states that my guilty pleas arose from inappropriate sexual touching, something for which I was actually found innocent.  

My former employer, to their credit, conducted their own independent investigation in 2010 to address the facts surrounding the MBPQA orders. e-MDs went so far as to speak with a physician who served alongside me in the Navy and who corroborated the information I provided to them. They concluded that the process had been unfair and biased and published their findings on their website for over a year. HIStalk republished their findings in this article. 

Due to the age of information and easy availability of this erroneous MBPQA order, a number of individuals have drawn incorrect conclusions regarding the facts and actual findings of law based on the MBPQA orders. I appreciate HIStalk giving me the opportunity to address this in a public forum and I am hopeful that the MBPQA successor, the Maryland Medical Board, will correct the errors in these documents.

While always conducting myself in a respectful way, I have learned to be cautious and somewhat guarded in my professional interactions over the 18 years that have passed since this situation arose. Thus, I was stunned to hear of the vague allegations brought forth by e-MDs. 

During my leadership, e-MDs was increasingly seen as a company willing to contribute substantially to core informatics efforts driving advances in healthcare and clinical research. In addition to running a company that saw a roughly 15-20% annual increase in revenue during my tenure, I represented e-MDs on multiple boards and played a direct role in informatics, policy, standards, interoperability, genomics, coding, patient safety, patient privacy, compliance, and educational efforts related to HIT initiatives; gave over 100 educations presentations; provided five testimonies to various work groups of the ONC; and was invited to a private White House town hall meeting on HIT in June of this year.

It is disheartening to believe that a company to which I dedicated more than five years to would publish something so vague as to invite innuendo and speculation. The unusual step e-MDs took in publishing conclusions based on a hastily conducted and inexplicably incomplete fact-finding process was highly unfortunate and damaging to my reputation. Knowing that inaction in the face of defamation can cause long-term damage, I have no other choice than to provide corrections through public forums while I work diligently to clear my name.

Michael Stearns, MD.

Response from e-MDs

e-MDs, Inc. removed all the material and information that comprised the web posting “The Truth About Michael Q. Stearns” that had been posted in March of 2010, and this removal occurred immediately following the action taken on July 2, 2012 by e-MDs that completely terminated its affiliation with Michael Q. Stearns.

Both e-MDs, Inc., and Dr. David Winn, each formally retract that entire prior posting statement and want to be very clear that statement should not be relied upon as the current position of e-MDs, Inc. or of Dr. David Winn.

HIStalk Advisory Panel: IT and Patient Outcomes 8/15/12

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: Why has healthcare IT not uniformly improved patient outcomes?

Vendors and Products Don’t Align with Clinical Needs

• Doctors don’t see technology as an ally in helping them take care of patients. Please see the article recently published on Medscape. The default mode of healthcare practice in the US is to practice defensive medicine (defense against lawsuits). Examples like those given in the article above don’t raise a healthcare provider’s confidence in technology. Notice how the article specifically gives the example of vendor contracts that say if something goes wrong using our technology, it’s not our fault.
• We have focused on a computer fixing a workflow problem while at the same time becoming more dependent on computers to tell staff what to do.
• With few exceptions, the vendor community supports our efforts to enhance and embellish the product with each deployment. In some cases, neither the vendor nor the client has an incentive to collaborate with other vendors, or other clients, to ensure that every deployment of IT is better than the previous one. This is getting better, but we still have much to do in this regard.
• Some outcomes take a long time to improve, longer than the HC IT has been in use. Some HC IT focuses too much on documentation without a balanced approach to deriving outcomes information let alone being integrated into the care process sufficiently to affect outcomes.
• The answer is in part within the question: IT implementation has not really been uniform across the care spectrum. As most realize, systems are often if not usually built from a developer / programmer standpoint, reaching out to address a problem rather than starting with a problem (or "job to be done") and working back to develop the necessary system to perform that job. This has lead to numerous issues of usability, human-computer interface problems. More importantly, and more fundamentally, many systems simply aren’t designed to improve patient outcomes. They’re built from the start to support billing, financial management, documentation, etc. As a corollary to the above, rarely is the clinical environment placed at the center of the system. This is evident in the approach vendors generally take with deals: focus on administrative and IT needs (decision-makers) with lesser attention devoted towards those who both use and see the actual patient effects.
• The Jurassic Park line, “Just because we could does not mean we should"says it all. Not every EMR or HIT app needs to be adopted or will prove to be of value. Not all of them are created equal. In many instances, it has been the technology that drove the cost with very little benefit.
• Clinical decision support that follows the rights (right clinician, right intervention, right time, right level of alert logic, right ease of use ) is almost non-existent, except for the simplest medication alerts. Apologies to Jerry Osheroff, I don’t think he gets this quite right. Until the biggest EHR players improve their CDS functionality, and there are good guidelines for turning structured knowledge into CDS, I don’t think we will get very far. We will, but I am waiting for the ability to use a general purpose programming language on data in the EHR to create new levels of CDS that are actionable. Further, I bet not much of this happens locally until the EHR players are forced to have some "skin in the game", some liability for the CDS that is already baked into their model install. It is just silly that each of 5,000 hospital CDS committees have to decide whether an aspirin after an MI is a good thing, or whether you ought to check a cholesterol every couple of years on a statin.
• There are many factors that contribute to uniformly improving patient outcomes. But one issue that is still a work in progress is developing and deploying a system to provide the right information to the right people in the right place at the right time. Integrating data on previous care that a patient receives from their primary care physician during regular clinic appointments, with emergency encounters, possible inpatient episodes, care provided at an ambulatory care organization, etc. pose a unique challenge to collect all of these disparate encounters and the data generated. While EHR systems bring together some of these important data elements, there are still gaps (for example — data on an emergency room visit while a patient is out-of-state on vacation). Additionally, even if data is integrated together, all of these indicators and data points need to be filtered and targeted to improve upon a specific outcome (e.g. reducing the likelihood of myocardial infarction readmission). Recommendations on improving outcome and supporting information need to be concisely delivered to the proper places when care is provided, to the physician when a patient presents at the emergency room with chest pain to the care coordinator prior to discharge.
• While there has been considerable time spent integrating healthcare IT into related systems of care, there needs to be a more systematic approach, time and resources spent integrating into the process of care – specifically clinician workflow so the tools are optimized.

Usability/Integration Issues

• I think Dr. Rick’s excellent articles have shed light on the usability issues of EHRs. He mentioned some data on how short-lived human working memory is. EHRs can take 5-10 seconds to respond to every mouse click.  These long delay times make it difficult to keep a coherent stream of thought going when documenting, especially when providers get interrupted (appropriately) by office staff who need something or the other. In the end, what gets produced are long canned narratives about generic patients. When the note is read a few days later by the provider or someone else, they see a generic note that tells them little about the patient. Our EHR would take 45 seconds to a minute to open a chart in the mornings. By the late afternoon, it was five minutes to open a chart. That’s typically caused by memory leaks. We (a medical clinic) had to call a technology firm that says its been in business for 20 years to tell them they had memory leaks! Now all charts take about 45 seconds to open.
• The main problem is usability, which involves both design and implementation. Many HIT systems are simply not designed well. They are often trying to "replicate the current way of doing things" with the idea that this will improve adoption. However, it turns out that computers are lousy at being paper, and so can never match up. However, computers are really good at being computers, and so the best HIT software takes advantage of the unique properties (e.g. complex data analysis, data visualization) and enables a better experience. Additionally, good design should start with observing the real needs of the end user (not just listening to what a user thinks they need), and most importantly should involve an iterative process which acknowledges that the programmer and physician should work closely for months to fine tune a system. However, the second problem may be even more worrisome. The same EMR system can be implemented in so many ways that the results can range dramatically. A recent editorial talked about how EMRs cost a lot, and slow down doctors, and introduce new errors, and are thus not ready for prime time. But the fact is that while this is a reasonable conclusion based on many experiences, it is a short-sighted view of the potential of what can happen when a good EMR is implemented well. I think the best use of an EMR is to allow for automation and delegation of various parts of the workflow to empower a team to do more care and to do it consistently – thus resulting in both higher quality outcomes as well as less work for physicians.
• Technology in and of itself is useless and even detrimental unless built and used correctly. In order to have a positive patient outcome, in my mind, a technology theoretically should be easy to use, be actually useful (for the user or the patient), and have minimal negative impact (on workflow or patient care). A breakdown of any single one can result in a subpar result. Patient outcomes may not have improved universally because current healthcare initiatives don’t necessarily encourage focus on all items. Also things like “usability” can be oftentimes extremely difficult to create.
• The hodgepodge of company acquisitions that has created a market where products have never been integrated. One of the reasons Allscripts is collapsing is because of an inability to integrate Eclipsys products. I find it hard to believe that companies that size, with the resources they have, can’t integrate two products. Clinicians have to sign onto several products multiple times a day to get information they need. It is guaranteed that in such a system there will be conflicting data in different databases increasing the risk of patient harm. Maybe this makes systems like Epic better, but that also stifles innovation. EHRs aren’t going to improve with markets dominated by companies like Epic as is being demonstrated everyday right now.
• Too many disparate systems that don’t talk to one another. Even with HL7 messages, there is still a lot of variance. All it takes is sending something in the wrong HL7 field to cause a problem.

It’s the User, Not Just the Technology

• A dependency on the skill and performance of the user related to the IT solution in question. The use of the word "uniformly" makes me consider that every user will create a different outcome. As an example, an electronic health record relies on inputs from various sources in order to aggregate the patient history and then present a user with information to make decisions. The term "decision support" is bandied about with great import these days but as the term implies the tool is there to simply support the clinician’s capability to make a decision. Almost all technology is just that, a support system to assist the clinician or user. The same can be said of a technology such as the Da Vinci Robotic Surgical System. In the hands of a great surgeon, the outcomes can be outstanding. In the hands of a first year surgical resident, the outcomes probably will not be the same.
• That is like asking why the carpenter’s apprentice who was recently trained on how to use a hammer, router, etc. (insert your specialized tool or technique of choice) hasn’t improved his/her ability to create beautifully crafted cabinets or furniture. It takes time to become competent, proficient, and then the master of skills with the usage of newly introduced and evolving tools. This describes skills improvement for the individual. To obtain uniformly improved skills and thereby products / outcomes, it takes even more time to build an organization or industry of skill masters. Our digital society that expects instant gratification and results has forgotten that it takes time and commitment to master skills and provide high quality products and services. This obviously is an oversimplification, but I think an appropriate analogy to the usage of a healthcare IT to improve outcomes.
• While this question is understandable given all of the federal government’s promises and expectations of what HIT will do to improve patient outcomes, the question reveals a lack of understanding of what IT in general can and cannot do. Healthcare IT (and in fact any IT investment) on its own can do nothing; it is only when used in conjunction with improved workflow and processes that patient outcomes can be improved. That is what we should be measuring. There is a reason why IT is called an “enabler”, and a “complementary” technology (like electricity). On its own, IT (like electricity!) has no value, and therefore won’t (can’t) improve anything. It has to be used in conjunction with changes in workflows and processes in order to improve outcomes.
• The effective deployment of technology has a number of requirements, of which the actual technology may be the smallest piece of the puzzle. At the end of the day, improved patient outcomes are a combination of provider decisions and judgment, patient compliance, adequate monitoring of efficacy of treatments and the use of technology to support all of those. The last item on that list is dependent upon the provider learning and adopting the technology to its full (not necessarily fullest) capabilities. Any one of these factors has the potential to derail the process, so if we don’t look at the process holistically, we shouldn’t expect uniform improvement.
• Lack of leadership on the provider side and lack of appreciation and understanding of HIT on the hospital executive side (one executive in charge of 11 hospitals did not know who Todd Park is).
• Ultimately it is not HIT by itself that will change outcomes, but what people do with it and how providers use it. Even HIT left unchecked can be harmful. I made more mistakes with electronic prescribing than I ever made on paper. I do not believe that we should stay on paper at all, but until we are all connected out there on the Medical Internet and the information flows freely, we will not reap the benefits of technology. One article in the Economist called "When the carpet calls the doctor" failed to explain how a device attached to the carpet that sends a signal to the doctor when the patient is about to fall is going to prevent that fall. Is the doctor or nurse supposed to get in the car or fly to the rescue? How about the apps that would monitor the patient’s weight or glucose — what will one do if the patient will not use it? Who is going to sit in a tower 24/7 to monitor all this and who pays for it? Not much is being said about that. As excited as I am about HIT, I do realize that our bigger-than-life expectations may not be materialized — not soon enough, anyway. Hope this helps, as it is written in between rounds at three hospitals, two of which are still on paper.
• Because IT alone won’t accomplish anything.  If you take a bad process and simply duplicate it with IT solutions, you still have a bad process.
• I would be mildly surprised if it had. In my view, outcomes will improve with decreased variability (with the most likely shapes of the outcome curve you can prove this mathematically) and clinical decision support. Theoretically, EHRs reduce variability with templates and order sets, but I have seen few real world examples of templates standardizing care, except in very limited areas, like DVT prophy. Clinicians still go off and do their own thing after the initial orders are in, and the templated H+P is done.

Variations in Implementation

• Probably the top reasons would include: variability in the technology itself, variability with the implementation, and variability of the adoption/use of the technology by the end users. All of those areas of variability exist at every hospital (even those within larger health systems who attempt to "standardize" their efforts). It should surprise no one, then, that "Healthcare IT" does not have uniform results. A poor implementation of even a very good technology solution will not have the same results as a good implementation. Similarly, poor adoption will not yield results from the effort to implement the technology (or may yield negative results directly due to the hybrid environment created by poor adoption where some are using and others not using the technology). Additionally, any negative outcome will be blamed on the new technology being implemented even if something else is actually to blame. However, I would posit that a good implementation with good adoption and engaged end-users with even a mediocre technology solution has the potential of generating positive results for patients.
• There is nothing uniform about the way we deploy healthcare IT solutions. We are often inwardly focused and insular as we define, design, and deploy the solutions that we must implement. We are often working very hard to leverage the technology we have acquired so that we can make the best use of scarce resources. We seldom take the time to measure our own local progress. We surely struggle to make time to share lessons learned with others. Our local efforts often limit the extent of our reach, while also limiting our ability to measure what impact we may have had.
• Just because your facility has implemented an EMR system, regardless of how mature the model is, it doesn’t mean the facility is using that technology to improve outcomes. Case in point: our facility is in the last stages of an EMR implementation. We are incorporating what our clinical team believes is industry best practices and evidenced based care i.e. Elsevier and Zynx, and we are going to reduce the variation in care that not only drives cost up but produces varying outcomes. We went on a site visit to a hospital who has already implemented this system but are using terrible practices. That is not the fist place we went where we saw this. It takes real leadership to stand up and say we are going to do it a specific way that uses evidenced based/best practice care. The IT systems can readily support an organization who is trying to do this with real time clinical behavior reporting. This will start to drive outcomes.
• Healthcare IT has not been uniformly distributed. The inequity among hospitals will be even deeper. Hospitals that are EMRAM level 6 or 7 and hospitals in rural areas that could benefit the most from health IT but cannot afford it.
• Lack of consistent adoption. Lack of understanding on how some technology can impact outcomes. Lack of discipline in organizations to use what they have. Poor BI use that would help isolate areas of improvement.

Lack of IT Support

• The CIO/IT Director doesn’t always get it. If we don’t understand the business of our organization, there is no way that we will provide the tools necessary to analyze / improve our business. A good example is that of business intelligence. My organization doesn’t think it is necessary or quite frankly, even understands what it is. I know that we have to have better analysis, and that in order to do that, I have to provide the appropriate tools. If I wait till the organization gets behind BI, it won’t happen for another 2-3 years and then it will be too late. I’ve searched out a solution that makes sense in our environment and began the implementation 12 months ago. The next step is to push it out to the organization and educate the management team on its value.

Meaningful Use has Distracted Clinicians and Vendors

• The emphasis on Meaningful Use metrics over the past years has led to a significant percentage of adopters to be focused almost exclusively on meeting those criteria that would allow for bonus attainment. These tools have the possibility to bring focus to a singular patient’s health issues and treating that patient as a unique individual with unique needs. This can be done efficiently and effectively when the clinician is able to utilize the tool as they see fit. Instead the clinicians become distracted by unnecessary hurdles mandated by someone sitting on Capitol Hill. The emphasis on evidence-based medicine and population health also distracts somewhat from the unique physician / patient experience by moving the focus up a layer or two from the primary interaction. Eric Topol has written a great deal about this.

The Healthcare Business Model Stands in the Way

• Our supply driven healthcare system and culture that needs to change. For-profit HIT, hospitals, and so on that has made us pursue the highly profitable but not always the most cost effective or valuable course of action.The only one whom I saw commenting on that was Peter Orszag, who said that it will be difficult to reconcile years of marketing in healthcare and direct-to-consumer advertising with customer satisfaction and reducing costs. We want to retire on 401(k) plans that invest heavily on healthcare companies and we want them to be profitable, but squirm when it comes to paying for it and attempting to cut cost. We cannot have it both ways.

Benefits Will Be Realized Only when Quality can be Measured

• Most providers / clinical entities are still trying to get past the data entry hurdles. Not yet at a point where most are focused on measuring quality. No defined quality standards that most agree on. Multiple groups with multiple standards, and these are not aligned with EMR companies.
• There is nothing stable about the environment into which we are implementing systems. The regulatory climate, the scientific environment, and the relentless pursuit of discovery creates a dynamic setting into which we are deploying systems. Collectively, this often prevents us  from thoughtfully, comprehensively, and accurately measuring the impact of our implementations. So to some degree, we don’t really know if we are making a difference. We don’t always measure the things that matter, and sometimes we aren’t certain of the aggregate benefit of our collective actions.
• Healthcare IT has not uniformly improved patient outcomes because we have few clinicians with sufficient vision and understanding of the potential that can, in turn, influence the change. The CIO/Clinical IT employees cannot produce the level of influence needed and it will take a lot longer to move from a world of data collection to a world of data analysis. In addition, we still take too much of an individualistic approach to patient treatment. Evidence-based medicine has not been accepted in any of the organizations with which I’ve been affiliated.
• There have not been enough in-roads in the establishment of systems where data has been uniformly stored and then shared. Taking those outcomes and running them through statistical engines is the holy grail to improve outcomes. It takes time to build the foundation to support this future endeavor.
• Patient outcomes have not been well defined and continue to elude us. A patient who does well after open heart surgery may do so because he has a supportive family as opposed to one who lives alone. HIT cannot alter that; it can only help measure it.
• Our litigation-crazy society has made it almost impossible to share and be transparent about mistakes and medical errors,HIT induced or not.
• I do not believe we learned any lessons yet. Someone should interview those hospitals that spent in the $100 million range IT budgets or the ones that made mistakes so we can all be enlightened.
• The most obvious answer is that healthcare IT has been used in different ways, and to different degrees, from one provider to another and from one department to another. Now that healthcare IT is becoming more broadly adopted, and as advanced analytics are developed to empower caregivers more, patient outcomes are expected to improve. Any discussion of outcomes should recognize its limitations. For example, some medical conditions lend themselves to objective measurements of improvement, while others don’t. Despite the extreme complexity of healthcare, there’s a natural desire to measure the end result, the output of the process, in objective and simple terms. Did the patient get better? If so, how much? Did the patient population get healthier? If so, how much? But not every patient with the same diagnosis(es) will get better in the same way. Can an objective measurement adequately convey the difference? Some patients won’t get better at all. For a terminal patient released to hospice, for example, shouldn’t we instead be asking whether the patient and loved ones feel they were treated with respect, dignity, and compassion? For them, that is an outcome. Acute care hospitals should follow the lead of the subacute sector, which focuses heavily on such measurements. For non-terminal cases – those that indeed may be expected to get better – were they and their loved ones kept informed throughout the stay, or did they feel frustrated by a disjointed, piecemeal system of specialists, which mostly kept them in the dark? Were they informed and guided through decisions? These considerations should be incorporated into any meaningful discussion of "outcomes."

News 8/15/12

Top News

SAIC completes its acquisition of maxIT Healthcare, making SAIC’s Health Solutions Business Unit the nation’s largest commercial consulting practice in EHR implementation and optimization.

Reader Comments

From Neal Patterson’s Evil Twin: “Re: new research group survey of hospital CIOs. It compares the cost of a major EHR upgrade to the original contract price: Epic (40-49%), Cerner (30-35%), Allscripts / Eclipsys (20-22%), and McKesson Paragon (10-13%). Epic had the lowest cost for minor upgrades at 1%. Amazingly, the CIOs surveyed seem to have been caught off guard – they didn’t develop an adequate total cost of ownership model.” Unverified, since the company producing the report requires registering to get a copy of it and I refuse to do that on principle. I agree that Epic, often bought recently at the height of organizational optimism and as a knee-jerk reaction to previous experience with unresponsive vendors, is going to be a big budget problem for a lot of hospitals that will never realize the ROI. I don’t know of any examples where IT on its own has ever changed the trajectory of an organization – it usually just accelerates it slightly. If your organization has always sucked at management, planning, and delivering quality care efficiently, it’s probably not lack of Epic that caused that situation nor implementation of Epic that will fix it for you. Like all non-profits, hospitals change only to threats to their existence.

From Don: “Re: E.J. Noble Hospital hiring a CFO to improve their financial software. They are CPSI even though the CFO’s relevant experience was with Meditech.” Trying to confirm which system a given hospital is using is almost impossible. I always Google and try to find a couple of items that seem to confirm and none that contradict (announcements, posted jobs, physician newsletters, etc.) but I always say it “appears” they’re using the system since you never know what’s changed. In the case of E.J. Noble, I turned up one Meditech user list that included them (perhaps that site incorrectly assumed that they are the same facility as Noble Hospital, a Meditech hospital in Massachusetts) and, most convincingly, E.J. Noble Hospital’s employment application specifically asks whether the applicant has Meditech experience, which is not a common question for non-Meditech sites. I assume the reader is correct, but I can’t prove that, either.

From Dell Encore: “Re: Encore Health Resources. In serious negotiations to be acquired by Dell.” I asked EHR CEO Dana Sellers, who says she hadn’t heard the rumor and says the company isn’t for sale. I believe her since she’s always been a straight shooter, but I should mention that when I ask CEOs about acquisition rumors, I get one of three possible outcomes: (a) they don’t respond, which leads me to assume the rumor is true and I’ll run it as an unverified; (b) they tell me the rumor isn’t true, although in at least two cases CEOs who I would consider to be friends of HIStalk flatly denied a reader’s rumor that turned out to be deadly accurate all along shortly thereafter, which I don’t really consider to be uncool since they can’t have me blasting it everywhere right in the middle of their negotiations; or (c) the CEO tells me off the record that the rumor is true, but implores me to hold off mentioning it until the announcement, which I usually do (sometimes they offer me an exclusive story or interview in return). Occasionally I get briefed even before anything is announced, allowing me in several cases to conduct an interview and have it ready to blast out the second the news hits the wire. The best ever was when a CEO arranged to call my house one evening to tell me that the company was going to be acquired for huge money by a publicly traded company, which was fun because, (a) he treated me like a real journalist, trusting me not to do something stupid like leak the news or trade the stock of the company that was involved, and (b) it was priceless when Mrs. HIStalk asked me who I was talking to and I casually mentioned that a CEO just wanted to chat with me about selling his company for a few hundred mil the next day. For at least 30 seconds, I felt like more of a big shot than just some hospital guy and spare bedroom blogger, but then I had to get back to work.

From Horshack’s Laugh: “Re: predictive analytics solutions. Lots of vendors and providers are talking about the need for them without offering a standard definition of what they are or aren’t. Have you looked into who might be the reportedly top 5-10 vendors? Thanks much … love your stuff.” My stuff loves you right back. I’ll defer to readers on the question since I know better than to opine in the presence of experts.

From Dr. Nancy: “Re: article in The Atlantic. It’s old, but worth reading if you haven’t seen it. You are the best.” The perspective of the 2007 article by Shannon Brownlee (Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer) is interesting and timely: do we have too many rather than too few doctors? It says that the usual arguments that aging Baby Boomers will increase demand just as aging doctors retire, causing a decline in patient outcomes, just might be wrong, quoting a physician researcher who said, “If we sent 30% of the doctors in this country to Africa, we might raise the level of health on both continents.” The article observes that docs congregate where business is good (bigger population, more insured patients) and generate their own demand by ordering more stuff for patients, but outcomes aren’t any better in those doctor-rich areas like Manhattan and Los Angeles. Doctor-patient ratios at academic medical centers are 2-3 times higher at UCLA and NYU than Mayo and Duke with no better results, it says, possibly because all those docs need to justify their existence, like by ordering unnecessary tests and not communicating with the hordes of competing specialists roaming the halls.

Acquisitions, Funding, Business, and Stock

Emdeon posts a loss of $35.4 million for Q2 compared to a net income of $9.2 million a year ago, attributing the red ink to the costs of its acquisition last year by Blackstone. Revenue was up 4.4% to $294.5 million.

HIM consulting firm TrustHCS acquires Legacy Coding LLC, a clinical coding and auditing form.

Health accelerator Healthbox starts its three-month Cambridge, MA program today, with 10 companies getting office space, mentoring, and $50K in seed capital in return for a 7% stake. I got distracted (and annoyed) by the write-up of Bon ‘App, which says its nutritional app has “simplistic language.” As Inigo Montoya says, “You keep using that word. I do not think it means what you think it means” (either that or its app is one to avoid).

Sales

Texas Health Resources selects Medicity’s HIE solutions to power information exchange among its facilities and physicians.

Winkler County Memorial Hospital (TX) will implement financial solutions from Prognosis HIS.

The George Washington University and the National Institute of Child Health and Human Development will use PeriGen’s PeriCALM Patterns alerting system for maternal in a research project involving the use of intrapartum fetal heart rate monitoring to predict neonatal outcomes.

People

Former Siemens Healthcare President and CEO Eric R. Reinhardt joins the board of Varian Medical Systems.

Seattle Children’s Hospital promotes Wes Wright from VP/CTO to SVP/CIO.

Beacon Partners promotes Kimberly Post from controller to CFO.

Announcements and Implementations

Harris Corporation will expand Florida’s HIE secure messaging service to 11,000 physician offices that use Care360 solutions from Quest Diagnostics.

Regional Medical Center at Memphis completes implementation of the Siemens perioperative management solution by SIS, which will interoperate with Soarian.

The Kansas HIN and ICA announce that Via Christi Health Systems and HCA Wesley have successfully transferred data into the KHIN production environment.

MEDSEEK will incorporate GetWellNetwork’s GetWell@Home into its patient portal.

University of Michigan Health system goes live this week on Epic’s MyChart patient portal. The article in the Ann Arbor paper also mentions that hospital executives attribute part of its fiscal year loss, announced in June, to the cost of implementing Epic.

Health Care DataWorks announces Value-based Purchasing, which tracks the 20 CMS VBP quality outcomes measures that affect hospital payments starting in October.

Government and Politics

Innovate Primary Senior Care (IL), Treasure Coast Healthcare (FL), and Virginia Commonwealth University Health System and the Medical College of Virginia Hospitals and Physicians (VA) join 16 independent practices in CMS’s Independence at Home Demonstration.

You might think the VA is paperless given the high marks its VistA system receives. Not so, as a VA OIG inspector knows after writing up its Winston-Salem, NC office for piling 37,000 claims folders on top of file cabinets, to the point that the sixth floor office’s floor was sagging and in danger of collapsing. The VA cleaned up the area and will spend $400K for a filing system to be located in the basement.

Innovation and Research

A group of 14 organizations in 10 European countries begins trials of the DebugIT antibiotic decision support system they developed, which applies statistical methods to their collective susceptibility information to recommend optimal antibiotic therapy to clinicians.

Other

The Kansas HIE board postpones voting on the proposal to dissolve the organization and instead forms a committee to analyze the proposal and return with a recommendation for the board’s September 12 meeting.

Greg Reed, CEO of the embattled eHealth Ontario, declines his $81,250 performance bonus for the second year in a row. The Ontario government is facing a $15 billion deficit and wants all public sector workers to take a two-year wage freeze.

The Surgeons of Lake County (IL) announces that an unauthorized user hacked into its computer system, encrypted the server, and demanded money in exchange for the password to regain access the EMR and corporate e-mail files. The practice refused to pay the ransom and instead turned off the server and contacted law enforcement. It’s unclear whether the practice had a backup, but the server remains unplugged. The practice believes the intent of the authorized access was to extort money rather than obtain patient information.

Ed Marx has an article called “CEOs, CIOs must look to IT for success” in Modern Healthcare (registration required).  

The Siemens folks at their user meeting sent this photo of John Glaser with Cal Ripken, Jr., who looks disturbingly like Uncle Fester in this shot.

Speaking of Baltimore, HL7 is holding its annual meeting there September 9-14. A reader invites you to attend a session on standards-based approaches for PACS-EHR integration, which will focus on DICOM and IHE workflow profiles. That session is September 13 from 11:00 a.m. to 3:30 p.m. at the Hyatt Regency Baltimore at the Inner Harbor. I would almost make the trip just as an excuse to revisit one of my all-time favorite restaurants, the brilliant Woodberry Kitchen.

Weird News Andy captions this article as “Say What?” but stop reading now if you’re one of those people that worries about bugs crawling on (or in) you while you sleep (or whether China has a HIPAA policy). Doctors at a hospital in China, examining a woman complaining about itching in her head, find and remove a spider that had burrowed into her ear five days earlier, easily discernible in the creepy photo above.

Speaking of HIPAA, the firefighter’s unions in Las Vegas, trying to convince insolvent cities to stop considering outsourcing non-emergency calls to private ambulance services, may have inadvertently violated HIPAA privacy laws by posting a list of private ambulance calls that took longer than their 12-minute contractual maximum. The list contained home addresses and reason for the call, which included such items as suicide attempts and drug overdoses. The image above blurs those reasons, but the one on Latefor911.com didn’t.

A New York Times article covers the huge profits being made by HCA and the mind-boggling money that private equity firms like KKR and Bain are making in orchestrating its complex financial transactions. How HCA does it: aggressive billing of private insurance, creative use of the coding system, turning non-emergent patients away from its EDs, and cutting clinical staff. On the other hand, the company at least pays taxes, unlike its non-taxpaying counterparts sometimes use those same tactics to boost their bottom lines. All of this was inevitable when the decision was made, going back to the early days of Medicare and Hill-Burton if not earlier, that hospitals should be run as businesses rather than as charities or religious outreaches. The new rules said you had to make money but weren’t specific about the limits of how you could do that beyond your organizational conscience.

Union representatives in Contra Costa County, CA say correctional system nurses filed 142 complaints about its new $45 million Epic system in July, claiming that they are Epic’s detention facility guinea pig. A nurse says super-users told management about the problems and warned that the two-hour training sessions weren’t adequate since the training system wasn’t fully set up. “What nurses want is for the Epic program to go away until it’s fixed,” she says.

A cardiac perfusionist sues Mount Sinai Hospital (NY) and her former boss for creating a hostile work environment, claiming everybody knew that he regularly watched porn on his smartphone while working cases in the OR.

Sponsor Updates

• Forbes includes Greenway Medical Technologies as one of its five favorite growth stocks.
• Like Kareo on Facebook by August 17 for a chance to win a Kindle.
• St. Joseph Health (CA,TX, NM) adds additional revenue cycle technology solutions from MedAssets.
• Simonmed Imaging will deploy Merge’s radiology and interoperability solutions across its 50+ sites.
• A Vitera Healthcare Solutions study finds that 91% of doctors want a mobile EHR solution, yet only 6% connect to an EHR through a mobile device.
• Allscripts says it will debut new mobility functions and integration between acute and ambulatory settings at this week’s ACE 2012 in Chicago. Wednesday’s opening address is available on the website.

Report from the Allscripts Client Experience – Day One
By Bill Rieger, CIO, Flagler Hospital

Today was a pre-conference workshop day. As CIO, I attended the executive session, which started off with Glen talking about transformation and change in a session titled, "It’s not about IT."  

He talked about the open approach Allscripts has, both from a philosophy and a technical perspective. He talked about Allscripts’ CLEAR values: Client experience (client always first); Leadership (inspire, innovate, grow);  Extraordinary people (learn, grow); Aspire (think different, think big); and Results (say, do).  

Kevin Larson from ONC spoke next and really didn’t enlighten us with any more information than we already had about MU and ONC initiatives. He brought up the concept of semantic interoperability (I saw a bunch of folks looking it up on their phones, me included!) and it became a buzzword that I heard multiple times throughout the day.

There was a panel discussion where LIJ, Brown and Toland, and Jefferson Medical college talked about accountable care and the iterations each organization has engaged in. Maureen Kahn, CEO of Blessing Hospital in Quincy, IL told a great community story and how the successful implementation of ADX 1.5 has impacted their organization.

Finally before lunch, Cliff Meltzer, VP of development at Allscripts, talked about what has been delivered since last year’s ACE conference: automated testing features, a client advisory group, and an early adopter program. He talked about the performance improvement with MSSQL2012 and how in 6.0 the whole environment can be virtualized. One of the things I liked that he talked about was end user performance monitoring.  I believe that the hourglass is the enemy of adoption, so I was glad to hear that they were focusing on that a bit.  

After lunch there were breakout / roundtable sessions that I found to be very valuable. I attended two of them. One discussed linking outcomes to income and heard several stories about using data to improve physician behavior leading to additional revenue. The other one was related to HIE, and dbMotion was there. There were some roundtable discussions that showed me that we are all not on the same page when it comes to simply defining what HIE is and what are the problems they are suppose to solve. Interesting, but frustrating.  

Finally, Thomas Atchison spoke. It was very entertaining, and I walked away with two thoughts. One is that in the absence of information, the void is always filled with negativity. The other is that words lie, behaviors never lie. Two things for me to chew on there. Looking forward to tomorrow when the regular conference begins.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 8/13/12

When I originally applied to be a HIStalk sidekick, Mr. H and I discussed what I could potentially bring to the table. One of his ideas was for me to review and comment on articles from the physician point of view. I’ve done that from time to time, but this is the first time I’ve decided to completely dissect an article with the intent of defending physicians from bad information.

There is so much going on in healthcare today that it’s nearly impossible to keep up. According to the conversations in the physician’s lounge, many physicians (especially those in primary care) rely on a variety of blogs, newsletters, and trade journals to try to keep up. Who wants to read 800+ pages of Meaningful Use legislation and thousands of pages of commentary? Who wants to read the Supreme Court transcripts related to the Affordable Care Act? (OK, y’all know I did read it all, and I know some of you did too, but that’s beside the point.)

One of my favorite quickie journals for trying to keep up is Medical Economics. The July 25 edition had a couple of articles which I found mildly aggravating, as they grossly oversimplified the analysis needed to determine if a physician should enter into the business of running a moderate complexity laboratory as a means of increasing revenue. However, the article on the potential influx of millions of patients to our already dysfunctional health care system left me grinding my teeth. Physicians who aren’t well versed in the gory details of the legislation, the regulatory environment, and how health systems run are likely to take this kind of writing as fact rather than as the quasi-opinion piece it is.

You’re welcome to read for yourself, but I’m putting on my “Mythbusters” hard hat and safety goggles to start debunking.

Myth #1: Having health insurance is going to make people run to the doctor and undergo lots of tests and procedures. I don’t disagree that there are quite a lot of people who would certainly take advantage of new coverage, many of them with existing health needs. However, I know a great number of people who have really good health insurance (many are my co-workers, neighbors, and friends) who simply don’t go to the doctor. Even with fully-covered preventive visits (no co-pay) they don’t see a need to go. Some patients are afraid of physicians and others are instead afraid of the federal government tapping their personal and health information. Others prefer to spend their time and resources on unproven alternative treatments and distrust the medical establishment. I imagine the percentage of people falling into these categories may be quite similar among currently insured and yet-to-be-insured individuals.

Myth #2: We can’t grow the physician workforce. The article states: “The AAMC notes US medical schools have complied with requests to boost class sizes by 30% time [sic] over the past 6 years, but the overall supply of US physicians cannot expand unless Congress increases the number of federally funded residency training positions, a number that has been frozen since 1997. The AAMC is working hard to revisit this freeze… staying where we are will leave US medical school graduates without a training position.” Not exactly true (and questionable editing, but I digress). According to 2012 National Resident Matching Program data, nearly 5% of family medicine positions were unfilled. A large number of federally-funded residency positions were filled by foreign medical graduates – in family medicine, only 48% of the positions were filled with graduating seniors from US medical schools.

Saying there are no positions for US grads simply isn’t accurate. The problem is that the positions are in specialties where US grads don’t want to work, such as family medicine. Low pay, grueling hours, and constant insurance and regulatory hassles do nothing to draw prospective physicians. Imagine the marketing campaign: Do you want to drive a ten-year-old Honda Accord? Love those Dockers you wore during your medicine sub-internship? Want to be 50 years old and take extra shifts in the ER to send the kids you never see to college? Primary care is for you!

There are a number of other ways to increase the number of physicians in the work force. I’d like to know how many of those new medical school slots are being used by MD/JD, MD/PhD, MD/MBA, and other combined program students with no intention of ever practicing. My medical school alone has historically graduated up to 10% of students who never intend to pursue clinical care. Additionally, why in the world do we require qualified physicians who have been educated in other countries to pursue a residency in the US? I’ve worked with a number of highly competent physicians who were practicing physicians in other countries who have been forced to either repeat training or change specialties to practice in the US. Years ago, my family knew a highly skilled physician who had defected from the Soviet Navy and was working as a home health aide because he couldn’t obtain a training slot. If we really have a shortage, this doesn’t make sense.

Myth #3: It’s easy to add capacity to the system. I was truly angry after reading the article’s “8 ways to see more patients” sidebar. The author interviewed Michael D. Brown of Health Care Economics in Fishers, Indiana. “Brown believes that physicians can easily move from seeing six patients per hour to 10 by socializing less. Many physicians spend the first 80% of a visit chatting.” First of all, having spent more than a decade in the primary care trenches, even seeing six patients an hour and trying to deliver comprehensive, compassionate, quality care is a challenge. Add to that the need to deal with complex regulations, insurance snafus, and time-sucking EHRs and it’s enough to overwhelm even the hardiest of souls. Ten patients an hour in primary care? Patients have revolted at the notion of the six-minute HMO visit and unless they’re bionic or extraterrestrial, I really do not see the majority of the PCP workforce being able to achieve this.

I haven’t spent 80% of a visit chatting since I was in medical school. I frequently have to redirect patients to stay on topic to just get through the updates on their diabetes, heart disease, and obesity. They want to tell me about their children and grandchildren and their vacations, but that’s just not a reality any more. The old-time family doctor I hoped to be is an extinct species. I have to ask patients to pick their top three issues to talk about just to stay on time. Patients always come in with more concerns than they told the scheduler, and that’s my only way to survive. It’s certainly not what I signed up for, but it’s the nature of the beast, and I run a reasonably high patient volume with a highly interoperable EHR and a strong staff. However, if I run late, my patient satisfaction scores drop. Since that’s what partially drives my compensation (and keeps the parade of regional practice administrators off my back), it’s what I do to stay afloat.

Brown goes on to say, “You can’t spend 8 of the 10 minutes you have allotted for a patient on unrelated matters and stay on schedule.” That’s funny, because in the previous paragraph he only allowed us six minutes per patient. Brown also goes on to say physicians who can’t handle 10 patients per hour should add two more appointment slots to each day. “At $75 each, times 10 per week, doing so can increase earnings an additional $37,500 per year with no added overhead.” I’m not sure what kind of practice management consultant forgets that seeing patients involves staff (especially if you’re going to leverage medical assistants and mid-level providers as he also recommends) which certainly involves overhead. If you’re already optimized, you can’t just cram more slots on the schedule without adding staff capacity or more time to the day unless you cut corners.

I’d keep going with the Mythbusting, but it’s late and I’m on teaching rounds this month. I have to be at the hospital at the crack of dawn, and due to work hour restrictions, most of my residents and students will have had more sleep than I will. It’s always challenging to be on service, but there’s no better way to shape the future physician workforce.

Have a medical or health care IT myth you’d like busted? E-mail me.

E-mail Dr. Jayne.

EHR Design Talk with Dr. Rick 8/13/12

Fitts’ Law and the Small Distant Target

“. . . the importance of having a fast, highly interactive interface cannot be emphasized enough. If a navigation technique is slow, then the cognitive costs can be much greater than just the amount of time lost, because an entire train of thought can become disrupted by the loss of contents of both visual and non-visual working memories." — Colin Ware, Information Visualization: Perception for Design

Paul Fitts was the pioneering human factors engineer whose work in the 1940s and 50s is largely responsible for the aircraft cockpit designs used today. His life’s work was focused on designing tools that support human movement, perception, and cognition.

In 1954, he published a mathematical formula based on his experimental data that does an extremely good job of predicting how long it takes to move a pointer (such as a finger or pencil tip) to a target, depending on the target’s size and its distance from the starting point.

Fitts’ Law has turned out to be remarkably robust, applicable to most tasks that rely on eye-hand coordination to make rapid aimed movements. Although digital computers as we know them did not exist when Fitts published his formula, since then his law has been used to evaluate and compare a wide range of computer input devices as well as competing graphical user interface (GUI) designs. In fact, research based on Fitts’ Law by Stuart Card and colleagues at the Palo Alto Research Center (PARC) in the 1970s was a major factor in Xerox’s decision to develop the mouse as its preferred input device.

As you would expect, Fitts found that it takes longer to move a pointer to a smaller target or a more distant one. The interesting thing is that the relationship is not linear.

If a target is small, a small increase in its size results in a large reduction in the amount of time needed to reach it with the pointer. Similarly, if a target is already close to the pointer, a small further decrease in its distance results in a large reduction in the amount of time required to reach it.

Conversely, if a target is already reasonably large or distant, a small increase in its size or small decrease in its distance has much less effect.

What is Fitts’ Law telling us? Why isn’t the relationship linear? Are the two tasks fundamentally the same or are they different, requiring different visual, motor, and cognitive strategies?

Perhaps the best way to get a feel for this aspect of Fitts’ Law is to try it yourself. If you have two minutes to spare, click on the link below for an online demo. You will see two vertical bars, one blue and one green. The green one is the target. Your goal is to use your cursor to move to and click on the green bar, accurately and rapidly, each time it changes position.

As you go through the demo, imagine that the bars represent navigation tabs or buttons in an EHR program. In other words, imagine that your real goal is to view EHR data displayed on several screens—clicking on the green target is just the means to navigate to those screens.

You will see some text displaying a decreasing count: hits remaining — XX. Keep track of this hit count while moving to and clicking on the green target. This task will have to stand in for the more challenging one of remembering what was on your last EHR screen (see my post on limited working memory).

When you finish, you can ignore the next screen, which displays your mean time, some graphs, and a button to advance to a second version of the demo.

Here’s the link to the online demonstration of Fitts’ Law.

What did you find?

You probably found that if the green target was sufficiently wide and close to the cursor, you could hit it in a single "ballistic" movement. In other words, with a ballistic movement, once your visual system processes your starting position and the target location, other parts of your brain calculate the trajectory and send a single burst of motor signals to your hand and wrist. The movement itself is carried out in a single step without the need for iterative recalibration or subsequent motor signals.

Your brain used the same strategy as the one used for ballistic missiles. The missile is simply aimed and launched, with no in-flight corrective signals from the control center.

Conversely, you probably found that if the green target was narrow and far from the cursor, you couldn’t use a ballistic strategy. After initiating the movement, most likely you had to switch your gaze to the cursor, calibrate its new screen location in relation to the target, calculate a modified trajectory, send an updated set of motor signals to your hand, and so forth in iterative loops, until reaching the target.

These two strategies are fundamentally different. Not only does the ballistic movement take less time, it requires much less cognitive effort. In fact, if the target is large and close enough to your cursor, you can make a ballistic hand movement using your peripheral visual field while keeping your gaze and attention on the screen content.

These differences between ballistic movements and those requiring iterative feedback may explain the non-linear nature of Fitts’ Law.

As I discussed in a previous post, the rapid "saccadic" eye movements we use to redirect our gaze are the benchmark against which all other navigation techniques should be measured. Not surprisingly, these saccadic eye movements, lasting about a tenth of a second, are ballistic. Once the brain has made the decision to redirect gaze, it calculates a trajectory and sends a burst of neural signals causing our eye muscles to turn the eyes to the new target and simultaneously preparing our visual processing system to expect input from that new location.

It makes sense that saccadic eye movements are ballistic. We want to turn our eyes to the new fixation point as quickly and effortlessly as possible. In fact, we take in no visual information whatsoever during the saccade itself. We only acquire visual information between saccades, when our gaze is fixed on an item of interest.

From an evolutionary standpoint, it would appear that saccadic eye movement, being more rapid and efficient than iterative strategies, was selected as our primary means of navigating visual space. If we want our digital input devices and interactive designs to approach the efficiency of saccadic eye movement, we should create user interfaces that facilitate ballistic strategies.

Returning to the vendor’s design presented in my last post, the "maximize" buttons, shown below outlined with red circles, are both tiny and distant:

There is no way we can move the cursor from one maximize button to another (except for the adjacent ones) using a ballistic strategy, whereas the design below, using a separate navigation map, supports such a strategy:

Of course, all design choices require trade-offs. The second design requires a major compromise. By requiring a separate navigation map, it adds another level of complexity to the user interface.

It’s not usually the case that one high-level design is good and another isn’t. Most high-level designs have their advantages. But if you are going to stick with the vendor’s design, at least use the entire area of the title bars as the targets. If you are going to use a separate navigation map, make the panes large and close enough for a ballistic strategy to work.

To be clear, the problem is not the extra second or so that it takes to acquire a small, distant target. It’s that poor designs cause the user to break concentration and use working memory for non-medical tasks. An unnecessarily difficult navigation operation can disrupt the train of thought needed to apply good medical judgment to an individual patient.

Quite simply, when designing EHR interfaces, many choices are not a question of preference or aesthetics. We are hard wired so that certain tasks are simply easier than others. Our EHR design choices need to be informed by an understanding of these human factors.

Next post:

A Single-Screen Design

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.

Monday Morning Update 8/13/12

From The PACS Designer: “Re: big data mining. One of the challenges facing healthcare is how to collect, manage, and view data that can improve outcomes. Some interest is brewing in the open source community to help with the challenge. An open source solution drawing this interest is Hortonworks with Apache Hadoop 1.0. While it’s still relatively new, the chances of HortonWorks being production ready in the next year or two are high, and it could show up in healthcare settings in several years.” The post also quoted EMC’s CTO, who listed some healthcare big data opportunities: (a) always-on end user query capability for all data sources; (b) data collection from real-time medical instrumentation; (c) in-memory capabilities for fast decision-making in the ED; and (d) real-time health scoring as is done in ICUs. Above is a nicely done overview of the Hortonworks Data Platform that should get tech geeks salivating.

From A Curious Reader: “Re: Meditech’s KLAS numbers. The 16 customer losses in 2011 are from the C/S platform, while the 14 are from Magic. The C/S losses are a mix of v.5.x and v.6. KLAS issued an trend alert in July reporting that 35% of over 50 hospital respondents said they wouldn’t buy v.6 again because of product immaturity and usability issues. Of the non-IT respondents, more than half said they wouldn’t buy it again. According to a CIO quoted, ‘Some of the applications have been developed in the new v.6 language and some applications are in the old NPR language. Because of that, the new v.6 platform requires a million connections, and from a management and monitoring standpoint, the transfer of data is very complicated.’” Just to address the counterpoints: (a) Meditech has a ton of hospital customers, so their percentage loss is probably tiny; (b) Magic is ancient and upgrading is almost like a re-install, so it’s not surprising that those clients would explore and sometimes choose alternatives; (c) Meditech hospitals tend to be small and thus more likely to be acquired and subjected to a forced system replacement, assuming those are counted by KLAS as “losses” (which would likewise give Epic an inflated count of wins.) The customer comments about v.6 are indeed troubling, however.

Listening: First Aid Kit, a pair of amazing sisters from Sweden who covered a Fleet Foxes tune with their camcorder running in a Swedish forest when they were 17 and 14, making them a modest YouTube sensation. That was five years ago and they’re still putting out mature, bittersweet harmonies that could be pegged somewhere between indie pop and American country-folk. They use talent, not studio tricks – check out this rather stunning video that was shot as they sing and play memorably while walking down a public street in Paris right before their show, with cars and people milling around them. They’re doing several US dates in September and October.

Two-thirds of us would be disappointed if we went straight from a routine doctor’s appointment to the hospital, which would have no record of our just-concluded ambulatory visit. New poll to your right: how has Meditech’s market position changed in the past year?

As I was creating the poll, I struggle as I always do with whether I should write Meditech (my usual) or MEDITECH (like everybody else does). It struck me that I should check the “AP Stylebook” (the Bible of news writing) that’s two feet from my chair, which says all-capital company names aren’t used unless the letters are individually pronounced. It’s OK for IBM or GE, but not Nasdaq or Meditech. That leaves me puzzled about HIMSS (Himss?) since it’s always sounded out. I also learned that characters are not used in a company name (so it’s MModal, not M*Modal), periods go outside parentheses unless what’s inside is a full sentence (so it’s outside this set), and the first word of a sentence is always capitalized no matter what (so it’s Athenahealth, not athenahealth, if it’s the first word of the sentence).

Speaking of MModal, the company agrees to release the projections its financial advisors used to determine that JP Morgan’s $1.1. billion buyout offer was fair. The disclosure is one of the terms in a settlement agreement the company reached with shareholders who felt the offer price was too low, representing just an 8.3% premium over current market share price and 18% less than a competing bid from Nuance that MModal’s directors rejected. Meanwhile, the company reports Q2 results: revenue up 7%, adjusted EPS $0.21 vs. $0.31, missing expectations on both but maybe backing up the board’s arguments that the buyout price is fair.

Bond ratings company Fitch warns bond investors that HITECH payments can hide the “otherwise anemic revenue growth” of hospitals given that it’s a one-shot payment that doesn’t even cover the IT costs required to earn it in many cases. They also say that the need to implement IT is helping drive hospital consolidation.

Presidential candidate Mitt Romney names Rep. Paul Ryan (R-WI) as his running mate. Ryan’s healthcare IT connections: (a) he wants to overhaul Medicare and Medicaid, saying the country can’t afford the cost; (b)  he was #1 on the “100 Most Influential People in Healthcare” for 2011; (c) he co-sponsored a bill in 2008 that would have established independent health record trusts that would allow consumers to manage their own health records, force EMR vendors to link to those trusts, and split the proceeds from de-identified data sales between the patient and the trust to fund the operation; and (d) he and four other Wisconsin politicians tried to influence the VA and DoD to buy systems from home-state vendor Epic instead of writing their own. My favorite trivia items about him: he was voted prom king and “Biggest Brown-Noser” as a high school senior and he worked a college summer job at Oscar Mayer and was allowed to drive the Wienermobile once (both irrelevant factoids courtesy of warring Wikipedia edits by fans and foes).

Allscripts chooses Symedical Server from Clinical Architecture to address clinical terminology requirements for its entire product line.

E.J. Noble Hospital (NY) hires a new CFO mostly for his IT experience, saying an unnamed system it installed in 2010 works OK for patient care, but isn’t user-friendly for the finance people. That system would be Meditech, according to noted healthcare IT expert Mr. Google. UPDATE: they aren’t Meditech, even though their job application asks about Meditech experience. Folks are suggesting they are using CPSI.

St. Luke’s Hospital (NC) goes live on McKesson Paragon after what it said was a 3,000-man-hour, $2.5 million project.

General Dynamics is awarded a five-year, $20.6 million contract to connect the Indian Health Service’s EMR system (an offshoot of the VA’s VistA called RPMS) to the Nationwide Health Information Network.

Former Awarepoint CEO Jason Howe is named president and CEO of Vaporstream, which offers a secure digital messaging channel for executive communication that prevents legal discovery.

Personal health records systems haven’t done much of anything, but that doesn’t keep everybody and his brother from cranking out low-rent versions sold cheap on the Internet or burned onto flash drives. Here’s a new $35 one from from “a local Mom” that runs on your PC and requires printing out your manually entered information in advance. The local mom even made a TV commercial. I couldn’t find a screen shot or example of the printed report anywhere. At least the local mom identifies herself as “Owner/Founder” on the site, unlike most spare bedroom part-time moguls who grandly label themselves as CEO like that’s going to fool someone into thinking they’re running multinational conglomerate.

This story about over-capacity Yale-New Haven Hospital buying the money-losing Hospital of Saint Raphael, also in New Haven, CT, illustrates how political the hospital business is. The YNHH people had to brief city aldermen whose constituents have been pestering them about their fear of losing their jobs or benefits. YNHH said only one group would definitely lose their jobs: the estimated 60 people on HSR’s payroll that Yale had previously fired, raising the ire of one alderwoman who said, “Just because Yale fired them they can’t work? You’re not willing to give them a second chance?” YNHH was also questioned about whether it would dismantle the Teamsters union at HSR; it said it wouldn’t. Maybe it’s no mystery why HSR needs a bailout given that it hires previously fired employees, has to deal with the Teamsters, and pays so much that employees are afraid of a gravy train derailment after being taken over by a university, a group collectively known (as are hospitals) for overpaying masses of marginally competent people who will never be fired or demoted for anything short of a felony committed on company time. Hospitals are like NASA: the science is sometimes questionable, the lack of value is inarguable, but nobody can touch them because they create a lot of jobs and political allies.

Bizarre: a new mom who agreed to appear in an instructional video for breastfeeding is horrified when Googling her own name to find a slew of porn links and explicit YouTube videos. The video company said it’s not their fault that somebody spliced the breastfeeding scenes into a porn video featuring graphic footage of someone who resembles the woman performing acts much less innocent than breastfeeding, but they don’t deny that the video displays the woman’s full name on the screen. She’s suing, of course.

Weird News Andy finds the story of this former law student inspiring (“Tough as Nails,” he labels it). Experts can’t figure out her skin disease, in which fingernails are growing out of hair follicles all over her body. She was referred to Johns Hopkins, where she’s racked up $500,000 in medical bills that her insurance won’t pay because it’s an out-of-state provider. She takes 25 medicines, of which insurance pays for five.

Vince responded to a reader’s request to have all of his HIS-tory episodes available in one place. All 50+ of them have been loaded to his company’s site, where I intended to take a quick look but got wrapped up in reviewing them all over again. This week’s edition is an introduction to the series, why he’s doing it, some folks he fondly remembers, and a plea for material for future episodes from those who lived the HIS-tory he writes about.

Sponsor Updates

• Certify Data Systems, which offers the HealthDock intelligent interoperability appliance, is named as a "Major Player” in HIE technology.
• A White Plume blog post observes that physicians seem to prefer to code E/M visits manually even though most EHRs can do it automatically.
• A HealthCare Anytime fact sheet describes its patient portal, which offers online bill pay, appointment requests, refills, messaging, and a PHR.
• Henry Elliott & Company’s hot position openings include Cache’ developers, MUMPS programmers, and several other technical jobs.
• Eastern Health goes live with the disease screening solution of NexJ Systems, which offers next-generation customer relationship management systems for healthcare.
• Besler Consulting provides an overview of CMS’s Hospital Readmission Reduction Program.
• Southern Oregon Orthopedics (OR) chooses SRS after de-installing its legacy EHR product that it says had tedious drop-downs, wasn’t meeting transcription needs, and wasn’t getting them to Meaningful use.
• Shareable Ink customer Sheridan Healthcare (FL) describes its use of the company’s “digital pen and paper” system.
• Current opportunities at Executive Search Recruiting include consulting VP, IS director, consulting partner, and certified consultants for Meditech and Epic.
• API Healthcare offers a free August 14 Webinar called “Will You Ever Love Your Patient Classification System? Embracing PCS with Evidence and Persistence.”
• Health Data Specialists, which offers consulting services for Cerner, Epic, Meditech, and Siemens, will exhibit at Siemens Innovations this week in Baltimore.
• TrustHCS, which offers coding, compliance, and ICD-10 solutions, will speak about ICD-10 readiness at the AHIMA convention October 1-3 in Chicago.
• OTTR Chronic Care Solutions will host its user conference September 17-19 in Omaha. The $485 registration fee includes 2 1/2 days of discussions, Q&A sessions, networking, lunch, and a half day of small group workshop training.

E-mail Mr. H.

Time Capsule: I’ll Have What He’s Having – Why Hospital Software Selection Is More Lemming than Deming

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

I wrote this piece in October 2007.

I’ll Have What He’s Having – Why Hospital Software Selection Is More Lemming than Deming
By Mr. HIStalk

It’s a wonder that any hospital IT systems are on the market today. Somebody had to actually start using those systems without the benefit of endless hand-wringing with peer hospitals. How do you like it? Would you buy it again? How’s it ranked? How is the response time, support time, and implementation time? Can we come see it at your place?

Hospitals gripe about lack of vendor innovation, but salespeople can’t wedge a foot in the CIO’s door unless at least 20 hospitals have been live on the system for five years. Half of those customers need to be within 20 percent of the prospect’s bed capacity and one of them should be in the prospect’s state or an adjacent one (geographic disparity must be ruled out). It’s like the collective migration of lemmings – everybody just blindly follows someone else who seems to have a clue.

Hospitals can be like indecisive restaurant patrons who point at someone else’s plate and tell the waiter, “I’ll have what he’s having”. If you develop a cure for cancer, you still may not be able to find a brave first hospital customer. I’m told that this rampant me-tooism is stronger in healthcare than in any other industry and I don’t doubt it a bit. That’s why healthcare IT is both wonderful and aggravating.

Here are some thoughts on why we play follow the leader:

• Hospital executives always (and sometimes rightfully) feel less competent than their private business counterparts. Therefore, they’re not about to lose one of few local jobs they’re qualified for just because some vendor has a risky product that could provide big benefits. If you can’t get promoted, at least don’t get fired.
• CIOs are too busy or indifferent to figure out for themselves whether a product is appropriate for their setting. The easiest course of action is to let someone else do the legwork, i.e. buy only those things that someone else bought or that a hopelessly broadly composed committee voted for. There’s mediocrity in numbers.
• Hospitals are not good at writing contracts that align incentives and hold vendors accountable, so they spend the effort instead buying the lowest risk products, which are usually those with the least potential to pay off big.
• Nobody wants to build software, even though many (most?) applications on the market started out as a custom development project for one or more hospitals. It’s easier to buy stuff that probably won’t work than it is to get exactly what you want, especially if you don’t really know what you want anyway.
• The urge to buy something often outweighs urge to do something. Grinding out years of hard process redesign is much less satisfying than throwing a software Hail Mary, one of few chances the IT department has to be decisive.

So, to clarify: hospitals want and expect massive improvement driven by sophisticated software, as long as it doesn’t require messy organizational change, risk, unproven technologies, or executive engagement. If you follow quality guru W. Edwards Deming, you’ll identify one way or another with his statement: “The timid and the fainthearted, and the people that expect quick results, are doomed to disappointment.”

While a conservative position is understandable given how busy everyone is, it does assure that averages aren’t skewed upward by risk-takers who improbably succeed wildly after a gamble on brilliant but unproven information systems.

Einstein defined insanity as “the belief that one can get different results by doing the same thing.” Add “… as every other unsuccessful hospital” to the end of his statement and you will have described hospitals seeking the software silver bullet – more lemming than Deming.

News 8/10/12

Top News

Allscripts reports Q2 results: revenue up 4%, EPS $0.04 vs. $0.08 (adjusted: $0.16 vs. $0.22), falling short of analyst estimates on earnings. The company raised earnings expectations for 2012 and says it will borrow money to buy back its own stock, sending shares up 18% on Thursday. Puzzling given the current lackluster results right there in black and white, but perhaps this was a relief rally since no new bombs went off like last quarter and pessimism was already built into the share price. Some highlights from the conference call:

• Two new Sunrise clients signed on in the quarter, one of them in the UK.
• The company says it continues to “make progress enhancing the performance and integration of our portfolio."
• Sunrise Financial Manager is entering early adopter phase and is scheduled for general availability in Q4.
• The company admits that upgrades have been spotty as some clients "experienced challenges."
• Allscripts expects 4,000 attendees to attend the Allscripts Client Experience in Chicago next week.
• The company says it expects to win more hospital business in the next year since unnamed competitors have "started to step away."
• Glenn Tullman admits that some prospects were holding back in case more corporate surprises surfaced or the company turned in a disastrous quarter, but says "the selling environment is going to come back."
• MyWay sales were announced as flat, with more of its users moving to Professional.
• Allscripts Professional will have an iPad version released at ACE.
• Glen Tullman describes Sunrise as "affordable, easy to install, and open."
• Glen Tullman: "The open message is starting to resonate … paying these astronomical amounts to installed a closed system doesn’t make sense for the future … they simply can’t afford it anyway … healthcare is going to get squeezed … we’re in talking to a lot of customers, including some customers who are saying, hey, we have this big system that’s from a well-known brand and we can’t afford it anymore, so how can you help us take down our cost.."
• More Glen Tullman: "And relative to population — health and population management, Humedica is our partner there. As full disclosure, we have an ownership stake in Humedica, that they’re known as industry leader in the space and we’re strengthening both our marketing and sales efforts, but we are also strengthening the integration between the products."
• On the relationship with clinical research organization Quintiles: "But as we talked about creating a partnership to improve research, that benefits the clients, it benefits the patients and it benefits pharma "

Reader Comments

The mere selling or providing of software to a covered entity does not give rise to a business associate relationship if the vendor does not have access to the protected health information of the covered entity. If the vendor does need access to the protected health information of the covered entity in order to provide its service, the vendor would be a business associate of the covered entity. For example, a software company that hosts the software containing patient information on its own server or accesses patient information when troubleshooting the software function, is a business associate of a covered entity. In these examples, a covered entity would be required to enter into a business associate agreement before allowing the software company access to protected health information.

From Digital Bean Counter: “Re: personnel updates. Michael Streetman has joined WellStar as VP of IT. His LinkedIn profile does not yet show the update. I am fairly certain Michael is Jeff Buda’s replacement (Jeff left for Floyd Medical Center, as you reported).” Unverified.

From Love is a Drug: “Re: HIMSS. Continues to demonstrate a complete lack of leveraging basic online business and IT practices. First it was the horrible, long post-conference survey, and now this week it tested a listserv in production, filling by inbox with a dozen garbage messages. They’re not moderating the comments on their mHIMSS site, allowing search engine manipulators to post spam. The industry is lost if this is our leader.” I see they’ve added CAPTCHA spam protection to their commenting function and have removed the garbage comments that were posted earlier.

From Chester the Investor: “Re: technologies. Speech recognition came out of nowhere after many years of dormancy to suddenly be the hottest thing in the sector, as just about all the players were acquired over a short period. Is there a similar technology that will follow that trajectory?” Real-time location systems.

From Pilsner Paul: “Re: surveys. How can vendors influence surveys conducted by reputable survey firms? You say they do, but I don’t see how.” The best way of all is the method drug companies have been using for years to get positive research articles published: commission a bunch of them, then toss all the ones whose findings don’t match your marketing plan. Nobody knows that the one good research paper represents 50 that failed to prove anything positive and therefore never saw the light of day (note to self: why doesn’t FDA require all research to be registered with them in advance as with hospital IRBs so we see all the results, not just the favorable ones that get published?)

From Hurry & Wait LLC: “Re: Meaningful Use. I’m hearing that OMB now has the final rules from ONC/CMS. However, it may take until the fall of 2012 (think turkey and stuffing) for the final rules to be published. With that comes the requirement that the MU2 attestation period will be 90 days in Year 1.”

HIStalk Announcements and Requests

If work, vacation, or Olympics TV viewing got in the way of reading HIStalk Practice this week, here are some highlights: a UC Medical School physician says EMRs are expensive, take time to implement, and decrease office efficiency. CareCloud adds a VP of product management. AAFP supports new measures to reduce prescription drug abuse. Better economic conditions and new insurance plans that support preventative care services helped drive clinician visit volume up 5% in Q2. The ever irreverent Joel Diamond considers the meaning of “ACO.” Kyle Swarts of Culbert Healthcare Solutions tackles business intelligence and the need to create a body of knowledge. My fragile self-esteem gets a boost each time a new subscriber takes the required two seconds to sign up for e-mail updates, so thanks for taking the time to boost my mental health. Thanks for reading.

Thanks to the folks at Vitera Healthcare, sponsoring both HIStalk and HIStalk Practice at the Platinum level. I figured we’d made them mad since they previously sponsored awhile back, but apparently their was some mixup that they’ve fixed by rejoining the fold of happy sponsors. They’re talking about the newly released Vitera Intergy v8.00 if you’d like to click on over to reassure them that they made the right decision. Thanks to Vitera.

This is the point where I cheerfully warn anyone who doesn’t already know (noobs) that I’m always behind, so set your expectations appropriately for me to respond to e-mails. Picture your own full-time job, then another 4-5 hours of heads-down focus when you get home, plus all weekend — that’s pretty much my life right there. My “sent” folder has 25,000 e-mails, so that gives you an idea of how long it takes to work my way through my inbox, which usually has hundred of e-mails crying for attention. I try to catch up over the weekend, so wait until Monday at least before resending, which just makes the situation worse. After nine years of writing HIStalk, I’m cured of the shame of not always being able to keep all the plates spinning in the air at once, so now I just say that’s the way it is.

I know how to keep women happy and dewy-eyed satisfied, at least if the ladies in question are Inga and Dr. Jayne, who will reward your skilled electronic touch (male or female) with a rapt, smoldering gaze of longing and maybe even a more intimate connection if you play your cards right. Here’s the move: (a) sign up for spam-proof e-mail updates; (b) arrange to have your paths cross by surreptitiously seeking them out on the usual social not-working sites (Facebook, LinkedIn, Twitter) and connecting with them; (c) influence them through their friends by reviewing those shimmering sponsor ads to your left and possibly perusing the surprisingly robust Resource Center that has cool, searchable sponsor information and maybe even some videos and stuff; (d) stand out in their crowd of smitten admirers by sending news, rumors, guest articles, and anything else that demonstrates your wit, wisdom, and charisma since everybody likes someone who can make them laugh or feel special; and (e) feel free to tell everyone you know about your shared experience — the ladies have enough reader love to go around. We appreciate your attention in whatever form it takes and we reciprocate whenever we can.

Acquisitions, Funding, Business, and Stock

Shares of Accretive Health fell more than 14% Wednesday after the company reported earnings that missed expectations and lowered its revenue forecast. Shares are down 41% since April 24, the day the Minnesota attorney general accused the company of using overly aggressive hospital collection tactics. The company tried to put some positive spin on the glum report by announcing that it has signed a five-year contract extension worth up to $1.7 billion with its largest customer, which to the slight detriment of the big news, happens to be partial owner Ascension Health.

Meditech files its 10-Q for the most recent quarter. Revenue was up 9%, net income increased by about the same percentage.

People

University Hospitals (OH) names John Foley (West Penn Allegheny Health System) as CIO.

NaviNet appoints Frank Ingari as CEO, succeeding Bradley J. Waugh. He was previously CEO of Essence Healthcare, a sister company of Lumeris Corporation, which acquired NaviNet earlier this year.

Cloud computing vendor ClearDATA Networks hires Ralph Reyes (an early partner in KLAS) and Jonathan Russell (HMS) as sales VPs.

CareCloud names Edwin Miller (Cardinal Health) as VP of product management.

Old news, but I missed the announcement if there was one: Jacque Dailey, formerly CIO of UPMC’s Children’s Hospital of Pittsburgh, is now CIO at Highmark.

Announcements and Implementations

Regional Medical Center at Memphis (TN) completes its six-month implementation of perioperative and anesthesiology systems from Surgical Information Systems.

The local paper in Cranston, RI profiles the use of GetWellNetwork by an 11-year-old boy whose rare skin disease requires frequent hospitalizations and surgeries. His condition precludes the use of his hands, so he has learned to use Facebook, control on-screen entertainment functions, and peruse medical education content by using his feet on the touch screen (he says he got a ton of Facebook Likes when he explained how he was posting.) If you watched the video I posted a couple of weeks back from the GetWellNetwork user conference in Orlando, you saw him (Antonio Torres) speaking to the group.

Grand Itasca Clinic & Hospital (MN) goes live next week on Epic (or EPIC, as they apparently can’t resist shout it out proudly), provided by Allina.

The Phoenix business paper covers the work of Dignity Health and the Arizona State Physicians Association to create an accountable care organization with Vanguard Health Systems, which will allow independent physicians access to an HIE powered by Siemens MobileMD.

Government and Politics

CMS releases details on the Medicare EHR Incentive Program 2012 Reporting Pilot for eligible hospitals and CAHs.

Other

The Geisinger-led Keystone Beacon Community (PA) will use Caradigm’s data-sharing technology to allow skilled nursing facilities to contribute their patient data to the HIE, even if the facilities do not have an EHR. The Caradigm “MDS to CCD Transformer” converts the minimum data sets (MDS) used by nursing homes into Continuity of Care Documents.

Columbus Regional Hospital (IN) blames its new EHR for temporarily doubling its average ED wait time to nearly five hours. Two months after the go-live, the average wait is still more than three hours, worse than before. The system vendor isn’t mentioned, but they were a Meditech site at one time.

A federal judge approves a whistleblower lawsuit against Florida Hospital Orlando and several other Adventist Health System hospitals in Central Florida. A former billing employee says the hospitals overbilled the federal government tens of millions of dollars in false or padded medical claims. The attorney for the plaintiffs says damages could exceed $100 million, barely containing his excitement over his mentally tabulated percentage.

CapSite’s 2012 US Medical Device Integration study finds that nearly two-thirds of 400+ bed hospitals recently bought such technology, with many of them implementing it right now. Cerner and Capsule were the most common vendors, with Capsule easily leading the pack in the 400+ bed range. iSirona is getting an equal number of looks from those considering vendors. The primary reasons for implementing medical device integration was to improve outcomes and efficiency. Of those big hospitals that haven’t bought yet, an amazing 82% say they’re planning to, most of them within two years.

A new KLAS report on hospital clinical system finds that when it comes to new wins, it’s pretty much all Epic with a bit of Cerner thrown in and everybody else eating their dust. There’s not even a clear-cut third-place winner for reasons spelled out in frank detail (remember, these are customers talking, not self-proclaimed experts.) Epic sold 54 hospitals of 200+ beds in 2011 and lost none. Biggest losers were GE Healthcare, McKesson Horizon, and Meditech (who lost more current product users than legacy product users.) Thanks to the folks at KLAS for allowing us to excerpt their report. Definitely worth a read if only to hear the customer-provided counterpoint to what some glass-half-full vendor CEOs are saying.

A federal monitoring team hits Parkland Hospital (TX) with scathing criticism about poor management and a quality culture that allowed patient-harming errors (and deaths) to occur. One bright spot: the report said Parkland was doing a pretty good job in enhancing its clinical systems (in other words, Epic is the best thing happening there, according to the report.)

A Reuters article frets that Obamacare will make it easier to identify and deport illegal aliens who seek medical care since they’ll be the only people left without an insurance card.

The teenager accused of impersonating a PA at Osceola Regional Medical Center (FL) and performing CPR on one patient, blames hospital personnel for giving him the wrong ID card. He says it was the hospital’s “stupid” mistake and that whoever made the error should be fired “because apparently they are too ignorant to have that position.”

Strange: in England, an NHS hospital ED doctor who took a six-month paid sick leave for stress and then worked at other hospitals goes on trial for defrauding her primary employer of almost $50,000. She was turned in by her former boss (also her married former lover) after boasting of her “megabucks” and “stupid amount of dosh” on Twitter, catching the attention of the former boss’s wife. The doctor said she worked the extra shifts to keep her clinical skills current.

Sponsor Updates

• Medicomp Systems announces its MEDCIN U conference October 14-16 in Reston, VA.
• dbMotion and Allscripts host a free webinar September 18 on preparing for accountable care within the workflow.
• Imprivata announces details of its HealthCon 2012 user conference November 6-8 in Boston.
• Alere Health and AT&T partner to deliver DiabetesManager,  a mobile health solution powered by WellDoc for type 2 diabetes management.
• Jay Savaiano of CommVault authors an article on big data in healthcare.

EPtalk by Dr. Jayne

It’s not just for pharmaceutical companies any more. ONC uses direct-to-consumer marketing to explain “how widespread adoption of electronic health records and other health information technology is giving our health care system a 21st century upgrade.” The animated video from ONC’s new Office of Consumer eHealth aims to “spark conversation” between patients and providers about leveraging technology. The opening slide shows various caregivers, including ‘my doctor’ and ‘my gynecologist.’ (last time I checked, gynecologists were doctors, too.) Some of the other graphics are downright goofy: a stereotyped female nurse in old-school whites and a cap and a hipster pharmacist who needs a shave.

All the health IT in the world can’t fix the fundamental problems: many people eat too much, don’t exercise enough, and indulge in habits with negative consequences. A Centers for Disease Control report published Tuesday corroborates this. The study was designed to assess the prevalence of walking, which was defined as “at least one bout of 10 minutes or more in the preceding 7 days” which is really quite minimal. Not surprisingly, one out of three US adults reports no aerobic exercise during leisure time and less than half report levels of activity meeting current guidelines.

In trying to convince patients of the importance of exercise as “medicine,” I started recommending the Presidential Active Lifestyle Award challenge program. Anyone age six or older can sign up for the six-week program and jump start their exercise plans. As an added bonus, those of us who weren’t proficient at the flexed arm hang or the shuttle run in middle school have another chance to earn a cool patch with the Presidential seal. The downside: the website is a little glitchy and they don’t have a mobile app. Perhaps the folks at ONC could help out.

I came across this publication in the AHIMA library: Ensuring Data Integrity in Health Information Exchange. It offers a good, high-level overview for anyone starting involvement with HIE. They address governance up front, which is unfortunately something quite a few HIEs fail to do effectively. This should be required reading for all tech people working on HIE projects so that they understand the big picture.

Thanks to Twitter to alerting me to this piece by Atul Gawande talking about how restaurant chains control quality, cost, and innovation. He wonders if health care can learn from the Cheesecake Factory. I found the discussion of “guest forecasting” and restaurant analytics fascinating and agree with Gawande’s premise. We need to be using aggressive analytics throughout healthcare and enable highly functional teams throughout the patient care space. He also talks about his mother’s knee replacement experience, which is timely for those of us with parents in the Medicare set.

Have an idea how long you have to spend on the treadmill to neutralize a piece of cheesecake? E-mail me.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Readers Write 8/8/12

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.

RTLS: A No Brainer to Enhance Top-Line Revenue and Drive Clinical and Financial Improvements
By Deborah Tuke Bahlman RN

Real-time location systems (RTLS) are underutilized in the health care domain. I consider myself and my organization fortunate to have access to this technology and can’t imagine what life would be like without it.

Just a little over a decade ago, our periop staff, surgeons, and anesthesia teams spent considerable time using the phone to determine the patient’s physical location and stage of care. Communicating this information by phone is inefficient and a waste of precious patient care time, resulting in numerous phone calls, potential delays to surgery, and an environment not conducive to healing and quiet.

At our two large flagship facilities in Oregon, we have more than 75 operating rooms. We have been able to accommodate growth by eliminating inefficiencies — like multiple phone calls — and can now find equipment quickly at the click of a mouse.

To accomplish this, we installed a real-time tracking system. We spent 18 months analyzing workflow and working with the vendor to design the application. We piloted the system in 2002, starting with asset tracking and then expanding it to track patients. This gave us the ability to locate people and equipment in real time and improve workflow, communication, patient throughput, and care delivery efficiency. The ability to instantly locate needed equipment also had a positive impact on the bottom line by reducing unnecessary purchases and rentals.

The benefits have been impressive. There are three key ways a hospital can optimize clinical performance, workflow, revenue, operations, and patient safety with RTLS:

1. Tracking. Being able to quickly identify and track any tagged equipment, staff, or patients anywhere within a facility equates to on-time procedures and efficient use of nurses’ valuable time. It helps staff easily locate assets, maintain an accurate inventory, and adhere to regulatory requirements. RNs typically spend about one hour per shift looking for missing equipment, additional staff, or the actual patient. This unnecessary time contributes to delays in 30% of all scheduled surgeries.
2. Rentals. The average US hospital owns or rents at least twice as many mobile medical devices (pumps, vents, wheelchairs, etc.) than it actually needs. RTLS provides visibility into inventory which enables facilities to better match supply with occupancy and acuity needs, which can eliminate excess inventory and result in significant cost savings.
3. Preventive maintenance. RTLS improves the timeliness of preventive maintenance by providing data that helps hospitals identify process inefficiencies in equipment management including cleaning and sterilization. Up to 25% of mobile assets are not properly cleaned between patients, resulting in hospital-acquired infections that can adversely affect a hospital’s bottom line now that insurers have stopped coverage for those conditions.

It is astounding that only 10% of hospitals have implemented RTLS, which can quickly boost top-line revenue. With health systems wrestling with declining reimbursement rates and increased regulatory mandates and quality improvement initiatives, the pressure to improve operational efficiency and care has never been greater.

For Providence St. Vincent Medical Center and Providence Portland Medical Center, RTLS has been a true asset. We plan to further maximize our RTLS investment by integrating it with our new EMR. The integration will streamline access to lab results, medication lists, and other critical data, positioning us to meet the challenges of the rapidly changing health system.

Deborah Tuke Bahlman RN is system manager of surgery information systems at Providence Health & Services of Renton, WA.

Carrying the Torch
By Guy Scalzi

As part of the Olympic coverage, I’ve learned more about the significance of the Olympic Flame and the journey it takes through the host country before the last torchbearer lights the cauldron at the opening ceremony in the Olympic Stadium, marking the official start of the Games.

As you know, the Olympic Flame stands for peace, unity, and friendship. As part of the London 2012 Games, 8,000 inspirational torchbearers carried the Olympic Flame through more than 1,000 cities, towns, and villages in the UK over a 70-day journey delivering that message: peace, unity, and friendship.

The stories of the torchbearers are inspiring, and the images of the 70-day relay journey are truly breathtaking. I encourage you to read their stories watch some of the relay footage.

You and I both know that it took many more than the 8,000 torchbearers to make this accomplishment possible. Day in and day out, all of us in the HIT field support our torchbearers – the nurses, physicians, and other clinicians at the bedside delivering care. And yes, our flame represents patients and their care quality and outcomes. We all play a part in carrying the torch, and it’s essential to keep our eye on the flame — the patient. The more the human element is kept at the forefront by all of us, the better healthcare will get.

I was invited to the Yale Medical School graduation in 2010 and heard Don Berwick MD speak to the class. He emphasized that the person-to-person, clinician-patient relationship and interactions are possibly the most important part of care giving. Two points he shared struck me:

• “All that matters is the person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wandering mind. The learned mind. The Husband. The Wife. The Son. The Daughter …”
• “Those that suffer need you to be something more than a doctor; they need you to be a healer. And to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace and treasure the memory of your shared, frail humanity …”

We in the IT realm don’t interact with patients for the most part, but we do interact a lot with the clinicians who treat the patients. If we listen to them, respect them and their work, and relate on a human level, I think this will translate to a better use of technology and perhaps have a ripple effect.  

As I shared earlier, the more the human element is kept at the forefront by all of us, the better healthcare will get.

Guy Scalzi is a principal with Aspen Advisors.

Four Tips for Addressing Healthcare IT Implementation Costs
By Walter Reid

A recent KPMG poll confirms that hospitals continue to struggle with managing implementation costs of healthcare IT systems, including electronic health records (EHRs). However, hospitals would do well to take a broader look at their entire IT agenda and make a long-term commitment to maximizing value from those investments.  Below are a few ways to better address the healthcare IT implementation challenge. 

1. Get more from the core. It’s been estimated that most providers only use about 50% to 80% of their IT system’s core clinical and revenue cycle features, and many routinely under-invest in learning about new releases. By re-evaluating your core system capabilities, you can analyze whether or not you are fully leveraging existing resources. Such steps will go a long way toward making the most of the technology you already have.
2. Promote from within. If you work with your HR team to develop your own internal “champions of change,” you can drive adoption of clinical informatics and reduce the expense of costly external consultants. That’s not all, as internal champions also can help you further generate – and sustain — system uptake to achieve long-term value. In addition, ensure your systems are readily accessible with easy-to-use applications, based on a familiar industry standard such as Microsoft Windows, as that can further encourage ongoing use of IT.
3. Keep it simple. Select an HIS with fully integrated applications and a single-database design. This will help your organization streamline current solutions, retire dormant third-party applications, and consolidate IT providers. Doing so provides opportunities to reduce acquisition costs, system complexity, and maintenance by requiring less hardware and fewer servers. In addition, systems with a faster deployment period and a lower total cost of ownership help ensure that hospitals achieve cost savings over both the short and long term.
4. Collaborate. Hospitals should expect greater flexibility and collaboration from those entrusted to develop, deliver, and deploy their critical HIS technology. Move beyond just demanding discounts and suggest collaborative win-win solutions that work for both you and your vendor. This includes offering flexible delivery options, new implementation alternatives, and more efficient and effective methods of system training, including using Skype or other web-based methods.

Ultimately, reducing healthcare IT implementation costs starts with IT vendors themselves. Those that demonstrate a willingness to truly partner with you and provide simple, flexible, cost-effective options are best positioned to help you achieve better business and better care.

Walter Reid is vice president of product strategy and marketing with McKesson.

Consumer Reports Points to Opportunity to Improve Patient Communications
By Tim Kelly

I used it before I purchased my last car, digital camera, and just a month ago when I purchased virus protection software. The “it,” of course, is Consumer Reports (CR) magazine. If you are nodding in understanding, you and I are like eight million other Americans who reference that publication to evaluate automobile tires and scrutinize models of the latest electronic gadgets.

It is thus intriguing that CR has, for the first time, introduced hospital ratings in its August issue. Until now, there were few well-known resources to compare one hospital to another. Arguably, both The Leapfrog Group’s Hospital Safety Score program and Health & Human Services’ Hospital Compare website are readily available to prospective patients. However, neither is “mainstream” and familiar to the readers of CNET, Yelp and TripAdvisor.

Consumer Reports readers will immediately recognize the standardized format with which hospitals are ranked. Safety scores are presented as horizontal bars with a numerical value, while the other key rating categories contain familiar red and black blobs. Both metrics are characteristic of CR ratings for hundreds of products and services.

Unlike the cleaning performance of a laundry detergent, the quality of care offered by a hospital is extremely difficult to summarize with only a number and a few shaded circles. Critics will argue that the historical data employed for the CR rankings is by default out of date when presented, imprecise, and limited in scope, failing to provide a complete picture of the organization. Ironically, those same concerns apply to the just-released U.S. News & World Report rankings of Best Hospitals. Yet for 23 years, hospitals have proudly cited their top U.S. News rankings on their organizations’ websites and in their press releases.

Clearly, the difference between the U.S. News approach and the Consumer Reports approach is that as an independent, non-profit organization, the publishers of CR do not hesitate to be critical – even to the extent of identifying the “Bottom 10 Hospitals” in their rankings. CR is also quite comfortable copiously assigning black blobs – its “worst” rating. Nowhere are the black blobs more abundant within the hospital ratings than in the “Communication” category. The CR article reports that not a single hospital earned its top score for communications.

This glaring weakness will have many in the HIT community scratching their heads. Conceivably, patient communications can be improved with proportionally less effort than might be required for other categories, such as rates of hospital-acquired infections or readmissions. A three-year study of 394,000 Kaiser Permanente members, published in the July issue of The American Journal of Managed Care, found that use of Kaiser’s online personal health record tools made patients 2.6 times more likely to remain members of Kaiser. The Kaiser experience demonstrates how technology can easily be deployed to assist patients with better understanding their procedures, how to prepare for surgery, what to do when discharged, and how to take new medications.

Consumer Reports has introduced a new ratings system, one that provides easy-to-understand comparison data on 1,159 hospitals. The ratings are from a recognized, trusted source, and they are presented in a familiar, digestible format. The impact, if any, of CR ratings on consumers’ choice of hospitals is unknown. The opportunity to redouble efforts to deploy HIT initiatives to improve patient communications should be clear to all of us.

Tim Kelly is vice president of Dialog Medical.

News 8/8/12

Top News

The board of the Kansas HIE, having found few takers for its fee-based services, meets this week to decide whether to dissolve itself and turn its operation over to the state, hoping to reduce its $400,000 in annual operating costs. Taxpayers would be on the hook to cover the remaining half of its costs. Former Kansas Governor Kathleen Sebelius, now HHS secretary, convened the commission that recommended creating KHIE by executive order in 2010, which makes it questionable as to whether the group has the legal authority to simply disband itself. KHIE funded its operations with a $9 million federal grant and has $5.5 million left.

Reader Comments

From InTheKnow: “Re: Alere. Just closed a deal to acquire DiagnosisOne.” Verified, but not announced as far as I can tell. Alere (the former Inverness Medical Innovations, which acquired interoperability vendor Wellogic last year ) offers diagnostic and health management  technologies and programs, while DiagnosisOne sells tools for order sets, decision support, analytics, and public health surveillance. DiagnosisOne is backed by Edison Ventures, which is how I verified the rumor after digging around forever – the acquisition was buried on one of the pop-up pages on their site.

From Justa CIO: “Re: Indiana University Health. Announced that Bill McConnell, Jr. started this week as CIO, replacing Chris Van Pelt, who has left the organization.” Verified. Bill has updated his LinkedIn profile showing that he started this month. He was previously CEO of FlowCo, which makes a stent-related medical device.

From Jeremy: “Re: 3D printed medicine. How would people feel about their EHRs printing the medicine ad hoc?” A research paper speculates that a 3D printer could be loaded with pre-filled, drug-containing vessels, allowing medications to be “printed” on demand.

From Rick Starkey: “Re: JAMA article. Very entertaining.” Indeed it is. John Lennon’s Elbow, by Robert H. Hirschtick MD from Northwestern University’s Feinberg School of Medicine, is funny as it criticizes EMR documentation with Beatles references (I won’t give away its conclusion, which yielded the title.) A snip:

I once asked an intern why his successively longer daily progress notes retained old or irrelevant test results. His response was revealing: “This way, my final progress note is also the discharge summary.” This Twelve Days of Christmas approach—building a final supernote by successive daily addition—yields a discharge summary that is long, thorough, and unreadable. Unreadability is a problem only if readability is a goal. But these notes are not constructed to be read. They are constructed to warehouse data. All the key information is contained within but as hard to find as a radial pulse beneath multiple color-coded wristbands.

From Consultant: “Re: Providence Health Systems. They are slowing down their Epic implementation, one of the largest in the US to learn from initial go-lives.” Unverified. The $750 million implementation was announced in 2010 and the first go-live was originally planned for 2012, with a 30-month completion timetable.

HIStalk Announcements and Requests

My top Olympics’ observation of the day: water polo players rock. Twenty-eight minutes of treading water and swimming and throwing a ball? The athleticism of it has almost inspired me to jump off the couch and go for a run. And speaking of runners, how about Felix Sanchez, the 35-year-old from the Dominican Republic who won the men’s 400m hurdles? Way to beat the youngsters. And speaking of youngsters, I am adding Uruguayan footballer Edinson Roberto Cavani Gómez to my Hot Olympian list.

Acquisitions, Funding, Business, and Stock

HCA reports Q2 results: revenue up 12% to $8.1 billion, EPS $0.85 vs. $0.43. The company reaffirms 2012 guidance, including estimated EHR incentive income of $325-$350 million and EHR expenses of $90-$115 million. The company also announced that it was notified this week that the Justice Department wants to see records from its heart procedures at certain hospitals. A New York Times report suggested that they performed unnecessary procedures to boost revenue in preparation for HCA’s 2011 IPO.

Mediware  will acquire the assets of Strategic Healthcare Group, an Indianapolis-based provider of blood management consulting.

Nuance announces Q3 numbers: revenue up 31%, EPS $0.25 vs. $0.13.

Staffing company Cross Country Healthcare swings to a Q2 loss due to a delay in an unnamed large EMR project for which it provides staffing.

It’s not healthcare related, but it’s a cautionary tale about letting computers do too much thinking (or maybe to do more testing before a rollout.) Stock trading firm Knight Capital, which single-handedly caused wild swings in stock market share prices last week when its newly installed high-speed trading software sent incorrect orders to brokerage houses over a 45-minute period, nearly goes out of business when the SEC holds it accountable for the $440 million in erroneous trades its software caused, four times the company’s profits last year.

Sales

Orlando Health (FL) selects onFocus epm software for enterprise performance management.

Muenster Memorial Hospital (TX), United Hospital District (MN), and Rothman Specialty Hospital (PA) sign with Park Place International for its OpSus|Live cloud-based hosting solution utilizing Meditech-certified servers and storage.

Poudre Valley Hospital (CO) selects ProVation Medical Software for gastroenterology procedure documentation and coding in its GI labs.

Windsor Health Plan will deploy MedHOK’s care, quality, and compliance platform that includes NCQA certified software for HEDIS, pay for performance, and disease management performance measures..

Anderson Hospital (IL) selects M*Modal Fluency Direct for use with Meditech in the hospital and NextGen in its physician offices.

Allied Services (PA) signs a contract to implement Cerner Millennium. It offers rehab, vocational, home care, and residential services.

Announcements and Implementations

South Lyon Medical Center (CA) goes live on CPSI’s EHR.

Powell Valley Healthcare (WY) goes live on NextGen’s Inpatient EHR.

Orion Health is named a reseller and services provider for Caradigm’s Amalga platform and Vergence SSO software in the Asia Pacific region.

McKesson announces McKesson Cardiology Inventory and McKesson Surgical Manager Point-of-Use Integration Module which allows a clinician’s single barcode scan to document, charge, and reorder items.

Chicago Mayor Rahm Emanuel proclaims October 30 – November 7 to be Informatics Week (plus a couple of days, apparently), a “city-wide celebration” of biomedical and health informatics that will precede the AMIA meeting there.

The VA begins its RTLS implementation at seven VA VISN 11 medical centers in Indiana, Illinois, and Michigan. HP is managing the project, which involves several brands of sensors providing real-time information to its Intelligent InSites RTLS software to track equipment and supplies, monitor temperatures, and trigger workflows. The $543 million project will eventually cover 152 medical centers.

Hospitals in Franciscan Alliance Northern Indiana Region go live on Epic, right on time from their project plan.

Zynx Health announces Version 3.0 of its AuthorSpace clinical decision support authoring tool.

Katalus announces an EHR Total Cost of Ownership model that will be offered as a cloud-based solution.

Government and Politics

The Substance Abuse and Mental Health Services Administration awards $4 million in grants to six organizations for HIT tools to expand access to substance abuse treatment in underserved areas.

Innovation and Research

Researchers from NorthShore University HealthSystem (IL) find that the increased use of EHRs by hospitals and health systems could help physicians make more exact, real-time decisions when prescribing antibiotics.

Technology

Health engagement management provider Eliza Corporation receives a notice of allowance from the patent office for its Complex Acoustic Resonance Speech Analysis System, which provides conversational, high-performance speech recognition.

Other

Hospital officials at Olympic Medical Center (WA) tell commissioners that their ongoing transition from Meditech to Epic will cost about $6 million, with ERP software from Infor/Lawson running an additional $1 million.  

A blog post from John Glaser of Siemens Healthcare compares his selection to throw out the first pitch at a baseball game to the impending accountability of healthcare IT to improve care (in neither case would you want to pull a Baba Booey in front of a crowd.)

HHS records show that the medical records of 21 million patients have been exposed by breaches since September 2009, with six organizations reporting incidents that affected more than a million people. Leading the pack is the federal government itself, whose Department of Defense / TRICARE (specifically, federal contractor SAIC) lost backup tapes during shipping in September 2011 that contained information on 4.9 million individuals.

ONC’s Office of Consumer eHealth puts out a video pitching EHRs to consumers.  

If you’re an Epic competitor, there’s not much good news in the KLAS Mid-Term Performance Review from June that a reader just sent my way. Unless you sell anesthesia information systems, anyway.

A pharmacy technician at University of Miami who “seemed to live beyond his means” in paying $56,000 in cash for a BMW is suspected of stealing $14 million in drugs from the cancer center pharmacy over a three-year period. The university’s CFO admits that the pharmacy had no inventory controls at all in place. The technician was caught pocketing drugs on surveillance cameras, but his lawyer says that while he did steal some drugs, it could have been anyone who nabbed the $14 million worth since anybody could just grab what they wanted. He was caught when the pharmacy buyer noticed discrepancies in the quantities on hand of the drug Neulasta, which she then inventoried manually since the new inventory software “was not the most trustworthy.”

Seattle Children’s Hospital, trying to cheer up a 16-year-old cancer patient who has been hospitalized in isolation for months and missing her cat Merry, crowdsources through Facebook to collect 3,000 cat photos to project in a “virtual feline cocoon” they built for her. Her response: “You guys remind me that there is so much good in the world, and its just makes me feel so much better, and connected. I can’t tell you how it feels sometimes, feeling disconnected and cut off from the world, and then with something like cat pictures bringing me back.”

Sponsor Updates

• GetWellNetwork launches a video on the future of patient engagement using interactive patient care solutions.
• Billian’s HealthDATA recognizes five hospitals to watch on Twitter.
• e-MDs hosts a webinar featuring Jen Brull MD, FAAP and her practice’s use of social media to build community and engagement with patients.
• GE Healthcare releases details of its Centricity Perinatal National Users Group conference in October.
• OTTR Chronic Care Solutions will participate in next week’s NATCO Conference in DC.
• Forrester Research names Covisint a cloud identity and access management leader in its Enterprise Cloud Identity and Access Management report.
• A Surgical Information Systems survey indicates that drivers for implementing perioperative IT include facilitating improvements in OR efficiency, the quality of patient care, and reduction of documentation errors. 
• Howard County Medical Center (NE) selects BridgeHead Software’s healthcare data management solution as its backup and archival system.
• Cumberland Consulting Group promotes Mark Riley to principal.
• T-System hosts a free webinar on proper documentation of E&M services to optimize reimbursement.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 8/6/12

One of the things my organization has always struggled with is the concept of professional development. Of course we require the physicians, nurses, and other licensed professionals to attain the required hours of continuing education in their respective fields. For all the other disciplines where it is not mandatory, we tend to do a relatively poor job.

Case in point: physicians and nurses who transition from clinical practice to administrative positions are no longer granted continuing education time or funding. Although we’re required to keep licensure, it’s up to us to do it on our own.

Those of us in the IT realm have come up with creative ways to earn our hours, such as attending sessions at our vendors’ user group meetings that have been granted continuing medical or nursing accreditation. Others teach medical students and residents or simply complete online continuing ed classes. While that meets the letter of the law, I’m not sure it does much for us as far as professional development.

Being a CMIO, CMO, or medical informaticist requires skills we weren’t born with. It is important to keep up with the constantly changing environment in which we work. It’s critical that people operating in those roles be allowed time and funding to attend formal programs to enhance their knowledge of healthcare IT, software, change management, conflict resolution, process improvement, and the many other disciplines that make the difference between successful projects and failures.

Considering this, it was a rare treat when I had the opportunity recently to attend formal training with our vendor. My last “official” training on our primary system was at least five years ago, and I must say that at that time I had no idea what I was getting myself into. It isn’t as if I’ve had no training since then, but the training that I’ve been able to attend has been very focused – around specialties that are being deployed, planned upgrades, and of course Meaningful Use. There hasn’t been much of an opportunity to really look at the EHR product as a whole and how it’s implemented in our hospital.

As I sat in the training center surrounded by soon-to-be new users, I enjoyed seeing their eager faces and lack of cynicism. It was fun to be the grizzled veteran in the bunch. We went through the applications from the ground up and what I learned was surprising.

Although we are among some of the most robust users on the company’s client list, there is still so much that we’re not using. I quickly learned of a handful of features that could make our providers’ lives easier and also some that would ease the burdens of configuration maintenance. It was also good to network with medical leaders of organizations who are late adopters. They have a very different view of things than those of us who are used to being on the cutting edge, and our after-class conversations were full of great ideas.

It really caused me to think about how we missed finding these items over the past several years. I’ve decided it was because the team was thinking like the IT equivalent of physician subspecialists rather than as primary care specialists. To put it in clinical terms: while we were focused on the musculoskeletal function of the wrist, we missed hearing about the latest and greatest strategies for health promotion and disease prevention. When faced with new features, we may not have understood how we could benefit from them, so we passed them by and never came back to them (usually because our team is running 90 miles an hour with dozens of competing priorities, so I completely understand how it happens.)

I’m encouraging our leadership to plan to fund opportunities for various team members to attend formal training sessions at least every few years so that we don’t find ourselves missing out on features or workflows that could have been beneficial. At the same time, I’m hoping that the experience will give concrete proof to the hospital’s administrators as to why it is important to facilitate learning opportunities for its medical leaders.

Have a great idea about professional development? E-mail me.

E-mail Dr. Jayne.

HIStalk Interviews Simon Arkell, Two-Time Olympian and CEO of Predixion Software

Simon Arkell is CEO of Predixion Software of San Juan Capistrano, CA. He represented Australia as a pole vaulter at the 1992 Summer Olympics in Barcelona, Spain and at the 1996 Summer Olympics in Atlanta, GA.

Tell me about yourself and the company.

Predixion Software is a three-year old company. We formed it back in 2009  in order to leverage what we thought was a big opportunity in the business intelligence market. That was this space of predictive analytics, which has historically been technology that is only attainable to the very most-trained data scientists and PhDs with very expensive and complex toolsets. We thought that there would be a great opportunity to take that and break down those barriers to predictive analytics and make it more available to many more people. At a very high level, that’s been our vision since Day One.

I’ve been involved in enterprise software for most of my career. I was a co-founder of a number of companies and have raised money from venture capitalists. I’ve even gone over to the dark side and done investment banking and private equity for a little while in order to really learn the business. Each time I came back to an operational role, where I just believe that this particular opportunity was the best I’d seen in my career.

The reason for that is that my co-founder and our chairman Stuart Frost had sold his company, which was in the data warehousing space, to Microsoft very successfully. It was his idea to identify predictive analytics as this hot space. The more research I did, the more I realized that we were in a position to not only create a game-changing technology, but also to leverage the success that Stuart had had a DATAllegro with the investor base.

At the same time as starting the company, we were introduced to a gentleman over at Microsoft named Jamie MacLennan, who, long story short, came across and became our founding CTO. Jamie had a vision for many years as head of data mining and predictive analytics over at Microsoft to do exactly the same thing, and that was to bring predictive analytics to the masses and to make it more available.

With that technical firepower in place up in Redmond, we now have a development office in Redmond, and have had since Day One. Our engineering team is effectively the former data mining team or predictive analytics team from Microsoft. With that story, we were able to be very successful in raising venture capital. We have a very large strategic partner — who is also an investor — that we don’t name, along with three other venture capital firms: Palomar Ventures, Miramar Ventures, and DFJ Frontier. We’re getting ready for our next round of investment.

We’ve been very successful in the healthcare space over the last year and a half. That happens to be an industry with a lot of issues and problems that are a great fit for predictive analytics technology. We’re well on our way with a great team in place and getting some really nice early success in healthcare.

What kind of healthcare problems can predictive analytics solve and what kind of data is needed to be able to start using it?

We have seen many problems in healthcare that are a perfect fit for predictive analytics. The low-hanging fruit, and the one that everyone’s talking about right now due to CMS mandates that are coming down and penalties that commence in October, is around preventable readmissions. We call them predictable readmissions.

Effectively, you can get ahead of a problem by predicting an outcome and preventing its outcome. We have nice tagline that says, “You cannot prevent what you cannot predict.” In the case of readmissions, we’re able to assign a risk of readmission to a patient when they admit into the hospital the first time. That admission or readmission probability improves in accuracy throughout the length of stay. At the point of discharge, the hospital is allowed to actually now have very stratified and targeted intervention based on the risk profile of the patient.

Being able to assign a risk profile to a specific patient when they admit the first time is something that’s a game-changing solution. We’re able to apply that concept to many different applications, like predicting hospital-acquired sepsis, predicting the length of stay, predicting which outpatients are likely to become inpatients, and the list just goes on and on. We think that being able to predict a particular outcome is what the industry needs. Customers are absolutely responding in a big way.

How customizable is the prediction algorithm based on what information a given institution has available, based its choice of electronic medical record or whether it’s doing physician documentation electronically?

Very. Everyone wants to build a Lamborghini, but we find that even if you’re not 100% data-ready and have the perfect electronic setup as a provider, you’re able to benefit from this technology. A common term in the predictive analytics industry is that, “lift is lift.” Meaning that if you can get some improvement through machine learning over and above just a human guess, then there’s a return on investment. Over time, if you bring more systems online, that can become more and more effective.

We’re seeing very, very accurate models. It’s fairly easy to determine the accuracy of a model because you just apply it to historical data and see how accurate it was in actually predicting what actually did happen. We’re seeing very accurate models, which are measured in terms of what’s called a c statistic. We have the highest in the industry, because we apply our models and our algorithms to the electronic data – whether it’s clinical data, claims data, etc. – at the hospital level.

We do not rely on a national algorithm, because no two regions and demographics are the same. You may have a hospital in Minnesota in the middle of winter, which would have an entirely different reason for readmissions than potentially one in Florida. By being local, being agile, being easy-to-use and adapt, we’re seeing a lot of uptake from our customers right now.

A few companies did a primitive version of this back into the 1990s, use technology such as neural networks to try to make patient predictions. They really didn’t get very far. Was the problem that their information wasn’t good enough, their algorithms weren’t good enough, or that hospitals weren’t ready to do anything with the information that they were getting?

I think it’s probably all of the above. Obviously there are some hospitals that are now electronically equipped and jumping on board all of the various government initiatives to bring them up to an acceptable level. The algorithms are much more accurate. We’ve got significant domain experience now in applying our algorithms or our technology to this problem set. We’re finding that the accuracy of our models is just as high amongst just about every one of the providers that we’ve used this with.

The other thing that’s much, much different is how you get the regular information worker in a provider network to actually access this information and respond to it. Having someone with a PhD in a white coat in a back room somewhere crank on these models and algorithms in order to get information is one thing, but how do you actually get that out into the hands of a nurse who can do something about it?

We’ve solved that with what we call the last mile of analytics. Two of our customers, just in the last couple of weeks, decided to move forward with our predictive readmissions portal. It’s an HTML5 thin client portal that can be accessed on any workstation or at a nurses’ station or in a hospital room, or even on a iPad or iPhone. It will give the nurse or the case manager a list of the patients that are currently under their care and are inpatients and their risk of readmission.

What we’re working on now with our customers is being able to respond according to a risk strata of the patient. Now all of a sudden your patient population of inpatients has a very low, a low, a medium, or a high risk of readmission. The intervention at discharge can be very different now for the first time. Instead of applying very limited resources to all patients that you discharge because you were using just guesswork as to who might be at the highest risk, we’re now able to create an intervention strategy for the very high-risk patients and medium-risk patients and then intervene on them.

Intervention to a high-risk patient may mean deciding whether to send them to a home healthcare facility or sending a nurse out every second day and then having someone call every day to make sure the patient’s taking their meds. You would therefore be able to put less attention to a very low-risk patient. You can become much more efficacious or accurate in how you intervene with the patients in order to reduce your readmissions rates.

The same concept applies with regard to targeted intervention for hospital-acquired sepsis, fall risk, etc. We’re seeing  a lot of new thoughts and excitement come out of our customers who now are able to do something for the first time that they previously didn’t think was possible. It’s having all sorts of ramifications with regard to brainstorming new ideas and applications and solutions.

That’s maybe the big difference from the 1990s. The idea then was to redesign a process, like using different drugs or creating different care plans, rather than intervening on individual patients, plus there was no economic incentive since hospitals got paid for readmissions anyway. Even though the technology may have been similar in a primitive way, it was a different climate.

Exactly. You know better than anyone as we move from fee-for-service to a wellness-based industry, getting ahead of the problem and actually being able to do something about it before it happens is everything.

The ramifications in the UK are even greater. One of our prospects who is about to move forward with our predictive readmission solution received a very significant fine just last month. It was over a half million dollars, just for having readmission rates at an unacceptable level. So you’re starting to see massive payback from putting in a solution that can solve this problem for you.

And you’re right, retrospective reporting is really what business intelligence has always been up until now. We’re in the business of putting prospective information into these reports so that you can get ahead of the problem and prevent it before it happens. Again, that’s not new; there are great companies out there like SAS and SPSS, which is now IBM, who have these very specialized workbenches. But again, you’re not putting the end results in the hands of a nurse or practitioner who can do something about the output; you’re relegating it to a back room with some guy with a white coat.

Kaiser Permanente is probably the most advanced user of healthcare data in the country and they’re your customer. How are they using your product?

They’re fairly private in how they announce their utilization of our technology and any other, but I will say that they’re being very aggressive with some of the stuff we’ve already talked about.

You made two trips to the Olympics as a participant. What would you say were the best and worst memories?

Good question, because everyone always talks about kind of the excitement and the best parts of it. I have learned a lesson since competing in the Olympics. Enjoying the journey is something to be embraced. I do that now in my career and in my life as much as I can.

The best part by far was living a dream and having it turn into a reality. From the age of 11, all I ever wanted to do was compete in the Olympics. The problem when I was 11 was that I wasn’t very good at anything, so I had to find my way. When I discovered pole vaulting, I absolutely fell in love with it, but realized I wasn’t very good at that, either. But my best friend was very good at it, so we kept getting invited back, and 20 years later, I got to compete.

It was a long, long journey, and one where the biggest lesson for me was that hard work and persistence absolutely pay off. I really was so excited to be walking into the opening ceremonies and marching in the Parade of Nations for the first time in Barcelona, which I then did again four years later in Atlanta. I’d say the worst part, though, was not performing to the extent that I was capable of and being too attached to a specific outcome as opposed to really just embracing and enjoying every second of it.

I would think it must be unusual for Olympians who have focused much of their lives on a single sport to suddenly do a 180 and go out and establish themselves in the world of business, especially a technology-related business. How did you get from one to the other?

The concept of risk is not one that I’m unfamiliar with. When you’re an athlete, especially an individual athlete, it’s all about risk and reward, and the risks that you take and the things that you put on hold in life.

I found that having come from Australia and being so focused on my athletics and getting to the Olympics that my friends were all getting very established in their careers, and becoming more and more senior. I continued to get educated along the way, but I started a couple of companies while I was still competing just to make sure I could get my business chops going. I knew that’s what I wanted to do.

I always felt after I retired from athletics that I had some catch-up to do, and the way to catch up was to start a company and make that highly successful, as opposed to going the common route, which is to and work for IBM or one of the big boys and work my way up. It turned into an entrepreneurial catch-up situation. I’ve been addicted to the high-risk start up environment every since.

I assume you’re watching the Olympics now. Thinking back to when you were a participant, what do you think has changed?

I think it’s much easier for the athletes to get into a whole world of trouble these days because of the advent of Twitter and Facebook. You see it time and time again. Australians were banned for posting photographs of themselves holding guns on Facebook. A triple-jumper from Greece was sent home because she made a racist comment on Twitter. You just see so much more at risk. You’re in even more of a fishbowl now as an athlete than back before social networking. 

I  see that as a big difference, but I still believe in the Olympic philosophy and competing. Competing is a great honor, and something that for me I’ll never forget.

We’re having a lot of fun at the office right now because everyone’s keeping up with the Olympics.  Our partner account manager, Tom Hoff, I’d known from the Olympic movement. He was a member of the US volleyball team in Beijing. He was the captain and they won the gold medal, so, we use and abuse that fact and have him show up at trade shows with his gold medal. Today we’ve brought our marching uniforms in and we’re going to be taking photographs. I’ve got my opening ceremony uniform and my competition uniform and he brought his in as well, along with his gold medal, so we’re going to take some photographs and have fun with it.

Send me the pictures when you’re finished. Any concluding thoughts?

Predixion Software is in the business that is solving such massive problems for the industry. We really believe that we can save lives. Everyone here is just so focused on execution and being successful, because we truly believe that our technology can save lives and really help an industry that needs help. We’re really excited to be in the game and to be going for it.

Monday Morning Update 8/6/12

From Fact Checker: “Re: New York Times editorial. Implies that an EHR might have prevented a 2007 death at Wyckoff Heights Medical Center, but a Meditech announcement says it went live on Q1 2006.” I don’t know which Meditech applications went live in 2006, but it probably wasn’t all of them. The hospital CEO’s comment specifically referenced clinician documentation of vital signs.

From The PACS Designer: “Re: chemo preparation. No one wants to hear they have cancer, but if you have to deal with it, there’s a website called Guide2 Chemo to help anyone get prepared for their treatment plan, along with an iPhone application.” The advertising company that offers it, Health Monitor Network, has a variety of sites and tools to “create a dominant presence in targeted physician waiting and exam rooms” that results in “NRx and TRx [new and total prescriptions] script lifts.” It sells its mailing list of condition sufferers to marketing companies. The company publishes a weird magazine called New York Giants Health Monitor with a claimed readership of 3 million “male condition sufferers 40+” that not only ties Giant players and coaches to health articles, but also offers companies promotional opportunities for hair growth, erectile dysfunction, and “always adding more.” If you want to control healthcare expenses, you might logically look at anything so profitable (i.e., costly to the system) that companies spend big money to promote it directly to patients. In fact, you might conclude that a lot of this mess started when laws were changed to allow companies to market to directly to patients and to run TV commercials, drumming up demand for products that patients themselves aren’t actually paying for.

Put your money in athenahealth if you’re buying a healthcare IT stock, say 40% of poll respondents. New poll to your right, checking up on interoperability: was the information from your most recent doctor visit immediately available at your hospital of choice? Mine was.

Welcome to new HIStalk Platinum Sponsor PeriGen. As the Princeton, NJ company’s name suggests, it offers fetal surveillance systems that support real-time decision-making in caring for mothers and babies. They include PeriCALM Tracings (bedside fetal surveillance with complication recognition and evidence-based data analysis for physicians and nurses); PeriCALM Plus (ONC-ACTB certified physician and nurse documentation, labor progress analysis, and decision support); PeriBirth (ONC-ATCB certified specialty EMR for obstetrics with protocols and best practices, real-time patient integration, and enterprise EMR integration); and PeriCALM Shoulder Screen (a Web-based prenatal tool for identifying shoulder dystocia). PeriGen systems are installed at over 150 hospitals. You may know former Allscripts sales SVP Matt Sappern, who was named CEO of the company in January 2012, or former Misys VP Mike Pritts, who is president and CTO. Thanks to PeriGen for supporting HIStalk.

Here’s a new YouTube video I found that covers PeriGen’s PeriCALM Plus.

Thanks to the following sponsors, new and renewing, that supported HIStalk, HIStalk Practice, and HIStalk Mobile in July (click a logo for more information):

Stanford Hospital announces that a laptop containing the information of 2,500 patients was stolen from a doctor’s locked office in mid-July. The article says the laptop was password protected but doesn’t specifically say it was encrypted, although the university’s IT security site says patient information cannot be stored on a computer without explicit permission, and if it is, the disk should be encrypted.

Weird News Andy finds this interesting. A 17-year-old high school student hears cries for help from a child swimming in the ocean. He pulls the child out, bystanders call for help, and both are taken to the hospital by ambulance. Weeks later, the student receives a bill for $2,600, including $1,907 for the 15-minute ambulance ride. His family, who has nine children and no insurance, is trying to arrange payments. After the story ran on TV, two anonymous volunteers offered to pay the full amount.

I mentioned the $70 Leap Motion input device awhile back. Some healthcare folks are discussing how it might be used in the clinical setting. Register for the company’s discussion board and then go to this forum to participate. The device, which won’t ship until December, is supposedly 200 times more accurate than Microsoft’s Kinect and can track the movements of all ten fingers individually. There’s a software developer kit that might be fun.

Wayne Memorial Hospital (PA) launches its Direct program using Secure Exchange Solutions.

A self-described “doctor uber-nerd” whose practice has been using an EMR for 16 years says Meaningful Use incentives have shifted focus away from the patient and instead caused a preoccupation with gathering compliance data. He says his vendor, who was “stuck in a pre-Internet, office-network design” shifted all their resources to Meaningful Use. He concludes:

This is sadly ironic. We were once using our computers in a meaningful way for the benefit of our patients, but now we are being pressured to abandon the patients in order to qualify for “meaningful use.” This should come as no shock to anyone who has watched American health care over the past 20 years. We have beaten doctors over the head with “clinical pathways,” and “evidence-based medicine,” all with a good intent: to make sure doctors gave good care. The problem was, however, that these criteria become more important than the patients they were meant to serve. The same is true with our payment system: designed with the initial intent of enabling patients to have access to care, but becoming a behemoth in the exam room, standing between the doctor and the patient.”

In Canada, an Alberta Health Services EVP/CFO resigns his $425K position after his expense reimbursements from his previous position are made public by a CBC Freedom of Information request. In three years with Capitol Health Authority (which was later absorbed into AHS) Allaudin Merali turned in $346,000 of expenses, which included costs for fixing his Mercedes, installing a car phone, buying gasoline and car washes, and purchasing a golf membership. He previously worked for scandal-ridden eHealth Ontario, where he billed an average of $76,000 per month, even turning in expenses for chocolate bars and tea. In investigating the expense claims, it was discovered that he had been paid $2.6 million in severance from his previous job, even though he ended up going to work for its successor organization. He’s eligible for almost $500K in severance this time around. His former boss at Capitol Health, who also found her way to Alberta Health Services as a board member, also resigned on the news. She had signed off on his expenses at Capitol Health, not to mention that when her CEO job there was eliminated, she received $4.1 million in retirement benefits.

A reader forwarded a client alert from law firm Post & Schell that warns companies, especially hospitals, to check their use of terminal and security software from Attachmate. They say Attachmate is aggressively auditing and suing its customers, especially those in healthcare.  The law firm warns that organizations might not even be aware that Attachmate software is installed, and since the products are licensed per PC, Attachmate could argue that running it on a Citrix server means that every PC needs a license. Attachmate bought Novell in 2011, so they advise checking those licenses as well.

The VA says the open source Web viewer it’s calling Janus will give clinicians a combined view of patient information from the DoD’s AHLTA and the VA’s VistA EMR systems, the first step in their integration project and also the first use of code from the VA’s OSEHR repository.

WellPoint takes a financial position (apparently $12 million worth) in SoloHealth, which offers a consumer health screening kiosk for vision, blood pressure, weight, and body mass index. According to the company’s site, the kiosk, which was just approved by the FDA, also allows consumers to find a doctor and schedule an appointment. An earlier investor in SoloHealth was Coinstar, the company behind Redbox.

Massachusetts announces that it will create a statewide HIE, with the $16.9 million cost paid for by the federal government in the form of ARRA and Medicaid money from CMS. Orion Health was chosen as its technology provider.

A Xerox survey finds that only 26% of Americans want their medical records stored in digital form, and 60% of them don’t think EMRs will improve care. On the other hand, the survey was conducted online and Xerox sells electronic document systems and the services of the former ACS Healthcare consulting firm (which it acquired for $6.4 billion in 2009) rather than EMRs, so the conclusion could be disputed.

SAP acknowledges that its ERP software has usability issues after companies such as Varian Medical Systems start to look for replacement products for non-core applications, citing changing user expectations brought on by the iPad and iPhone. SAP plans to offer software that allows IT departments and individual users to personalize its screens.

An $8.1 million federal lawsuit against Kernan Hospital (MD) that claimed the hospital intentionally coded patients with a rare malnutrition disease to increase reimbursement is dismissed. A federal court said the government did not provide evidence that the hospital actually submitted the claims for payment. The hospital’s claims for kwashiorkor as a secondary diagnosis increased from three in 2005 to 358 in 2008. One of the patients was also documented as being overweight and was counseled to go on a diet. The University of Maryland Medical System, which owns the hospital, said the coding is confusing.

A GAO report covering only Florida, New York, and Texas finds that 7,000 Medicaid providers who were paid $6.6 billion in 2009 owned $791 million in back taxes. It recommended (and the IRS agreed) that more rigorous review is needed. One provider owed over $6 million in unpaid federal taxes.

Chicago-based startup Procured Health, which helps hospitals evaluate medical devices for potential cost savings,  raises $1.1 million in seed funding from several investment groups and athenahealth’s Jonathan Bush. The company is testing its product and plans to launch in 2013.

Vince’s HIT time travels this week involve Pentamation (spoiler alert: they were acquired by Keane indirectly via an acquisition in 1992) and a sales executive who ended up as a Hollywood and Broadway producer. Vince got help this time from Gary Pollock and Doug Abel and he would he happy to receive your assistance as he continues to dig into the (sometimes) storied histories of the (sometimes) fondly remembered healthcare IT companies of yesteryear.

E-mail Mr. H.

Readers Write 8/4/12

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.

The Doctor Shortage Calls for Innovation
By Jonathan Bush

It was hard to read the recent sobering article in The New York Times, “Doctor Shortage Likely to Worsen with Health Law,” without picturing a lot of very smart people throwing their hands up in collective despair. Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, summed up the likely scenario in his part of California quite starkly: “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.” Not exactly a rousing call to arms.

What, if anything, is to be done about this crisis in the making? In an article otherwise devoid of solutions, Dr. Olds hinted at an answer when he suggested that “changing how doctors provided care would be more important than minting new doctors.” As the article points out, the proportion of medical students going into primary care has declined over the past 15 years as PCP earnings have diverged from those of specialists. But that’s not the whole picture.

Along with low remuneration, a 2009 study of the work conditions of family and general practitioners identified adverse workflow as a major driver of dissatisfaction, with 53% reporting time pressure during exams and 48% burnt out from the chaotic work pace. The same 15 years that have witnessed PCP decline have seen PCPs take on an ever-rising burden of paperwork, a more complex billing landscape, and a dizzying array of new federal requirements and mandates. Despite these rising challenges and seismic shifts in health care, the organization of the typical medical practice looks much as it did 50 years ago.

The narrow focus of the PCP shortage debate on the need for primary care to expand to meet rising demand misses the more significant point that it needs to be redefined through innovations that improve efficiency and restore the sanctity of the physician-patient experience. Technology can, and should, play a central role in this process. Rather than add work to physicians’ plates and hindering productivity, as many electronic health records (EHR) still do, the EHR should reduce work for physicians and delegate it to other clinical staff. Delegating work and empowering clinicians to practice to the top of their licenses not only reduces costs overall, but frees physicians to be fully present with a patient when their complete attention and training is truly required.

Non-clinical, routine work that bogs down PCPs should be removed from the office entirely. Even in our digital age, vast amounts of paper still clog practices and consume valuable staff time. At athenahealth we know that, on average, providers must process more than 1,000 clinical faxes every month, not to mention the forests of paperwork associated with insurance claims and government programs. This routine work can be offloaded to others in the supply chain who can eliminate it, automate it, or execute it more efficiently at scale.

By finding new efficiencies through technology, delegating care, and moving administrative work out of the practice, primary care can not only become more financially sustainable but more attractive to new entrants. Innovation, not just expansion, is the key to success.

Jonathan Bush is CEO, president, and chairman of the board of athenahealth.

Why Device Connectivity Matters Now
By Dave Dyell

Patient data is the cornerstone of many HIT initiatives, including Meaningful Use, health information exchange, and ACOs. Behind these acronyms and initiatives, though, is the real reason to care about patient data: its ability to improve clinical decision making.

Clinical decision-making has always been fueled by information or data. That hasn’t changed. What has changed is the amount of data now available and the ease with which it can be accessed by clinicians. Access to this data is, of course, the aim of electronic records. But what populates the record? Where is the data coming from? In many cases, it’s coming from medical devices.

When devices are connected or integrated with the electronic record, the data from those devices populates the record in real time, giving clinicians access to the up-to-date and error-free patient data they need.

The ECRI Institute sought to remind us of the significance of this relationship between device connectivity and electronic records when it published its annual ECRI Institute’s Top 10 C-Suite Watch List: Hospital Technology Issues For 2012.

The report placed “Electronic Health Records: Is your hospital making all the right connections?” at the top of its list. It also proposed an antidote to this most important HIT issue of 2012: device connectivity, or device integration.

“Hospitals must develop a medical device integration plan,” the report noted. “A strategic approach with the right medical device integration connections will get your hospital moving along the optimal path for success.”

This “optimal path for success” certainly includes the achievement of Stage 2 Meaningful Use. According to the ECRI Institute, “Stage 2 certification requires hospitals to not only have the necessary IT infrastructure, but also the ability to integrate patient care device data into the electronic health record.” In particular, the threshold for electronic recording of vital signs is expected to increase from 50% of all patients in Stage 1 to 80% in Stage 2. Looking ahead, compliance will demand the integration of more than just monitors and vital signs — it will extend towards the data in all medical devices.

The report goes on to state that the successful deployment of device integration solutions should not only ensure Meaningful Use reimbursement but also “facilitate nursing workflow.” This was certainly the case at St. John’s Medical Center in Jackson, Wyoming, where vital signs integration— importing rather than hand-entering vital signs data—resulted in time savings of 60%. Not only did device integration get patient data to the record faster, it also freed up significant amounts of nursing time that could then be spent on direct care.

So why does device connectivity matter now? The answer, put one way, is Stage 2 compliance. Put another way, though, the answer is that device connectivity reduces transcription errors, improves access to data in the record, and increases direct care. “Remember,” the ECRI Institute astutely concluded in its watch list, “medical device integration and Meaningful Use ultimately aim to improve healthcare and patient safety.”

Dave Dyell is founder and CEO of iSirona.

Using the Cloud for Testing and Deployment for Hospitals and HIT companies
By Mark Olschesky

Last week I shot a quick message to Mr. HIStalk, relaying the news that Windows Azure offered to sign Business Associate Agreements (BAA) for some of their cloud deployment and storage packages.

If you’re unfamiliar, Windows Azure and Amazon Web Services are two of the largest “Cloud” service providers. Most plans are pay-as-you-go for usage and differentiate themselves from other “cloud” offerings in that they offer immediate access to computing resources when needed. Even if you’re unfamiliar with the product names, you know their customers: Azure hosts Apple’s iCloud and handles the rendering of your favorite Pixar characters, while Amazon hosts the Washington Post and your favorite outfits and recipes on Pinterest.

Entering into BAAs is an interesting move from one of the larger cloud vendors. Now covered entities can enter into an agreement with this vendor to set terms on how HHS’s Office for Civil Rights (OCR) audits and non-compliance for a patient data breach will be handled. Likely, if the data breach is their fault, the agreement should outline that they will pay the fines and investigation fees, along with cooperating with an audit. This makes it more feasible to store PHI in a responsible manner in virtual, shared remote hosting.

I say responsible, because an entity storing data in the cloud still needs to audit and restrict access to PHI just as it would with locally hosted data. If you think that salt and hash are a great breakfast combination, or the title to a Cheech and Chong beach movie, you may want to consider managed hosting. Microsoft is saying that they are accountable for informing you of access to systems and stopping people from running off with servers with your PHI in the night. This is the same expectation you should have from your other vendors and your staff for handling locally hosted PHI.

So, how can this help you? Allow me to offer an example. Your vendor just released a new version of the software that you are actively installing. Surprise — it requires three Windows servers instead of the two you purchased. You need to take this upgrade. In the past, you would have completed the paperwork to buy a new server or scrambled to find local VM space on another. This would have been passed up the chain and hopefully there was budget available. Then, your already-swamped DBAs would need to handle the installation.

There were a lot of people and moving parts in this. It took months and stopped build and testing from getting off the ground. Instead, if you signed a BAA in advance with a cloud vendor, your existing staff could spin up a VM when a server was needed and install files as necessary. It’s not for all scenarios or for production at first, but if it saves you money, time, and the ire of your project managers, you would consider it, right?

Being able to store data in the cloud with fewer worries is a major benefit to us as a startup. It allows us to keep our costs low and pass the savings along to consumers as we look for a pilot for our first product. There is a certain amount of “keeping up with the Joneses” in remote hosting, so I would bet that Amazon and some of the other major players will begin offering to sign BAAs soon. This is only good for us as consumers looking for flexible options to get HIT projects completed easily and on time.

Mark Olschesky is co-founder and CTO of Moxe Health.

Time Capsule: Lay Your Hands on the TV to Be Healed: The Emergence of the Superstar Remote Physician

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 September 2007.

Lay Your Hands on the TV to Be Healed: The Emergence of the Superstar Remote Physician
By Mr. HIStalk

What do these micro-trends have in common?

• Big-name US hospitals open branches overseas
• Recognized organizations and practitioners offer remote second opinions
• Centralized intensivists monitor ICU patients
• The military uses telemedicine to improve battlefield care and services to remote locations

It’s a two-part answer: (a) all were made possible by technology, and (b) all point to a growing de- emphasis on the traditional patient-physician relationships. (There’s actually a third part: providers following an evidence-based practice framework can deliver better outcomes than free spirits making it up as they go, valuing conformity as much as brilliance).

Blame HMOs and hospitals if you don’t like this inevitable future of care delivery. Both organizations deal swiftly and decisively with episodic symptoms, but aren’t so hot when it comes to mind-body-spirit care or, in fact, anything that requires more than a set of labs, rads, and physical measurements to conclude that a surgery, treatment, or prescription is in order. It’s like Whack-A-Mole-Medicine — diagnosis and treatment for a generation raised on video games.

We patients have been dutifully conditioned to expect nothing more from our sometimes faceless providers or interchangeable institutions. No one cares that you’d rather see a doctor instead of a physician assistant. You can do well in a hospital stay attended to by non-physicians 23.75 hours a day. Doctors cover for each other without advance notice. Apparently it doesn’t matter who’s manning the stethoscope.

Patients are accustomed to being told which movie, car, or college is "best". It’s not much of a leap, then, to expect them to flock to notable experts for serious diagnoses, even if that person won’t every lay eyes or hands on them. Can the local, faceless doctor with a state school education and an unimpressive residency do as well as an Ivy League super- specialist working remotely, just because you’re sitting naked in front of them? There’s an obvious precedent: pathologists and radiologists who rarely leave their darkened basements to render professional services.

This will happen: very good doctors, singled out as such by any of dozens of score card and pay-for- performance plans, will be busy offering remote services to those who grew up believing that medicine is about objective processing of health data, not being a family friend who’s know everything about you and your family. They’ll make a mint, of course.

Remote medical practice will drive – and be driven by – the interoperability of electronic medical records. Accurate decision-making and efficiency will demand extensive data review: notes, diagnostic images, prescription records, digital pictures, video, and sound files.

Remote, faceless medicine is inevitable except for those with the financial means to seek alternatives. It will require extensive electronic, portable records with a wide variety of sources and formats. Good doctors will have their reach extended by the reduced need to be tied to a physical location, broadening their customer base like a TV preacher or Suzanne Somers hawking jewelry on the Home Shopping Network.

Doctors will be a brand name. Information demands will be extensive. Interoperability will be a given. And if you want a (figurative) shoulder to cry on, you’ll have to join an online support group.

News 8/3/12

Top News

Even though the Stage 2 MU final rule has yet to be published, the HIT Policy Committee MU Workgroup releases its preliminary draft recommendations for Stage 3 MU. Among them:

• Threshold requirements are higher in several areas, including the percentage of EP prescriptions sent electronically (50%), percentage of hospital discharge medications sent electronically (30%), percentage of lab results that must be stored in the EHR as structured data (80%), and percentage of patients using secure messaging communications with providers (15%).
• More clinical support interventions are required (15 related to five or more clinical quality measures).
• New EHR certification standards, including requirements that EHRs maintain up-to-date and accurate problem and medication lists.
• Increased emphasis on patient and family engagement, including requirements to provide patients an option to submit data online and to offer additional patient education material in languages other than English.
• Expanded requirements to improve care coordination and population and patient health.

Reader Comments

From Hilltopper: “Re: AHA Solutions endorsement. Two years we (naively) responded to an AHA RFP to become an endorsed solution provider for a specific category of consulting services. We were down-selected, went to Chicago for a presentation, and were eventually named their vendor of choice for the prescribed consulting services. We then found out they wanted way in excess of six figures for their endorsement (advertising, promotion over a three-year period) and a percentage of new business, we declined. What a waste of time, and it was not disclosed earlier in the process.”

From Benny Hanna: “Re: MUMPS. It’s ugly and I despise it, but like XML, DB2, or NoSQL, it works. If you index properly (or at all) and your storage is fast, the database will perform. The biggest news around MUMPS was your item about Dell/Epic to allow virtualization of their servers, both application and database. Now you can throw a whole farm of processing and storage power behind that old flat file database.”

From Lovelietuva: “Re: Adventist Health System vs. Moleski. The pre-trial hearing is October 8, 2012 at the Orange County Courthouse in Orlando. AHS is the Goliath that owns the Orange County justices.” This is the “Death by Deletion” former Adventist Health System risk manager and whistleblower who claims she was ordered to deleted electronic patient information to cover up errors and who also says AHS’s Cerner system caused incidents of patient harm. She should definitely press for a change of venue.

From BlueDog: “Re: Community Health Systems contractors. The rumor is true, although the number seems high. I know that they sacked roughly 80 contractors working on Allscripts Enterprise EHR projects and scaled back a lot on Allscripts and athenaclinicals implementations. All eyes within CHS IT are on an Oklahoma City Allscripts Enterprise EHR implementation that begins in five days.” Unverified.

HIStalk Announcements and Requests

I’ve been struggling with badminton today. I admit there probably has been a time or two I intentionally threw a gutter ball while bowling in order to commence happy hour, and I do recall a certain strip poker game in college. But intentionally losing at the Olympics makes no sense to me. Maybe my real issue is that I dislike badminton since it conjures images of sixth grade PE and those horrible one-piece uniforms we had to wear. Speaking of images, if you haven’t seen one of US rower (and Wilhelmina model) Giuseppe Lanzone, he’s worth a Google.

 HIStalk Practice highlights from the last week: as mentioned below, a few observations  from the just announced Stage 3 MU draft recommendations. Medicare and Medicaid issue $6 billion in MU payments through the end of June. Dr. Gregg whines about his unread EMR prose. My thoughts on why some crunching of MU attestation numbers may be meaningless. The ONC says the TOC is higher for a SaaS EHR than an in-office solution. I’ll keep it simple this week: go to HIStalk Practice, read good stuff, and sign up for e-mail updates. Thanks for reading.

Listening: new Rush, thanks to reader Mark, who tipped me off that Amazon is running it as a $0.99 full-album download.

Acquisitions, Funding, Business, and Stock

Visage Imaging signs a definitive agreement completing the sale of its Amira Division to Visualization Sciences Group for $15 million.

Quality Systems, Inc. continues its public spat with big shareholder and director Ahmed Hussein, who has nominated his own slate of directors to be considered at the upcoming shareholder meeting. Management says he’s trying to take the company over without paying a premium via a proxy fight and hasn’t made a convincing case that his nominees would enhance shareholder value, also calling out the company’s historically successful (until recently) share value growth, its sales opportunities, and its opportunity to focus on revenue cycle management. They also say Hussein has violated the company’s insider trader policy by pledging all of his company shares as collateral for margin accounts, requiring him to liquidate 2.24% of the company’s shares and further driving share price down. They also comment that his track record in creating value for his other businesses is poor. His press release says as a board member, he’s never heard anything about the strategies the company says they’ll follow and that his gripes aren’t with management, but rather with the current board.

MedAssets reports Q2 results: revenue up 11%, adjusted EPS $0.28 vs. $0.23, beating consensus estimates of $0.22. Shares jumped 20% Thursday on the news.

Vocera reports Q2 numbers: revenue up 30%, non-GAAP EPS of $0.09 vs. $0.00, beating expectations of $0.01 and raising guidance. 

Sales

The Purdue REC will use SA Ignite’s MU Assistant for client MU reporting.

Franciscan Alliance chooses Merge Healthcare’s iConnect Access to image-enable its EMR.

People

AirStrip Technologies hires Lori Jones (McKesson) as chief commercialization officer, Matthew Patterson MD (McKinsey) as SVP of business transformation, and Rudy Watkins (GE Healthcare) as SVP of business development.

NexJ Systems appoints former SAP North America president Robert Courteau to its board.

Cumberland Consulting Group promotes Amy Meiners from principal to partner.

Kelley Schudy, group SVP at Allscripts, announces that he’s leaving the company.

Baptist Memorial Health Care (TN) promotes chief nursing officer Beverly Jordan to VP/chief clinical transformation officer, leading its Epic implementation.

Precsyse appoints former IDX CEO James H. Crook, Jr. to its advisory council.

Announcements and Implementations

St. Francis Medical Center (CA) goes live with electronic medical records from QuadraMed, including medical device integration using iSirona.

Government and Politics

Medicare’s fraud unit opens a $3.6 million command center in Baltimore that includes a giant video screen that two Republican Senators are labeling a boondoggle, saying that the fraud unit is not implementing common sense recommendations in claiming that they are understaffed. The unit’s computer system went live last summer, but by Christmas had only stopped one suspicious payment totaling $7,600.

Other

Providers are concerned about vendor training and readiness for hybrid OR suites when selecting interventional systems, according to KLAS. Toshiba earned top scores for overall satisfaction, though Siemens had the greatest market penetration.

About 50 unionized transcriptionists at The Ottawa Hospital (CN) complain about losing their jobs to Dragon Voice Dictation, trying to get doctors on their side by sending them a Christmas card saying they were being let go and including an instruction book for Dragon. According to the union’s spokesperson, “Not only was technological change implemented without any canvassing of staff, but an interesting fact is that at the end of a transcription, the voice recognition software adds a disclaimer stating that the document ‘may contain errors.’ There has got to be a better solution, especially when it comes to patients’ health.”

Olympus, fresh off accounting fraud problems, informs the Department of Justice that its physician training program in Brazil may have violated the Foreign Corrupt Practices Act. The company says that DOJ was already asking questions, potentially indicating that Olympus and perhaps other companies were being investigated following DOJ’s multi-million settlements with Biomet and Smith & Nephew over bribing foreign doctors to use their medical devices.

The TV program “In Focus with Martin Sheen’” will cover electronic medical records in a series of reports. The show doesn’t say it’s a paid infomercial that runs between PBS programs, but it seems like that might be the case.

In Canada, patients at St. Joseph’s General Hospital have been without TV since mid-May after Healthcare Resource Group shut down its prototype touchpad-driven bedside entertainment system. The company restructured and found that its server licenses from Microsoft, Adobe, and Dell had been illegally registered under the name of their former CTO. The hospital says HRG missed their final deadline to sort out their problems and will be replaced.

Strange: a blind Native American man files suit against a hospital, several doctors, and others, claiming he’s the victim of a racial hate crime because his non-blind friends are telling him that scars from his emergency stomach surgery kind of look like the letters KKK.

Also odd: the family of a deceased man files a $2 million lawsuit against a New York medical school, claiming the school humiliated them by declining to accept the man’s donated body as a medical cadaver because he was too heavy.

Sponsor Updates

• TELUS Health Solutions and Sun Life launch an eClaims solutions for extended healthcare providers in Atlantic Canada.
• BridgeHead Software and the European Centre of Expertise for the Health Care Industry EEIG partner to provide a cloud-based archiving solution for European hospitals.
• Lippincott Williams & Wilkins, part of Wolters Kluwer Health, launches an EHR learning tool to prepare nurses for new practice requirements.
• GE Healthcare IT reports that its customers have received more than $100 million in MU incentive payments since the program’s inception.
• CommVault and Fujitsu expand their partnership to offer an integrated solution with Fujitsu’s ETERNUS DX storage arrays powered by CommVault Simpana 9 software.
• Kareo CEO Dan Rodrigues advises physicians on the use of technology to thrive in business.

EPtalk by Dr. Jayne

HIMSS issues its call for proposals for the HIT X.0: Beyond the Edge “conference within a conference” at HIMSS13. No, that’s not a mistake in the link – it’s a HIMSS12 link. If they can get their act together, they will accept proposals from August 1-31. I’m pretty burned out on HIMSS between the annoying mailbox clutter and the feeling that they’re not really doing anything new or different these days. But I am looking forward to getting my New Orleans on, whether I actually attend the meeting or not.

Northwestern Memorial Hospital’s Home Hospice office was burgled last week, resulting in the theft of laptops and tablets. Supposedly their security controls were suspended because they were receiving upgrades. They are offering credit monitoring services to affected patients. Luckily the authorities do not suspect that PHI was specifically a target of the theft. That’s a good thing, because I can’t imagine anything more pathetic someone preying on hospice patients.

In a reminder that they’re not just a software company, McKesson is ordered to pay $151 million in a legal settlement involving related to Medicaid drug price inflation. Although New York State Attorney General Eric Schneiderman issued a statement that, “This settlement holds McKesson accountable for attempting to make millions of dollars in illegal profits,” the company denies price manipulation or illegal activity.

News outlets continue to report that there will not be enough physicians to meet the country’s health care needs in coming decades. I don’t disagree, yet I don’t see people dangling money in front of me to convince me to return to traditional primary care practice. I’m not hopeful for the next generation, either. A high school student I have been mentoring decided that he wouldn’t be meeting with me any longer because he had decided on a new career path. His choice: game warden.

I’m a sucker for technology stories of all kinds, so I was interested to hear today about a Dark Matter detector in a former gold mine in South Dakota. Here’s to unlocking more mysteries of the universe right in our back yard.

No, it’s not Las Vegas: Cerner partners with the town of Nevada, Missouri (pronounced Ne-VAY-da) to reduce costs and improve care. The project will involve health education via the local school district, construction of sidewalks and bike lanes, and digitizing health records at Nevada Regional Medical Center.

As the world comes together at the Olympic Games, I am reminded of the vast disparities still present in world healthcare with two sad stories from Uganda. Ebola virus is causing an outbreak of hemorrhagic fever, and this is on top of a mysterious illness called nodding syndrome that has killed more than 300 children and neurologically devastated more than 3,000. Even with all the negative things about our healthcare system, we should be reminded of how lucky we really are.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 8/1/12

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

Burn the Resume

Unlike Hillary Clinton’s infamous visit circa 1996, I landed in Kosovo under relative calm. We flew in an unmarked military aircraft that was appointed more as a corporate jet than government transport. Despite the sight of armed soldiers, we had no fear of danger.

Coming off the plane, we were greeted by a chiseled young Army sergeant named Jeff Masters. “Welcome to Kosovo, ma’am/sir,” which he punctuated with a crisp salute.

A month prior, I had received a call from the Army. I feared the worst. My deputy CIO Mike had voluntarily been activated to Kosovo as part of an aviation mission. To my great relief, he was fine.

So why the call? Christmas was approaching, and the Army asked me to join generals, politicians, and business leaders on a trip to encourage the troops stationed in Kosovo. I had resigned my officer commission five years earlier, and the opportunity to spend time with troops again was a special honor.

Our roles had reversed. My deputy was now in charge. He took me out in a “don’t ask for permission” lights-out, fly-by-terrain excursion in his Blackhawk. What a rush. Mike pushed the flight envelopes trying to make me sick. Surprisingly, I did not pay a deposit to my barf bag. If I had, I would’ve never lived that one down.

Sgt. Masters, the soldier who initially greeted us, was assigned as our escort to make sure we got from point A to point B without getting lost or killed. He went out of his way to make sure our party was comfortable, answered all questions, and pointed us to the mess hall and latrine. He was polished and confident, and his passion for service was evident. In fact, that first evening, we observed an award ceremony where Sgt. Masters was decorated for superior performance. Generals sang his praises. I knew instantly I wanted this man to work with me when he left the service.

Sgt. Masters, a combat medic, had no technical experience. Before active duty, he was a carpenter’s apprentice. I didn’t care, because this man possessed what couldn’t be taught: a passion for service and superior leadership. Like anyone else, he could learn IT.

My convictions grew stronger as the week progressed. Once discharged from active duty, Jeff Masters brought his talent to my IT division.

I’m not big on resumes or the typical prerequisites. In the struggle to land my first “professional” job, I kept hearing recruiters cite my lack of experience or targeted education. Although I knew I could do the job, I could never break through. I was equipped with a Master’s degree and modest experience, but moreover, a passion to move mountains. A huge chore list growing up and having to pay my own way through college had built in me a hearty work ethic.

I had the goods for success, yet I could not get my foot in the door. I was frustrated.

When I did enter the workforce, I found little correlation between experience and education and actual performance. Ideally, you seek a high performer with requisite degrees and experience. But by no means is a robust resume a guarantor of success. I owe my career acceleration to leaders who embraced the talent philosophy. Each took what traditional managers would perceive as great risk and offered me opportunities for which I did not “qualify.” I’m forever grateful to my connectors, Mary, Mike, and Kevin.

My journey brought clarity and success to my own recruiting and hiring decisions. Time taught me that the key to good hiring is spotting talent — the natural reoccurring behaviors and thought patterns of a champion. I’ll take talent over years of service or education any day.

Nine months after Kosovo, we assigned Jeff Masters to manage a challenging project that was disorganized and poorly led. A year later, the project successfully wrapped and yielded promised benefits. Working closely with our technical division, Jeff learned field engineering skills and took a leadership role. Next, he joined the application team and learned CPOE. He brought enthusiasm and organization to the team. He was then selected as the IT manager for coordinating the technology of a new hospital construction effort. The hospital opened on time and on budget and is serving its community today.

What a joy it is so see Jeff flourish, leveraging all his talents and continuously learning new skills. I have every expectation that this apprentice carpenter / combat medic will continue to hone his skills and achieve great things for those whom he serves. He has since begun work on his Master’s. But that’s just window dressing for someone who’s already a talented and highly competent professional.

Burn the resume. Hire talent.

Footnote: on our way home from Kosovo, we stopped in Ireland to refuel. We waited in the gate area when another plane pulled in. The soldiers who disembarked were the first rotation of troops returning from Iraq. Realizing the situation, all of the generals, politicians, and leaders formed a “troop line” to welcome the soldiers for a job well done. This marked one of my proudest moments as an American. There was not a dry eye.

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