Dr. Sam 6/18/12

A Key Missing Element of EHRs

Nurses play a key — if not crucial — role in successful hospital EHR implementations.

• They are the first people that frustrated physicians complain to and often have to deal with borderline or actual abusive commentary or language emanating from an angry physician.
• They are often the initial super-users who can show physicians how to navigate through specified workflows that they may not have absorbed during EHR training (if they attended training sessions at all).
• They often have to enter orders or deal with verbal orders given by a physician who cannot (or does not want to) enter orders by Computerized Provider Order Entry processes (CPOE – please note use of the term “Provider” and not “Physician,” which is the true appropriate use of the acronym CPOE.)
• They are often the first users in the go-live schedules for clinical documentation.

In spite of their key role in patient care, by tradition (in both paper and electronic worlds), their clinical notes are almost universally unread by physicians. In spite of being the caregivers who spend far more time at the bedside than any other clinicians, their notes are either ignored, or at best casually reviewed by physicians.

As a result, both the paper and electronic environments are often replete with documentation contradictions with inaccurate information entered by either the physician or the nurse, or with information that conflicts with patient status. After cataract surgery, a nurse might enter “Pupils Equally Round and Reactive to Light and Accommodation (PERRLA) when one pupil is pharmacologically dilated or constricted, or a physician might document “Patient fully ambulatory and stable” when the patient is in fact unable to get out of bed or has had fluctuating vital signs. The number of possible conflicting entries is both unlimited and endemic.

This is where standard vocabulary becomes as important as accurate clinical observations. An EHR functionality that has been lacking since the early years of clinical information system design has been the ability to cross reference nursing and physician clinical documentation notes and to generate alerts when contradictions are present. This is not only of essential importance to patient care, but to reducing vulnerability to medical liability.

Sam Bierstock, MD, BSEE is the founder of Champions in Healthcare, a widely-published author, and a popular featured speaker on issues at the forefront of the healthcare industry.

Curbside Consult with Dr. Jayne 6/18/12

Yesterday was Father’s Day. I hope all the dads out there were able to spend time with their loved ones.

This is the first time in many years that I wasn’t able to spend it with my dad. I knew my summer schedule would be quirky, so I made a point of getting back to my roots a couple of weeks ago.

My dad always has a way of reminding me that no matter how hard I think I’m working, there’s always more work to be done. Nothing drives that home like spending time on a farm. In addition to having the opportunity to do lots of “farm things” (aka “work”) the best thing about being on the farm is that cell service is spotty. It forces you to spend time in the moment and focus on concrete tasks. I spent some quality hours behind the wheel of a tractor, which is always good for reflective thinking.

Everything on a farm is about cause and effect. Preventive maintenance is key. In a lot of ways, it reminds me of healthcare. (Farming also reminds me of healthcare in that I’ve learned I can handle anything as long as I have gloves on, but that’s a story for another day.). When you neglect something on a farm, it almost always comes back to haunt you. It’s important to pay attention and do the right thing the first time. Not just because someone told you to do it, but because it’s the right thing to do.

Doing the right thing is good for the land, your neighbors, and the community. You don’t do it because the government mandated it, but because you should.

Another key piece of learning on the farm is that when something needs to be done, everyone needs to pitch in. I check my MD at the door (well, actually when I turn off the paved road onto the gravel road) because higher education doesn’t exempt anyone from brush hogging, hauling wood, or any number of exciting activities. It does guarantee though that you’re the first person approached when there is a deer tick that needs to be removed.

One of my dad’s mantras is that if a job is worth doing, it’s worth doing well. Anything less than your full effort is unsatisfactory. I see a lot of people in healthcare IT that look like they’re just going through the motions, forgetting that we have people’s lives at stake. I try my best to model that work ethic for my team and to encourage them to practice it as well.

My dad also taught me that when things go wrong, the best thing to do is to stop, get your wits about you, figure it out, and fix it. And if you can’t fix it, at least come up with a solution that doesn’t make it worse while you find someone smarter to help you fix it.

Whether it’s the hydraulic line on the front-loader that decides to spray fluid all over you or whether it’s a complex laboratory interface that suddenly spews data where it doesn’t belong, neither overreacting nor being paralyzed by fear leads to a good outcome. I know about both of these first hand, and both require teamwork and careful thought to get things flowing back where they should.

Most days on the farm leave me dirty, tired, and generally achy. But there’s nothing quite like crashing in a lawn chair under a 70-year-old tree and watching the sun set over the fields. No matter how fast technology moves, when ICD-10 gets implemented, or what the Supreme Court decides to do, the corn’s going to keep growing. In the morning, there will still be plenty of work for everyone.

Can you name the ideals of 4-H? E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 6/18/12

From Pathological: “Re: Epic. How do they handle blood product orders (type and screen, specifically) that go to LISs? FDA requires 510(k) approval of any CPOE module that electronically touches a regulated, FDA-cleared transfusion medicine module and Epic doesn’t have that approval. What do they tell new clients?” I could use some reader help here, so please add a comment if this is your area of expertise.

From Neighbor Ned: “Re: Lahey and Allscripts. They’ve had problems and haven’t seen the post-acquisition synergies. Bruce Metz came on board as CIO and wants a ‘unified architecture,’ which sounds like Epic. Decision to come within a month.” Unverified, but from a non-anonymous second-hand source, which is the best I have since Bruce hasn’t responded to my e-mail.

Welcome to new HIStalk Platinum Sponsor Park Place International. The company offers cloud-based technologies and consulting services that give Meditech customers a stable, optimized, and sustainable reference architecture. OpSus|Live is the company’s cloud-based hosting service that provides customers with a solutions and services package tailored to their unique needs. Its OpSus|Recover cloud-based disaster recovery service offers several service level plans based on recovery point and time objectives. They can design a certified infrastructure solution for new customers, or for existing Meditech customers experiencing performance problems, their technical consultants can provide rapid remediation and intervention. Hospitals interested in storage virtualization, thin provisioning, data encryption, vendor-neutral image archiving, secure virtual desktops, single sign-on, or hybrid cloud integration can get all the help they need from a focused company whose experienced consultants offering fresh approaches. Thanks to Park Place International for supporting HIStalk.

A slight majority of respondents said that opening up government healthcare data could provide health improvement. New poll to your right, in honor of Dr. Jayne’s recent rant: should HHS (and ONC specifically) back up new provider measures of quality or Meaningful Use with evidence proving that they work to improve patient outcomes?

Listening: new from one of my favorites, Metric. I’m also enjoying the new Beach Boys album, which thankfully is (a) all of the surviving members together other than in a courtroom; (b) mostly Brian Wilson and not much Mike Love; (c) not a bunch of rehashed old demos and laurels-resting, but new music; and (d) full of amazing harmonies that sound like the 1960s, but with the wisdom and wistfulness inherent with band members now in their 70s. Live video here. How they still hit those high notes is beyond me. The final track, “Summer’s Gone,” might bring up a tear if you’re sentimental or worried that this might be their last hurrah after 52 years. The new album is #3 on Billboard’s chart, “That’s Why God Made the Radio” is their highest-charting single since 1965, and the ironically named ‘Boys have broken the record of the Beatles by having over 49 years of Top 10 records.

Michigan-based hospital users of Epic form the EHR Michigan User Group, with 150 attendees from all 11 Epic-using hospitals gathering at Beaumont Health System for their first meeting. An Epic developer gave a preview of future Epic versions, warning the group not to share details with the media or competitors, with the TV station’s summary being, “Suffice it to say the software basically tracks patients in the hospital like the screens over the patients in Star Trek’s sickbay – only you can get the information anywhere, securely, on a tablet or smart phone.” That same TV station, loathe to run a picture-free online story since nobody can read without pictures these days and the user group apparently didn’t send over a photo, lazily headed over to Wikipedia for a startlingly irrelevant screen shot of the VA’s VistA as “as an example of an electronic medical record.”

Speaking of Epic, it drives me up a wall when people insist on spelling it as EPIC for some strange reason, apparently missing the point that even though it’s a short word, it’s still not an acronym (and the fact that Epic itself clearly does not capitalize it). Confounding the issue is Mount Sinai Medical Center (NY), which is installing Epic but calling its project EPIC in a highly contrived acronym (Efficiency, Patient safety, In/outpatient communication, Care.) Given Epic’s legendary and legally enforced paranoia about its intellectual property (as in the story above that warns about loose lips), I’d be careful. 

A CareFusion site from which medical equipment firmware updates are distributed is found to be loaded with malware, triggering a Department of Homeland Security investigation. Google’s Safe Browsing program flagged several pages related to CareFusion’s ventilators as being infected with 48 separate Trojan Horse programs and two scripting exploits (the screenshot above is from when I ran it.) Kevin Fu of the Medical Device Security Center discovered the problem when downloading an update for AVEA ventilators. He reported the problem to the FDA, adding that CareFusion’s instructions advise users to just ignore the usual security warnings. Fu also points out that vendor people and hospitals have gotten lax about running updates for pacemakers or other critical medical devices from the Internet or from someone’s USB key without thinking twice about it. Homeland Security’s analysis found that some of CareFusion’s sites were running six-year-old versions of ASP.NET and IIS 6.0.

Congresswoman (and Nurse) Renee Ellmers (R-NC) sends a letter asking HHS Secretary Kathleen Sebelius if HHS has adopted recommendations from the IOM’s November report involving the safety of healthcare IT. She wants to see a plan to minimize patient safety risk, a list of HIT-related errors that have caused harm or introduced risk, and a plan for a mechanism to allow users and vendors to report HIT-related deaths. She sent Sebelius a letter in August 2011 asking for a study of healthcare IT adopt, benefits, cost effectiveness, and medical error rates.

A June 14 power outage at an Amazon Web Services data center in Virginia takes down several cloud-based businesses, including Pinterest, for up to eight hours.

This makes me cheer given that the “site errors” people complain to me about that nearly always involve bugs in Internet Explorer, the worst browser ever written, and 90% of the time it’s an old version they’re running (because hospitals are stuck in a Microsoft time warp, often standardizing on IE6 from 2001 or IE7 from 2006 paired with their 2001-vintage Windows XP). An Australian retailer slaps a surcharge on orders placed by customers using IE7 since his company spends a ton of development time “rendering the website into an antique browser.” The company says only 3% of users run IE7, but most of his Web development team’s time is spent trying to code around its abundant flaws. I’ve had to pay people several times to do the same for HIStalk “problems” that don’t exist in Chrome, Safari, Firefox, or Opera.

Vince’s topic this week is more about Dairyland, but he’s got some fascinating pricing information from a number of vendors that will shock industry noobs (a five-year total cost of ownership for a full-line financial system of $400K? Yes, please.)

Discussion at a summit organized by the Association for Pathology Informatics on June 8 addressed the push for enterprise-wide systems that creates headaches for lab managers. Bruce Friedman MD said hospital administrators and IT people don’t appreciate the complexity and criticality of what he calls T-LISF — total lab information system functionality — that includes the LIS itself, middleware, outreach support, and firmware. Consultant Dennis Winsten said he has worked with several clients whose labs were being pushed into switching to Epic’s work-in-progress Beaker LIS by the offer of a free site license, requiring the lab people to perform an assessment of whether Beaker could meet their needs. Interesting: Cerner, McKesson, SCC Soft Computer, and Sunquest had speakers or attendees at the conference, but Epic passed on its invitation. 

Steve Larsen, the federal government’s most powerful health insurance regulator responsible for consumer protection and insurance exchanges, quits to become EVP of Optum, part of insurance company UnitedHealth Group.

Strange: a nurse in a hospital in Scotland streams so much porn from his NHS-provided laptop that he drags down the entire hospital network, with noticeable problems in radiology and videoconferencing as he is enjoying “Busty Japanese Girls” and “German Lesbians, Very Hot.” Officials inspecting his office found dozens of unopened referrals for his services going back to 2004. He was fired and his RN license was revoked this week, ironically denying patients his services as a member of the addictions team.

Eric Topol MD lists five technology devices that physicians should know about:

The smartphone-powered ECG, which he used on a flight to diagnose a passenger experiencing a heart attack, resulting in an unplanned stop to rush the passenger to the hospital.

The smartphone-powered continuous blood glucose monitor.

The iRhythm patch for Holter-like monitoring of cardiac arrhythmias for up to two weeks.

The AirStrip Patient Monitoring system for remotely monitoring ICU or other critical patients.

GE Healthcare’s Vscan ultrasound device that he says has entirely replaced his use of a stethoscope for listening to a patient’s heart.

E-mail Mr. H.

Time Capsule: Private vs. Public Vendors: I’ll Take the Former

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 July 2007.

Private vs. Public Vendors: I’ll Take the Former
By Mr. HIStalk

It used to be that every company’s goal was going public. Now, it seems like they all want to go private.

Private equity was all the rage back in the 1980s, when companies like KKR ruled the roost with their leveraged buyouts and hostile takeovers of stagnant companies, often using Michael Milliken’s junk bonds to finance the raid.

Their goal was simple: strip the target company’s assets clean and sell the parts for more than the cost of the whole. Long-term strategy was for suckers. Real money came from flipping.

Private equity is back. You’ve seen the headlines about buyout kings The Blackstone Group, whose proposed initial public offering has even attracted the investment interest of the Chinese government.

Several healthcare IT vendors have taken the private equity route (Kodak’s health group, Surgical Information Systems, Dairyland, and quite a few more come to mind.) Do customers fare better under private investors as opposed to being publicly traded? My tentative answer is yes.

Going public provides obvious benefits: a mammoth influx of capital, easy distribution of liquid equity to early investors and executives, and access to customers and investors who prefer doing business with companies that meet rigorous financial market requirements (see: Enron).

Stock money isn’t free, though. Outsiders get a big piece of the action in return. Administrative costs skyrocket. Business must be conducted transparently, sometimes reducing competitiveness. Worst of all, fear of irrational investor decisions brings the strategy horizon down to about two quarters.

Private equity managers can bring in their own capital from a long line of salivating institutional investors. Their holdings can operate as secretively as they like, free of SEC oversight and even Sarbanes-Oxley (at least until some Enron-type bloodletting sends investors screaming to their Congresspeople). They can overcompensate executives, rake off huge amounts of money as management fees, and secretly plot the day when they IPO the formerly low-flying company for a quick buck (which some would say was their primary motivation in the first place.)

It’s still greed, which as Gordon Gekko and I always say, is good.

From a customer’s perspective, I’d rather see my vendor go private than public. Only a few vendors went public during my customerhood. All of them went from pretty good to pretty awful once they’d sold their souls. Maybe they would have tanked anyway, but innovation and responsiveness took a back seat to snaring new business and bringing in dispassionate Wall Streeters to manage their particular HIT widget. As a customer, I was suddenly less important than big- money investors because they’d already taken my money.

Private investment at least gives the illusion that the company resisted the urge to cash in. Their companies don’t manage quarter by quarter. Sometimes the equity firm has a good track record of being a benign steward, happy with slow, steady growth instead of yearning for a quick flip. They bring in far better talent than would have ever worked for the previous owners.

Your mileage may vary, but as a customer, I’ve never seen a company improve by going public. And while I’m sure vendors sometimes get worse by turning over the keys to private money, I’d take my chances.

HIStalk Interviews Sean Kelly MD, CMO, Imprivata

Sean Kelly MD is chief medical officer of Imprivata of Lexington, MA.

Give me some brief background about yourself and the company.

I’m a practicing ER physician in Boston at Beth Israel Deaconess Medical Center. I’ve been there for about 11 or 12 years. Emergency medicine is my specialty. I went to UMass Medical School and did my ER training down at Vanderbilt for three years, stayed as the chief resident and attending there for a year, and then moved back up to the Boston area, where my family’s from.

I have a bunch of interests. I worked for a while as the graduate medical education director of our hospital, which is the head of all the educational programs. I was in hospital administration half-time while I was practicing the other half-time doing academics and research, mostly around medical education and the effects of overcrowding and the effects of modern healthcare on education and training.

As well as clinical practice, I got to see the administrative side of the hospital. It’s pretty big, with a $65 million budget as far as all the different Medicare money coming through. It’s just interesting the macroeconomics of the world as they change how it affects the hospital and how we do our jobs and how much medicine has changed over the past dozen or 20 years since I have been involved in it.

One time I took a transfer call from a friend of mine who works out at Martha’s Vineyard. He was sending in a trauma patient. I started talking to him and he asked me to come moonlight out there at their hospital, so I started moonlighting there. They have a huge influx of patients that hits Martha’s Vineyard since it’s a vacation destination. They get overwhelmed in their healthcare. It’s like Hurricane Katrina every day.

I was working in the ER there and about a 100 times people would ask us, “Hey, could you be our private MD?” A friend of mine and I created something outside of the system, just a concierge practice, which was unique at the time.A couple of ER doctors doing urgent care. We started what’s called Lifeguard Medical Group, which is a concierge practice, an entrepreneurial venture which has been a lot of fun. It’s been up and running five or six years.

I addition to my ER practice, I do a private practice, which is old-fashioned medicine seeing people at their houses doing home visits, but combined with a bunch of very cool IT toys that we have these days. We have a PC-based EKG machine and an i-STAT for point-of-care testing. We can do most basic blood work that we can get in ER right at someone’s bedside in about five minutes.We have a portable ultrasound machine, a little bigger than a little laptop or a little kind of minicomputer. We have a lot of good capability right at the bedside.

This whole idea of bridging technology and medicine became more and more interesting to me. I’ll say off the bat that I’m not an IT expert. I’m not someone who writes code or grew up doing IT, but I’ve always been an early adapter of technology. Part of my job out there is to take care of people, and many of those people were venture capitalists or private equity guys. I started talking with them more and more, doing some informal consulting. That led me to Imprivata, where I’ve now worked over the past seven months or so.

I’m having a great time bridging that gap between medicine, healthcare expertise, technology, and business. I found myself gravitating to that more and more, because every conversation I was in with somebody who was an expert either from a business management side of things or from a technology side of things. It really brought synergy. That was what I was getting more and more interested in. How you allow people that have access and knowledge of great technologies to learn more about healthcare, what doctors want, how doctors think, what nurses want, how nurses think, and patients. That’s the world that I’ve grown up in and continue to work in. How do we make sure that the worlds, when they collide, that everybody leverages each other’s knowledge base maximally?

At Imprivata, it’s been a great fit for me. It’s been a very fun time over the past few months as we’ve integrated more and more into healthcare. Essentially, the problem that Imprivata solves is that there’s a big tension throughout healthcare between security and efficiency. The way doctors think is that they’ll do the right thing if they can.  They want to be secure and respect people’s privacy, but if there’s something that requires creating a workaround to systems that are in place in order to provide what we would think of as the best care, then I think that that’s where there’s this tension that comes up between hospital administration trying to make sure the people don’t use these amazing tools that are in their pocket, like their iPhones and their BlackBerrys, inappropriately because they’re out of band and not governed by the administration. 

We’ve become more and more interested in making sure that we leverage our huge partnership with our 900 to 1,000 hospitals across the world. We work with IT and with the end users — the doctors and the nurses and the patients — to figure out instead of creating this tension between efficiency or convenience and security, how do you address both, and how do you create systems that are very secure? And therefore, the right thing to do, but also efficient in design the way that doctors and nurses want to use technology to help patients.

As we get more and more into healthcare and become the healthcare experts in healthcare IT security, my role in the company is to act as a liaison and translator for all of our contact points at the hospitals around clinical workflow. We have a lot of good experience working with IT departments throughout the country and talking about specific technologies. But in my limited experience, technology is just a means to an end, and a lot of the endpoints that we’re striving for — if you ask patients and doctors, it’s about quality healthcare, and if you ask administration, it’s about quality healthcare, too, but also with a very keen eye on regulatory input and restrictions. 

I think having in-depth knowledge of all of those particular factors and making sure that each one is addressed to the right stakeholder is the only way that a lot of these solutions are going to come to bear and be successful. I think the more we are successful in healthcare, the more Imprivata continues to gain ground and knowledge in that area.

What’s Imprivata’s take on the risks and benefits of the bring-your-own-device movement?

Essentially it’s the same take as we have on our core product with single sign-on and authentication. The whole idea to allow people to use their own device, or to use devices which are taken in by the hospital when run, but leverage the power of those devices while still maintaining the security. We have designed a whole new product line called Cortext — which is a secure healthcare messaging platform — to leverage the power of everybody having these smart phones in their pocket.

There are plenty of cases where I’ve used my own smart phone with the patient’s permission and to snap a picture of something that I’ve sent out over the AT&T lines because there wasn’t a way to get our PACS systems to talk to each other, for example. We had one case where I was on Martha’s Vineyard. This woman who had polio as a child had had her leg intentionally re-broken by the orthopedic specialist in New York City, and they put a big extension brace on her leg and lengthened her leg little by little. But inside of there was a bunch of broken bones. She fell, had a trauma on Martha’s Vineyard. We met her in ER and got X-rays.

While we were reviewing the X-rays, we saw a bunch of broken bones in her leg. We knew she had had a bunch of broken bones in her leg, but we couldn’t get our teleradiology PACS system to communicate with the one down in New York. I was talking to the specialist on the phone in New York who had the old films, I had the new films, and in talking with the patient, I said, “Do you mind if I take a picture and send it to him?” He does likewise. I had them print out a hard copy of the film, put it on the old light box, took a picture with my iPhone, sent it to the New York orthopedics. He sent me back the old film. We compared the two. No changes, so she was safe to go. She didn’t have to fly off the island to go back to New York.

That’s just one of the many examples where technology is very powerful. People are used to their own devices. They like their own devices, but they bring a security risk. Rather than having theses texts go out of band where they’re not secured and they’re not technically auditable therefore not HIPAA compliant and someone could be out of compliance with regulatory oversight, we’ve created a system is double encrypted. There’s an audit trail, and it’s HIPAA compliant. Not only that, but it’s actually more functional than the regular texting systems that most people use because it has a lot of healthcare-specific features and it integrates directly with the hospital’s active directory as well.

We’ve created a whole product line designed on leveraging the power of bring-your-own-device while still making sure that the security aspects are addressed. Partnering with many hospitals, including Johns Hopkins, and approximately 60 hospitals volunteered to be design partners with us. They’re just begging for these solutions. That’s part of what Imprivata is trying to do — recognize that we have a whole host of great partners out there and a good solid knowledge base in healthcare, so we’re trying to address those.

Your concierge practice sounds like that Royal Pains TV show, where the ED doc goes out to the Hamptons to be a doctor for hire.

[Laughs] Tim, you know, I’ve never seen it, but I think they looked at our Web site and ripped it off. I’m definitely not getting royalties.

I wanted to ask you about that. Who was first?

[Laughs] It was us. We were first. Believe me, it kills me. And I’m sure it’s much nicer to be play a doctor on TV than to actually be a doctor. [laughs]

You’re working in the ED at Beth Israel Deaconess, which spun their ED software out as Forerun. Why did the hospital develop their own software and decide to commercialize it? 

John Halamka is an ER doctor.  He hasn’t practiced for a while, but he comes from our practice. There’s another guy named Larry Nathanson, who is fantastic and practices by us side by side, who I think is a brilliant IT person. It’s a homebuilt system that is a specialty best-in-breed system.

As much as there’s this movement out nationally to move to the Epics of the world where there’s cross-connectivity in a platform across the entire spectrum of healthcare whether it’s within the hospital even inpatient or outpatient — and that’s definitely a plus in many ways — it neglects to mention one very important thing. How useful is it for each part of a hospital? 

People outside of the hospital tend to think of a hospital as a uniform environment. It’s just super important to remember that the culture and the needs and the actual constraints for your everyday working situation is incredibly different in the ER than it is from labor and delivery, than it is from the floor, than it is from a psychiatry clinic, than it is from oncology procedure rooms. I mean, it couldn’t be more different in some cases.

Trying to come up with a one-size-fits-all tool is like saying that in a restaurant, the cooks are doing exactly the same job and need the same kind of tools as the wait staff and the hostess. IT at many of these high-powered hospitals has great capability and Halamka and Larry Nathanson and these guys have created great solutions.

Unfortunately, we’re like drinking from a fire hose. For every problem we seem to undertake and solve, there’s another hundred waiting in the wings and things change so rapidly. It’s a wonderful system, but when you try to commercialize it, it’s pretty difficult to then patch it into other systems, because so much of it depends on how you communicate with a legacy system. Are the labs is coming from Meditech, or are they’re coming from somewhere else? How do you communicate with that or the HL7 feeds? There’s a lot stuff that I don’t understand, necessarily, in the black box that’s sometimes hard to coordinate. The old adage is, “If you’ve seen one hospital, you’ve seen one hospital.” The set of circumstances in many other hospitals is very different.

For our particular case, we found something that really works and they’ve spun out to try to put it elsewhere. But it’s funny — I’ve seen the reverse happen with Imprivata, where there’s a solution that we have found has worked very well. It works to get people in the front door to all those systems. The more you have these different, disparate systems throughout the hospital, and the more you’ve got these trends towards ACOs or other integrated healthcare networks, the more you need the ability to jump on, move between applications quickly, and make sure you have authentication in place so you can see what people are logging onto and when and why.

The ED is really different. Lots of times you’re seeing patients that have no history available, or they have no history with your organization. You have to make quick treatment decisions, you’re expected to be right all the time, and you may never see that patient again. How do you think that’s going to change with the accountable care model? Is it going to be just like it is today, only with a different patient mix?

In Massachusetts, we are a bit of predictor for some of the movement nationally, because we had guaranteed health insurance before healthcare reform dictated that nationally. We saw the effects of giving everybody access to healthcare insurance. We expected it, but it didn’t get much press ahead of time. One of the issues is that giving people healthcare insurance doesn’t necessarily mean they have access to healthcare. There’s such a shortage of primary care physicians and even specialists that people can’t get in to see them, particularly the ones with the poor payer mix. 

You had one barrier keeping people from using the ER — that they would get this exorbitant charge. If you take that away and replace it with a co-pay, now these same people who have insurance, they try to do the right thing. They try to get an appointment with the doctor for their sore throat or for their abdominal pain or whatever it is, but they can’t get in to see him, or they have a month wait. So they end up guess where – back in the ER. 

I  don’t know if that problem is ever going to go away entirely. The better we try to capture people into the system and keep them in correct systems so they can have their care well managed and prevent disease is a great long-term goal. I’m not sure how long that’s going to take. Certainly it’s not going to be any time in the next five years that we have the supply-and-demand curve figured out for giving people access to good healthcare. I think there’s always going to be a spillover.

The second part of that is if people are going to show up on your doorstep in the ER, isn’t there an easier way to jump online and see what they are with HIEs or something else? We’re suspicious as to whether that will actually happen, because on the one hand, everybody’s clamoring for collaborating and sharing of data. On the other hand, you’ve got many different EMRs that don’t particularly want to share data. You’ve got all the concerns about risks, about data breaches, and letting data get out there. What is the authentication and security process around that data and those HIEs, and who agrees to let it get shared, and how do you control access to it?

So I think that there are some steps in that direction. It’s very unclear how it’s going to shake out, but I don’t see it as a problem that’s  going to go away realistically any time soon.

What percentage of patients that you see would you say truly need to be seen in the emergency room?

It totally depends. We work at several different ERs, including community ERs, and the mix is somewhat different. The appropriateness of their visit depends on the time of night, the time of day, the access to the other doctors, economic incentives to those other doctors. But in general, at least 30% and sometimes up to 60% or more of those people really don’t need to be there.

I remember I had a great day when I was training down at Vanderbilt. A tornado hit Nashville. When I say great day, it didn’t really do this much damage as people thought, so I can actually say that. This tornado came basically right through the center of Nashville and it took out part of this rehab hospital. We were the main trauma center in Nashville, so we had permission that day to go on disaster duty, and we went through the ER. As the senior resident, it was my job to go through, and like duck-duck-goose, tap everybody on the shoulder who didn’t need to be there and kick them out. It was immensely gratifying to walk down the line and say, “Room 7, sore throat, discharged. Room 8, belly pain, discharged. Room 9, here for Percocet, out.” Probably eight out of 10 people just got jettisoned to prepare for this onrush of disasters that we’re expecting to get sent in. That was a gratifying day and not a typical thing.

When you teach medical residents, how are they different in how they view and use technology than their counterparts from five or 10 years ago?

It’s fascinating. They’ve grown up on Facebook and Google. It’s funny, they actually create things when we haven’t thought of it. One of the main issues is, where can you put information that you as a group or several groups subdivided can look at and parcel out in a way that makes sense from a specialty perspective and also a security perspective? They created a wiki. The residents created wikis in medicine, in emergency medicine, OB-GYN. Sometimes there’s crosstalk between them, sometimes they’re their own thing because of that whole phenomenon of the microenvironments within the ER.

But they’re very clever. They’ll go pull YouTube videos about how to do a procedure that are out there, that are part of some textbook, or a Netter diagram of anatomy that is particularly helpful, or a list of supplies that you need to get together when you’re doing a central line. How do you teach people to synthesize data and to learn how to reach for information rather than just memorizing things? Because you can’t memorize everything any more.

Back 20 or 30 years ago, there were something called blood disorder. Now blood disorder turned into leukemia, and now there’s like 69 different kinds of leukemia, and each one of them has a different cause and a different kind of treatment. Even the ones that have the same treatment have subsets depending on what they respond to, as far as the oncology and the chemotherapy. It just keeps getting enormously more and more complex. You can’t memorize everything, so there’s all these systems out there.

A lot of people go to UpToDate, go to Epocrates, go to all these specialty apps. At Imprivata, one thing we’ve noticed is that even places where EMR — Epic in particular, when they bulldoze the landscape and take over and a whole place goes to a single EMR — even in that case, there’s a ton of other apps that people go to that they need to go and find information on. It’s just continuously evolving. 

It should evolve. People should be able to use technology to its fullest. We do it socially. We do it for every other place in our lives. When we get our car taken care of, the mechanic seems to be able to know a lot more about that car than I can tell about a patient who hits the ER. To continue to provide easy, smart, and quick access to these different systems is really important.

I want to bring up one aspect of what Imprivata does that I think is key to understanding why I think we’re so sticky and have gotten so much leverage into the healthcare market. People talk all the time about saving clicks or saving time when you’re allowing a clinician to optimize their workflow. It is about time, but the big factor that I don’t hear mentioned enough is that it’s not just time, it’s the interruption and the cognitive dissonance in interrupting your thought process. I’ll give you an example.

We had a very high-stakes stroke patient. A clinician who passed out during rounds. He had a massive stroke and had a bunch of medical problems unbeknownst to everybody around him. He essentially dropped in front of the team while he was upstairs in the surgical ICU. They rushed him down to the ER.

We all gathered around him. This is what you trained for. You’ve got this person who comes in, who’s young and healthy, who’s got complete paralysis on one side, who can’t speak, and literally was down taking care of a patient next to you.

You’ve got this case and you just want to mobilize everything as quickly as possible. Your brain’s going a thousand miles an hour and you need to do several things. Stroke care is very time dependent, so you need get a CT scan very quickly, get a consult with neurology. You want to get the best neurologist around to look at the studies very quickly. You need to find out if the person has a medical history, including allergies to certain dyes you might use in the radiologic studies. You need to find out if they’re on blood thinners, and if there’s any contraindications to using thrombolytics, which are the clot-busting drugs. You have to do all these things very quickly. 

As you can imagine, he hadn’t received his regular care at our hospital because it’s a privacy issue. He wanted to be somewhere else. So we couldn’t look up his old records. It’s just what you intimated before about ER – some things just get dropped into your lap. You don’t know the patients and it’s a difficult problem right when it matters most.

To get stopped because you don’t have the right password, you can’t remember a password, your password changes, or you’re just logging on and off a multiple systems … there is a time factor, but it’s not about the return on investment of gaining 45 minutes a day at that point. It’s really about keeping your thought process and being allowed to think on the things that are truly important and complex, and as you’re moving through the paradigm of care and trying to figure out like, “OK, I’ve figured out these seven of the eight factors. The one more thing I’m going to do is…” and you hit the button and you get locked out because you need to reset your password or you put it in incorrectly and it locked you out of the system. You’re calling the ITS help desk.

That kind of breakage in your thought process is very dangerous for patient care, and very frustrating. When you have well-designed systems that allow you to jump on and navigate quickly between all these evolutionary systems that we’re coming up with, which have great capability … you know as well as I do that sometimes with all the information out there, you’re starving in the sea of plenty, where you just can’t find the one thing you need. Being able to get on there and navigate quickly around those different things –  it really helps.

We end up taking very good care of this guy. He had all the things he needed very quickly. He actually got a 100% recovery, which was a great outcome. But it’s not always that way, and the IT systems and the ability to navigate on and off of them can be a significant contributor in how well people do. It’s a cool thing to be part of an innovative company that helps people optimize their workflow and use their EMRs better and is having a lot of success because of it.

News 6/15/12

Top News

NIH and the National Cancer Institute announce grants to fund development of tools that empower consumers, patients, and/or their providers. The grants, worth up to $1.15 million each, encourage developers and entrepreneurs to partner with large health systems and health-related vendors. A long list of possible tool categories is provided.

Reader Comments

From Shhh: “Re: Epic. Speculation that it will have an SaaS offering.” A Forbes article written by a healthcare strategy consultant (who also has an article about Epic in The Atlantic that I’ll cover shortly) observes that Epic’s “fundamental but hardly delightful” system (KLAS scores suggest that Epic’s customers are pretty close to delighted, but let’s not quibble) that is client-server based and doesn’t communicate well with other systems. It says Epic is OK for healthcare innovation if you think repeatable processes will do that, but otherwise not. My opinion: I don’t really agree. I don’t get the cloud fixation – large hospitals that are accustomed to running data centers and hiring DBAs not only don’t demand a cloud-based system, they often don’t even want one. There’s nothing magical about “cloud” – somebody’s running a data center somewhere, so you’re just paying them to do it instead of doing it yourself, hoping the economy of scale they enjoy offsets the profit they demand. As far as the implication of clueless Epic customers, hospitals buy systems based on the benefits they expect, and it’s silly to think that an outside observer has the information to second guess their decisions (although I would agree that hospitals are awfully breezy with their ROI figures for Epic projects running into the hundreds of millions.) Epic is just Meditech for bigger and more egotistical hospitals – integrated, tightly controlled, as technically obsolete as their competitors, and sold by non-trendy and basically honest technologists who would rather walk away from a deal than herd you into a hard-sell Vision Center or make “partnership” promises they know won’t come true. Companies should stop fixating about mounting a full frontal attack on Epic that’s sure to fail and instead innovate on building products and services for Epic’s large client base just like the companies that coexist successfully with Meditech. As far as healthcare innovation goes, don’t put your hopes on the tools of the trade – the software market would spring to life tomorrow if healthcare incentives were changed. Today’s software market, right or wrong, reflects exactly what customers demand, which in turn reflects what the market pays them to do. HITECH created a false urgency that spurred providers to buy the same old systems they could have bought with their own money and hadn’t.

Massively looking forward to working with Bryan Sivak, new CTO of HHS!!

— Todd Park (@todd_park) June 14, 2012

From Don Johnston: “Re: Bryan Sivak, chief innovation officer of the State of Maryland. He will be the new HHS CTO, taking over from Todd Park.” Verified. He was previously CTO of Washington, DC. Before that, he had founded customer service portal vendor InQuira, which was sold to Oracle last year for an unannounced price.

From Ron Mexico: “Re: Lahey Clinic. I’ve been told they are replacing Allscripts. Heard anything?” I e-mailed CIO Nelson Gagnon twice and he hasn’t responded. They have Allscripts for both inpatient and ambulatory, I believe. 

HIStalk Announcements and Requests

From HIStalk Practice this week: the AMA says Stage 2 MU requirements are too demanding for physicians. Practice Fusion CEO Ryan Howard invests in Ringadoc, a provider of virtual medical visits. A simple explanation of cloud computing from MGMA’s Rosemarie Nelson. The rise of cloud computing in healthcare and an Epic-directed dig. Aaron Berdofe weighs in on centralized repositories as a healthcare infrastructure data model. Pop over for a quick visit and don’t forget to sign up for e-mail updates. Thanks for reading.

Dr. Jayne warned me in advance that she was being “pissy” when she wrote her Curbside Consult this week, in which she laments that physicians are being pulled away from delivering care by the distraction of “pseudo-quality initiatives, MU, and demands by marketing teams that we have an online presence.” She also throws down a challenge that any new Meaningful Use or quality measures should be accompanied by evidence that they work to improve outcomes, the same standard that a drug or device would be held to. I saw lots of tweets referencing her post, and Evan Steele of SRSsoft cites Dr. Jayne in a blog post of his own that suggests that doctors are questioning the real value of chasing MU requirements.

Ed Marx updated his CIO Unplugged post this week, When the Worst is Best, with responses to your comments.

Acquisitions, Funding, Business, and Stock

Axial Exchange, which offers care transition software, acquires patient-facing mobile app vendor mRemedy from DoApp and Mayo Clinic.

Patient Safety Technologies files a patent infringement lawsuit against ClearCount Medical Solutions, claiming that company’s surgical sponge counting technology violates its intellectual property.

Microsoft will acquire Yammer, a Facebook-like application for enterprises, for around $1 billion, according to a rumor run by The Wall Street Journal.

Sales

Evangelical Community Hospital (PA) selects Allscripts Sunrise Clinical Manager for inpatient EHR. The 127-bed hospital already uses an Allscripts ambulatory EHR.

Global Healthcare Exchange selects Meddius to provide data exchange for its Implantable Device Supply Chain solution.

People

Practice Fusion hires Todd Martin (NewsRight) as SVP of business development and Sheila Ryan (CBS Interactive) as VP of people and culture.

Dan Michelson (Allscripts) is named CEO of Strata Decision Technology.

Announcements and Implementations

Home health software provider HealthWyse forms a strategic collaboration with Sutter Care and Home to enhance development of HealthWyse’s chronic care management solution.

Florence Hospital at Anthem (AZ) goes live on Stockell Healthcare’s InsightCS RCM system.

AirStrip Technologies expands its platform to provide real-time delivery of data stored in disparate EHRs to clinicians using mobile devices. Travis covers it in detail on HIStalk Mobile.

MappyHealth releases the beta of  a web app that mines Twitter data for terms that could indicate a health-related development, such as a disease outbreak.

MedAssets opens the call for exhibitors for its Technology & Innovation Forum, to be held October 9 in Dallas, TX. Companies that aren’t already covered by a MedAssets purchasing agreement will present to its clients, with high-scoring vendors earning the chance to have their products added to the company’s contract portfolio.

Secure storage sharing vendor Box says it recently added four healthcare customers, including Greenway Medical, and that its healthcare cloud adoption is up 200%. It offers a free personal account with 5 GB storage if you want to play around with it.

Other

Here’s a new cartoon from Imprivata.

More than a third of physicians participating in an athenahealth/Sermo survey say their EHR was not designed with doctors in mind, while almost 3/4 report that using an EHR distracts them from face-to-face patient interaction.

An article in The Atlantic called Is One Company About to Lock Up the Electronic Medical Records Market? (co-authored by the same consultant who co-authored the Forbes piece above) says Silicon Valley types don’t understand how Epic can be successful when it breaks all their high-tech rules: it uses no open standards and it does not open up its information for other uses, but customers buy it anyway. It concludes that what Epic offers is the opposite of innovation – the quick implementation of its own rules that hospitals haven’t had the willpower to introduce on their own. In other words, hospitals buy Epic because they don’t really know how to improve their processes and use information to improve care, so they trust Epic to do it for them. While Epic’s paternalistic rules smack of industrialization, they let hospitals quickly gain efficiency and capture data they need to make both clinical and operational decisions. On the downside, Epic forces the practice of big-hospital medicine and locks customers into its outdated technology with high costs. I would generally agree – Epic’s success means we’ll see more organizations work like the big-name academic medical centers. Epic will drive some long-overdue evolutionary changes in healthcare delivery, but it’s not going to foster revolutionary gains on a broad scale. Given the country’s high healthcare costs and modest results, incremental improvements in health may not be enough, especially given the provider-centric view that improving healthcare services delivery is the same as improving health. 

A NEJM article, Escaping the EHR Trap – The Future of Health IT, argues that healthcare needs a dynamic information infrastructure instead of putting all the eggs in the EHR basket. The authors are Ken Mandl and Zak Kohane of Harvard and Children’s Boston, the guys behind the SMART project that advocates an iPhone-like apps ecosystem for healthcare IT (I haven’t heard much about that project lately.) Among the article’s talking points:

• EHR vendors have dragged their feet in the nearly 50 years since MUMPS was invented, avoiding modular architectures that would support product extension, data sharing, and interoperability;
• The business model of vendors is to control data, which prevents clinicians from having longitudinal and population-based views;
• Google-type EHR data searches and population analytics are not easily accomplished without exporting information to neutral systems;
• The hodgepodge of hundreds of non-interoperable EHR products hasn’t helped either doctors or patients;
• Modern tools should be embraced – cloud data storage, secure communication via the Direct Project, collaboration applications to manage group tasks, and non-healthcare specific analytics tools;
• Generic rules engines and user interface development tools could be used instead of each vendor using proprietary methods;
• ONC grants are funding development of “post-EHR" products that will create innovation (like the project the authors are running, it should be noted in the interest of disclosure.)

Another article in the new NEJM is Unraveling the IT Productivity Paradox – Lessons for Health Care (don’t underestimate the significance of these two articles given that they’re running in the highly respected NEJM). It says that healthcare IT is following the path of other industries that embraced technology earlier: (a) trying to correlate IT use to productivity is iffy because metrics don’t capture true productivity and value; (b) healthcare is late to the IT party and hasn’t had time to redesign processes around it; and (c) poor software usability has historically undermined potential productivity gains. Conclusion: it’s too early in healthcare to say whether IT is worth it or not.

Here is Atul Gawande’s keynote from Health Datapalooza last week. He speaks as well as he writes – telling simple but compelling stories, speaking slowly and without obvious ego, and tying it all into a message that you didn’t necessarily see coming. He has an interesting perspective about how battlefield medical services have improved and how that might impact non-military healthcare delivery.

A reader from Catholic Health Initiatives obliged my request for more information about its $1.5 billion EHR project. The five-year project called OneCare will include electronic health records for both inpatient and outpatient, infrastructure, user access enhancements, and an HIE with portals. Its Hoover’s profile says it has 14,000 acute care beds, which would be just over $100K per bed. That’s a lot less than some hospitals pay per bed, but it’s hard to compare size and scope. They were implementing Allscripts on the outpatient side a couple of years ago, trying to get it to talk to Cerner and Meditech inpatient systems, but they seem to be posting Epic jobs lately.

A delay by University of Michigan in reporting suspected child pornography that led to the arrest of a pediatric ED resident could cost the school more than $500K. Its contract with a Chicago law firm calls for a minimum payment of $395K, with the lead attorney and a a partner billing $725 per hour, the associates at $540-595 per hour, and paralegals charging $180-280 per hour.

Weird News Andy can’t figure out why a woman would go into an empty stairwell with her abuser in this sad story. A surgeon who is also a former Special Forces weapons expert plants a tracking GPS in his former girlfriend’s car, stalks her house, and threatens to kill her more than once. He allegedly lures her into the stairwell of the hospital in which she worked, shooting her dead with a high-powered pistol. Police think he’s mentally unstable.

Strange: a nurse who stole a doctor’s iPad from the ICU lounge is caught when the device automatically connects to the hospital’s wireless network, allowing hospital security to catch him heading toward his car with the device.

Sponsor Updates

• City Hospitals Sunderland NHS Foundation Trust implements BridgeHead Software’s Healthcare Data Management archiving solution.
• CommVault is positioned in the Leaders quadrant of Gartner’s just-published report on enterprise backup and recovery software.
• eClinicalWorks releases a case study highlighting the clinical and administrative improvements realized by Block & Nation Family Medicine (FL).
• TeleTracking reports that over 80% of hospitals named in US News & World Report’s 2012 Best Hospitals use its applications.
• OptumInsight is offering Webinars for clearinghouse customers, Epic users, and GE Centricity users.
• Beacon Partners offers new white papers on HIE and organizational culture.
• Gateway EDI highlights Mid-Illinois Medical Care Association and their claims processing success.
• A MEDSEEK blog entry provides advice for overcoming physician resistance to patient portals.
• Impact Advisors has been named to the 2012 Healthcare Informatics 100 list.
• An Informatica-sponsored report reveals the vulnerability of sensitive data due to insufficient controls preventing unauthorized access.
• Wipro Mobility Solutions collaborates with Kony Solutions to offer mobile application technology and services to enterprise customers in the US, UK, Australia, and the Middle East.
• Puerto Rico Hospital Supply, Dell, and NextGen Healthcare will co-market and deliver medical technology and service to practices in Florida and the Caribbean.
• Waterbury Orthopaedic Associates (CT) selects SRS EHR for its four providers.
• Meditech collaborates with Intelligent Medical Objects to provide mapping of diagnosis and procedure terminology to billing and medical concepts.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 6/13/12

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

When the Worst is Best

Years ago, I played on a church softball team. We lost every game we played in the city league for multiple seasons.

Some team members were proud of the fact we were well known for our “good attitudes and behaviors,” but I wanted no part of a losing team, bad or good attitudes aside. I figured if we won a few games along the way, our good sportsmanship reputation would be better respected.

I stayed engaged. As the best player on the team, I was eventually asked to manage the team. I essentially took over the Bad News Bears.

Early the next spring, I held tryouts. I also secured a sponsor who provided us with all the equipment and uniforms necessary to field a team. My criteria for players? In addition to good attitudes, they had to be better players than me. I could hold my own fielding and batting, so I figured if I were the threshold, we would be competitive.

We practiced. We scouted our opposition. We started winning. In making lineup adjustments, I eventually scratched myself out of the starting lineup.

We took first place in our league and won tournaments. We were now known for good sportsmanship and as the team to beat. Fun and satisfying! I still have all the trophies boxed up in the attic, unable to completely let go.

What I learned about leadership and teamwork during my softball era helped shape who I am today.

My objectives at work are similar. As I build teams, my goal is to be the least-talented and gifted leader. If I am the threshold, I think we will serve our organization well.

You’ve heard the adage that C leaders hire D players and B leaders hire C players, but A players hire A+ players. My ultimate objective is to eventually work myself out of a position. When a leader leaves an organization, it should be positioned to accelerate.

Hiring and cultivating leaders who are—or who can become—better than you takes confidence. It’s an intimidating step that will expose insecurities you didn’t know existed. Fight through the weaknesses and self-doubt. Learn from your team.

But be careful! Don’t let your insecurities interfere. Don’t sabotage your leaders out of fear. Put on your big boy pants and die to yourself.

Die. To. Your. Self.

Here’s the deal. Being the best on your team limits your organization’s potential. Being the best in a position where you’ve reached the top means you can’t learn from those around you. Where is the genuine satisfaction in that?

If I insisted on being the best player on my softball team, I would’ve made great plays and batted in some runs. Would we have won? Probably not. Sure, I would’ve received plenty of ego strokes, but at what price?

Ironically, not only did our softball team win, but I improved as a player. At work, I continually grow. Why? My team. Funny how that works.

Update

Thank you for your responses on “When the Worst is Best.” In addition to those on HIStalk, I received many via Facebook, LinkedIn, Twitter and e-mail. They are overwhelmingly positive, albeit some missed the primary point and  took offense to forming a competitive team from a church.

Let me put it this way. As a carpenter, Jesus himself would not only have made himself one heck of a bat, He would have aimed to win. Since we had 100+ turn out for the tryouts, we also fielded some recreational teams for those who just wanted to “play” and did not care about winning.

There is room for that in softball, but in our profession where we impact people’s lives, I only want the best and I am not ashamed to say it.

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.

An HIT Moment with … Dan Michelson

An HIT Moment with ... is a quick interview with someone we find interesting. Dan Michelson was announced this morning as the CEO of Strata Decision Technology of Chicago, IL. He was chief marketing and strategy officer for Allscripts until earlier this month.

What does Strata Decision Technology do?

Strata Decision Technology is a pioneer and leader in the development of innovative SaaS-based solutions for financial and business analytics and decision support in healthcare. We provide a single integrated software platform for budgeting, decision support, financial forecasting, strategic planning, capital purchase planning and tracking, management reporting, and performance management.

Our customer base includes over 1,000 organizations, including major academic medical centers, community hospitals, children’s hospitals, and many of the largest and most influential healthcare systems in the US including Adventist Health, Christus Health System, Cleveland Clinic, Dignity Health (formerly Catholic Healthcare West), Duke University Health System, Intermountain Healthcare, Legacy Health System, NYU Medical Center, Spectrum Health, and Yale New Haven Health.

Why did you join the company?

I have a strong belief that the next wave of value with healthcare IT will be in information rich edge solutions, like analytics and decision support, which surround the core clinical and financial systems that have now been deployed.

What I found so intriguing about Strata Decision is that they fit perfectly into this space, and while I have been in healthcare IT for over a decade, I had never even heard of them. The company is a hidden gem because they have had spent very little on sales or marketing.

But what they had built was pretty incredible – a very solid and complete set of solutions on the right technology platform, SaaS-based typically requiring only one day of customer IT staff time to deploy, along with a top tier base of over 1,000 healthcare organizations and very high customer satisfaction. 

Additionally, they have an exceptionally talented and motivated team. A big part of that team from my perspective was Dr. Don Kleinmuntz and Dr. Catherine Kleinmuntz, two brilliant PhDs that co-founded the company, who will be staying on in executive leadership roles. 

So I see a great market opportunity for a company that is exceptionally well positioned to get after it.

The announcement says you’ll help take the company to the next level. What level is it at now, and what is the next level?

From a solution set perspective, they have been laser focused on building out world-class financial and business decision support tools. Over time, it’s safe to say that our customers will begin to ask us to expand that scope to include clinical information to give their organization and their providers a more integrated view.  That is not essential for the solutions we provide today, but it represents a great opportunity down the road. 

Everyone knows that this is where the market is heading, and for the last 30 years in healthcare IT, it has always been relatively small, dynamic companies like Strata Decision that end up defining emerging markets  — practice management, EHRs, connectivity platforms, mobility, etc. The most nimble companies, who focus 20 hours a day on one zone, have always been the ones to blaze the trail. There is no reason that Strata Decision can’t be that company in this market.

As we scale the company, there will be opportunities to create more leverage through better systems and processes, as you would expect. But the bottom line is the foundation is incredibly solid and there are going to be many opportunities for this company to add value to and grow our client base in the years ahead.

What accomplishments and regrets will you remember from your time at Allscripts?

I joined Allscripts over 12 years ago when we had about 100 people and $26 million in revenue. Today the company has over 6,000 people and $1.4 billion in revenue. Looking back now, it’s hard to believe.

More importantly, during that time we helped define and develop the electronic health record market and build the largest client base in the industry. And we created an amazing company that provided lots of opportunity for lots of people, but also gave back in a big way to the community.  

Relative to regrets, building a market and a company at that scale is incredibly hard work. There are many things we could have done differently, but I will leave it to others to debate what those right moves could have been. Monday morning quarterbacking is not my thing. 

The bottom line is that I am incredibly proud of what we accomplished and am very grateful that I had the opportunity to work as part of Glen Tullman’s leadership team.  He has been both a terrific mentor and role model for me.

News 6/13/12

Top News

Private equity firm TPG Growth acquires critical care systems vendor iMDsoft. We reported that rumor here on June 8, along with the rumored sales price of $80 million that was not confirmed in the announcement.

Reader Comments

From SmallBiz: “Re: Accolade. Your post about Accretive Health’s chairman Michael Cline and reference to Accolade made me curious. A quick Google search shows the company on the SBA 100 list of companies that have received small business assistance. Call me crazy, but I thought SBA assistance was meant for budding entrepreneurs or bootstrappers trying to change the world, not for multi-millionaire private equity guys who want to add one more high flyer to their portfolio. The more one researches Accretive, the more one scratches their head.” Ditto the more one tries to understand how the federal government can be so free with taxpayer money while drowning us all in red ink.

From The PACS Designer: “Re: Apple’s iOS6 Preview. This fall we’ll see the arrival of Apple’s iOS 6 platform. For now, we have the iOS 6 Preview announced by Tim Cook this week. TPD particularly likes the Apple Maps, which shows cities and their skylines through Apple’s detailed  air mapping process.“ I’m not really an Apple fanboy even though I use the iPad for routine stuff (checking the weather, looking up something I’m watching on IMDB) but I admit that I intently follow live blogs of their World Wide Developer’s Conference every June. There’s just something compelling about the excitement of the unveiling and the hipness of Apple that makes me want to feel like I’m there among the geeks and crusties. The big announcements (other than Apple dumping its Google relationship for maps) involved a refresh of the laptop line (including a rare price drop on the Mac Pro) and some iOS enhancements. Boring if you were expecting a new Apple TV or the iPhone 6. It was cool, though, that everything being announced other than the new Mountain Lion OS was available for online purchase the same day (once they brought the Apple store back online later Monday.) Other than Google, the companies taking it in the shorts from Apple were Intel and its partner companies trying to sell Windows-powered Macbook Air lookalikes (aka ultrabooks) that aren’t nearly as cool for about the same price ($999), the same Apple manufacturing pricing advantage that makes it suicide to roll out an iPad competitor. Even the low-end Air now comes with all-flash storage, Thunderbolt and USB 3 connectors, and a FaceTime HD camera. For Maps, it looks like Apple has struck a deal with TomTom to turn the iPhone into a free, voice-powered GPS with real-time traffic updates driven by automatic data from individual iPhones and integration with services such as Yelp and OpenTable.

HIStalk Announcements and Requests

Maybe it’s just me, but has Facebook been dog slow lately? Are they punishing users for their unimpressive IPO by throttling back the Web server horsepower? Ditto the hourglass city for Twitter. How many billions does it take to keep the Web page coming up?

I’m speaking to the men here, but the ladies are welcome to read. I was reading a list of suggested ways to make the woman in your life happy. A common answer was to hug her from behind, kiss her cheek, and tell her she’s beautiful whether she is or not (assuming she is to you, anyway, which I hope is the case.) You and I probably have in common the fact that we haven’t done this with either Inga or Dr. Jayne even though they are clearly loved and beautiful, so here’s a list of alternatives: (a) sign up for spam-proof e-mail updates; (b) give them a virtual hug by friending, liking, and connecting via all the hipster social not-working sites; (c) send us news, rumors, photos, or anything else that is informative or entertaining; (d) intently study our sponsors via the categorized and searchable Resource Center or the gloriously non-animated ads to your left, and if you’re provider seeking consulting help, fill out a quick online form and get a bunch of responses via the Consulting RFI Blaster; (e) have patience with our sometimes terse and/or delayed responses or occasional crankiness since we work full time elsewhere, and doing all things HIStalk is an intensely enjoyable but time-sucking hobby that requires constant reallocation of hours. Do these things and the smart and sassy HIStalk ladies will virtually lean their heads on your shoulder and sigh contentedly, squeeze your bicep and insist that your workouts are buffing you up, and pretend to find your timely Caddyshack quips to be funny. Heck, I might do that myself since we appreciate all of our readers and sponsors.

Acquisitions, Funding, Business, and Stock

The Chicago business paper reports that Fidelity Investments, the largest outside investor in Merge Healthcare, has sold most of its shares, dropping its ownership from 6.7% of the company to around 1%. Shares were up 1.34% on the day, although they’re still down by more than 60% since late March.

Compuware hires an underwriter to prepare for the IPO of its Covisint business. The company hopes to raise $200 million.

Sales

Bacon County Hospital (GA) selects Summit Healthcare’s Express Connect and Provider Exchange interoperability technology for its Meditech 6.0 system.

Huntington Memorial Hospital (CA) announces a strategic collaboration with Cerner to implement its clinical and financial solutions and connect with the hospital’s information exchange.

The Orange County Partnership RHIO (CA) selects Mirth’s data exchange solutions.

Catholic Health Initiatives selects Orion Health as its HIE technology partner for its $1.5 billion EHR initiative. I’m interested to know the scope of the overall project given its cost, so help me out if you know.

Thailand-based medical tourism hospital Bumrungrad International Hospital chooses business intelligence tools from Agilum Healthcare Intelligence of Nashville, TN (known as Anthem Healthcare until a name change a few weeks ago.)

Wireless infrastructure vendor Firetide wins a contract for 4,000 centrally managed access points for a 180-hospital WLAN rollout in Korea.

Dallas County Medical Center (AR) chooses the Prognosis HIS EHR after reviewing a dozen vendors. The hospital’s CEO says a key factor was a guaranteed 120-day go-live and the 100% of customers who have received Meaningful Use money.

Federal contractor CACI International is awarded a $20 billion contract to provide IT services to the National Institutes of Health and other government agencies. The company says healthcare IT is an important growth area and that its services will provide “innovative solutions to enhance taxpayer services.”  

The Navy rejects the EMMA computerized medication dispensing system from INRange Systems because of concerns about the security of its wireless communication. They planned to pilot it, but changed their minds when it failed to earn certification and word of bad experiences from Army pilot sites got out. They also said its potential to control drug abuse among service members was overstated.

People

Steve Sarros (Spectrum Health) is named VP/CIO of Baptist Health Care (FL).

Announcements and Implementations

Agfa Healthcare selects Dell to host its medical imaging archiving services.

Precyse signs a software interface license agreement with 3M Health Information Systems to interface Precyse’s computer-assisted coding product with 3M’s Coding and Reimbursement system.

T-System introduces RevCycle+, an RCM solution for the emergency department that encompasses facility coding, physician coding and billing, and consulting.

M*Modal announces its Catalyst suite of cloud-based applications that allows extraction of data from unstructured clinical documentation (such as dictated encounter notes) that can be merged with structured EHR information. A key benefit is the ability to search all medical documents regardless of source and system while preserving context beyond simple keyword searches.

Hospira announces enhancements to its TheraDoc clinical surveillance system to support hospital antimicrobial stewardship programs, including an eMAR interface, dashboards, and alerts.

Business analytics software vendor SAS partners with the non-profit Health Care Incentives Improvement Institute to develop analytics-powered provider reimbursement models to support bundled payments and ACO shared savings models. I’m impressed with the most recent (and fun) blog post by HCI3’s executive director Francois de Brantes (formerly of GE) or his ghostwriter — Too Many KITAS can be a PITA, which applies behavioral theory to ACO-type reimbursement:

The carrot and stick approach, what Herzberg refers very cynically in his paper as the KITA method (for kick in the ass), doesn’t work very well. Instead, he suggests an exercise in minimization of toxic environmental factors. We’ve grown accustomed to thinking that incentives can be optimized, that behaviors can be finely tuned to respond to the incremental adjustment in fee schedules or bonuses. They can’t. What we must do is actively minimize misalignment of incentives – factors that lead to job dissatisfaction. If I encourage employees to seek care while penalizing physicians for delivering too much care, then I’m creating a toxic environment leading to dissatisfaction. If I put physician income at risk but only tell them after the fact what their budget was and that they blew it, then I’m creating a toxic environment leading to dissatisfaction. If we want physicians to develop and maintain an internal motivating generator (as Herzberg refers to it), we have to minimize the factors that are stopping them from achieving their potential.

Government and Politics

AHRQ produces an e-prescribing toolset for physician practices that includes a readiness assessment, sample workflows, a task table, an e-prescribing vendor assessment tool, sample project timelines, a computer skills assessment, and a flyer for patients.

Innovation and Research

A JDRF-funded study demonstrates the feasibility of an artificial pancreas for ambulatory use. Two patients were connected to an insulin pump that was controlled by a smart phone that constantly monitored their blood glucose levels and adjusted their insulin doses accordingly, allowing them to eat meals and sleep outside the hospital while maintaining near-normal blood glucose levels without medical intervention. 

An Arizona teen wins an innovation award for his enhancements to existing free software that allows people with Lou Gehrig’s disease to control a browser using their eye movements. Commercial equivalents cost $20,000, but his version costs less than $2,000 including hardware. He’s talking to some VCs about marketing it.

Other

HIMSS Analytics introduces the Ambulatory EMR Adoption Model, which will track IT adoption in more than 28,000 ambulatory facilities that are part of hospitals or hospital systems. None of the 9,247 ambulatory facilities that are providing information to HIMSS Analytics are at Stage 7 and nearly half are Stage 0 (purely paper-based.)

The Advisory Board Company’s daily briefing newsletter highlights this story, in which a researcher digging through boxes of old paper at the National Archives finds 21 pages of notes taken by the first doctor to attend to Abraham Lincoln after his shooting at Ford’s Theater. The doctor, who was also attending the play “Our American Cousin,” had earned his medical degree just six weeks before. I couldn’t help but think how uninformative the rich historical narrative would be had it been reduced to today’s codes and checkboxes.

A UK hospital admits that it believes one of its employees leaked information to a tabloid about the cystic fibrosis diagnosis of the four-month-old son of former Prime Minister Gordon Brown in 2006. The tabloid is owned by Rupert Murdoch.

In Canada, a Grey Bruce Health Services computer problem takes down the phone and computer systems of six hospitals.

Patient advocates complain that University of Iowa Foundation sent patient information to the questionable fundraising groups it hired, allowing them to enhance their mass mailings seeking donations to its hospitals by adding the signature of each patient’s doctor. The hospital says the practice is legal and everybody else does it. One of the fundraising companies raised $1.1 million for the university, but charged $1 million for doing so. The newspaper article only casually mentions an item that I consider the most troubling:

The head of the hospital’s ophthalmology department says the flow of information works both ways in that the foundation tells him which of his upcoming patients have agreed to donate money. The foundation and hospital have also agreed in writing to collaborate on “wealth screenings of patients” in order to maximize donations.

An American Medical News editorial calls Meaningful Use Stage 2 “a recipe for failure,” saying its increased number of performance measures and higher thresholds raise the chances that a practice will miss out on their HITECH check, possibly through no fault of their own (like practicing in an area where labs can’t accept electronic EHR data and patients who aren’t interested in using technology).

Inga says she hopes she has a leg up on Weird News Andy in finding this story. A Gulf of Mexico shrimper drags up a $30,000 custom-painted artificial leg from the water, saying, “I was hoping I wasn’t going to find a body with it as well.” The leg’s University of Kentucky motif allowed him to track down the owner, who says he lost it while swimming over Memorial Day. The diehard Wildcats fan wasn’t reduced to hopping on one leg in the interim: he has two more like it.

Sponsor Updates

• AirStrip Technologies and Palomar Health launch a vendor-neutral mobile platform to provide access to clinical data.
• Kony Solutions hosts a June 14 Webinar on developing an enterprise mobile strategy.
• EBSCO Publishing releases three medical e-book collections of top-rated content on its EBSCOhost electronic library collection of 300,000 e-books and audiobooks.
• The Ohio Orthopedic Center of Excellence selects eClinicalWorks EHR for its 59 providers.
• Covisint announces that DocSite is open for 2012 PQRS submission, which costs a flat $299 per provider. It also offers free webcasts and a 2102 CMS Incentives FAQ document.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 6/11/12

As a physician, I sometimes have to make the last note in the patient chart, officially “pronouncing” the patient to be dead. Regardless of how many times I’ve done it, I don’t think it is something I ever will get used to. Depending on my relationship with the patient, I sometimes receive the death certificate to sign a few days later, formally documenting the cause of death. It’s a very concrete reminder that the sacred trust given by our patients is real and enduring.

No matter how heart-wrenching, it’s good to have these reminders from time to time. Many of us in healthcare are so beaten down by the absolute enormity of what we are trying to do and how fast we are supposed to do it that we forget why we went into this business in the first place.

In many departments at my hospital, people seem to be increasingly pressured to check boxes, complete projects on time, and adhere to the almighty budget. This is particularly acute in the IT department of late.

Because physicians planned poorly for Meaningful Use and are now demanding that the hospital purchase their practices, we’re doing a massive fire drill to try to install them, train them, and help them attest before the end of the year. Our hospital has never been known to say no to a physician acquisition regardless of the circumstance. As long as you can be credentialed by payers, you’re in.

Our teams are being driven in a way they’ve never been driven before. Leadership keeps voicing how high the stakes are and how we must continue to deliver the impossible – again and again. Resources are being diverted away from the practices that have been moving towards actually using an EHR meaningfully (rather than achieving Meaningful Use.) For example, rather than building new reports for our long-adopted practices who want to tackle new quality challenges, the data analysts are spending their scarce time obsessively running MU reports for the latecomers.

We’re continually reminded how much money is at stake with MU. I don’t disagree that it’s millions of dollars for our health system, but really, it’s a small amount for the individual providers. Divide $44,000 by five years and we’re reminded that it’s $8,800 per year. (Yes, I know it’s an offset against future penalties, etc. and as a CMIO, I get it and don’t need the lecture.) But as a physician, it seems like too small a price for which to sell the heart and soul of medicine.

For the extra time that most of my physicians spend clicking boxes and delivering interventions that are largely irrelevant to good patient care, they could have seen two more patients a day. That’s a revenue boost, but what’s more important is that volume boost equates to almost five hundred patients per provider per year that could have been served in our community. These are patients who need care and still have long waits to receive it, even in a major metropolitan area.

Physicians are constantly distracted – by pseudo-quality initiatives, MU, and demands by marketing teams that they have an online presence and know how to use the media for promotion. We’re doing more paperwork than ever (even in the electronic world) and spending less time with patients. The essence of medicine is being lost.

We’re forgetting why we went into this business in the first place. For many of us, it was not to receive Most Wired awards, Top Hospital trophies, or write-ups in US News. It was to help people, cure disease, and reduce suffering.

I’d like to challenge those who are leading the initiatives and formulating the rules of this new game. For each new measure you add to Meaningful Use (and for the existing measures too), I’d like to see concrete evidence that jumping through the hoops you’re holding in front of us will actually help patients in a truly meaningful way.

When the FDA is considering a new drug, proof is demanded and studies are performed. When payers decide to cover a preventive service, they determine how many patients have to screened vs. treated in order to make it cost effective. However, when we upend the healthcare delivery system, our interventions are not held to the same standard.

Are you in favor of evidence-based Meaningful Use? E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 6/11/12

From Consulting Dude: “Re: Accenture. Help me out here. Stanford is kicking them out due to non-performance on their contract for outsourcing and Epic implementation and support. Partners HealthCare is supposedly hiring Accenture to implement Epic. Does the East Coast not talk to the West Coast?” Unverified, but any time you have huge academic medical centers, there’s a good chance their own bureaucracy and executive egos will cause a vendor to fail even though the situation isn’t entirely their fault.

From RTLS Experts: “Re: VA RTLS contract. They finally announced HP Enterprise Services as the winner of the $543 million contract covering 152 medical centers. There are several sensor solutions involved in this groundbreaking project, but not much has been disclosed. The RTLS Enteprise Visibility software solution tying it all together comes from Intelligent InSites out of Fargo, ND. Centrak will be used to provide location data. This breathtaking investment has stirred the Navy to release their own RTLS solicitation last week for all their facilities and the Air Force is rumored to be preparing a RTLS RFP with the same focus.” Excellent information – thank you. I haven’t seen an official announcement, but information about the award, which was announced Friday, is here. 

From Certifiable: “Re: Friday’s comment from Nurse Informaticist. If they aren’t valued by their big vendor employer, I’m recruiting for a position on my team and it doesn’t get more informatics-y than this.” Since Nurse Informaticist didn’t leave contact information, I’ll bend my no-solicitation rule and offer to forward his or her contact information to Certifiable if they’re interested enough to e-mail me.

From A CIO: “Re: Accretive. I think they’re toast in most markets. I’ve not worked anyplace where we would sign up for a service with such bad press. Sure, you can set rules of engagement, but can you afford the PR hit if things to wrong and some reporter outs you for using them after their history?” I would tend to agree. Rightly or wrongly, big organizations look for scapegoats to fire quickly to make ugly headlines go away, even though those sacrificed didn’t make the decision unilaterally and often weren’t even guilty of anything. They usually end up suing afterward. Accretive has a real challenge on its hands. Shares are down around 60% since February and the class action shareholder lawyers are circling the blood in the water. Not to mention that Accretive’s chairman J. Michael Cline lost a previous tangle with Minnesota AG Lori Swanson (above) over a consumer debt arbitration firm that she said hid its connections to the collection industry to dupe consumers, which led one of his companies to file bankruptcy and the other to shut down. In addition to Accretive, Cline is chairman of Accolade, which works “one-on-one with your employees to help them understand their health care.” It’s hard to tell from the lofty description, but it sounds like they work with big, self-insured companies to guide the health services utilization of their employees.

From The PACS Designer: “Re: more Windows 8 details. Windows 8 will come with the touch technology from mobile devices and its own anti-virus software for the first time. Also Microsoft will enhance its Windows security features and give purchasers of new PCs now and until next January a certificate to get Windows 8 for $14.99.”

Listening: Edenbridge, neo-classical operatic metal that follows the formula: soaring compositions, stunning near-classical musicality by menacing-looking Northern European dudes, and featuring an alluring female lead singer. They’re studio-quality flawless on the live video. They were recommended as being similar to my all-time favorite After Forever by Spotify, which I’m using and liking. As someone commented on a YouTube video, “For kids used to plastic dolls with Autotune on, this is what a real female singer sounds like.”

Thanks to the following sponsors, new and renewing, that supported HIStalk, HIStalk Practice, and HIStalk Mobile in May. Click a logo for more information.

Three-quarters of respondents say hospital CIOs stifle innovation. If you’re a CIO stung by the results, why not e-mail me a few lines with examples of how you encourage innovation that I can run for the benefit of other CIOS, which might boost the perception scores next time around? New poll to your right: is the push to open up the government’s health-related data appropriate or overblown?

Constantine Davides of JMP Securities has updated his HCIT Consolidation Chart (aka the HIT vendor family tree). He says this will probably be the final version since untangling the HIT acquisitions hairball is an unending project. The only straight lines (no acquisitions) that I see are Epic, CPSI, Healthcare Management Systems, and eClinicalWorks.

Here’s video of Todd Park, asked by O’Reilly Media whether open data is all about the apps. Short answer: no.

A law firm files a class action suit against Emory Healthcare for losing 10 disks earlier this year when someone took them from a storage cabinet. It seeks $200 million.

Vince’s HIS-tory this time covers Dairyland. It’s good.

E-mail Mr. H.

Time Capsule: Vendors: Develop an "Antivirus" Program to Warn of Your Software’s Bugs

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 June 2007.

Vendors: Develop an "Antivirus" Program to Warn of Your Software’s Bugs
By Mr. HIStalk

CIOs and vendors spend lots of money and time addressing system redundancy. Thank goodness. When clinical systems go down, patient risk goes up (or so you hope, anyway, since that’s the ultimate validation of that system’s influence on patient outcomes.)

We can agree that downtime is bad. What vendors haven’t fully acknowledged, however, is that systems can be up and running, yet still endangering patients because of internal logic or data errors. Known bugs, in other words, that cause errors that are subtler and, for that reason, potentially more dangerous.

I’ve worked in vendor support, so I’ve seen hundreds of examples:

• Medication doses, lab tests, or nursing actions are omitted from their respective printed or online schedules
• Interface problems allow time-critical information to be delayed or ignored
• Lack of sufficient storage space causes transactions to be lost
• Patient merging or discharge cancellation does something undesirable to visit information
• Technical issues cause background processing to fail, delaying reports or updates until a user finally notices.

I could go on, here’s my point. The vendor’s support people knew about these problems. They could get on a client’s system, query the database, and say, "Yep, we’ve seen this problem before." In most cases, a simple utility program could have detected the error condition proactively and warned someone immediately, allowing the problem to be resolved before patients were exposed to data-driven risk.

Vendors don’t like this idea. First, it admits that their software has bugs (which it always does.) Secondly, it also admits that even well-documented bugs can’t always be fixed immediately.

I don’t buy the idea that it’s the customer’s job to find and report problems. It’s never acceptable to endanger a patient with a known software defect, even if a fix is on the way. The obvious solution (temporary or otherwise) is to write a program to detect the problem, let the customer choose how often to automatically run it, and provide the appropriate alert when that problem is found.

Here’s a simple example. Suppose I have CPOE and pharmacy systems that should always be synchronized via complex interfacing or integration. That’s great, but what if something goes wrong? The unacceptable answer: let the clinician find the problem. Oops, the antibiotic order is active in CPOE, but expired in pharmacy. Customer support: "Thanks for telling us, but we already know about that problem, even though we can’t fix it. Continue to be vigilant. Can we close your case?"

This is not necessary. A program could easily have detected the problem. Programs are better than clinicians at comparing List A to List B. So, why are preoccupied clinicians expected to be the safety net for programmers?

None of the applications I’ve used provided these low- level diagnostics. Finding bugs was a user’s problem, even after those problems had been documented, acknowledged as bugs, and scheduled for an eventual fix.

This drives users through the roof. IT is proclaimed as unresponsive and the vendor is branded as incurably stupid.

My message to vendors: It’s your job to tell customers when your software has a problem, not vice versa. Ask your support reps for a list of known problem symptoms. Get your developers to write a diagnostic program that users can run on a predefined schedule, including their preference for alerts.

Think of it like your PC’s antivirus program. It has a core detection engine. Users determine how often it runs and what happens when it finds a problem. Automatic updates to its detection patterns let it find even newly discovered problems immediately.

Developing a problem detection engine isn’t an admission of failure. it’s a reflection of reality. Software always has bugs that leave detectable tracks in the customer’s database. Finding the occurrence of those clinical software bugs is good for everyone involved, most notably the patient.

News 6/8/12

Top News

Microsoft and GE Healthcare complete the formation of Caradigm, their 50-50 joint venture that will be led be CEO Michael Simpson from GE Healthcare. Lauren Salata (Care Innovations) joins as CFO an Michael Willingham (Philips Healthcare) assumes the role of quality assurance and regulatory affairs executive.

Reader Comments

From LesserEvils: “Re: what uninsured un/under-employed do. They have several choices. They can wait until they are really sick and visit an ED, which just makes the cost of care even higher. Or they can become self pay, which in many cases translates to no pay, which we all end up paying for in some way. Or, they file for bankruptcy. Something like 60% of personal bankruptcies are due to the un/underinsured being unable to pay medical expenses.”

From Paul: “Re: Cerner. Featured in Investor’s Business Daily. Feels like an optimistic PR announcement, but I see solid stability with their hosted offering and decent improvements on the ambulatory side.” IBD quotes analysts who like the fact that Cerner shares have done well lately, bucking past experience in which any one HIT vendor that reported bad results (like Allscripts) dragged the whole sector down. They also like Cerner’s chances to offset eventually declining EHR sales with revenue from medication dispensing cabinets, medical devices, and outsourcing services. It says that although Epic wins most of the high-profile hospital deals, Cerner’s win rate has improved in the last couple of years.

From AcuVedder: “Re: patient right to access and correct their health information. The Office for Civil Rights posts a video explaining patient rights.” I don’t know if it will help or hurt hospital foot-dragging (long delays and high per-page costs involved with giving patients copies of their own records), but at least the video sends a signal that the government sides with patients, in theory anyway. If it’s so time-consuming and expensive to give patients a copy of their records, imagine the disarray that must be involved with providers trying to access and use those same records for treating those patients during their stay. Or at least that’s how I would see it as a patient. Imagine a garage that isn’t able to provide estimates, sells services ordered by third-party mechanics over which it has limited control, and expects customers to just pay their bills afterward with no explanation of what was done or how their car should be driven or serviced in the future.

From Izzie: “Re: Accretive Health. Are hospitals more or less likely to hire them as their RCM vendor since their dispute with the Minnesota attorney general?” I would expect that’s the case since nobody wants bad press, but let’s ask their customers and prospects: have the headlines changed your plans involving Accretive? How? Tell me. I’ll keep you anonymous.

From Nurse Informaticist: “Re: help! I work for one of the big vendors that thinks a nurse is a nurse. They have no idea what my specialty certification in informatics is or what it means. How about a shout-out for the fact that nurses specialize and have expert knowledge to contribute to system design? Long time, die hard fan!” I’m not an expert on ANCC certification, but I recall that it requires passing a test and clocking a bunch of hours working in any kind of informatics role. Vendors may see that as more of an indication of interest rather than of specific, value-added skills since anybody can call themselves an informatics nurse and lots of nurses make their living doing informatics-like work  (training, consulting, support, etc.) with no higher education or certification at all, just applied informatics experience (which is often true of other professionals as well.) Then there’s the Epic model, where they’d rather have impressionable, cooperative (read: young) licensed people who have recent frontline care delivery experience and no IT connection. Finally, some vendors have a warped view of the provider food chain in thinking that physicians can intelligently speak for nurses, therapists, pharmacists, etc. and don’t seek other clinical expertise. I’ll poll HIStalk’s readers again: are nurses with informatics education and/or certification adequately involved in system design and implementation by your organization? Why or why not?

From Not Very Innovative: “Re: CMS’s $10 billion Center for Medicare and Medicaid Innovation program. In a WSJ editorial, Steven Greer MD says Congress should dismantle it since it’s a poorly conceived, politically motivated system that is unlikely to deliver innovation or ROI.” He should know – he was chairman of its grant review program, concluding from his experience that it is “nothing but a pork program that diverts untouchable Medicare entitlement funds to political cronies in key states.” The first millions went to a Chicago group run by the President’s golfing buddy and a program that eventually subcontracted the work out to IHI, formerly run by Don Berwick, who was running CMS at the time. He concludes, “The newly created CMMI is nothing but a stealth stimulus plan to help job creation and politicians’ careers, just like the extremely ineffective ARRA ‘stimulus plan’ was in 2009. The ARRA did nothing to reduce unemployment, and neither will the much smaller CMMI.” It probably doesn’t help Dr. Greer’s credibility that he is a UFO contactee who has accused the government of an alien cover-up, not that there’s anything wrong with that.

HIStalk Announcements and Requests

Life got in the way of mentioning HIStalk Practice highlights last week, so here are a few don’t-miss items from the last two weeks: Dr. Gregg discusses intriguing new bedside monitoring technology from Blnk Medical Technologies. David Wellons muses on the next generation of healthcare informatics. Over the last decade, more widespread use of EHRs has contributed to a 17% increase in the use of the two highest-level codes for established office visits. Consumer Reports adds ratings for Massachusetts primary care providers. eClinicalWorks treats employees to ice cream in exchange for donations to the troops. I have resigned myself to the fact that I will never catch Mr. H in terms of the number of LinkedIn connections, Facebook friends, or Twitter followers. The only thing that keeps me from falling into a deep depression is seeing lots of visits to HIStalk Practice and new sign ups for the e-mail updates. Thanks for your support, which is far more effective than therapy.

Acquisitions, Funding, Business, and Stock

Streamline Health reports Q1 results: revenue up 31%. EPS $0.05 vs. –$0.03.

Stanley Healthcare Solutions, a division of Stanley Black & Decker, acquires RTLS provider AeroScout. We reported that rumor on May 18.

Veritas Capital completes its $1.25 billion purchase of the Thomson Reuters Healthcare business, which will be known as Truven Health Analytics. You may recall that Veritas sold government healthcare IT contractor Vangent to General Dynamics for $960 million last August, making a 240% profit on its investment.

Ringadoc receives $750K in an angel-led seed round, with the participation of Practice Fusion CEO Ryan Howard and LA-based technology incubator Curious Minds. The company offers virtual visits from its physicians at a cost of $89.99 per year and $29.99 per call, with three free calls per year. Fast Company just profiled Ringadoc, saying that it’s operating out of Practice Fusion’s San Francisco offices and using its EMR. The company says it has 1,600 registered users and will soon launch a service that will allow physicians to use its technology in their practices.

Allscripts creates an incentive program based on earnings-per-share performance for 10 of its executives, but CEO Glen Tullman was not be included for unstated reasons. The company also amends the employment agreements of Glen Tullman, Lee Shapiro, Diane Adams, and Laurie McGraw to require that they resign within 10 days of a change in company control to earn their cash payment for not being retained.

Discharge planning and readmissions software vendor CareInSync gets $1.6 million in Series A funding from HealthTech Capital. Above is a video of staff from Marin General Hospital talking about their use of the company’s Carebook transitions software.

Athenahealth launches a “More Disruption Please” program that will sponsor hack-a-thons, invest in startups, and open up the athenahealth platform via APIs.

An Israel business publication cites sources claiming that iMDsoft is talking to a private equity fund about an $80 million sale of the company. I didn’t realize that its three founders also founded population management systems vendor CareKey (sold to TriZetto for $60 million in 2005), and two of the three also founded consumer telehealth systems vendor American Well.

People

Consultant Karlene Kerfoot, PhD RN joins API Healthcare as VP of nursing.

Lifespan (RI) names Ian Hyatt (GTECH) VP/CTO.

ZeOmega appoints Christopher Mathews MD (Community Health Network) SVP/CMO and adds Anne Wilkins (Healthways) and Anna Haghgoole (Sandbox Industries) to its board.

Santa Rosa Consulting names Patrik Vagenius (Dell Services) as EVP of sales and marketing.

Larry Stofko, formerly SVP/CIO of St. Joseph Health System (CA), has been promoted to EVP of the system’s Innovation Institute, which will design, develop, and commercialize potential solutions; create and manage a venture fund; and convert delivery opportunities into business units.

CareCloud appoints Joseph P. Sawyer (American Well) as VP of marketing.

MediRevv names Holly Krueger (CureIS Healthcare) as director of sales.

Acuo Technologies hires Barry Gutwillig (Virtual Radiologic) as senior director of business development.

Vocera appoints Steven Soderberg (Force10 Networks) as CIO.

Orange Regional Medical Center (NY) hires Sujatha Ramanathan (Pain Centers of American) as its director of ambulatory EHRs.

Announcements and Implementations

NY eHealth Collaborative announces that three RHIOs and three HIE vendors will participate in the state’s HIE.

RadNet, an operator of 232 outpatient imaging centers, implements eRAD’s RIS, PACS, and report generation solution.

The Advisory Board Company launches its 2012 Patient Engagement Blue Button Challenge to encourage the creation of apps for improving care by sharing health data. The prize is $25,000 and submissions are due August 6.

The EntryPoint module of PatientOrderSets.com earns ONC-ATCB certification.

MyHealthDIRECT wins ONC’s discharge follow-up appointment challenge, earning the company $5,000 and the opportunity to run a pilot project.

A team from IOSTREAM wins another ONC challenge, this one for creating the MedDAERS portal that providers and consumers could use to report adverse events and other problems with medical devices.

EXTENSION announces the release of Version 3.0 of its clinical alerting system.

Anthem Blue Cross and Blue Shield in Colorado announces that providers can access Availity’s Health Information Network to verify eligibility, submit claims, and review clinical histories and care alerts.

Government and Politics

HHS posts recorded streaming video of the Health Datapalooza plenary sessions. For celebrity watchers, Jon Bon Jovi goes on at the 1:43:00 mark of the Tuesday morning video. He muffs some lines when reading the script, but then ditches it and speaks really well. He mentions his “pay what you can afford” JBJ Soul Kitchen restaurant in Red Bank, NJ and his corralling of Aneesh Chopra outside a White House men’s room to talk about apps that can find available shelter beds and medical providers in real time.

The Congressional Budget Office says that if lawmakers do what they usually do to address budget problems (i.e., make them worse), healthcare entitlement spending will in 25 years make up 10% of GDP, pushing the country’s red ink to 200% of GDP.

The House passes a bill that would repeal PPACA’s medical device tax that is intended to subsidize the cost of providing insurance coverage to 30 million new people. The bill isn’t likely to pass a Senate vote and the President says he will probably veto it anyway. Device manufacturers will pay 2.3% of gross sales starting in January, and several of them have already announced layoff plans to offset the new expense.

The Federal Trade Commission files charges against electronic payments and collections vendor Checknet, whose customers include healthcare providers, for leaking consumer data. Checknet’s COO installed file-sharing software on his computer, exposing the health insurance and medical information of 3,800 patients to anyone using the same peer-to-peer software.

A proposed Michigan law would create a Peace of Mind Registry, an online database where patients can record their advance directives for review by providers.

Other

If you are a vendor looking for a cool trade show give-away, here is something better than a tee shirt, stress ball, or even a warm chocolate chip cookie. Pong Research announces a $120 iPad case that not only provides protection, but boosts the iPad’s 4G reception up to 10x, the Wi-Fi reception up to 9x, and range by 2x. Plus, it reduces exposure to electromagnetic radiation. The trinket bar has been raised.

Harvard Professor Latanya Sweeney PhD announces theDataMap, a crowdsourcing project to map the flow of personal data in the US. She says her early attempts to document the ever-increasing flow of patient information into more and more corporate hands elicited gasps every time she showed the graphic.

Two of New York City’s biggest health systems, NYU Langone Medical Center and Continuum Health Partners, announce plans to merge into a super-system that would cover the most affluent Manhattan neighborhoods and flank Mount Sinai Medical Center. The reaction of Princeton health economist Uwe Reinhardt: “Economists have for some time now worried about the ceaseless consolidation on the supply side of the health care market, facing a much more splintered payment side with less market power … So a hospital can literally tell an insurer you either take our prices or you take a walk, and that’s what’s happening. Both sides always justify that, not on the basis of crude market power — we want more market power to get better prices — they always find some kind of high national purpose.”

Rapping 10-year-old twins star in a hand hygiene video for caregivers that was developed by All Children’s Hospital (FL), where one of the twins had been a patient. The video won an award from an infection control group. Now I can’t get “scrub-a-dub-dub” out of my head. 

Mostly unrelated except for a medical clinic mention: the best graduation speech in history, even better than the one Steve Jobs gave at Stanford. The message to rich kid high school graduates: you’re not that special – we all are.

HealthLevel Script Object Notation, an open source HIE standard based on JavaScript Object Notation, seeks board members to steer what it says will be the most widely used HIE standard in the world. Nominations are due June 30.

An Oklahoma doctor asks in The Atlantic, Are Computers Getting Between You and Your Doctor? He says doctors are starting at computers instead of listening to and touching patients, are copying/pasting medical information without adding any value, and are forced to ignore the patient and click screen after screen to justify their payment. He concludes, “On my best days in practice, it seems as though all of my patients are savvy, engaged, and connected: e-patients. On the bad days, I feel like an overcompensated data entry clerk.” Check out the hideous stock photo used to illustrate the article (since nobody reads anything unless there are pictures, even unrelated ones): the monitor looks like it was made in around 1997, there’s a keyboard but no mouse, and the office furnishings look a lot more like a lab in Bulgaria than a US doctor’s office.

A doctor’s former receptionist is arrested in Connecticut for using the practice’s computer system to create narcotics prescriptions for herself.

iPhone/iPad EMR vendor Drchrono adds the ability for practices to process patient payments using the Square credit card reader. Square just announced that its reader will be sold at Walgreens and Staples stores or can be ordered at no cost from its site, with swipe card transactions charged at 2.75%.

A PwC report concludes that patients want mobile health to provide convenience or save them money, while doctors have less interest unless it can improve care, ease patient access, or reduce in administrative time. The report also predicts that change-resistant providers will slow mHealth adoption as everybody tries to protect their own turf, with the best chances for adoption being developing countries, and that the entitlement attitude of patients means that vendors need to appeal to payers.

eHealth Saskatchewan finds a computer problem that prevented diagnostic imaging results for about 100 patients from being faxed to their doctors for several weeks.

A group of high-profile healthcare CEOs and the Institute of Medicine develop a 10-point checklist of actions that can reduce costs and improve care. Among them: program hard stops into the CPOE system for duplicate lab test orders, requiring the prescriber to call the lab to override the block.

An editorial in the local paper by Mark Herzog, president and CEO of Holy Family Hospital (WI), talks up the hospital’s EMR. He goofs in his description of the one specific benefit by saying that in bar code medication verification, nurses “scan prescription bottles.” I would hope isn’t the case because only clueless hospitals dispense medications in bottles instead of unit dose packages, but I figure he dumbed it down for the lay folks.

Weird News Andy says clinicians must have had a flaccid response to this patient. He’s suing a Yale-New Haven Hospital emergency facility, claiming that staff watched a baseball game on TV instead of treating his priapism.

Sponsor Updates

• Black Book Market Research ranks Certify Data Systems third out of 20 private core HIE system vendors.
• HealthMEDX’s Bridgette Leonard offers advice on auditing EHRs to reduce readmissions.
• The California Health Information Partnership and Services Organization awards Family Health Care Network of Visalia (CA) $573,750 to advance its use of MED3OOO’s EHR.
• CTG Health Solutions releases CTGTALK 4.0, which allows users to manage the application via mobile devices or PCs.
• Nuesoft announces that its NueMD Android EMR app will be available this summer.
• RelayHealth launches RelayAnalytics Pulse, a comparative analytics solution for hospitals and health systems.
• Practice Fusion releases a 10,000-record HIPAA-compliant dataset and launches a data challenge to solve public health issues
• Western Kentucky Orthopaedic & Neurosurgical Associates selects SRS EHR for its 11 physicians.

EPtalk  by Dr. Jayne

The HIMSS Virtual Conference & Expo began this week. Keynote speakers included MedVirginia CEO Michael Matthews and political commentator Jonathan Alter.

When I’m teaching students and residents, I often challenge them to use non-medical search engines such as Google in addition to “traditional” platforms for finding medical information. A recent study in the Journal of Medical Internet Research found that identical searches performed using multiple search engines will produce different results. Since two-thirds of physicians and an even greater number of patients use standard Internet search engines to find medical information, the doctrine of caveat emptor becomes increasingly relevant.

In follow up to my piece on goat farming, a reader shared this story about a pediatrician’s frozen yogurt shops along the Jersey Shore. I know a lot of primary care physicians who have left medicine (or who have gone part time) and can’t help but think that if the pay were better the impending primary shortage would look different.

I wrote last month about medical schools compressing coursework for students choosing primary care careers. The American Board of Family Medicine, the Association of Family Medicine Residency Directors, and TransforMED are now working in cahoots to expand family practice residency training to four years. I don’t disagree that it will provide additional educational opportunities to trainees, but extending training (which translates to lost lifetime income for family docs) to an already-depressed specialty isn’t going to help recruit new family docs.

CMS keeps e-mailing me with reminders that Version 5010 Enforcement is almost here. The discretion period ends June 20, 2012 and practices that are still experiencing issues should work with clearinghouses and payers to resolve any problems. I’ve asked my trusted source Bianca Biller to provide a summary of her 5010 experience, but it appears she’s so busy fighting fires that she hasn’t had time to write.

Travis from HIStalk Mobile shared a link on Twitter that discussed whether so-called “sunshine laws” really work. These laws require drug and device manufacturers to disclose payments to physicians. I don’t see drug reps any more, but recently encountered this with a medical device manufacturer rep who wanted my NPI and state license number before buying me a drink. Since I’d already authorized purchase of tens of thousands of dollars in hardware, I didn’t think one Cosmopolitan celebrating the closing of the deal was going to cause an ethical lapse. Although I know my state license number from memory, I was particularly glad that my OCD had led me to store my NPI in the contacts section of my phone.

Speaking of phones, MSN reports that nearly 20% of smart phone users are sexting or otherwise sharing explicit photos or text messages. The most common age groups are men aged 18-34 and women aged 35-44. The report states, “only 3 percent of American adults who are smart phone owners say their biggest concern about losing their phone is that their inappropriate pictures or text messages could be exposed… this number is shockingly low when you consider that 69 percent of smartphone owners have lost their phone.” Grammatical issues aside, I find the quote surprising. If I ever lose my phone, I hope the finder is titillated by the sassy acronyms found within: CCHIT, ONC, HIPAA, EDI, PCMH, and HL7.

Have tantalizing news? Let me know on Twitter @JayneHIStalkMD, on Facebook, or if you’re old-school, e-mail me.

Health Datapalooza from the Eyes of an Entrepreneur
By Dan Wilson

Our company, Moxe Health, was invited by HHS to attend the Health Datapalooza (HDI Forum) because of a product we designed during the Milwaukee BuildHealth Hack-a-thon seven weeks ago. Triage.me was our response to a challenge posed by Aurora Health Care: "Reduce the number of ED visits for non-emergent care in Milwaukee County."

I first learned about the Datapalooza listening to Todd Park’s presentation at the HIMSS conference. We had no idea we were going to be participating until a month ago. Talking with other folks around the event, our experience wasn’t unique. In a sense, Datapalooza is a large-scale agile conference. Hosted by the government. For healthcare. It’s pretty wild.

The last conference I went to was HIMSS. The Datapalooza is definitively not HIMSS.

As an exhibitor, we had the same amount of space as IBM, Aetna, and SAS. Specifically, an 8×8 booth, with nothing allowed to hang overhead and no swag over $10. It was refreshingly low key. Also, startups didn’t pay for their own booth (thanks, HHS!) That’s Mark and me in the Moxe / triage.me booth. We were among the first to set up on Monday. Really nice convention space.

This is the closest you’ll see to the government holding a startup event. They pulled it off, and a lot of respect is due to the folks at HHS and the ONC. Todd Park deservedly gets a lot of the attention, with some folks (HHS Secretary Kathleen Sebelius) even referring to it as the "Todd Park Roadshow." But the event was much bigger than that, and it’s clear there’s a lot of momentum propelling it event forward.

As further evidence of the underlying focus on innovation, one of the most anticipated sessions was held in a side room to make sure the Wednesday afternoon app demos could be simulcast online. While two youngbloods from Wisconsin (and the other code-a-thon winners) were presenting their product on the main stage being simulcast across the nation, Atul Gawande and Farzad Mostashari were facilitating an ACO breakout in a relatively small, overheated room with spotty Internet connectivity. We’re not sure if this was by design or by accident, but the it reinforced the statement that the only thing bigger than the technologists innovating things at the HDI was Bon Jovi (who aside from his noble work for the homeless, also innovated the technological wonder that is "Living on a Prayer.")

Even the ACO event panelists were made up of a number of small, yet terribly innovative companies. One example I learned about was Forward Health Group, a 20-employee company that’s coming up with awesome ways to connect and visualize data. They’re now working with the Guideline Advantage program, which is a collaboration of the American Heart Associate, American Cancer Society, and the American Diabetes Association.

From our standpoint, the event was a huge success. As a young company, we gained incredible insight and valuable contacts from ONC, HHS, and private enterprise leadership. I’m excited to see where the Datapalooza goes next, and I’ll be doing everything I can to stay involved.

Random Musings

@Farzad_ONC Humble apologies, sir! Truly, I did think…no bowtie…aaarghh. But that apron…oh dear.

— Forward Health Group (@ForwardHealthGp) June 6, 2012

• The bow tie is in vogue around the ONC.
• The new Healthdata.gov site launched. I spoke with one of the guys who helped program it. His take is that structurally, the site is a step forward and a good foundation for releasing better data. He also felt that the currently available data/APIs weren’t much changed and there’s still a ton of work required to make sure the data being opened up is both valuable and usable.
• Kathleen Sebelius mentioned that another 150 ACO organizations are slated to start in July.
• VC investment is up 60% in the HIT sector since 2009.
• From Kathleen S.: a recent diabetes study showed patients cared for by a doctor using an EHR had a 600% better chance of receiving the right care.
• I think Bill Frist summed up the focus of the conference well: "The goal is to turn data into discovery."

Dan Wilson is CEO and Mark Olechesky is CTO of MOX eHealth, LLC.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Readers Write 6/6/12

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!

Moneyball and the Power of Data Analytics
By Gerard Livaudais

I’m not much of a baseball fan, but I really enjoyed the movie Moneyball. If you haven’t seen it (or read the equally excellent book by Michael Lewis), here’s a ten-second synopsis. Billy Beane, general manager of the Oakland As baseball team, bucks traditional scouting methods by using data analytics to find undervalued players. He is pilloried by baseball purists for his stats-obsessed methods, but he builds a winning team on the league’s lowest payroll.

Moneyball may be a baseball movie, but the real story is about the transformative value of data. And as the final credits roll, what’s clear (at least to this viewer) is that even the most under-funded team in baseball uses data more effectively than most healthcare providers.

The use of data as a business intelligence tool is hardly new. In almost every industry on the planet, companies are leveraging data-driven decision-making to realize productivity gains, achieve competitive advantages and improve overall performance. Even the smallest of SMBs (small and medium-size businesses) are getting in on the act, thanks to the simultaneous rise in computing power and drop in hardware and storage costs.

Businesses like the Oakland As are using data to win baseball games. In a hospital, access to the right data at the right time saves lives. Yet healthcare organizations as a whole are failing to use current, accurate data to support their clinical, financial, and operational decisions.

Healthcare should be setting the standard for data-driven business intelligence. Here are three strategies we can use to get there.

1. Focus on the Data that Matter

Healthcare organizations certainly don’t lack for data. Thanks in part to a constellation of regulatory mandates, we already capture, store, and report phenomenal amounts of data. On the other hand, financial incentives – never the top priority but always a factor — for effective use of data are rising. Meaningful Use Stage 2 includes numerous value-based purchasing elements and aggressive penalties for hospitals and physicians who fail to demonstrate the quality of care they deliver.

One way we can leverage data more effectively is by breaking down the data silos that prevent the right information from getting into the right hands. As an industry, we spend billions of dollars building and maintaining the data warehouses that power analytics across healthcare environments. These internally-hosted systems may be great at assembling data and powering analytics for specific departments or functions. But they also isolate that data, inhibiting its value as a decision support tool.

The right business intelligence technology can break down these data silos much more easily and cost effectively, enabling all decision-makers within an organization to access the most relevant metrics and performance indicators. The implementation and support cost factors for Software-as-a-Service (SaaS) solutions are several orders of magnitude less than internal systems.

2. Leverage Internal and External Data

Once internal data silos are torn down, healthcare organizations have the ability to seamlessly share information across departments and business units. Integrating data from outside your organization is essential to enabling true comparative analysis. Inconsistent data formats are a nightmare to normalize and aggregate manually. But industry data standards such as HL7 are helping enable true interoperability among best-of-breed technology solutions.

3. Influence Positive Patient Behavior

Health outcomes are ultimately dictated by patient behavior. One of the most promising frontiers of clinical business intelligence is the ability to blend data that reflect not just clinical activity, but social factors that can help predict how well certain patients will comply with a treatment plan, particularly for chronic illness.

These factors can range from patient-generated measures – such as how patients prefer to interact with their physicians – to the presence of psycho-social indicators such as depression and exercise level. Their economic impact can be profound. The cost to treat diabetes in patients with depression is more than twice that of diabetes patients without depression. By blending clinical and social indicators, providers are able to “personalize” treatment plans that simultaneously raise the probability of successful health outcomes and reduce the overall cost of treatment.

However, some of these measures of efficiency are not universally appreciated just yet. As Billy Beane discovered, prioritizing on-base percentage over batting average may be a more efficient path to building a successful team. But his Oakland As had to win games first – a lot of them – before his industry appreciated his logic.

The good news for healthcare is that everyone – from physicians and providers to device manufacturers, pharmaceutical companies, insurers and other payers, and even academic and research institutes – benefits from more efficient and successful patient outcomes. All parties also benefit from instant access to accurate healthcare data. The right tools can open up a world of opportunity to improve outcomes and save lives.

Gerard Livaudais is chief medical officer of Quantros.

Care in an Emerging Market
By Arvind B. Deshpande

Recently my father, who is 84, was hospitalized for profuse sweating based on telephonic advice of our family doctor.  I live in a city about 150 km from Bangalore (or Bengaluru). I am describing the care at the hospital.

We arrived on a Saturday around midnight without calling the hospital. As soon as we reached the hospital, staff at the entrance wheeled him to ED. The duty doctor took an ECG and advised moving him to ICCU. By the time I finished the paperwork at billing (where they located his nine-year-old ECG record in less than a minute,) he was in the ICCU on the first floor of the four-floor hospital.

The doc in ICCU immediately connected a vital signs monitor. Noting the low heart rate of 40, he mentioned that an external temporary pacemaker might become necessary. I signed the consent, giving my contact details.

Around 2:30 a.m., I got a call saying they had connected the external pacemaker after his heart rate became irregular and he had been defibrillated. My father stayed in the ICCU until Monday morning, when the interventional cardiologist took a look and advised an angiogram. He mentioned that if there was a heart block, they might have to introduce a stent.

I again signed the consent papers. The whole procedure, including angioplasty, was completed in an hour. My father was moved back to ICCU. Care in ICCU was good, timely, and home-like, to say the least.

The doctor mentioned that he would stay in ICCU for two days, then be shifted to the ward for another 2-3 days. The external pacemaker would still connected as a safety standby. He was moved to the ward after two days and the external pacemaker was disconnected on Day 4. He continued in the ward until Day 6 as a precautionary measure, then was discharged from the hospital.

I had the opportunity to interact with the doctor every morning. The findings were recorded on paper and explained to me daily.  On the last day, all the records were signed off, billing was completed, and we came home,  which is about a 10-minute drive from the hospital.

This 30-bed hospital dedicated to cardiac specialty has its own IT hardware setup and software locally developed to support them. Meaningful Use and EMRAM standards do not exist and are not mandatory. This hospital is ISO 9001 certified ,and one can say they comply with the standard in letter and spirit.

I work for a medical device manufacturer here. I am an avid reader of your blog, from where I have gained some insight into how providers and vendors work towards patient care in the US.

I am not suggesting that the recent measures announced in the US are not necessary. The above incident is only to spread awareness as to how good care is primary and systems are required to support care.

Arvind B. Deshpande is head of quality assurance and regulatory affairs for Larsen & Toubro of Mumbai, India.

Why We Do What We Do
By Dan Herman

I have received a birds-eye view of our healthcare delivery system while tending to my mom over the past couple of months. She had major open heart surgery at a hospital outside of Chicago in late April. She was discharged to rehab and is doing pretty well for a woman who will turn 82 next week.

The hospital that cared for her is part of a large IDN, highly integrated on a single EMR platform for their inpatient and multi-specialty physician group practice.

They are a HIMSS Analytics EMRAM Stage 6 organization. Not only was the care and patient service impressive, but the collaboration and coordination among the care team was practically seamless. Her internist, cardiologist, thoracic surgeon, and anesthesiologist; nursing teams in the med-surg, ICU and SICU units; physical and speech therapists; dietitian; and social worker for discharge planning were all working in synch across her episode of care and had access to her clinical information across the care continuum (including her previous problem list and meds and allergies from her internist that practices at the medical group). Mom also accesses her regular lab results from home (and now the rehab facility) through the health system’s patient portal.

My key observation was the impact of what we do as healthcare IT and operations improvement professionals. The hospital that cared for my mom has long been recognized as a leader in the use of information technology to support care delivery, operational, and financial management processes. They had a paperless business office in the early 80s; standardized the nursing documentation process across their four acute care sites in the 90s; and obtained 90%+ CPOE adoption almost 10 years ago.

During the inpatient stay, I didn’t see any paper. Everything was documented in the system – nursing notes, MD notes, anesthesia and OR record, legal documents, ICU monitoring device results, etc. But more than the IT aspects, I noticed a very streamlined and coordinated care process that was centered on the patient. Patient safety and service was the driver behind the outstanding use of the top-of-the-line technology. Always confirming the patient’s name, medication bar coding that ensured the right meds, doses were delivered to mom at the right time (she really hated being woken up at night or at 7 a.m.)

Mom was transferred there from the hospital down the street (it’s where the ambulance took her). She never felt comfortable and safe at the first hospital. Her doctor didn’t practice there. They didn’t explain what was going on. They didn’t have access to her past clinical history. The caregivers weren’t coordinated. Patient safety was in question (a nurse came in with meds for another patient). The facility wasn’t as nice, and the food was not nearly as good. However, they used the same EMR.

It’s not about systems. It’s about leadership, accountability, and the care delivery process. The contrast between the two hospitals was a case study. This overall experience drove home the significance of what we do. Whatever your specialty is or your role within your organization, it’s essential to never forget our true mission – improving healthcare.

Dan Herman is founder and managing principal of Aspen Advisors.

News 6/6/12

Top News

An article in The Economist covers the programming that powers medical devices such as smart IV pumps and pacemakers, proprietary systems that the FDA has the power to examine but rarely does even though the programming can be sloppy, error-filled, or vulnerable to hacking. Penn researchers are working with the FDA on an open source alternative that would bypass uncooperative manufacturers, hoping to prevent more bugs and turn fixes around more quickly. Similar projects at other universities address open source CT and PET machines and surgical robots. The article also mentions $10 million NIH-funded The Medical Device Plug-and-Play Interoperability Program and the more ambitious Medical Device Co-Ordination Framework of Kansas State University, which is developing a core set of downloadable, open source apps that could be pieced together to create medical devices.

Reader Comments

From Defiant: “Re: the University of Missouri billing fraud story. The dean of the med school is also the former chair of the Department of Radiology. He was the key influencer in having the Cerner RadNet application uninstalled six months after installation some six years ago. The Feds would be wise to plan an extended stay at this place.” Unverified. The health system announced that Dean Robert Churchill MD will retire after news of the federal investigation broke.

From Who CaresFX: “Re: Carefx. Looks like Chairman and CEO Andy Hurd has left for greener pastures. I heard they were doing a RIF, but the CEO? His profile has been removed from the site.” He has indeed been expunged from the site, but that’s because he left to become CEO of Epocrates in March. Harris bought the 250-employee Carefx just over a year ago for $155 million, expressing interest in its interoperability business .

Acquisitions, Funding, Business, and Stock

Awarepoint raises $14 million in funding, including the first investment of the Heritage Healthcare Innovation Fund, which is backed by several health systems and vendors.

Data analytics vendor MedAssurant changes its name to Inovalon.

Sales

Winter Haven Hospital (FL) will implement Amcom Mobile Connect for encrypted smart phone communications.

The VA awards Harris Corporation a two-year, $19 million contract to create a wireless network infrastructure for 26 medical centers.

People

Physician learning network QuantiaMD appoints Beth Israel Deaconess Medical Center CIO John Halamka, MD to its board.

Harry R. Jacobson MD, former vice chancellor for health affairs at Vanderbilt University Medical Center, joins ICA’s board.

M*Modal hires Jonathan A. Handler MD (Microsoft, MedStar Health) as the company’s first CMIO.

WebMD names former Pfizer executive Cavan M. Redmond CEO and a member of the company’s board. He replaces Wayne Gattinella, who resigned in January following a failed attempt to sell the company.

RF Technologies hires Ken Sandifer (GE Healthcare) as SVP of service and operations.

Anthelio Chairman and CEO Richard Garnick resigns in what the company describes as “an amiable and mutually agreed upon process.” Chief strategy and innovation officer Rick Kneipper will serve as interim CEO until a permanent CEO is hired.

Medsphere Systems names Lily S. Chang (Advent Software) as CTO.

Shareable Ink names Keith Slater (Henry Schein Medical) as VP of client services.

Mediware SVP/COO John Damgaard resigns effective September 7, when he will join an unnamed private company as president.

Halfpenny Technologies appoints Brian Muck (Vitera) as EVP of sales and marketing.

Plastic surgeon Howard Krein MD PhD, Organized Wisdom’s CMO, makes non-HIT headlines for his marriage last weekend to Ashley Biden, daughter of VP Joe Biden. I loved his unofficial bio, published in an independent Jewish newsletter:

Dr. Krein, 45, is quite the catch. He is double board certified in otolaryngology and plastic surgery and has a PhD in cell and developmental biology. He is an assistant professor at Thomas Jefferson University as well as maintaining a busy medical practice. Krein, who is a Cherry Hill, N.J. native, also serves as chief medical officer of Organized Wisdom, a company founded by his brother to provide digital solutions to medical professionals. Most importantly, he is a mensch.

A 21-year old Chicago man becomes the youngest student ever awarded an MD (as well as a PhD in molecular genetics and cell biology) by the University of Chicago. Sho Yano began reading at age 2, was writing and composing music at age 3, and earned his undergraduate degree from Loyola at 12. He’ll begin his residency in pediatric neurology. When I was 21, my biggest accomplishment was winning the Quarters tournament in my dorm. 

Announcements and Implementations

The DoD extends Authorization to Operate certification to Mediware, paving the way for the implementation of Mediware’s HCLL Transfusion software to 68 MHS sites worldwide.

PDR Network announces that 18 EHR vendors have signed agreements to deliver its drug and safety information to their users.

Release of information vendor MRO Corp. announces availability of its patient portal solution, ROI Online.

Government and Politics

CMS reports that Medicare and Medicaid EHR programs have paid hospitals and EPs over $5 billion in incentives through the end of April.

ONC extends the public comment period for the Nationwide Health Information Network Condition – Conditions for Trusted Exchange until June 29.

Even CEOs and politicians wish they were rock stars, and you can see why given Jon Bon Jovi’s draw with the ladies at Tuesday’s opening sessions of the sold-out Health Datapalooza in DC (the photo is from the IOM.) The live streaming was of really good quality, so I watched Todd Park speak for a short time before I had to get back to work. HHS Secretary Kathleen Sebelius will speak Wednesday morning, with former Senate Majority Bill Frist later in the morning and other speakers and demos in between.

Innovation and Research

Children’s Healthcare of Atlanta and Georgia Tech form a $20 million research partnership that will develop pediatric technologies, including medical devices and healthcare software.

Technology

Matt Grob, senior director of enterprise IT planning at The Mount Sinai Medical Center (NY), says he was inspired by recent HIStalk and HIStalk Mobile articles on pagers to write this mHIMSS blog posting that works in a mention of Caddyshack’s Dr. Beeper and the drug dealer/doctor pager connection in adjacent paragraphs.  

Other

The Consumer Federation of America says CSC’s Colossus evaluation software, used by insurance companies to classify bodily injuries in auto and homeowner insurance claims, intentionally downgrades injuries and saves the insurers 20% over the evaluation of human adjusters. The group claims the software can be used with other applications that reduce “usual and customary” medical costs. The above description is from CSC’s site.

The company that operates Walmart’s retail medical clinics is piloting in-store telemedicine-based video consultations.

Consumer Reports will publish ratings of Massachusetts physicians  in copies of next month’s issue that are distributed to that state.

In Greece, the diabetes association claims that diabetics are at risk because pharmacists have cut off credit to the country’s largest healthcare fund, which owes them $670 million. The health ministry says it can’t pay its debts without more bailouts, leaving patients without the 75% medication subsidy it provides.

A Norwegian foreign exchange student rushed to a California hospital after a rattlesnake bite is billed $144,000, almost all of that the cost of antivenin. The patient, who notes that the same services would be free in Norway, expects insurance to cover most of the costs. Yesterday I opened a bill for recent medical expenses and nearly cried reading the astronomical amount due in the “patient responsible” column. Not to get political, but what do the uninsured and un/underemployed do?   

Weird News Andy finds this story to be a mash-up of recent HIStalk ones involving heroic Army nurses and surgeons removing explosives from patients. A helicopter crew of four New Mexico National Guardsmen volunteers to medevac 20-year-old Marine Lance Corporal Winder Perez from the site of a Taliban attack in Afghanistan despite the presence of a live, foot-long rocket-propelled grenade lodged in his leg. They work on the patient in flight, exposing themselves not only to the possibility that the RPG would explode in their faces, but also that it might ignite the helicopter’s 300-gallon jet fuel tank just 18 inches away. They bring their patient safely to a field hospital 65 miles away, where a Navy lieutenant commander nurse and an Army staff sergeant, wearing full combat gear and flak jackets, remove the explosive so the medical teams can get to work. The patient is recovering at Walter Reed. As WNA says, “May God bless these brave people.”

Bizarre: a 31-year-old police officer dies during a sex threesome that doesn’t include his wife. His family sues the cardiologist he had seen the week before for chest pain for medical malpractice, claiming the doctor didn’t advise the man to avoid physical activity. His stress test appointment had been scheduled for the day after he died. The jury awards the family $3 million.

Sponsor Updates

• nVoq will exhibit at the 11th International Congress on Nursing Informatics this month in Montreal.
• DIVURGENT employees raise $5,000 for Miami Children’s Hospital Miracle Network.
• EMC presents World Wide Technology with its Velocity National Partner of the Year Award.
• Macadamian Technologies’ Matt Hately, VP of product Strategy and innovation, will participate in a panel discussion on mHealth opportunities during next month’s 9th Annual Healthcare Unbound Conference in San Francisco.
• Billian’s HealthDATA presents EHR saturation by physician specialty based on CMS’ latest attestation reports.
• PROFIT Magazine names NexJ Systems Canada’s fastest-growing company.
• Christi Clinic (IL) selects eClinicalWorks EHR solution suite for its 150 providers.
• The Advisory Board Company highlights best practices and new technology supporting ACOs at this week’s Health Datapalooza in Washington, DC.
• An Allscripts-sponsored study finds that C-level executives have an positive attitude about value-based purchasing and its impending takeover of traditional fee-for-service reimbursement.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 6/4/12

Being an anonymous blogger, I never know when an idea is going to drop into my virtual lap. When I’m not in the healthcare IT trenches, I like to embrace certain summer pastimes – drinking mint juleps on the porch, gardening, and making the occasional trip to see some minor league baseball.

I was seated behind first base enjoying some Cracker Jack when the conversation turned to healthcare IT. A particularly tech-savvy friend of mine was talking about iPad apps. Knowing I’m a physician, he mentioned that his old college buddy recently showed him an electronic health record app that he’d been working on.

Turns out Joe College works for a major HIT vendor. My curiosity got the best of me. I asked my friend what he thought of the app. This was his response:

Well, he kept trying to show me a bunch of features that weren’t coded yet. It looked like something that was designed by an IT guy who may have talked to a doctor once and really didn’t have any idea how to do a good user interface.

Knowing the vendor in question, I’m not sure if I should be surprised or not. I didn’t have details on whether the app was for hospital or ambulatory scenarios so I don’t have a lot to go on, but it got me thinking about the role of physicians in software design.

Working for a major health system I’ve been exposed to many vendors. There is significant variation in whether they have physicians on staff, let alone physicians who participate in the design process. Some are very open about the docs on their teams and will connect clients with them for doc to doc conversations. I’ve found those valuable, especially when implementing new software and those “what were they thinking” questions arise from end users.

Others rarely mention whether they have physicians on staff. If you push them they may trot out one of a variety of archetypes:

• The physician who hasn’t practiced in decades but is great with software
• The physician who is a highly-trained informaticist but doesn’t understand office practice
• The physician who really knows what he or she is doing, but is far too busy to interact with clients.

After talking to a couple of my CMIO buddies, I think it’s time to have a little industry conversation about the role of physicians in design and usability testing.

Much like when Mr. H poses “state of the industry” questions to the leaders of the vendor space, I’m giving an opportunity for companies to speak up about how they use physicians and other clinical experts in design, implementation, and support. Here’s the hitch though – I’m not going to come begging for information.

This opportunity is for companies with staff that are loyal HIStalk readers. Let me know how your organization leverages licensed providers and at which stages of the game. I’ll feature the responses in an upcoming Curbside Consult. Priority placement will be given to companies with witty submissions. Extra credit will be awarded for photos of your physician team in action.

Got docs? E-mail me.

E-mail Dr. Jayne.

EHR Design Talk with Dr. Rick 6/4/12

Special Edition: The ONC/NIST Workshop on Creating Usable EHRs — Part 1

On May 22, ONC and the National Institute of Standards and Technology (NIST) jointly sponsored a workshop in Gaithersburg, Maryland on Creating Usable EHRs: A User-Centered Design Best Practices Workshop.

If any major vendor CEOs had attended, I think they would have come away with the mission to make EHR usability, defined broadly, a top priority of their organization.

In his opening remarks, Farzad Mostashari, National Coordinator for Health Information Technology, noted that when talking with clinicians across the country, the number one issue he hears is that their EHR is unusable, that "the system is driving me nuts."

Broadly speaking, EHR usability is about suiting EHR design to human requirements and abilities, not the other way around. I’ll start by giving three examples.

Example #1

Pediatric cardiologist David Brick presented an error-prone EHR design that could lead to a catastrophic result in a safety critical environment, a neonatal ICU. In the medication module of the EHR, the column containing the names of the medications is too narrow, presumably to conserve screen space. Consequently, the names of medications are truncated. In the example below, the truncated forms of the medications amiodarone and amlodipine are visually similar.

Administering amlodipine to a neonate when amiodarone was intended is an error with potentially fatal consequences. One can see how a neonatologist might confuse the two, especially in a high-stress clinical setting.

Example #2

As part of his talk, Bentzi Karsh, Professor of Industrial and Systems Engineering at the University of Wisconsin-Madison, conducted an audience-participation experiment by presenting the same data set in two different formats. (The 2 figures that follow are printed with permission from Sue M Bosley, PharmD, CPPS.) Our task was to determine as quickly as possible how many of the lab values were outside the normal range for the patient below. Try it:

In the view above, it took us anywhere between 15 and 45 seconds to determine the number of out-of-range labs and 20% of us came up with the wrong number. Furthermore, we were so focused on the task at hand that not one of the 150 of us noticed that the patient was a dog.

Then the same data was presented in a format better optimized for visual processing:

Using the visual display of the same information, we all identified the out-of-range lab value in less than 3 seconds and there were no errors.

Example #3

The third example comes not from a presentation, but from a conversation over lunch with fellow attendees of the workshop. Jared Sinclair, an R.N. and developer of iOS applications for bedside nursing, was telling us about a widely-used workaround that hospital-based nurses have devised to deal with an EHR design problem.

One of the major tasks of hospital-based nurses is to make sure that each patient assigned to them gets the right medications at the right time of day. The EHR medication screen view that nurses see is called a Medication Administration Record (MAR). It serves both as a schedule for administration and as a tool to document whether and when medications were actually given. Jared was kind enough to create the MAR mock-ups below (shown as an overview and then a zoomed-in view) based on the design of several widely-used EHRs:

What nurses need for each patient, however, is a portable list of medications organized by the time of day those medications should be administered. Because most EHRs don’t provide this alternate view of the data, at the beginning of every shift nurses create their own paper-based lists (see example below):

***

Each of the three examples above represents a disparate aspect of EHR usability. The fact that they are so different helps explain why designing usable EHRs is so difficult.

Further complicating the discussion is the fact that usability can be defined in a number of ways. If usability is narrowly defined, it can focus on the kinds of issues in example #1 to the exclusion of the kinds of issues in examples #2 and #3, which in fact may represent greater risks to patient safety.

The three examples above just scratch the surface of the EHR usability problem. To better understand these issues, I recommend a superb viewpoint paper in JAMIA discussing EHR usability and related issues. The two lead authors, Bentzi Karsh and Matt Weinger,  spoke at the workshop. Their points are easy to follow. In my opinion, their paper should be required reading for vendors, administrators, and clinicians alike.

Broadly speaking, the field of usability can be divided into two parts:

• User-Centered Design (UCD), which deals with the design process, and
• Summative Usability Testing, which evaluates and validates designs toward the end of the design process.

While these two components can be seen as parts of a continuum, in practice it is helpful to separate them.

I was glad to see that the ONC/NIST workshop focused on User-Centered Design – the process of creating usable EHRs – as opposed to focusing narrowly on testing protocols. Of more consequence, in its March 2012 Notice of Proposed Rule Making (pp. 13842-3), ONC states that a significant first step toward improving overall usability is to focus on the process of UCD (as opposed to mandating formal summative testing).

For me, there are two major questions:

1) What exactly is User-Centered Design (UCD)?

2) What role, if any, should ONC play in regard to UCD and EHR usability?

I look forward to sharing my thoughts on these issues in my next post.

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.