Monday Morning Update 9/17/12

From Another View: “Re: your Time Capsule editorial. You have missed a competitor to Epic … Sunrise/Eclipsys. Ring any bells? Long Island Jewish has it installed as well as others and it is well received. Is the price tag of Epic is going to bankrupt medicine? I really think Sunrise could very well be the Apple product that beat the giant Microsoft. Any thoughts?” Read more closely: I specifically mentioned (twice, in fact) Cerner, Eclipsys, and McKesson as Epic’s big-hospital competitors. That was true when I wrote the article in 2007, but I would expect that Allscripts/Eclipsys and McKesson have faded since then in terms of big-hospital customer count. Epic’s huge number of wins since 2007 were replacements, meaning their gain was somebody else’s loss. No, I don’t think that Allscripts (or any other vendor, at the moment) can compete with Epic in the large-hospital inpatient clinical systems market. Reasons: (a) incomplete integration; (b) narrower product line; (c) lower customer satisfaction; (d) lack of momentum; (e) hospital consolidations favoring existing Epic customers; and (f) trying to disrupt the status quo with one hand firmly planted in Wall Street’s lap. It’s not the end of the world for Allscripts – 80% hospitals aren’t candidates for Epic but need a lower-priced, pre-packaged, hosted product, meaning the biggest companies to beat are Meditech, McKesson, Cerner, and Siemens. Struggling to compete against Epic in big-hospital accounts hasn’t hurt Cerner, which doesn’t bag a lot of fresh Millennium wins over Epic but still has turned its assets into a $12 billion company. If you want to score Epic vs. Allscripts without emotion or subjectivity, it’s easy – just watch the number of new sales, the total number of beds and EPs covered, and KLAS scores.

From Music Lover: “Re: Epic UGM. You missed it, Mr. H! Some cool end users rocked the house Monday night. Anyone have pics or YouTube?” I only found the video of the opening session above, which is a clever riff on a horrible Journey song (was that redundant?) that reminds of me when Mrs. HIStalk dragged me to grit my teeth through the traveling Broadway version of “Rock of Ages” (who would have guessed that disco would be more fondly remembered than 80s hair bands?) By user group standards, though, it is darned cool. From the end of the video, it appears next year’s theme will be, predictably, Deep Space (the new 14,300-seat Deep Space auditorium pictured above will be open then.)

Listening: new from The Avett Brothers from Concord, NC, who have matured from frantic newgrass revivalists into something like an indie, rootsy Beatles with banjos. Long-term fans will have to decide whether the de-emphasis on hillbilly picking and grinning is inevitable maturity or perhaps overly slick production by hit-maker Rick Rubin. The new album is more accessible and probably less embarrassing to crank up in a vehicle that isn’t a pickup truck.

I was making an appointment for my annual PCP visit last week. After navigating through the annoying phone tree, waiting on hold, and negotiating with the scheduler for a convenient appointment time, the phone connection dropped on their end. My call-back went right to the “we’re too busy to talk to you now” message, so I figured I’d just try another day. The next day, I got an e-mail confirmation for a date/time I had declined, so it must have gone through as we were changing it. I noticed an unobtrusive link in the e-mail to “click here to cancel or reschedule” and darned if it didn’t work – I clicked, it gave me available days/times on the screen, I clicked on a convenient date/time, and I was all set. It actually felt like 2001 instead of 1980 in using Expedia to book a flight instead of wasting everybody’s time by calling a travel agent for an inefficient and entirely unnecessary telephone conversation. It’s not exactly cutting edge, but very few businesses let you schedule appointments online (restaurants being one exception, and that’s only because of OpenTable). Scheduling an appointment is a lot different than buying a product online, so the usual snarky Amazon references don’t apply.

Forbes chose the wrong company as the most innovative in healthcare, according to readers who said it’s actually Epic (had Forbes included non-publicly traded companies, of course). Cerner wasn’t too far off the mark, though. New poll to your right: have you ever requested and reviewed your electronic medical information from your PCP? The poll accepts comments if you’d care to elaborate on your experience. I didn’t even bother asking about hospital records since I know what a nightmare that can be.

Allow me to introduce new HIStalk Platinum Sponsor ChartWise Medical Systems. The Rhode Island-based company describes ChartWise:CDI as a Computer-Assisted Clinical Documentation Improvement solution that improves the accuracy and speed of documentation. it guides physicians to high-quality and complete documentation, using its built-in intelligence to analyze labs, meds, and procedures to suggest diagnoses and complications that may not have been correctly coded. Easily retrievable, auditable, and AHIMA-compliant query templates ensure compliance and consistency for internal QA and external auditors, with physician communication automatically initiated and documented by e-mail. Customers can reduce staff and physician training, ensure continuity when key team members leave, and get real-time metrics for their CDI programs. It’s offered by a subscription-based license, online training is free, and ICD-10 is built in and carries no upgrade fee. Customers can use it their way, regardless of whether documentation is on paper or EMR and with or without the participation of physicians. Half of Medicare paybacks are due to erroneous or incomplete documentation and you know the RAC auditors are out there digging since they’re paid a percentage of recovered dollars. The company was founded by Jon Elion MD, who also developed the Heartlab imaging software that was acquired by Agfa in 2005. Thanks to ChartWise for supporting HIStalk.

CapSite releases its new HIE report. It shows a big jump in hospital HIE participation in the past year (from 30% to 50%), with 71% of respondents planning to invest in new HIE technologies in the next two years. Surprisingly, two-thirds of respondents chose their primary HIE vendor because the company was an extension of their core hospital system (Epic was the most-named HIE vendor, so that gives you an idea). That probably reflects the uptick in private HIEs.

A hospital in England uses Skype for video teleconsultations with ADHD and Asperger syndrome  patients.

The flagship product of Detroit-based startup SchedFull manages an online waiting list for physician practices that allows them to fill appointments opened up when patients cancel, alerting the standby patient by e-mail or SMS if an opening matches their expressed preferences. The product is in beta.

Twenty-three employers participated in a jobs fair that was held last week in the new Sheik Zayed Tower at The Johns Hopkins Hospital, hoping to hire healthcare IT and informatics graduates from Johns Hopkins University, George Washington University, and University of Maryland University College (surely the strangest and most multiply-redundant college name ever, which they cheerfully admit and explain here). The event was held in the Chevy Chase Conference Center, which I assume is named after the nearby municipality rather than the embarrassingly unfunny comedian who did in fact have a Hollywood theater named after him for six weeks in 1993, which is all it took for his horrible late night TV show to flatline.

The Dallas-Fort Worth TV station covers the technology used in a new Texas Health Alliance hospital.

The local paper covers the use of shared medical appointments by Reliant Medical Group (MA), in which 90-minute visits are scheduled with groups of patients suffering from the same chronic health issues. Patients have the option to request one-on-one doctor time during the visit if they feel the need, but three-quarters of them like the group appointments. That’s an interesting approach to maximizing the use of resources while providing peer support for patients, which is probably far more effective than the usual online groups. All that’s missing is a financial incentive for consuming fewer resources, which is of course a healthcare problem not limited to how patients schedule their visits.

Raul Recarey is named executive director of the Illinois HIE in his third HIE leadership role in less than three years, having been named COO of the West Virginia Health Information Network in November 2009 and CEO of Missouri Health Connection in March 2011.

Indian River Medical Center (FL) will implement centralized appointment scheduling using McKesson’s Paragon Resource Scheduling, which issues printable appointment itineraries and procedure instructions. After the May go-live, the hospital will implement patient self-scheduling.

A hospital in Scotland is found by NHS to be cancelling 12% of its outpatient appointments due to problems with its new computer system. The hospital cancelled 105,000 outpatient appointments and 7,500 inpatient appoints in a 15-month period.

The author of an upcoming book says that children’s hospitals are banking huge cash surpluses and paying eye-popping executive salaries despite their non-profit status and ongoing solicitation for donations, which he says threatens their non-profit status, government subsidies, and community reputations.

California’s attorney general sends out subpoenas to several big health systems (Scripps, Sharp, Sutter, and others) in launching an antitrust investigation to determine whether consolidation among hospitals and physician groups is increasing healthcare costs through increased pricing power over payers.

A nurse working for an Atlanta-area anesthesia service is released to rehab after being charged with driving the wrong way on a highway and causing several vehicles to crash, injuring six people. She is alleged to have stolen propofol from Gwinnett Medical Center and starting an IV on herself to administer it in her car right before the accidents.

Vince tells the story of Compucare and QuadraMed this week, going right to the source in somehow connecting with Dynamic Control co-founder David Pomerance, who then introduced him to Ron Aprahamian, whose fascinating story is that he bought all of Compucare’s stock for $50,000 as a 29-year-old, struck a deal with Meditech, took Compucare public for $40 million, took leadership roles at Superior and First Consulting Group as those companies were acquired … well, just check Vince’s slides because it’s too amazing for me to summarize. I’m glad Vince shared Ron’s story because even though I knew his name, I had no idea how much influence he had on so many major industry players. We would never have heard these stories if it weren’t for Vince, who seems to be the only person willing to work hard to preserve our industry’s history. If you can help him with stories, photos, or connections to folks he should talk to, give him a shout.

E-mail Mr. H.

Time Capsule: Two Economic Theories That Explain Why Epic’s Competitors Had Better Improve Fast

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

I wrote this piece in November 2007.

Two Economic Theories That Explain Why Epic’s Competitors Had Better Improve Fast
By Mr. HIStalk

Let’s say you own a hot sports team. Your tickets are more expensive than those of any other team in the league. Your venue sells out for every game with no group discounts, $8 concession stand beer, and an indifference to customer requests to change the uniforms, get better-looking cheerleaders, and add more women’s restrooms. You as the team owner know what’s best, and if the fans don’t like it, there are thousands more eagerly willing to take their seats.

Welcome to Team Epic Systems.

Arch-competitor Cerner embarrassed itself last week by complaining that a big provider in its back yard, University of Kansas Hospital, chose Epic over lower bidder Cerner in a $50 million deal. According to a spokesperson, the Epic choice was “a disappointment to Kansas City.” Cerner, she said, would have spent a ton of research money at KU, but will have to look elsewhere because KU’s doctors vastly preferred Epic’s product (the unpatriotic nitpickers).

Make no mistake, Epic has changed the industry, at least when it comes to high-end academic medical centers. Back in the late 1990s, economists might have characterized the healthcare systems market as an oligopoly. That’s when four or fewer sellers own at least 40 percent of the market. SMS, HBOC, Cerner, Meditech … yep, sounds like one to me.

Epic’s remarkable record of big-provider wins moves the high-end HIT market closer to a monopoly, a market with no substitute goods or economic competition.

Epic is quirky. They don’t negotiate pricing. They share the “we know better than our customers” business model as Meditech, but from the opposite end of the pricing spectrum. Complain and it’s the Soup Nazi – no system for you. They’ve got all the customers they need, so they aren’t about to put up with foolishness.

Some of the Epic craze is surely due to the bandwagon effect (buying what everyone else like you or better buys), but most of the credit goes to its only real competitors in the high-end market – Cerner, Eclipsys and McKesson. What does it say about the products and services of those companies when customers like KU buy from high bidder Epic even though it costs far more and VIP coddling is highly improbable?

Perhaps the next market phase will follow a far more obscure economic theory called Hotelling’s Law. It postulates that sellers will make their products as similar as possible to maximize overall demand, even though customers would benefit from product differentiation (examples: drugstores and gas stations operate across the street from each other, airlines copy each other’s flight schedules and prices, both of which benefit the businesses at the expense of customer convenience in having a choice).

In other words, if I’m a vendor and Epic is beating me like a drum, maybe I’d better just copy what they do. For businesses, the best role model is the one making the most money.

Epic needs more competition than Cerner, Eclipsys, and McKesson are giving it. For those companies, Epic’s product is seen by prospects as so vastly superior (including in KLAS rankings) that they’re willing to pay more for it, quirks and all.

It would be good for the entire industry if those or other vendors could mount a credible challenge to the big dog. Unfortunately, operating in a publicly traded, quarter-by-quarter mindset, nothing suggests that such an invasion of Epic Stadium is imminent.

News 9/14/12

Top News

Mediware will be acquired by PE firm Thoma Bravo LLC for $195 million, the company announced Wednesday. The $22 per share cash offer represents a 40% premium over Tuesday’s closing price.

Reader Comments

From Shades of Green: “Re: RECs and EPs. You point out that only 17,144 EPs have demonstrated Meaningful Use through the REC program. I did a little digging and found that total grants for RECs to date (which does include some funding for rural hospitals) is $706 million. That comes to $41,181 for each of the 17,144 EPs demonstrating Meaningful Use.”

From N2InformaticsRN: “Re: MappyHealth. You mentioned a few weeks back our entry into the HHS NowTrending 2012 Challenge. I have an update – we won! Not bad for two nurse informaticists and a computer science student.” Social Health Insights LLC’s free application mines real-time tweets via Twitter’s open APIs to serve as an surveillance system for emerging health issues. The challenge, which drew 33 entries, was created by HHS after it observed that social media trends can be correlated to disease outbreak. The team is Brian Norris, Charles Boicey, and Mark Silverberg. I’m sure they are keeping their fingers crossed that their app doesn’t get hosed as Twitter continues to reduce the functionality and terms of service of its APIs in hopes of monetizing tweets instead of allowing others to build applications around them. Several small companies whose only products were Twitter add-ons have already gone belly up when their data hose went dry.

From The PACS Designer: “Re: iPhone 5. Faster, thinner, 4” display, and iOS 6. Apple is prepared to meet Q4 demand by preparing suppliers to ship as many as 50 million of them in the quarter.” The only Apple products I own are an iPad and a Nano, but I still watch blow-by-blow live-blogging of every Apple announcement, which is an indication of how dramatic Apple makes their unveilings (not to mention how well they keep those huge, world-impacting announcements a secret, which is truly amazing to me). I can’t think of any reason I should care given that I’m not in the market for new Apple products, but I still do. I’m not convinced that the iPhone 5 is better than some of the Samsung or other Android phones (many of the new iPhone features have been on Android for a long time, leading some analysts to openly ridicule Apple for under-delivering), but I can safely predict that the fanboys will be camping out at the Apple store next Thursday night (what recession?) I read the other day that Apple’s iPhone sales volume alone is bigger than all of Microsoft.

From Arnold: “Re: KLAS report on Epic consulting firms. They just posted an update saying one firm has been removed because KLAS mistakenly gave them credit for another company’s survey. How shoddy, and it isn’t the first time we’ve seen this kind of mistake.” I blurred the company’s name on the KLAS announcement since it’s a good news/bad news thing – in removing some other company’s negative survey, this company’s score went up, but then it didn’t have enough surveys, so KLAS removed it completely from the updated report.

From Blue Dog: “Re: Allscripts Enterprise EHR. Heard CHS in Oklahoma City had a great implementation and they are re-looking at using it in other markets. They had a huge contractor downsizing and had postponed or shifted to athenaclinicals in many markets.” Unverified.  

HIStalk Announcements and Requests

This week’s HIStalk Practice highlights include an example of “EMR garbage.” Opinions on why specialists may seek MU incentives less often than primary care providers. Healthcare expenditures fall when patients have more access to office-based care after hours. An internal medicine physician grades his EHR. More feedback from the HIStalk Practice Advisory Panel on the ACA’s potential impact on patient volumes. Culbert Healthcare Solutions VP Jeff Wasserman offers strategies to help independent practices enjoy the financial benefits of quality-based care. Thanks for reading.

Despite the inconvenience of the new adapter, I am ready to take advantage of the $199 option to upgrade my iPhone 4 to the 5. The fast-draining battery has always been my biggest gripe with the iPhone, so longer battery life is the most appealing new feature. A bigger display will also be nice and I am envisioning all the cool panoramic photos I’ll be able to take at the upcoming MGMA meeting. I’ll be one of the geeks standing in line at the Apple store on September 21.

I was waiting for the elevator at work today with the “going up” button lit. As I stood patiently, some guy charged around me and gave the already-lit button several quick jabs. Do you suppose he thinks there’s an algorithm built in that gives preference to the number of times the button is pushed, does he harbor suspicions that elevator lights are rigged, or is he just an impatient jerk who assumes I’m not capable of pushing the button correctly?

Acquisitions, Funding, Business, and Stock

Streamline Health reports Q2 results: revenue up 22%, EPS –$0.04 vs. $0.00.

MRO Corp. acquires the assets of Florida Medical Records Services, a provider of release of information services.

Athenahealth signs a definitive agreement to acquire Healthcare Data Services, a provider of healthcare data analysis and population health management solutions for payers and providers.

Nightingale Informatix secures $2.75 million in Series B funding.

In England, mental health EHR vendor Strand Technology is acquired by Advanced Computer Software Group for $3 million.

Sales

Community Hospital Anderson will use Summit Healthcare’s Express Connect and Provider Exchange technology  for internal and bi-directional integration with its Meditech system.

Cherry County Hospital (NE) chooses Access Intelligent Forms Suite for electronic forms management as it migrates to Meditech 6.0.

The Federal Economic Development Agency will use the Connected Wellness Platform of NexJ Systems for its Connected Health and Wellness Project.

Fort Drum Regional Health Planning Organization (NY) selects Wellcentive to provide disease registry, case management, and predictive analytics.

Anne Arundel Medical Center (MD) chooses Medseek’s ecoSmart Patient Precisioning CRM solution for patient engagement and education.

Key-Whitman Eye Center (TX) selects Versus Advantages RTLS to track patient progression and staff workflows.

HealthEast Care System (MN) chooses Humedica for its ACO and PCMH initiatives.

People

Lance Fusacchia (Webmedx) joins Shareable Ink as CFO.

CHIME awards its State Advocacy Award to Texas Health Resources SVP/CIO Ed Marx.

Tom Penno (Indiana HIE) joins NoMoreClipboard as VP of channel management.

SuccessEHS promotes Lori Junkins and Elizabeth Featheringill Pharo to VP and Elizabeth Pitman to general counsel.

Jim Speros, who led the VA’s innovation prize contests and promoted its use of Blue Button, died September 3 at 59.

John Cox, former CIO at the Hospital for Special Surgery (NY), died September 12.

Announcements and Implementations

HIMSS names Hawai’i Pacific Health the winner of the 2012 Enterprise HIMSS Davies Award of Excellence.

In the UK, Moorfields Eye Hospital NHS Foundation Trust adds three modules to OpenEyes, its self-developed, open source patient management system. The new modules include surgical notes, discharge letters, and prescriptions.

Government and Politics

HHS announces $983,100 in grants to support improved healthcare access and coordination for veterans living in rural areas using telehealth and health information exchanges.

HHS Secretary Kathleen Sebelius admits to violating the Hatch Act, a federal law that restricts the political activity by government employees. Sebelius called for the re-election of President Obama at a February speech to a gay rights group. Sebelius has apologized and the Democratic National Committee has reimbursed the government for the cost of her trip.

ONC’s blog urges nurses to request a copy of their own electronic health record, verify the accuracy of its contents, and sign an online pledge. I suspect few of us in healthcare IT have requested electronic copies of our information, so I will post this as a challenge of my own to all readers. Request a copy of your EHR information and let me know how the process went – how convoluted the request process was, how long it took, and how accurate and complete your information was. I’ll run anything you send me. Somehow I think that, like almost everything related to healthcare, it doesn’t work nearly as well as patients have a right to expect. It’s not exactly Golden Rule territory.

ONC releases its educational security training game for medical practices. I played it and it’s pretty cool.

Medicare says it won’t pay providers based on copied-and-pasted patient notes.

Other

Beth Israel Deaconess Medical Center is named the #1 company in the InformationWeek 500 list of the most innovative users of business technology. Other healthcare organizations in the top 50 include Quintiles (#6), Sparrow Health System (#16), Premier Inc. (#30), Miami Children’s Hospital (#31), RadNet (#32), McKesson (#34), Intermountain Healthcare (#48), Kindred Healthcare (#48), and Sharp HealthCare (#50).

CareCloud will establish a Massachusetts office to take advantage of the region’s technical talent.

I said in January when US CTO Aneesh Chopra resigned that I expected him to run for lieutenant governor of Virginia, but instead he went back his previous employer, The Advisory Board Company. I should have paid more attention to the election calendar: the election is in 2013 and he has announced as a Democratic candidate for that office.

A Financial Times article called “Healthcare: Cyber wards” covers Silicon Valley companies trying to break into healthcare. It doesn’t contain anything all that interesting, but it does quote an entrepreneur who says VCs are still wary of investing in companies because of long healthcare sales cycles and their previous experience with products that were never perfected.

University of Minnesota Medical Center, Fairview violated patient protection and EMTALA laws by its aggressive collections tactics overseen by Accretive Health, a federal investigation finds. Fairview says they “continue to learn from this experience.” Shares in Accretive were down 11% Thursday on the news, by far the biggest percentage loser on the NYSE. The company had already paid a $2.5 million fine and agreed to cease operations in Minnesota. Shares owned by founder and CEO Mary Tolan  are still worth $108 million.

Weird News Andy is convinced that being real smart doesn’t preclude being real stupid. Richard Keller MD, a pediatric endocrinologist and Harvard Medical School instructor (WNA summarizes as “a vile human being,” at least assuming he’s found guilty), is arrested when a package containing 50 DVDs of child pornography is delivered to his attention at Phillips Academy, where he was medical director until last year. He might be one of few people whose life goes directly into the toilet because he forgot to update his shipping address or perhaps had the misfortune of back-ordered porn.

Markle Foundation puts out a video promoting the consumer use of Blue Button.

The computer hacker / brain tumor patient in Italy who cracked the proprietary formats of his electronic medical records so he could post them publicly to seek help has updated his site with the ideas he has received so far. It’s getting interesting – he’s about to publish a tutorial explaining the quirks he found with DICOM images and he’s putting out some rather eloquent ideas about health and technology:

The definition of "diseases" is "reserved" to doctors. Often using words which we don’t understand and, most important of all, touching only a part of the human condition, which is made from body, but also of spirit and sociality. The DICOM format is open, yes, but in a very "peculiar" condition of openness: it is like the openness of the words which they use to tell you about your health condition, and with which they describe and actuate their version of the "cure": you can’t understand it, you can’t reuse it, you can’t combine it with other possibilities. It is thought for "experts" and "professionals" (of one single type), leaving little space for other possibilities for expression and socialization … Maybe we could start to think about an "open" world in this sense, too, not dedicated to "professionals" and "procedures", but also to human beings.

Sponsor Updates

• Vonlay created a Web page featuring live tweets and photos from the Epic UGM this week.
• PDR Network announces that its flagship service meets Meaningful Use Stage 2 requirements in delivering real-time FDA drug safety alerts and product program information at the point of prescribing.
• More than 50 employees from the Burlington, VT office of Allscripts will take part in a Habitat for Humanity build this week.
• Amerinet makes McKesson’s pharmacy automation solutions available to its 3,000 hospital members.
• Intelligent InSites integrates its RTLS with Haldor’s ORLocate surgical instrument tagging to offer a surgical instrument management and tracking solution.
• Lifepoint Informatics announces its Silver Level sponsorship of next month’s Pathology Informatics 2012 conference in Chicago.
• LDM will provide consumer medication information from Polyglot Systems in its point-of-care messaging solutions.
• HIStalk sponsors Allscripts, NTT Data (formerly Keane Inc.), and World Wide Technology earn spots on the annual InformationWeek 500 list of innovative business technology users .
• Forbes cites Greenway as being “ahead of the pack” in delivering information exchange and interoperability between its PrimeSUITE and the EHRs of other vendors.
• Orion Health will incorporate images from Agfa’s clinical imaging platform into its clinical portal.
• DrFirst and Meditech will demonstrate their combined solutions during a series of Webinars in September and October.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 9/12/12

Elevation (Part 2)
As Slope Rises, Leadership Must Rise

Last month, I posted on elevation using a mountain climb metaphor and honed in on the privilege of leadership. The unwritten covenant of leading people:

To be the leader I aspire to be, I must elevate to match the slope before me. Anyone can lead when the terrain is flat or even at a moderate incline. But there comes a time when the journey leads to a peak. It’s on this trail where leadership is tested, validated, and honed.

A few months back, I spoke on elevation. Someone asked, “How do I know I and/or my team need to elevate?” That’s a great question.

How do you know you need to elevate? Self-awareness. Take a good look in the mirror.

• Comfort. If you feel everything is comfortable, you’ve probably reached a state of stagnation. Comfort is cozy, but retards growth.
• Perfection. When you believe everything is fine, or you’ve reached the top.
• Reality. When you are unable to discriminate the top 10% of your staff from the pack because they are all “best in class.”
• Self-evaluation. When you do your annual review, you think you are a perfect performer.
• Invincibility. You talk more about past accomplishments than the work ahead.

How do you get your team to realize they need to elevate?

First, admit your own need to elevate, and then make necessary changes. Second, provide clarity around expectations and hold others accountable. Finally, share behavioral examples of what it means to elevate. The gaps should become self-evident. Sharing what it means to elevate helps even the most defensive person begin to see a need for change.

Here are a few behavioral examples to begin with. Feel free to add others in the comments.

Elevation is:

• Manic attention to detail. Mistakes happen. I make them and we all make them. I get it. That said, when I make mistakes because of lack of attention, it makes me look sloppy and takes away hard-fought wins. When I’m late, turn in inaccurate numbers, neglect spell check, screw up e-mail, storage, etc., it hits my credibility. If I lose credibility, I lose our ability to lead.
• Loving my people by disciplining them when warranted. Just as I lavish praise and recognition for incredible performances, I must balance with discipline. Discipline should always be private.
• Leading my customers. Customers are not always right. Steve Jobs recognized this. He knew the concepts customers wanted and designed from there and led. Old IT simply responds to customers – order takers. That worked in the past, but will not work for the future as the slope of competition rises. I must be unafraid to lead my customers, even when the customer does not want to be led.
• "My team is never my enemy." We are a team. We don’t have cycles and emotions to waste fighting one another. I address team conflicts within the context of organizational values and inside our own house. Don’t go outside of this boundary. Don’t go complain to the customer. They have their own issues and don’t want to hear about ours.
• Not allowing variation from good practice. Or, better said, mavericks will kill you. We’ve all experienced the negative impact of mavericks. Leaders must root out mavericks for the higher good. I am not talking about someone who does things differently and brings unique perspective. I am talking about those who willfully do things they know they should not because they think they know better.
• Assertiveness. I tire of hearing lame excuses about why things are delayed, i.e. waiting on so-and-so to call or e-mail me, or “The reason we have poor performers is because of HR.” No, I don’t buy that. I pick up the phone or go to their office. Make it happen. The ball is in my court.
• I can be counted on to do the job expertly and without complaint and without silliness. Reminds me of Garcia. This is required reading.
• Messaging commander’s intent throughout your organization. If the captain says take the north hill, we take the north hill. If I allow the message to be reinterpreted, I’ll find staff taking the south hill. If there’s a major disconnect between what’s commanded and what people do, it’s a leadership issue.
• Evaluating employees honestly. If the majority were top performers, we’d have a perfect organization, which we don’t. If I’m friendly to a fault with some of my subordinates, this might blind me, so I must constantly acquire external opinions. If a staff member loses their position, am I concerned more about their impact on our mission or the impact on their lifestyle? My primary concern should be the organization.
• Knowing I need to elevate. Most do not perceive a need for elevation. Leaders elevate constantly. Period.
• Being a non-conformist. (Not to be confused with maverick.) Don’t “get” just to get along. Don’t comply simply to fit into the culture. Push against grain where warranted. Change culture if necessary. Never for self; always for the organization.
• Knowing the mind gives out before the body. Train myself to be strong in mind and my body will follow. Healthy mind, healthy body.
• Ownership. Own problems. Don’t play ticket tennis. Never give up. Don’t point fingers. Take responsibility and practice accountability.
• Busting silos. If someone is bleeding, should I wait for a medic since I’m not the medic? No. I go stop the bleeding. Don’t let artificial walls keep you from action.
• Continuous self-improvement. Don’t wait for a required book study or a class to come along. Ask: How am I better than last year? How have I transformed?
• Line of sight. Knowing how my efforts lead to the fulfillment of organizational objectives. I must know my individual staff’s mission and staff should know mine. Collectively, they should inspire all of us.
• Faithfully lifting up and living out the values of the organization.
• Raising my hand to say, “I found a risk, and we need to address it.”
• Competency. Doing my job, and doing it well. No shortcuts or cheating the system.
• Cross-organizational teamwork.
• Spending more time with users than with my office mates.
• Embracing correction.
• Getting eye to eye with those I’ve been entrusted to serve (lead). Never, ever deliver difficult messages via any other means except eye to eye. Never.
• Pouring myself into those I’m entrusted to serve.

Leadership is tough, especially when the slope rises. You may reach a point along the journey where you hit your limit. That’s okay. Recognize it, and deal with it.

Not everyone reaches the summit. Most mountain expeditions have less than a 50% success rate. Smart climbers know their limits, and they stop and turn around to avoid disaster. Sometimes you need to head back down and regroup before you start back up. Other times, it’s best to let someone else lead.

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.

Tweets and Photos from Epic UGM 9/12/12

They have the best swag! #epic #ugm2012 #newbie

— Michael Lamb (@lambatwork) September 10, 2012

Barry Bershow from Cedars-Sinai (Lake Wobegon West) where all the men, women, children, and Epic progress notes are good looking. #UGM2012

— Jorge Scheirer (@infomedoc) September 10, 2012

I’d like to thank google maps for the ability to see in real time that traffic at Epic Lane is already backed up to exit 77 #ugm2012

— K Wroblewski (@kdwroble4) September 11, 2012

#UGM2012 stats: 7900 customer attendees, 3400 gallons of coffee

— borborygmi (@nickgenes) September 11, 2012

Epic CEO Judy Faulkner on rock theme for #UGM2012: says “hey Jude” has particular meaning for #healthIT “take a sad song and make it better”

— borborygmi (@nickgenes) September 11, 2012

Only 1.2% of US hospitals are at top HIMSS stage for #EHR integration — and 3/4 of those hospitals are at Epic’s #UGM2012

— borborygmi (@nickgenes) September 11, 2012

CEO Judy Faulkner says Epic is installed in over half of US academic medical centers #UGM2012

— borborygmi (@nickgenes) September 11, 2012

47% of Epic expenses are R&D. Moving into long term care, home care. Faulkner wants her programmers to have individual offices #UGM2012

— borborygmi (@nickgenes) September 11, 2012

Epic CEO Judy Faulkner: too few physicians on meaningful use committees, and their input is lost on way from ONC to CMS #UGM2012

— borborygmi (@nickgenes) September 11, 2012

Next big things for Epic seem to revolve around mobile apps on your phones and tablets. #UGM2012

— Sarah Nelson (@Sarah_at_Vonlay) September 11, 2012

#UGM2012 physician slicer dicer: from evidence based practice to practice based evidence. Cool!

— Arjen Noordzij (@dokter_no) September 11, 2012

Especially excited about Epic planned release of patient centered product for pts in hospital. Very cool for pt engagement#UGM2012

— Luis Saldana (@lsaldanamd) September 11, 2012

Great riff on ICD-9 and ICD-10 in relation to Spinal Tap and going to 11. "It’s one version higher. So it has to be better." #UGM2012

— Sarah Nelson (@Sarah_at_Vonlay) September 11, 2012

RT @gruntdoc: #EPIC #EPICUGM 14K here, about 7.4K are clients, rest Epic staff; 10 countries rep’s. #UGM2012

— Luis Saldana (@lsaldanamd) September 11, 2012

#UGM2012 Wouldn’t it be great: the UGM2013 app with your schedule notifying when to go and showing how to get there?

— Arjen Noordzij (@dokter_no) September 11, 2012

After day 1 at #ugm2012 I am exhausted, but #Epic has been fantastic, need to take notes on guest services!

— Autumn (@rhodes_aut) September 12, 2012

In upcoming Epic release, patients will be able to log into myChart and download their records to a PDF #UGM2012

— Robert S. Miller, MD (@rsm2800) September 12, 2012

#ugm2012 300/500 of the Epic hospitals are using barcode med administration. Very good for patient safety!

— GruntDoc (@gruntdoc) September 12, 2012

Good job Epic – lots of cool new features. Loving the emphasis on analytics! @epicugm #UGM2012

— Krishna Ramachandran (@krishna_gr) September 12, 2012

#ugm2012 good news, Epic is going to have an opt-in for benchmarking across Epic hospital systems. Terrific!

— GruntDoc (@gruntdoc) September 12, 2012

Beacon oncology updates: therapeutic substitutions 4 antiemetics 4 drug shortages; breast ca survivorship plans; better analytics #UGM2012

— Robert S. Miller, MD (@rsm2800) September 12, 2012

Epic will use protocols from #DirectProject to push information to outside EHRs #UGM2012

— Robert S. Miller, MD (@rsm2800) September 12, 2012

Mobile payments to be built into Epic myChart. Can also sign up via mobile for paperless statements #UGM2012

— Robert S. Miller, MD (@rsm2800) September 12, 2012

#ugm2012 Need this Cogito data model! It is a data warehouse that compiles Epic and non epic data in one place to help reporting.

— GruntDoc (@gruntdoc) September 12, 2012

#UGM2012 #Carl Dvorak did it! His childhood dream came true: live on stage with a guitar.

— Arjen Noordzij (@dokter_no) September 12, 2012

#ugm2012 surreal seeing software planned for release in 2 years, that we won’t get for at least three. Like hearing about the cool1/2

— GruntDoc (@gruntdoc) September 12, 2012

Fun idea to improve clinical note quality: ‘Like’ button on peer’s progress notes! #UGM2012

— K Wroblewski (@kdwroble4) September 12, 2012

Was intently watching #UGM2012 tweets and Apple anncmt live blogging. Neither affects me, but I felt temporarily cool.

— histalk (@histalk) September 12, 2012

News 9/12/12

Top News

ONC publishes a Health IT Dashboard that includes six views and 250 custom dashboards for states, ONC programs, and grantees. It includes charts, maps, and downloadable tables pertaining to EHR adoption, REC programs, and HIT workforce training. An interesting statistic: of the 143,890 EPs enrolled in RECs, only 17,144 (12%) have demonstrated MU. Also surprising: only 39% of acute care hospitals were using even a basic EHR by the end of 2011.

Reader Comments

From David: “Re: Dr. Jayne’s comment on ‘educational session’ put on for members of Congress. As someone who used to put these on, these are simply a forum for making a lobbying pitch to lawmakers and Congressional staff under the guise of education. The ‘education’ is to get lawmakers to vote in the interests of the event’s corporate sponsors.” Sponsors listed include HIMSS, Ingenix, Allscripts, BCBSA, and a bunch of other companies, government contractors, and member organizations. It was the Washington schmoozing and complete surrender to its Diamond members that largely turned me against HIMSS as an organization that represents me as a non-profit hospital employee and dues-paying member instead of a piece of meat offered up for ogling by its conference exhibitors. I would rather see HIMSS split into two groups, one for providers only (like it almost was before the current regime got dollar signs in their eyes) and the other being the vendor trade association that HIMSS denies being despite ample similarities.

From Dell-lightful: “Re: Dell Services layoff. It’s true. I’ve spoken to two senior salespeople in the healthcare vertical who were laid off in recent weeks. One of them said the action was called Operation Savings Storm. He e-mailed me a picture of him shaking hands and smiling with Michael Dell. I suppose that only Michael is smiling now since his labor cost just went down, good for his quarterly report.”

From Eileen Dover: “Re: Lahey Clinic. Scrapping their Allscripts implementation and going big with Epic. You probably already knew that.” I ran reader rumors to that effect in June, but got no response from the CIO when I asked about the “unified architecture” the rumor said they were pursuing (which means they’re planning to buy Epic nine times out of ten). Their original strategy involved using Orion Health to serve up scanned PDFs of inpatient records and using Allscripts on the outpatient side, which doesn’t sound like much of a strategy at all given Meaningful Use requirements and changing care models. I’ll leave this as Unverified since I’m missing the standard confirmation: the posting of a ton of Epic jobs on their site.

From SubDude: “Re: athenahealth. Saw this poster on the green line of the Boston T.”

From Empty Handed: “Re: Encore Health Resources. In talks to be acquired by Dell.” I asked the Encore folks a few weeks back and they said this rumor isn’t true. I believe them, but I also noted from experience with other companies being acquired that you always get that same answer even when it really is true, with an apology later for being less than truthful out of necessity. All I can say is that I’ve heard the rumor from anonymous readers twice now, the company denies it, and I have nothing to back it up.

From Debunker: “Re: the EMR cost study you mentioned. There are also significant issues with how the HIMSS Analytics data collection is performed when you look under the covers at the raw data.” That’s a good point. Everybody trying to do these lazy database-matching “studies” assumes that those databases have perfect information, which I’m sure they do not.

From Neal: “Re: Glen Tullman compensation by Allscripts. Thanks for keeping an eye on the mega-earnings of the vendor CEOs. However, it’s fair to note their value is not reflected solely by share price. Tullman grew Allscripts from a niche ambulatory vendor to a near-competitor with Cerner if not yet Epic across virtually every segment of the market. It’s too early to tell if he’ll be successful, but they will be a serious competitor if they can integrate their myriad solutions. He has one year, two tops, to deliver or face the boot from his new board.” Glen did a masterful job of wresting control of the company from Misys and then buying Eclipsys. The mistakes he’s made from my cheap seats view: (a) paying too much for Eclipsys, which nobody else seemed to want; (b) declaring mission accomplished with Sunrise integration almost immediately after the acquisition, backing up that statement with questionable comments that having two unrelated systems both running on Microsoft-powered servers meant they could just start happily interoperating once the ink dried on the sales collateral; (c) trying to pass off Allscripts as a serious competitor to Epic; and (d) escaping an ugly board power struggle and then caving in to a proxy fight that gave a dissident shareholder board seats. You are right that Wall Street encourages actions that boost share price for all the wrong reasons, often at the cost of long-term possibilities, like when Cerner stock took a beating in the late 1990s as they dared spend research dollars to build Millennium instead of booking big earnings per share. Allscripts needs to deliver technically before the competition (both inpatient and ambulatory) pushes it permanently into the mid-majors. If you’re a customer, you’re better off with Glen in charge than selling off to private equity investors, who would have a field day retiring products, selling off divisions piecemeal, and milking services revenue to juice the bottom line to enable a quick flip. We’re already down to basically three vendors for big hospitals (Epic, Cerner, and Allscripts plus a bit of Meditech in the mix). I don’t see Allscripts gaining much inpatient ground given its few announced sales to mostly small hospitals, which is the same problem Eclipsys had despite an arguably superior product, but I hope they keep it competitive. I should have also mentioned that despite seemingly generous compensation, this particular bonus plan announcement actually represented a pay cut for Glen.

HIStalk Announcements and Requests

Say hello to LDM Group, supporting HIStalk as a Platinum Sponsor. The St. Louis-based company offers behavior-changing prescription management programs. Specifically, its patented process improves patient compliance and outcomes by connecting patients with their prescribers and pharmacists. The company’s electronically targeted ScriptGuide messaging (print, e-mail, SMS) helps build tighter provider-patient relationships and helps meet Meaningful Use and ACO requirements for customized patient education and engagement. LDM Group’s network of providers, EMR/EHR vendors, and sponsors of educational material (pharma, payers, health plans, and PBMs) help patients become better educated about their healthcare via personalized messaging from their trusted providers right at the point of service. The company’s case studies show that medication adherence increases up to 16% for specific disease categories, potentially avoiding expensive interventions due to non-compliance. Thanks to LDM Group for supporting HIStalk.

Epic’s UGM is underway. Your report, photos, etc. are welcome since we are not in attendance. So many conferences, so little time.

Acquisitions, Funding, Business, and Stock

Mediware completes its acquisition of the assets of Strategic Healthcare Group, a provider of blood management consulting, education, and informatics solutions. Mediware also reports Q4 results: revenue up 4%, EPS $0.29 vs. $0.25.

Elsevier acquires ExitCare, LLC, an enterprise-wide solution for patient education and discharge instructions.

Sales

Rush University Medical Center (IL) selects MethodCare’s Charge Recovery Solution to optimize charge capture.

The University of Colorado Hospital will implement Infor Lawson Healthcare’s financial, supply chain management, and human capital applications.

Coordinated Health (PA/NJ) selects Allscripts Sunrise Clinical Manager. Their hospitals are Coordinated Health Allentown Hospital (22 beds) and Coordinated Health Bethlehem Hospital (20 beds).

Cancer Treatment Centers of America chooses QlikView to replace its existing business intelligence software, using its analytic capabilities to find opportunities for improvement and planning its future use to predict which therapy options will work best for a given patient.

People

Clarity Health names Bill Bunker (Vertafore Agency Markets) as CEO, taking over for founding CEO and newly appointed executive chairman Peter Gelpi.

The GAO appoints Christopher Boone, director of outpatient quality and HIT for the American Heart Association, to fill a vacant patient advocate seat on the HIT Policy Committee

Announcements and Implementations

West Virginia University Healthcare installs the Patient Safety Net incident reporting system from Datix and UHC.

HIMSS Analytics recognizes Hennepin County Medical Center (MN) and Truman Medical Center (MO) with its Stage 7 award for EMR adoption.

Franciscan Alliance goes live with iSirona’s device connectivity solution at multiple facilities.

In Southeast Texas, CHRISTUS Health, Texas Children’s Hospital, UTMB Galveston, and Legacy Community Health Services sign up with Greater Houston Healthconnect to exchange patient information.

Medecision’s care management solution is added to the Availity network to support post-discharge planning and coordination.

Government and Politics

ONC posts draft test procedures and test data files for the 2014 Edition EHR certification criteria.

HHS Secretary Kathleen Sebelius announces that the public can vote for their favorite innovation among finalists in the HHSinnovates Program, which is designed to recognize innovative projects developed by HHS employees to solve healthcare challenges. Public voting is open until September 14.

Allscripts CEO Glen Tullman pens a Forbes opinion piece extolling the accomplishments of his friend President Barack Obama, also saying great things about his stimulus bill, particularly the HITECH part that benefited Allscripts immeasurably. He concludes, “Now what he needs is one more term to finish the job.

Technology

AirStrip Technologies is awarded a patent for its technology and process for delivering physiologic monitoring data to smartphones, tablets, and other devices.

A 17-year-old invents an inexpensive and portable EKG that collects heart rhythm data via Bluetooth and sends it to a remote physician.

An orthopedic surgeon uses an iPod Touch in knee replacement surgeries, saying it allows more precise placement of the artificial knee and thus reduces complications and provides a greater range of motion.

Weight loss company Diet Doc offers its customers weight loss consultations with physicians at its 30 locations via Skype. The (female) CEO cites the “growing possibilities that telehealth has” in decided to replace its telephone-based consultations with video in managing its human chorionic gonadotropin diet plans. They’re probably the only telehealth-using provider featuring a Star magazine cover of Kim Kardashian with the CEO’s unsolicited opinion that “comfort foods added a few pounds to her frame” but that she has thankfully “slimmed down to snag a man.” The FDA doesn’t have anything good to say about HCG diets and has banned non-prescription sales. It requires prescription HCG products to be labeled with a warning that there’s no proof that they work.

Other

Two University of Miami Hospital employees are accused of selling the information of thousands of patients they obtained from registration face sheets over 22 months. The university’s medical school reported the theft of a pathologist’s briefcase earlier this year that contained an unencrypted flash drive with six years’ worth of patient medical record data.

A computer hacker in Italy with brain cancer, desperate for second opinions, cracks the proprietary format of his electronic medical records, converts them to an open format, and shares them on his Web site. Two doctors responded in the first 24 hours to what the patient is calling “My Open Source Cure.” He invites doctors, hackers, musicians, or anyone who can help to review his information and e-mail him their “cure,” which he will post on his site. If you’d like to help out, you will need someone who can read Italian to translate the scanned records.

The former hospital equipment designer who in 1982 designed the first laptop computer, the GRiD Compass, has died. Bill Moggridge was 69.

In the UK, Fujitsu is reportedly blacklisted from being awarded any government services contracts after previous failures, notably its work on the failed NPfIT project.

A Chicago-area health department says EMR implementation temporarily reduced the walk-in patient capacity of its clinics by half right after go-live last week. At a two-physician clinic whose appointments are booked out for months, one patient said the line that snaked around the corner looked like “a Depression-era soup line.”

Weird News Andy says an interdiction might be placed on the future work of this surgeon, who is being sued by a patient whose lawsuit claims his cancerous penis was amputated without his consent.

Sponsor Updates

• HTMS, an Emdeon company, and Managed Care Executive Group launch the fourth annual Industry Pulse Survey to identify issues and concerns important to healthcare payers.
• Pivot Point and NextGate collaborate to offer identity management, credentialing, and RCM enhancement solutions to HIEs, ACOs, and health systems.
• Orion Health posts the agenda for its October Healthcare Collaborative in Colorado.
• Imprivata demonstrates its secure no-click access at Epic’s annual UG meeting and offers a white paper on optimizing Epic clinical workflow.
• Awarepoint adds VT Group as a VAR for its aware360 RTLS suite.
• MED3OOO announces the keynote speakers and agenda for its October National Healthcare Leadership Conference in St. Thomas, USVI.
• Greenway recognizes Pediatric Associates (WA), Premier Family Physicians (TX), and Medical Park Orthopaedic and Sports Medicine Clinic (AR) for their innovative use of Greenway solutions to improve care delivery.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Readers Write 9/10/12

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.

I Am the BOSS!
By Bill Rieger

There is no question who the boss is around here. I earned the office with two — count ’em, two — windows.  My paycheck is at the top of the pile and serves as a paperweight for the rest of them. The CEO and I swap stories about how great we are. I am the one in front of the board every month reviewing IT strategy and direction. Make no mistake about it, I am the man!

Ever work for anyone like this? Maybe you still do, although it may not be this obvious. Or, are you yourself like this?  

WAKE UP! The time for career oppression is over.

Change is happening faster than ever. We no longer have the luxury of centuries, decades, months, weeks, days, or even hours to adapt. While back in the day it took just about 2,000 years to invent the stethoscope after discovering that heartbeats do actually have clinical meaning, today a discovery can reach millions of scientists around the globe in seconds.

Have you seen some of the "Did you know" videos that illustrate the rapid pace of change today? Certainly not all of them are validated, but it makes you think, doesn’t it? One of the statistics I like is about text messages. The first commercial text message was sent in December 1992. Today the number of text messages sent and received every day exceeds the total population of the planet. 

The point? As stated before, change is here and it is coming faster every day. If you think you can manage the change of this generation alone, you will cut short yourself, your organization, your community, and all of those you influence.

At our hospital, a member of the IS leadership team had previously been exposed to the Clifton Strength Finders book. Their idea was to purchase it for all IS staff members to help them find their strengths. This led to a whole mindset shift of the IS leadership team, including me. Instead of focusing on what we don’t have, let’s determine what we do have and capitalize on it.  

What a difference it has made. All staff members who participated have proudly tacked their list of strengths to their cubicle or office. The entire IS leadership team from supervisors on up have gone on to read Go Put Your Strengths To Work to help align staff member roles with their strengths.

From here, it is a work in progress. I am fully confident that many more ideas will come from this and we will continue to focus on and better use the strengths of the team. What if I would have said, "Great, Chris, now go back to your office and get me the budget report?" or something else insignificant in comparison? Where would the department be? Where would the organization be, as this concept is certainly leaking out of the IS department?  

Healthcare is in the beginning of great change and healthcare IT is in the middle of frantic change. As the stethoscope example indicated, healthcare changes slowly. After all, change in healthcare is risky. My response to that is that indeed change can be risky. In order to mitigate that risk, you cannot — I cannot — be the big shot in the corner office. 

You have to — I have to — seek out who can best help manage the seemingly unmanageable change that is coming. The talent exists. It is up to leadership to draw out those strengths that will be needed.  Leadership should be seen as a springboard, not as a ceiling.

When Abraham Lincoln worked hard to free the slaves, his original idea was to "free" them from their oppressors and then send them to Jamaica or Cuba where they could be "free." When some of the slaves were freed, they asked to be able to fight for and with the Union. That was great, and in response, they were given shovels and uniforms. When they asked for weapons, they were originally told that they could not have them. It literally took an act of Congress to get weapons in the hands of the newly freed slaves. The fear was that they would turn on their oppressors. What actually happened is that they fought with honor and courage and played a vital role in the final defeat of the Confederate army.

That is exactly what I believe some leaders are like: afraid to empower their teams, afraid they will turn on them when they lose control of them. If you want to see an empowered employee, bring them to the CEO’s office, the next board meeting, or the next department meeting and give them credit for a great idea. Watch their world change as they grow in front of your eyes.  

How many more ideas will be born of that one? How many light bulbs and stethoscopes will be created from simply giving credit where it is due? As a result of our Strength Finders journey, the IS org chart changed. The CIO and the directors are at the bottom, supporting those who are above. The ceilings are gone. Fly, people, fly! 

Bill Rieger is CIO of Flagler Hospital of St. Augustine, FL.

Moving from Care Following Technology to Technology Following Care
By John Haughton MD, MS

How is it the feds have paid out $5.7 billion for Meaningful Use Stage 1 incentives and we are still missing community-wide patient views and shared care plans accessible across EHRs and mobile devices for acute providers or across providers and payers working to enhance coordination of care or across acute and post-acute providers engaged in streamlining health delivery effectiveness?

The answer is threefold, but simple. Standards-based interoperability using discrete data is hard. Available EMRs, at their core, were designed with an encounter and billing perspective rather than a discrete patient level portable data and shared care focus due to business and legal needs. Technology in the standalone, client-server / web screen-sharing world is not designed for moving data across systems.

Integration and processing of discrete data across populations requires dynamic community views of information coming from multiple sources to realize the true value of shared care – better coordination, pre-crisis intervention, and decreased redundant care delivery. To date, incentives and needs haven’t requested the collaborative care technology infrastructure. That’s changing.

Enter the cloud and native Internet applications integrated with secure cloud information brokers, cloud consumers, and cloud providers. Cloud coordination is front and center in general federal IT acquisition activities. These systems are designed for collaboration and to share information across organizations, systems, and technologies from different vendors in different formats.

True and complete interoperability requires standards that are useful and usable, which are still hard to come by in general and certainly in healthcare. Heck, even a simple one – Medications and RxNorm didn’t allow for the prescription of birth control pills (two in one box) or prenatal vitamins (more than three ingredients in one) until recently. Fortunately, there are ways to use modern security, data, and analytic processes to move information now. Methods that are proven from other industries to work in environments without perfect standards are available to healthcare.

MU 1.0 was a good first step: $2 million or more for hospitals and $18K to start for providers. Money flowed into the system to purchase IT. Even so, the electronic health records purchased by and large don’t talk to each other yet. Even the Beacon Communities are into their third year without real interoperable clinical data from various EMRs (fingers crossed — we should see data movement starting this fall. Lots of folks have been working hard to make it happen.)

Now with MU 2.0 out, the money for change won’t come so much from the same ONC carrot. The majority of incentive dollars will have been earned during MU 1.0. Instead, there’s a new carrot — shared savings rewards in ACOs and other value purchasing — and now a stick in penalties for fee-for-service Medicare payments for a lack of reporting and performing on various quality of care metrics. Additionally, rewards and penalties from commercial insurers are creating narrow networks with less revenue and access for providers at the lower end of the cost-quality matrix.

What is the right design for EHR and community care systems in the evolving world? At a minimum, systems must make sure the data collected is secure, accessible, portable, and interoperable. To make this happen, EHR systems must include the perspective of being part of a network — part of a data fabric — at their core.

Newly emphasized functions from MU 2 for collaborative care include: data formatting; content normalization; patient-level information aggregation – in discrete, standardized elements – attributable to sources; population analytics for opportunity identification and effectiveness measurement; workflow that includes access to information at a place where it can be used; and collaborative communication across teams. Expanded decision support rules are useful for clinical care, financial management, and measurement and reporting for payment based on value.

As we move forward, the biggest change will be a change in design mindset for electronic health records, from one of monolithic, vendor-specific islands of technology to a connected ecosystem of secure data collection, portability, display, aggregation, and access across the community, across payers and providers, across patients and their caregivers , across healthcare and the general community.

Change is unstoppable as we move to networked healthcare. That’s good, but it’s tiring. In the new world, providers will no longer be dependent on singular big IT infrastructure as secure, clean, portable data and identity coupled with lighter-weight modules, interoperable widgets and applets solve real problems. Vendors will open communication channels as a strategic asset rather than “wall the garden.” Monolithic HIE umbrellas will fade as government initiatives — such as Direct for the patient and Query Health for the population — continue to gain traction as front and center techniques for simplifying interoperability and shared care tasks.

What will be needed? Outside of healthcare, the federal government has a framework. It’s moving into the cloud – a framework that includes cloud suppliers and cloud brokers – to ensure a secure, reliable interoperability experience. In fact, it is the cornerstone of the federal strategic plan for technology and information management: increasing usability and access to information while decreasing the complexity and cost of information technology. Why should healthcare be any different?

John Haughton MD, MS is CMIO of Covisint of Detroit, MI.

Patient Engagement
By Kim South, RN

With the new Stage 2 Meaningful Use rules finalized and released, patient engagement is becoming a major focus. Can providers control that their patients are logging in online to view their medical information? Can providers control their patients to the point of sending secure messages? Everywhere I turn, these are the questions I am hearing. 

The short, quick answer is, “Of course we can’t control them.” That’s also the answer the people who are asking the questions are searching for. 

On the surface, it’s an accurate answer. We can’t control our patients. We can’t make them engage in their care. We can’t make them be interested in losing weight or quitting smoking. But we do have the potential to influence their behaviors and encourage them to be our partners in their health.

As an oncology nurse, I spent hours every day talking with my patients and their family members about what was discussed in the recent office visit. It’s so much foreign information to take in, remember, and explain to others. Online access to this information has the potential to seriously reduce office time spent in this role, which translates directly into the nurse’s ability to focus on other tasks. 

I’m no longer a practicing oncology nurse, but it’s where my heart lives. Being on the vendor side now, my patients are always in the back of mind: what would benefit them, what would make their burden less, what would make them feel more in control of this disease process? Patients with chronic diseases are hungry for information. What better information to supply them with than their own? It makes perfect sense to me. 

I’m sure I’m in the minority, but I actually see this transparency with medical records as a benefit to both the patients and the medical personnel who care for them. Fewer phone calls about what was said, secure messaging to answer questions that would be a phone call interrupting a clinic, the ability for patients to visually see their health. It’s very powerful stuff and why I stay in the healthcare field — to make a difference for the patients.

Can we control patients? No, but we sure can influence them. I could sell online access to my cancer patients in a heartbeat. Online access to their office visit information, online access to their lab results, online access to send me a question as they think of it regardless of the time. 

The 5% threshold to meet these measures is very attainable. Having the right tool to enable your patients to participate in their health is core, but those tools already exist. As a medical community we need to embrace patient engagement and give our patients the tools to be intelligent about their health.

Kim South, RN is product manager of Jardogs, LLC of Springfield, IL.

Curbside Consult with Dr. Jayne 9/10/12

Today is the start of National Health IT Week, which was created to “raise awareness about the power of health IT to improve the quality, safety, and cost effectiveness of health care.”

One of the events being held in conjunction with the festivities is a Blog Carnival. HIMSS invited bloggers to submit posts answering the question, “How will health IT make a difference a year from now at the next National Health IT Week?” Posts had to be submitted during the last month, and selected contributors will have their pieces appearing this week. I wasn’t confident that HIMSS would select anonymous bloggers for their showcase, so I didn’t bother to try. Plus I’m not much for deadlines these days since I’m getting pounded with work at my day job.

Another event will take place on the 13t, the Capitol Hill Health Information Technology Showcase. It is sponsored by the Congressional Steering Committee on Telehealth and Healthcare Informatics and will offer Members of Congress and staff “first-hand demonstrations of health IT and interoperable communications capabilities.” I was surprised to learn that this Steering Committee was founded in 1993. You would think if you had a bunch of lawmakers advocating for telehealth for nearly two decades, they would have figured out a way for providers to be reimbursed for providing it. If they haven’t been doing that, what have they been up to?

I surfed the Internet a bit and couldn’t find that they do much beyond organizing “widely attended educational sessions and healthcare information technology demonstrations” for Congress, legislative staffers, agency officials, industry, and the public. A different search revealed that the Committee is part of the Institute for e-Health Policy, which is part of the HIMSS Foundation. The Institute also sponsors a Congressional Luncheon Seminar Series funded by a vast array of IT vendors, insurers, hospitals, and government contractors. There was a smattering of quasi-nonprofit organizations on the list, but they may be there just for show.

In that frame of mind, I’d like to try to answer the question originally posed. Putting on my academic hat, it’s really a terribly worded question. It may have been more interesting if they added some qualifiers – such as how will health IT make a difference in a specific area? Or to patients? I’m admittedly in a cynical mood, but I’m going to have to say that I don’t think health IT is going to make any more of a difference next September than it does today.

Flash forward to September 2013. Vendors will be shipping out their “MU Stage 2 Compliant” releases to get customers ready to start attesting come January 2014. That means they will have spent the better part of the preceding year “teaching to the test,” or rather focusing their efforts on coding to the specs and achieving certification. Any innovation they had planned will likely be sidelined as they are forced to shift pre-defined blocks of resources to coding for MU goals rather than being revolutionary.

Customers will be readying last-minute upgrade plans and running full tilt towards the dual threats of Meaningful Use and ICD-10 mandates. Rather than focusing on clinical transformation and physician adoption, they will also be “teaching to the test” and training clinicians to make sure every nonsensical “i” is dotted and “t” is crossed. Providers will receive monthly (or worse, weekly) reports from practice and health system administrators that do nothing more than measure their performance on checking boxes.

Patient care will be largely unchanged. Rather than focusing on specific diseases or quality improvement projects, they will be scrambling to make sure they don’t lose revenue or get dinged in audits. Hundreds of millions of dollars will be spent, but clinical metrics will not be appreciably better.

Maybe it’s better that I didn’t submit for the blog carnival. I bet the chosen bloggers will paint a dramatically different picture. I can’t wait to see what they come up with.

E-mail Dr. Jayne.

Monday Morning Update 9/10/12

From Lickety: “Re: percentage of EPs/EHs achieving MU Stage 1. Does anyone know the percentage of all EPs/EHs to get a feel for where the country is in total?”

From Candy Albicans: “Re: Allscripts. Considering selling its profitable MyWay division to SYNNex, a reseller that has purchased 1 million licenses.” Unverified.

From Eric the Well-Read: “Re: your posts. I’m pretty sure I see another site that you’re writing for under a different name. True?” False. I barely have enough hours in the day to write HIStalk. I suppose I could attempt to pimp myself out in several ways (writing elsewhere being one) and use the proceeds to quit my hospital job, but I like things the way they are, which is they way they’ve been for the past nine years. That represents either high satisfaction or low ambition (probably the latter).

From Mrs. Beasley: “Re: EMR implementations led by hospital business units. This seems to be more common, especially with Epic. I’m curious to hear whether anyone else thinks the role of the CIO is changing because of this. I’m in the middle of one and wondering whether after the install, it will be business as usual for IT.” I’ll expand your original thought a bit for the benefit of the many CIOs whose hospitals are implementing Epic: if your hospital has been live on Epic for more than a year, how did your IT budget, staffing, priorities, consulting budget, staff training costs, and personal responsibilities change? I bet I’m not the only one curious about what happens in the Epic afterlife.

President Obama would win a close race if the election were held today and my poll respondents were the only voters. New poll to your right: which of the five listed inpatient clinical systems vendors offer the most innovative products? I’m asking since Cerner was just named by Forbes as one of the top 10 innovative companies overall, but I’m skeptical about how the magazine arrived at that conclusion since they didn’t actually say. And note that there’s no “none of the above option” since it’s unnecessary based on the question being asked.

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

Listening: new from Katatonia, brooding Swedish progressive metal that is admirably devoid of the characteristics of suckier bands that drive many potential fans away: grunting, screaming, excessive tempo, and a wall of impenetrable noise. Good vocals, minor key melodies, and fine musicianship.

Hey, EHR vendors! tweet a pledge to do View/ Download/Transmit in 2012. Will shout out on Monday. #ONCPledge #VDTnow #HealthIT4U

— Farzad Mostashari (@Farzad_ONC) September 7, 2012

I’m impressed with how openly Farzad Mostashari uses Twitter. Granted the bar was set low by his deadpan predecessors, who probably would have been happy to turn the ONC Twitter account over to a federally contracted, chirpy, 23-year-old marketing ghostwriter with a blissfully empty head, but he’s out there tweeting away with original thoughts at all hours. Here’s a brilliant throw-down he posted Friday afternoon: which vendors are willing to publicly promise that they will roll out View / Download / Transmit capability for patients by the end of 2012? He says he’ll post the names Monday, with takers so far being eClinicalWorks, athenahealth, SOAPware, and Greenway. What say you Epic, Practice Fusion, NextGen, Cerner, McKesson, SRS, Allscripts, and GE? Farzad wants to know whether you own cattle or just big hats.

Speaking of ONC, they decide not to proceed with their intended regulation of NHIN’s “conditions for trusted exchange.” Reason: regulation might slow things down, which is just about the last thing that HIEs need.

The board of Allscripts approves a $1.9 million 2012 incentive for CEO Glen Tullman. His total compensation in 2011 was $7.2 million. Above is the two-year MDRX share price (blue) compared to Cerner (green), athenahealth (red), and the Nasdaq (brown). Had you invested $10,000 in each two years ago, the value of your holdings today would be worth $6,257, $22,854, $32,844, and $14,025, respectively.

Orchestrate Healthcare names former Dean Health Systems IT VP Jerry Roberts as VP of its Epic practice.

Olympic Medical Center (WA) will spend $7.6 million to get Providence Health and Services to implement Epic for its hospital and clinics over the next year. They expect to get $7 million in HITECH money in return. Annual support fees will run around $750K. The CEO says they’re getting a tremendous deal, especially given that Epic will replace five systems. “I think our current systems really don’t help us take care of our patients the way they should. I think Epic is the best system available.”

Nuance announces its 2012 Understanding Healthcare Challenge, offering prizes to the top three developers to describe how they would integrate Nuance’s clinical language software into their products. Entries are due October 5.

Crain’s Chicago Business found 10 Illinois physicians who are making at least $1 million per year from Medicaid, with four of them being pathologists (as with most businesses, those higher on the supervisory food chain did better than those doing the actual work). Leading the pack: the head of pathology at safety net hospital Sinai Health System (also their CMO), who pocketed $5.9 million in a three-year period. The second-highest was a urologist who raked in $5 million while being investigated for questionable billing. The third was the medical director of Planned Parenthood of Illinois, who just agreed to a $367K settlement for overbilling. She made $3.9 million in just over one year of the study period before being cut off because of the billing investigation.

Vince finishes up his HIS-tory of Keane with the stories of First Coast Systems and Source Data Systems. As always, he welcomes your contributions about vendors of yesteryear.

A reader sent over an article from the HIMSS cheerleader rag, knowing I wouldn’t have seen it since I don’t read free healthcare IT magazines (they’re mostly just re-worded press releases). The article proclaims, “It’s confirmed. Electronic medical records can indeed yield marked savings for hospitals.” Just to be a contrarian, I dug up the original article to see what they were gushing about (other than everything that’s pro-vendor).

As I expected to find, this is another example of the pitfalls of outsourcing your conclusions to non-experts armed with the dual motivations of (a) not biting the hand that feeds them, and (b) drawing in readers with sexy headlines that the article doesn’t support. I think the work of the study authors was OK, but hardly conclusive or even convincing.

What the paper actually says is that EMRs have provided “mixed performance,” i.e. the paper isn’t suggesting predictive value. The authors tried to prove (unsuccessfully, in my opinion) that the driver of whether hospitals save money as a by-product if implementing an EMR is the availability of local technical expertise, which just doesn’t make a bit of sense given that (a) technical resource availability doesn’t have much impact on cost since it’s a tiny portion of overall hospital cost, and (b) hospitals use remote and/or contracted technical resources all the time, making geographic location only marginally relevant.  

My reactions:

• The study is just a paper, so it hasn’t gone through peer review or acceptance. I would hardly say it “confirms” anything.
• This was yet another drawing room study where someone just mashed up conveniently available but questionably relevant data, in this case the HIMSS Analytics database, the Medicare Cost Report, and the AHA Hospital Survey.
• The databases were current only through 2008, so this is four-year-old information that predates almost every significant EHR event.
• The study’s main finding is that the average hospital that implemented an EMR during the 12-year period saw no improvement in efficiency, and in fact, saw their costs go up after adoption (“quite high,” the article says). I notice that didn’t make the magazine’s headline.
• Hospitals located in areas with a lot of IT talent saw costs go down 4% from previous IT cost (those adopting basic EMRs) and no change (those adopting advanced EMRs).
• Hospitals in low-talent areas increased their costs 2-3% with EMR adoption.
• I didn’t really understand how they considered hospital ownership, which is a good predictor of both IT utilization and overall cost structure. Or for that matter, separating hospitals that outsource IT functions from those that don’t.
• I don’t think most hospitals buying an EMR in the early 2000s expected or even wanted to reduce costs, so I don’t really see the value of finding out whether they did.
• The idea that the likelihood of a given hospital reducing its costs by implementing an EMR is based solely on how many programmers live in its area does not pass any sniff test I can envision.
• The article’s abstract contains the real conclusion: “Adoption of EMR is generally associated with a slight increase in costs. We argue that this average masks important differences over time, across locations, and across hospitals.”
• The thrust of the article can be inferred from its title, “The Trillion Dollar Conundrum: Complementarities and Health Information Technology.” It is actually, to a certain extent, debunking the questionable conclusions of CMS and the Cerner-funded RAND study in proclaiming that EMR adoption will reduce healthcare spending. The article says EMR cost savings will be “mixed” until technical resources are more widely available. That doesn’t really sound like the upbeat conclusion the magazine trumpeted.
• As always, even if you buy the study’s methodology, it at best identifies a slight correlation rather than causation. I would not attempt to predict the impact of a $200 million Epic install in a large academic medical center to generalized, old information of mostly small hospitals (which as a percentage, is most of them).
• Implementing an EMR to save money is an iffy proposition at best, not to mention that maybe patient outcomes should be the stronger consideration.

My conclusion is that it’s not a bad study, just not all that conclusive and certainly not worth detailed coverage in an industry magazine. I lost interest in further analysis at this point since it was time to have a beer and watch some college football. If you didn’t, feel free to elaborate further.

E-mail Mr. H.

Time Capsule: Actual vs. IT-Measured Quality: Giving Data the Benefit of the Doubt When Money’s On the Line

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.

Actual vs. IT-Measured Quality: Giving Data the Benefit of the Doubt When Money’s On the Line
By Mr. HIStalk

It’s inevitable that hospitals and providers will someday get paid more or less based on how they perform on quality measures. Smart people will create a list of clinical actions that supposedly measure quality, or at least serve as a proxy for it. Follow those standards and you’ll get a bonus (or, for you fellow pessimists, avoid a penalty).

Coming up with standards is hard. Medicine keeps reminding us that it’s an art and not a science. Patient outcomes don’t always bow down obediently to even a well-designed medical cookbook (if they did, all doctors would already be treating patients the same). And if you start paying hospitals to give aspirin for heart attacks, you’d better make sure it adds value.

Still, at least for common chronic diseases, the standards are starting to become clearer and more defensible. Widespread use will prove or disprove their value. They can always be changed to reflect new knowledge.

Once the standards are in place, what’s left sounds easy: just sift through reams of electronic information to see how well providers have followed them. Then, write those checks. However, an editorial in the current issue of JAMA reminds us that data standards are poorly defined.

I don’t think providers will cheat, but I think they will err on the side of getting paid when the information is murky. For example, heart attack patients who smoke are supposed to get advice on stopping. Somewhere in the digital soup lives a data bit. It gets turned on when a nurse checks off a “smoking cessation education offered” item.

But, what does that check mean? (or as the geeks say, what is the metadata?) Does the nurse check the box only when she’s done a bang-up job of patient education, including having the patient demonstrate their understanding? Or, does a “smoking cessation” item pop up from an order set, which creates a task, which creates a “click here to make this item go away” entry on the flowsheet?

Reminder: you get paid for checking the box, not doing a wonderful job.

Hospitals are supposed to give clot-buster therapy to new heart attack patients with 30 minutes of their coming through the door. That means you need a super-accurate recording of the time they came in, plus the actual time the drug started coursing through their veins (not when the order was entered or when a nurse pulled the med from the Pyxis machine).

Reminder: conveniently retrievable data isn’t necessarily the same as clinically relevant data, even though it fits the loose definition of what’s being sought. It’s easier to rationalize that what you have is good enough than to go after something new.

Payers might want doctors to encourage patients to get flu shots. Do they pay them for actually giving it, or just for recommending it? Is it for all patients, or just those who happened to have an appointment at the time of year the flu shot inventory is available?

Reminder: physician payments may be based on a denominator of all patients under their care, not just those who have had an office visit.

I’ve looked at a lot of hospital data, particular that involving medications and treatments, and I wouldn’t trust it in many cases. There’s a lot of variability behind what looks deceivingly black and white to a programmer.

We IT people like the idea of pay-for-performance because we are logical and data-driven. It also provides the comforting illusion that providers who follow checklists will keep us from dying. Where we may get uncomfortable, however, is when we realize that our information systems will be taken as gospel by the check-writers. Deep down, I don’t think we really believe that our information is quite ready for that level of scrutiny.

Now’s the time to review your data and metadata. Most quality measures involve just a few data points: when something happened, what drugs were given or what tests were performed, and what was done when the patient was discharged. If you can comfortably produce that data without crossing your fingers behind your back as to its reliability, then you are ready for data-driven quality measurement.

HIStalk Interviews Greg Dorn MD, President, First DataBank

Gregory H. Dorn, MD, MPH is president of First DataBank of South San Francisco, CA.

Tell me about yourself and the company.

I’m a physician. I went to medical school, undergraduate, and medical school at Columbia. I trained in surgery at UCLA and then did a Masters in Health Services Management at UCLA.

During my residency, I became very interested in the process of care and how to improve the clinical process of care. That stemmed from my undergraduate work in operations research, or really industrial engineering. This became a nice marriage of the two.

Throughout my clinical training and subsequent to that, I saw a lot of opportunities where there were clinical practices that weren’t always well substantiated as being best practices. Also, in the hecticness of clinical practice, you would see a lot of errors that would occur, particularly with complex medications in the ICU — I’ve spent a lot of time there.

That passion grew in me. That’s where I helped start a company called Zynx Health. It has grown to become, I think, a standard bearer within the field of evidence-based medicine. Subsequent to that, I moved over to First Databank to take what I’d learned at Zynx, and also prior to that , to bring it to bear within the clinical drug decision support environment. To try to optimize what I think is a really significant opportunity to inform clinical practice at the point of care around drugs. That’s one of the most heavily integrated into the workflow decision support domain today, as opposed to perhaps referential content or medical or nursing or traditional clinical information.

First Databank has been around for about three decades, focused exclusively on integrated drug knowledge. I emphasize the “integrated” piece because there’s a lot of drug knowledge out there, reference and integrated. But from its very inception, FDB has been heavily focused on integrated. That means embedded into the software application used by the clinician, whether she or he be a nurse, a pharmacist, a physician, a nurse practitioner, a physician assistant, and any myriad of care extenders that may come to bear here as the healthcare economy expands tied to the Affordable Care Act. 

We’re focused on delivering that clinical content to the point of care. We’re not focused on being a supermarket of information, or being all things to all people and assembling every different type of clinical content you might want, but rather to be true experts at the point-of-care decision-making process such that clinicians get the most value out of that alert, that ordering sentence, or any other type of dosing information or a range of other clinical decision support in the drug domain.

Both First Databank and Zynx have strong brands, to the point that I’m not sure everybody knows that both owned by Hearst. What are the commonalities between the two companies?

Hearst is a very broad, diversified media company. They own the San Francisco Chronicle, Cosmopolitan, parts of ESPN, A&E, and Lifetime. They’re all organized into major operating clusters that are thematic. We’re in Hearst Business Media, which is focused on business-to-business, workflow-embedded content — decision support.

First DataBank, Zynx, and Map of Medicine in the UK are all focused on the medical-clinical side or healthcare side of things. The relationship specifically between Zynx and FDB is that Zynx takes a broad view of clinical decision support and says, “What are all the sources of information I can derive a best practice from? How can I then package that information in a useful clinical format — an order set, a care plan, an intelligent clinical alert?” There’s also a significant amount of forecasters and calculators. Taking a broader approach to distilling best practices.

FDB goes one layer deeper. Zynx can run on the infrastructure of nomenclature data, alerting, drug structured information that FDB provides.  We go that layer deeper, where we’re optimizing the exact order sentence. If you have a Zynx order set that’s evidence based that’s going to drive reductions in mortality and you select to execute that order sentence, the next series of steps to make that orderable sentence truly specific to the patient’s context and very intuitive to the clinician but also that it translates into a dispensable that can be handed out by the pharmacy –we have specific data sets that allow that translation to occur seamlessly.

If you think about ordering that medication in the setting of a particular diagnosis or co-morbidity or the setting of another medication or the setting of a particular lab result, our alerts are optimized to make sure that that alert is meaningful to the clinician. That’s where the interplay between Zynx and FDB comes in. Those that use both see significant benefits.

You could argue that most of the value of CPOE and other clinical systems, beyond standardizing what’s available for ordering, is the third-party content such as that offered by Zynx and FDB. Are you actively looking for other areas where critically reviewed literature might come into play to enhance existing clinical systems?

Yes. We think of the clinical decision support environment as a cycle. If you can think of the patient making a transition from healthy to sick and then having to interact … this could be in a chronic sense. I don’t have a chronic disease, I now have a chronic disease. I don’t have an acute condition, I now have an acute condition. At that point, there are three phases where an individual interacts with the healthcare economy with regards to clinical decision support.

There’s something we call a pre-encounter phase, which is before I have an encounter with the healthcare system. There are whole hosts of activities that occur – eligibility, necessity, formularies.

Then there’s the encounter stage, which is when I’m actually in front of the physician. There’s that intimate moment with the nurse, the physician, the pharmacist when the decision is being made. That’s what we’d call the encounter phase of the clinical decision support cycle. 

Then there’s the post-encounter phase, all of the activities that relate to what happens after the patient has had an encounter with a health system that are related to clinical decision support. There you’ve got a measurement around data and dashboards and you’ve got clinical billing and just a whole host of activity – claims paying and so on.

We look at the universe with that framework. Today we’re very focused on the encounter phase. As you can see, Zynx and FDB really dominate that encounter phase. When you’re at that moment of receiving care, we can influence the decisions that are being made and reduce mortality and morbidity. We are very interested in looking at types of content that fit the other two domains, whether that be post-encounter and pre-encounter and beyond. Without getting in too many specifics, just know that those are very interesting to us right now.

You recently announced AlertSpace. What are its advantages?

In this encounter phase,  there’s this problem of alerts being highly sensitive but not specific. You get lots of alerts, but you don’t know which one is really germane to your patient’s care, so you ignore a lot of them. What we’ve seen in our research is that by clicking through alerts, unfortunately, there’ll be a click-through of the one alert that really mattered. The patient can have an adverse outcome by oversight of that valuable dosing alert, valuable drug –disease interaction, or whatever it may be.

In AlertSpace, we’re allowing institutions to customize their alerts — turn off the alerts that are not as meaningful clinically to them and promote or retain the alerts that are highly clinically meaningful to them. This is done through a web-based tool, a SaaS approach, so it’s pervasive. It’s available to any subscribing institution. 

They actually customize their data directly before they get their data load. They’re able to see those alert customizations the next time they publish their FDB data,  which can be weekly, monthly, or even daily.

AlertSpace helps reduce the noise factor and highlight the alerts that are truly clinically meaningful, thereby reducing the risk that meaningful alerts are overlooked and patients have adverse outcomes. Right now we have a whole of host of institutions that are using the tool. It’s been our most successful new product launch in the history of FDB.

AlertSpace is a tool, a solution to helping with alert fatigue. But there are also other approaches that we’re taking around the editorial choices we make about which alerts and serve upstream and trying to understand the validity of the content before it has to be adjusted by AlertSpace. There are myriad of approaches we’re taking to optimizing alerts. It’s not just that we’ll keep publishing the same content and give you tool to fix it. It’s more that we’re going to really improve the alert relationships and give you a tool.

That’s an interesting approach. Instead of relying on EMR vendors to repackage your data with the inherent delays, you’re letting customers pre-customize their own. What was the thought process there?

We wanted to close the cycle time gap between new technology reaching the end user. We obviously work with all of our vendor partners because they have to support these customizations, but what I experienced at Zynx, where we have a web-based authoring environment that allows for content to be customized and then published within a myriad of target systems … that paradigm is one we brought over to FDB. We thought FDB had the capabilities to deliver an end user application. We thought that would be very valuable to our brand and to the value we bring the clinicians.

It’s a little bit of what we learned in Zynx. It’s a little bit of trying to close the cycle time between innovation and the end user’s access to that innovation without having to enter into, as you can imagine, a long product cycle or revision cycle. How can we get this alert customization technology into the hand of end users as fast as possible? Through our client base, we know about the mistakes that occur out there around drug CDS. I know personally of hospitals that have had errors that are related to alerts. We’re mission driven about that now.

The rebranding of the company’s image appears to signal that FDB wants end user visibility, not just to the IT folks or people who apply your updates. Are you looking for a brand identity with the end user? 

Absolutely. That’s been one of my focuses since I’ve been here.  We’ve talked a lot about it, the idea that we are so pervasive throughout all of these different systems — not just with hospitals and medical groups, but  PBMs and insurance companies – but yet if you were to go to AMDIS or HIMSS or a whole range of different meetings and ask CMOs or CMIOs, “Have you heard of FDB? Do you know of FDB?” Even the end user clinician, chances are they’re going to say, “No, I haven’t heard of it.” 

Based on the impact we’re having and the impact we can have on clinical workflow, we really wanted to have that be more effectively recognized by the marketplace. End user tools that don’t interfere with our relationships with the large system vendors are a very significant strategy going forward for us. I think the reception’s been pretty good. We had a lot of large systems who we’ve met with and they like the approach so far. So I think you are right on there. We’d like to raise that profile.

We’d like to do more around end user tools; help customize the content. The thing I observed when I came in was that pharmacy clinical information was one size fits all. This is across the industry. People just publish a file, the system takes it, puts it in, and you deal with the result. That’s maybe 1.0, or even 0.5 – the first phase of the industry.

Drug CDS 2.0 is going to be about customization and personalization. That’s where we’re headed. Tools and the highly specific content that gets right down to the individual nuances, whether it be their renal function, liver function, physiology, a whole range of things. Eventually and in the not-too-distant future, their genotype and how that’s expressed as a phenotype and how they then metabolize drugs will be a very important area for us.

How do you prepare to start using genomic information?

You have to be vigilant, first and foremost, about the body of evidence — what the body of evidence is telling you about where you can adjust dosages. We’re tracking that. That’s first and foremost. As that grows, we’re compiling it.

The second piece you really need is physicians, nurses, pharmacists, and healthcare institutions to become much broader users of genetic testing. Then using those results to close the loop for a metabolic adjustment with regards to a drug. We can capture the data and develop a dosing tables that say, “If you’re a cytochrome P450 metabolizer, this is your warfarin dose” or whatever it may be in a chemotherapeutic regimen. We can do that. We have people tracking that today.

What we need is the input side, which is doctors becoming reimbursed so that it becomes more common to order a genetic test. That result can be pinged off our data and a more specific dosing parameter can be returned. Our goal is to try to help move that along. Obviously we don’t control all the pieces, but we’re very excited about how that might unfold over the next five years.

You joined the company after average wholesale price lawsuits had come up. What was the impact on the company, and how do you think the industry has changed now that average wholesale price not used to calculate provider drug payments?

That’s a great question. I joined right as we were heading into this cessation of publication, so it was a little bit after my tenure. I spent about six months re-analyzing that challenge. Hearst asked me to do that. 

What we realized is that we couldn’t continue to publish AWP, which if you really look into it, is a relatively arbitrary measure. Ceasing publication of AWP had very little impact on the company. We were able to go to our customers and provide them with alternatives, whether it be wholesale acquisition cost or other measures, that they could use to meet their needs. We very successful in being able to provide alternatives that were anchored more directly to data submitted by manufacturers.

What we moved on to is that we are in partnership with the State of New York, doing a survey of average acquisition cost. New York is collecting acquisition costs from pharmacies. We’re averaging those in partnership with Ernst & Young. That’s potentially generating a new benchmark for the State of New York. 

You also probably know that Alabama and Oregon both have acquisition price types. California, which we’re very close to, is close to moving forward with an acquisition price type. The federal government has launched an acquisition price type initiative. We’re doing our utmost to push towards this acquisition metric in the hopes of adding transparency around pricing, but still not saying it’s the only measure, but saying there is now a range of price types that can be used. We’ll definitely do our utmost to be first and foremost with the acquisition price type.

I think it’s very exciting. If we can get  better transparency on drug reimbursement, it’s better for the patient, it’s better for the healthcare economy, it’s better for employers. There’s a whole host of benefits. I think part of being innovative in that space is what’s been interesting for me.

Any concluding thoughts?

I want to make sure that your audience understands that we’re not just a US-based drug clinical decision support company. We have a division in the United Kingdom — FDB UK — and they have a very, very large position in the UK with drug clinical decision support. We have a significant presence in Asia. We also have a very nicely growing footprint in the Middle East.

We operate as a global drug clinical decision support company. If you look at all the different drug clinical decision support companies, we may be one of the few that do that successfully.That’s an important characteristic of who FDB is. As the healthcare IT market grows globally, we’ll be ready to address the needs that come, wherever they may come from.

News 9/7/12

Top News

Merge Healthcare’s board hires an investment bank to seek strategic alternatives for the company that could include a merger or outright sale. Merge, which has lost money for six straight quarters, has seen its share price drop 40% on the year, although shares were up 10% Thursday on the announcement. Above is the one-year share price compared to the S&P 500 (green) and Cerner (red).

Reader Comments

From Acorn: “Re: emergency power off switch. An engineer fell onto ours today.” Been there. We had just moved into a new data center at my previous employer and the entire data center was going dark a couple of times per day. We couldn’t figure it out, but suspected a construction mistake. The UPS wasn’t kicking on and the standby generator wasn’t coming up, so all systems were going down hard, creating a nightmare of system outage and recovery downtime (we’re talking every server, connection, telephone system, etc. spanning several hospitals). We eventually figured out the problem: the big, red emergency power-off switch was right beside the exit door where the old data center’s “press here to open door” button was located. Employees were smacking it by habit as they exited, and then sheepishly running for the hills without telling anybody when the data center suddenly went dark and quiet. We put a $1 plastic cover over the switch and that was the end of the problem.

From Sadie: “Re: Merge Healthcare. Three weeks after an RIF in France and one week after a 56-person RIF in the US, Merge announces plans to sell the company. I hate to say that I called this months ago.”

From MindYourOwnBusiness: “Re: UPMC. They’re in the hospital (and EMR) business, not the law enforcement business.” A patient who says she contracted hepatitis C from syringes infected by a drug-using radiology tech at UPMC sues the hospital and two of its staffing agencies. The lawsuit says UPMC caught the tech in the act of stealing fentanyl from the OR and told his contract employer to stop sending him to work there, but didn’t notify anyone else. The tech then worked at eight more hospitals, spreading hepatitis C to at least 30 cardiac cath patients and possibly hundreds or thousands. I’ve negotiated the “resignations” of a couple of hospital employees for known or strongly suspected drug theft over the years, and as irresponsible as it sounds, begrudgingly let them walk away without a resume blemish. The reason: the hospital’s legal counsel said that unless we had an airtight case against them (which is almost impossible to obtain) and ran them through a couple of cycles of optional drug rehab at our expense, they would probably sue us immediately for even insinuating to a potential employer that their records were anything but impeccable. In this case, the tech wasn’t even a UPMC employee. Nobody is bothering to sue the actual criminal, of course, given his unattractively shallow pockets.

From Curious: “Re: Dell. Heard they’ve cut a large number of experienced senior people from their outsourcing group.” Unverified.

HIStalk Announcements and Requests

HIStalk Practice highlights from the last week include: MGMA urges CMS to remove duplicate e-prescribing requirements in the MU and PQRS programs. Physicians express concerns about the impact of the ICD-10 transition on finances and practice operation. GenX physicians want a life outside of work, rely heavily on EMRs and smartphone apps, and like sharing the load with other doctors. Dr. Gregg has a geeky moment about Scanadu. The HIStalk Practice Physician Advisory Panel provides insights on patient volumes and the impact of EMRs and other technologies and the anticipated impact of the Affordable Care Act, with the possibly surprising finding that many of them won’t increase their patient volumes or workload even if it means higher incomes. Thanks for reading.

On the Jobs Board: Cerner and Epic Resources, Inside Sales Manager, Services Implementation Consultant.

Travis’s post on HIStalk Mobile, What I Learned about Health IT in Medical School, seems to be popular based on who’s linking to it or tweeting it (including some high-profile folks). Sign up for his updates and you’ll get the viewpoints of somebody who’s both a doc and an mHealth expert.

If Inga, Dr. Jayne, and I were running for office, we would kiss babies, try to appear humble by wearing carefully casual costumes to our scripted photo ops, and make a lot of promises we know we can’t keep. We aren’t, so the only vote we seek is one of approval, which you may cast by (a) connecting with us on the usual social not-working sites (and thus enlarge your own network significantly); (b) signing up for spam-free e-mail updates; (c) sending us news, anonymous rumors, and anything else that might amuse us; (d) enjoying the company as we do of our much-appreciated sponsors, whose click-worthy electronic greetings you see entirely coincidentally on this page (they look a bit like ads); (e) peering into the Resource Center, which contains more detailed sponsor information; and (f) telling others that you are shocked by the irresponsible and objectionable material you see here since nothing draws Internet page views like bad behavior. We thank you for reading, and if you were in the room with us, there’s a good chance Inga and Dr. Jayne would plant a kiss on each of your cheeks simultaneously.

Acquisitions, Funding, Business, and Stock

Registerpatient.com, which offers a Web-based patient registration and scheduling system for $50 per provider per month, raises $1.1 million towards a $4.1 million target.

Pamlico Capital acquires home health technology provider HEALTHCAREfirst from fellow PE firm The Riverside Company.

Vocera Communications announces a public offering of 4.5 million shares of common stock.

MobileHelp, a provider of mobile emergency response technology for personal use, acquires Halo Monitoring, a developer of home monitoring products.

Harris Corp. is investigating potential violations of US anti-bribery laws by its Carefx China division, whose employees were found to have provided gifts and payments to prospects and customers. Healthcare executives in government-run healthcare facilities in Europe and Asia are considered foreign government officials by the Justice Department and SEC.

Physician networking site Doximity secures $17 million in series B financing led by Morgenthaler Ventures, bringing its total funding to $27 million.

Sales

Intermountain Healthcare (UT) chooses Accelarad’s medical imaging solution for its 22 hospitals and 185 clinics.

Medical Center of the Rockies (CO) selects ProVation from Wolters Kluwer for GI documentation and coding.

People

Healthcare Quality Catalyst names Todd Cozzens (Optum) to its board. Todd got in touch to say that the company is building data warehouses and Subject Area Marts on top of Epic and incorporating quality and workflow principles developed at Intermountain into more of an industry quality engineering type capability. He’s been around healthcare for a long time and has a nice viewpoint from his work at Sequoia Capital, so when he says it’s the next big thing, it just may be. I interviewed Steve Barlow, CIO and co-founder, a year ago.

Intelligent InSites appoints Margaret Laub (Policy Studies, Inc.) president, CEO, and board member. Interim Doug Burgum will become executive chairman of the board.

Ivo Nelson (Encore Health Resources) is announced as a financial partner of Health Care DataWorks, where he has served as a board member.

Announcements and Implementations

HIMSS Analytics recognizes the University of Iowa Hospitals and Clinics with its Stage 7 award for EMR adoption.

Caverna Memorial Hospital (KY) and Palestine Regional Medical Center (TX) go live on their HMS information systems.

OB-GYN PM/EMR vendor digiChart will integrate Dialog Health’s text message patient reminder system into its product.

Oregon Community Health Information Network will provide Epic to 10 public health centers in King County for $500K per year.

Government and Politics

CMS reports that through the end of July, 128,000 EPs and 3,624 hospitals have collected almost $6.6 billion in MU incentives from Medicare and Medicaid.

A BMJ editorial by two professors says that, based on their fields of behavioral economics and social psychology, pay-for-performance probably won’t deliver the expected results. Their reasons: (a) risk adjustment methods are inconsistent; (b) the system can be gamed by upcoding; (c) process-based indicators are poor proxies for quality of care; (d) social characteristics of patients can make good doctors look bad; (e) overly detailed criteria may encourage just checking off the boxes instead of really taking care of the patient; and (f) doctors may stop exhibiting empathy and pride in their work since nobody’s paying them for those qualities.

A new report from the Institute of Medicine says that the US healthcare system wastes 30% of its cost, or $750 billion, on unneeded care, administrative overhead, and fraud. It says that if other industries worked like healthcare, an ATM transaction would take a full day, laborers building a house would each use different plans without talking to each other, stores wouldn’t post prices, car warranties would not be offered, and airline pilots would make up their own pre-flight check list if they felt like following one at all. Many of their potential solutions for creating a continuously learning healthcare system involve technology.

Other

Surescripts will connect Epic’s Care Everywhere interoperability framework to its network, allowing Epic users to exchange patient-specific information with other providers regardless of their technology platform.

Forbes puts Cerner in good company as one of the 10 most innovative companies in America, citing it as #8 because “its servers handle 150 million healthcare transactions a day.”

Florida’s HIE adds Broward Health, Health First, Martin Health System, Mt. Sinai Medical Center, and Tampa Bay Regional HIE to its clinical exchange network.

Bill Clinton was such a good president (especially when graded on the 25-year curve) that the man formerly known as Slick Willie has completed his ascent to Elder Statesman/Rock Star, capped by his ad-libbing convention speech this week (how many people were like me and thought, “Why can’t we vote for him?”) and the announcement that he will deliver the Wednesday afternoon keynote at the HIMSS conference in New Orleans in March. HIMSS didn’t mention Hillarycare or his Monica Lewinski-driven impeachment, which I find myself being OK with since his relatively benign scumbaggery was eclipsed by his results in office. He could easily be elected president again, I expect, were it not for the anti-FDR 22nd Amendment that limits him to the two terms he already served. I don’t know what HIMSS is paying for his hour or so at the podium, but his rumored rate is in the $400K neighborhood. Also announced on the post-election, politics-heavy HIMSS keynote schedule: James Carville and Karl Rove, which I would find more interesting as a boxing match.

An ACO formed by Blue Shield of California and Dignity Health (the former Catholic Healthcare West) saved $37 million in projected costs over two years for the CalPERS state retirement program, with most of the improvement due to shorter hospital says and fewer readmissions.

Temple Community Hospital (CA) notifies 600 patients that their information was contained on a computer that was stolen from a locked office in the radiology department. The hospital says it will upgrade its security, presumably meaning it is belatedly considering encryption.

Lucile Packard Children’s Hospital (CA) announces a 150-bed, $1.2 billion expansion ($8 million per bed, $2,300 per square foot).

The San Franciso Jewish newspaper profiles David Jacobs, who started kidney paired donor-matching software company Silverstone Solutions within a month after his own kidney transplant in 2004. He expects to add several large hospital groups as customers in the next few weeks.

The feel-good Weird News Andy, temporarily changing his e-mail signature to Wonderful News Andy, likes stories about surgeons who help others (“a cut above,” he calls them). Two Salt Lake City surgeons win awards for their combined 100+ foreign medical trips, taken at their own expense to treat individual patients and educate physicians. WNA’s carriage turns back into a pumpkin with what he calls, “Doctors – The Flip Side,” as he reads the story of a patient undergoing surgery in a Swedish hospital whose anesthesiologist decides to knock off for lunch at the stroke of noon even though he’s the only anesthesiologist working. The patient crashes an hour later, employees can’t reach the anesthesiologist, and in the confusion someone turns off the respirator of the patient, who dies weeks later of brain damage.

Ministry Health Care (WI) tentatively agrees to join Ascension Health. Ministry’s stats: $2.2 billion annual revenue, 12,000 employees, 15 hospitals, and 46 clinics.

Self-proclaimed “EMR geek” Rob Lamberts, MD lists 10 ways EMRs could be made better. Ones I particularly liked: (a) require all visits to have a simple summary entered; (b) since the patient is often the “interface” between EMRs anyway, allow them to pull up their own records and show them to their new doctor; (c) maintain one comprehensive patient calendar that can be shared among providers; (d) let the patient manage the information they provide, such as family history, meds list, and social history; and (e) make patient records searchable.

Sponsor Updates

• A letter to the editor of SIIM by Brad Levin of Visage Imaging offers suggestions on how the organization can decrease radiology technology commoditization by offering crowdsourced innovation theaters, product showdowns, and demonstration of extreme use cases.
• Trustwave introduces security education services to help organizations protect against security risks and compliance missteps.
• Jay Deady, president and CEO of Awarepoint, discusses RTLS technology in an interview.
• MED3OOO announces that its customer PriMed (CT) will participate as an ACO in the CMS Shared Savings Program.
• SimplifyMD will offer Capario’s EDI platform to its customers.
• 21st Century Health selects Sandlot Solutions as a profiled business.
• MedHOK’s 360ACO solution is NCQA certified for P4P, HEDIS, and disease-management performance measures.
• NextGate begins operations at a new corporate office in Monrovia, CA.
• Divurgent hosts The After Party September 12 after Epic’s UGM.
• Wellsoft demonstrates its EDIS at next week’s 2012 ENA Scientific Assembly in San Diego.
• T-System issues a call for presentations for its April linkED emergency care conference.

EPtalk by Dr. Jayne

I’ve spent a lot of time the last several weeks digesting everything there is to read about Stage 2 Meaningful Use. My eyes are glazed over and my brain has become addled. To help providers make sense of it all, CMS has released some tables comparing Stage 1 and Stage 2 Objectives and Measures. I’ve found them helpful, although I wish their page breaks made a bit more sense and didn’t chop a single row into multiple pages.

Mr. H wrote Monday of the Epic vs. McKesson patent appeal. For those readers who enjoy shoes as much as Inga and I do, here’s a bit of patent news. The 2nd US Circuit Court of Appeals reversed a lower court decision, with the outcome that Christian Louboutin was entitled to trademark protection of its well-recognized red soles, but only on contrasting shoes. Competitor Yves Saint Laurent is still allowed to make red soles, provided they are attached to red shoes.

A Medscape article reveals results from a survey on physician EHR preferences. Although nearly two-thirds of users were happy, that means there are a lot of unhappy users out there. Other interesting (but not surprising) tidbits: many physicians are unaware of whether their systems are hosted vs. locally installed, the magnitude of maintenance or installation costs, or what happens in the back office.

CMIO magazine has renamed itself Clinical Innovation + Technology, citing a recognition of “the ever-growing convergence of the IT and technology management teams within the provider setting.” I’m pretty sure that at most places the IT and technology management teams were already intermingled. I think it would have made more sense to say that the IT and clinical management teams were converging. For those hospitals that are still in denial about the need for a CMIO in the first place, it’s probably validating.

A recent study demonstrated that men who consumed chocolate reduced their likelihood of stroke by 17%. It’s not entirely proven how chocolate provides health benefits, but dark chocolate in particular is thought to have anti-inflammatory properties. Maybe I should try some medicinal cocoa instead of ibuprofen after my next workout.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Interviews Larissa Lucas MD, Senior Deputy Editor, DynaMed

Larissa Lucas MD is senior deputy editor of DynaMed of Ipswich, MA.

Tell me about yourself and the company.

I’m a general internist. I trained at Cambridge City Hospital. I practiced there in primary care after my training. 

I joined DynaMed and EBSCO Publishing about five years ago. DynaMed is a point-of-care reference tool to help clinicians answer questions in an evidence-based way while they’re with their patients. EBSCO Publishing is a larger publishing company that provides information through databases and eBooks and other technology to libraries around the world.

You called DynaMed a point-of-care reference company, which I assume is a somewhat different model than the company had when you started with them. How important is it to push the information out where it can be used?

It’s very important. Physicians are challenged today with so many changes in the healthcare system — needing to use electronic health records, communicating to patients through e-mail, and the volume of evidence that is published. It’s nearly impossible to keep up with all that information. It’s critical for physicians to have that information at their fingertips where and when they need it.

If you were to pull 1,000 patient charts and compare that to the evidence that you have on record in your product, how much compliance do you think you’d find?

What a great question. That would be an interesting study to do. For my colleagues, they’re probably pretty good. I think physicians in general do the best they can to stay current with the evidence and follow practice guidelines. Using electronic health records and  clinical decision support tools certainly has made that easier. I would say a chart review in the last five years would probably reveal a lot more compliance than a chart review 10 or 20 years ago.

Physicians presumably don’t know what they don’t know rather than ignore solid medical evidence. Do you find them to be receptive to being presented with the evidence and then changing their practice?

I think they’re receptive. It’s a matter of time balance. There’s a lot to cover in that 15 minutes. Clearly we want to spend as much time of that 15-minute visit addressing what the patient needs. A lot of the documentation and investigation of the questions that come up needs to happen usually at the end of day, before the day begins, and during lunch.  

The problem we’re trying to solve is to integrate that back into patient care, the face-to-face, point-of-care decision point. That’s where you should have the information.

The issue of information needs at the point of care has been studied by a few folks, such as our friends over at InfoPOEMs, Allen Shaughnessy’s group. Many physicians finish their clinical day with five to 10 unanswered questions. That could be disturbing from a consumer point of view, but it can also be disheartening for the physician who probably feels like they just can’t get to all of it in the same day. Creating tools that make that easier is really what we’re trying to do.

Academic medical centers have rounding teams, which you would assume probe the evidence more thoroughly than in the ambulatory setting, where it may be seen as undesirable to leave the patient to look something up. Where do you think the evidence is most heavily used and most lightly used in terms of practice setting?

The scenarios are quite different. Even in an academic setting, you have the team that’s rounding that is really also the education unit. It’s got students and residents in it and hopefully a teaching faculty that’s at the bedside engaging those residents, teaching them what questions to even ask.

There’s a lot more richer learning there, but there’s been a change in the way patients are treated in a hospital now. They’re not in the hospital for very long. A lot of those problems either get solved quickly by an intervention or they’re discharged from the hospital and those problems have to then be resolved outside the hospital.

Even that academic, rigorous learning experience has changed dramatically in the last 10 years so. You don’t necessarily have the opportunity to do the rich investigation at that time.

Studies have attempted to prove that physicians deviate further from the evidence the longer they’ve been out of medical school, which then roughly correlates a patient’s mortality risk to the age of their physician. I notice that DynaMed was recently voted by Harvard Medical School students as one of their top five favorite apps, so I was thinking that maybe having residents fresh out of school using apps like yours would influence the attending more than if that same doctor was out on their own in a non-academic setting.

Oh, absolutely. I agree with that. It’s very important to have the students and residents around. They’re asking those key questions and they challenge us to answer the “why.” Products like DynaMed also challenge the users. 

People define evidence-based medicine in different ways. I like to see it as understanding why we make our medical decisions, not just which medical decisions we should make. Many guidelines, many decision support tools, will put a patient on a protocol that doesn’t actually require a lot of thought. Sometimes that’s more efficient, sometimes not. 

From an academic standpoint, I prefer we as educators, life-long learners, and physicians think about, “Why are we doing it this way?” instead of, “What should I be doing next?” Investigating the evidence and synthesizing it around that clinical question helps answer the “why.” Certainly students and medical students and residents challenge us to do that.

Do you think having reference material available on an iPhone or an iPad has changed the willingness of physicians to use information at the point of care than when it existed only as a book they had to go find?

Definitely. Having it at the fingertips makes it a lot easier. Even as a busy clinician, you can integrate it more easily into your workflow, because now it actually seems realistic that you could achieve that steady state of having some tool that you can constantly look things up on and stay current. Before, it was such a daunting exercise that I would think it was overwhelming to physicians to think, “How could I ever look everything up that I don’t know?“ Now it’s much easier to do that.

The ideal point of inflection would be the EMR, where you have patient-specific information available on the same platform from which the treatment decision will be created. What’s the level of integration of your product within applications from vendors like Epic, Cerner, and Meditech?

DynaMed integrates very well with electronic health records. Our structure is very templated and volatized. You can see the answer to your question very quickly and you can launch different sections depending on whether you’re interested in diagnosis or treatment.

In Epic, it can integrate all the way down into the problem list. It seems to be more of a limitation on the EMR side than on our side. One of the challenges of the EMR is that each one is so different it’s hard for all of that technology to talk to each other. But we integrate very well, and with order sets, too.

We collaborate with Zynx order sets to support some of their evidence.  Users can link right to DynaMed or the Zynx evidence. That’s really where we need to be, because that’s now where physicians are interacting with their patient, and they’re interacting with their own question and intellectual curiosity.

Obviously DynaMed will continue to research the literature, but is it a different mission to work with these vendors to turn your information into more useful forms? You have more incentive than they do to accomplish that.

Yes. I think that’s on the technology side, not so much for us editorially. Editorially, our prime objective and vision stays the same. We certainly have enhanced our interface quite a bit in the last year, but more in response to our user feedback and also a need in the market for a tool that both sends out alerts and is a searching tool. We added that alerting feature as well. That doesn’t interact with the EMRs, but we are modifying the way that we’re producing the content a little bit to answer some of those demands from the market.

Do you have examples of how customers are using the information at the point of care?

We have people using it on iPads and iPhones, obviously, and we have quite a few customers using it integrated within Epic and within Meditech. I’ve seen it in Epic, either in just the InfoButton, the information drop-down menu at the top where an institution may have links to multiple resources that they subscribe to, all the way to an InfoButton right next to the problem list so that you could click on the diabetes in the patient’s problem list and launch the topic in DynaMed that would about diabetes.

Is the InfoButton the least common denominator, or is the look-up function even more standard?

All EMRs have the look-up function, usually in their top menu where institutions can put links to external web sites that have information. That’s the most basic integration that anybody can do.

The InfoButton is still somewhat unusual for a vendor to enable?

Yes. It just takes a little bit more technology.

Do you have significant usage by nurses or other clinical users who aren’t physicians?

Absolutely. DynaMed is part of a suite of point-of-care medical products that use the same evidence-based methodology and literature. We have one for nursing — that’s Nursing Reference Center. We have Rehabilitation Reference Center for physical therapists, Patient Education Reference Center for patients. 

If a hospital subscribes to all those products, they’re fully integrated within one search engine. We also provide full-text data bases to Cochrane reviews and other journals in Medline. Subscribing to the whole suite of medical products gives you information across different disciplines. We have quite a few users that go between products, so nurses will look something up in Nursing Reference Center, but then they also jump over to DynaMed and use that as well.

How is DynaMed differentiated from its competitors?

We’re all very different. DynaMed is based on the critical appraisal of the literature. Then the rest of the content is built around that, but it’s synthesized around the evidence in presenting the limitations and the strengths of the research that support our decision-making.

The other products in the market – UpToDate, ACP PIER, BMJ Point-of-Care — many are published still in a traditional textbook publishing model. The whole chapter is written by the author and then updated and kept current with the literature. It’s just a very different model. They’re all very good. I think we’re all very good at what we do.

How we’re set aside from the competition is that we are very focused on the critical appraisal piece of the evidence and providing the information to support the medical decisions so that physicians are more informed about why they’re deciding to go down a certain pathway.

You have folks on the front line that are contributing their expertise as well, right?

Yes, all over the world.

Is that hard to coordinate?

It’s very challenging.  We have sought experts from around the world. Sometimes time differences are challenging to deal with, but we try to be global.

We have a team of very experienced medical writers from varied scientific backgrounds. They’re very good at what they do, objectively evaluating the evidence. The collaboration with clinicians happens very smoothly and very naturally to make sure that relevance piece is part of what we do. With validity, anybody can follow a protocol in how to critically appraise and assess the validity of a trial, but the relevance needs to happen from the physician level. We’re always engaging with other physicians to get that input.

Do you know how your products are being used and being received by frontline physicians?

Every page has a “send comment to editor” button. That e-mail goes to myself, the editor-in-chief, and our support team. We get a lot of feedback from customers who are using it right at the point of care. That’s very helpful. It helps us drive our editorial priorities as well when we hear directly from customers.

We also work closely with many residency programs and get their ongoing feedback for how it’s used in their practices, in their education, and in their workflows. Our peer reviewers are also always giving us feedback. We definitely solicit feedback and we get it passively from our users. We love it. We’re dynamic. That’s why we have that name.

I once suggested to one of your competitors that it would be interesting to analyze the lookups of a reference product to infer information about prevalence of disease or outbreaks, like people who are always trying to use Twitter or Google searches to spot epidemics early.

That would be interesting. I’ve seen some of that research. Certainly our influenza topics had huge usage when we had the outbreak of H1N1, but typically our usage logs are consistent with what is seen in most general practices. Our top-hit topics are asthma, diabetes, pneumonia, sepsis, heart attacks, and urinary tract infections. 

It’s interesting to me, because you’d think some of the more common diseases that we see in practice, we wouldn’t have to look up answers to questions because you see it so often. You should be comfortable with it. But I like seeing that data, because it tells me my colleagues are constantly striving to see if there’s anything new. I’ve treated 50 UTIs this month, but is there anything new I can learn? In that sense, it’s very rewarding to see those usage logs are hitting some of the major topics.

Any final thoughts?

The challenges facing physicians are so complex. I really enjoy being part of this tool that’s hopefully going to make practicing medicine easier for physicians and make physicians feel more comfortable as they have to make quick decisions in their patient care. It’s definitely going to improve quality. It’s definitely going to improve patient outcomes. Those studies are yet to be determined, but I’m hopeful that all of this technology is going to to make it easier to practice medicine.

News 9/5/12

Top News

HL7 will make its standards and other intellectual property available to all healthcare stakeholders at no charge by the first quarter of 2013. The company says it hopes to increase private and governmental use by eliminating licensing fees, thereby improving care and reducing costs.

Reader Comments

From Mandrake: “Re: NuPhysicia. I’m looking for information from healthcare systems that have worked with them, but I’m not having any success and I see they haven’t been mentioned on HIStalk even though they’ve been around for several years.” I couldn’t find anything either, but I snooped around and found that the company – which has offices in Houston, Brazil, and Malaysia – shares its Houston address with medical staffing company eCareGroup and is apparently the same operation even though they never actually say so (NuPhysicia also offers telemedicine services under the name InPlace Medical Solutions). NuPhysicia is selling a commercialized version of telemedicine software developed at UTMB, best known for its use in prisons, but also used in retail clinics and on oil drilling rigs.

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor Vonlay. Given their location in the epicenter of Madison, WI, you might cleverly guess that Vonlay is an Epic consulting firm and a successful one at that, with 30 clients in more than 20 states. It deploys some of the industry’s best EHR consultants individually or on teams, working at your site when you need them there or via Vonlay’s Remote Services program, which offers big savings to its customers. If your Epic go-live is impending or completed, Vonlay’s remote experts can help work down your open tickets, pitch in on applying upgrades and SUs, and help you phase out more expensive on-site consulting services. The company also provides application mentorship and management-level strategy consulting on how to design, build, and roll out EHR projects, including technical assistance with system builds, Cache programming, interfaces, Web services, and portals. You’ll be in their neighborhood if you’re going to next week’s Epic UGM, so keep an eye out for their folks. Thanks to Vonlay for supporting HIStalk.

Here’s a fun Vonlay video I found, Attack of the Issues List.

Acquisitions, Funding, Business, and Stock

Net Health Systems, which offers an EHR for wound care, acquires competitor Wound Care Strategies.

Data analytics startup Predilytics raises $6 million in its first round of VC funding.

Sales

Geisinger Health System (PA) selects TeleTracking’s RTLS technology to track mobile medical equipment at two of its six hospitals.

Saint Vincent Health System (PA) contracts with onFocus Healthcare for its enterprise performance management software.

St. Vincent Hospital (WI) will implement Merge Healthcare’s complete cardiology solution across its enterprise.

Rex Healthcare (NC) will use Passport’s eCare NEXT solution for eligibility checking, demographic verification, precertification, and estimation of patient payment.

People

Virtual Radiologic names John Way (UnitedHealth Group) CFO.

John Gomez of JGo Labs is interviewed at Apple’s WWDC.

Announcements and Implementations

South Lyon Medical Center (NV) will complete transition to CPSI’s clinical applications by the end of the year. 

Government and Politics

The VA says that over one million patients have registered to download their health information via Blue Button.

The FDA issues a warning letter to Merge Healthcare, saying the company isn’t manufacturing its blood pressure monitoring kiosks within FDA’s guidelines.

Other

Picis, Epic, and GE own the largest share of the anesthesia information system market, according to KLAS. The survey found that customer satisfaction is highest when AIMS purchasing decisions are handled cooperatively between the hospital and OR/anesthesia department rather than either entity making the decision alone.

ZirMed will undertake a $5.1 million expansion project that is expected to create 85 jobs over the next two years at its Louisville, KY headquarters. The state is offering $2 million in incentives for up to 10 years.

Apple announces a September 12 event that is likely to include its announcement of the iPhone 5 (note the shadow in the picture. )

Scotland-based Craneware says demand for its hospital revenue products has returned to high levels after a slow first half caused by US hospitals focusing on EHRs.

The government of China will invest $63 billion in its healthcare system over the next seven years, with part of the money going toward creation of an electronic health information network.

Technology investor and Sun Microsystems co-founder Vinod Khosla says computers will eventually replace 80% of doctors because computers are cheaper, more accurate, and objective, while healthcare is “witchcraft … based on tradition.” He also says that it will take outsiders to fix healthcare rather than those working within it. He has a knack for throwing out outrageous sound bites that earn him exposure, such as saying that hybrid cars offer no environmental advantage – they just make their owners feel better about themselves.

Highly regarded UCSF physician Bob Wachter, MD (chief of medicine, invented the term “hospitalist,” author) says UCSF’s new Epic system generates an impressive-looking progress note from fragments of manually entered information, but the “monkeys and typewriters” approach not only violates the legendary teachings of SOAP note inventor Larry Weed MD (in the 1971 video above that everybody who designs physician documentation systems should study regularly), it’s not as useful as the old fashioned written note. However, he also offers a solution: ditch the use of Epic’s Smart Text and offer a “Big Picture” field where physicians are encouraged to tell the patient’s story as of that moment (although he wonders whether natural language processing will make that unnecessary at some point). Wachter describes the current state as:

Why did Epic and our UCSF IT gurus structure things this way? The primary virtue is that this charting-by-problem approach allows the patient to be followed longitudinally, since one can track problems such as “hypertension” or “ovarian cancer” over years, seeing how they have been managed and observing the response to therapy. It isn’t a bad conceit, and it probably makes tons of sense when described in a fishbone diagram on an informatics seminar whiteboard. But the effect I witnessed on patient care and education was less positive. When I was on clinical service in July and read the notes written by our interns and residents, I often had no idea whether the patient was getting better or worse, whether our plan was or was not working, whether we need to rethink our whole approach or stay the course. In other words, I couldn’t figure out what was going on with the patient.

Small software vendor QueueVision says the Tampa VA hospital is refusing to pay for its medication tracking software despite using it since 2006. The company says the purchase was approved by the hospital’s pharmacy administration, but the VA won’t cough up the $214K it owes. Says a partner in the company, “We were suckers. They took us. I figured the veterans were so happy, the staff was so happy, everybody loved it. So we thought they would pay. We never fathomed that they would lie to us.”

In England, small blood-tracking systems vendor MSoft eSolutions is expanding after winning eight of eight RFPs last year. Its Bloodhound system provides positive ID of employees and patients throughout the blood transfusion process.

I liked this Facebook article by disgraced investor / interesting author Henry Blodget, in which he says publicly traded companies destroy their own value by trying to appease impatient investors and venture capitalists. He explains why nobody should be surprised at the fall in Facebook’s share price (May IPO price $38, Tuesday’s closing price $17.73) given the clear message that CEO Mark Zuckerberg has sent all along that he’s focusing on the customer experience and long-term value as Amazon has always done rather than next quarter’s share price. A snip of Blodget’s paraphrasing of a section of Zuckerberg’s pre-IPO shareholder letter:

Let me remind you that I own 57% of the voting stock of Facebook, which means I have complete control over it. I organized the company this way many years ago, with the very deliberate intention of maintaining complete control over it. I did this so I wouldn’t get overruled and canned by venture capitalists, a fate that unfortunately befalls many entrepreneurs. I also did it so in the event that we ever had to go public—which we unfortunately have to do now—I would never have to pay attention to whiny short-term public shareholders. Those whiny short-term public shareholders have destroyed many great companies by making management obsess about absurd near-term financial targets … Maximizing near-term profits" often means under-investing in future innovation, customers, and employees. And although it sometimes temporarily boosts stock prices, it often guts companies and clobbers their value over the long haul.

The Florida teenager accused of impersonating a PA and practicing medicine without a license is found guilty by a Florida jury and could go to prison for up to 10 years.

Sponsor Updates

• Aetna will offer eviti’s oncology decision support tool on its Medicity iNexx platform.
• The Surgical Information Systems anesthesia information management system earns the highest client satisfaction scores in KLAS’s anesthesia specialty report.
• MED3OOO CMO Paul McLeod, MD discusses the challenges of controlling ER visits in a blog post.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 9/3/12

This weekend on HIStalk Practice, Dr. Gregg wrote about the possibility that the “infamous tricorder from Star Trek” is about to become reality. A company called Scanadu has a prototype handheld diagnostic device that (at least according to their website) will debut in a little over a week. Although I agree with Dr. Gregg that it has huge potential to empower consumers with auto-diagnosis tools, I really have to wonder about the entire premise.

Their trailer video is quite engaging. They walk through a parent diagnosing their child’s rash, a mom receiving a warning about a whooping cough outbreak and the fact that her daughter needs an additional immunization, and parents diagnosing their sick child with a potential urinary tract infection and being sent to an urgent care facility. The voiceover states, “We’re building a way for people to check their bodies as often as they check their e-mail.”

Like so much today, some technology is surrounded by a lot of hype. While I don’t doubt that this is going to be a very cool and potentially powerful technology, I have some concerns with it. It feeds into the idea that we just have to embrace technology and we will live happier, more fulfilled lives.

I’m betting most Americans will hope that at the end of the diagnostic algorithm, it suggests a single pill that can fix everything. Just a few seconds of scanning a day will convince us that everything is OK.

Guess what? It’s not OK. Americans are fatter and more unhealthy than ever. We don’t need any miracle technology to tell us this. There are simple things we can do every day for our health that we are simply unwilling to do because they’re not sexy or high tech. They’re hard work and involve difficult choices and possibly sweat.

Physicians and other health providers have been preaching these things for years, yet people do not follow these recommendations. Will it make a difference if the recommendation comes from an impersonal device? I doubt it. I’m willing to keep an open mind, though, if there is even a small chance it will make a difference.

I’d like to live in an age where people are as obsessed about their body mass index as they are about finding out what Snooki named her baby. An age where people sit around the pub comparing their best fitness data instead of the statistics of their fantasy football teams. An age where I never have to diagnose another child with diabetes.

The folks at Scanadu have a great tagline: We are the last generation to know so little about our health. I really don’t think that’s true. I think we know a lot about our health. We’re just unwilling to do anything about it.

I look at my thousands of co-workers at Big Hospital. We all have to check our biometrics every year in order to get the best discount on our health insurance premiums. But looking at our population as a whole, having this information hasn’t led to a tremendous cost savings or healthier employees. People know their numbers, but they simply don’t care. They don’t want to give up habits or behaviors they find pleasurable. They haven’t come to grips with the fact that in the end, it’s a zero-sum game. Unless you’ve won the genetic lottery, each of us has to pay for our dietary and exercise indiscretions.

Being a physician doesn’t make me any better than the next guy. I have weak spots for chocolate and martinis. Those who know me really well know that I also have a thing for Buffalo chicken wings and all things fried. I love to watch bad TV and once became nearly vegetative watching a marathon of Deadliest Catch.

At the opposite end of the spectrum, I work with residency faculty members whose most indulgent meal is a baked potato with some olive oil and spices. They may get by on that, but I know that ultimately I am going to make less than perfect food choices and I’m going to have to balance it out with healthier meals at other times and also with daily exercise. I don’t take my health for granted – none of us should.

Technology can be a great motivator to help people track their health. I love reading HIStalk Mobile and seeing all the cool trackers and apps that Dr. Travis finds. I’ve even tried some of them. Recently a community group I’m part of decided to take part in the Presidential Active Lifestyle Award challenge. We created a group where we could log our activity and track some group goals as a motivator. As a community group that mentors youth, the adults have a vested interest in making healthier lifestyle choices so we can serve as role models.

After two months on the challenge, we have exactly four people who are willing to go online and log their activity, and only two of them are actually active. It’s a sad commentary. (I have to think we’d have better participation if The President’s Challenge had a mobile app, but alas, they do not.) Today I can’t even log in. We can put a man on the moon, but we can’t handle our exceptions, apparently.

I’m looking forward to seeing what Scanadu has in store for us. Having served on the sidelines for youth sports teams, I’d love a hand-held scanner that can help me determine the prognosis for a concussion or whether that student with mononucleosis really has an enlarged speen and needs to sit on the bench. As someone who cares for children, I’d love something that can reassure a parent when their toddlers slip in the tub and hit their heads. I’d be thrilled with any handheld device that can actually get people excited about their health and convince them of the need to eat less junk and move their bodies regularly. Unfortunately, I’m just a little bit skeptical at the moment.

E-mail Dr. Jayne.

Readers Write 9/3/12

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.

Routine Killer
By Bill Rieger

I was at a conference recently. Before I left, I was looking forward to getting away and enjoying the sights, sounds, and energy of Chicago. The first few days were awesome, filled with several miles on foot experiencing the Magnificent Mile, Navy Pier, Lake Michigan waterfront, and several good restaurants. 

By the third day, I started to feel “it.” I wasn’t sure what "it" was, but I knew it was uncomfortable and it was starting to impact my trip. By Friday, I was drop-dead ready to return home. You know that feeling. Tired, "problems" because of way too much restaurant food (OK, maybe that’s too much information, but it’s true), and sorely missing my wife and kids. 

The weekend was great and very busy. The weekend before the first day back to school is always crazy, but compound that with the fact that I had been gone all week and still hadn’t resolved what "it" was, I could have been a better husband and father.  

I got up Monday at 5:00, hit the shower, made the coffee, read for 30 minutes, prayed, got the kids up, made breakfast, got dressed, and walked out the door headed to my drive (which always includes a podcast of something educational or uplifting). It hit me. I figured out what "it" was. My routine had got way out of whack.  

As I started to consider this more, books I have read that speak to the significance of routine started running through my squirrel cage.  Podcasts I listened to and personal conversations I have had that reinforced purposefully creating a schedule started reverberating through my head.

One of the best books I have ever read relating to personal growth and development is The Compound Effect by Darren Hardy. He reveals a formula that I have adopted as a way to manage my own growth: 

Choice + Behavior + Habit + Compounded (over time) = Goals

The funny thing about this formula is that if you remove one of the addends, the sum could be reduced dramatically. The lack of routine in my trip, I believe, decreased my effectiveness on the trip. As a result, I didn’t get as much out of it or pour as much into it as I could have.  

As I continued to reflect on this, I started looking around me at who I influence: my wife, my kids, my co-workers, my team. The trip I took, at least to some degree or another, impacted their ability to achieve those goals that I’m helping them with. I am not saying here that the world revolves around me (or any one of us specifically), but we do have an impact on those around us. Even if you cancel the weekly meeting ahead of time, the routine is broken when you aren’t there. According to the formula, there is an impact.

This reflection has been a good one for me. The next time I travel, I will develop a schedule and routine for the trip. The next time I have to cancel a standing meeting with a staff member, I will try to think about how that is impacting the routine that is built into that relationship.

Routines and habits make up who you are. Our lives are defined by how we spend out time, talents, and treasures, I want to be as responsible and accountable as possible for all of these areas of life.

The takeaway: Routines have impact.  If you do not have habits or routines, take the time to make up daily routines and you will experience growth. The people around you will benefit immensely. I have a schedule I use as a template that I would be glad to share. E-mail me at bieger@gmail.com.

Bill Rieger is CIO of Flagler Hospital of St. Augustine, FL.

It Doesn’t Matter if Allscripts is “Open” – Their API is a Game-Changer
By Jonathan Baran

More and more vendors are thinking about going "open" — turning their EMR into a platform for third-party application developers. Allscripts is the first major EMR vendor to the party. Because of it, they are taking criticism for whether they are truly "open."

I’m here to say that it doesn’t matter if you call Allscripts open or not. Their API will create an ecosystem of innovation that will both solve provider needs and increase vendor revenue.

My company has first-hand experience with their API. This is what we’ve learned:

The Allscripts API removes the burden of integration away from the health system IT staff

For an EMR app to be truly useful, it will require data. In a pre-API world, you can use HL7 or a Web client to get some data, but what does it cost? It seems like regardless of how simple the project is, it will take three months of IT time. When tacked onto a list that is already 12 months long, there is a lot of waiting for an innovation to reach the light of day.

Compare this with an Allscripts world. Want to get an application integrated? Call your Allscripts sales rep and the app will be integrated that afternoon. The integration has been completed once with Allscripts API, which means it can scale to all their users on that single product. This simple elimination of IT time could have a profound impact on the pace of new technology adoption.

By using an API, applications can work in the background, minimizing the training and go-live time

Now that you have gotten the application integrated, it’s time to train the users. But of course that will not be easy, because HL7/Web client are a good source of clinical data, but demand a disjointed experience for the user. This requires awkward steps like seeing websites “embedded” in the EMR, having to click a button to transfer data, requiring users to copy and paste text, or needing to have a completely separate application. Even the simplest process becomes difficult when you’re asking users to take these pseudo-integration steps. I know this because we did it. Ugly.

Compare that with Allscripts. Everything can be done in the background. Want to pull tasks out of a task list and read the patient’s medication list? Want to have everything happen automatically in the background with no clicks? Done. It is easy to see how this could impact training and go-live. In the first example, every staff member in the organization needs to be trained on the "new system.” In the second, they don’t even need to know it is happening.

API level access means that your product can fit within the end users existing workflows

Workflow change is hard – really hard. The only easy way to change a workflow is to get rid of it. Eliminate steps. Remove clicks. How can you do this when by definition you are adding something? The answer is "addition by subtraction.” By getting deeper levels of integration, workflows can actually be made better.

This is only a small sample of the benefits that come to mind. Others include piloting (“Dr. CMIO, would you like to try the solution out this afternoon?”) and the App Store (find new apps in a single marketplace).

Jonathan Baran is co-founder and CEO of Healthfinch of Madison, WI.

EHR Donation and Accountable Care
By Jed Batchelder

I’m working with a healthcare system that is in the process of developing an EHR subsidy for the independent affiliated physicians in their community. They’ve just made a large IT investment, including EHR and HIE, and have started building a platform to help deliver accountable care.

Right now the challenge is how to structure the subsidy so it is attractive enough to entice physician adoption while remaining fiscally responsible for the sponsoring entity.

Much of industry is still living in the fee-for-service world, which is perfectly understandable given that’s how we get paid today. But we need to imagine and prepare for how that is all going to change in the coming years and make the right decisions now to prepare for it. We have the unenviable task of having to live and pay the bills in the fee-for-service world while investing in an infrastructure for the next value-based world.

Imagine you own a large retail store in the year 1997 and are trying to decide how much money to spend on web sites, computers, e-commerce solutions, and Internet connectivity. You can already hear the disagreement in the budget meetings and smell the fear in the room. You can’t yet see how the web is going to transform how you conduct your business, how sales transactions will occur, and how you’ll get paid.  

All of your revenue comes from customers who walk in the door of your stores, but you keep hearing about this thing called the World Wide Web and e-commerce that is supposed to be the next big thing. You could take a wait and see approach, possibly allowing a disruptive innovator like Amazon or Zappos to take your market share. Or you could pause and notice the ways that the world is already changing. (Best Buy just reported a 90% drop in earnings last quarter.) In a bricks and mortar retail model, large IT investments can initially look reckless, but once that new world arrives, you’re relieved that you took the risk.

When viewed solely from the view of the numbers, the EHR subsidy doesn’t make a ton of sense in the fee-for-service model. In fact, it looks more like a charity. But what happens when you look at it through a value-based ACO model, where providers will be compensated based on how well they jointly take care of patients, how well they coordinate the care, and how healthy their patients are? Just as it was difficult to predict the extent that the Internet would transform commerce, it is difficult to imagine what care will look like in a post fee-for-service world.

These points support both the idea that the hospital should take on more of the cost and the idea that independent docs should put more skin in the game, lessening the financial burden on the sponsoring hospital system. How far should we move the slider? How much skin should both sides put in? Who is more at risk by not having the connectivity and common platform? Who stands to gain the most and lose the most? These are perhaps the most pressing questions.

Jed Batchelder is an independent healthcare IT consultant.

Monday Morning Update 9/3/12

From HITEsq: “Re: McKesson. Won its appeal against Epic for patent infringement. The Federal Circuit, en banc (i.e., before all the court of appeals judges), overturned existing law to find in favor of McKesson. The case is remanded to the lower court to decide if Epic really does infringe.” It’s a complex issue, and since I covered it when McKesson lost the original appeal in April 2011, I’ll recap from there. McKesson said Epic’s MyChart violates a McKesson patent for a method of placing visit-specific patient information on a Web page so that patients can schedule appointments and request prescription refills. The original  “joint infringement” decision (about which the three-judge panel argued a lot) was that Epic wasn’t liable since it doesn’t directly offer those capabilities, but rather allows individual patients to request MyChart access subject to the approval of their physician. Since no single party violated McKesson’s patent, the original court said Epic wasn’t liable. Legal experts are troubled with this latest decision, which appears to make “inducing infringement” actionable even if no infringement has been proven. All of this is way over the heads of mere non-lawyer mortals like myself who can’t resist snickering while repeating phrases from the document like “joint tort feasor” in humorous voices because it’s just so weird and funny, so if any legal beagles wish to expound pro bono, here is your electronic lectern.

Patent on personally controlled health record with notation of source/ authority (filed 3 yrs ago) HT @craigjoseph patft.uspto.gov/netacgi/nph-Pa…”

— Farzad Mostashari (@Farzad_ONC) August 31, 2012

From Lex Luther  Van Dam: “Re: Epic’s patent for a patient-controlled, patient-generated health record. This is bizarre. Much of this was already on the market when the patent was filed, so either Epic didn’t know or forged ahead anyway, and either is not good. Epic has seemed indifferent to patients controlling their own information, to the point that they don’t even talk about Lucy, their own PHR solution, and they certainly don’t cooperate with anyone else offering a PHR solution.” My guess is that this patent either covered Lucy when it was first being developed or was simply a legal stake in the ground to prevent further legal incidents like the McKesson one above. I also don’t know that Epic’s customers, being turf-protecting and somewhat patient-paternalistic academic medical centers, have a heartfelt interest in empowering their patients via PHRs from Epic or anyone else. Or for that matter, avoiding the “walled gardens” between proprietary EMRs that Farzad was railing against given that Epic-to-Epic direct data exchange has displaced the interest in a vendor-neutral exchange in some areas where most of the major players run Epic.

From MU Nick: “Re: worksheet. Has anyone created a worksheet for MU2 for the EP and EH requirements (as opposed to a PDF?)” If you’ve put something together and are willing to share, let me know.

From DanburyWhaler: “Re: Western Connecticut Health Network. Hired Steve Laskarzewski, Waterbury’s former CIO, as clinical applications director. Looks like they’re grooming him for the top spot when Kathy DeMatteo steps down later this year.” Steve’s LinkedIn profile says he started in June. He’s one of the 2,716 members of the HIStalk Fan Club that reader Dann started years ago, so he gets a shout out.

From Douglas: “Re: Mr. HIStalk. Why do you use that name?” I needed an e-mail address when I started HIStalk back in 2003, and being in a minimally creative mood at that moment, the best I could come up with was mr_histalk (the name HIStalk itself was equally lame, with the HIS standing for Hospital Information System, which was in vogue at the time). I had zero readers and minimal expectation of gaining any, so I didn’t give it much thought. I don’t recall having actually called myself that at any point, but readers did over time, and then Inga at some point shortened it to Mr. H. It feels odd since I have never even once referred to myself as Mr. Anything in real life since I’m not too impressed with titles in general. My latest pet peeve: family members of dead doctors who stick “Dr.” in the title of their obituary listing instead of just their name like everybody else does, apparently hoping that like Egyptian boy kings, their most valued earthly possession will carry over into the afterlife. Putting “MD” after your name is perfectly fine on your office door, as is “Doctor” in front of your name is for professional encounters. A doctor who is so deficient in self-esteem as to demand the use of those titles in social situations when nobody else is calling themselves Mr. or Ms. is, in my opinion and experience, an arrogant ass. Lots of people earn doctorates, many of them requiring more education than a medical degree, and yet it’s most often an MD (or, in the case of male MDs, their wife) who insists on cramming their title down everybody’s throat at the auto repair place or at school meetings (my theory: that’s why hospital administrators enjoy putting physicians in their place). So, to complete my circular logic, the Mr. HIStalk thing is not indicative of a superiority complex since if anything, my tendency is the opposite.

It’s Labor Day, so I am appropriately laboring (in the non-obstetrical sense). I hope your holiday is – or was, depending on when you’re reading – delightful.

We are collectively fatigued with the endless Meaningful Use palavering, apparently, as 46% of respondents say they are indifferent to release of the Stage 2 rules. Of those who cared, reaction was split between positive and negative. New poll to your right: if the presidential election were being held today, who would you vote for? An online issues quiz says that I’m exactly evenly split between the two major candidates with a 63% alignment with my beliefs for each, but both are far dwarfed by my 91% match with Libertarian candidate Gary Johnson, who I’d never heard of until I took the quiz. That leaves the same options I had in the last presidential election: vote for either of two candidates that I would dread seeing take office or vote for one I’d like to see win who doesn’t have a chance.

Surescripts acquires Kryptiq, of which it previously owned a 21% share. Surescripts uses Kryptiq’s secure messaging technology for its network. Other healthcare IT vendors are also among its customers (GE Healthcare and Vitera), and its other offerings include clinical messaging, a patient portal, and electronic prescribing. Kryptiq announced earlier this year that its revenue grew 60% and its user count exceeded 40,000.

Cambridge Health Alliance chooses EDCO’s Solcom electronic document management system for managing historical paper records and paper documents originating outside of CHA. It will integrate that information with its Meditech and Epic systems to eliminate the file room and hybrid record environment.

Joint Township District Memorial Hospital (OH) chooses the Optimum general accounting suite from NTT Data. The company also announces that its NetSolutions Point-of-Care clinical and billing system for long-term care facilities will now send care data toAssured Proactive Analytics to optimize payment.

A Wells Fargo Securities report sent over by a couple of readers says that hospital users of Meditech, Cerner, and CPSI lead the pack in total number of Meaningful Use attestations through June 30. On the ambulatory EHR side, it’s Epic, Allscripts, and eClinical Works, although Epic would drop to third if it didn’t have 10,000 Kaiser doctors of its 15,000 attestations. Of new attestations, it’s Cerner and CPSI leading for hospitals (those same two vendors also led in the overall percentage of client base attesting) and athenahealth and Practice Fusion for EPs. A reader, however, notes that the numbers suggest that Epic has 650 hospital customers, which seems awfully high, so there’s always the question of what’s behind the data.

CoCentrix hires Clayton Ramsey (Elsevier) as SVP of delivery.

I chose this graphic in mentioning the new KLAS evaluation of Meaningful Use consulting firms a few days ago and regretted it the next day when I had more time to ruminate on it. I’m unhappy with how KLAS presented the graphic since they committed the cardinal sin of not setting the Y-axis of the graph to zero. That’s usually a red flag indicating that someone is trying to make an overly dramatic point that their data points don’t support. In this case, the actual range of consulting firm “money’s worth” scores was 7.1 to 8.8, which are pretty good numbers within a fairly narrow spread. The KLAS graph only shows the range of 7.0 to 9.0, making it appear that huge gaps separate the firms, which is absolutely not the case. This doesn’t give me a lot of confidence that the behind-the-scenes work at KLAS is statistically rigorous, a often-made but never-answered charge. I would also question whether this graphic means anything at all considering that the Y-axis is customer-reported value, while the X-axis is “relative cost per resource,” whatever that means. Should we infer that a company with a high per-resource cost can’t be worth it no matter how satisfied their customers are? My main gripes with KLAS (and the Most Wired surveys and HIMSS Analytics and so on ) is their tendency to take a modest amount of data and over-extend it to lofty conclusions using a black box that nobody’s allowed to peer into. I like what they do, but as we healthcare types say, “In God we trust – everybody else bring data.”

Among the speakers at this past weekend’s health IT conference in Hyderabad, India were Lee Shapiro (Allscripts president) and Marc Probst (Intermountain Healthcare CIO).

TeraRecon launches its iNtuition Review, iNtuition Enterprise Medical Viewer, and iNtuition SHARE at the AOCR/RANZCR radiology conference in Sydney, Australia. The products provide multi-modality review and the capability to distribute images throughout the enterprise via a browser-based viewer.

Cancer Care Group (IN) announces that medical information of 55,000 patients and the organization’s own employees was exposed when server backups were stolen from an employee’s locked car. The announcement leads off with, “Patient confidentiality is a top priority,” which is apparently now a bit closer to the truth since they’re suddenly considering encrypting backups and mobile devices. It’s an immutable rule that nobody encrypts anything until they are publicly embarrassed for not having done so, and then they can’t jump on board fast enough.

Novant Health (NC) rolls out a screensaver featuring former UNC star Michael Jordan to remind employees of its zero-tolerance handwashing program, launched in 2005 after three premature babies died in one of its hospitals from MRSA infection. The source was tracked back to staff who hadn’t washed their hands, which Novant found was common with a compliance rate of only 49%. They’re at 98% now.

In Australia, a hospital CEO sues a nurse who he says disparaged him in her Facebook comments that were brought on by a labor dispute. One of her comments: “We don’t take kindly to misinformation by well-paid fat cats who only visit the hospital wards for photo opportunities.”

Surgeon and best-selling author Atul Gawande, one of the most visible and respected people in healthcare, apparently is sold on the use of analytics but  isn’t a fan of using technology in his own practice. Some snips from a recent interview:

• I do use the iPad here and there, but it’s not readily part of the way I can manage the clinic. I would have to put in a lot of effort for me to make it actually useful in my clinic. For example, I need to be able to switch between radiology scans and past records … I haven’t found a better way than paper, honestly. I can flip between screens on my iPad, but it’s too slow and distracting, and it doesn’t let me talk to the patient.
• I think that information technology is a tool in that, but fundamentally you’re talking about making teams that can go from being disconnected cowboys in care to pit crews that actually work together toward solving a problem.
• I worry the most about a disconnect between the people who have to use the information and technology and tools, and the people who make them. We see this in the consumer world. Fundamentally, there is not a single [health] application that is remotely like my iPod, which is instantly usable … In many of the companies that have some of the dominant systems out there, I don’t see signs that that’s necessarily going to get any better.
• The reason [data analytics] works well for the police is not just because you have a bunch of data geeks who are poking at the data and finding interesting things. It’s because they’re paired with people who are responsible for responding to crime, and above all, reducing crime … That’s what’s been missing in health care. We have not married the people who have the data with people who feel responsible for achieving better results at lower costs.
• Timeliness, I think, is one of the under-recognized but fundamentally powerful aspects because we sometimes over prioritize the comprehensiveness of data and then it’s a year old, which doesn’t make it all that useful. Having data that tells you something that happened this week, that’s transformative.

More on Keane’s HIS-tory this week from Vince.

E-mail Mr. H.