HIStalk Interviews Lou Halperin, CEO, OTTR Chronic Care Solutions

Louis E. Halperin is CEO of OTTR Chronic Care Solutions of Omaha, NE.

Give me a brief overview about yourself and about the company.

I’m CEO of OTTR Chronic Care Solutions. I’ve been in healthcare about 25 years and worked on just about everything there is technology-wise except for in the pharma space.

The company was founded as Hickman-Kenyon Systems in the solid organ transplant business. We’ve expanded that after acquiring the company last year into OTTR Chronic Care Solutions. When you manage patients that are awaiting organ transplant, they’re generally the same types of disease states with chronic conditions – liver disease, kidney disease, all the way up to a heart failure. We think it’s an important niche in the marketplace, particularly in light of the move to accountable care organizations and the changes in insurance.

I was intrigued by your background. You got an engineering degree from one of the best schools in the United States, you’ve got patents, you’ve worked for big companies. I’m curious how your life’s journey took you to where you are today.

I worked for a few big companies, being Medtronic, GE, and Philips. I got restructured out of Philips a few years back based on the job I did and being remote from the corporate offices.

I was very fortunate that I had built some relationships here in Nebraska with the medical center through an angel investing group that I’ve been involved with. I started doing consulting for them. I found HKS Medical Information Systems and we put together a partnership with an equity partner out of Dallas and a business partner who’s our chief operating officer, Paul Markham. We acquired the business last fall because we saw a great opportunity to grow it. It’s the right place at the right time. All the things I did working for big companies prepared me to lead this business.

It might be a surprise to the person who spends most of their time thinking about healthcare IT in hospitals and physician practices that there is a transplant industry out there and it has specialized needs that may not be met by traditional software. How big is the transplant industry and how are its IT needs different?

If you look at solid organ transplant, there are approximately 254 solid organ transplants centers in the US today. What most people don’t understand is that transplant was the original accountable care organization. For more than 20 years, CMS has been making lump sum payments to solid organ transplant centers for the care of patients, so you have the full Medicare cost report and driving that forward. 

Your patient may travel 100, 200, 300 miles to solid organ transplant center to be evaluated and put onto a transplant waiting list. You may be on that list for anywhere from months to years to as long as a decade, depending on which organ is at risk and what your absolute condition is. Because of that, you need to track the data around those patients very differently. You’re not looking at it as one episode of care and the next. You’re looking at it over a 3-, 5-, 7-, 10-year period of time. That’s the same in the post-transplant world.

The other thing that’s different is that the data that you’re looking at isn’t just from the healthcare system where you’re going to be transplanted. It maybe from a laboratory that’s local to your community. If you’re a kidney patient, a local nephrologist may be following you and providing you your direct day-to-day, weekly, monthly care. 

You may only be seen at the transplant center once a year every two years for a follow up. Yet when an organ comes available that has your name on it, that surgeon only has a few minutes to make a clinical decision about that organ — whether it’s right for you and whether they want to accept it.  Therefore, they want to see all the data, not just from that one institution.

For a lot of healthcare systems that have transplant, their profitability really depends on transplant. There was a major Midwestern integrated delivery system that we were visiting where the transplant surgeon ensured us of roughly 40% percent of the total profit margin for the healthcare system came from having transplant. It’s not just from the surgery, but it’s what it does to your labs, pathology, bringing in patients for evaluation and such. Centers that have transplant as part of their business — it enhances their profitability and helps them deliver those service lines that aren’t profitable. It’s a challenge, but that’s what we’re seeing, that’s why we love what we do. We think we can help people.

I supposed you have a finite list of prospects since there are only 254 of them. Do you have competition, or are you the only recognizable name in the transplant niche?

There are few other names and some companies that do it. They’ve grown out of a couple of other centers that provide software. But it’s a challenge, because not everybody understands that there are special needs in transplant. Again, it’s the longevity of time of the data that you’re looking at it. It’s how physicians want to be able to see it and how surgeons want to be able to see it differently. So there is some competition. There are companies that grew out of Ohio State and UPMC. 

There are EMR companies that want to try and play in the space with us. Some can be credible about it, but it’s really a different way of looking at data than what EMRs tend to do.

I would have assumed that this a critical, regulated, and not very large market that EMR vendors would steer clear of. I see from your literature that you’ve interfaced with systems like Cerner and Epic. Is it a difficult sale to make when you tell a new Epic customer that they now need a best-of-breed transplant solution?

We’ve been reasonably successful. I can point to a couple of sites in Florida where Epic was the EMR of choice and the departments wanted their own solution. We’re currently in negotiation with another center that has Epic. Epic has a solution that they’ve brought to the market around solid organ transplant, but we’ve still had pretty good success there.

But it’s a challenge. Epic’s a great company. They’ve got great software for what it is that they do. It’s competition, but I told the team here that I’d just as soon compete against the best than I would against anybody else. It has been a fun fight.

We think that we’re different. If you were to ask me where the EMR is great, I’d say when you’re documenting inpatients in a bed of if they’re in your clinic as an an outpatient and you’re going to bill for those services. EMRs are the absolutely correct place to be able to document on your patient.

If you’re looking at data that might Meaningful Use Stage 2, Meaningful Use Stage 3 where it’s a remote lab, it might be a remote follow-up, it maybe follow up notes from a local nephrologist or hepatologist who’s following that patient because they happen to live … I’ll make it local here in Nebraska, where we’re headquartered. They might be out in Scottsbluff, which maybe even easier to get to Denver than it is to get in Omaha if you were going for a transplant. But those patients are not going to travel 300 or 400 miles to get their regular follow-ups for care. It just doesn’t work in an EMR. Again, we will see what happen as Meaningful Use Stage 2 and Stage 3 get here, but as of right now, we’ve been doing this for close to 20 years and we’re very comfortable at being able to track that data.

Transplants have gotten to be almost routine, I guess. You don’t hear a lot about it except when they do one of those donor chain matches or somebody gets in trouble for poor record-keeping or someone like Dick Cheney or Steve Jobs gets a transplant. Do you need special knowledge on your end to deal with procedures that are somewhat political, always expensive, and critical to both the recipient and the person who didn’t get the transplant?

One of the things that I found in 25 years in healthcare is that having domain expertise, no matter what it is you’re selling, is critical — whether you’re in cardiology, radiology, oncology, or transplant. I think that our customers look to us to be able to help guide them as to how to use a transplant database to keep track of the data that they need. 

You look at it as a highly regulated part of the business, also. There’s CMS regulations and audits which can cause a program to be shut down. There’s a group out of Virginia called the United Network for Organ Sharing or UNOS, which is also a regulating agency. Every patient that’s listed for a solid organ transplant is listed according to the rules of UNOS. They get organs based on hierarchy and priority that UNOS has established for allocating organs out. It’s not just matching a type of organ that’s there.

You mentioned that Cheney received a heart within the last couple of weeks. There are only about 2,000 donor hearts that are available for transplantation every year in the US. That limited number is one of the reasons why Ventricular Assist Devices or VADs have grown in use as a destination therapy.  

Everybody says Dick Cheney was too old or he only got the heart because he’s a former vice president of the United States. When you look at the rules that are there, he got a heart based on his condition, based on his likelihood of success in a transplant, based on how it matched to that organ. He was the best person listed in a region where that heart could transplanted to be able to receive that heart. 

There’s all this regulation. That’s really why we’ve had great success in staying in the centers where we are and co-existing with EMRs even as things change. We help our customers to be able to meet their regulatory requirements. We helped them meet CMS. We helped them present the data that they need and we help them present the data they need to make their UNOS certification.

Steve Jobs moved to Nashville because he would be higher on that area’s waiting list, which is allowed. Is the transplant business competitive at all, other than geographically, or is it just one big transplant center per region?

It depends on where you are. If you go up to the Northeast and you go into New York City, you can find the three major hospitals directly in New York City that all do solid organ transplant — Cornell Presby, Mount Sinai, and Montefiore Hospital.  But even when you then get outside of New York City, you can circle down into smaller communities where there are transplant centers. Kidney being the dominant transplant center, followed relatively closely by liver programs and then heart, lung, etc. 

It really depends on where you are. When you get west of Omaha or west of the Twin Cities in Minneapolis and St. Paul, the number of transplant centers certainly decreases until you get to California and the West Coast. It all depends on your geographic location. The ability to get yourself to a transplant center if an organ becomes available is what’s critical. The reason why Steve Jobs could continue to live out in California while being listed in Tennessee is that he had access to a private plane. When that organ became available, the clock was ticking. He was rushed out to the airstrip and they got clearance to fly. That’s how he got to Nashville for his liver transplant.

Does the hospital keep its own list or is there a registry or bureau that just tells the hospital, OK, you’re getting a patient?

That process is done by UNOS. The whole organ procurement side of the business is not something that we manage directly with our software. Throughout the US there are groups known as OPOs, or organ procurement organizations. They’re the groups that are out there when someone has a car accident. When an organ is becoming available, they’re there at the hospital to be able to help instruct removal of the organs. Those organs and the data about the donor is sent up to Virginia to UNOS. It’s then used to match against the lists that are maintained by UNOS and then it propagates out to the appropriate center in the region where that organ is available.

If you’re on the list and not sitting by the phone at that time, I guess you could miss your chance.

To a certain degree, yes. We were visiting with customers last week in the state of Florida. They were talking about what the transplant coordinators do and how they use our software to know about the patients and where they are. Often, if there is a separate transplant database, the phone number for the patient or for the closest relative who’s their contact is probably more accurate within the software than it may even be within the hospital registration system. That’s because the critically of reaching that patient is so important. 

That’s one of the challenges when you start looking at how you integrate into the environment in the hospital. How are you updating those ADT transactions about that patient information? That transplant coordinator may know better than central registration.

In a short period of time, the company was acquired, you got involved, the name was changed, and then the offerings where expanded to move in to bone marrow transplant and ventricular assist devices. What’s the big picture and what other changes do you see coming?

I think you mentioned two really interesting areas in bone marrow and VADs. The bone marrow product was actually in development before we came in. It’s been a three-year journey to really get that up to snuff. It’s an interesting area. Almost the only thing that bone marrow transplants and solid organ have in common is the word “transplant”, but it’s still the same type of specialty care of looking at very detailed clinical workflow, the need for discrete data, a lot of follow-up for patients that may or may not be local to your environment. The same thing with VAD. It was a logical outgrowth of the solid organ transplant for heart.

The next phase is to continue the work on chronic disease management, like what was here when we came in to the business, but really needed to be expanded. Heart failure is one those things that CMS is going after strongly. I think I saw $7.5 billion over the next four years is going to be taken down from lack of compliance within all of the advanced heart failure programs in the US. 

What most people really don’t understand about heart failure is that the heart is usually the last organ to fail. It usually starts with kidney problems or renal failure, peripheral vascular disease, maybe pulmonary dysfunction. All disease states that we help clinicians to manage with our software. Then you start going into the other concomitant diseases of heart failure, which are gout, diabetes, and other types of circulatory problems. All things that we’ve had some level of offering for within the product and that we’re going to continue to expand and work towards. 

The future is going to be to help people be able to met their JCAHO requirements around advanced heart failures, CMS reporting requirements, and to help manage those patients. Again, even in an advanced heart failure center, those patients may not be being seen in your clinic every time, every visit. They may be coming from a hundred miles away looking for care. You’re going to try and do that, but they maybe getting their labs locally, they have home health follow-up, there may be a lots of other places with data that you’re going to want to see as a clinician.

Any concluding thoughts?

I think it’s just a really interesting space. If you look back at HIMSS 2012, there was an article that came out from Dr. Antonio Linares from WellPoint, the medical director there, talking about the fact that in the future accountable care world, an EMR may not provide all of that data that you need in order to help the insurers meet their requirement. We think that we provide a solution that fits into a part of that niche. There’s a certainly a need for HIEs to fill another part of that niche. 

I think the message that we have — and it’s not just about our software, but a lot of clinical solutions that are out there — is that EMRs are great and they’re going to be important in terms of managing healthcare moving forward and helping us to control cost, but there’s another layer that needs to be there to support ACOs and what it’s going to take to help us really reform healthcare and control cost and really get better clinical outcomes. That’s why we’re here, and that’s why I’ve committed 25 years of my life to healthcare and healthcare technologies.

News 4/20/12

Top News

Cerner CEO Neal Patterson makes the cover of Forbes in a piece called Obamacare Billionaires. It’s generally positive given the awkward situation that it’s a right-wing magazine covering a fellow rich guy making big bucks from left-wing healthcare policies. There were some fun background facts I hadn’t heard:

• Neal was moved up to first grade in his boondocks school because otherwise there would have been only one male student in the class
• The three founders came up with the idea of starting Cerner while studying at a picnic table for the CPA exam as Arthur Anderson employees
• The word “cerner” is Spanish, meaning “sift”
• The magazine says Neal is worth $1 billion, although SEC filings show him directly holding less than half that amount in the form of CERN shares
• The infamous “tick, tock” e-mail is of course mentioned (you just know that, as with Jim Morrison’s grave, former Cerner associates will be spray-painting it on his tombstone for decades after Neal has checked out)
• The reporter saw the fancy Vision Center demos of Millennium, then observed firsthand the “klutzy” (I assume they meant “clunky” since “klutzy” usually describes people, not objects) real-life version running at Truman Medical Center, although the hospital still said mostly good things about it

Here’s a snip from the article:

Cerner’s new offerings, on display at its gleaming headquarters with a heavy dose of skilled salesmanship, have the whiff of the future. The company is giving hospitals, for free, software to help predict which patients will get deadly, hard-to-treat blood infections. A new type of patient record is quickly and automatically searchable, even if the data go back decades. A fictional case study shows how a heart attack patient could be cared for in this new system, starting with wireless monitors that he’s wearing when his heart rate speeds up; through a visit with a nurse who talks to specialists using an iPad and FaceTime; to improved versions of the bar-code-reading devices at Truman.

Like in real life, Epic and Judy Faulkner are everywhere Neal turns, even within the current edition of Forbes. She gets a piece called Judy Faulkner: Health Care’s Low-Key Billionaire. There’s not too much new there for those of us who already know the Epic story – as usual, Judy declined to be interviewed – but it’s a fun read. One interesting factoid: when Forbes estimated her net worth at $1.7 billion, she denied to them that she has reached the billionaire club, with her spokesperson saying that Judy owns less than 40% of Epic’s shares (although as could be the case with Neal’s money, there are many ways to make that statement honestly while still being misleading, such as not counting shares held in family trusts or other ownership that’s indirect but controlling). The hardest fact to believe: Judy is 68 years old, which is about 15-20 years more than she seems to be. There’s an intriguing mention about Kaiser Permanente’s insistence that it be given equity in Epic as a condition of signing the contract for its $4 billion HealthConnect project, to which Judy provided a two-letter reply: “NO.”

A sample of the article:

Beneath the rock star antics on view strictly for customers, Faulkner is not eager to telegraph her newfound wealth and power. She turned down our request for an interview. “She doesn’t want the spotlight on her,” explains her spokesperson. Interviews with people who know Faulkner paint a picture of a forceful, yet modest woman. Leonard Mattioli, an Epic board member, recalls chiding Faulkner for driving an old Volvo. “I told her next time you buy a car, take a man with you,” says Mattioli, the founder of American, a midwestern retailer of appliances and electronics. A few years later, Mattioli introduced his fiancée to Faulkner. She proceeded to pepper her with questions Epic typically asks prospective employees: “How many square yards of astroturf are there in the U.S.? Which person, dead or alive, would you most like to have lunch with?” Turning to a bewildered Mattioli, she said “next time you take a wife, take a woman with you [for advice].”

Both articles are interesting primarily because the average Forbes reader has probably never heard of Patterson or Faulkner, much less been aware that healthcare IT has created a couple of billionaires (well, the articles didn’t really make a convincing case that either is a billionaire, but I think we can agree they’re doing pretty well considering they sell almost entirely to non-profit organizations). I wonder if some big wheels in stagnant industry sectors won’t suddenly develop a healthy curiosity (no pun intended) about what healthcare IT is all about now that they’ve seen dollar signs?

Reader Comments

From TheRock: “Medicaid MU programs. Have any states begun issuing 2012 payments for eligible hospitals?” I’m not sure. CMS issued a statement this week announcing that Louisiana’s Medicaid EHR incentive program was the first to issue payments for “Eligible Professionals.” Meanwhile, the Louisiana Department of Health and Hospitals says they are the first state in the nation to issue (any) payments for the second phase of the Medicaid EHR incentive program. Readers?

HIStalk Announcements and Requests

HIStalk Practice highlights from the last week: Emdeon CEO George Lazenby will lead Nashville’s IT Recruitment Task Force. MGMA opens registration for its 2012 conference in San Antonio. Why physicians ignore alerts in their EMRs. Hayes Management Consulting’s Rob Drewniak offers tips for successful change management in healthcare. Sign up for e-mail updates while checking out the news; it ensures you stay in the know and makes me feel loved.  Thanks for reading.

More tales from my recent medical office visits. I wasn’t too surprised that the specialist’s office used paper charts, but I was shocked when they asked me to sign an insurance form so they could mail the claim to the carrier. Maybe I am out of touch with reality, but I thought 99.9% of practices file electronically. I might note that the claim was only for the professional fee and I assume the facility (part of a large, for-profit hospital chain) has more sophisticated technology in place. Now that I think about it, I see a great opportunity for the healthcare system to offer some technology subsidies to their providers.

Here’s one of those uncomfortable IT office moments. You get a new manager (or a new employee to manage), someone you’ve ignored in many previous close encounters in the elevator, restroom, or hall because they’re just some faceless person you don’t really know and don’t care to know. Once the org chart umbilical cord has been attached, however, it becomes obligatory to be their BFF with each chance encounter in making small talk and calling them with gusto by the name that you just learned.

On the Jobs Board: Implementation Project Manager, Director of Marketing, HL7 Business Analyst. On Healthcare IT Jobs: PACS Application Coordinator II, Cerner Orders iView Consultant, Soarian Financials.

Acquisitions, Funding, Business, and Stock

Mediware closes its $2.2 million acquisition of Cyto Management System, an oncology management system, from Holland-based Cobbler ICT Services BV.

Sales

ProMedica (OH) selects athenahealth’s athenaCollector and Anodyne Business Intelligence Services for its 400-physician network.

The National Institutes of Health awards a sole source contract to Carestream Health for its Vue RIS.

Porter Adventist Hospital (CO) signs an agreement with OTTR Chronic Care Solutions to deploy its Transplant Care Platform.

People

CareCloud hires Brad Blakey (NextGen) as VP of sales.

Trinity Mother Frances Hospitals and Clinics (TX) names Jeffrey Pearson (Bon Secours Health System) VP and CIO.

Holon appoints Dyanne Tiller (Bottomline Technologies) its quality assurance and release manager.

Announcements and Implementations

Community Health Network (IN) says it will have its $120 million Epic system in place by November.

NovoPath announces that its anatomic pathology system, which is certified as an EHR Module, can now download pathology patient reports to iOS and Android devices.

Cerner will collaborate with Advocate Health Care to develop a solution that integrates Advocate’s administrative and electronic health information to create predictive models for health outcomes.

CareFusion and Cerner announce the release of a bidirectional solution connecting the CareFusion Alaris infusion pump system with Cerner Millennium EHR. The offering is already in place at Oklahoma Heart Hospital.

Intelligent InSites releases its InSites Connect RTLS mobility solution as an iPhone app.

Other

Hospitals recognized on Thomson Reuters’ 100 Top US Hospitals in 2009 or 2010 had more advanced levels of EHR adoption, according to HIMSS Analytics.

The CEO of Yuma Regional Medical Center (AZ), which goes live on Epic on May 1, says the organization has been experiencing staff changes — including layoffs — as a result of improved procedures and technology. The implementation has affected 33 core employees and 45 adult acute care positions.

And in still more Epic press, its undefeated newcomer StarCraft II team faces IBM in the After Hours Gaming League grand finals this Saturday. Good luck, guys (am I safe in assuming that the electronic warriors are all male, and also likely to have no conflicts with a Saturday night game?)

Emory Healthcare (GA) announces that 10 old computer disks containing information of 315,000 patients are missing, either misplaced or stolen from the unlocked cabinet in which they were stored (it’s in a locked office, though.) Unlike most breaches, Emory didn’t do anything eye-rollingly wrong, and in fact their response seems thoughtful and thorough.

The University of Ottawa Heart Institute posts an RFP for a mobile clinical communications system, specifically nurse hand-held devices that contain a physician directory.

A Louisiana doctor is sentenced to six years in prison for possession of child pornography. He was the medical director of Intra-Op Monitoring Services, whose doctors monitor neuro surgeries in remote hospitals. The company previously admitted that it billed for services that weren’t performed, sometimes not even bothering to make a connection to the remote site or having technicians using the doctor’s logon to make it look as though the monitoring occurred.

Weird News Andy, noting this cash-strapped hospital in Canada that asks patients to do their own laundry on cash-only machines, ponders the likelihood of a coin-operated MRI.

Sponsor Updates

• Account exec Brady Taylor of electronic forms and workflow automation vendor Access drops by Tucson Medical Center to present an iPad to Rita Cartwright, senior business systems analyst. She was an HIStalk Booth Crawl winner at the HIMSS conference in Las Vegas.
• PatientKeeper and Geonetric partner to offer integration of Geonetric’s Patient Portal and PatientKeeper’s Physician Portal.
• The Academy of Managed Care Pharmacy presents First Databank VP Tom Bizzaro with its The Grassroots Advocacy Award.
• Beacon Partners offers a new white paper, Accelerating the Development and Adoption of Affiliate EHR Programs
• Versus hosts an April 24 Webinar featuring Memorial Miramar’s integration of RTLS with Epic.
• Lifepoint Informatics announces its participation at next week’s CLMA ThinkLab ’12 conference in Atlanta.
• Norton Healthcare (KY) contracts with CSI Healthcare IT for 85 go-live resources for their Epic activation.
• The University of Waterloo will award NextJ Systems founder William Tatham an honorary doctorate during its spring convocation ceremonies.
• MedAssets announces the general availability of its Collections Management solution.
• maxIT Healthcare profiles Stanly Regional Medical Center (NC), which successfully deployed EHR and RCM with assistance from maxIT.
• Minnesota Eye Consultants selects the NextGen Ambulatory EHR for its 22 providers.

EPtalk by Dr. Jayne

Thomson Reuters releases its annual “100 Top Hospitals” report, which purports to recognize the best US hospitals. Measures include organizational performance, operational efficiency, and financial stability.

The HIMSS13 call for proposals is open now through May 30. I don’t know about you, but I’m thinking about skipping HIMSS next year and just showing up for HIStalkapalooza. My health system refused to pay for my trip this year, feeling that it’s just not valuable for the cost. I’m sure budgets won’t rebound this year. Who else out there thinks it’s getting a bit pricey?

An article in the Journal of the American Medical Informatics Association looks at the use of health information exchanges in the emergency department environment. Researchers (including Dr. Jayne’s secret crush #3, Dr. Mark Frisse of Vanderbilt) found that HIE access was associated with cost savings and reduction of admissions.

American Medical News ran this piece on EHR alert fatigue. I know several of the people quoted in the article and found it interesting that it really only references inpatient systems. Personally, I’ve found ambulatory systems to be much more annoying with alert fatigue that hospital-based CPOE systems, although more likely to allow individual providers to adjust the level of alerts they receive. I still struggle with physicians who want to turn alerts off completely, which is a bit frightening.

This doesn’t really have anything to do with health information technology, but I found it fascinating. I’ve long been a fan of Lechuguilla Cave, located in New Mexico’s Carlsbad Caverns National Park. Researchers studying bacteria which have never come into contact with humans have identified strains which are resistant to antimicrobial agents. All were resistant to at least one antibiotic and some were resistant to at least 14. Another good reason to continue to fight antibiotic resistance, because obviously bugs are built to survive.

I had the opportunity to hang out this week with some true in the trenches “IT guys” and was reminded what a fun bunch they can be. Most of them have accepted me into the tribe and no longer hold the fact that I’m a physician against me. Words that describe these guys and gals: brilliant, dedicated, straight shooters, funny, detail-oriented, and occasionally downright hilarious. One of them owes me, though, for almost making me spit red wine all over the place, so he’d better be on the lookout. I’m going to find a way to pay him back, mark my words. Thank you for standing guard over my systems 24/7 and for alerting me when administrators and other bean-counting individuals cause trouble. I’ve got your back. And I promise if one of you ever accidentally activates the Halon system again and shuts down the entire health system’s network, I’ll still be your friend.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Interviews Steve Liu, Founder, Ingenious Med

Steven T. Liu MD, SFHM is founder, executive chairman, and chief medical officer of Ingenious Med of Atlanta, GA.

Give me some background about yourself and about the company.

I was an engineer first and earlier in life – electrical — and it’s just it wasn’t for me. I couldn’t see myself doing this for a long period of time. I decided at the last minute to do what I really wanted, which was become a physician.

When I got out, it was a really interesting time. In 1999, there was this new movement called hospitalist, which is what I became. I took a chance and jumped in to that. 

At the same time, I started building tools that I needed for myself to manage the hospitalist group — capture data, improve quality, and improve the practice’s performance. It was nice because that ultimately resulted in me building the company. There was an opportunity. I built some tools that were really helpful for myself and it turns out there was a market — a lot of other folks were having the same problems. That’s the inception of Ingenious Med.

At this point, we’re probably the largest inpatient revenue capture physician management solution out there, with about 14,000 users. We did the tally a couple of months ago. We did about 10 million individual encounters that we captured for the physicians and hospitals across the nation in 2011.

We’re a point-of-care solution. We’re in the physician’s hands every day on every patient. We’re able to engender correct actions in data capture and give feedback and align those physicians with the goals of their organizations, whatever those might be — cost, quality, revenue.

Describe the workflow of your users and how your application captures charges and documentation within that workflow.

Our bread and butter used to be hospitalists. They’re the minority of our users – it’s really inpatient physicians. The workflow is pretty similar across the board, whether you’re a cardiologist or a hospitalist or whatnot. 

Physicians round in the hospital. I measured it one day — I walk something like five to eight miles a day in a hospital when I’m rounding. They’re extremely mobile. As a result, it’s hard to always have access to a workstation. They see patients, but actual patient care time is only about 15 minutes. The rest of the time is spent thinking about patient, documenting information, and then capturing your revenue by making sure you document for compliance and quality and all those other things that your organization needs you to do.

We’re at the very front part of that revenue cycle process. There are only a few technology touch points with a physician where you can give them feedback and have them change behavior. Most of the time it’s through the EMR, but another opportunity is what we do, which is the mobile cloud space of revenue. When they finish doing everything they do with the patient, they need to capture the work that they performed. That’s what we do.

We do a whole bunch of stuff once they enter information for us. We give them a lot of feedback and education to hopefully enhance their behavior and performance. Then we take all that information and process it, give reports back to administration, to the physicians, score cards, etc. Then get it to the billing services or the back offices to be handled from their standpoint.

We’re highly adopted – we’re literally there at the point of care on every single patient of our users every day. It’s sort of an opportunity to do all this cool stuff.

Who are your competitors and what’s the alternative for physicians to improve if they aren’t using any system?

Back in ‘99, everyone was on paper. That was the best solution. Paper is probably one of the most ergonomic things out there. You can’t supplant it in many different areas, obviously, because we’re still 10 years out and we see practices still walking around with 3×5 cards and superbills. 

That’s the de novo basic situation. It has a lot benefits, but a lot of inefficiency. There’s been many studies and a lot of data on just how moving to electronic systems gets rid of all the inefficiencies of lost paper, illegible handwriting, and all that sort of stuff. 

There’s probably about two major competitors that focus on our space. They have wonderful products and we highly respect them, but it’s what you do with the charge capture. Everyone has charge capture, even 10 years ago. EMRs, HIS systems … people have it. But it’s such a critical part of a practice. If it’s not done correctly, your livelihood is very much at risk.

As a result, people started to migrate towards best-of-breed solutions rather than the de novo systems that were available, maybe even for free. That’s why people come to us.

It’s almost as though you’re the CPOE of physician financials. It’s easier for them to use paper, but you have to give them an incentive to go electronic.

I’ve never heard that spoken that way, but that actually is a really great way to describe what we do. That’s perfect. We’re the CPOE of financials and revenue for the physician — exactly. It’s not just capturing an E&M code and some diagnoses. It’s way more than that. That’s our core business, but there’s so much that goes on, so much that can be lost revenue-wise, and so much opportunity to do other things outside of just charge capture.

The whole industry is living towards managed care. Instead of charge capture, it’s work capture. With that information that you get right there at the point of care, you can do some really, really great stuff that impacts things that are non-financial or indirectly financial, like quality and core measures and all the things that are now becoming the new way to have a healthy revenue in your practice.

So your goal is not to be a documentation system, but to capture information that isn’t available in other systems as a by-product of capturing charges?

We think of ourselves as a complementary. One of our major missions in whatever we design in a roadmap is to always complement the EMR, not to go head to head with the big functionality that they do. 

One of the things we do is complement the documentation. We don’t really want to become the medical record. It’s really not our role. But existing systems may not do things as well as they could. You find that with all the requirements coming in healthcare in both financial as well as quality reform, the physician’s pen is the most powerful thing in the hospital. Everything comes out of that. As a result, you can shore up documentation. That’s how we think of our role in documentation — shoring it up.

Do you find it tough to fight for space on the portable devices or desktops, like what happened with the proliferation of devices and applications that demanded the attention of nurses a few years ago?

Not really. The reason why, I think, if something is pretty usable …  ergonomics and ease of use are absolutely paramount to have any sort of adaption. It’s like Hair Club for Men – I’m not only telling you to use the product, I’m a member. I use the product. That’s why I still practice. You have to be a clinician and use it in order to actually design really good stuff.

We have something that’s very embedded and keeps pace with the physicians from an electronic device – Web , PDA, or smart phones. It has to be usable, and then also useful. I think because we’ve got that combination, they do generate more revenue, capture more value, showcase more quality, or improve their care with our functionality. It doesn’t feel like a hindrance. It’s looked at more as a useful tool that you use every single time you see your patient.

How do lay out your turf beyond just charge capture?

Only 10-15% of our solution is charge capture these days. Over the past 10 years we’ve built that and we continue to build that up, but that’s a small part of what we do.

Our most powerful points — why people often choose our platform — is not necessarily for the revenue and the charge piece, but the other tools — the physician management functionality, the reporting and ability to scorecard your physician and let you know exactly what they’re doing to manage their performance and give them feedback and really engender change. That’s one of the most powerful things that has been very successful for us. I think it’s what we do very well, if not the best way in our particular market.
That’s an area for sure that we will continue to move down.

I think some of the other areas in terms of point of care, education and feedback … even a limited focus of decision support is probably another area that we would like to establish as huge experts in.

Most companies have figured out an angle to ride the wave of Meaningful use, accountable care organizations, analytics, or more than one of those. Are you finding that those are good springboards for your business or are they taking people’s attention away from what you’re offering?

Meaningful Use doesn’t impact us too much. It’s not a huge focus, simply because that’s what everyone else is focusing on. That doesn’t impact us as much. 

ACOs, however, do. If in a world of managed care and ACOs, you just change the word “charge capture” to “work capture.” You still have to measure the amount of productivity that physician actually does in order to see how contracts gets renegotiated, etc. ACO is an area that has been beneficial for us. We see that as an area of opportunity as we transform our offerings to fit the coming landscape.

The other areas that we see as being directly related through the functionality that we have are value-based purchasing and quality improvement and capturing all that data. PQRS is the physician component of VBP. That’s what we do. We were one of the nation’s first PQRS registries and we have 100% success with that. We would like to take our knowledge there and move it towards VBP.

You won a physician entrepreneur award in the fall and almost immediately brought some new folks into the company at the executive level. What’s the long-term strategy for the company?

You’ve probably heard this a million times .. an entrepreneur five years ago, eight years ago who said, “We’re at the hockey stick inflection point where we’re really about to grow.” You check in four years later they just haven’t done it for whatever reasons. I’ve been saying that for a long time. 

What happens is — especially with a growing company — if you’re smart, you reinvest and reinvest and reinvest in the company. That’s what we have been doing. We really have hit that inflection point. We’re on the other side. As a result, you have to go through big organizational change.

A couple of years ago, I put in a CEO to replace my role as CEO at the company, more for personal reasons, so I could start a family. That was one of the best decisions I ever made. We were able to really, really focus on strategy for the coming change. As a result, that was the first step in maturing the company — putting in the CFO and our CTO and really capable management. The new stage is large enterprise healthcare organizations — being able to support their needs. And not even just with those clients, but also to build the company out for what needs to be done 2-3 years out for the coming change.

Any final thoughts?

I’m humbled and thankful to be where we are right now in healthcare. It’s a pretty exciting time. It’s a time that forces folks to think about the future and innovate and grow. There’s a lot of opportunity. I think it’s a neat place to be. I’m pretty thankful about that. 

With everything that’s going on, it’s nice have sites like your own to have a touch point for what’s going on in the industry. Believe it or not, you really do educate myself and a lot of the healthcare folks out there about what’s going on in the industry and trends and all of that. 

I’m thankful just for having a role and being able to be successful in providing really, really neat, great functionality to the hospitals and providers out there that hopefully improves our lives. It’s part of our mission statement. It’s nice to be able to live on that.

News 4/18/12

Top News

Verizon Chairman and CEO Lowell McAdam, addressing the World Health Care Congress on Tuesday, outlines the challenges to US healthcare delivery and announces a relationship with NantWorks to create the Cancer Knowledge Action Network that will give physicians access to best practice treatment protocols. NantWorks is owned by billionaire Patrick Soon-Shiong. Excerpts from the transcript:

It’s now been almost three years since Congress authorized $27 B to fund the transition of electronic medical records, and in that time we’ve seen a tremendous amount of innovation across the whole health care marketplace. The CDC reports that 57 percent of America’s physicians have now adopted electronic medical records … Yet for all of this innovation, technology has yet to truly transform health care as it has other sectors of the economy. Doctors report that their productivity actually goes down, not up, when technology is introduced because of incompatible systems and frustrating interfaces. The amount of digitized medical information is rising exponentially, but systems still can’t talk to each other easily, in part because of the licensing and security issues unique to this industry … And maybe the most surprising thing in an anywhere-anytime age is that patients don’t have the seamless connection to their health care systems that technology affords them in every other facet of their lives … In order to realize the full disruptive potential of technology, we need holistic approaches to solve these fundamental issues and deliver next-generation health-care experiences to consumers … The World Health Organization has just published a report on the fantastic potential for using these wireless networks to deliver m- and e-health care solutions to the world’s population. They note that, while there are lots of small-scale m-health experiments going on, no one has really solved the security, interoperability and standardization problems that are getting in the way of delivering these vital services in a system-wide, worldwide basis in a secure and interconnected way. At Verizon we think it’s time to scale up.

Reader Comments

From Beth: “Re: AHIMA ICD-10 Summit. Pat Brooks, a senior technical advisor with AHIMA, just finished presenting. All indications is that 10/1/14 is go for ICD-10 implementation. Most important so far: CMS will continue the partial freeze on updating ICD-9 and ICD-10 codes until one year after ICD-10 implementation. They’ll go back to regular, annual code updates on 10/1/15.” More details on the partial code freeze here.

From Kevin: “Re: HIPAA fine. I found this blatant disregard for privacy shocking, but then I thought of all the other minor displays I’ve seen that are HIPAA violations.” Phoenix Cardiac Surgery (AZ) pays $100,000 to settle an Office for Civil Rights HIPAA investigation. The practice was posting its appointments publicly on an Internet-based calendar.

From Aspiring Philosopher: “Re KLAS and Epic. I notice a lot of, ‘they are the best of a bad lot’ commentary. That proposes an unspoken implication that paper records are superior and the inefficiencies of paper record keeping of today can be overlooked and are preferred over new technologies that are intended to improve safety and communication across practitioners. If the most money is spent developing the idealized products and we cannot get something better than ‘bad’ I don’t know where that will ultimately leave us. Thoughts?” The most important point: the naysayers aren’t the people using these systems and, in fact, usually aren’t providers at all, just preachy sideline watchers. That would be like not buying a car because a handful of people who don’t own one keep harping about how inferior they are to walking. If the feeling was widespread, you would see providers going back to paper in droves and that is just not happening – that’s the strongest of rebuttals to the “paper is better” argument. I even take KLAS reports with a big grain of salt because you just don’t know if their interviews with a particular provider really reflect the big-picture attitude there about a product. Taking the MBA viewpoint, vendors will match their effort vs. reward curves, and if customers keep buying (or keep paying maintenance fees), you’ll never see products get a lot better — think Detroit rustbuckets pre-Japanese imports. Also, much of what is labeled as product failure is user failure – providers who don’t really want to standardize or change or don’t have the skill to manage the process well – non-IT precedents are ample. The bottom line: there are only a dozen or so full-line hospital system vendors out there and all have successful and unsuccessful users, which indicates that there’s more to the equation than just which product is “better.” I’ve advocated in the past that user organizations should undergo the same subjective assessment before being allowed to implement patient-impacting technologies such as CPOE.

From Portnoy: “Re: Epic. They are working with the open source GT.M database to allow them to offer a free alternative to the expensive Cache’ so that smaller hospitals can afford to implement Epic.” Unverified, but it makes sense. Everybody (including me) obsesses with Epic’s success and Judy’s net worth, but it of all the money that has been made from companies with roots going back to Meditech in the 1960s, InterSystems may be on the leaderboard. Every time Epic makes another big sale, InterSystems sells a ton of per-user Cache’ licenses and collects yearly maintenance fees on every one of them forever. My information is dated, but when I last bought them for my hospital employer, seats were $1,000, as I recall, and the maintenance percentage was pretty steep.

From EHR Warrior: “Re: [vendor name omitted]. The certified EMR is next to dead. You talked to them awhile back and they just BS’ed you. Now they have sold off their IP to a mail drop in Texas. Nothing wrong about failure, but to stiff employees, creditors, and users with lies is hopefully unacceptable, even in this climate.” I’m leaving this as unverified for now since I haven’t been able to confirm. If anyone recognizes the company being described and has verifiable information, let me know.

HIStalk Announcements and Requests

Last week I mentioned visiting the doctor and being geeked with my brush with technology. Alas, when I went for a follow-up appointment yesterday, my physician said she needed to fax my records over to a specialist. I had a momentary flashback to my neon yellow track suit and Jennifer Anniston haircut.

I ran an unverified rumor from Senor Ortega on Monday about a company he claims has ceased operations. I declined to name the subject of the rumor until I gave them a chance to respond to my inquiry. I haven’t heard anything back from Allocade, so the rumor is still unverified. That’s all I know. If the company wants to provide a response, I’ll run it.

Acquisitions, Funding, Business, and Stock

Humedica raises $10 million in a new round of funding, bringing its total VC investment to $63 million.

Sales

The board of directors of 37-bed Palm Drive Hospital (CA) will vote on the purchase new EMR and financial system within the next month. The hospital was set to approve a $3.8 million McKesson solution last month, but deferred the vote to determine if McKesson could interface its financial product with a clinical-only system designed by one of the hospital’s physicians. I admit it: I felt genuine pain for the McKesson rep who was thrown this last minute curve ball.

The Air Force awards LongView CIO Group a five-year, $985 million contract to provide management and professional support services to the Air Force Medical Service.

The urgent care franchise Doctors Express selects DocuTAP’s EMR and PM software for all its new urgent care centers and most of its existing facilities.

People

AsquareM Healthcare Consulting co-founders and managing partners Timothy Ogonoski and Victor Arnold have joined Huron Healthcare as managing directors.

Mental health research and technology non-profit Centerstone Research Institute promotes COO Tom Doub PhD to CEO.

Healthcare software usability firm PointClear names Justin Neece (above) as VP of corporate development and Jerry Hill as director of operations, technology practice.

Tom Stampiglia, formerly CEO of Medical Present Value, is named CEO of revenue cycle vendor Origin Healthcare Solutions.

Announcements and Implementations

Dell announces that its Clinical Service Desk is working with Mount Sinai Hospital (NY) to implement Epic.

Datalink deploys a $3 million unified virtual data center infrastructure for Cook County Health and Hospital Systems (IL) and two dozen of its facilities.

The American College of Surgeons and the CDC collaborate to use standardized quality measures and HIT resources to track, report, and prevent surgical site infections and other adverse outcomes.

North Hills Hospital (TX) implements VeinViewer, a computer-powered, hemoglobin-sensing instrument that projects the patient’s vein images on their skin, giving nurses a high probability of starting an IV on the first stick. It’s apparently been around for some time.

Innovation and Research

One of the winners of Penn’s Wharton Venture Award is 1Docway, an online doctor’s office in which patients can schedule appointments and connect to secure video chat with their physician.

Express Scripts is implementing ScreenRx, predictive software it developed that uses 400 factors to identify patients most likely to skip prescription refills so they can be contacted in advance. That must be an odd conversation to have.

Other

From KLAS: urgent care organizations are searching for EMRs to better manage their growth. Technologies under consideration includes ambulatory EMRs, ED solutions, and best-of-breed urgent care EMRs.

Memorial Healthcare System (FL) fires two employees who are suspected of accessing the names, dates of birth, and Social Security numbers of 9,500 patients with the intention of filing fraudulent tax returns.

Because it’s tax day, it seems appropriate to mention the thief who stole the identities of 56 patients at the Long Island Head Injury Association. The former manager used the personal information to file false tax returns and pocket the refunds.

A Mayo Clinic doctor develops a real-time ED dashboard that he says cuts patient ED stays by 30-60 minutes. A Mayo spokesperson says that on one occasion, it warned physicians that the patient they were discharging was having a heart attack. A consulting firm has licensed it to use with Microsoft Amalga.

Where was this service post-HIStalkapalooza? An enterprising Las Vegas anesthesiologist launches Hangover Heaven, a converted 45-foot tour bus that serves up a hangover cure called “Salvation.” For $200, patients can hop on the bus and be infused with two bags of saline mixed with vitamins, ketorolac (an anti-inflammatory), and Zofran (for nausea.) I think even Mr. H would allow him himself to be over-served so he could be treated by the medical assistant “wearing a white, sexy nurse costume with white fishnet stockings and white knee-high boots.”

Weird News Andy likes this story, in which a surgeon with a MIT engineering degree restores a woman’s ability to speak using concepts he learned from studying jet engines. The woman’s vocal cords were destroyed 35 years ago in a car accident, after which she noticed when calling her parents for help that, “I sounded like Linda Blair in The Exorcist.” The engineer-surgeon rebuilt her larynx using muscle from other parts of her body, allowing her to speak. She concludes, “My husband probably thought he had it made … a woman who couldn’t talk.”

Strange: a 52-year-old UC Irvine Medical school physician and professor sues Johnny Depp, claiming that his bodyguards forcefully took her iPhone from her and then had her handcuffed by security at an Iggy and the Stooges concert as she took her assigned seat in the VIP area where Depp was sitting. She says she suffered extensive injuries that caused pain, insomnia, numbness, depression, insomnia, post-traumatic stress disorder, nightmares, and phobias that have left her unable to work.

Odd lawsuit: a 28-year-old South Dakota prisoner sues the hospital that circumcised him at birth, saying he just realized that he’s had the procedure. He wants $1,000 and surgery to have his foreskin put back.

Sponsor Updates

• Awarepoint CEO Jay Deady is featured in a podcast discussing hospitals’ substantial gains using RTLS solutions.
• Thomson Reuters releases its 100 Top Hospitals study.
• Hayes Management Consulting announces that its revenue cycle business has tripled from March 2011 to March 2012.
• Greenway Medical provides an update on the 2012 PQRS incentive pathways and qualifications.
• eClinicalWorks recognizes several customers for achieving NCQA Level 3 Physician Practice Connections PCMH status.
• Santa Rosa Consulting offers an explanation of the the CMS readmission reduction program timeline and penalties.
• AT&T mHealth introduces the WellDoc DiabetesManager application, which aids in disease management and cost control. 
• MaxIT Healthcare ranks No. 5 in Indy’s Top Workplaces for 2012.
• CynergisTek CEO Mac McMillan discusses security and privacy solutions at several upcoming April events.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 4/16/12

I cover the emergency departments of different hospitals. One of my facilities (part of a large health system where, thankfully, I have no responsibility for any of the IT decisions) is about to upgrade its ED information system.

Working there has driven me to near madness. The medication prescribing system is atrocious. It not only contains “do not use” abbreviations, but also doesn’t allow you to prescribe any medications that are not pre-built in the hospital-centric medication database.

Being spoiled by other vendors that use high-quality third-party medication content, it’s definitely a challenge. There’s no ability to free text notes to the pharmacist and no e-prescribing either. Half the time I end up taking the computer-printed prescription form and handwriting comments on it to avoid pharmacy callbacks (most of the patients I see have no insurance and pharmacies are constantly calling to substitute things due to cost — I like to give the pharmacists flexibility to substitute when needed.)

Because I’m a part-timer, I rarely work with the same nursing staff repeatedly. While challenging, it’s rewarding because I’m guaranteed to learn something new on every shift.

Last night, Nurse Tina introduced me to what I can only categorize as forbidden fruit. The drawer under the counter where the physician’s PC sits contains more than just pencils and paper clips — there are (gasp) pads of prescription blanks! Yes, Virginia, there IS a Santa Claus and he just brought me something good. Better than dark chocolate.

I gleefully spent the rest of the shift hand writing prescriptions whenever I ran into an issue with the software, something I hadn’t done in years. Because of the limitations of the prescribing system, not only was hand writing the prescriptions faster, it was better for the patients. I could write exactly what I wanted rather than trying to hijack a poorly built “default” medication selection. I had to find a suitable notes field in the system so that my handwritten scripts were documented and I did sacrifice allergy and interaction checking, so it wasn’t a perfect solution.

The system is due for a much-needed upgrade, which has been postponed twice previously. I hope this time it actually occurs. I will attend training in a couple of weeks and I hope there are good things in store.

I’m a little concerned, however, because I learned from Tina that the non-physician staff haven’t received any notification of the upgrade, nor have they been scheduled for training. That should make things interesting.

Because I’m just a hired gun providing clinical coverage, no one gives a hoot about my IT opinion. That’s frustrating,  but refreshing. It allows me to see the systems as the rest of the physicians do. I’m just  someone just trying to do her job and care for patients. This gives me greater perspective on how my own systems should operate and whether our communication plans, training, and upgrade preparations are adequate.

I’ll know more in a couple of weeks about whether we’ll really have improvements. Hopefully provider-specific medication favorites are coming, or maybe even an actual comprehensive medication database. I’m crossing my fingers and will keep you posted.

E-mail Dr. Jayne.

Readers Write 4/16/12

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!

Making More Meaningful Use of Data Through Device Integration
By Stuart Long

Far and away, the main theme of Meaningful Use is an increased focus on making health information exchange not simply a capability, but a reality. As providers seek reimbursement for technology implementations designed to do just this, they need to take a step back to understand what is necessary to go beyond incremental improvements in order to see the larger picture – which means going further than Stage 2 to Stage 3 and beyond.

There has been recent discussion around the importance of medical device integration (MDI) as a necessary component on the path toward achieving health IT (HIT) initiatives such as Meaningful Use, HIE, and ACOs, among others. Healthcare providers need to understand the impact medical device integration can have across the entire hospital enterprise – “the big picture.”

While not addressed in Stage 2 (which takes effect in 2014), medical device interoperability is a stated 2015 objective. Stage 3 criteria are obviously yet to be detailed and finalized, but one of the criteria is for medical devices to be interoperable with EMRs and clinical information systems.

The theory of medical devices being interoperable is a good one. However, the chance of this actually being achieved across all device manufacturers is not realistic under the stated timeframe. Only a small fraction of devices today can send interoperable HL7 data. This means that many of the devices already installed within the hospital are not interoperable. Therefore, hospitals may be required to purchase new devices to meet the objective. With already strained budgets and resources, many hospitals would not be able to do so.

The most realistic means to meet the interoperability objective now and in the future is by implementing a vendor-neutral connectivity solution that would convert all data from all connected devices to HL7 so multiple people receiving information system(s) can accept it. Such a solution would enable interoperability, allow a hospital to use the equipment they have in place today, and minimize the points of integration for easier management, flexibility, and scalability – key ingredients to deriving real value out of required technologies like EMRs, CPOE and others.

Beyond Meaningful Use, the question is: how can hospitals fully leverage MDI to deliver the even greater benefit of transforming patient safety and outcomes? Imagine the ability to take collected data and compare, contrast, and analyze it from multiple sources, and then deliver it back to caregivers in a meaningful way. Imagine the ability to effectively manage smart pump connectivity and bi-directional communication. These are all possible through a middleware, vendor-neutral device integration solution.

However, let’s be realistic about the timeframe to make such possibilities a reality. For true end-to-end and bi-directional communication to become a reality, there are multiple factors that will have to come in to play. Multiple vendors with varying degrees of responsibility and intellectual property will need to communicate and operate with one another in order to make the data collected meaningful and to ensure that such data is presented back to the caregiver or other healthcare professionals in a meaningful way.

While this will take time, there really is only one way to facilitate this exchange of data – through a middleware provider who has established relationships with all the vendors in the mix: device manufacturers, information system providers, system integrators, and predictive outcome vendors. Having middleware that is vendor neutral gives hospitals the advantage of being able to bridge the gap between these worlds.

The point is, device integration is evolving. It is going beyond the simple connection of devices to systems. The next evolution will be using the data collected so it can be compared, analyzed, and delivered back to the healthcare provider and healthcare executives in ways that will truly transform patient care and outcomes. While it will take time, it isn’t a matter of whether it can be done — just when it will be done.

The beauty is hospitals can realize all the many benefits of device integration today (improved patient care, reduced errors, improved decision making, and even Meaningful Use) and position themselves to then realize the many benefits coming in the future. It’s a win/win, really, because device integration aligns with the ever-growing strategic approach to technology investments and implementations — to increase efficiencies and improve patient care.

Meaningful Use requirements will come and go, but hospitals will still remain. Decisions and investments made now will have a long and lasting impact on the future of healthcare. The best approach is to create an agile, scalable healthcare environment that can adapt to the changing needs of patients for years to come. Medical device integration is one technology that aligns with all of these objectives and more.

Stuart Long is president, North America of Capsule Tech, Inc. of Andover, MA.

Clinical Intelligence to Improve Quality and Reduce Costs
By Michael Weintraub

The business model for healthcare is changing very quickly and most providers do not have the information resources to support value and risk-based accountable care. What is needed now is longitudinal information that is patient / population centric, across the continuum of care, outcome and health status oriented. It must support performance improvement and cost management, particularly for disease states such as congestive heart failure, hypertension, diabetes, asthma and others, where better management impacts health status and reduces total costs.

Accountable care requires clinical intelligence – information resources and analytical tools – to improve care to populations, over time and across the care continuum. Analytics is a tool for extracting useful properties from data, but intelligence is about making sense of the data and figuring out what to do about the findings.

Quality improvement in recent decades has been aligned with a volume driven fee for service business model. Claims based data analytics and process measures were adequate, though their value in improving care has been disappointing despite the commitment and best efforts of so many. As Chassin and Loeb conclude, “Health care quality and safety today are best characterized as showing pockets of excellence on specific measures or in particular services at individual health care facilities.” ¹

As we move toward a value-based system with accountability over time, the focus of analytics is shifting as well. Historically the field of “analytics” only encompassed scorecards focused on traditional quality measures (e.g. aspirin on arrival for MI patients). But as the business model of health care shifts from fee-for-service to fee-for-value, organizations have also had to shift their analytic focus from “service” in the form of traditional process-based measures to “value” in the form of population health. This shift has driven expanded requirements for more robust clinical intelligence and predictive analytics to measure, understand and drive improved clinical performance tied directly to the bottom line.

Clinical data is the anchor for clinical intelligence and vanguard IDNs, hospitals, and medical groups are using clinical intelligence (CI) solutions that unlock the value of digital clinical data. Adoption of HIT is an enabling but not sufficient prerequisite for CI. Data warehousing and registries may also be enabling, but they are not CI. CI requires four advanced capabilities: data management, data quality, analytics, and shared learning.

Data Management

Even organizations with the most comprehensive EHRs find their data difficult to access and extract for analysis. Data formats and definitions are not standardized across IT applications or across entities even in the same enterprise. Extracting, organizing, and normalizing clinical, financial, and operational data from disparate systems and across the care continuum — inpatient and ambulatory — is key to unlocking intelligence in the data. Data management functions can be performed behind the scenes on a near real-time basis avoiding costly interfaces. They should tap valuable unstructured data using natural language processing to enhance the value of the extracted and normalized database for population management.

Data Quality Services

One of the persistent concerns of those who use data or are the subject of that data is concern about its accuracy and validity. These concerns are well grounded. The explosive growth of digital information with poor data governance has led to a state of disorder that has done little to improve trust and willingness to act on data.

This problem is compounded exponentially when trying to mine clinical data from EMRs. Unlike the well-understood structures and nomenclatures that support ICD, DRG, and CPT coding, clinical data are unstructured and unlimited in terms of their heterogeneity. CI solutions solve this problem by performing forensics that clean, validate, and map the data. These data quality processes provide insight into the areas ripe for data quality improvement in EHR and other data sources and enables monitoring data quality over time. The result of data management and data quality is a continuously refreshed database ready for use.

Analytic Technologies

CI employs analytic tools that are clinically and statistically rigorous and transparent so it is easy to access and understand the underlying data. Innovations in advanced data visualization and analysis guidance such as report libraries support a broad range of uses from clinical performance profiling to dashboards and analyses of at risk populations. For at risk patients and populations — for example, CHF patients — CI uses predictive analytics to identify where intervention may prevent hospitalization. Valid comparative data for benchmark analyses is an essential component of CI and a prerequisite for sustainable performance improvement. Smart analytic tools also help support employees who are learning to work with expanded data sets and new tools.

Shared Learning Resources

Over and over, it has been shown that quality and performance improvement benefits from collaborative learning. Using normalized and comparative data, CI leaders engage with one another through learning communities, such as those being convened through the American Medical Group Association (AMGA). With CI, the clinical comparative data and analytics are the glue for the community of stakeholders actively engaged in learning from one another.

Leading healthcare organizations preparing for value and risk-based accountable care understand they must move beyond limited purpose process measures and claims data to CI. They are leveraging their investments in HIT and unlocking the power of clinical data for population management and health system improvement.

[1] Chassin, M. and Loeb, J. “The Ongoing Quality Improvement Journey: Next Stop, High Reliability.” Health Affairs, 30, no.4 (2011): 559-568

Michael Weintraub is president and CEO of Humedica of Boston, MA.

How are you Managing your Revenue Cycle?
By John O’Donnell

The complexity of managing the revenue cycle has never been greater than in today’s healthcare environment. From the economic impact on an organization’s bottom line to the continued advancement of healthcare reform, the need to stay three steps ahead has never been more important for your organization’s financial health.

Staying ahead means knowing your strengths and weaknesses. Do you have the right talent? Do you know what the market conditions are doing to your revenue cycle? How do you approach declining reimbursements without impacting quality or strategic initiatives? These are not easy questions to answer.

Knowing what your organization does well and what it does not do well is one way to determine how to best approach your revenue cycle.

Take Business Intelligence (BI), for instance. It’s not just a term for reporting. It applies to the overall approach to your revenue cycle. BI can help you evaluate areas with the greatest impact to your cash—like denials management and follow-up. As you examine these areas, BI will begin to display a picture with areas of concern.

You may come to realize that outsourcing portions of your revenue cycle might be an option. For example, converting to a new billing system is going to impact A/R and denials no matter how good your organization. You cannot install and manage the old A/R at the same time.

Leaders need to look at what makes good business sense for the organization — especially regarding denials management — and ultimately, what’s good for the patient. Can you financially support growth if your cash flow is being impacted?

Cost pressures from staffing and IT costs are all having dramatic effects on the providers, not to mention ICD-10. The implications of ICD-10 on the billing process itself are staggering with regard to workflow, systems, and reimbursement. Documenting the clinical process correctly is critical.

Physician alignment is one area that will be crucial in transforming your revenue cycle. Whether inpatient or outpatient, the revenue cycle will impact physician compensation. This means you have to include physicians in any associated initiatives. Bring them into discussions about charge capture. Educate them on the impact on denials and eligibility. Have the physician sit down next to you as you both look at options in managing the revenue cycle.

The management of the physician practice does directly impact all aspects of your revenue cycle, and ultimately your cash flow.

The old manual models are a thing of the past. Technology is woven into our daily lives and needs to be integrated into the revenue cycle. This does not mean a minimal touch approach of writing off denials in advance. It means using people and technology to limit the denials ahead of time.

Accountability will force providers and the business office to work side-by-side to maximize reimbursements, especially as reform advances. Healthcare reform / accountable care organizations — it’s all here and it’s still advancing, whether you’re good, bad, or indifferent about it.

Today’s current economic factors are in some cases crippling providers. Throw in reform and without question a transformation of the current model is needed. Changing from fee-for-service to accountability is going to impact cash flow.

I believe this transformation is forcing mergers and acquisitions across the spectrum, which will impact both your inpatient and outpatient revenue cycles.

For example, if your hospital adds new physician groups to the mix, great. That will feed the inpatient cycle. But what does that mean to your existing revenue cycle? Does that mean a best-of-breed or an integrated system approach? And how do you scale the operations to support growth? You have to look at different options.

We’ve all heard the real estate mantra, “location, location, location.” Well, with your revenue cycle it’s all about cash, cash, cash. Without it, buildings don’t get built, physicians don’t get paid, and the patient is left looking for care elsewhere.

In the end, it’s about knowing how to scale the operations to meet the needs of the organization to support financial stability and growth. It’s also about using BI to monitor performance. None of this means your cash has to be impacted. You just have to know and understand your options.

John O’Donnell is president and CEO of SPi Healthcare of Tinley Park, IL.

Monday Morning Update 4/16/12

From ZZtop: “Re: Meditech ambulatory. Meditech is developing an ambulatory product written in part with M-AT (focus) and M-AT WebServer (unreleased and a SAAS application). It will be available in 2013 starting at the 6.1X product line as they are merging P/BR and B/AR into one application. The design is very un-Meditech with horizontal tabs. Looks a bit Epic-ish.” Unverified.

From Epic Dude: “Re: Nuance. Apparently sunsetting their RadPort imaging decision support service.” Unverified.

From Senor Ortega: “Re: [company name omitted]. Ceased operations on Monday, April 9 and will declare bankruptcy next week, according to an e-mail sent by a member of their board of directors.” Unverified, so I’ve left the company name out for now. I e-mailed and asked them to confirm or deny and will re-run with their name if they don’t respond.

From Dr. Beeper: “Re: Henry Ford Health System. They spent $150 million to replace the 25-year-old McKesson MIMS product starting in 2006, bringing in CSC, RelWare, and Siemens to develop Care Plus Next Generation (the intellectual property is still owned by HFHS and RelWare.) That product did not have revenue cycle capabilities and it captured, normalized, and stored data from over 150 interfaces. HFHS needed to replace 150 individual solutions with a single, unified record with full RCM, inpatient, and ambulatory. That’s why they are spending $300 million on Epic.” Above is a March 2011 quote from the HFHS’s president and COO, talking to the local TV station upon Care Plus Next Generation’s go-live. Eight months later, HFHS was finalizing its contract with Epic to replace the whole thing.

From Epic Envy: “Re: Epic. I get it, Epic is the best of a bad lot. They’ve copied the Meditech business model and have executed it well. But does anyone really believe their KLAS scores aren’t ‘engineered?’ Ask who is KLAS’s biggest paying customer while reading KLAS’ users comments. Ask yourself what effect their ‘good maintenance’ contract incentive has on muting malcontents. Finally, allow your mind to wonder why they don’t foster the use of social media customer dialogue. I am envious, indeed but not naive.” Point A, not effective – just because they’re a KLAS customer doesn’t automatically mean they get to fudge the numbers and I don’t think they control the results any more than other vendors who encourage certain customers to participate. Point B, effective, but I think there’s another factor that automatically quiets down any complainers – who wants go to public with gripes after you’ve just spend hundreds of millions of dollars on Epic? (the hospital’s board would not appreciate public second guessing after approving a decision of that magnitude and the messenger would undoubtedly be shot). Point C, not effective – customers can talk among themselves all they want and I haven’t heard any say that Epic’s giant user group meeting is full of bitter complaining like I’ve seen at similar events held by Epic’s competitors. Point B wins – nobody buys a Rolls Royce and then whines about crappy gas mileage or expensive oil changes because it would just make them look stupid for buying it in the first place. Compounded by the fact that Epic seems to be pretty open with its customers, so there’s not a lot to be gained by airing dirty laundry to a bunch of sideline-watchers, especially when the company is privately held and thus not too worried about negative publicity that might otherwise get shareholder attention.

From Deep Throat: “Re: Thomson Reuters Healthcare Division. Any news about who has purchased it?” I haven’t heard anything, but maybe someone has and will share.

From The PACS Designer: “Re: Windows 8.  Microsoft has released a consumer preview for Windows 8. The new version has vast changes from previous versions and will take some time to get used to if you are in the market for a new system.  In many respects, it appears that Microsoft is trying to challenge Apple’s iPhone/iPad user interface to create some marketing buzz amongst consumers.” Microsoft couldn’t possibly do like everyone else and post the intro video on YouTube or something that might involve a competitor – they had to run it in the non-shareable, proprietary Silverlight format. Luckily someone smarter than the Microsoft marketing folks (why wouldn’t you use a competitor’s free service to pitch your product?) posted an intro video to YouTube where someone might actually see it, which I’m including above. We’ll see on Win 8. Given the radical changes, I’m not convinced it won’t follow the “every other release sucks” pattern like Vista before it and Windows ME before that.

HIStalk readers apparently aren’t all that interested in the JOBS act and aren’t that optimistic that it will spur startup growth and create jobs. New poll to your right, from recent headlines: should hospitals decline to hire overweight people or smokers? The poll accepts comments, so feel free to argue your position.

My Time Capsule editorial this time around: Rogue IT Shops: Provide Rules, but Leave Them There. A flash of the goods: “As soon as IT gets in trouble or tries to hide staff shortages like a balding man’s comb-over, it’s all hands on deck to save the tanking projects, meaning those previously dedicated departmental resources will be yanked to put out some new fire, often self inflicted by poor planning.”

I periodically need to vent about a pet peeve, so here’s one: a character-based GUI is not the same as a DOS application. If you hear someone refer to Meditech Magic or a mainframe app as “DOS-based,” stop listening because they just revealed a startling lack of even basic IT knowledge. I’m also lately irked when I read, “I had a couple drinks …” or something like that where somehow the author feels the “of” separator is superfluous, which to me sounds like someone who’s talking after more than just two drinks.

FirstHealth of the Carolinas CIO Dave Dillehunt left an excellent comment he left on Travis’s HIStalk Mobile post on pagers that hits a point I’ve been trying to tell people about: one-way pager coverage sucks and is getting worse once you get even a few miles away from a reasonably sized city, just like cell phones of the 1990s. They work fine on a hospital campus, but not well for folks covering call from home or traveling even locally. Not to mention that if you aren’t in range when the page goes through – unlike a cell phone – there’s no notice to the sender or voice mail for the recipient since alpha paging is incredibly unintelligent technology. For example, above is a USA Mobility coverage map for Tennessee. They may well have statewide coverage, but only if you’re in the blue areas (which look to be maybe 10% of the geographic area), so if you’re on weekend call, the electronic leash is pretty short. There may be a way for the commonly used Amcom paging system to detect failed delivery or to allow users to forward to a cell number to have the page converted to an SMS text message, but I haven’t figured it out if so. Anyway, here’s what Dave had to say:

Because traditional paging technology is dying, and customers are leaving in favor of their smart phone texting apps, the industry is now milking what revenues they have left and are no longer repairing or replacing damaged and failing paging towers and equipment. As a result, paging coverage is rapidly deteriorating. This is now causing more people to abandon that technology, further worsening the problem. While cellular coverage is sketchy as well, technologies that send out through both cellular and wi-fi are a good start and probably provide better coverage than the current (worsening) paging coverage. Our physicians (and others) are now demanding something other than paging (beeper) systems. Personally, I predict that paging will be gone within 36 months.

Beaumont Health System (MI) promotes Subra Sripada to EVP/chief administrative & information officer. He was previously SVP/CIO.

The Healthcare IT Week in Review

1. Utah: Do These Breaches Make My Butt Look Big?

Facts and Background

European hackers penetrate a Utah Medicaid claims server, downloading files covering nearly a million individuals and stealing the Social Security numbers of more than 250,000 of them.

Opinion

Hackers can get into anything stored online given the proper motivation and resources. Breaches happen all the time. This just happened to be a very large one and the state  government just happened to be very wrong in its initial assessment of the extent of the breach.

Musings

• Of all the things you could profitably hack, why would you want to steal the identities of welfare recipients? Possible answer: health records are often complete and therefore a convenient package for stealing someone’s identify.
• An IT technician’s weak password was identified as being cracked to gain access. That illustrates two points: (a) trying to compose and remember a bunch of complex passwords means most people won’t do it, and (b) at least this was a refreshing way to hack since most PHI exposures are due to inappropriate server security settings rather than old-school password cracks.
• The more other industries beef up their information security because they can and must, the more healthcare becomes the target of choice because security is primitive compared to that used by banks and retailers. Not to mention that healthcare records may include valuable data elements these days, such as bank account and credit card information.
• Utah had better be glad it’s not two states west since California’s breach penalty would have triggered an automatic penalty of $800 million.
• The state is now warning consumers that scammers may take advantage of the situation by calling people up randomly, telling them their information may have been compromised, and asking them to provide personal information (like their SSN) to find out.
• Adequate security is probably an unreasonable target when possession of just a couple of numbers (SSN, insurance ID, date of birth, etc.) is presumed to be positive identification to receive expensive benefits.

2. DoD’s EMR, Out-Of-Control Psychiatrists Prescribing Blamed for Addicted Marines 

Facts and Background

Poor EMR medication functionality is partly to blame for high rates of abuse of both prescribed and illicit drugs in a program for wounded Marines, according to the Defense Department’s inspector general. Also blamed is overprescribing of addictive drugs, particularly by psychiatrists.

Opinion

It may well be that the multi-billion dollar AHTLA EMR can’t bring in data from community pharmacies or the VA to help prescribers identify overmedicated patients. However, that would put it right on par with the systems used by non-military doctors.

Musings

• For identifying patients who may have an addiction problem, why can’t the government ignore prescribing records and instead look at pharmacy dispensing records? The only ways the problem can be identified in the private sector are by doctor shopper databases and examination of claims records (which won’t work if drug-seeking patients get smart and pay cash).
• While illegally obtained drugs are mentioned in the report, the emphasis seems to be on those prescribed from a sound doctor-patient relationship. In other words, the real problem is the doctors doing the prescribing, who in the absence of other motivation must think they’re doing the right thing clinically (i.e, it’s an education problem).
• The problem here is the same as it is in private medicine: doctors are pressured by patients to overprescribe, use of addictive drugs is often anything but evidence based, and any crackdown means chronic pain patients with a legitimate need for aggressive pain therapy will suffer from under-medication.

3. 3M Acquires CodeRyte

Facts and Background

3M announced last week that it acquired CodeRyte, which offers medical coding tools based on extracting information from free text using natural language processing. 3M was already using CodeRyte’s technology in some of its offerings.

Opinion

CodeRyte had put together some attention-grabbing bullet points: 250 customers, heavy penetration into deep pockets academic medical centers, 3M’s reliance on its products, and a potential ICD-10 play. If you’re going to make yourself attractive to a potential acquisition partner, it’s nice when your attributes make a deep pockets partner the logical choice.

Musings

• CodeRyte’s #1 philosophy, according to its corporate overview, was to “stay private as long as possible to allow the technology to become ubiquitous rather than a benefit to a small subset of health care through one vendor’s client base.” I translate that to mean, “3M, you’d better bring a wheelbarrow full of money if you want to get our attention.” Which I assume was the case.
• The company had brought over some former Cerner execs: Glenn Tobin as COO and Don Trigg as chief revenue officer.
• CodeRyte’s board of directors had five members other than CEO Andy Kapit. Every one of them was from a different venture capital firm with investment in the company. Surely the company’s financial ambitions were obvious.
• 3M has a steady cash cow in coding solutions and it has made few obvious acquisitions or investments in that market. This move seems preordained.
• The integration of CodeRyte’s product into 3M’s was not all that great, at least according to folks I talked to. Now 3M loses both its barrier and its excuse.
• 3M and Nuance announced just over a year ago a deal to deliver computer-assisted physician documentation and coding solutions from speech recognition. I don’t know if 3M’s contribution of the coding technology relied on CodeRyte to take the Nuance-converted dictation text and apply NLP to it, but that seems reasonable.
• CodeRyte’s technology was developed by linguistics professor Philip Resnick PhD, who still advises the company.

Time Capsule: Rogue IT Shops: Provide Rules, but Leave Them There

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 April 2007.

Rogue IT Shops: Provide Rules, but Leave Them There
By Mr. HIStalk

An ongoing hospital IT dispute involves the common existence of so-called “hidden IT shops.” Those are pockets of specialized IT that, instead of reporting to IT, are managed within their individual departments, such as patient financial services, human resources, and laboratory.

I’ve been on both sides of that particular fence, so I feel qualified to opine.

More than once, I’ve been in an IT leadership role as we reined in rogue IT operations. We cracked down on non-rules following departments that were spending IT funds unwisely, exposing the organization to risk, and insulting our IT leadership by flaunting their minimally supervised existence.

Also more than once, I’ve worked for a clinical department’s rogue IT operation, born of necessity after a Dilbert-esque IT shop couldn’t meet our department’s needs. The IT suits talked endlessly about professional IT management, but they were mostly known for starting projects they could never finish, using help desk analysts as human shields to prevent users from talking to the few experts they had, and conducting endless meetings to grind down the rational opposition to whatever they had already decided to do behind closed doors. They were much like a questionably motivated vendor, in other words.

If I have to take a position, I’ll side with allowing user departments to keep their existing IT employees.

“Common plumbing” is an IT responsibility. Departments shouldn’t have their own network technicians, e-mail administrators, server experts, or database administrators. They should not negotiate IT contracts or make capital purchases. I’m sure we agree on this.

Beyond that, my experience is that departmental IT people do a better job than their IT counterparts. They have the luxury of working hands-on with their users, free of the distrust that IT departments often generate. Since they understand the workflow and the specific technologies in place, they excel at setting priorities, can develop creative system workarounds and extensions, and are unsurpassed at retrieving and analyzing system data.

They also are keenly motivated because they are judged exclusively by their departmental co-workers, who ensure their high performance by lauding them for even the most mundane and sometimes comically easy accomplishments that seem hard to a layperson (I think that last issue is what steams the IT guys.)

I know the IT arguments because I’ve used them myself, although only half-heartedly:

• IT systems involve risk that only an IT department can assess and manage
• Centralizing IT creates efficiencies and prevents critical reliance on an individual
• Project funding should be centrally administered based on overall organizational priorities, not the needs of a single department
• Standardized practices should be used for the help desk, change management, knowledge management, and project management

What I’ve seen in reality from both sides of the fence:

• All the logical arguments aside, the primary motivator for IT centralization is the ego of the IT department’s management
• The IT department’s insistence on rules is often at the expense of creativity and flexibility
• Despite all the available tools, the IT department can’t match the service levels of locally assigned and managed IT employees
• As soon as IT gets in trouble or tries to hide staff shortages like a balding man’s comb-over, it’s all hands on deck to save the tanking projects, meaning those previously dedicated departmental resources will be yanked to put out some new fire, often self inflicted by poor planning
• Department employees often despise working in the detached, command-and-control bureaucracy of the IT department, so they leave, taking years of specialized experience with them and disproving the theory that IT can provide more resource depth than was already in place

I have loyalties both ways. These conclusions come from multiple personal observations.

Certainly other less dramatic options exist. You can have local IT resources report via dotted line to the IT department, providing guidelines on what they can and can’t do. You can insist that those teams follow documentation and change management standards. You can steer them toward standard technical tools, provide them with training, invite them to meetings, roll up their budgets under IT, and even move their chairs to the soulless cubes that IT departments love.

If you do decide to absorb the hidden IT shops, beware. Unless your IT shop is superbly managed, you’ll probably set unattainable expectations that you can’t deliver.

News 4/13/12

Top News

The Defense Department’s inspector general finds that drug abuse among Marines in the Wounded Warrior Battalion at Camp Lejeune, NC is hard to detect because of shortcomings in its CHCS and AHLTA EMRs. Prescription information from the VA and civilian doctors are not visible in AHLTA. An Army doctor said AHLTA’s medication module is “a mess,” saying that it’s so bad that doctors just free-text in the patient’s medication list, especially after the most recent update that added interfaces to civilian pharmacies and the VA. The battalion also wanted to implement the EMMA medication dispensing system used by the Army at Fort Bragg, but the Navy nixed that idea over concerns that it might not be HIPAA compliant.

Reader Comments

From X-Ray Gun: “Re: Philips. In December, decided to discontinue their RIS product, XIRIS in NA. They have also decided to discontinue their Digital Dictation and VR solution.” Unverified. They live on at least as artifacts on the company’s webpage.

From WildcatWell: “Re: requirement to have health insurance like car insurance. Will it flood my TV with endless commercials such as we see now from Allstate, GEICO, et al? It’ll be worse than political season! But, imagine: ‘15 minutes on HIStalk could save you $15K or more on life insurance.’ Send me a royalty! Keep up the good work.” I would need to dress Inga up in all white with red lipstick like that loopy Flo chick from the Progressive commercials, which are indeed ubiquitous. I’m more of a fan of the Allstate ones since they feature Dennis Haysbert, best known for playing Pedro Cerrano, the Jobu-worshipping outfielder in Major League, one of the best movies ever.

From Recent Interviewee: “Re: interview. I’ve been answering very nice e-mails since the HIStalk interview ran. Congratulations on such a great service you provide to the industry. Everyone reads it.” Thanks. I do quite a few interviews and always let the interviewee know upfront that the result is usually quite a few reach-outs from folks who’ve lost touch over the years. I don’t think they generally believe it until it happens. Healthcare IT really is a small world and most of the players just move around in it without ever straying far.

From Gesundheit: “Re: Henry Ford Health System. The $100 million MIMS system was built in the 1980s, when there were no good vendor offerings. It lasted over 20 years – not bad in today’s environment. However, adding $300 million for Epic is insanity or some lack of governance process or client acceptance. I’d like to see the fact finding on this one.”

From Ixnay: “Re: Meditech. Heard they’re ditching LSS to create their own ambulatory product.” Unverified. That rumor has been going around for at least a year and they’ve bought the remainder of LSS in the mean time. I don’t know if it’s a competitive offering, but the rumors would suggest that at least some folks think it isn’t. Most inpatient vendors still have a weak ambulatory albatross hanging around their necks, not surprising for systems whose underpinnings go back decades when nobody in hospitals cared what physician practices did.

From Jonathan Grau: “Re: International Congress on Nursing Informatics. The meeting is one of the most important activities of the International Medical Informatics Association -Nursing Informatics Special Interest Group (IMIA/NI-SIG) and is held every third year to promote all aspects of nursing and health informatics globally. We expect over 800 in Montreal, June 23-27.” I don’t usually give free plugs since I don’t want to open the floodgates, but I’m feeling uncharacteristically generous. Jonathan is with AMIA. Attendees can hang around afterward and catch the Montreal jazz festival, with performers that include Norah Jones, BB King, Ben Harper, George Thorogood and the Destroyers, James Taylor, Liza Minelli, Seal, Stanley Clarke, old favorite Van der Graaf Generator, and an interesting group whose 1970s LPs populate part of my collection, Tangerine Dream. They put me to sleep every time with their all-instrumental space music that sounds like Pink Floyd taking an on-stage break, but I like the name and covers.

HIStalk Announcements and Requests

Catch up on your HIStalk Practice reading so you have the full scoop on these posts: PCMHs improve quality and reduce costs in New Jersey. CareCloud CEO Albert Santalo joins President Obama during the signing of the JOBS bill. AMA names HP its preferred provider for technology products. Dr. Gregg sends out an RFP for an EHR – and stirs some good discussion from readers. I am a firm believer that you can never be too rich, too thin, or have too many HIStalk Practice e-mail subscribers, so please either send money or diet tips or sign up for the e-mail notifications. Thanks for reading.

Listening: the brand new first album from Alabama Shakes, Joplin-esque (or is it Otis Redding?) Southern soul from Athens, AL, just in time for summer. Singer Brittany Howard, 23 years old, belts it out and leaves it all on the stage. Killer Led Zep cover here.

Travis is on fire over on HIStalk Mobile, with one excellent, meaty post after another. His latest: Pagers – There’s an App For That, which arrives at thought-provoking conclusions about the situations when hospitals can and can’t do like drug dealers did in the 1990s in dumping the typewriter of the communications world, alpha pagers, which surely have no market left other than in healthcare.

On the Jobs Board: HL7 Business Analyst, Director of Marketing, Director of Business Development. On Healthcare IT Jobs: PACS Application Coordinator II, McKesson Paragon Consultants, Cerner Go-Live Project Manager.

It’s a strange, strange world we live in, Master Jack. Reality TV that’s anything but real, rampant Facebook narcissism, crumbling economies, and celebrities whose IQs and morality levels compete like golfers shooting for the lowest score. One thing you can count on, though – like Big Ben or Old Faithful, I will be predictably spooning with my PC to bring you news, rumors, and Cerrano photos almost every day of the week just like I’ve been doing for nine (!!) years. How might one harvest this rich outpouring of prosaic potpourri, you might ask? Simple – just click the Subscribe to Updates link at the upper right of the page to get into the exclusive club of industry movers and shakers who read HIStalk but probably won’t admit it publicly, putting it right up there with pr0n in the guilty pleasure category. Should  you wish to take our relationship to a deeper level, may I suggest: (a) electronically bond with Inga, Dr. Jayne, and me on social not-working sites like Facebook and LinkedIn, where rejection is impossible because we accept connections from everyone; (b) send me rumors and secrets; (c) pay homage to the companies that pay the bills by perusing the Resource Center and the plethora of newly animation-free ads to your left, replacing heartfelt applause with mouse clicks to see what they all actually do; (d) if you are a provider seeking consulting help, broadcast your RFI to several companies in seconds via the RFI Blaster; (e) tell someone you know about HIStalk since they won’t hear about it otherwise; and (f) bow your head humbly as I strap on the Honorary Reflector Thingy in knighting you with gratitude as my tireless confidante and defender. Thanks for reading.

Acquisitions, Funding, Business, and Stock

Emdeon reports Q4 revenue of $284 million, up 3% from a year ago. Net loss for the quarter was $71 million compared to the previous year’s net income of $15 million. Emdeon, which went private last year, says the loss was “primarily due to costs and expenses, including increased interest expense.” The company also announces its intention to re-price its existing senior secured credit facilities to take advantage of current market rates and borrow $60 million of additional term loans for general corporate purposes, including potential acquisitions.

McKesson shares rose 4% to a 52-week high Thursday on news that its $4 billion per year drug supply contract with the VA will be extended for up to eight more years.

I recently interviewed Brian Phelps, the ED doc who co-founded iPad-based system vendor Montrue Technologies, whose Sparrow ED product won the Nuance’s Mobile Clinical Voice Challenge that I judged a couple of months ago. The company learned Wednesday that it had won the $160,000 Southern Oregon Angel Investment prize. It had already received $200,000 in angel investor money at a similar conference and some pretty nice prizes from Nuance.

CPSI will move some of its Mobile, AL operations to Fairhope, saying it has run out of room.

Sales

The State of Minnesota selects Hielix, Inc. to develop a statewide HIE.

Bayfront Health System (FL) signs an agreement with Unibased Systems Architecture to deploy its surgery management and physician order management solutions across more than 20 operating rooms.

Blue Mountain Hospital (UT) chooses clinical and financial solutions from Prognosis. 

Orion Health wins the HIE contract for North Texas Accountable Healthcare Partnership. Also announced: former T-System VP Joe Lastinger was named CEO of the HIE.

Franciscan Alliance selects iSirona’s enterprise device connectivity solution to integrate medical devices with Epic in its 14 hospitals.

Care Logistics sells something that sounds kind of software related to Catholic Healthcare East, but I can’t figure out what it is from this sly hint: “This comprehensive approach combines an organizational commitment to efficiency, systemwide process reengineering and enterprise logistics software to help hospitals achieve reliable and predictive operational performance in the areas of throughput, quality and patient experience.” Their site is similarly vague, but is clogged up with enormous blocks of dense text sure to send all but the most determined visitors fleeing.

People

Post acute care IT provider American HealthTech names David Houghton (Advocat) as COO.

Hospice and homecare IT provider CareAnyware names Ray DeArmitt (CellTrak Technologies, Allscripts Homecare) as sales VP.

Quest Diagnostics appoints former Philips Healthcare CEO Stephen H. Rusckowski president and CEO immediately after his resignation from Philips. He replaces Surya N. Mohapatra, who will join the company’s board.

Philips Healthcare promotes Deborah DiSanzo to CEO. She was previously CEO of Patient Care and Clinical Informatics for the company.

MediClick names Scott Pettingell (GHX) VP of the company’s new consulting services business.

The Healthcare Financial Management Association appoints Joseph J. Fifer its president and CEO, succeeding the retiring Richard L. Clarke. He most recently was VP of hospital finance at Spectrum Health.

Announcements and Implementations

The Hawaii REC names Curas its preferred eClinicalWorks vendor.

The Carolina eHealth Alliance (SC) announces that 11 Charleston area emergency departments are now connected to its HIE.

NexJ partners with Beth Israel Deaconess Medical Center (MA) to digitize the health system’s Passport to TRUST program and make it available through NexJ’s Connected Wellness Platform.

The New York Times profiles remote monitoring system vendor AirStrip Technologies in its list of companies it says are pushing healthcare transformation. Also on the list: Avado (Web-based forms and health status tracking); ClickCare (secure physician communication for consultations); ZocDoc (making physician appointments); and Telcare (cloud-based glucose meter data sharing).

Yuma Regional Medical Center (AZ) will go live May 1 on its $73 million Epic system.

Government and Politics

CMS Innovation Center picks seven states to pilot the Comprehensive Primary Care Initiative, which aims to strengthen coordination and collaboration between private and public healthcare payers to improve primary care.

Other

The athenahealth folks sent over this video entitled It Sucks to Be Me, which highlights why it’s not easy being a physician, nurse, administrator, and patient. OK, so it’s mildly cheesy like an overwrought, applause-milking truck show Broadway musical on opening night in Omaha  (check out the drummer’s cowbell and wood block work – think Waiting for Guffman), but you’ve got to love athenahealth for its out-of-the-box marketing.

Several members of the Medicare Payment Advisory Commission (MedPAC) express concern that federal incentives may not cover the true cost of implementing an EHR. Some specific worries are that Stage 1 requirements are set too high and some required elements are too expensive to implement and offer questionable value.

Allscripts CEO Glen Tullman writes a Forbes piece on how consumer technology can be used in healthcare. He mentions FaceTime, Kinect, and FitBit. He included a video from Madonna Hospital showing some futuristic ideas that I was going to run here, but I noticed it’s a couple of years old and I would hope they’ve come up with new stuff since then.

This seems like a bad idea: an Indiana hospital implements a Web-based incident management system, intended for use during tornadoes and other natural disasters during which Internet connectivity is often lost.

A laid-off IT security administrator at Waterbury Hospital (CT) is arrested for hacking into the hospital’s computer system hours after he was marched out, using his boss’s own e-mail account to send him threatening messages.

A newspaper’s investigation finds that five electrophysiologists – cardiologists with the Ohio State University Wexner Medical Center were each paid a $1.3 million bonus in 2011, raising their one-year pay to $2 million each. The only employee at the state university to earn more was the basketball coach.

Sponsor Updates

• EHRtv posts its HIMSS 2012 interview with T-System CEO Sunny Sanyal.
• Macadamian assists in the design of Elsevier’s Mosby’s Certified Nurse Exam Prep smart phone app and its development for the iPhone, iPod Touch, and iPad. 
• HealthMEDX provides an update on its HIPAA 5010 readiness preparations.
• Allscripts President Lee Shapiro participated this week in a TechNexus panel discussion on the changing face of technology in healthcare.
• A white paper from Care360 discusses the positive impact of technology on the quality of patient care.
• NextGen will integrate Entrada’s clinical documentation technology with its PM/EHR.
• GE Healthcare launches Centricity EDI Services 5.4,which includes support for HIPAA 5010 and stronger analytics.
• Beacon Partners expands its ICD-10 Assessment Service with the addition of an ICD-10 translator and business intelligence application from McGladrey.

EPtalk by Dr. Jayne

The Colorado Regional Health Information Organization (CORHIO) releases a report on integrating behavioral health information through health information exchanges. Although agreeing that information on mental illness is a vital part of the overall data influencing the health of a patient, a role-based tiered consent structure was recommended. Surprisingly, the roles weren’t based on physician vs. nurse vs. checkout clerk but rather the specialty of physicians involved. For example, participants in community focus groups felt that specialists such as OB/GYN or dermatology had less need to know information than did hospital-based physicians. Being a primary care doc at heart, I think any time you start excluding classes of providers (especially when drugs to treat mental health have a number of potential interactions and contraindications) it’s a detriment to patient safety. Who will be liable when harm occurs because a physician was denied information that would have made a difference? Needless to say, I’m not a fan of pick-and-choose consent policies.

CMS has compiled individual quality and resource reports for physicians in Iowa, Kansas, Missouri, and Nebraska. Practices have been e-mailed a link to the reports, but only 3,300 of 23,730 reports have been accessed. I reached out to at least 10 physicians in these states and none of them knew anything about it. My guess is the e-mails either went to spam folders or are sitting in some administrator’s inbox.

I’m a reasonably diligent reader of the Federal Register but somehow I missed this item. The Drug Enforcement Administration is increasing physician fees for the privilege of prescribing controlled substances by nearly 33% – from $551 to $731. This allows us the privilege of having drug-seekers hassle us for meds and increases scrutiny of our practice patterns (not to mention an increase in medical liability insurance premiums.) It seems like what the feds provide in MU funding just slowly erodes to other areas.

I’m a little behind on my reading, so I laughed when I came across this article about the recent Utah Medicaid data breach reported to affect 24,000 patients. As of today, the number is closer to 900,000.

One of the folks I’ve found on Twitter has turned out to be one of my new favorite bloggers. Skeptical Scalpel is written by a surgeon with considerable (40+ years) experience in the field. Worth a view, especially if you have a clinical background. And if you aren’t clinical, it may provide some good conversation-starters to help you bond with physicians who are generally ticked off at the world when all you’re trying to do is fix their laptops.

I enjoy reader correspondence and always like to try to share information when I can. Recently a reader asked, “I am looking for a good hospital BYOD policy for physicians. We’re enabling physician use of iPads and similar devices to connect to our clinical systems and I am in need of a policy that covers their use. Have you come across a good one yet? If so, can you share it?” Being from a strictly “don’t touch my network” hospital, I don’t have personal experience with the thrill of being able to actually use my own device on the network. I do however have much experience hooking to the patient access network so I can use the forbidden Twitter and Facebook. I also have experience carrying both my own smart phone and a hospital-issue BlackBerry, which really makes me look goofy at times. Can anyone help a fellow reader? E-mail me.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 4/11/12

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

Satisfaction—I Can’t Get No….

“You have a Masters in Computer Science?”

The hiring manager’s initial question took me aback. Human Resources had obviously misread my degree qualifications, yet my resume still passed the screeners.

Eager to land my first salaried position, I cleared my throat and hoped my answer wouldn’t displease. “Although I do know something about computers, my Masters is in Consumer Sciences, the philosophy and practice of customer service.”

Despite her realization that I had the “wrong” degree, the hiring manager looked past this and focused on talent. And thus began my journey into the convergence of healthcare, technology, and service.

This initial position was not IT, but rather an adjunct to the corporate strategy office. Specifically, physician relations. They wanted a person with a technical background who could market the IT applications, thus endearing physicians (and their referrals) to the hospital.

IT had only achieved 5% physician adoption. They lacked the service orientation and communication skills necessary for success. By adopting service-oriented practices and strategies, we increased utilization to 85%. It was during this time that I experienced my defining moment, launching my healthcare IT career.

Customer satisfaction is a passion of mine. A service orientation mindset changes an organization. I’ve seen the positive correlation. Not only are more customers satisfied, but the benefits extend outward. Employee morale increases. Productivity increases. The organization becomes more effective and efficient.

Here are a sampling of results achieved by customer-centric teams.

• In a mid-size hospital, we deployed several applications to physicians in our region with hopes of gaining market share. We poured service all over our offerings and reached a 91% customer satisfaction rating. In one year, we went from 45% to 55% market share in four strategic indicators.
• In an academic health system, we quadrupled “top box” customer satisfaction scores in four years. Financial and quality scores increased exponentially on the same slope. Employees who were once embarrassed to be part of IT now delighted in the honor of being part of the team.
• In an integrated health system, we increased “top box” satisfaction 30% in three years. While we maintained revenue targets, we exceeded many quality targets.

How do you achieve superior customer satisfaction and sustain the gains? My team identified nine keys:

Right people in the right positions. Everything rises and falls on leadership (Maxwell). The first thing you must do is ensure the right people are operating in the right roles. Although painful, you must remove some from the “bus” and have others change seats. The quickest way to change the direction and service orientation of your organization is to put people into positions that best utilize their natural talent.

Effective communication. Personally and sympathetically counter negative perceptions and battle anecdotal commentary with facts. Establish monthly reports with dashboards on service levels, project status, key deliverables, and achievements. Share the good, the bad, and especially the ugly. Deliver presentations whenever and wherever you can, evangelizing IT. Become a valued member of every management team.

Relationship building. Strong relationships cover a multitude of sins. Assign IT leaders directly to operational leaders and make routine calls and visits to address concerns. This allows operational leaders to have a single “go-to” person for all their IT interactions and reduces associated complexities. Involve IT leaders in organizational events such as blood drives, sporting events, service opportunities, volunteering, and charity work. Establish a program for connecting with clinicians.

Strategic planning. “Where there is no vision, people wander.” This proverb characterizes IT: a bunch of well-intentioned professionals without direction. Consequently, there is stifled progress, pent-up demand, and frustration. Solicit input from your enterprise and fashion a strategic plan. Review annually and ensure organizational alignment and convergence.

Comprehensive governance. Implement a formal but agile governance process comprised of and led by customers. This ensures IT alignment with organizational vision and gives you a level of rigor, accountability, and transparency not previously possible. Include rank-and-file customers, senior executives, and especially nurses and physicians.

Continuous quality improvement. Your survey vendor will provide in-depth analytics and recommendations based on the results. For instance, after learning that nurses represented our most dissatisfied customer group, we swept through nursing floors and made sure IT became a clinical care enabler. We added hundreds of mobile computers to patient floors to satisfy their greatest complaint — lack of devices.

Aligned incentives. Create a single key performance indicator on which incentives and raises are based … the annual customer satisfaction score. Everyone will become focused on service.

Execution excellence. Without excellent execution, all other strategies are moot.

The secret weapon. The secret weapon is heart. Heart is the wellspring from which motivation emanates. Empathy, compassion, and humility combine to mold a heart that seeks to serve. I’ll hire those with high talent and high heart but mediocre skills any day over someone who has low talent and no heart. Skills can be taught, heart is caught.

Superior customer satisfaction and information technology need not be mutually exclusive. It is less a matter of programs and more about a sustainable leadership imperative that transcends culture. It is a journey, not a destination, and requires a steadfastness of focus, discipline, and courage.

Unlike The Stones, you can get Satisfaction. Hey, hey, hey, that’s what I say …

How do you create a service oriented culture? Share your ideas below and I will send you a presentation I did on developing a customer service culture plus the accompanying Gartner case study.

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.

HIStalk Interviews Shelli Williamson, Executive Director, Scottsdale Institute

Shelli Williamson is executive director of Scottsdale Institute of Minneapolis, MN.

Tell me about yourself and about Scottsdale Institute.

I have been in healthcare all of my life. I spent 21 years with the combination of American Hospital Supply Corporation and Baxter Healthcare in a variety of roles. I was fortunate to get a broad perspective on different components of the healthcare system through those years.

When I left Baxter, I joined First Consulting Group, where I was immersed in the IT world. I was introduced to the Scottsdale Institute through that relationship. I’ve been at the Scottsdale Institute managing our programs for about 12 years.

We are a 501c3 not-for-profit association, primarily consisting of large health systems. We are designed for networking and collaboration among our members. We’re here to help our members help each other. Scottsdale Institute acts as the convener for systems to learn from each other and share what they’re doing as it relates to strategic information technology-related initiatives. Boy, has there an never been a better time for talking about that.

Our programs consist of face-to-face initiatives, such as our conferences and collaborative meetings. A lot of virtual activities — we do about 80 teleconference sessions a year. Last year, about 10,000 people participated in our live weekly teleconferences. We do two publications a month. We really want to act as a convener to help people share what they’ve learned and hopefully help people avoid reinventing the same wheels that are being reinvented across many health systems.

How do you position your group against VHA, Premier, CHIME, and HIMSS Analytics?

There are many excellent groups out there. We’re not a GPO, so we have no GPO-like activities. Certainly many of our members belong to all these other groups as well – it’s not an either-or and I wouldn’t try to position it that way. 

Our meetings are designed for executives of all types, so we’re not functionally organized. It’s not just CIOs, CMIOs, CMOs, and CEOs, but rather all of the executive types together. I think people enjoy that idea of being able to exchange different perspectives based on the fact that chief nursing officers are in the room with CIOs and CEOs and others.

We do not technically do research. Some of the groups that you might think of publish research papers and do those kinds in-depth studies. Our activities are more peer to peer — networking, collaborating, sharing of information. It’s more in the trenches. It’s not academic in any way. It’s really how we’re doing things that we’re doing, what we’re learning, what we’re doing well, and what maybe we didn’t do so well and might do differently another time. It’s more those kinds of exchanges that we try to support and foster.

The other thing that might be noteworthy is that our membership is a flat fee. We do not have a limit to the number of seats or people within the organization that can participate and download and access and so forth. Some of these large health systems, such as Ascension Health, Trinity, and others … there are many hundreds even bordering on thousands of actual users within those organizations that access SI resources and participate in the weekly discussions.

From that perspective, it’s a great value for these large health systems who want to expose their team members to education and these kinds of collaboration opportunities, but without the cost of necessary travel and being away from the office.

Also, our benchmarking service is open to all health systems, not just SI members, and is no charge as part of our 501c3 mission.

I see on your website that you offer some conferences and publications. What kind of topics do you typically cover?

Our conferences in recent years have been focused around reform-related activities. Anyone can see all of agendas for our conferences on our website. Those links are public,  so anyone can feel free to browse the agendas.

The face-to-face meetings are small, intimate by design, and exclusively for the senior officers and senior management teams. While I mentioned that we will have a variety of title types at these meeting, this organization was started 19 years ago by a handful of CEOs who saw the writing on the wall that IT was going to be strategic and wanted to start this organization to provide a venue where people and executives can look at IT from a strategic point of view.

I think 19 years ago … that was very, very forward thinking. We take that for granted, but at that point in time, the genesis for Scottsdale Institute was the idea that IT was going be strategic. We still keep that as a main focal point of our conferences and publications.

The publications, in a similar vein, are written for the busy healthcare executive so that person — be it a CFO, CNO, or board member — can get a handle on what these challenges are around IT and begin to understand and appreciate things that all of us in IT know and are near and dear to our hearts. The publications are written in simple English. They are not in tech speak, and are purposely written that way so that busy executives can begin to get comfortable with the IT issues and solutions that their organizations are adapting and implementing.

My experience with IT benchmarking has been mixed. It’s always a tradeoff between doing a survey of reasonable length that someone can complete without becoming frustrated. Also, it’s tough to start up a program like that since you need enough organizations to give participants a good probability of finding benchmark partners that are like them. How do you approach that?

You hit the nail on the head when you talk about the tradeoff between getting every piece of information possible versus something that people are willing to sit down and fill out. We have tried very hard to keep it brief enough on critical elements so that people are able to sit down and do it in 30 minutes.

The purpose of our program is not to try to come up with industry averages or recommendations about what is the right amount of money to be spent on IT. We don’t believe that has any place, at least in the program that we have offered.

What we have done is create a tool where you and your health system or anyone can pick out two, three, four comparable peer organizations based on demographics and then normalize your data with them to see where you are. It creates more of an apples-to-apples comparison. IT budgets are not created equal. Some people include biomed, some include HIM, some include physician or patient portal and their IT budget, some have the CMIO in the IT budget and others don’t. Some have PACS, some have part of PACS, some have telecommunications.

What this tool is designed to do is compartmentalize all of those costs. If you count HIM as a part of your IT shop and I do not, I take your HIM number out, and then we look more and more apples-to-apples. Same thing with biomed, same thing with security and privacy. Even depreciation, which is a huge number. If that’s part of the IT budget in your world and it’s part of the finance in my world, the tool automatically normalizes that information. 

It helps peer organizations get closer. It’s certainly not perfect and nothing is, but it gets a lot closer to apples-to-apples comparison. If you and I are spending the same amount of money but you’re further along in Meaningful Use than I am, that tells us something. I need to learn something from you about what you’re doing.

The other problem with IT benchmarking is the people usually participate because they believe they’re above average and want to back it up so they can tell their organization what a great job they’re doing. But if their expenses are higher, they always question the methodology or the quality of the data from the peers who submitted. What do people typically do if their results don’t show that they’re above average?

Our approach is to help people if they wish to connect with their other peer organizations to see, once they normalize, what is driving the differences. If you’re at HIMSS Level 6 and I’m HIMSS Level 4, that explains a lot money. We have that point of comparison in there as well. Same thing with Meaningful Use data. If you’ve already attested and I’m a long ways away, that could be an explanation — you’re further along in terms of advanced clinical IT deployment.

All we’re trying to do is help people understand the differences. Then, if they wish, connect with these peer organizations to dig deeper into individually what’s going to help each person answer that question.

The end result of benchmarking is you always want to talk to the peer organizations to find out what the survey didn’t tell you. So you facilitate that contact?

Right. I think that’s where the real value is. It’s in the learning. The data is hopefully the beginning point for participants as they work with each other. We don’t necessarily get involved in those discussions. You would be talking to one of your colleagues from another organization without our intervention.

The other challenge that I’ve not seen convincing proof that IT cost correlate to — much less cause – a change in quality. Are you being challenged to help clients prove value beyond just having a reasonable expense?

That is an excellent point, and probably the future. We are not at this moment trying to address that, but certainly cost does not equate to value. That’s what we need to learn — how to equate this IT expense into value. Of course, it isn’t just the IT that does anything — it’s the people on the process. We can’t say cause and effect, but we can show correlation between IT and quality.

Thomson Reuters just completed a study which we’re going to be discussing at our Spring Conference in Scottsdale, Arizona. That actually shows some correlation between the Thomson Reuters Top 100 Hospitals — as the way they measure it — and the use of advanced IT. So again, correlation, not cause and effect, because obviously people have to make this stuff work. But there is a correlation there that we’re excited to be talking about next month.

Any final thoughts?

This is such an exciting time, as we all know, to be in healthcare, and specially to be in healthcare information technology, I feel that every day, somebody says to me, “Thank you for what you all are doing for us.” That just is a very motivating and thrilling kind of place to be.

News 4/11/12

Top News

HHS proposes a one-year delay for ICD-10 compliance, pushing the deadline to October 1, 2014 and giving providers and other covered entities more time to prepare and test their systems with the new code sets. HHS also issues a rule requiring all health insurance plans be numerically tagged with a unique health plan identifier, which it says would save providers and health plans up to $4.6 billion over the next ten years.

Reader Comments

From What Next?: “Re: Epic starting their own consulting business. Anyone heard that rumor? They’re supposedly trying to hire back former employees to provide supplemental staffing for application build and design, credentialed training, and go-live support. They would price this as part of the license cost under ‘enhancement implementation services.’” Unverified.

From Baldp8: “Re: Medicare reimbursement break-even in hospitals. How will this impact the IT capital and operating budgets? More spending to automate costs out or less spending to get to a number?”

From Lovin’ Sunshine: “Re: McKesson Practice Partner. Heard that Mel Coovert is no longer with the company, making us consultant folks wonder if Practice Partner is headed the way of Horizon Clinicals. Makes us go ‘hmmmm’ being right in the middle of an implementation.” Melissa Coovert left the company last month, according to her LinkedIn profile. That’s all I know.

HIStalk Announcements and Requests

I had a brush with technology at the doctor’s office this week. I had a minor procedure a couple weeks ago and the incision area has not healed well. Yesterday I decided I should have my doctor check it out, but she had taken the day off.  I saw one of her partners instead, who asked me to compare the site with its appearance a week ago. That’s when I whipped out my iPhone and showed him a picture I had taken. He then made his assessment (I’m getting better) and I went on my way. It’s the little things that get me geeked.

The folks at Imprivata sent over this brilliant item from their April newsletter.

Acquisitions, Funding, Business, and Stock

Cerner CEO Neal Patterson earned $5.6 million last year, a 10% boost over 2010. Compensation included a salary of $1.025 million, $1.6 million in cash incentives, and stock options valued at $2.8 million on the date they were granted. He also received $122,412 in “other compensation” that included $110,000 for his private use of the corporate aircraft, plus contributions to his 401(K), insurance plans, and private security systems.

Sales

Mercy selects Merge Healthcare’s iConnect VNA as its image archive solution for more than 200 facilities across the Midwest.

The 200-member IPA of Nassau/Suffolk Counties (NY) selects Greenway’s PrimeSUITE EHR/PM solution.

FirstHealth of the Carolinas selects Thomson Reuters’ Integration Discovery, powered by CareEvolution, to provide clinical interoperability across its system.

People

Cardinal Health names Donald M. Casey, Jr. CEO of its medical products and services business. He was previously CEO of the West Wireless Health Institute.

John D. Bennett MD, FACC, FACP, president of CDPHP, joins the board of New York eHealth Collaborative.

David O’Hara, COO of Microsoft Advertising, joins the board of Intelligent Insites.

Announcements and Implementations

The Hawaii HIE goes live on messaging and referrals using the Medicity platform.

Elsevier launches ClinicalKey, an online collection of clinical resources covering every medical and surgical specialty and including over 700 textbooks and 400 medical journals.

Capsule Tech releases the first of a series of videos called Connected Consultants intended to educate clinicians and IT staff about medical device integration. The first one is pretty funny.

UnitedHealthcare donates $700,000 to the California Telehealth Network to expand telemedicine training and support rural and medically underserved clinics and hospitals in California.

Government and Politics

CMS announces that 27 ACOs have entered into agreements to participate in the Shared Savings Program beginning April 1, 2012 and has selected five organizations for inclusion in its Advanced Payment ACO model. CMS is considering an additional 50 applicants for the Advance Payment program beginning July 1st.

CMS publishes a full set of proposed Clinical Quality Measures for 2014 as part of the proposed Stage 2 EHR rule.

Other

I loved this headline and yes, it prompted me to read the article. The Washington Post article discusses a letter recently published in the British Medical Journal, which highlighted the amount of data entered incorrectly into the UK’s medical system.

A class-action lawsuit is filed against St. Joseph Health System (CA), which in 2011 accidentally released information on 31,800 patients. At the time of the breach, personal and medical information stored in unencrypted electronic reports were searchable online. The suit seeks $31.8 million, following California’s mandatory damages of $1,000 per affected individual.

Weird News Andy spotted this major breach news. An IT tech’s weak server password allows European hackers to penetrate a Utah Department of Health Medicaid claims server, where they download thousands of files covering nearly 900,000 individuals, of which 280,000 have their Social Security numbers stolen. Here’s an interesting quote from RSA’s CISO:

Why do we continue to see these large aggregate databases? Why should hackers be able to steal 10 million credit card numbers or 700,000 personal records at once? We need to think about distributing that information so that when networks do get penetrated, we’re not looking an all-or-nothing situation.

WNA also likes this story about the geriatric ED at Mount Sinai Hospital (NY), of which there are several dozen nationally. He’s a bit creeped out by the dome in the photo, saying it reminds him of Edward G. Robinson in Soylent Green.

A state audit of SUNY Downstate Medical Center finds that only 10 of its 200 departments are using the $2 million purchasing system it implemented over a four-year period.

A Time article says that cash-strapped universities, following the lead of for-profit schools, are cranking out high-margin professional certificate programs that are attractive to mid-career students who don’t need financial aid or whose employers reimburse them. Healthcare technology management was mentioned. Experts question the quality and the career value to students.

HealthPrize Technologies, which encourages medication adherence through online games and rewards, brings on new staff to support what it says is major growth. Founder and CEO Tom Kottler’s first startup was revenue cycle vendor MedAptus.

The CEO of Sony, which just announced a $6.4 billion loss for the year, says the company may get into the medical products business.

Jack Tramiel, who bought a typewriter repair shop and turned it into Commodore, the company whose early computers (VIC-20, PET, Commodore 64) helped make home computing popular, died this week at 83.

The CEO of Henry Ford Health System (MI), reporting a 64% decrease in net income to $22 million, calls the past two years “transition years” as the organization spent $300 million on Epic less than a year after going live on its $100 million homegrown system.

Four former executives of iSoft, including former chairman Patrick Cryne, will be tried in the UK, charged with making intentionally misleading statements to inflate the company’s financial position.

An attorney and former employee of the Austin, TX-based Cancer Connection volunteer program sues her former employer for wrongful termination, saying the organization ignored her strong warnings that it needed to implement HIPAA training and to stop giving volunteer-prepared baked goods to cancer patients. One of the organization’s founders and board members, known as “the brownie lady,” told her the baked goods policy would not be changed.

Sponsor Updates

• In Turkey, Emsey Hospital implements iMDsoft’s MetaVision in its ICU.
• Culicchia Neurological Clinic (LA) selects SRS EHR and Patient Portal for its 17 providers.
• MEDecision announces details of its Client Forum 2012 conference May 1-4 in Philadelphia.
• Liaison Technologies completes all milestones required as part of a $30 million investment from Merck’s Global Health Innovation Fund.
• Kony Solutions appoints Harold Goldberg (Merced Systems) its chief marketing officer.
• Raymond Gruby MD, FACS, chief medical officer at Intelligent InSites, will present a session on RTLS in medicine at this week’s meeting of the SD/ND chapters of the American College of Surgeons.
• MEDSEEK and Microsoft co-host an April 12 Webinar explaining why healthcare reform strategies will fail without patient engagement.
• Kareo launches a Resource Center that includes webinars, white papers, and educational videos.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

3M Acquires CodeRyte

3M announced this morning that it has acquired CodeRyte, which offers natural language processing and computer-assisted coding tools. 3M has offered CodeRyte’s computer assisted coding products to its own customers since 2009.

CodeRyte offerings include Health System Coding (natural language processing and coding workflows); CodeAssist (automated coding using extracted text from physician documentation); CodeComplete (outsourced coding services); and DataScout (analytics using information extracted from both structured and unstructured records.)

3M Health Information Systems VP/GM Jon Lindekugel was quote as saying in the announcement, “This acquisition allows us to apply CodeRyte’s leading edge NLP technology to our new 3M 360 Encompass System. We believe CodeRyte’s powerful NLP engine combined with 3M’s deep expertise in coding, reimbursement and patient classification will foster further innovation in the application of NLP.”

CodeRyte’s 130 Bethesda, MD-based employees serve 250 customers, which the company says represents 85% of academic medical centers that use computer-assisted coding.

Curbside Consult with Dr. Jayne 4/9/12

The hot news around the non-virtual water cooler this week has been the call by many physician professional organizations to reduce unnecessary medical tests and procedures. The move is aimed at lowering health care costs and improving decision making. The campaign, called “Choosing Wisely,” hopes to engage doctors and patients in a dialog around the procedures and tests.

In my experience, even the most educated patients are reluctant to go along with guidelines and evidence-based medicine, frequently demanding tests “just to make absolutely sure” that a problem doesn’t exist, or even worse, “because insurance will pay for it.”

I have had countless arguments with patients over all manner of tests and treatments. It’s difficult to help patients understand that medical testing isn’t entirely harmless. There is always the risk of a false-positive test that can result in further unneeded testing, stress, and potential harm. Radiation exposure is cumulative. Tests aren’t necessarily indicated just because a cardiology practice that owns a CT scanner is running radio ads that offer discounted cardiac risk scoring.

Many of the tests on the list are obviously questionable, yet patients consistently demand x-rays for low back pain. I have many colleagues who order colonoscopies every seven years for low-risk patients.

I’m sure many think this list will be helpful to stimulate discussion with patients, but I’ve tried the literature and data route before. Patients have accused me of trying to ration care when I’m simply following evidence-based guidelines.

Every patient has a story about something that “the doctors missed” and is afraid it will happen to them. There is also the subset of providers who don’t want to get caught on the wrong side of a lawsuit should something be missed.

A glance at my local newspaper today revealed four of five reader comments along the lines of, “The doctor didn’t want to do the test, but I demanded it and it saved me from a life-threatening situation.” I appreciate these individuals’ stories, but ordering every test on every patient every time is not only poor patient care, but a recipe for economic collapse.

The participating physician groups are partnering with Consumer Reports and AARP to get the word out, but I’m not sure it’s going to make a difference. As long as payers continue to cover some of these items (such as annual EKGs for low-risk patients without symptoms) it’s going to be an uphill battle.

Additionally, hospitals still often require some of these tests – such as a preoperative chest x-ray for all patients regardless of risk – making it difficult for physicians to just say no. The entire list of 45 procedures (each of the nine participating specialty groups identified five procedures that are overused) can be found online at Choosing Wisely.

From an EHR perspective, figuring out how to work clinical guidelines into real-world workflows and ensure truly usable clinical decision support is tricky enough when the guidelines are clear cut. When they’re not so clear (especially when you have multiple bodies recommending strategies which are contradictory, such as the mammography guidelines) it’s nearly impossible.

I’ve been asked by individual physicians to re-code clinical decision support during EHR go-lives because they don’t agree with the national standards. Indeed, we are in America, but as long as providers continue to have cowboy attitudes this will be a struggle. Similarly, the transition from “patients as patients” to “patients as consumers / customers” has also created difficulties. When physicians are graded on patient satisfaction scores, the decision to deny unneeded antibiotics or a requested test becomes more difficult.

I’m interested to hear how these recommendations have affected you. If you’re a physician or provider, are your patients hearing any buzz on this topic? And if you’re in IT or software support, are you receiving requests to modify clinical decision support to reflect constantly changing guidelines? Let me know what you think. E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 4/9/12

From N2InformaticsRN: “Re: UCI Medical Center. Developed a program to bring staff nurses into the field of nursing informatics in support of their EMR implementation. It uses ONC’s Health IT Workforce Curriculum as its core.” Above is the video explaining the program.  

From El Pescador: “Re: HITECH incentives. I don’t disagree with you often, but I do this time. We are one of the systems that is going to get a ‘windfall’ in MU money without significant investment. Where I take issue with your response is that when the looming reductions in reimbursement are taken into account – surprise – it’s almost dollar for dollar. Zero sum game for our organization. Perhaps others don’t find themselves in the same boat. Enjoy your website immensely … best source of info in the industry.” I think my point is still valid. CMS may indeed take your money elsewhere, but that was not related to your unrestricted HITECH “grant.” Without it you would be in the hole rather than even. It’s like winning $2,000 on a scratch-off lottery ticket but blowing your car’s transmission at a repair cost of $2,000 on the way to cash it in. You still won the lottery, and the repair was going to cost you $2,000 in any case. WildcatWell’s original question was: is it fraud when providers use a free EHR to earn HITECH money? Answer: no, there is no requirement to spend anything to earn an MU check. Most providers will indeed spend money (and sweat) to earn their payout, but that’s between them and their vendor … Uncle Sam doesn’t care when he writes the check.

From WildcatWell: “Re: Jason Dufner. Would a Masters win bolster his sponsor’s footing? Doubt it. At Augusta, a Greenway label comes across like a landscaping company. Wasted marketing dollars.” Above is an Associated Press photo of him after the second round with the Greenway logo on his shirt. Like NASCAR drivers and football coaches, life is good when you get big paychecks just for wearing logo apparel in public. I don’t know how you’d calculate the ROI on wearing a PM/EMR logo in front of a golfing audience, but I assume there’s leverage opportunities with prospects who enjoy watching someone else play golf.

From Fish: “Re: Epic’s 2006 ambulatory sale to Capital Health in Edmonton, Alberta. Whatever happened to it?” Beats me. Readers?

Imprivata provided a response to 1Sign’s unverified rumor about Dell having discussions with the company about an acquisition. Here it is: “Not true.”

Our judicial handicappers expect the Supreme Court to strike down just the insurance part of the Affordable Care Act, with equal minorities saying it will be all or none. New poll to your right: how much impact will the JOBS Act have on healthcare IT startups and innovation?

In case you don’t know what the JOBS Act is, here’s a CliffsNotes version. The JOBS Act, signed into law last week, makes it easier for small business startups to raise investment capital. Anybody can offer the general public shares in their venture, which was previously illegal (investors had to be accredited, i.e. wealthy and vetted, before being allowed to buy their way in.) The new law lets anyone invest and allows early-stage and tiny companies to solicit investors, even via Web-based “crowdfunding.” On the downside, amateur investors are on their own to perform due diligence, some shaky companies are now going to be free to pitch to investors, and lawyers will probably make a fortune as would-be CEOs and their unsophisticated investors butt heads. The hope is that small businesses can grow faster with easier access to unrestricted capital, allowing them to hire employees earlier than they would have otherwise.

An article in Clinical Pharmacology & Therapeutics called Electronic Health Records: The New Vehicle for Drug Labeling, Safety, and Efficacy by Ed Fotsch MD, CEO of PDR Network, proposes that services like those offered by his company could increase safety and decrease liability by delivering up-to-date drug labeling, REMS, and adverse event reporting right to individual provider EMRs. It finds from its own database that 25% of brand name drugs have clinically significant changes in their professional labeling each year, meaning that paper-based literature used to make clinical decisions is often obsolete. The problem: most EHRs don’t have the capability to electronically receive these alerts and confirm receipt. The article also says that EHRs could be used to file adverse drug event reports with the FDA and improve patient adherence.

Note: I come home straight from work on Tuesdays and Thursdays and jump right in to spend an unbroken 4-5 hours writing HIStalk and I’m up pre-dawn the next day to go to work. Therefore, I will rarely be able to reply to any Tuesday or Thursday e-mail until the next evening at the earliest. Re-sending the e-mail doesn’t do anything except clog my inbox even further. I always catch up, but it takes time.

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

Law firms are using California’s Confidential Medical Information Act of 1981 to file profitable class action lawsuits against providers, who are required by that law to pay $1,000 for each person whose information is exposed. The article says McKesson lobbied to have the damages clause removed retroactively about a year ago, but failed. Courts will need to decide whether the law is appropriate since when it was written in 1981, breaches were both rare and small, but today a single breach could result in millions of dollars in payments, which the lawyers find irresistible. 

E-mail Mr. H.

The Healthcare IT Week in Review

1. Newt’s Think Tank Tanks

Facts and Background

The Gingrich Group LLC, doing business as the Center for Health Transformation, filed for Chapter 7 liquidation after struggling to maintain relevance once founder and former Congressman Newt Gingrich resigned last spring to run for the presidency. The for-profit group offered its strategic services to healthcare companies whose products and services addressed Gingrich’s big ideas themes, including healthcare IT. The company had pulled in $55 million by charging companies such as Blue Cross Blue Shield, Allscripts, HealthTrio, and VISICU up to $200K per year to gain access to Gingrich and his contacts.

Opinion

CHT was not illegal, just distasteful. It’s satisfying that it went down in flames, but unfortunately Pilot Newt had already done a DB Cooper and bailed out with the money. It’s too bad that the smoking wreckage still had employees who lost their livelihoods because Newt decided to run an unsuccessful political campaign, not to mention surprising that he didn’t just end his presidential run and go back to the one thing he’s been really successful at — selling his influence. It’s too bad that he presumably had at least some hand in  getting the $19 billion HITECH package inserted into the stimulus bill.

Musings

• CHT was like William Shatner signing autographs at Star Trek conventions. If you wanted Newt’s attention, it was going to cost you.
• Unlike Shatner, CHT claims it wouldn’t accept money from anyone whose agendas didn’t align with Newt’s, but offered no proof that Newt’s rich man’s club had standards that exceeded passing a mandatory checkbook inspection.
• Newt’s loyalties were apparently available even when for issues that would not typically enjoy widespread Republican support, such as pushing federally subsidized EMRs and mandatory health insurance.
• One of CHT’s most controversial clients was Freddie Mac, which paid CHT $1.6 million to advise it on potentially troublesome new Congressional regulation. He claimed he was hired as a historian, which probably encouraged historians everywhere to offer their services as a slight discount. Freddie Mac’s bailout will cost taxpayers up to $360 billion.
• Newt was adamant that CHT did no lobbying, which was critical to preserve his presidential run. That’s probably legally correct, but the average citizen would find it hard to believe that paying a former Speaker of the House to make introductions to his political pals and and to pitch client offerings in Washington isn’t pretty much the same thing.
• In a fit of stimulus schizophrenia, Newt called the stimulus package a “big politician, big bureaucracy, pork-laden bill” that should be stopped, but lauded the HITECH part of it that benefitted his clients as “a key part of the stimulus package.”
• After the stimulus bill passed, CHT set up regional meetings called the “EHR Stimulus Tour” with Allscripts and Microsoft, urging doctors to implement EHRs to get their taxpayer payouts.
• While running CHT, Newt kept popping up like Where’s Waldo at Washington events and even on the Capitol floor, but his former colleagues never questioned why he was entitled to have that access. Some said later they didn’t realize CHT was a for-profit organization, assuming from its name that it was a non-profit think tank with purely altruistic interests.

2. CSC: Pardon the $30 Billion UK Black Hole –What US Healthcare Needs is Lorenzo

Facts and Background

Government consulting CSC, a key player in the massive NPfIT failure in the UK, says it will use the lessons learned there to launch its Lorenzo product in the US.

Opinion

Choose your site visits carefully.

Musings

• CSC bought iSoft a year ago when that company, which was also the key supplier in CSC’s NPfIT contract, was about to go belly up after huge losses and government financial investigations.
• iSoft had a long record of missing its NPfIT dates, although it was an awkward arrangement between CSC as the contractor and iSoft as its most important provider.
• Once NPfIT was shut down, individual trusts could decide whether they still wanted the previously mandated Lorenzo. Many didn’t.
• When the UK government talked about the money that could be saved shutting down NPfIT, CSC said it would sue the government since it had spent $1.5 billion trying to get Lorenzo running in England and was planning to make an extra $3 billion for the planned one-year extension.
• The company’s UK problems triggered layoffs and investor lawsuits.
• CSC joins every other NPfIT contractor and supplier in nearly going under after winning what seemed like a windfall NPfIT business, but accepting such hardball contract terms that they couldn’t deliver.
• CSC named former Misys PLC CEO Mike Lawrie as president and CEO in February.
• Shares are worth half what they were five years ago.
• A key CSC healthcare acquisition was First Consulting Group in 2007 for $365 million.
• Much of the reason US vendors such as Cerner have struggled in the UK is because of localization issues, trying to get software designed around US healthcare processes to work elsewhere. Lorenzo will have the same challenge in reverse here.
• All that said, it will be fun to see if Lorenzo is competitive with the usual suspects (Cerner, Meditech, Epic, etc.) and whether CSC will offer a wide range of department and financial systems instead of just clinical systems. The market could use another choice.

3. Data Entry Error Kills Baby, Costs Hospital $8 Million

Facts and Background

Advocate Lutheran General Hospital (IL), which admitted that a pharmacy technician’s IV machine data entry error in 2010 killed a baby, settled the family’s lawsuit for $8.25 million last week.

Opinion

Many hospitals have electronic interfaces that connect their pharmacy system to their IV manufacturing systems. Why didn’t Advocate? Hospital system vendors often consider such interoperability only begrudgingly since there’s no benefit to them other than keeping clients happy, so it would be interesting to know whether that option was available.

Musings

• IV room automation is perhaps the least-understood, yet most patient-impacting technology a hospital owns. The final product is a clear solution that may or may not contain the intended contents in their correct amounts, and mistakes are often deadly and undetectable.
• IV compounder data entry errors are not uncommon, just not commonly reported and not always fatal. Any time you have people keying highly critical numbers into a machine there’s a good chance that they will eventually mess up. Allowing this work to be performed by unlicensed personnel is not a good idea, but the reality is that anyone – licensed or not – could have made the same mistake.
• IT departments are usually at least slightly involved in IV compounders because they require a server, but often they stop there and assume the pharmacy department knows what it’s doing.
• Potentially life-saving alerts on the compounder were turned off, but activated after the fatality.
• A lab tech sealed the baby’s fate by assuming that his high serum sodium level was a mistake, rather than what it really was – the last chance to catch the IV error before it was too late.
• Some clueless critics blamed CPOE for this error. That had nothing to do with it – the order was entered correctly by the prescriber and the pharmacist in the CPOE and pharmacy systems, respectively. It was the sometimes forgotten but most important step of actually preparing the ordered dose for the patient where things went horribly wrong.
• CIO lesson learned: don’t assume the world revolves around big-iron IT systems. Go to the sharp end of the stick (on the nursing stations, ED, and particularly high-acuity areas like the OR and ICU) and see what gets put into patients. Then track it backward to see where it comes from. Technology could be increasing the chance of mistakes, or it could offer opportunities to reduce them. Serious patient drug harm is rarely caused by drug ordering (which is where IT systems focus), sometimes caused by drug preparation, and often caused by drug administration.

Time Capsule: My Secret Nostalgia for Small Hospitals

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 March 2007.

My Secret Nostalgia for Small Hospitals
By Mr. HIStalk

I have a dream at least once a week. I’m working in a tiny hospital in a flyspeck of a town, an architecturally outdated cinderblock building plopped in a big field in the shadow of lofty mountains. I’m running my little department nearly single-handedly. I’m feeling good, relaxed, and confident that I’m making a great contribution. I like the administrators, the physicians, and my co-workers.

If you’ve ever worked in a small hospital, you know how honorable and satisfying a profession that can be. The commute is traffic-free and I just might stop off on the way to work to buy bag of biscuits for the people I work with. If anyone in my family has medical needs, I know they’ll be treated very well by my peers who are – dare I say it? – friends. The “we’re all in this together” feeling is universal.

In other words, I’m back in the 50-bed hospital I worked for right out of college. The soft gauze of time has probably softened the memory of low pay, stretched resources, and plain-Jane facilities. Still, I never had to attend meetings, I didn’t worry about being on the wrong end of a corporate back-stabbing, and I knew I could make a difference in just about any way I chose. I was on top of my game and I knew it.

I miss it, even though I’m sure it’s changed since then. Sometimes I think I shouldn’t have been so anxious to move up to bigger and allegedly better places with their layers of bureaucracy, unchecked egos, and big but sometimes poorly managed budgets and IT projects.

I like small-hospital IT, even though it’s the minor league of the industry. I keep reminding myself that the majority of hospitals aren’t sprawling medical complexes – they’re little buildings where proud locals are born and will die, with no interest whatsoever in heading off for an impersonal and often dangerous big-city medical center.

Any plans to raise healthcare’s technology bar must include that majority of hospitals that are small, poor, and under-resourced. They need simple, affordable technologies that work, not $25 million systems that require a small army of support staff and an ego- driven CIO making $400,000 a year.

Luckily, some very good vendors are happy to sell into these little hospitals at an affordable price. In fact, some of their customers have outdone their big- hospital peers in rolling out CPOE, paperless medical records, and IT-driven improvements in outcomes. I love to see that. Too often, they feel inferior at the modest scope of their efforts.

I’m sometimes guilty of getting on my high horse about big-hospital IT. That’s odd since, as an insider, I know how poorly it can work even in a big hospital. I’ve played a role in huge IDNs that bought little hospitals and haughtily tossed out all their highly functional systems just for our own IT convenience, i.e. “standardization,” knowing that they were actually way ahead of us with their little econobox IT stuff because they actually used it right. Too bad.

Maybe I’m just being uncharacteristically and overly sentimental, but I’d like to give a respectful nod to that great majority of hospitals that vendors, consultants, and member groups often forget about. Some of us in seemingly glamorous places have a secret: we recognize that you sometimes do a better job for your patients than we do for ours. And, in our dreams, at least, we sometimes come back home.

HIStalk Interviews G. Cameron Deemer, President, DrFirst

G. Cameron “Cam” Deemer is president of DrFirst of Rockville, MD.

Tell me about yourself and about DrFirst.

I started in healthcare in the pharmacy benefits management industry. I joined PCS Health Systems in the early ‘90s and spent about 10 years there, largely in product management. I worked in developing what were at that time brand new concepts, like tiered formularies, closed formularies, and performance-based programs.

After the fourth acquisition of PCS, I left and joined NDCHealth, primarily to help them get their e-prescribing initiative off the ground. At the time, they were very much aiming to be what Surescripts is today. I spent about a year working on that with them until they decided there really wasn’t much benefit in continuing to pursue that direction. I moved instead to working with their EMR and practice management system strategy. In 2004, I joined DrFirst.

To give you a little background on DrFirst, the company started January 1, 2000. It was founded by Jim Chen, who is still CEO of the company today. Jim a was one of early inventors of virtual private networks in his previous company, V-ONE . He believed that he could use that VPN technology he developed to deliver affordable systems to physicians in an ASP environment.

Toward that end, in the very earliest days of the company, he went out and bought a worldwide unlimited license to NextGen and set the company up as a NextGen VAR. He quickly realized that wasn’t something that DrFirst could scale. It wasn’t really going to get the company where he wanted to be.

In 2001, the company started working on an e-prescribing system, with some early pilots at MedStar Health System and Kaiser Permanente.  They eventually developed a product with a real nice workflow that became the core technology that would take the company through the next eight or nine years.

Around 2004, we decided that it really wasn’t going to be a long-term proposition to be an e-prescribing company. It was clear even then that the industry would eventually move away toward EMR, and e-prescribing would just be a part of a larger application. That was the year we started developing our platform strategy, that we would put together a set of technology platforms to try to fill some of the gaps that other vendors had in their capabilities or strategies. 

We started with our e-prescribing system since that’s what we had at the time. Tore it apart into its constituent pieces and offered it out as a platform for other vendors.

MediNotes was our first client. Since then, an additional 249 EMRs have selected us as a technology platform to build their e-prescribing on top of. Since then, we continued forward with e-prescribing. We’ve developed a modular EHR for Meaningful Use that we consider a step up from e-prescribing. And then we have this very large set of partnerships with EMR vendors to which we can transition physicians when they’re ready to make that next step to a fully paperless office.

On the application side, we’re pursuing a step-wise approach for physicians. In the broader scheme of things we’re developing, we’re continuing to develop a series of platforms to fill gaps that we see in healthcare.

The company was offering back in 2000 what we would call cloud technology today. Now you’re moving into something like apps, working with other systems to offer specialized functionality. That’s good foresight. Do you think other vendors will build products to plug into existing products that may have shortcomings?

We’ve seen a couple of other companies get into the space, primarily around e-prescribing. For us, all of the platforms we offer reinforce one another. We don’t think there’s a lot of benefit in going at it piecemeal, just picking a technology and saying, “Hey, we’re going to do that one.”

For instance, I mentioned that we started with our e-prescribing platform. About that same time, we also offered a hosting platform for payer information — eligibility, medication history, formulary. That way, as physicians adopted e-prescribing, if there were payers that weren’t hosted by Surescripts, we would be able to provide the hosting service, so that physicians in a specific area, whether they were in a hospital or in the ambulatory space, they would be able to access this payer data they wouldn’t otherwise have access to. And payers, who for whatever reason chose not to be hosted, would have access to the technology so they could get their information out to their physicians.

We subsequently offered another platform for hospitals. It provided medication history as the front end of a medication reconciliation process and discharge prescribing as the back end. Those, of course, are reinforced by the fact that we’ve got e-prescribing out in the ambulatory environment feeding into the hospital admissions process, and then have the information coming back out of the hospital available to all those e-prescribing physicians. 

All of our platforms are like that. They all tie together in some way that reinforces the community aspect of healthcare, as well as the different stakeholders and what they might want out of the processes. So yes, I think other companies will get into the apps space. I hope we’re doing it in a more integrated way that will have lasting value to people who participate on our platforms.

There are people who are critical of almost any given technology, from CPOE to Meaningful Use, but e-prescribing was such a natural that nobody seemed to rally a defense against it. Do you think the battle of getting e-prescribing adoption has been won?

Absolutely. It’s a very interesting point. It’s exactly true. If you think about the claims side of the business, pharmacy actually was well ahead of medical claims in getting their act together in that space. Again, I started healthcare with PCS, and even back in ‘90s, everything was pretty buttoned down as far as pharmacy claims. 

It was no big surprise to me that pharmacy got out ahead on the e-prescribing side as well. They had a well-established standards-setting organization in NCPDP. They had a track record of cooperation between vendors and payers. So yes, I think the battle actually was won a long time ago, but we’re just continuing to watch it play out now as we move to the mainstream of physicians.

The next level of value added could be detecting patient non-adherence, treatment conflicts, or medication reconciliation. You also have your RcopiaAC product that allows hospitals to get a full medication history from outside their four walls. Other than patient convenience, what do you see as the next level in terms of patient benefit and improvement of outcomes?

The next level of value that we’re trying to provide is what we call our Patient Innovations platform. This is where we look at the whole compliance and adherence process for the patient and we work to have some impact at each point in that. This is different with e-prescribing versus working off pharmacy claims. With e-prescribing, you have a chance to move the whole thing further forward in the process, because now you’ve got a record of the physician intent and not just what the patient did later.

We have an opportunity when the physician writes a prescription to really give the patient information they need to be comfortable with a therapy. Provide inducements to get that first fill done, which is a big part of the battle, with estimates between 20 and 30 percent of scripts never being filled. And then as the patient is out receiving therapy, we can continue to message the patient. We can provide additional information.

But most importantly, we can give the physician feedback in real time on how the patient is doing in compliance with their therapy.  The next time that the patient comes in to see the physician, they’re sitting face to face, the physician looks at his e-prescribing system, and he can see right there whether the patient has been compliant with therapy and can have an interaction.

Giving the physician the tools they need, helping the patient stay highly informed, and then providing rewards and incentives … we’re trying to put that all together into a single platform that we can offer out to the industry rather than just use it inside our own application.

It’s an interesting point from the physician’s perspective. They don’t know if the patient received what they ordered unless the patient tells them. In this age of trying to be accountable for overall coordination of care and wellness, that’s going to be a huge weak link if they don’t even know whether the patient had their prescription filled, their labs drawn, or their images taken. Are physicians ready to take that role on, to get all this information but then be required to follow up if something doesn’t happen?

I’ve been in a number of focus groups or informal discussions with physicians. DrFirst works with many large enterprise organizations, which gives us an opportunity to have talks with people who are pretty sophisticated about this. What typically happens in one of those meetings is the physicians will all agree right away, “This is a great idea. We want to know whether the patients are compliant with therapy.”

And then one physician will sit back, kind of cross his arms, and say, “Now wait a minute. Are you creating a whole new demand on me? Are you creating a liability, where I’m going to have to chase down my patients and make them do what I told them to, or that’s going to come back to me in court sometime?” That will generally start a big ruckus in the room. 

About half the docs will line up on that side and say, “Look, my patients are adults. They’ll make their own decisions. I just tell them what’s best in my opinion and it’s up to them whether to comply.” And the other half will say, “No, I want this information no matter what.”

This was confounding for a while. But we found that what would work for all the doctors we talked to was, “When the patient’s back with me, that’s when I want the information. I don’t have any problem at all knowing it when they’re sitting in my office. I just don’t necessarily want to be expected to track them down outside of my regular encounter time with them.” So we’ve designed our platform specifically to give the physician information when they’re actually engaged with a patient. That seems to meet everybody’s needs.

How would your platform fit in with interoperability projects like HIEs that try to collect a bunch of different information and put it all together?

It’s going to be a little funny to list off platform after platform here, but that’s really how we’re structuring the business going forward — as a series of valuable platforms that people can tap into for the APIs and be able to offer these things up in a way that makes sense within their own systems.

We have a messaging platform that hasn’t quite launched yet. That’s the product that will tie all of our data back in the HIEs. We’re in the process of just cleaning up the APIs and getting our software toolkit together. We’ll be making that available to the industry very soon. It’s a very flexible system, with some really exciting capabilities well beyond what anyone else is doing. we believe. We’re excited to offer that. We see the need and that’s why we put the additional platform together.

You mentioned that you’re looking at different elements of missing functionality. What areas do you think could be improved that there might be an opportunity for DrFirst?

In the industry today, there are just some structural problems because of the large number of EMRs, EHRs out in the market. We count about 600, of which 250 are our current clients, but we’re broadening our client base now to include EHRs who don’t necessarily want to do e-prescribing with us but would find some of our other platforms valuable. If those 600 EMRs, for instance, want to tap the data analytics market, there are a few very large ones who already have projects under way, but it’s questionable whether some of them are big enough to really do this in a serious way.

We hope to be able to bring things to the market that make it possible for a large number of EMRs to band together and access sources of revenue that wouldn’t otherwise be available to them, whether that’s revenue in the payer space or the pharma space. Help them have access to sophisticated technology.

Let’s say the sophisticated technology is related to patient communications. Things that they may not be able to develop themselves, but would love to have as part of the way they interact with patients. We want to bring those things in. The idea is to create a central point where every EMR in the country can come to get the service they would like to have. And on the other side of that, have a single point of contact for other entities down into the EMR community.

We feel DrFirst is very well positioned to do that by virtue of our track record of success in working with a large number of partners. We’ve clearly shown that we’re a company that can be trusted. We have the best interest of our partners in mind. We just want to continue to bring a series of valuable revenue and technology opportunities to both sides of the equations — to the EHR, EMR, hospitals on the one side, and to payers, pharma, patients, pharmacies, everyone else who would like to tap in to that community on the other side.

I noticed on your site that you have a tool where you can search for EMRs by capabilities. I suppose they are your customers more than the end users, although you can help them create demand for their products. Being in a neutral position supplying a number of them with technologies, how do you see those 600 EMR vendors differentiating themselves as the market evolves?

That was the purpose of that evaluation tool on our website. One of the things that we offer to bring to the EMRs that currently work with us on e-prescribing is that we would be more than happy to be a point of lead generation for them. We talk to physicians all the time through our own sales force. Often, physicians are not looking for e-prescribing or a modular EHR such as we offer. Instead, they’re looking for an EMR. We happily point them to our partners, because we like for them to be successful as well.

If you look through the tool, you can see they’re distinguishing themselves on the basis of specialty focus or functionality, support, certification. We try it to make it possible for them to be able to position themselves however they’d like to position themselves. We try very hard to not play favorites.

As a platform vendor, we would like them all to succeed. We’d like to be that rising tide that lifts all ships. They really do need to pursue their own individual business strategies as well.

If you look down the road five years, where do you see the industry going and what must you do to be competitive?

I think the whole industry will continue to be impacted by Meaningful Use for easily the next five years. We would expect to see a lot of creativity around EHRs going forward. A lot of startups — lots and lots of startups – are still entering the market. People are bringing in new technology to replace old technology. We’re pretty excited about the level of energy that’s still going in to this market.

I’m very encouraged by the direction the ONC is taking. They seem to be stepping back a little from a very onerous “one way fits all” strategy and instead are making room for people to do similar things, but in different ways. We think that’s very positive.

We as a company would really like five years from now to be a part of more than half of the EMRs– hopefully 75% of the EMRs offering one or more of our platforms. Helping them be successful in this space.

We really embrace the fact that there are such a large number of EHRs because it shows that no one’s quite yet figured out exactly how do healthcare IT right. There’s room for lots of differences of opinion. We’d like to help them all be successful at driving the business the way they want to drive it.

I get asked a lot about who our competitors are. It’s very difficult, I think, to find another company in this space that sees it quite the way we do. It is an interesting task trying to find a way to stay neutral, but yet help people really feel that you care about what happens to them as a business. But it’s a lot of fun seeing so many creative, smart people trying to figure out ways to do things better than other people. It’s been really great to have an opportunity to work with so many of them and be a little part of what they do.