Monday Morning Update 8/6/12

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Mr. H.

Readers Write 8/4/12

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

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

The Doctor Shortage Calls for Innovation
By Jonathan Bush

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

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

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

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

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

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

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

Why Device Connectivity Matters Now
By Dave Dyell

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

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

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

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

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

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

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

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

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

Dave Dyell is founder and CEO of iSirona.

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

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

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

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

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

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

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

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

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

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

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

I wrote this piece in September 2007.

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

What do these micro-trends have in common?

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

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

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

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

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

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

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

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

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

News 8/3/12

Top News

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

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

Reader Comments

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

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

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

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

HIStalk Announcements and Requests

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

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

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

Acquisitions, Funding, Business, and Stock

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

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

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

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

Sales

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

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

People

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

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

Cumberland Consulting Group promotes Amy Meiners from principal to partner.

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

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

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

Announcements and Implementations

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

Government and Politics

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

Other

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

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

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

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

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

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

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

Sponsor Updates

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

EPtalk by Dr. Jayne

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

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

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

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

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

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

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

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 8/1/12

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

Burn the Resume

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Burn the resume. Hire talent.

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

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

News 8/1/12

Top News

Accretive Health will pay $2.5 million to settle charges by Minnesota’s attorney general’s office over its aggressive patient collection tactics in hospitals (including those of Fairview Health Services) and lax security controls involving a stolen PHI-containing laptop. The company will cease all business operations in Minnesota, is banned from returning for the next two years, and can re-enter the state within the following four years only with the attorney general’s approval. Accretive is also required to return all patient information to the hospitals that provided it. The attorney general says she will turn over the patient affidavits her office collected to CMS, suggesting that Accretive’s hospital clients may have violated EMTALA laws that require them to treat emergency patients before trying to collect payment. The $2.5 million settlement will be added to a fund to compensate patients. Chicago Mayor Rahm Emanuel, who had previously inserted himself into the proceedings by trying to use his Democratic Party influence to get AG Lori Swanson to back off, declined to answer questions about his involvement.

Reader Comments

From Yesterdays: “Re: Community Health Systems. Contractor friends tell me they were part of the nearly 600 IT contractors laid off by CHS recently.” Unverified. I didn’t bother trying to confirm since I recently e-mailed someone at the for-profit hospital operator about a rumor that they were switching EMRs, but didn’t hear back.

From Wildcat Well: “Re: Practice Fusion. They have discontinued their affiliate program, which pays websites to promote signups for their ‘free’ EHR.” Unverified. They’re still taking signups on their Web page from what I can tell.

From Carolyn: “Re: National HIT Week. Are you involved in any of the activities?” No. To be honest, I’ve hated that concept from the day HIMSS started pitching the idea that provider IT people should stand shoulder to shoulder with their vendor brethren in trying to persuade politicians to throw taxpayer money at products sold by the vendor members of HIMSS (or as HIMSS nobly rephrases it, “public and private healthcare constituents will work in partnership to educate industry and policy stakeholders on the value of health IT for the US healthcare system.”) I don’t blame vendors for trying to influence the DC crew, but I am totally mystified how hospitals can justify spending the time and money required to send their IT people traipsing around Capitol Hill for the benefit of for-profit companies.

From Safety Paradocs: “Re: Wyckoff Heights. Wired for safety ‘well before ARRA’ as reported by the newsroom of Meditech, yet the young patient was not safe. How can we prevent such striking deaths?” Wyckoff Heights Medical Center in New York, which The New York Times politely calls “one of the most troubled hospitals in the city” because of mismanagement and its hiring of political cronies, admits a 22-year-old student who had consumed a diet drug and beer while pulling an all-nighter for her college Latin course. The hospital gives her IV lorazepam, ties her arms to her bed, and makes no notations in her chart (all documentation was on paper) that anyone was checking on her. Nobody notifies her family. She dies. A few weeks ago, the hospital’s own 83-year-old former chairman, who had been forced to resign and was then admitted for fainting spells, was found in his hospital room with a broken neck. Despite its problems (check out its reviews on Yelp), the hospital earned HIMSS EMRAM Stage 6 and $4.9 million in federal taxpayer dollars for its Meditech MAGIC implementation. To be fair, the incident occurred in 2007, which I assume was long before all of its EMR accomplishments. My takeaways are as follows: (a) while it’s true that better hospitals use more technology, it’s also true that technology didn’t make them substantially better – its use is correlated, but not causative, and plenty of crappy hospitals are using cool systems; (b) all the IT systems in the world won’t help if you have unskilled or uncaring caregivers, so choose your hospital based on quality and reputation, not what they’re packing down in the data center; (c) never, ever go to a hospital for anything serious without having an intelligent and alert advocate sitting by you at close to around the clock as possible, because having worked in several hospitals for most of my adult life, I can say that every one of them screwed up regularly due to inattentive or poorly trained staff, overworked doctors, unwashed hands, failure to notice when patients start to slip, overly aggressive treatment just because it’s possible, and lack of care coordination by all the one-trick specialists running around treating their particular body part of interest. Bring along a friend or family member to check your meds, personally challenge each major decision to make sure it’s based on conviction and science rather than lack of objection, and ask nurses whether your doctor and treatment plan are any good because they know but won’t say unless you press them. I think most hospital employees would agree that you need a wingman.

From Westie: “Re: cancer patient whose costs exceeded insurance cap. Wins a victory via Twitter.” Treatment of a 31-year-old’s colon cancer exceeds the lifetime dollar limit of his Aetna student insurance plan, leaving him with no insurance. He gets into a Twitter debate with Aetna CEO Mark Bertolini, who decides to cover the $118K in bills the patient racked up before was able to sign up for a different insurance plan. The tweets are fascinating as observers jumped on Aetna, blaming the company for selling insurance with low caps, questioning what would have happened had the patient not drummed up his own social network, ridiculing the CEO’s $10.6 million salary, and questioning how the Affordable Care Act will or won’t help. I’m glad he’s getting help, but we’re back to the original issue that patients can easily run up more expenses than the insurance they voluntarily signed up for will cover, and unlike every other kind of insurance, everybody expects someone else to pay without objection even though they met their legal obligation. I’d be interested to see who charged what of the $118K University of Arizona Cancer Center bill since those folks aren’t sharing Aetna’s financial sacrifice on the patient’s behalf as far as I know.

From Frank Fontana: “Re: paid endorsement programs such as those from AHA Solutions and the HFMA Peer Review Program. What do readers think about those programs?” I said years ago that they were pay-to-play, but they do still require products to be vetted, leaving me neutral on their value (I don’t see the benefit, but if they help connect vendors with prospects, then I see no harm.) Your opinions, please.

From EMR User: “Re: downtime penalty terms in contracts. We negotiated that any issue that we deem adversely affects our access or system usability allows us to subtract 5% of our monthly fee. We can do this daily up to five times per month.” I’ve said it before, but maybe it bears repeating. List the top handful of items that would be worst-case to you once you’re live on a vendor’s system (downtime, vendor acquisition, hardware failure, lack of acceptable implementation people, poor support) and insist on a penalty if any of them occur. Or, if you’re a glass-half-full type, reduce your fixed payment amount and offer a bonus if none of the events happen (same result, but it sounds nicer.) That makes sure your vendor has a vested interest in not allowing your worst dreams to come true, and at least if they do, you get the slight satisfaction that you’re getting paid for your trouble.

From Laboratorian: “Re: Epic. Could you opine to the extent to which MUMPS is constraining the growth of Epic? Everyone suggests this is a limiting factor, but so far it hasn’t been. How and when would they hit the proverbial wall?” It’s armchair quarterbacks, not customers, that keep trying to create a non-existent Epic Achilles’ heel out of MUMPS and Cache’. Most of that hot air comes from competitors Epic is killing, self-proclaimed experts who’ve never worked a day in IT or in a hospital, and cool technology fanboys who can’t stand the idea that Epic doesn’t care what they think. Despite the use of some ancient underpinnings, Epic’s product is apparently almost infinitely scalable, it does everything customers need it to do, and it works reliably. Nobody cares what it’s written in except their programmers – customers just want solutions, and the decision-makers when Epic is purchased are usually end users and operational executives, not IT geeks who salivate over source code. The only walls Epic could hit would be if InterSystems decided to go out of business (that’s not happening – they were absolutely printing money even before all those thousands of new Epic Cache’ user licenses dropped into their lap); if InterSystems decides to get greedy and either raise their Cache’ licensing fees or stop developing it (doubtful); or if Epic can’t get programmers willing to learn MUMPS (which has never been a problem because they do all of their training in-house and new UW psychology grads aren’t exactly swimming in job offers from Microsoft or Cisco). Anyone who claims Epic is about to hit the technical wall is just trying to plant fear, uncertainty, and doubt in the market. If there’s an Epic wall to be hit, it will be high costs that hospitals can no longer afford with reduced reimbursement, lack of ability to scale as it tries to extend its dominance outside of the US, some kind of meltdown like Judy stepping down and creating a vacuum of power, or perhaps some major and heretofore unfelt shift toward open systems that would put its rather closed model at risk. You’ll know that’s happening when you see the KLAS scores move from green to yellow. The only opinions that count are those expressed by customers with their dollars.

From Infrastructure Manager: “Re: downtime. I used to work with McKesson Horizon Clinicals, which didn’t have a great downtime report system. We scripted a routine that generated a PDF on a different server than Horizon and also copied it to a few PCs. It’s not a fast system to begin with, and you can’t help but feel the system drag when running those reports every hour, even with a huge Oracle server farm run by skilled DBAs. Also, the database design is poor and the tables are not indexed properly – you’ll see 4000 IOPS on a table/storage location and wonder that the hell is going on. If you’re hosted, who cares? Chew up those servers in a data center you don’t run and hope they’ve scaled to the appropriate size. If you aren’t hosted, take these reports very seriously.”

HIStalk Announcements and Requests

Unlike the curmudgeon Mr. H, I have watched a good deal of the Olympics. Who knew team handball was even a sport, much less an Olympic one? Yep, that’s what’s on at 5:00 a.m. on Sunday (don’t ask why I was up so early.) Go Iceland, by the way. So far my biggest complaint is that the men beach volleyball players don’t wear uniforms that are nearly as hot as the women’s. Thank goodness for men’s synchronized diving, however. I have decided that someone ingenious needs to develop an app that blocks all spoilers on Twitter and Facebook so that I will be totally surprised when Michael Phelps becomes the most decorated Olympian of all time (thanks all you expats in England who just had to share the news on Facebook.) Finally, good thing Rio is only one hour ahead of Eastern time so we’ll all see more live coverage in 2016.

Just  to prove to Inga that I’m not totally Olympics ignorant even though I haven’t watched the tape-delayed spectacle, here’s an interesting fact: the 300 hospitals beds used in the producer’s opening ceremonies tribute to NHS will be donated to hospitals in Tunisia.

Listening: reader-recommended Son Volt, music for driving or moping in smoky bars. Born of the remnants of 1990s minor stars Uncle Tupelo, somewhere between alt-country and roots rock. REM meets Neil Young.

Acquisitions, Funding, Business, and Stock

CommVault beats Wall Street expectations with its Q1 performance: net income of $10.1 million ($0.21/share) compared to $3.1 million last year on revenues of $111.3 million, up from $91.5 million.

Merge Healthcare announces Q2 numbers: revenue up 13%, adjusted EPS $.02 vs. $0.06, beating earnings estimates by a penny.

Sales

The Canadian Centre for Addiction and Mental Health selects Cerner Millennium as its clinical information system.

North Carolina HIE expands its relationship with Orion Health with the implementation of the company’s Health Direct Secure Messaging. The HIE went live in April 2012 and 70 providers have signed up, with the next phase being rollout of Orion’s EMR Lite. NC Direct is free for NC HIE participants and $100 per year per mailbox otherwise.

St. Louis-based Mercy chooses Humedica MinedShare as the Epic-integrated clinical intelligence solution it will use to manage population health for its 31 hospitals and 200 hospitals.

People

Lifespan (RI) names Eric Alper MD (UMass) as information systems medical director, charged with overseeing the development and implementation of clinical applications for the health system.

Amanda LeBlanc (Encore Health Resources) joins CTG Health Solutions as managing director of marketing and communications.

Announcements and Implementations

Yavapai Regional Medical Center (AZ) implements Cerner.

Christus St. Vincent Regional Medical Center (NM) goes live on the second phase of its Cerner implementation with the addition of CPOE and documentation for physicians, nurses, and ancillary care providers.

The VA system in western New York announces its participation in the HEALTHeLINK HIE as part of the VA’s Virtual Lifetime Electronic Record Health Communities Program.

Vocera announces the availability of its B3000 Communication system in France and introduces the Vocera Secure Messaging application for tracking messaging communications.

Jacksonville Medical Center (AL) goes live on CPSI.

E-prescribing system vendor NewCrop will incorporate interactive drug services from PDR Network into its platform, allowing its users to receive updated drug information, safety alerts, and regulatory and liability messages at the point of prescribing.

Caradigm (the GE-Microsoft joint venture) announces GA of Vergence 5, the latest release of its single sign-on and context management platform for healthcare.

Iowa Medicaid says its integrity program saved the state $30 million in its second year of operation, bringing the total to more than $50 million. Optum administers the program that analyzes provider claims for overcharges due to upcoding, unnoticed private insurance coverage, fraud, and simple math errors in bills.

Technology

The FDA clears Proteus Digital Health’s ingestible sensor, which works with a companion wearable patch and mobile app to monitor medication adherence.

The DoD and VA release PE (for prolonged exposure) Coach, a free smart phone app to assist service members and veterans with PTSD.

Other

Minnesota achieves the highest rate of e-prescribing use in 2011, with 61% of prescribers routing prescriptions electronically. Massachusetts and New Hampshire had the highest physician adoption rate at 86%.

The New Orleans paper reveals that two-thirds of the full-time physicians working in Louisiana state prisons have been disciplined by the state medical board for issues that include pedophilia, substance abuse, and dealing methamphetamines.

Hartford Hospital (CT) and a home care group announce that information about 10,000 patients was contained on a laptop stolen from an employee of Greenplum, a “big data analytics” vendor and division of EMC that was doing readmission analysis for the organizations. The laptop was not encrypted.

I’m always skeptical of the Meaningful Use attestation numbers, so here’s an example that Meditech sent over in response to some of our recent posts. Inga’s analysis of numbers provided by CMS showed Meditech with around 120 hospital customers attested through May 2012. Meditech’s official number is 431, and even if mega-customer HCA is counted as only one hospital, they’re still at 271. That would place Meditech at #1, far above CMS’s #1 Epic, except that maybe CMS has their numbers wrong, too. I personally don’t think the number of attesting customers means much and this makes me even less interested in the vendor totals.

Physicians and experts testify to a House subcommittee that small practices are dropping like flies, with physicians moving to employed positions because of declining payments and increased reporting requirements. An orthopedist said his group shut down and took hospital jobs after spending $500K on an EMR hoping to reduce cost and improve quality, but the initial savings were eaten up by increased IT labor costs, upgrade fees, and the work required to document Meaningful Use.

Weird News Andy dubs New York Mayor Michael Bloomberg as “Dr. Bloomberg” after his push for hospitals to discourage new mothers from using canned baby formula instead of breast-feeding. WNA adds that he assumes the newborns won’t be allowed to have 32 ounce Big Gulps, either.

Sponsor Updates

• Wolters Kluwers executive board member Jack Lynch discusses the emergence of “compliance clouds” during the company’s Half Year Media Roundtable meeting in Amsterdam.
• Informatica gains partner support for its latest release of Informatica Cloud.
• Impact Advisors earns the highest ranking in KLAS’s HIE consulting report, specifically identified as the only fully rated vendor providing HIE advisory and technical work.
• DrFirst Chief Strategy and Privacy Officer Thomas Sullivan testifies at an ONC hearing on identity-proofing solutions for the electronic prescribing of controlled substances.
• HIStalk sponsors earning a spot on Modern Healthcare’s Best Places to Work in Healthcare in 2012 include Aspen Advisors, DIVURGENT, Encore Health Resources, ESD, Hayes Management Group, Iatric Systems, Impact Advisors, Imprivata, Intellect Resources, Intelligent InSites, maxIT Healthcare, Santa Rosa Consulting, and The Advisory Board Company.
• Allscripts, Beacon Partners, Cumberland Consulting Group, ESD, Merge Healthcare, and The Advisory Board Company receive the Healthcare’s Hottest companies designation by Modern Healthcare.
• eClinicalWorks and Intelligent Medical Objects host webinars to introduce eCW IMO Problem IT Smart Search for ICD-10 coding.
• United Hospital System of Kenosha (WI) renews its licensing agreement for Streamline Health’s Enterprise Content Management Solution.
• MED3OOO customer Family Healthcare Network (CA) receives over $500,000 in EHR incentive payments.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 7/30/12

This is the final piece in my series about vendors using physicians and other clinical experts in design, implementation, and support. I heard back from a few individual physicians working for vendors who asked not to be named. I’ve paraphrased their responses as well to give them a little more anonymity.

Miriam works for a top-tier ambulatory vendor. Although she does primarily go-live support and physician-to-physician training, she also works with content designers on specific specialty-related projects. Although there are a large number of physicians in her company, she thinks that the physicians are underutilized in the development process.

I would like to be involved more upstream in the development cycle. Since we’re in the field so much, we know better than the development teams as far as how the users work.

She notes a high degree of physician turnover due to the 75% travel schedule her company requires.

Jae is an internal medicine physician working as a consulting firm subcontractor. Although he would like to work for the vendor directly, he previously worked for a client and an anti-poaching agreement prevents him from being hired. He was involved in what sounds like a fairly messy practice breakup and the remaining partners would not give him a release, so he’s spending a year in what he calls “independent contractor limbo.” Although he does the same type of work as other physicians employed by the EHR vendor, his services are passed through the consulting firm to avoid actual employment.

I do a lot of liaison work with sales prospects, especially sales demos since I still do some locum work and can say I am a practicing physician. I can also technically say I’m not on the company payroll, although I’m not crazy about how the sales team sometimes plays that. The contractor thing isn’t all bad, though. I probably make about the same salary as the employed physicians once you figure the difference in hourly wage vs. paying for my own benefits, but I probably have a lot more control over my schedule this way. I don’t think I have as much influence in development, though.

There’s more to his very interesting story, and I must say I admire the vendor’s way of intentionally working around their no-hire agreement. Given the recent reader comments about a certain vendor’s no-hire agreements, it’s interesting to see it work the other way.

I’ve been saving this early submission for a strong finish. Dr. Ryan Secan of HIStalk sponsor MedAptus sent information about his work as chief medical officer, including an action photo.

I share many of your concerns about medical software, as I’ve often noted that the applications I’ve needed to use don’t seem to have had any input at all from a practicing clinician and are not designed with my workflow in mind. This is why I joined up with MedAptus last year. It was chance to help create software for physicians from the point of view of a practicing clinician. While my role at MedAptus includes participation in the sales process and acting as a liaison with client physicians, I also have an integral role in the design process. I understand physician needs for clean, simple, and intuitive interfaces that facilitate their work rather than hamper it. At MedAptus, we believe that our software should fit itself into physician workflow rather than forcing physicians to change their workflow to match the software. This has been particularly important as we prepare for ICD-10 implementation and the sheer volume of codes threatens to overwhelm the provider. Leveraging my clinical experience has allowed us to continue to put out a product that remains easy for clinicians to use despite the increasing complexities of medical billing and coding.

The above photo is me with James Scott, who is the vice president of engineering at MedAptus. James and I meet regularly to discuss feature enhancements, usability design, and navigation. This was taken during a meeting in which we were reviewing changes to the physician interface of our professional charge capture application to support end-user ICD-10 code searching and selection.

There were a few respondents who said they were going to obtain permission to send something but then never got back with me, so I assume the marketing and communications gatekeepers were not big fans of the idea. Or maybe, like my experience last week, they were pulled to work a double shift at the hospital. If they ever make it through the PR gauntlet, I’ll be happy to run their pieces.

E-mail Dr. Jayne.

John Gomez 7/30/12

HIT Integration Analysis Guide

Over the past several months, one of the biggest questions I have gotten regarding the state of HIT is related to platform and technical integration. Specifically, the debate related to single platform vs. an integrated platform. Typically the question is posed by someone who is not technical and who is concerned about separating vendor hyperbole from reality.

In order to try and shed some light on this topic (which is not a simple one), I have developed what I am tentatively calling the “HIT Integration Analysis Guide,” which I outline below. The purpose of the guide is to provide those analyzing single vs. integrated platforms a means to better understand the true nature and ability of integration. I will provide further light on this shortly, but for right now, let’s create some definitions for what I mean by single vs. integrated.

A “single platform” is one that provides a single set of technologies and database across a set of applications. The common example of this is where you have an EMR which relies on a single database across ED, lab, surgery, OB/GYN, pharmacy, acute, ambulatory, physician and nursing documentation, CPOE, and other venues. In a single platform offering, you have a single technical offering with all data being shared across the different venues of care.

An “integrated platform” is one which uses technical and architectural approaches to “integrate” the various venues of care together. Data and other features may or may not be shared, depending on the level of integration.

To help clarify this a little, let’s consider an analogy.

A store such as Target is a good example of a single platform system. When you shop at a Target (or similar department store), you are able to have most of your needs met (to varying degrees of satisfaction) while never leaving the store. You can get a DVD, clothes, food, household items, and appliances. Regardless of the department in the store, you expect consistent signage, vocabulary, customer service, and support. When you check out, you can use a single method of payment. You have more than likely have saved time by simply dealing with a single vendor. If you need to return an item or have another issue, you can resolve it with a single vendor — the department store.

In contrast to this is the mall (such as the Mall of America), which is representative of the “integrated platform” experience in HIT. In this model, you go to the mall, and although everything is housed in a single location with similar look and feel in common areas, similar operating hours, and other shared services, the experience you have with each vendor in the mall is unique to that vendor. Customer service levels, return policies, product quality, and other attributes are specific to the store you enter within the mall. Although there is some commonality throughout the mall, it ends at the door of the individual store.

Each of these models has its pros and cons. What is important to keep in mind is that the tradeoff is often on depth of service vs. convenience and “good enough” service. For instance, you are apt to get better service regarding an iPad at the Apple store in the mall then you would for the same iPad at Target. Yet the number of people and level of chaos at the Apple store may not make it right for you.

Unlike this analogy, in the world of HIT there are some hidden factors which need to be evaluated when you are deciding the “single platform” vs. “integrated platform.” This bring us to the “Integration Analysis Guide” and the meat of this diatribe. Although there may be other tests, criteria, or scorecards for measuring how well things integrate, I think it is important to have something that is simple to understand, that provides some key and direct questions you can ask your vendor’s executive management, and that removes the complexity and the “marketecture” from your vendor’s presentation.

Single Platform Analysis

The key concern here is related to understanding if the vendor’s system is truly on a single platform and using a single set of technologies. This should not take long to determine. To be honest, the technologies they are using are not as important for this analysis as to whether or not there is a single set of technologies. Here is what I would be asking:

1. Do all your applications run from a single database?
2. Do you have a single technical stack across all of your applications?
3. Do you employ a single programming language across your technical stack?
4. Do you have a single configuration system, help system, HIE system, HL7 sub-system, reporting system, security framework, and user documentation across your platform?

That’s pretty much it. The answer should be a resounding “yes” to each question for a vendor to declare a single platform architecture with single database. Are there are other things to consider? Of course, but to keep this simple, those are the big things to understand.

If the answer is “no” or “we are working on it,” then start asking for percentages of completion. “What percent of your system is on a single security framework?” for instance.

Integrated Platform Analysis

Analyzing the Integrated platform is not as simple as the single platform analysis, but I will do what I can to keep it as simple as possible. For the techies among you, please note that I am deliberately pushing topics related to technical integration to the bottom of the list, because unlike single platforms, the specifics of workflow are more important then what technology or programming language is being utilized. At the end of the day, the goal of embracing an integrated platform by a healthcare system should be that the individual specialties of the system (ED, lab, CPOE, etc.) are much more advanced then that offered by a single platform vendor. Hence we will focus first on workflow and then on technical integration.

Level 0 Integration – The Basics

If we think of this as a set of building blocks, the most basic building block is the exchange of rudimentary information among the various components and application offered by the integrated platform vendor. How this integration occurs is not as important as the fact that it does occur reliably. To understand how well your vendor is doing this, here are some questions to ask and the right answers:

• Question: please list for me the basic data you are sharing among your modules and applications. Answer: problems, allergies, immunizations, history, orders, demographics, family history, billing information, and care team. This is a pretty basic list, and to be honest, most of it is what is required to effectively support HIE systems (regardless of what the government thinks.) Also, much of this can be done via HL7 or other simple data exchange. The point being that if your vendor cannot exchange this information, then regardless of how advanced their technology, you are in for serious workflow challenges.
• Question: what is the latency encountered with sharing data? This is how long it will take for data to show up that is entered in one application in another application. For instance if you update an allergy in the ED system, how long before it shows up in the ambulatory system? Answer: three minutes. I know three minutes sounds like forever in healthcare, right? But it is realistic, and without a major infrastructure investment by you the healthcare provider, you should consider this an adequate answer.
• Question: what occurs if there is an application outage? If we enter an allergy in the ED system and the ambulatory system is down for maintenance, what happens? Answer: the applications will resynchronize after an outage to assure all information is correct. Simply stated, all the data is always up to date give or take three minutes, even after a system outage.
• Question: how does integration support workflow? Answer: any data that is exchanged is treated as if it was entered by a human, and so all workflow remains effective. The goal here is to assure that when data is passed back and forth behind the scenes between systems, it does what is supposed to do. For example if you have a rule in your ambulatory system that if a patient’s body weight drops more then 12 pounds a blood test should be drawn, then that rule should fire even if the data was entered in an ED system and sent to the ambulatory system behind the scenes.

Level I Integration – Content Integration

Assuming your vendor can fully support your needs for Level 0, then you should begin Level I analysis. If the vendor cannot support Level 0, there is no need to consider Level I or continue your analysis of the vendor, if your goal is to hope for a truly integrated platform that is not on a single platform.

Level I is concerned with content integration and how critical it is that information that is heavily relied on by the care team is always available, regardless of how it was entered. To be frank, most vendors can do Level 0, but they cannot do Level 1 unless they are on a single platform. Level I is by far the most difficult part of integration, and frankly, the most critical to get right.

• Question: do you exchange all nursing and physician observations and are they editable? Answer: yes. All nursing and physician observations are exchanged among all systems. You can edit them and update them in any application. Let’s walk through an example. A nurse inputs an observation in a surgery system. That observation should now be in the acute care system. If the nurse using the acute system needs to amend that observation, they should be able to do so without issue. (Editing is something debatable, but the point is the observation should be exchanged and should act as if it was entered by a human.)
• Question: do you exchange all nursing and physician documentation and allow it to be edited? Answer:  yes. All nursing and physician documentation is exchanged among all systems in our platform. You can edit them and update them in any application. Again, the issue here is that you need to share content. A physician sees a patient in their office, makes some notes on the patient, admits the patient, and then later sees them in the hospital. They need to see that note and then continue updating it. Same goes for the nurses’ needs related to documentation.
• Question: is your content ubiquitous throughout your system? Answer:  yes. We provide the same level of content across our system. You want to make sure that all content is the same. You don’t want a situation where one application on the platform supports oncology content and then another application does not or doesn’t support it to the same level.
• Question: do you support the same vocabulary throughout all your applications on your platform? Answer: yes. If you are going to eventually be doing analytics related to performance, cost management, and compliance, you are going to need a single vocabulary shared among all the applications.
• Question: does personalization follow the user? Answer: yes. Things like patient list layout, favorites, order sets, documentation sets,  and personal rules and shortcuts follow the user regardless of the application they are using. Users tend to spend a good deal of time once they get to know a system setting it up to meet their needs. If their personal settings are not available or don’t follow them, you need to know this upfront.

Level II Integration – Infrastructure

Here is where we start to look at the technical integration, but still from a business and user perspective. We are not going to concern ourselves with technical choices, but rather with technical implementation by the vendor. Most of these questions will be similar to those you ask of a single platform vendor.

• Question: do you have a single reporting and analytics system? Answer: yes. Regardless of the application you are using, we provide a means to access all data from a single location for purposes of reporting and analysis. It is important that reports, dashboards, and other analysis can be run across applications. If you are going to truly have a holistic view of your platform, the vendor most provide you with reporting tools that go across all integrated applications.
• Question: do you have single security framework? Answer: yes. You only need to define a single set of user groups and user IDs and you can centrally manage all users. If the vendor does not support this, it will mean that a physician using a system in their office will have a different user ID and password for that system than the one in the hospital. The vendor at a minimum should support a single sign-on solution, but keep in mind most SSO solutions don’t allow for role-specific management and policies across applications.
• Question: do you have a single configuration system? Answer: yes. You can manage all configuration some a single set of tools. Again, if this is not the case, you will need to figure out how you will manage and configure each system on the platform and how you will distribute changes. This becomes much more of an issue as you consider things like content changes, standardized care, reporting, and other workflow items.

Level III – TCO Analysis

This section is not so much a series of questions to the vendor, but more so a series of things to consider when you are evaluating a single vs. integrated platform. Each of these items relates to the impact of costs. How much of an impact and if it is of concern is left to you to determine. What is important is to consider the tradeoffs in depth versus breath that you get from a single platform vendor vs. that of an integrated platform.

• If the vendor doesn’t support a single look and feel across all their applications, will the cost of training different users on multiple systems be an issue? Most integrated platform vendors do not provide a single look and feel across all their applications. This means that a user who has to interact with multiple applications will need to learn different menus, commands, and layouts.
• Will you need to increase staff to manage different applications using different configuration tools if the vendor doesn’t have a single configuration system? If the vendor doesn’t support a single configuration toolset, what impact will that have on your staff in responding to changes and upgrades?
• Does the vendor require different technology for each application? Although we didn’t dive into technical architecture, you should understand if on a per application basis the vendor is using the same technology and database across all their systems. If not, you may have to maintain technical staff with different areas of expertise, different licensing agreements, and even manage different versions of a similar technology.

Although this is a rather lengthy article overall, I tried to keep it as short as practical and provide some focused questions that help you quickly determine what is right for you. And more importantly, to understand if your vendor is able to meet your needs. There is so much more that we could evaluate regarding either side of the coin, but I am rather confident that if you use the information above, you will quickly be able to pinpoint where your vendor stands and if they are able to deliver.

Lastly, yes you can and should analyze the single platform vendor as to if they can truly do all that we asked of the integrated platform vendor. Although chances are that they can, and it is probably harder for an integrated platform vendor to achieve the same level of ability, there is a chance that a single platform vendor made design choices that preclude them from sharing data among their applications in a way that you need. If you feel you need to dive deeper, you can certainly ask all of the “integrated platform” questions of the “single platform” vendor.

I will refrain from providing an opinion here on weather or not you should move in one direction or the other (single vs. integrated). What I will say is that you need to keep in mind that at some point you will need to integrate third-party systems into your ecosystem. Regardless of if you go single or integrated, you do need to consider the openness or closed nature of your vendor offerings.

I do believe there are many myths related to this topic in HIT. It is a topic I will think about exploring and writing about in the future. But for now, let me say that I do not see any one vendor being tremendously more open or closed then any other vendor. In fact, I would say that most HIT vendors offer closed systems, which is unfortunate.

All that aside, I hope that as you continue your journey the information here is somewhat helpful and useful.

John Gomez is CEO of JGo Labs.

Roper To Acquire Sunquest for $1.4 Billion

Roper Industries announced this morning that it will acquire laboratory and diagnostic information systems vendor Sunquest Information Systems. The all-cash transaction is valued at $1.415 billion.

Roper Chairman, President, and CEO Brian Jellison was quoted in the announcement as saying, “Sunquest meets all of Roper’s key acquisition criteria and is an ideal fit with both our Medical and Software platforms. The business is the market leader in software solutions for the critically important healthcare provider laboratory market. We expect Sunquest to benefit in all economic environments from very favorable market forces – an aging population, expansion of anatomic pathology, and the need for reduced healthcare costs and improved quality of care. Sunquest’s software and application engineering capabilities deliver an outstanding return on investment for their customers. The company has attractive cash return characteristics and generates significant recurring revenue through long-term customer relationships and very high retention rates.”

Jellison also stated that the company will continue to operate under the Sunquest name with full continuity of personnel. Closing is expected within 30 days.

Sarasota, FL-based Roper Industries is an industrial manufacturer whose medical units include measurement systems, medical devices, and imaging solutions. Sunquest is owned by an investor group that includes Huntsman Gay Global Capital and Vista Equity Partners.

Monday Morning Update 7/30/12

From Meaningful Juice: “Re: GAO report from last week. Of 4,855 eligible hospitals, 776 were awarded eligible $$$ juice for 2011. Phew – my tax dollars are not being wasted!” Among the GAO’s recommendations was that CMS needs to beef up its scrutiny of whether providers really were eligible to get their payouts.

From Dave: “Re: Michael Stearns, before being fired as e-MDs CEO. See this document.” This is old news that has been mentioned here before. The Maryland State Board of Physician Quality Assurance suspended the medical license of Dr. Stearns in 1997 after he pleaded guilty to four counts of assault and battery in a US Navy court-martial case in which four female patients claimed “inappropriate sexual touching” during his examinations of them. David Winn, who as e-MDS board chair fired and replaced Stearns as CEO on July 2, defended him in this 2011 write-up, saying that Stearns was never convicted of a felony and was perhaps misled by poor legal counsel in a Tailhook-sensitive environment and inconsistent behavior by the Maryland board after the fact. Mike Stearns says he will address this and other issues in an HIStalk Readers Write article in a couple of days. He hasn’t said that he’s suing his former employer even though he claims the allegations behind his termination are meritless, but one might assume that’s his only remaining option. I’ve heard from several folks who extolled the character and capabilities of both Dr. Stearns and Dr. Winn, so hopefully they will avoid the public debate, reach some kind of agreement, and move on without further embarrassment.

From Happily Hosted I Hope: “Re: host environment performance. Do any of your readers have language around system performance and high availability in a hosted environment that they could share? We’re going to be installing an EMR through a hosting arrangement with a local hospital and I’m looking for advice.” Given the high-profile downtimes that have come up recently, I think it’s a great topic to address. If you’ve put terms and conditions into a contract with an EMR hosting provider and would care to share details, please send them my way. I won’t mention either client or vendor and will strip out anything identifiable, so your non-disclosure terms are safe.

From EHR Warrior: “Re: NextEHR. Looks like it’s finally dead as the company that bought the intellectual property changed its name to iPenMD.”

From ITKnowsTheScoop: “Re: [vendor name omitted.] Under FDA review regarding surgery and anesthesia solutions. They had to remove or reclassify features, which halted sales for four months.” Unverified, so I’ve omitted the company’s name.

From IT Director: “Re: Cerner. I have an unfortunate trove of horrid experiences related to extended planned or unplanned service interruptions, some of them due to a shoddy corporate implementation of Cerner Millennium. Our implementation spanned time zones, so we had a six-hour downtime twice a year when Daylight Saving Time changed. We has spectacular outages where the entire hospital system went dark with no local backup whatsoever. The corporate implementation was insistent on a paperless workflow, so we weren’t even allowed to print periodic paper backup copies of order synopses or MAR summaries. During our first major downtime, a little girl was left in writhing pain for most of the night because the house officer didn’t know the timing and dose of her pain meds. This downtime was rumored to have been caused by a profound error in hardware sizing, but poor database design didn’t scale well even with additional hardware. I don’t blame Cerner as their staff were truly engaged and helpful, but rather a centrally managed health system corporate mentality of arrogance and ignorance that discounted the local reality and specialized workflows. Perhaps the morale of the story is simply that any given implementation is only as good as its implementation team. If they’re evil, then the implementation will be similarly evil. In some ways, Cerner as much as a victim as the hospitals of setting poor implementation leadership.” Your experience matches mine. Unless every vendor’s implementation has been a disaster, it can’t be their fault alone (i.e., one successful comparable client means the stuff basically works). The main problems usually involve: (a) lack of customer technical and implementation resources; (b) poorly developed, self-deceiving project budgets that don’t support enough headcount, training, and hardware to get the job done right; (c) letting IT run the project instead of getting users involved, which is especially problematic if the corporate IT people are clueless; (d) unreasonable and inflexible timelines as everybody wants to see something light quickly up after spending millions; and (e) expecting that just implementing new software means clearing away all the bad decisions (and indecisions) of the past and forcing a fresh corporate agenda on users and physicians, with the vendor being the convenient whipping boy for any complaints about ambitious and sometimes oppressive changes that the culture just can’t support. I might also mention sloppy contracting on the client’s side, since I’ve seen hundreds of contracts and am often amazed that the interests of the vendor weren’t legally aligned with those of their customer via a few standard terms and conditions.

From Commando: “Re: Cerner. Cerner has two electronic downtime solutions for remote hosted clients. The read-only methodology referred to requires the user to be able to log into the system back in KC, which wouldn’t be possible with the DNS servers out of business. There is another level of downtime service – something I guess his/her organization decided not to purchase. That next level dumps patient information to local computers (at our hospitals, at least one on each floor) at regularly scheduled intervals. i.e. updated every 5 minutes. That way, even if all connection with KC is lost, staff has information (including meds, labs and more) locally on each floor which is accurate up to the time of the last update. Finally, since this outage was due to a DNS problem, anyone logged into the system at the time it went down was able to stay logged in. This allowed many floors to continue to access the production system even while most of the terminals couldn’t connect.” Assuming this is an accurate description of the available options with Cerner hosting, it might be a good time to check out the local caching option. That would be protection against even internal network problems, which in a lot of hospitals is not uncommon. I recall that Kaiser uses that with good success for its Epic/HealthConnect system that’s deployed regionally. You could probably create a poor man’s solution by running specific reports (MAR, active orders, recent lab results, etc.) to a PDF file and dropping them in specific folder locations on a frequent schedule, like maybe once an hour.

From West Coast: “Re: John Muir Health. Hires a CIO.” The internal memo sent my way indicates that Jim Wesley has been announced as SVP/CIO of John Muir Health. He was most recently a consultant, but has healthcare CIO experience. John Muir’s hot button is getting Epic up and running.

From Maryann: “Re: Epic. I work directly for a hospital that is implementing several Epic modules over the next 5-7 years. I have two Epic certifications. I applied to several consulting companies and each one told me that they couldn’t hire me if my hospital was in the middle of an Epic implementation because of an agreement with Epic. Is this legal? How long to I have to wait if I leave my hospital before a consulting company will hire me?” Welcome to the murky world of Epic non-competes and recruitment restrictions. Epic controls your opportunities with potential employers via separate agreements and/or implied punishment for poaching Epic-certified people. Is their practice legal and binding? Almost certainly not, but you’d need a lot of lawyer money to find out, and by the time you got a ruling, you could have just sat out your time as an untouchable by working in a non-Epic role somewhere (I think it’s a two-year timeout, but it may just be a year … I seem to remember there was discussion about changing it.) Epic’s practices are designed specifically to thwart exactly what you want to do – use your short-term Epic experience and certification to bail out on your employer and cash in with a consulting firm. Even if you had the financial resources and extended timeline needed to mount a legal challenge, there’s still no guarantee that you’ll get hired, because legal or not, nobody wants to cross Judy for fear of choking their own particular gold egg-laying goose. Not to add more rain on your parade, I’m not sure you can even easily move to another Epic hospital, but I’ll let those who have first-hand experience explain how all of this works.

From The PACS Designer: “Re: waterproof accessories. If you want to limit infection from entry devices, there’s now a solution from Seal Shield. They feature waterproof keyboards and other computer input devices that are easily washable and ready for reuse, thus reducing the spread of infections that could come from multiple users of those devices.” I’ll say this – they make a fantastic commercial. You can waterproof your iPad for $30 or your iPhone for $20.

Welcome to new HIStalk Platinum Sponsor M*Modal. The company’s cloud-based Speech Understanding solutions that are used by 2,400 customers include Fluency (converts physician’s narrative into electronic documentation that can be integrated into workflows, in effect speech-enabling EHRs); Catalyst (retrieving information from unstructured encounter documentation, with the first in a series of tailored versions being Quality and Radiology); and SpeechQ (dictation capture for radiology). The company also offers transcription services via its 10,000 transcriptionists (it’s the largest in the US) as well as coding services for clients struggling with Discharged Not Final Billed accounts and the possibility of negative audit findings. We know from recent headlines that M*Modal is a very successful company since arguments have been made that JP Morgan is getting too good of a deal in acquiring it for $1.1 billion, so that’s a nice debate to be having. Thanks to M*Modal for supporting my work.

Here’s an M*Modal video I found on YouTube.

Listening: new from Citizen Cope, which is primarily singer-songwriter Clarence Greenwood. A uniquely American mix of soul, blues, and roots music. Eric Clapton is a fan.

TPD has updated his list of iPhone apps.

I have zero interest in the sprawling commercial spectacle of the Olympics for a variety of reasons (athletes itching to bag endorsement deals the day the flame and their short-lived fame are simultaneously extinguished, smug US cheerleading, glorification of photogenic participants and sports to the exclusion of most of the others, participation of state-sponsored and chemically altered participants and richly compensated professionals like LeBron James that make a joke of the phony, feel-good “amateur” aspect) so I won’t have anything to add to the already smothering media coverage that I won’t be following (except for articles involving widespread Olympic Village debauchery.) Inga bah-humbugged me and says she’ll pipe in with anything HIT-related (like the frequent GE commercials she’s already mentioned to me), so we’ll count on her to make it interesting.

Speaking of Inga’s Olympics chime-in, she sent this newspaper article criticizing the UK’s NHS promoting itself to a worldwide audience just after several high-profile incidents of patient harm that occurred under its supervision:

Sitting in a home somewhere while fireworks lit up the Olympics opening ceremony would have been the family of Kane Gorny. They watched their cherished teenage son die of thirst at the hands of incompetent doctors and nurses … The letters ‘NHS’ dazzled in bright red like some triumphant advert. All around these pranced self-indulgent nurses who had volunteered to take a few days off to be part of the ceremony … That such a politically divisive subject was included at all is utterly shocking. Not least because it glossed over the cracks in a system that is creaking at its seems crying out for urgent reform.

And speaking of NHS, it apologizes to the family of a 76-year-old hospitalized cardiac patient who died right after her son discovered three workers drilling holes in the ceiling above her head to install a patient entertainment system.

Readers say the future of public HIEs is bright, at least if you count dying a screaming death in a giant nuclear fireball of failure as bright. New poll to your right: in which HIT-related company would you invest $100K today? (assuming you have to choose one).

Defense Secretary Leon Panetta disappoints a House committee by advising them that integration of the respective electronic medical records systems of the DoD and VA (AHLTA and VistA) won’t be finished until at least 2017, and he didn’t even sound confident about that date. VA Secretary Eric Shinseki observed that simply reaching DoD-VA consensus on a open architecture system was quite an accomplishment given previous discussions with “a proprietary contractor.” Rep. Bill Johnson (R-OH) wasn’t happy with that answer: “I understand that you can’t account for the last 10 years, Mr. Secretary. And I understand that you’ve got two bureaucracies that don’t necessarily like to be told what to do and (don’t) get along all the time. But I will submit to you that another five years is unacceptable (and) ought to be unacceptable to you.”

HIE Networks and Hillsborough County Medical Association (FL) announce their collaboration to deploy a county HIE. HIE Networks operates the Florida Health Data Network.

Some quotes I highlighted from the McKesson earnings call:

• The clinical conversions — when we talked about our Horizon to Paragon strategy, we talked about the fact that we believe it is a viable solution for our customers, and that over time they need to evaluate that as an alternative because of its more tightly integrated infrastructure and its lower cost of operations … we’ve seen many of our Horizon base evaluate the products. We’ve seen some of that base already contract to move to Paragon, and some already have moved because of whatever remaining development is necessary and Paragon was not of import to those customers. Others have said, you know what, we’re going to go, but we want you to build out another module or we’re going to go after we get our Meaningful Use dollars settled.
• We are really pleased with our position in RelayHealth. I have to admit that the e-prescribing portion of the market’s transition is not a particular profit driver for us. We’re in that transaction both in our electronic medical record businesses as well as in Relay. But that’s not really where the opportunity lies. The opportunity lies in the continued build out of our financial systems.
• And if it’s a surprise to anyone that clinical buying is beginning to wane, they must not be deep in the industry. We believe that our customers have largely made their clinical decisions … We’re in the implementation phase now. Actually if you look at our results under the cover, you actually will see that our hospital buyers are beginning to come back to purchasing other solutions beyond clinicals. And I think those companies that don’t have a portfolio beyond clinicals are probably feeling the effect of a pipeline that is probably headed in a different direction.

Some quotes I highlighted from the Cerner earnings call:

• While there is one competitor that remains a challenge, our competitive position against them continues to strengthen. At the same time, their weaknesses are becoming more known in the marketplace. As we’ve discussed, our significant improvements to our physician solutions and the workflow is neutralizing one of the primary areas they used to compete. And we believe the capabilities we are rolling out in Millenium+ and PowerChart+Touch surpass their capabilities. In addition, our investments in our operability, data analytics and population health management are becoming an increasingly important differentiator against them as their platforms make interoperability and data analytics very challenging. We also believe they will face an inevitable upgrade from their MUMPS-based platform that is needed to catch up in these areas, and this will be very disruptive and expensive.
• Currently, approximately 45% of our core hospital clients have attested for Stage 1 Meaningful Use, and we expect approximately 85% of them to have attested for Stage 1 by the end of the year.
• As background, our experience with data and analytics dates back to 1996 when we started Health Facts, which is a research database that now has over 150 million patient encounters and nearly 2 billion lab results. While in the past this data has largely been used to support pharma and biotech research, our server map organization is now using it along with published evidence to accelerate the development of predictive clinical agents.
• But we clearly have a significant amount of cash on the balance sheet. We think we are in a situation in kind of part of the market that there could be some interesting opportunities for us to deploy that cash in a way that could be — either supportive of Millennium, get us more quickly into some of the new businesses that we’re looking at. I think, relative to the existing traditional HIT market, the window is getting very close to being closed for that being interesting to us. So I think the status of many of those competitors are a little bit on the downhill side of the hill.
• I think probably the one country that’s got a lot of demand is going to really be — just a funding issue — is the UK. As more and more of those trusts are becoming foundation trusts, which means they control their capital outlet — outlay as opposed to the government putting the dollars out there, we think that’s going to turn into a more normalized US- type market where each trust is going to go out to the market and look to acquire technology. In 2015, the current NHS contracts expire. So almost all of those trusts are going to be looking in the market in some form or fashion, probably depending on their access to capital.
• The RFP volume, I’d attribute a lot to the failures of many of our competitors to be ready for the changing landscape. And so they’re in the midst of either — they’ve done acquisitions and they’re trying to put things together, they’re trying to move to new platforms, they’re sunsetting existing platforms, they are on old technology. And those types of things, as people look to what the future is, they know that they have to have data liquidity, their systems have to be interoperable, and they’re going to need that data no matter where the person is in the entire care cycle, inclusive of the home … the recognition that Cerner can do that work, that their current providers can’t do that work.

Vince’s HIS-tory continues with the story of Keane and its Threshold product that could run on any hardware vendor’s UNIX platform.

E-mail Mr. H.

Time Capsule: Google Health: Does Anyone Still Care?

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

I wrote this piece in September 2007.

Google Health: Does Anyone Still Care?
By Mr. HIStalk

I like just about everything about Google. I like its products, its offbeat style, its innovative products, and it’s "we’re really just geeks like you" winking acknowledgment of its own cool technology.

Notice I said I like "just about" everything Google. What I’m sick of hearing about is Google Health, whatever it is (if it’s anything at all).

Everybody’s atwitter because the company’s health guy, Adam Bosworth, either quit or got fired last week. Google kept it mighty quiet, not admitting it until a blogger ran the story from a tip. The acknowledgment was terse, so you might well figure that he either got canned or went off to start a competitive business.

Google’s entire health output so far is, well, zero. The company hasn’t even announced anything. Googlers don’t show up at conferences, don’t write white papers, and don’t dazzle us with their usual brilliance. Maybe the company got embarrassed and cleaned house.

Of course, most Googlers are engineers. They are a great asset in solving purely technical problems, like writing search algorithms. Could it be that they’re ill equipped to understand the rat’s nest that is US healthcare, much less do anything to improve it, or even more importantly to shareholders, profit from it?

Everybody assumes Google’s healthcare people have been sequestered while creating a world-beater personal health record. I wasn’t so sure since it seemed like an odd business for them (and everybody else) to be in. Leaked screen shots of a cheesy (not sparsely elegant) prototype weren’t encouraging. This is the best that a $164 billion market cap company could come up with? It looked like one of those "$40 on a USB stick" spare bedroom programmer products that are giving the PHR genre a bad name.

It wouldn’t surprise me a bit to see the company get back to what it knows best: advertising. Google doesn’t know EMRs, PHRs, or HISs, but it knows how to jam context-sensitive ads in your face and get you to click on them. Why would Google want to get into the ugly Vietnam of clinical systems and low-rent PHRs when it could simply find new places to serve up more of those ads that effortlessly bring in billions? Like in front of doctors who have already amply proven to be influenced by obnoxious drug company advertising, for example.

You’ve seen the faltering first steps of ad-powered physician systems, healthcare social networks, and online references. The approaches have been amateurish, but I guarantee somebody will figure out that the real money will be made by giving drug and medical device companies access to prescribers at the point of decision-making. Pay-per-click gets much more valuable when presented in context to free EMR content and patient-specific information. Say, do you really want to order Drug A? Why not try Drug B instead, especially since this patient has renal problems and we’re offering a special price? Click here for our convincing medical references. In fact, we’ll buy your whole office lunch if you’ll just click OK instead of Cancel.

Many big company toes have been dipped into the healthcare waters over the years. Most got drawn back quickly, burned by an industry in which even deeply experienced organizations often fail. Fresh healthcare ideas are a dime a dozen, but the bigger the company, the more ludicrous the results have been.

At this point, I’m past whatever interest I had in Google’s healthcare efforts. They’ve had plenty of time to dazzle me. I don’t care any more. Just stick those AdSense ads in clinical software and let’s move on.

HIStalk Interviews Linda Peitzman MD, Wolters Kluwer Health

Linda Peitzman MD is chief medical informatics officer of Wolters Kluwer Health.

Tell me about your job and the company.

Wolters Kluwer is a large company that started as publishing of information. It now creates software and information to help with workflow and decision support in the verticals of tax accounting, legal, and health to help the professionals in those areas with their decisions and information needs. 

I’m with the healthcare division. I’m a physician who worked for a long time as a full-time practicing clinician trying to figure out ways to solve problems and make things go better and help the systems that I was using.

I got myself involved in the IT side way back and started working with ProVation Medical. I came into Wolters Kluwer through the acquisition of ProVation Medical. Since that time, I have been working with the health division and spending most of my time with the Clinical Solutions Group at Wolters Kluwer Health, which provides workflow software, information, and decision support at the point of care for healthcare professionals.

You’ve worked a lot with order sets, which early on were just collections of commonly used paper orders that somebody keyed in to a CPOE system. What’s the state of the art in the use of order sets today and what’s coming in the future?

That’s a big question. There are a lot of things going on with order sets, for many reasons. There’s a lot of regulatory and other pressure to implement CPOE systems, so there’s a lot of work effort being focused on order sets.

As you say, they’ve been around for a long time because they help doctors with time and efficiency, and they’ve been around in paper form. But one of the big problems has always been once you get all those orders set out there, how do you maintain them? How do you make sure they are evidence based? How do you make sure they’re driving the right behavior in terms of quality patient care?

Some of the things that are going on right now with order sets include the use of tools to help with all of those things. To help with the complex governance process in your organization, to go through all of the review, the review of the evidence, the review of the order sets, the agreement upon what should be done at that hospital and in that organization, making sure it’s consistent with the hospital’s formulary and the types of tests and drugs they think should be ordered for that condition. Then I’m making sure that gets into the CPOE system and is used by the clinicians at the point of care.

All of that depends upon the processes and tools that an organization has and the culture that an organization has. A lot of it depends upon the capabilities as well of the CPOE system that the hospital happens to use.

It seems like hospitals generally struggle with the whole idea of evidence-based process, like formularies or trying to consolidate their medical devices into the most cost-effective ones. Everybody likes the concept of evidence-based order sets, but hospitals don’t seem to be ready for them yet. Do you think that’s the case?

I don’t know that that’s the case. I think that most hospitals really want to use evidence-based medicine. It’s just complicated to maintain that, to know exactly what’s going on in the literature, to make sure that you keep everything current. I think it’s also complicated sometimes in the culture of an organization to go through the process of review by all the people that need to do that and then get it done in a timely fashion. 

There’s a lot of tools out there to help organizations with that now. I think that some of the regulatory and payment pressures are focusing hospitals in certain areas and certain medical conditions, to make sure they are doing certain things for that care of patients that are consistent with evidence as well.

I think that just about every hospital is focused on evidenced-based medicine, particularly with order sets, at least in some areas. That’s why they’re doing what they’re doing – to provide the best care they can for their patients.

Efforts are being made to put clinical content in the clinical workflows, such as with the Infobutton standard. What changes do you think we’ll see in the next few years to make clinical content more available when it’s needed and to make it more specific to the clinical situation at hand?

I think there are a lot of things happening. A lot of groups that are working on experimenting with getting the right information at the right time. Alerts are popping up all the time when you’ve seen it a hundred times has really been discouraging for some clinicians. They haven’t really done as much as people thought initially they might do.

There are other things that have really been successful, like some things in the background in terms of drug information and drug interactions. drug dosage, and getting the right medications dispensed. Some things have been really successful. I think the work continues to try to figure out how you get the right nugget of information into the clinician’s hand at the time that they are thinking about it and deciding what to do. 

There are a lot of forms of clinical decision support. One of them is an order set. Having the right order set when you’re admitting the patient and you have to be using an order set anyway. Having the right information there that really takes you through the workflow and helps you make the right decisions that’s helpful. Having really smart rules and alerts than can be configured to provide benefit, but not get in a clinician’s way. 

That’s a real hard nut to crack, but a lot of people are working on it. Even having smart documentation, when you’re documenting something and going to the next step of deciding what the next thing to do is, being able to walk you on the right path.

There’s a lot of work going on. The technology is starting to evolve to allow some of that. If an EMR now has the capability of sending out to a clinical decision support system information about the patient that is very specific, then the information sent back can be much more specific and can be more focused right on what the clinician might want to know instead of  having more broad-based alert that might be more of an annoyance than a help. As those things continue to evolve and more and more EMR systems have those capabilities, I think organizations like Wolters Kluwer and others can help provide more focused information right at the right time into that workflow.

We have a group called the Innovation Lab. It’s partnering with several organizations looking at just that. How can we get clinical information right at the right point of care into the workflow of a clinician when they have to be ordering or when they are opening a problem, a record of a patient if that patient isn’t on a critical medication that is called for by virtue of the fact that they have these six conditions and they’re already on these other two drugs? Can there be a really smart alert that says hey, have you thought about this, and maybe a link to the supporting evidence to show the clinician? 

There’s a lot of work going on. I don’t think anyone has solved the problem completely by any means, but it’s really exciting to think that we could help clinicians make decisions at the right time in the point of care.

Going back maybe 20 years ago, you had publishers of journals you put on your shelf, but early electronic order entry systems that didn’t look at clinical content at all. Those systems were happy to just get an order entered and routed correctly. Is there still a lot of work to be done to take all that information that’s in almost limitless supply in research and publications and turn it into something that can be used at the bedside?

I think it’s an almost impossible task for an organization like a healthcare provider organization by themselves to accomplish that. Clinical information is said to be doubling every three to five years, and unfortunately my brain isn’t growing at that rate — just the task of managing all that and sorting through the literature. 

Part of our organization has a group of clinicians on the UpToDate team does that for their product, sorting through hundreds of the journals every month to try to identify the real changes in practice. By partnering with organizations where we can separate the wheat from the chaff and provide the real nuggets of clinical information as to what might really matter in terms of changing practice and then do work to try to figure out how to get that information into the hands of the clinician at the right time in the point of care, it can really help.

There’s so much going on and so many things published to be able to identify, first of all, what has changed? What really matters to my practice or the practice at the hospital? And now that we know that, where are the order sets that matter? How do I update them? Where are all the education pieces that I need for the physician? How are the patient education materials and how do I update them? As we were talking about before, I think maintenance of evidence-based practice is the big thing we need to solve. I think there’s a lot of people working on tools to help organizations with that.

The company’s doing some work to support Meaningful Use requirements. Can you describe that?

Meaningful Use requirements include quite a few different things. In this first phase, you need to be able to be report on certain measures. That requires certain systems in place that you have purchased, and you have to show that you’re using them in a meaningful way. We have a wide variety of products, including one that is a documentation product that helps to document and report some of those measures. In a broader sense, all of our products and other organizations’ products that are working in clinical decision support are trying to help support hospitals in the work they’re doing. 

One of the things that they’re really focused on right now is Meaningful Use and core measures. In all of our product lines from our order sets to our other types of clinical decision support, we try to point out the areas that matter for those things. For instance, in our order sets, we have quality indicators with each order set that show what the CMS measures are or Joint Commission or other kinds of areas that would matter for regulatory organizations for this particular order set or this particular condition. We try to help tie the works that hospitals are doing for things like Meaningful Use into other product lines. 

We are trying to assist organizations with implementation of CPOE systems, which is one of the things that they are working on doing towards that goal by providing the tools to help them come to consensus with their order sets, release their order sets, and then also provide some integration into their CPOE system so they can go live with CPOE and meet their measures of providing orders in the CPOE environment for things like Meaningful Use.

You mentioned that you were involved with ProVation before it was acquired. That’s a product that basically owns the gastroenterology market, a very specialized product. Will the idea of having specific documentation products for specialties continue or will the market push specialists toward standard products whose weaknesses they’ll have to live with?

We started in GI, in gastroenterology, but ProVation MD expands many other specialties for documentation. We have products in cardiology, cath lab, echo, nuclear, and surgical areas such as general surgery, plastic, ENT, eye, OB/GYN, and a variety of other surgical sub-specialties, orthopedics, and pulmonology as well. We span most clinical procedural specialties with ProVation MD.  That’s used in a variety of specialty areas to allow people to document and report on procedures in those areas, including in the cath lab, echo, cardiac, etc.

However, in a more general way, I would say that there are pressures on both sides. There are pressures to try to get one system to do as much as you can, because if you are working on the IT side of a hospital, you don’t want to have thousands and thousands of systems that you have to maintain and integrate and update and keep current with each other.

On the other hand, I think it’s becoming more and more clear that standard EMRs are not going to be the providers of everything for a hospital IT environment in terms of particularly current information and content and sometimes even very specific workflows for clinicians. I do think that there will be partnerships with the EMR systems that are the systems in place that are storing that patient record and information and workflow software providers that can join together to meet the needs of the various clinicians in the various workflows they need to complete.

However, the problem has been integration and ability to pass information back and forth. Also ease of use, in terms of having a provider needing to go from one system to the other. There’s a lot of pressure now on trying to make sure that there’s adequate integration involved and that an end user does not have to know that they’re in one system vs. the other – they can just do their work and then all the information can go to the right system and go to the EMR to be stored and viewed as the patient’s record. I think there’s a lot of work going on there. 

I do not believe that any one system is going to solve all the needs, for many reasons. One is because there is just huge tasks involved with understanding which workflow involves different clinicians and managing all that clinical information that’s happening in all of those clinical specialty areas.

That acquisition of ProVation is interesting, but I’m not sure most people realize how long the list of other Wolters Kluwer acquisitions is. There was also UpToDate, Lexi-Comp, Pharmacy One Source, and even a joint venture in China. What’s the company’s strategy?

The ones you mentioned are all within the Clinical Solutions business unit of Wolters Kluwer Health. That’s the group that is working at the point of care to provide workflow software and content solutions for clinical decision support for healthcare professionals.

We have a variety of products, from providing the answers to the clinicians with a product like UpToDate, providing tools to manage order sets like the Provation Order Sets product, and clinical documentation with ProVation MD. With the acquisition of Pharmacy One Source, also are working in the areas of the workflow of the clinical pharmacist and in surveillance. We now have tools available to help hospitals with real-time surveillance, looking for patients that might have indications that they need something done. For instance, watching for earlier signs of sepsis to make sure that the hospital can intervene in appropriate time and help provide morbidity and mortality associated with that. Many other things as well, including antimicrobial stewardship. 

We also have a lot of drug information products. Lexi-Comp, Facts & Comparisons, and the database of Medi-Span, which does alerts and reminders and drug-drug interactions, etc. for drugs used in the clinical setting. Each of those products represents a form of clinical decision support and help to the hospital environment.

But what we are really working on is looking across them and trying to find ways to do two things at a very high level. One is to integrate those products together in ways that are helpful to our customers that have more than one of them. UpToDate information is embedded inside of order sets, and if you have both products, there are ease of use issues across order sets and UpToDate that help the clinicians and helped the hospitals. We do that with many of our products. We try to integrate, so we have UpToDate patient educational materials inside of ProVation MD and other things such as that.

At the second level, what we’re working on trying to do is to really look at the problems, the current problems that our hospital and clinical customers are having, and say what can we do, not just with one individual product, but maybe with pieces of products and with our expertise from those product lines to bring them together in a new way to try to solve those problems? 

As I mentioned earlier, we have a group called the Innovation Lab at Clinical Solutions that has a steering team that represents the clinicians and informaticists and technical folks across all of those products that we just mentioned. We are a partner with hospital systems to try to solve very specific problems and are taking to the pieces of both content and technology to try to come to bear on problems that hospitals are having in new ways. 

We are working now in the area of mobile devices to help with early detection of sepsis. We are looking at providing, as I said earlier, ways to get nuggets of clinical decision support into a clinician’s hand at the right time and the workflow, which will be in EMR setting, through APIs and other things. We’re really excited about that and have quite a few hospital partners that are working with us to try to solve some of their problems in that way.

The old Internet saying was that “content is king.” Does the content piece get enough recognition when people talk about EMRs and Meaningful Use and how these products will actually deliver the benefit they’re supposed to?

People that are focused on one side or the other tend to have less of an understanding of the technical versus the content side. I believe it’s both. If you don’t have the right content and have the capabilities of understanding all of the changes in clinical practice and sorting through all the literature and making sure you keep your order sets current with evidence-based medicine, then you’re not doing your patients or your organization a service.

On the other hand, if you don’t have am EMR or a CPOE system that allows ease of use for the physician to be able to order something, or even has capabilities of being able to override things and be able to say why and track why are certain things were not ordered, you really can’t provide the best care. You also can’t measure what you’re doing well enough to be able to go back and improve it in a continuous improvement cycle. 

Content is king, because without the content, without knowing what you should do for patients, it’s hard to do it. On the other hand, if you don’t have systems and a workflow on place that makes that easy to use for a clinician and then can track what’s actually been done so you can improve it, then it’s also a really next to impossible as well. Both things have to continue to improve, and the ability to manage the content and get it into the workflow of the technologies is what really it has to happen. There are a lot of things being done towards that goal now, but there’s a lot of work that remains to be done.

Do you have any concluding thoughts?

It’s a really exciting time right now in healthcare IT for many reasons. It’s also a very frustrating time for people on the front lines in healthcare IT. There are so many pressures both currently and coming down the pipe, from switching from ICD-9 to ICD-10 and Meaningful Use and core measures and value- based purchasing and ACO pressures. Trying to manage all that and figure out what to do first and how to best accomplish it and still have systems that are maintainable and manageable in your hospitals is a really overwhelming task. 

There are tons of opportunities. There are tons of ways we can help make things more efficient and improve patient care. There’s just so much going on right now that sometimes it can be a little overwhelming. That gives organizations like mine an opportunity to try to identify what those top priorities are for our customers and try to help solve them in a variety of innovative and unique ways.

News 7/27/12

Top News

Quality Systems Inc. (NextGen) reports Q2 numbers: revenue up 18%, EPS $0.26 vs. $0.32. The company also eliminates future guidance, apparently burned in this case by impending deals that didn’t close by the expected dates. CEO Steven Plochocki blames the drop in net income on fewer higher-margin software system sales. Shares dropped 33% (Nasdaq’s biggest percentage loser of the day) on the news to their lowest price since November 2008, dropping the company’s market cap to under $1 billion. In the conference call, President Scott Decker said the loss of long-term client HMA was caused by HMA’s lack of resources to roll out its product, and said HMA won’t replace NextGen completely but that HMA wasn’t contributing all that much revenue anyway. The company says it will move more work to India to reduce costs. It also predicts that Meaningful Use Stage 2 and ICD-10 will take out a bunch of its competitors. When asked about pressure on hospital-owned practices to move to competitive products, Scott Decker said he wasn’t worried about Cerner, Siemens, or Meditech, but Epic is “a challenge for us like it is for everybody in the market” that “causes a little bit of pain.” Above is a one-year share price chart, with QSII in blue and the S&P 500 in red.

Reader Comments

From Winning: “Re: Microsoft. It will sign now business associate agreements with partners for Azure storage and core services (their cloud offering). That means Microsoft will shoulder some of the burden of ensuring HITECH and HIPAA compliance in the cloud. Hosting costs are high for a startup like us since HIPAA requires the database to be logically separated from the Web server, meaning we need at least two servers. That’s not cheap with .NET/MS SQL. The value proposition from a major player like MS Azure is pretty high. I wonder if we’ll see more of this from other vendors?” I appreciate that update. I would have put in a little plug for Winning’s company to return the favor, but I was running too late to ask if that was OK. The topic might make a good Readers Write if he’s inclined to write one. That’s a nice move by Microsoft.

From Jonathan Grau: “Re: AMIA 2012 Annual Symposium. We’re in Chicago this year from November 3-7.” Jonathan, VP of corporate relations and development for AMIA, keeps me in the loop about their activities. I couldn’t help but notice that five of the seven conference sponsors are also HIStalk sponsors (CAP, FDB, IMO, Philips, and nVoq).

From IT Director: “Re: Cerner downtime. Just so you know, it lasted about six hours … and you didn’t hear it from me.” According to the purported Cerner communication attached, a Cerner network administrator received an error when trying to update DNS records via the management console, so he or she made the change manually and inadvertently deleted a DNS zone while doing so, an unfortunate change that was then replicated to all servers. Anything using that zone was instantly hosed, and the tools needed to fix the problem were also not available because of the error. They had to restore the file from backup and replicate it manually to all the controllers.

From Doc Down: “Re: Cerner downtime. I’m a doc at a Cerner remote hosted site. We got our first e-mail about a ‘performance problem’ at 12:45 p.m. and the downtime was resolved at 5:35 p.m. In between, we got an e-mail that referred to some sort of DNS issue, but it was a bit confusing to understand what actually transpired. We got one message saying it should be fixed by 4 p.m. then another saying it would be fixed by 5 p.m. We have the read-only product for use during downtimes, but that couldn’t be accessed either. We recently moved our inpatient physician documentation to electronic, so reverting to paper with no access to anything recent was a nightmare. Don’t know anything that could have been done any differently on the hospital end, but it would be nice if Cerner would be transparent and describe to organizations and interested users what really happened as it doesn’t inspire much confidence. Unanticipated things do happen, but I’ve personally been unimpressed by the software or support. Though I have met a few topnotch Cerner folks, most seem fixated on selling us new modules, consulting and programming devices, etc.” Downtime is going to happen despite best intentions and known ramifications, but I’d be concerned that the read-only option, which exists solely for that eventuality, didn’t work.

@histalk We had e mail updates from Cerner every 15 minutes.Our production owner called us with updates. Handled well by Cerner.

— Richard Turner (@Therapist38) July 25, 2012

HIStalk Announcements and Requests

This week’s HIStalk Practice includes a statement from former e-MDs CEO Michael Stearns regarding his recent firing. Epic, Allscripts, and eClinicalWorks lead other vendors in the number of ambulatory EHR attestations. ONC says the total cost of ownership of an in-house hosted EMR is less that the SaaS option. A Florida ACO uses Craigslist to recruit physicians and offers up to $100,000 a year in shared savings. Julie McGovern of Practice Wise points out a few considerations for practices moving their applications to the cloud. When you pop over to HIStalk Practice, click on an ad or two because you might find a sponsor offering a solution that will make your world better. And sign up for the e-mail updates because it could be the only way I know you care. Thanks for reading.

On the Jobs Board: Manager Systems Development, Database Administrator, Services Implementation Project Manager.

The HIStalk vital signs consist of measurements that you can actually influence: number of readers, number of e-mail subscribers, and the vitality of reader interaction in the form of comments and news tips. That means that you get to control our electronic destiny, which makes you a pretty powerful force with which to reckon (cue some tears-inducing Sarah McLachlan heartfelt warbling to move you to action). Actions that will stave off our eventual demise include (a) signing up for my spam-free e-mail updates, so you’ll be the first to know when I dig up some incredibly juicy industry gossip or random sophomoric humor that I can’t resist sharing; (b) electronically mate with Inga, Dr. Jayne, and me on Facebook, LinkedIn, and all that truck; (c) peruse the fun Resource Center, where you can search and navigate through a bevy of benevolent sponsors who crave your electronic attentions just as much as I do; (d) use the Consulting RFI Blaster to … well, that one’s pretty self-explanatory; (e) get off your figurative couch and out here on the healthcare front lines with us and participate with your comments, insight, or anonymous tips (e-mail works, but so does the nauseatingly green Rumor Report button glaring spitefully from the right side of the page); and (f) play a few rounds of Sponsor Roulette, scrolling the page and randomly clicking the ads to your left to see where you land, assured that it will be among friends since only the cool companies sponsor HIStalk instead of the boring alternatives. Inga, Dr. Jayne, Sara McLachlan, and I appreciate your participation in our continued non-flatlining. Every day we wake up and the page is still displaying is a good day.

Speaking of the three of us working in healthcare day jobs, Dr. Jayne’s healing talents were required for an encore shift in her local hospital’s ED, meaning she didn’t have time to contribute this time around. I suppose saving lives and all that stuff is a good enough excuse to let her slide this time.

Acquisitions, Funding, Business, and Stock

Compuware releases Q1 numbers: revenue down 2%, EPS $0.05 vs. $0.08, beating consensus earnings expectations of $0.04. Revenue for the company’s Covisint business unit grew 27% to $21 million.

McKesson announces Q1 numbers: revenue up 3%, adjusted EPS $1.55 vs. $1.27, beating expectations of $1.49. Revenue in Technology Solutions was up 4%, with adjusted operating profit of $109 million.

Clinithink secures multi-million dollar investments from Finance Wales and existing investors to fund ongoing technology development and establish the company’s US operation.

Cerner reports Q2 numbers: revenue up 22%, adjusted earnings $0.59 vs. $0.44.

CPSI announces Q2 results: revenue down 6%, EPS $0.75 vs. $0.72.

Facebook’s first earnings report wasn’t so hot, with revenue increasing 32% to meet expectations, but growth was the slowest in 18 months and the company doesn’t appear to be monetizing heavily increasing mobile usage very well. Shares dropped 9% Thursday and are down another 11% in after-hours trading Thursday evening. In the mean time, shares in Facebook-dependent game maker Zynga (FarmVille) continue their toilet orbit after a bleak Q2 earnings report, knocking another 40% off the share price and dragging shares down to 70% less than their December IPO price to the embarrassment of idiotic stock pickers who somehow thought Zynga had a real, sustainable business instead of a hyper-annoying fad with a low barrier to entry.

The CEO of HealthStream says the education and HR technology company may move into related healthcare business such as long-term and behavioral care.

Sales

Cedars-Sinai Health System (CA) chooses Health Care DataWorks to provide a clinical data warehouse and analytics solution.

The Commonwealth of Virginia’s Department of Medical Assistance Services awards HMS a contract to provide a customized Medicaid fraud and abuse detection system.

Norton Healthcare (KY) contracts with CSI Healthcare IT to provide 100 resources for the second wave of its Epic activation.

People

Healthcare analytics company ArborMetrix appoints former Covisint VP Brett Furst as CEO.

The Commonwealth Fund, a private healthcare-focused foundation and think tank, names former National Coordinator David Blumenthal MD its next president, effective January 1, 2013. He is chairman of the organization’s Commission on a High Performance Health System. Blumenthal will replace Karen Davis, who announced previously announced plans to step down at the end of the year.

Luther Nussbaum, retired chairman and CEO of the former First Consulting Group, is elected to the board of consulting firm MedSys Group.

Healthcare billing and payment systems vendor Zepherella names David Bond (A4 Health Systems, Allscripts) as EVP of sales and marketing.

Announcements and Implementations

St. Francis Medical Center (CA) and O’Connor Hospital (CA) go live on iSirona’s device integration solution that connects medical devices to their QuadraMed EMR.

Transitional care provider Remington Medical Resorts (TX) goes live on HealthMEDX Vision at all of its Texas facilities, including rolling out a paperless environment that allows physicians to work from iPhones or iPads.

The new Palomar Medical Center (CA) will open next month, a 288-bed, $956 million “hospital of the future” that has been under construction since December 2007. Space was pre-built to allow expansion to twice the number of beds if needed.

In Australia, New South Wales completes the initial phase of the rollout of TeraMedica’s Evercore imaging exchange in 12 hospitals.

Government and Politics

HIMSS proposes language for inclusion in the Democratic and Republican National Committee party platforms in support of HIT to improve healthcare efficiency, quality, and outcomes:

“In order to improve the quality of healthcare for all Americans while reducing costs, the Party will continue its strong support for the rapid, nationwide adoption of Health Information Technology including electronic health records and secure health information exchange capabilities.”

Other

The Ventura County Board of Supervisors (CA) approves an additional $5.75 million for its $41 million Cerner EHR implementation, which is scheduled to be operational at two county hospitals by July 2013

Compared to physicians, physician assistants, APRNs, and RNs spend more time online for professional purposes, use smartphones more during patient consults, and more frequently access pharma or biotech Websites.

A Milwaukee newspaper article notes that Wisconsin hospitals are charging victims of sexual assault up to $1,200 for the cost of collecting evidence to identify and prosecute their attacker. Sometimes insurance pays, sometimes the hospital knows to bill the government fund that was set up to cover the cost, but in some cases the patient ends up getting stuck with the bill.

A Harvard health economist says that 90% of the country’s economic growth over the past 10 years got sucked up by increased healthcare spending, but the CEO of Marshfield Clinic says at least some parts of the Affordable Care Act (though he declined to guess which ones, but IT is mentioned) will eventually slow the increase. As I always say, everybody’s for reducing excess costs as long as they don’t personally have to take a pay cut.

Weird News Andy found this story, in which Mayo Clinic apparently fired a pediatrician who wrote a Arabic blog post advocating female circumcision. Mayo says female genital mutilation not only has no medical justification and thus can’t be performed in its facilities, but is also considered a felony-level child abuse crime in the US.

The University of Missouri School of Medicine will use a $13.3 million HHS grant to create electronic dashboards that will allow physicians to get a quick read on how individual patients or groups of patients with a single condition are being managed. The project has been christened LIGHT².

Kiplinger’s Personal Finance ranks Madison, WI as the best city for young adults, with UW-Madison and Epic helping push it to the top. Rounding out the Top 5 were Austin, Boston, Washington DC, and Denver.

It really bugs me when PR-seeking hospitals decide to magnanimously waive their bloated, cost-shifted charges for high-profile victims. Three Colorado hospitals say they won’t charge victims of the Dark Knight shootings, some of whom had no medical insurance, for their care. I’m all for generosity, but I like it better then it’s less self-serving and selective. I’d rather they take it out of their executive salaries instead of just pushing the cost onto those who have insurance and less-publicized medical problems. Everybody struggles to pay for their healthcare, and fuzzy accounting like this isn’t helping.

In Canada, Eastern Health fires a nurse for inappropriately accessing and sharing the records of 122 patients. She’s the fifth employee the hospital has terminated for privacy violations so far this year.

Some bored newspaper folks apparently decide to check whether former HHS Secretary (and former lobbyist and current Senate candidate) Tommy Thompson ever had a VeriChip implanted in his arm as he said he would in 2005 when he joined that company’s board. Answer: no. His reason: hospitals didn’t buy the technology to read the chips, so the company tanked. He sure was pitching it hard on Squawk Box back in the day, but he’s a politician after all.

Sponsor Updates

• Software Testing Solutions will have an active presence at the Sunquest User Group conference August 6-10 in Scottsdale, AZ. STS will demo Version 4 of its Test Manager product; CEO Jennifer Lyle (above as your HIStalkapalooza co-host in Las Vegas) will conduct an automated testing cost justification session on August 8; and the company will offer its popular Breakfast with the Puppies event on Thursday to collect donations (which the company will match) for Home Fur Good, a Scottsdale-based no-kill shelter.
• Santa Rosa Consulting is named to Modern Healthcare’s Best Places to Work in Healthcare for 2012.
• Trustwave and Microsoft partner to support additional Web server platforms, including Microsoft’s Internet Information Services and Nginx.
• Certify Data Systems earnsMajor Player distinction in IDC Health Insights’ HIE vendor assessments report.
• Consulting firm ESD (your gracious HIStalkapalooza sponsor last time) earns a Healthcare’s Hottest award recognizing fast-growing established healthcare companies. ESD also was named by Modern Healthcare as one of the Best Places to Work in Healthcare for 2012, the second year in a row.
• Prognosis participates in this week’s Texas Healthcare Trustees Annual Conference in San Antonio.
• NextGate’s continued growth requires a second move into larger space in Monrovia, PA.
• The Huntzinger Management Group reports significant growth in 2012 as it helps organizations address regulatory compliance issues, changing reimbursement models, and IT demands.
• MedAssets heads to San Antonio next month for the AHRMM 12th Annual Conference..
• Wellcentive introduces Provider Benchmarking capabilities within its Advance Outcomes Manager solution.
• Macadamian CEO Frederic Boulanger is selected as a Quebec finalist for Ernst & Young’s 2012 Entrepreneur of the Year in the Technology and Communications category.
• FTI Consulting signs a five-year licensing agreement with Streamline Health for its OpportunityAnyWare business analytics and patient financial services solutions.
• NextGen Healthcare selects Health Language to provide standardized terminologies within its ambulatory product suite.
• Culbert Healthcare Solutions publishes a white paper on centralizing patient access and revenue cycle functions.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Advisory Panel: Wrap-Up 7/25/12

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

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

Budget Expectations for the Next Fiscal Year – Which Initiatives Will Get Funding?

• I think HIE-like or lite type of activities will begin to take place requiring new funding in this area. The scope of engagements / integration will be limited to only strategic business and patient care partners in order to fully understand the care benefits, risks, value to our organization in investing and sharing more patient care data than what we already do. MU stage 2 efforts will require additional funding.
• Big data (clinical and business analytics), IT security, support for ICD-10 and MU Stage 2, EHR optimization and rollout to affiliates.
• Disaster recovery / business continuity will get significant funding. High availability is part of that, so it will be infrastructure spend.
• Decreased:  anything discretionary. Increased (or at least not cut):  anything required to meet MU (1 or 2).
• Data security and protection will require significant funding, as will software upgrades for MU2 and ICD-10. Capital will go to increased virtualization, significant expansion of wireless capability for clinical equipment, and a shift from COWs to fixed (multi-purpose?) workstations in patient rooms.
• We will probably be spending more than average on contracted help next year. We in the midst of replacing core systems and need help. The next capital wave for us will be another year down the road when we have to buy some niche system to address an issue in the core system that isn’t working as we thought / sales demonstrated.
• Because of the large number of new software applications we installed this year, we will see a significant increase in maintenance contracts in our operational budget. Capital budget requests for next year include a new OR system, additional pieces for MU Stage 2, and disaster recovery.
• Disaster recovery and data warehousing seem to be increasing for us.
• Optimization, quality-improvement related IT projects that enhance our EMR investment. With Meaningful Use, we’ve just laid the foundation. Much opportunity to optimize the EMR around specific quality goals. Beginning to look beyond the EMR towards revenue cycle solutions. How can we better integrate inpatient, outpatient revenue cycle (along with home care) within an IDN and see value from clinical-revenue cycle alignment?
• We will be embarking in two main areas. We will be piloting an ACO, so that means a significant investment in data exchange, storage, and portal access. We will also be investing in a enterprise data warehouse.
• Small niche projects. After paying for Epic, that’s all the money we got.
• We’ll be spending money on VDI and a Windows 7 upgrade in the latter half of 12 and into 13. We’ll be deploying a lot more PCs (almost all VDI) in patient rooms and adjoining clinical areas. And virtualizing everything in the data center that we can. Other than that, it’s all Epic, all the time.
• BI/analytics: increased. HIE: increased. ICD 10: more. All else: less.
• As far as our application projects, our budget requests and approvals will be driven by MU, namely patient portals and quality reporting solutions. We’ve attained Stage 1 and need to stay on course. I’d like to say ICD-10 was going to be a priority this coming year, but the delays have caused folks to take their eye off the ball on this one for now. Our technology requests will be weighted toward technology refreshes that have been neglected over the last few years to free up dollars for our EHR and MU initiatives.
• Infrastructure will be a slight uptick due to our acquiring practices and hospitals. So may staffing. Coming off of an Epic install, the CFO does not want to entertain too much in IT capital. BI may also get funded.
• We are focusing on outpatient MU. Next year will probably be a retrenchment year, focusing on optimization and backlogged maintenance. 
• Increasing funding: analytics, implementation of decision support. Capital budget requests: platform to integrate physician mobile devices to EMR, integration of hospital medical devices to EMR.
• Continued emphasis  on funding data sharing around ACOs, medical homes, continued rollout of advanced clinical systems, and keeping up with Meaningful Use. More emphasis on eliminating redundant functionality and standardizing applications.
• We have a big increase of completion of CPOM (we use "M" for "management" instead of "E" for "entry", as anyone can enter orders, but only docs/APs can manage them) and our custom physician documentation and inpatient problem list tools which docs are really liking. Other increases: HIE linkages to additional in-house system and to other HIEs, big data systems in support of accountable care. FY14: barcoding, optimization. Decreased: legacy systems,ICD-10 (because I predict that either CMS is going to make it optional – a real mess if this happens – or Congress will legislate against it).
• I don’t think we will see a decrease in IT spending, but a decrease in overall spending to try and cut costs. For example, less money for clinical support staff (e.g. RNs, medical assistants), especially as HIT starts to automate their jobs. More funding for quality, decision support, analytics, BI. Hopefully balanced by more revenue from gain sharing and other value-based reimbursement supported by and proven by  HIT. If not next year, coming soon.

Good Experiences with Vendors

• Iatric is one of the vendors that provide “clothes” for our “pig” (Meditech Magic). They have been a wonderful vendor, though at the moment they are a little stretched and having difficulty delivering on a couple of their applications. They have a proven track record and I believe that they will deliver as promised.
• eClinicalWorks has a good product and their support has improved, but the communication barriers are still serious.
• We recently has an engagement with Encore. They came in here and did a Meaningful Use assessment, focused on the quality components. They were thorough, very professional, and left us with a very clear list of items to address with a full understanding of what we need to do to address them. It was a great engagement and they are a very strong organization.
• Working with Iatric Systems and Intuitive Technical Solutions on interface development. Both firms doing well.
• I want to suggest that other vendors take Voalte’s lead and put a “contact us” button directly in their application. The Voalte people did that as part of product development with our team. They also responded by text message back to the users about their individual suggestions as they came in. As a vendor, you may not be able to handle the volume of suggestions that come in from every individual user point, but I know our IT department would appreciate a way to get direct feedback from users from a “we care” button in the application.
• If I did not mention Zanett, I should have. We use them for PeopleSoft help and they are quite good – knowledge, price, and flexibility.
• Allscripts. Trying hard to provide a better medication / orders reconciliation system. They showed an understanding that it really does need significant improvement. 

Bad Experiences with Vendors

• Meditech still doesn’t get it. Their recent Physician Forum offered physician representatives “choices” such as “which is better, A or B”, where the real best choice was “C”, neither of the above. Specifics to that were, “Our existing lab display is hard coded to have oldest displayed on left, newest result on right; in a new report for one thing (only), we are considering letting the user chose to have it oldest on the right, newest on left next to the label. Which is better?” Correct choice (not offered), is to let user pick left>right or right>left chronology, not hard code it. Usability (and safety) can be addressed with icography, user-centered design, etc. Many other examples exist.
• Siemens. New physician documentation application is another (separate) application, won’t pull data from (existing) nursing documentation into templates, users cannot create/edit templates for another year, requires separate user IDs that must be synchronized with the three other separate Siemens apps (pharmacy, Soarian, med rec).

Small or Little-Known Vendors

Aceso

“We contracted with Aceso Patient Interactive solution as part of our Patient Engagement initiative. It’s inpatient-focused initially and uses the HDTV in the room.  We have linked it to the Epic EHR so the system knows all the problems with a particular patient and can push the appropriate patent education to the bedside. For example, if the patient had a hip replacement but also has diabetes, Aceso system knows to push education on both conditions. Patients can also manage their own pain assessments through the system. The plan is to extend to the home system through our patient portal. This also satisfies a stage 2 MU requirement.”

ExitCare

Isabel

“Isabel is a small/little-known vendor with a nice product and professional support.”

Philips eICU

“The Visicu e-ICU division of Philips is still relatively small and still relatively unknown. Philips is clearly not small and unknown, but the e-ICU group is — Visicu out of Baltimore. Very cool product, great ROI, great success stories with customers, big positive impact on patient care and quality of care.”

Tableau

“I use Tableau (data visualization software) and love how easy it is to work with and management likes how it presents complicated information in an easy fashion.”

News 7/25/12

Top News

@Erblove Our apologies for the inconvenience today. The downtime should be resolved at this point.

— Cerner Corporation (@Cerner) July 23, 2012

Cerner had an apparently significant disruption of its remote hosting service on Monday, leading to extended downtime for clients all over the country (and possibly outside of the country as well, according to some reports.) Information is hard to come by, so feel free to leave your comments if your organization was affected. Would you do anything differently next time in terms of preparation or downtime procedure?

Reader Comments

From Mr. Allscripts: “Re: Surescripts outage. I have more info.” Mr. A included a document suggesting that the Surescripts network had connectivity problems over about an hour last Thursday, during which time prescription routing and medication history transactions may have failed.

Thank you Cerner for being down all day. Just how I like to start my week…with the computer system crashing for all of NorCal

— Avinesh Raman (@UhVeeNesh) July 23, 2012

@histalk we have not charted any pts today. Not acceptable from a health care leader.

— scott newcomb (@wsnewcomb) July 23, 2012

From Kaplan: “Re: Cerner. Remote hosting is down – it’s all over Twitter.” Apparently true, but I got just one reply to my Twitter inquiry of affected users for more information. Judging from the timing of some of the tweets, it looks like it was down for at least four hours. You can imagine the disruption of having your entire hospital go offline at once without warning, but at least it’s someone else’s problem as the IT folks sit and wait along with their users. I’d want an explanation, of course, and hopefully those affected were smart enough to have put a downtime penalty clause in their agreements.

From Mister X: “Re: Cerner downtime. Communication was an issue during the downtime as Cerner’s support sites was down as well. Cerner unable to give an ETA on when systems would be back up. Some sites were given word of possible times, but other sites were left in the dark with no direction. Some sites only knew they were back up when staff started logging back into systems. Issue appears to have something to do with DNS entries being deleted across RHO network  and possible Active Directory corruption. Outage was across all North America clients as well as some international clients.” I’ve lived through a lot of downtime it’s the same story as in this case. You don’t know when the systems will come back up until right before they do in most cases – 90% of the time required is diagnosis, not treatment. Users always want to know “how much longer” and you as the IT organization hate to tell them, “Beats me” even though that’s usually the case. Not to mention that when resources are stretched trying to get the problem fixed, there’s nobody sitting around to shoot the breeze with users wondering how it’s going (the user-to-geek ratio is about 1,000 to one, and you haven’t lived until you kill your pager battery within about 15 minutes with the constant pages demanding an individual briefing on what’s going on.)  And I can also say from experience that the worst problem isn’t server or power failure since those systems are backed up – it’s something like this, where Active Directory gets trashed, your name server dies, or you lose IP connectivity inside your data center. It takes forever to diagnose and fix.

From HERSS: “Re: mHealth Summit. I got an e-mail from HIMSS saying a certain company ‘will make their first appearance at the 2012 mHealth Summit as a Platinum sponsor and as such will have a significant role in the summit program and a key presence on the exhibit floor.’ I head to read twice to make sure this wasn’t from the basement sweatshop World Healthcare Congress sales reps and their over-the-top spamming. HIMSS has dropped to a new and very disturbing low. I would never have come out and said that a vendor will play a significant role in the program – that hardly inspires me to spend my hard-earned money for a conference pass. ‘A key presence on the exhibit hall floor’ means the vendor paid their prostitution dues to the pimp and are being properly rewarded for it.” Most of the HIMSS e-mails I get these days are just another form of vendor spam, pitching products, Webinars, or urging political action to interfere with the free market in healthcare IT. To be honest, I’ve twit filtered them into oblivion. When HIMSS speaks, it’s like a bad ventriloquist act – it’s easy to spot the arm up their backside. I really think they mean well and they have some honorable and dedicated people working there, but like a politician pandering to special interests, they lost their connection to the average provider once the dollar signs filled their eyes.

Nurses bragging on doctors, & doctors bragging on nurses. One doctor had no time to wait for an OR & began surgery in middle of the ER…

— Jacob Tamme (@JacobTamme) July 22, 2012

From Colorado Health Exec: “Re: Aurora shootings. While I was not involved, I want to extend my thanks to the healthcare professionals that did a great job in the early hours of Friday morning.  There were many heroes that day, from people in the theater, to the police, firefighters, and last but not least the nurses and doctors that treated the patients injured and consoled families trying to make sense of a senseless act. My thoughts and prayers go out to the victims and their families. Say what you want about the politics of healthcare these days, but professionals like these are the reason I am proud to be in healthcare.”  The above is from Denver Broncos tight end Jacob Tamme, who continues to tweet about being moved by his ongoing visits to Swedish Medical Center to visit with hospitalized survivors.

HIStalk Announcements and Requests

Welcome to new HIStalk Gold Sponsor CIC Advisory. Their tagline is “trusted informatics experts” and you probably really would trust them – the principals are Cynthia Davis, RN, FACHE (who’s been a CIO and has led several EHR/clinical transformation projects) and Marcy Stoots, MS, RN-BC (who has an interesting history of being an ICU nurse, wrote her master’s paper on data mining, is finishing a DNP in informatics, and led the EHR implementation at BayCare and other places). They’ve also just co-authored a HIMSS book called A Guide to EHR Adoption: Implementation Through Organizational Transformation. Testimonials are here. I was impressed that both ladies are members of the HIStalk Fan Club on LinkedIn, which always scores points with me. If you need help with EHR projects, informatics issues, Meaningful Use, business intelligence, or strategic planning, Cynthia and Marcy would be happy to speak to you. Thanks to CIC Advisory for supporting HIStalk.

It’s not quite as pervasive as squeezing “sort of” into every sentence, but what’s with everybody suddenly leading off a thought with the word “so” like they’re telling a story in a bar? You ask someone when they’ll finished a particular task and you get, “So we’re working on the documentation …” I’m also noticing that the young folks (who raise their inflection to a painfully high pitch at the end of every sentence as though they’re asking a question even when they aren’t) are also prone to sticking a confusing “no” in front of their “yeah” when excited. Example: “I just heard this great new band …” and they burst in with, “No – yeah, they were dope.” Curious.

I was thinking about the “deceased” flag in everybody’s EMR system after reading a story about a dead patient receiving an appointment in the mail in the UK. I assume that field populated only if the patient dies while admitted and someone keys in the discharge disposition. For research and population management purposes, it would be nice to know whether the patient is actually still alive, not just whether they went home that way last time from your own facility. If there was a national patient identifier, state and national death records could update everybody’s system. Seems pretty basic if we’re really going to try to account for patients between episodes. Or maybe somebody’s already doing this. Seems pretty basic: “Is this patient still alive?” “All I know is that he was the last time he came to the office.” Small-town doctors used to peruse the newspaper obituaries to send condolences and archive charts when appropriate.

Acquisitions, Funding, Business, and Stock

The senior management team of Quality Systems (NextGen) sends shareholders a letter voicing their strong support for the QSI board nominees. This move follows actions by dissident director and board member Ahmed Hussein, who is attempting to gain control of the board by nominating his own director candidates. The letter urges shareholders to support the QSI board nominees at next month’s annual meeting.

The FTC grants early termination of the waiting period for the acquisition of M*Modal by One Equity Partners, clearing the way for the deal to close.

HealthStream announces Q2 numbers, which were in line with estimates: revenues up 23% to $25.8 million; net income up 33% to $2.4 million.

Philips reports Q2 numbers, with earnings beating expectations and healthcare leading the way with a 7% jump in sales.

Apple misses Q2 expectations, turning in its second quarterly miss in year and setting lower guidance for the next quarter. iPhone sales were way down, which could be attributed to the lack of the iPhone 5 rollout, a struggling world economy, or impatient users moving to hotter new phones like the Samsung Galaxy S3.

Sales

Providence Health & Services will deploy Nuance’s Dragon Medical 360 voice recognition technology across its 250 clinics and 27 hospitals, integrating it with Epic for the health system’s 8,000 clinicians.

Centura Health (CO) selects the Explorys platform and Enterprise Performance Management applications for their ACO and PCMH initiatives.

Jordan Hospital (MA) selects dbMotion’s interoperability platform to connect multiple acute and ambulatory HIT systems throughout its local medical community.

Pomona Valley Hospital Medical Center (CA) selects ProVation Order Sets.

People

The Missouri Health Connection names Mary Kasal (Cornerstone Advisors) president and CEO of its statewide health information network.

HIT Application Solutions hires Richard Crook (onFocus Healthcare) as VP of consulting services.

Rodney M. Hamilton, MD (PointClear Solutions) joins ICA as its CMIO.

Floyd Medical Center (GA) names Jeffrey D. Buda (WellStar) as CIO.

Announcements and Implementations

The SE Michigan HIE announces that it has completed all milestones to provide its e-disability claim filing service to the Social Security Administration, which will accelerate the processing of disability claims from 457 days by paper to six hours electronically.

Canada’s Eastern Health goes live with NexJ’s Disease Screening solution for its Colorectal Screening Information and Reporting System project.

Military robot maker iRobot, worried about losing profits due to reduced military spending, decides the time is right to jump into the healthcare market with a new product in a partnership with InTouch Health. iRobot, which also makes the Roomba room vacuum cleaner, says the head of its new robot head is a moveable monitor that can be controlled, allowing the remote physician to look around the room. It comes with a stethoscope that it doesn’t know how to use, which makes it very doctor-like if you’re talking about psychiatrists, dermatologists, and physician executives who haven’t actually listened to anybody’s chest since residency, but who strut around in a white coat and draped stethoscope so they look more doctorly.

The chief administrative officer of Northwest Imaging (MT) develops a shift-budding app that he plans to complete and commercialize.

Cleveland Clinic and The Ohio State University announce a partnership to commercialize products that include medical software.

Technology

HELO announces its new TabletStrap PRO, a rotating leather hand strap for 10-inch tablets. Looks pretty cool for $60. Holding the iPad is awkward for me, especially when walking and poking at it, and this looks like it would be more comfortable and secure.

Other

A reader last week asked if we were aware of updated MU attestation data by vendor. As it turns out, CMS published new information last week that includes details through the end of May. I used Excel to play with the numbers a bit, but a more robust reporting tool would probably be more efficient. EHRs by Epic, CPSI, Cerner, and Meditech were the most widely used products by attesting hospitals, which really isn’t much of a surprise. If you are interested in ambulatory EHRs, I created a similar chart on HIStalk Practice showing EP attestations by vendor, with Epic, Allscripts, and eClinicalWorks leading the pack.

Cerner partners with the city of Nevada, MO to focus on creating a culture of health in the community through education, incentives, infrastructure, and partnership with local employers and community organizations. Cerner will also deploy its CommunityWorks critical access clinical suite at Nevada Regional Medical Center.

AHRQ issues an RFI pertaining to quality measures enabled by healthcare IT.

Sponsor Updates

• Stockell Healthcare Insight client Cooper Green Mercy Hospital earns $2.1 million for meeting Alabama State Medicaid’s EHR adoption, implementation, and use requirements.
• A Calgary newspaper highlights TELUS Health and its remote patient monitoring tools.
• MED3OOO’s chief medical executive, Paul McLeod, MD tackles the question of bundled payments in the company’s July newsletter.
• Orion Health HIE is named to the Leader category in IDC’s MarketScape Vendor Assessment report.
• Holon Solutions will install its CollaborNet interoperability solution at George Tech’s Interoperability and Integration Innovation Lab.
• Aspen Advisors produces a white paper on assisting Frederick Regional Health System (MD) develop a business intelligence strategy.
• Hayes Management Consulting offers a free white paper on patient portal design and implementation.
• Over the last 15 months, Emdeon has boosted its employee count by 300 as a result of acquisitions and organic growth.
• Informatica Corporation joins the Google Cloud Platform Partner Program as a Technology Partner.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

EHR Design Talk with Dr. Rick 7/23/12

Pane Management — Part 2

The human visual system evolved over tens of millions of years to help our ancestors keep track of and interact with real objects in the physical world. To the extent that an EHR user interface design can harness our finely honed visual-spatial capabilities, using it will be intuitive and nearly effortless, even though the "space" we are navigating is that of data and the "objects" we are manipulating are abstract concepts.

Unless acted upon, objects in our physical world don’t move around, get larger or smaller, or change their orientation in relation to other objects. The human visual system "understands" these properties of the physical world. We are very good at constructing mental maps of what we see and using those maps to keep track of how objects are organized in space.

Unfortunately, graphical user interface (GUI) designs are not bound by the laws of physics and the constraints of the physical world. When we manipulate one object on the screen, other screen objects, for no apparent reason, can disappear and suddenly re-appear in different locations or radically change their shape and orientation.

While we might enjoy an altered set of physical rules as part of the challenge of playing a video game, it would be disconcerting, to say the least, to encounter such behavior in an EHR user interface.

Consider the EHR design below, by a well-known healthcare software toolkit developer.

Above is the physician’s home screen for a particular patient. Six panes are used to display six categories of patient data — Most Recent Activities, Medications, Patient Charts, Risks, Lifestyle, and Current Care. For clarity, I have enlarged the font size and drawn red boxes around the title bar of each pane.

Each pane is assigned to a particular location on the screen. One at a time, each pane can be expanded and then contracted by using the mouse cursor to click on the "maximize" button at the far right of its title bar (see Risks pane above).

So far so good. But look at what happens to the other panes below when I do expand one pane, such as the Risks pane (purple arrow). For clarity, I have significantly shortened the horizontal span of the screen in the next two figures:

When I expand the Risks pane, all the other panes close so that just their title bars are displayed. Worse, they all change their position, size, and orientation. The Most Recent Activities pane (red arrow) and the Medications and Patient Charts panes (blue arrows) are now oriented vertically along the far left of the screen. The Most Recent Activities pane is twice the width of the others.

The Lifestyle and Current Care panes (yellow arrows) maintain their horizontal orientation and relative position, but have been shifted to the bottom of the screen and stretch along its entire extent.

If I need to expand another pane, such as the Medications pane (indicated by the blue arrow below), all the other panes again change their position, size, and orientation:

With the Medications pane expanded, the Most Recent Activities pane (red arrow) is now oriented horizontally instead of vertically and extends along the entire top of the screen.

The Patient Charts pane (bottom blue arrow) keeps its vertical orientation, but now is displayed on the right side of screen, elongated to span the entire screen height. The Lifestyle and Current Care panes (yellow arrows) change from horizontal to vertical orientation as does the contracted Risks pane (purple arrow). In addition, the Lifestyle pane has been stretched vertically.

In fact, whenever any pane is expanded, the other, non-expanded panes somewhat arbitrarily change their position, size, and orientation in this way. This is a poor mapping. It doesn’t correspond to our mental model of the physical world. It doesn’t take advantage of our highly evolved ability to organize objects in visual space.

Instead of the design above, why not use a small overview map for orientation and navigation, as in the figure below?

This is a more natural mapping. The positions of the six panes in this small overview map correspond to those of the home screen (first figure) and those positions remain constant regardless of which pane is expanded. Furthermore, this overview map (overlaid below, for comparison, in the lower right corner of the expanded Risks pane) takes up less than 3% of the screen area, whereas the vendor’s design (outlined by the yellow border below) uses almost 20%:

It’s not that physicians and other users can’t work with problematic EHR interfaces such as this one. Humans are remarkably adaptable and flexible, but it requires cognitive effort. It’s not just the extra second or so that it takes to find a pane in its new location. That’s the least of it.

The real problem is that, unlike computers, humans have extremely limited working memory. Having to deal with the shifting location, size, and orientation of data objects is disorienting.

Whenever we use a slot in our visual working memory for these kinds of tasks, we can no longer use that slot for clinically relevant information. It’s easy to underestimate how much this kind of EHR interface can interfere with our ability to make sense of complex patient data in the clinical setting.

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

Curbside Consult with Dr. Jayne 7/23/12

Last week was the first in a series of pieces about vendors using physicians and other clinical experts in design, implementation, and support. I mentioned that some vendors were awfully quiet, which seemed to shake loose some additional responses. As one of the first folks to reply to the original challenge, HIStalk reader Dr. Lyle sent a few thoughts:

I’ve actually spent a long time balancing clinical care and product development (and have been at various levels, from actual programmer to high-level vision guy), but a few key things always come to mind:  Don’t just ask what docs want – observe them and their workflows to see what they really need. No matter where you start, you will need to evolve, so keep a system in place for quick iterations to get to a better product. And as you implied, even if you have a doctor who can bridge that gap between clinical and IT, the vendors rarely use them that way. I have been medical director and consultant to a number of EMR and IT companies over the years and I finally grew tired of trying to explain things and then watch a product get twisted by IT and marketing to a point where it was no longer usable. I started a new company last year where the core team is me, a human factors engineering expert, and an IT guy. We think that threesome is what it takes to make great healthcare software. We are focusing on building physician efficiency software tools which integrate with EMRs to help automate and task-shift work. We had a nice writeup and I blogged a bit more about it. It’s been fun and quite an experience to move from the idea to building to launching to actually seeing a vision in place. Our first client found that our software cuts their doctor’s refill workload by over 50%, saving them 15-30 minutes a day. Finally, HIT which makes life easier for docs!

What Lyle says about observing physicians to see what they need is so true. I’ve found that clinicians can rarely articulate their workflows in a way that matches exactly what they actually do (except for surgeons, who are usually spot-on) so asking them often misses larger pieces of the puzzle.

I received a nice response from HIStalk sponsor Iatric Systems with a thorough write-up of its Physician Design Team, which was created to develop its IatriCare and OrderEase solutions. They win the prize for accompanying their submission with professional head shots, which I know always makes Inga and Mr. H happy. They also get points for showing that they actually read Curbside Consult:

Iatric Systems’ Physician Design Team is made up of physicians, nurses, and programmers. The providers on our team have years of clinical experience. For example, Suresh Nekuri MD is the medical director and a practicing hospitalist at Roane Medical Center (part of Covenant Health) in Knoxville, TN. He participated in the implementation of CPOE and the development of order sets for all eight Covenant hospitals. Michelle Schneider, a registered nurse on the team, has clinical experience in cardiac and intensive care. She worked for 14 years in a healthcare system that uses Meditech before joining Iatric Systems. The team’s focus was to design a CPOE solution that streamlines physician workflow so doctors can provide quality care to patients in less time.

Dr. Jayne, you indicated priority placement of postings would be given to companies with witty submissions, but it turns out there’s nothing fun or witty about our team’s development process; it was all business! Since members of the team had worked with deficient CPOE systems before, there was a mutual intensity, a real motivation to create an exemplary solution. Michelle Schneider confessed to being a taskmaster in design team meetings. She said, “We had new software developments to show in every meeting, and we needed to get the team’s feedback. So for example, if a meeting lasted 60 minutes, 56 of those were intense.”

Members of the team brought a diverse wealth of knowledge to the table, ranging from emergency department and inpatient experience, to skills that provided outpatient and private practice perspectives. So the team was able to focus on development of a solution that accommodates best practices while keeping in mind personal user preferences, too. Nurses and programmers on our team are full-time Iatric Systems employees, and they remain intimately involved in implementation and support. Because we choose physicians who are practicing providers, we employ them in consultative arrangements.

Since the initial development phase is over, the vast majority of enhancement feedback we receive now comes to us directly from physicians and clinical IT staff at hospitals that use IatriCare and OrderEase. But we retain the physicians on our Physician Design Team as needed. In fact, Dr. Nekuri joined Iatric Systems this month at the 2012 International Medical User Software Exchange (MUSE) Conference in Orlando, speaking with customers and participating in MUSE’s Physician Summit, where he and four other physicians discussed a variety of CPOE topics including standardization, physician engagement, training, support, order sets, policies and more. We are committed to quality patient care and user satisfaction, and we believe our Physician Design Team configuration has served us well in reaching those goals. One might sum it up by reiterating your father’s mantra, “If a job is worth doing, it’s worth doing well.”

I did receive a couple of e-mails from people who seemed to not read the request I originally posed. Just citing the number of full-time physicians on your staff wasn’t what I was after. There was also one addressed to “Diane” that sort of grazed the issue. If I haven’t yet replied to you, you might want to check your Sent Items folder then edit and resend.

E-mail Dr. Jayne.