News 4/6/12

Top News

From the earlier news blast: The Gingrich Group LLC, doing business as the Center for Health Transformation, has filed for Chapter 7 bankruptcy in a Georgia court. The for-profit organization, which makes up the majority of Newt Gingrich’s net worth in the form of money it owes him for his share of ownership, struggled to survive after Gingrich resigned as its chairman last year to run for the presidency. The organization listed its assets as less than $100,000, with liabilities stated as $1 million to $10 million. Several healthcare IT companies are listed among its creditors, including Cerner, Greenway, and Health Trio.

My initial reaction to CHT’s tanking:

1. So much for pretending that Center for Health Transformation was anything more than a way for Newt to sell his political influence to high-paying vendors under the guise of healthcare advocacy. The business folded almost immediately once he quit to run (badly) for the presidency.
2. How could CHT owe vendors money? Membership refunds? Or maybe the value of services not yet rendered?
3. Thanks to immediately available electronic images of the bankruptcy filing, you can learn Newt’s home address and read a list of the CHT staff members getting stiffed, like the recently hired project assistant who left her Dress Barn sales job to work there.
4. There weren’t many employees left by the time the bow slipped beneath the waves since most were apparently smart enough to have abandoned ship as soon as Captain Newt sailed off in his political life raft.
5. The most surprising aspect: why doesn’t Newt pump a few dollars into CHT to keep his seat warm since he’ll be needing a job shortly? That one seemed to have compensated him very well. Maybe political jab-taking had tainted the CHT name and his involvement to the point it was more of a liability than an asset.

Reader Comments

From 1Sign: “Re: Dell. After the Wyse acquisition, Dell is in discussion with Imprivata to complete their Mobile Clinical Computing solution. Imprivata is the last major SSO vendor not acquired and the Board is pressuring the leadership team.” Unverified.

From Rommel: “Re: shakeup coming at [vendor name deleted.] One executive gone in some manner, just the beginning. Q1 numbers are way off and the CEO is on the hot seat and may be clipped shortly.” Unverified, so I’m not comfortable naming the company. I would say the mood there probably is tense, though.

From Boston: “Re: Partners HealthCare. Enterprise-wide EMR decision has been postponed until later in the spring, probably June.” Unverified.

From K-Federal: “Re: [practice EMR vendor name deleted.] Heard from two reliable sources that it’s on the block to either Greenway or Allscripts.” Unverified, so again I’ll omit names. We snooped around a little and nobody’s talking, which may or may not mean anything. Supposedly a significant investor in the company may be selling some of its stake, but maybe there’s more to the story.  

From Loquacious: “Re: Vitera. Lee Horner is no longer listed as SVP of sales and marketing on their site. Is he still there?” His LinkedIn profile says he’s still there, although I’ve found that people often forget to keep those current when they change jobs.

From WildcatWell: “Re: HITECH incentives. If an EHR vendor offers their system as ‘free’ and a subscriber then demonstrates MU and pockets $44K, that’s not a cost-offsetting incentive, it is stealing from taxpayers. Where is the taxpayer outrage? Is anyone policing this stuff?” HITECH doesn’t require a provider to spend one penny to collect their check. Meaningful Use money is not a rebate or subsidy – it’s just free money from generous taxpayers helping subsidize some high-earning professionals and organizations. Practices or hospitals that are running systems they bought years ago get a surprise windfall, although they might have to use those systems more intensely to qualify. Enjoy that thought as you send in your tax form and as you watch the national debt rise from $16 trillion to who knows where as politicians bribe us with our own taxpayer dollars not to touch our Medicare, welfare, and social security. In the likely event that elected officials won’t suddenly grown spines, you just may get to see Greece-style fiscal meltdown and near-anarchy first hand without the pesky jet lag.

HIStalk Announcements and Requests

The latest and greatest from HIStalk Practice: CMS extends the deadline for EP Meaningful Use eligibility appeals. CareCloud’s Albert Santalo says the new JOBS bill may help his company go public sooner. E-prescribing payments jumped 83% and PQRS grew 65% between 2009 and 2010. Medical schools teach students how to stay connected with patients while using HIT. Dr. Gregg ponders whether the clinical narrative is really dying.  Julie McGovern of Practice Wise offers some great tips for successful EMR implementations and their ongoing success. None of these goodies can be found on HIStalk, so make sure you are receiving and reading your HIStalk Practice. Thanks for stopping by.

On HIStalk Mobile, Dr. Travis covers incubator Healthbox’s investor day.

Listening: Mew, brilliant, dreamy alt rock (or is it progressive?) from Denmark that’s reminiscent of Muse or Sigur Ros. If you like complex, almost orchestral music like early Genesis or Yes minus the overwrought excesses, they’ll hook you right in. Amazing stuff that you can feel smugly superior having discovered when nobody else has heard of them. And sometimes people ask what series I like on Netflix, so here’s what I’m watching at the moment: Frasier, Peep Show, and The Killing. Since I have 60 minutes of free time at most per day and that’s only if I sleep less than six hours, those will take awhile to finish.

On the Jobs Board: Soarian Clinical and Financial Go-Live Support, Epic and Cerner Resources, NextGen Go-Live Support. On Healthcare IT Jobs: Manager IS Enterprise Systems, Epic Principal Trainers, Technical Project Manager.

Acquisitions, Funding, Business, and Stock

TriZetto will build its new $40 million headquarters building in the Denver area, giving it space to house up to 750 jobs over the next five years.

CSC, trying to minimize the billions worth of damage it took from the NPfIT fiasco in England, now says it will use the knowledge it gained there to launch iSoft in the United States. A freelance journalist writing for ComputerWeekly doesn’t mince words in expressing his thoughts:

But from whence had its chutzpah come? Not only had CSC still not satisfied its NHS contract, it hadn’t even finished writing the software. Initial roll-out was due in 2007. Complete delivery was due this year. Hains told Wall Street CSC was now at last ready to roll out phase one but for a contractual settlement with the UK’s coalition government. But this was okay. Because CSC had a plan. This was not a plan for the reparation of 10 years of time and money the NHS has wasted on CSC. Nor was it a plan to recompense for the opportunity cost the NHS incurred while CSC dawdled over its clinicians’ request for better patient information. It was a plan to get its own finances in order, negotiate a firm settlement with the NHS and dazzle Wall Street with a come-back launch into what is tipped to be one of the few global growth markets: healthcare IT. Wall Street analysts privileged with the opportunity to ask Hains about this glorious transformation neglected to get his estimation of the value the British public subsidy had added to his corporation’s healthcare business in the last 10 years. British tax payers are due a share of this tremulous global growth machine, no?

Sales

Jefferson Radiology (CT) will implement TeraMedica’s Evercore Smartstore DICOM module at 11 regional imaging facilities.

Lutheran Medical Center (NY) will deploy PatientKeeper charge capture software.

People

Jean Schat, former of Curaspan Health Group, joins PerfectServe as a VP of sales.

South Dakota-based FQHC Horizon Health Care promotes Gin Wingen to director of clinical informatics.

Announcements and Implementations

The statewide ConnectVirginia HIE goes live with DIRECT messaging, free to registered providers through April 1, 2013.

Hurley Medical Center (MI) goes live on its $40 million Epic system.

Allscripts releases Wand, a native iPad app that extends functionality of its Professional and Enterprise EHR solutions.

OTTR Chronic Care Solutions launches OTTRbmt, a patient management system for bone marrow transplant centers that manage patients long term.

In Iowa, University of Iowa Health Care and Mercy Medical Center of Cedar Rapids announce plans to collaborate, including creating an Medicare ACO. UI Health Care, which has been live on Epic for more than three years, will help Mercy with its Epic implementation when it gets underway this summer. The organizations say they will use Epic to share information once Mercy is live.

Government and Politics

Members of the HIT Policy Committee express concern about several aspects of the proposed Stage 2 MU regulations. Specific issues:

• Requiring 10% of patients to receive secure electronic messages is too high.
• Public health agencies are not ready to receive electronic data.
• Communities with one dominant EHR vendor may make it difficult for providers to electronically exchange 10% of transition care summaries to other organizations on a different platform.
• Too many of the measures require EPs to collect data.

Innovation and Research

AHRQ is conducting a study about its offerings and is interested in talking to high-level professionals who either (a) develop health IT tools for patients, or (b) work for organizations that select those tools (hospitals, practices, health plans, government purchasers, etc.) They’re doing 90-minute interviews from mid-April through mid-May. Participants will be compensated for their time. If you’re interested, contact Jonathan Wald MD, MPH, director of patient-centered technologies the Center for the Advancement of Health IT for non-profit RTI International, which is working with AHRQ.

Other

A new KLAS report says that Cerner, Meditech, and Siemens are the only HIT vendors that provide their solutions to all world regions. Most purchasing activity is centered in Asia, the Middle East, and the UK. Few sites outside of North America are doing deep clinical adoption, largely due to economic and governmental challenges.

Weird News Andy wants to know if this is where we’re going. In the UK, a surgical practice drops an 83-year-old patient they had been treating for 30 years because of “green travelling issues” that make it “advisable to register at surgeries nearer to where they live.” The distance from her house to the office that raised the carbon footprint concerns: two miles. The woman thinks she was sent packing because she complained about a doctor.

Advocate Lutheran General Hospital (IL) settles for $8.25 million in a lawsuit brought against it after the death of a 40-day-old premature baby in 2010, caused by a pharmacy technician who incorrectly entered a post-op order into the IV compounder that overdosed the baby on 60 times the intended amount of sodium chloride. The hospital admitted that the compounder had the capability to issue automated warnings about potential entry errors, but they were turned off.

I’ve seen this several times recently at work. Someone who is offsite “attends” a meeting remotely by getting someone to conference them in on speakerphone. Everybody in the room forgets that person is on, and when the meeting is over, everybody walks out (more like “sprints” if the meeting was soul-sucking, as is often the case.) The person on the line, who has muted their phone in order to sleep or mow the lawn or whatever, finally pipes up, only to realize that a new group has taken over the conference room.

Adam Gale posts on KLAS’s blog about a Cerner turnaround that has moved them up the KLAS rankings from seventh to second in the past four years. He credits a new leader or two at Cerner, but I’ll offer my more cynical analysis: they didn’t have a choice unless they wanted to hand the keys to Neal’s soccer team over to Judy Faulkner, because Epic was tearing them a new one.

Sponsor Updates

• CTG Health Solutions announces an extension of its stock repurchase plan.
• Practice Fusion announces plans to add drug formulary and clinical messaging functionality to its EHR.
• Elsevier releases its 2012 spring eLearning schedule, which includes a revised ICD-10 Readiness Assessment tool.
• Premier Healthcare Alliance adds MedPlus to its ambulatory EMR software agreement portfolio.
• Kokua Kalihi Valley Comprehensive Family Services (HI), a FQHC, selects the e-MDs EHR suite for its 13 providers.
• Memorial Health System (CO) realizes a $2 million savings within three months of joining the MedAssets GPO.
• Mike Mistretta, CIO of MedCentral Health System (OH) details how his hospital’s use of SIS in the OR has provided data to control costs and improve efficiencies.
• Bill systems vendor AdvancedMD integrates its product with RaomSoft’s RIS/PACS.
• Aspen Advisors releases a case study on its work helping Akron General Health System (OH) develop an ICD-10 project management office.

EPtalk by Dr. Jayne

It’s all about the data. Studies indicating a decline in hospitalizations and deaths from pneumonia over time may not be due to better care, but rather a change in coding practices. Investigators propose that the coded diagnosis of pneumonia often took a back seat to sepsis or respiratory failure. As one who stalks the hospital floors, I know this to be true. We’ve been increasingly pushed to put more significant diagnoses first in our problem lists and discussions to indicate more complexity and support higher reimbursement. I wonder how the data would skew under the constraints of ICD-10?

It’s all about the audience. A recent study in the International Journal of Medical Informatics finds that EHR medication alerts are geared around how pharmacists think rather than prescribers – typically physicians and nurse practitioners. Alert fatigue is a constant danger and the authors recommend that alerts should leverage patient labs, balance the strengths of automation with human cognition, and support both pharmacist and non-pharmacist prescribers. My favorite of their recommendations: reduce alerts that contradict broadly accepted clinical practices. I hope this initiative succeeds, although I might be at risk for missing the lovely alerts that warn me that the diabetes medication I’m prescribing “might lower blood sugar.”

It’s all about perception. The New York Times publishes a piece about dressing for success. When subjects were told white coats they donned belonged to doctors, their attentiveness increased. When they were told the coats belonged to painters, no improvement was noted. The new phenomenon is being called enclothed cognition (the effects of clothing on cognitive processes.)

Speaking of dressing for success, one colleague shared news that her employer (a prominent health system) recently changed the dress code for physicians in response to patient satisfaction surveys. Previously recommending that neckties be avoided due to infection concerns, they have reversed course to now require them for male physicians because of a patient marketing survey that indicated that physicians with ties were viewed more favorably. Female physicians are not allowed to wear dresses without stockings or hosiery – no bare legs. I wonder what’s next – will they put nurses back in caps?

Being a patient and also a family member of patients myself, I take particular offense at one of their new rules – requiring surgeons to change into street clothes before they speak to a family after surgery. Nobody wants to be confronted with bloody scrubs (a true rarity) but I for one don’t want them wasting time changing clothes to come out and talk to me in the operating room waiting area. Just put on a cover gown or a white coat and come tell me what happened and how my loved one is doing.

Speaking of scrubs, Nurse TECH Talk launches its Most Bodacious Scrubs Contest. Entrants must join HITR and submit a picture of a bodacious scrub top to be in the running for the $100 gift card prize. I’ve got a crazy one that I’ll post just for fun if I can find it – on a transplant mission a few years ago it somehow made it into my bag because it was simply too strange to be believed. Think Nurse Chapel on the original Star Trek.

I’m happy to be surrounded by smart people and Weird News Andy is one of them, educating me on Wickard v. Filburn as the depression-era case responsible for Justice Breyer’s comments on growing wheat and its relationship to interstate commerce regulations. He also cites that decision as “a stretch worthy of Mrs. Incredible,” which made my day. Jonathan H. also commented that the home marijuana growing comment related to another precedent. Some happy Googling reveals that case to be Gonzales v. Raich.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Gingrich’s Health IT Group Files for Liquidation

The Gingrich Group LLC, doing business as the Center for Health Transformation, has filed for Chapter 7 bankruptcy in a Georgia court. The for-profit organization, which makes up the majority of Newt Gingrich’s net worth in the form of money it owes him for his share of ownership, struggled to survive after Gingrich resigned as its chairman last year to run for the presidency.

The organization listed its assets as less than $100,000, with liabilities stated as $1 million to $10 million.

Several healthcare IT companies are listed among its creditors, including Cerner, Greenway, and Health Trio.

Healthcare IT from the Investor’s Chair 4/4/12

From a recent HIStalk post:

Facts and Background 
Shares in mobile healthcare communications Vocera jumped almost 50% in their first three days of trading after Wednesday’s initial public offering, opening at $16 and closing Friday at $23.40.

Opinion 
The company either priced its shares incorrectly or intentionally undervalued them to create positive press from the price run-up. Either way, investors and not the company pocketed the $41 million price difference in the 5.9 million shares offered. Still, the company was smart enough to up the originally planned $12-14 price. A $100 million IPO yield is impressive for a company that isn’t all that widely known and that lost money in FY2011.

Sorry, Tim, not sure I totally agree with this assessment. 

With the benefit of hindsight, Vocera and its underwriters did under-price its IPO, but there’s no way to predict how a company will trade once it’s public. See my earlier post on the full mechanics of how companies go public here, but recall that the underwriters (led by JP Morgan and Piper Jaffrey in this case) had to take their best guess on how much investors would pay for Vocera stock at the time of pricing. The initial filing range is an even broader guess (albeit an informed one, based on how comparable companies are trading).

As the roadshow continued, there appeared to be more buyers than sellers (the offering was over-subscribed) so the underwriters raised the pricing range. Throughout the roadshow, JP Morgan built an “order book,” where each investor (typically mutual, pension, and hedge funds) indicated how much stock they would buy at any given price. Clearly the Vocera IPO was multiple times oversubscribed, which is the goal.

The art of pricing (and it does seem to be more art than science) is using that information to set the initial offering price. Too low and you’ve left money on the table (as VCRA apparently did). Too high and not enough funds purchase once the stock trades in the aftermarket and instead simply dump their shares rather than build a larger position. This results in the stock trading down and embarrasses and annoys all parties involved.

The trick here is balancing supply and demand precisely and in real-time and with very imperfect information (as investment funds don’t always reveal their intent, either). It’s interesting in that it’s one of the few businesses where the price of the product is directly affected by the customer to whom you sell.

That said, it’s also worth noting that underwriters have multiple incentives, and it’s not always clear who the client is in these situations. On the one hand, because they’re getting a 7% fee, they have a definite motivation to maximize the initial stock price. By pricing at $16 rather than $23.40, they missed around $3.5 million in fees.

On the other hand, any given fund can easily pay 10x that in commissions any given year, so there are those who feel that banks have an obligation to take care of their trading clients more than their underwriting clients. Suffice to say, there’s more than a little dynamic tension between different parts of the firms, but in my experience, pricing for a successful offering trumps the desire to maximize the fees for the specific deal under consideration.

As an aside, I believe the positive press effect is less the case now than during the dotcom days and not a motivator for either issuing companies or their underwriters.

One way of avoiding this phenomenon of under-pricing IPOs is by using what is known as a DutchAuction, which arguably creates the most efficient price. In 1998, an investment bank called WR Hambrecht began trying to use this method to price IPOs, calling it OpenIPO. With the notable exception of Google, it never really caught on. (I’ll try to do some research as to why for a future note, but I assume typical issuers remain risk averse and prefer the tried and mostly true IPO method.)

Because insiders rarely sell at the time of an IPO (and be careful if too many are doing so), it’s not as if management or the venture capitalists involved have a personal stake here, either. Further, in the long run, pricing the IPO with perfect accuracy just isn’t viewed as that important relative to the benefits of assuring a successful offering with a healthy balance sheet, good research sponsorship, and long term investors for the future .

Ben Rooks, founder of ST Advisors, spent ten years as an equity analyst, six years as an investment banker, and is now much happier (and adding more value) as an independent advisor to HCIT companies. He loves questions and feedback on his column. Incidentally, ST Advisors is pleased to count Vocera as a former (but not current) client.

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

The Problem with Scrolling

Imagine that you are a member of an EHR software development team. Your team has been given the task of designing a new user interface that will provide an overview of an entire patient encounter in a single screen view.

Your current user interface requires clinicians to navigate to multiple screens to enter and review data for a single patient encounter. Many clinicians find that the navigation interferes with focusing on patient issues. Even worse, they can’t keep the relevant data in their working memory as they navigate from screen to screen (see my last post).

Your team starts out by drawing a rough sketch of what the new screen view might look like:

Each pane will display data. Your problem is how to display each category of data within the areas of these small panes.

Your team decides to start with the redesign of the medication pane. Your EHR’s current medication screen is shown below for a particular patient who is taking nine medications. I have resized your screen view to fit the width of this post, but in your EHR application you can easily see the entire medication table on a single screen without scrolling.

How do you display the medication data above using a much smaller pane size? One of your team members suggests a commonly used EHR design — vertical and horizontal scrollbars for each pane. Your team decides to explore this scrolling option first.

You sketch a pane with vertical and horizontal scrollbars, as below. The example below displays the upper left portion of the medication screen above. The red arrow to the right shows the position of the vertical scrollbar.

Right away you and your team realize that this design has problems. First of all, a clinician using this design would have to scroll down to two additional locations in the table (only one shown below) just to see the complete list of meds:

Similarly, she would have to scroll across to two additional locations in the table (only one shown below) to see the complete data for any particular medication:

She would have to navigate to nine different views within the pane to see all the data! As Alan Cooper points out in About Face 3: The Essentials of Interaction Design, scrolling is a form of navigation even though we don’t usually think of it as such.

Furthermore, the scrollbar design doesn’t solve the working memory problem. As soon as the clinician scrolls to a new position in the table, the previous information is gone from view. She might as well navigate to the full screen medication window.

You and your team note additional problems with the pane with scrollbars design:

• It does not display a summary list of all nine medications.
• The clinician can inadvertently scroll past critical information.
• Using the scrollbars requires fine motor skills and eye-hand coordination, interfering with the clinician’s ability to focus on patient issues.
• Text can be truncated both horizontally and vertically, making it difficult to read.
• The scrollbars and header bar waste valuable screen real estate.
• Depending on operating system speed, there can be latency between the scrolling action and the updated screen.

Despite the fact that the pane with scrollbars is a common EHR design element, the result is a computer-centered, not a user-centered design.

It’s back to the drawing board. In my next post, I will show some better EHR software designs for presenting multiple categories of data in a single screen view.

Next Post

Overview with Details on Demand — a Versatile Design

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

News 4/4/12

Top News

A National eHealth Collaborative paper says that HIEs have great potential to improve care and reduce cost, but despite ONC emphasis and incentives, not a lot of value has been realized so far. Big issues remain funding, provider adoption, and difficulties connecting to the wide variety of available EMRs. They recommend focusing on patients above all else, build trust and a common vision among participants that often don’t particularly like or trust each other, ignore “one size fits all” proposals and listen to what the local community wants, and figure out how to make money once the grants run out.

Reader Comments

From Hardware Sue: “Re: Navin, Haffty & Associates. Heard that Park Place International is looking to buy them out.” Not true, NHA President John Haffty tells me. Park Place has expanded its technical offerings related to Meditech and NHA has collaborated with them on projects and will continue to do so since their work is complementary, but no acquisition-related discussions have been held or encouraged. Per John, “We have great respect for the old and new team over at Park Place, but we are committed to maintaining our independent status.” Norwell, MA-based NHA offers consulting services exclusively for Meditech customers.

From JayGlo: “Re: security testing firms. Know any that specialize in EHRs in general and Epic in particular? Who are the best white hat hackers?” I’ll defer to readers – leave a comment if you have suggestions.

From ForthePatients: “Re: Tampa Bay RHIO. Work has been dragging in the swamp for almost five years with a long list of special interests – academic medicine, lawyer, homegrown exchange vendor, and hospitals interested in connecting to their own practices. Who controls what is clearly a the crux of this one and not a focus on the patients or the community.”

Acquisitions, Funding, Business, and Stock

Santa Rosa Consulting announces that it has completed its acquisition of Nashville-based healthcare IT consulting firm InfoPartners.

Charge master vendor Craneware opens an office in Scottsdale, AZ.

Merge Healthcare shares dropped 16% on Tuesday after the company filed an SEC 8-K form indicating that a $2.75 million sale of kiosks was to higi LLC, a company founded and controlled by Merge Chairman Michael Ferro. Merge’s audit committee had cleared the sale. Merge topped the biggest percentage price decliner on Nasdaq list, shedding nearly $90 million of value for the day.

Sales

Cooper University Hospital (NJ) signs a three-year agreement with Newport Credentialing Solutions for its reporting and analytics software and back office credentialing solutions.

Southeast Michigan Beacon Community selects Covisint’s accountable care technology to aggregate regional health information.

DuPage Medical Group (IL) selects Humedica MinedShare to provide clinical benchmarking and analytics from its Epic EMR.

Einstein Healthcare Network (PA) licenses business analytics and patient financial services solutions from Streamline Health to monitor and drive revenue cycle performance in its 1,000- physician ambulatory care network.

Mount Sinai Medical Center signs with Siemens MobileMD for an HIE service agreement.

People

Cognosante names Eileen Cassidy Rivera (Vangent) as VP of marketing and communications.

Former Cigna VP of IT Marcus B. Shipley joins Trinity Health (MI) as SVP and CIO. He  replaces Paul Browne, who has been named Trinity’s SVP of integration services.

Nashville-based The Rehab Documentation Company, which sells therapy documentation systems, names Antoine Agassi as president and COO. He comes from Cogent Healthcare and was previously chair of Tennessee’s Governor’s eHealth Advisory Council and held executive roles at Spheris and WebMD Transaction Services.

Announcements and Implementations

Southeastern Med (OH) hosts a midnight ribbon cutting ceremony to officially launch its Meditech go-live.

West Calcasieu Cameron Hospital (LA) launches bedside bar code verification with McKesson’s Horizon Admin-RX.

Biggs-Gridley Memorial Hospital (CA) goes live on the Prognosis ChartAccess EHR.

Humana Cares completes installation of a 1,600 monitoring devices for a telehealth pilot project, where nurses will remotely check the vital signs daily of CHF patients in hopes of decreasing hospitalization. The project uses the Intel-GE Care Innovations Health Guide, a blood pressure monitor, and scales.

Government and Politics

A bipartisan group of House and Senate lawmakers introduces a bill proposing to link the prescription drug monitoring programs of individual states, allowing prescribers to look for patterns of prescription drug abuse across state lines.

VA CIO Roger Baker says the $4 billion joint VA/DoD EHR system could be available by 2014 and will be piloted at military installations in Hampton Roads, VA and San Antonio, TX.

The VA cancels its Software Assurance agreement with Microsoft covering its 300,000 users, giving the agency flexibility in seeking non-Microsoft alternative technologies, such as tablets and cloud-based systems.

The Coast Guard prepares to go live on its Epic-based EHR. It plans to provide mobile access via cellular network and to run cached copies of information from its vessels, which often do not have connectivity. The Coast Guard is looking for companies to provide service desk support.

Innovation and Research

A study performed in large UK teaching hospital finds that off-hours clinician response and satisfaction improved when pagers were replaced with wireless call handling and task management. Tasks were logged on a PC that sent messages to a coordinator’s tablet, who then routed the tasks via text message to on-call phones. Users liked the improvement in handoffs: task prioritization, the ability to monitor task assignment and completion, and elimination of handwritten notes.

Technology

Rochester, MN-based mobile healthcare apps vendor Preventice, partly owned by Mayo Clinic, expands into the medical device business with BodyGuardian, a diagnostic heart and respiratory monitor that patients can wear during normal activity. The company says the final product, when approved by the FDA, will be just 8×8 mm in size (about a third of an inch high and wide) and will attach like a Band-Aid for up to seven days, sending the physician a text message and EKG by Bluetooth when it detects cardiac events. The company plans to hire 15 employees and will move to new headquarters in Minneapolis.

Microsoft announces the 11 startups chosen from 500 applicants that will participate in its 2012 Kinect Accelerator. Among them are GestSure, which creates touchless interfaces for surgeons and interventional radiologists; and Jintronix, a virtual reality rehabilitation system for patients with motor control problems.

Other

The University of Arizona Medical Center will replace Allscripts and iMed with Epic at its two hospitals and outpatient centers. The project will cost $100-135 million, will require 87 full-time employees over the next three years, and will involve providing 12 hours of training to each of 6,000 employees. Four miles away, Tucson Medical Center is already running Epic, having completed its rollout in June 2010.

Partners HealthCare researchers find that the number of lab tests ordered for outpatients who were seen at both at Brigham and Women’s Hospital and Massachusetts General Hospital dropped from seven to four after implementation of an HIE that allowed previous results to be viewed by either facility. The full text article isn’t available online to non-subscribers and the usual disclaimers apply: the study sample appears to be quite small, the study data was old (1999 to 2004), and whatever correlation was implied does not prove causation. 

Despite a fall in net income from $158 million in 2010 to just $1 million in 2011, Novant Health (NC) will spend $600 to $700 million over the next four years on its Epic project. Novant expects the first of its 13 hospitals to go live by the end of 2013.

Several readers found this non-HIT story interesting enough to send over. The $4 million-per-year CEO of Pittsburgh-based insurance company Highmark is fired after an ugly love triangle fight over his 28-year-old girlfriend, who worked for him at Highmark. Kenneth Melani, 58 and married, showed up at the girlfriend’s home and refused to leave when ordered by her 48-year-old husband, resulting in criminal charges. Melani has engaged an attorney to determine whether his dismissal was legal, while the DA agreed to postpone his preliminary hearing provided he undergoes anger management counseling.

Leila Denmark MD died this past weekend in Georgia at 114 years old. She she was the world’s oldest practicing physician when she retired at 103, having begun her pediatrics practice in Atlanta in 1931.

Sponsor Updates

• Practice Fusion customers have received $22 million in EMR incentives through January, the company reports.
• Emdeon offers a free weekly webinar on Emdeon Vision for Claim Management.
• The HITR nursing technology blog is running a Bodacious Scrubs contest through April 25.
• Iowa Health System contracts with Hayes Management Consulting and Coastal Healthcare Consulting to provide legacy support services.
• MED3OOO’s IT and services divisions hosts a virtual job fair May 2. 
• Encore Health Resources names attorney Tom Luce to its board.
• ICA launches HIT Me Blog with commentary on current healthcare and HIT issues.
• Lifepoint Informatics will participate in the 2012 Executive War College on Laboratory and Pathology as a corporate benefactor. The event will take place in New Orleans May 1-2.
• Cognosante and 3M partner to provide 3M’s ICD-10 Code Translation Tool to state-sponsored health plans.
• MedHOK announces that its 360Measures V 2.55 has achieved 2012 P4P certification.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Readers Write 4/2/12

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!

Cloud-Based Medical Data Exchange: Promising Results So Far
By Michael Trambert, MD

At RSNA 2011 and since then, my colleague Mark D. Kovacs, MD and I have been communicating to our peers about the new cloud-based services for exchanging imaging and other medical files.

Based on our study of an early adopter, Virginia Commonwealth University Medical Center (VCU), we’ve concluded that cloud-based medical data exchange has, in its best form at least, neatly addressed all of the major issues associated with older methods such as exchanging files by CD or VPN.

The “new” approach – which is actually about two years old and used by over 400 facilities – works seamlessly. Files are exchanged in minutes – reliably, securely, and at low cost. That includes exchanges between proprietary IT systems that don’t normally “talk to each other.” The cloud mediates the exchanges as easily as if it was e-mail being sent.

To appreciate what an improvement the cloud services represent, it helps to understand previous methods. Before the advent of cloud services, medical institutions turned to workaround solutions to deal with the incompatibility of proprietary healthcare IT systems.

The most popular of these was burning files to CD and sending them by mail, courier, or with the patient. Facilities that had a steady need for such exchanges with each other sometimes used virtual private networks (VPNs). For reports and other non-imaging files, some institutions used faxes.

The inherent problems with each of these methods are well known. But let’s examine the additional downstream problems.

Take, for instance, CDs – by far the most widely used method. This approach fails a significant percentage of the time, for reasons such as lost or misplaced CDs and files that can’t be opened. The significant time delay and risk of loss and or damage due to physical transport also undermines the rapid diagnosis and treatment of critically ill patients. Physical media makes it impossible to access studies contemporaneously from far away and by multiple caregiver / consultant sites.

When imaging studies are not successfully transferred, frustrated physicians at the treating institution often order redundant imaging studies. Studies show this occurs as much as 10% to 20% of the time. This unnecessary imaging exposes patients to excess radiation, which can contribute to cumulative deleterious effects. It also adds billions of unnecessary dollars to national healthcare costs.

VCU has been using a cloud-based service since late 2010. The cloud-mediated file transfers (in VCU’s case using a service called eMix) has been disruptive due to ease of use, speed, and dependability. Transfers are trouble-free.

As with any new approach — even one this simple — minor workflow adjustments were made. VCU is a Level I Trauma and referral center, so data exchanges usually involve other institutions’ sending files to VCU rather than vice versa. Those facilities had to switch over from a workflow built around burning and sending CDs to one requiring uploads to a cloud server. This required a simple change in workflow, much more efficient than burning CDs or utilizing VPNs.

Based on what we observed at VCU, Dr. Kovacs and I feel that change is exactly the right choice in this case. Cloud-based medical data exchange represents a boon to patient care because a patient’s imaging files, reports, and other crucial medical data from multiple previous providers can be sent to the current care provider whenever they are needed – in minutes, not days and with no hiccups in usability. Multiple consultants in geographically different locations can access this data from anywhere they require to provide input for a patient’s care.

These services also represent the efficiency gains that advocates such as the Bush and Obama administrations have been promising for healthcare IT in general. Unlike other forms of IT such as EHRs, some of the cloud-based services require no new capital purchases. That is, an institution does not have to purchase hardware or software. They simply have to pay a metered fee, as they do for electricity and water.

Besides eMix, current cloud-based services include lifeIMAGE and SeeMyRadiology, among a number of others. I cannot speak to the relative merits of each. But I can say that it’s nice to begin seeing the era of CD-burning and VPNs in our rear-view mirror.

Michael Trambert, MD. is the lead radiologist for PACS reengineering for the Cottage Health System and Sansum Clinic in Santa Barbara, CA.

ACHE Impressions
By Darkened Room Observer

After attending my third straight American College of Healthcare Executives’ Congress on Administration in Chicago, I’ve come away with the realization that there is a large vacuum of leadership within our industry.

I have attended the majority of sessions in the healthcare information technology “mastery series.” Each year, executive after executive talks about their success in implementing healthcare IT projects. When the question is asked, “To what do you attribute your success?“ the response is usually, “Well, I’m not really altogether sure.”

The lack of leadership this year was clearly evident a session in which a CEO got up in front of a group of about 200 people and said they decided that they did not want to go down the road of modifying a solution so, “We contracted with a vendor that didn’t allow customization to their product.”

Another CEO boasted that they chose a vendor who required them to hire a certain amount of people with specific talents and skills. The vendor would give the customer a rebate if they met specific milestones.

In another session, the CEO and CIO expounded on how well they were doing, based on the vendor’s established criteria and reporting mechanism.

With both financial and political pressures being applied to the healthcare marketplace at unprecedented levels, leadership to ensure that we are not simply doing things right, but are doing the right things is imperative. Yet we seem to have leadership that is so focused on ensuring that everyone is “happy” that they relegate true leadership, vision, and goal setting to their vendor. Although none of the presenters were allowed to disclose their vendor, it was clear to me that these entities were going to have epic changes to their businesses.

It appears that it may not be the actual technology a vendor brings to the table since the company in question deploys relatively arcane language, hardware technology, and definitely not state-of-the-art functionality by today’s standards. It has much more to do with a their philosophy of leadership by contract that appeals to this crop of hospital executives who lack the intestinal fortitude to ensure that their clinical staff change how they practice medicine as a result of implementing this new tool.

Can you imagine if the people marketing laparoscopic technology were required to modify their products to allow physicians to continue doing business as usual? Yet most vendors, in an effort to sell more in the short run, allow their clients to dictate modifications, enhancements, or wholesale scope changes in their contracts to “keep” clients.

Eventually these vendors suffer from trying to support 300 clients with extremely customized applications, setting the vendors up for failure. Like parenting or growing a good business, strong leadership and discipline are essential for truly happy children. Appeasing clients (like a child) only creates spoiled children.

Every time I turned around, it seemed that the only people exposing the truth were either from outside healthcare or were retired and finally saying what they couldn’t say while still needing a job.

Why Mobile Device Strategies are Missing the Point of the iPad
By Jared Sinclair RN

A friend of mine who has been a bedside nurse for many years has to lock herself in her bathroom whenever she surfs the web so that her elderly mother won’t complain about her wasting time with her laptop. My friend’s mother lived most of her adult life on another continent and without access to a computer. To her, a laptop is just another household object. She observes her daughter using the laptop as if she was mindlessly staring at a hunk of plastic and metal, while in fact, my friend is doing all kinds of things: researching, reading the news, paying bills, etc. The intangible nature of software is missed by her mother, who sees only the physical qualities of the machine itself.

Some of us in the healthcare tech industry have been making a similar mistake by thinking of mobile devices like the iPad as defined by their physical form. The form factor of a mobile device — the lack of a keyboard or a mouse — is what makes a mobile device portable, but portability is not its defining characteristic. A touch interface is what make a mobile device unique. This may seem obvious, but it deserves thoughtful consideration.

For many years, the PC industry itself also misunderstood this fact. While the iPad is far and away the most successful tablet, it is not the first tablet. PC manufacturers have been making tablets for years. Their products were never widely successful. Their approach was, in essence, to remove the keyboard and trackpad from a laptop and call it a tablet.

Because PC manufacturers didn’t write their own operating systems, they had no choice but to ship these tablets with Microsoft Windows. This operating system was not optimized for touch screens, which meant that the hardware had to conform to the limitations of the software and not vice versa. In other words, they had to require the use of a stylus. Smart managers would never have released these products on the market. The mistake of the PC manufacturers was in thinking that the defining quality of a tablet is its form factor.

The defining quality of a tablet is touch.

The iPad does not ship with the same operating system that ships with Apple’s desktops and laptops. It never will. IOS, the operating system that Apple created to run the iPad and the iPhone, was designed from the ground up for a multitouch experience. Other mobile operating systems, like Android and Microsoft’s Metro, have followed suit.

Without a mouse and a mouse cursor, many of the conventions that we take for granted when using traditional desktop or laptop operating systems vanish. Touch-based operating systems have no concept for right clicking, or for hovering the cursor. Because the tip of the human finger is much less accurate than the tiny one-pixel tip of a mouse cursor, on-screen buttons need to be much larger. Because touchscreens tend to be much smaller than desktop or laptop screens, care must be taken to maximize efficient use of screen real estate.

One of the main reasons for the iPad’s success compared to previous tablets is that it uses its constraints as advantages to be enhanced, rather than limitations to be overcome with a stylus. Gestures allow users to swipe, pinch, rotate, and flick through apps. User-interface designers create novel ways for people to interact with their apps based upon these gestures. Angry Birds, an app that everyone by now has enjoyed (or at least endured the sound of it being played), is much more fun on a touchscreen than on a PC.

It’s frustrating to read about hospitals so anxious to use the iPad in a clinical setting that, rather than waiting for a native app to be developed, they deliver a desktop EMR interface via a virtual client like the Citrix app. The experience is always dismal. This is not the fault of the EMR vendors. Their software was designed for a mouse and keyboard. It’s not surprising to hear physicians report that on-screen buttons are too small, or that it becomes tedious to constantly pinch and zoom in and out of a virtual image of a desktop EMR interface.

Healthcare IT leaders need to understand that a mobile device like an iPad is not defined by its hardware alone. Sports fans don’t buy high-definition televisions because they are rectangular. They buy them so that they can enjoy watching games with a clarity that they could not experience with any other kind of TV. For the same reason, consumers buy the iPad because it allows them to use a computer in ways that they could not use a computer before.

"Going mobile" is not a strategy. Any HIT mobile device plan that does not include touch-optimized native apps as part of its mission is doomed to failure or mediocrity. Sheer portability alone is not enough. Rather than cramming software paradigms designed for desktop computers into these brand new devices, we should be using the mobile device revolution as an opportunity to re-think the way we interact with our EMRs.

By the way, this article was dictated on an iPad. In a few years, we will probably all be talking about voice interaction the way I’m talking about touch today.

Jared Sinclair is a registered nurse and an iPhone and iPad developer. He’s the founder of Splint, a startup focused on developing mobile apps for bedside nurses. He is also the creator of Pillboxie, a fun medication reminder for iPhone and iPad. He lives in Nashville, TN.

Curbside Consult with Dr. Jayne 4/2/12

Last week the Supreme Court heard an historic number of oral arguments as it considered challenges to the Affordable Care Act. Unlike other portions of the federal government, those responsible for the transcripts move at the speed of light. Some of them can be fairly enjoyable – the Justices have well-developed senses of irony, sarcasm, and humor.

Monday was essentially the challenge to the individual mandate provision requiring insurance coverage. One of my favorite exchanges involves Chief Justice Roberts, who says:

The idea that Congress has acquiesced in what we have said only helps you if what we have said is fairly consistent. And you, yourself, point out in your brief that we’ve kind of gone back and forth on whether this is a jurisdictional provision or not. So, even if Congress acquiesced in it, I’m not sure what they acquiesced in.

Is everyone clear on that? It just goes to show how complex this issue is and how the eventual ruling will involve the splitting of more than a few hairs.

Another great example is Justice Alito speaking to Solicitor General Donald Verrilli Jr. saying,

General Verrilli, today you are arguing that the penalty is not a tax. Tomorrow you are going to be back and you will be arguing that the penalty is a tax.

The challenges have certainly put the government in as many different positions as an advanced yoga class.

My favorite quote of the session is from Robert Long, arguing his case to the court and stating,

Not all people who litigate about federal taxes are necessarily rational.

I wonder if he includes himself in that assessment?

The hearing continued Tuesday with some interesting discussion comparing people’s need to enter into the healthcare market with their need to enter into the market for police, fire, or other emergency services. Chief Justice Roberts:

Well, the same, it seems to me, would be true, say, for the market in emergency services: police, fire, ambulance, roadside assistance, whatever. You don’t know when you’re going to need it; you’re not sure that you will. But the same is true for healthcare. You don’t know if you’re going to need a heart transplant or if you ever will. So, there’s a market there. In some extent, we all participate in it. So, can the government require you to buy a cell phone because that would facilitate responding when you need emergency services? You can just dial 911 no matter where you are?

The Solicitor General argued that it was different and what followed was a great exchange with Justice Alito asking Verrilli if he thinks there is a market for burial services. Alito went on to ask:

All right. Suppose that you and I walked around downtown Washington at lunch hour and we found a couple of healthy young people and we stopped them and we said:  you know what you’re doing? You are financing your burial services right now, because eventually you’re going to die and somebody is going to have to pay for it and if you don’t have burial insurance and you haven’t saved money for it, you’re going to shift the cost to somebody else.

With arguments like that, how can you not love these guys and gals? It’s like being on rounds with the Meanest. Attending Physician. Ever. At one point, Justice Scalia compared the individual mandate to forcing people to buy broccoli.

As the day progressed, Justice Breyer discussed the ability of Congress to regulate interstate commerce and used this example:

And I look at the person who’s growing marijuana in her house, or I look at the farmer who is growing wheat for home consumption…

Where in the world did THAT come from and what does it have to do with anything? It gets better:

I say, hey, can’t Congress make people drive faster than 45 – 40 miles an hour on a road? Didn’t they make that man growing his own wheat go into the market and buy other wheat for his – for his cows? Didn’t they make Mrs. – if she married somebody who had marijuana in her basement, wouldn’t she have to go and get rid of it? Affirmative action?

I tried to decipher the meaning but couldn’t. I’m not sure what Breyer is growing in his basement, but I think I want some of it. He did return to coherence a few paragraphs later:

So what is argued here is there is a large group of – what about a person that we discover that there are – a disease is sweeping the United States, and 40 million people are susceptible, of whom 10 million will die; can’t the Federal Government say all 40 million get inoculation?

The transcript is full of aphorisms that would make Ben Franklin proud. Justice Kagan asked one speaker whether his argument was “cutting the baloney thin.”

Arguments continued Wednesday morning around severability, or the premise that if the individual mandate is unconstitutional, then the rest of the Act has to go as well. Justice Kagan asked whether Congress wanted half a loaf and whether half a loaf is better than no loaf. I think that’s somewhat debatable, depending on the loaf. If it’s Nutraloaf, I’d personally rather have no loaf at all.

At one point Justice Scalia also referenced “cruel and unusual punishment,” asking a petitioner what happened to the Eighth Amendment when it was suggested that the Justices might want to look at all 2,700 pages of the Act to determine “what the text and structure mean with respect to severability.”

The non-stop action continued later Wednesday afternoon with the discussion of Medicaid expansion. The first 20 pages were pretty dry, until it came to the point where Paul Clement, representing 26 states, was asked by Justice Scalia,

Mr. Clement, I didn’t take the time to figure this out, but maybe you did. Is there any chance that all 26 states opposing it have Republican governors, and all of the States supporting it have Democratic governors? Is that possible?

There was laughter in the court as Clement admitted the correlation.

I met up with some colleagues over the weekend and had the chance to hear different opinions on where the Court might land. The only consensus reached was that although none of us can predict which way it will go, we were unanimous in feeling that it will be a 5-4 decision. Regardless of the outcome, it will be interesting to see how Congress responds and how the Presidential candidates respond. The summer promises to be anything but dull.

Have a question about legal precedent, jurisprudence, or what you have to do to file an amicus curiae brief? E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 4/2/12

From HMSUser: “Re: HMS CEO departure. The company confirms.” HIS vendor Healthcare Management Systems (HMS) confirms the rumor I ran here Friday from HMSUser: President and CEO Tom Stephenson, a 25-year company veteran, has left “to pursue some long-time interests.” According to his LinkedIn profile, he is now assistant grass cutter at Stephenson Landscaping Services LLC. Pretty darned witty if you ask me.

Survey respondents say that companies in the hospital and physician practice market will lag those that are working in interoperability and post-acute care. New poll to your right: how will the Supreme Court rule on PPACA? (no fair answering after the decision is announced.)

My Time Capsule editorial this week from the 2007 vault: Brailer’s Santa Barbara RHIO Baby Goes Down the Tubes. The expensive flop that was the Santa Barbara RHIO launched David Brailer into the first ONC job and got everybody stoked about interoperability despite not having one iota of impact on patients or providers. Some of my parchment-scribed words from way back then: “SBCCDE was a ‘big hat, no cattle’ kind of project that left two sad legacies: (a) it blew millions in grant money,  and (b) it seduced politicians and reporters into thinking they’d seen the Second Coming of CHINs, only destined for success this time. They were half right.”

Readers keep asking me to do some kind of “top stories” summary each week. I used to do that with the Brev+IT newsletter I started, in which I rattled off stream-of-consciousness cynical musings about the week’s top news, usually after I was tired from writing HIStalk for the weekend and therefore likely to blurt out just about anything to get finished. I’ll revive that practice at the bottom of this post and give it a try for a few weeks. I’ll kill it if I get bored with it, if I don’t have the time, or if nobody seems to care much one way or another. I’m not looking to create more work for myself, but I’m pathologically eager to please.

Welcome to new HIStalk Platinum Sponsor TrustHCS. The Springfield, MO company’s consulting expertise covers coding, compliance, ICD-10, and cancer registry. Vacant coder positions threaten financial performance and TrustHCS can help out with staff augmentation or full outsourcing of coding services, with every one of the company’s employees holding AHIMA and/or AAPC credentials. They can work on-site or remote, with flexible pricing to meet budget requirements. The company can help provider organizations take advantage of the ICD-10 breather by performing the assessment, analysis, and education that they might have skipped back when the implementation deadline was looming. TrustHCS works with hospitals, practices, ambulatory surgery centers, and any other provider organization that does coding, offering whatever level of support is needed to optimize the revenue cycle. The company can provide the oversight and coding compliance training needed to avoid headlines that throw the whole “bad press is better than none” concept into serious doubt. Relationship matters and experience leads at TrustHCS, whose support I gratefully acknowledge.

Weill Cornell Medical College establishes the Center for Healthcare Informatics and Policy, which will conduct HIT-related research and offer a two-year fellowship in quality and informatics. Rainu Kaushal MD, MPH, a medical informatics professor and director of pediatric quality and patient safety at New York-Presbyterian Hospital, will serve as executive director.  

A nice HIStalk Practice post by Dr. Gregg poses the question: are EMRs to blame for terse physician documentation, or are lengthy patient “stories” less common due to (a) lack of physician time, (b) wordy residents who grew up to be more concise, or (c) lack of value when documenting the same old acute conditions over and over?

Vince continues his HIS-tory this week with Part 2 on MedTake. These pieces aren’t just overly fond looks back at long-dead companies – they always contain lessons that might prevent someone from repeating the same mistakes.

HIT Application Solutions raises $2.75 million in a Series A funding round. The Exton, PA company offers the Notifi communications platform for alerts, broadcast communications, and critical test results.

San Francisco-based healthcare IT incubator Rock Health will expand to Boston in June, adding a program on the campus of Harvard Medical School.

Epic did its always entertaining April Fool’s Day page, even dropping in an Inga mention with ”The Shoe’s on the Other Foot: HIStalk’s Inga Disputes Rumor She Wore Birks to Symphony.” I like it because I did a similar HIStalk spoof years ago and referred to Epic as the Birkenstock-wearing crowd.

E-mail Mr. H.

The Healthcare IT Week in Review

1. Vocera IPO Shares Jump 50%, Meaning the Company Paid Good Money for Bad Pricing Advice

Musings

• Timing is everything when it comes to IPOs. Riding Facebook’s IPO coattails isn’t such a bad thing, at least unless Facebook stumbles.
• The company, like most hardware vendors that are anxious to avoid commoditization and increase margins and professional services income by turning themselves into software vendors (think RTLS and bed management systems), markets benefits around its “Star Trek” badge communicators that include care transition, patient transfer optimization, and patient discharge communication.
• Vocera made some key acquisitions in the past couple of years: Wallace Wireless in January 2011 (delivery of alerts to smart phones) and two White Stone Group spinoffs in November 2010 (handoff communications.)
• More acquisitions are sure to come now that the company has $94 million of IPO money in the bank and needs to feed the earnings engine. A priority will almost certainly be value-added software for nurses that can run on the company’s existing communication platform since nurses are its primary users and therefore are most likely to advocate new purchases to otherwise indifferent hospital executives.
• Chairman and CEO Bob Zollars, who joined the company in 2007, was best known as having run high-flying healthcare supply chain vendor Neoforma, and before that having executive roles at Cardinal Health and Baxter. He rode the irrational exuberance bubble hard in January of 2000, when Neoforma.com’s IPO, priced at $13 for 7 million shares, soared to $52.38 on their first day of trading. Not bad for a company with revenue of $464,000 in the previous nine months, in which the company lost $25 million but formed a complex ownership and incentive agreement with hospital buying groups VHA and UHC. Neoforma announced plans to buy Eclipsys for $2.1 billion of its stock in March 2000, but backed off two months later when its own shares dropped by 70%. He knows how Wall Street works and has a real company with strong revenue this time around.
• It’s interesting that the Vocera IPO did so well while investor interest in the HITECH-goosed side of HIT seems to be waning. But everybody likes IPOs, at least for the first few weeks before the quarterly earnings grind sets in.
• I don’t see Vocera getting into the mHealth market, but the successful IPO gives it a strong position in mobile apps for clinicians. It needs a doctor product, though, preferably one with direct impact on patient outcomes since that’s what hospitals will pay big bucks for.
  

2. Tampa Doctors, Hospitals Fight Over Which Group Will Lead Their Selfless Data Sharing Efforts

Facts and Background

A group of Tampa-area hospitals and the county medical association are pursuing independent efforts to share electronic patient information.

Opinion

Florida has quite a few active HIE/RHIO projects that haven’t made much progress, probably because competition there, particularly among large health systems, is intense. This is one of few times where the previously unstated suspicion and distrust came right out on the table, as observed by a perceptive local reporter.

Musings

• Neither group seems to be making much progress, which isn’t surprising when asking competitors to collaborate selectively with unknown benefits to each.
• Florida’s AHCA issued a four-year, $19 million contract to Harris Corp. in late 2010 to develop a statewide HIE. Two months later, Harris announced that it had acquired Carefx, which offers the Fusionfx data sharing technology for competitors that need to exchange information. The only progress I’ve heard of is the availability of a secure e-mail program for providers and limited patient look-up services among the Big Bend RHIO and a couple of health systems, but it’s only been a year. I don’t know who’s getting ONC’s HIE grant money in Florida.
• Hospitals bring most of the money and technical expertise to the table, while practices create much of the information that needs to be shared. Doctors also believe their motivations are purer than those of hospitals, which have a reputation for wanting to control anything they’re involved with for their own financial or strategic benefit. That plus the technical challenges may kill this initiative off early.
• The main benefit of interoperability comes from hospitals exchanging information with their affiliated practices, which they often undertake without going to a third-party interoperability project. Unlike in some areas, Epic does not dominate the Tampa market. That would be an interesting follow-up article for the reporter – how well do the hospitals that want to control this project interoperate with their owned or affiliated practices?

3. Post-Op Patients Love iPads So Much They Don’t Mind that their Surgeons Don’t Visit Them

Facts and Background

Henry Ford Health System implements telerounding, where post-operative patients are given iPads to communicate by video with their surgeons, who may be miles away.

Opinion

This is a really good idea since it seems cool and high tech, but basically frees surgeons of the requirement to actually make post-op rounds and makes them immediately available so that delayed actions don’t hinder the discharge pathway. But most of all because this is the first high-profile use of the iPad by patients since video projects usually involve Skype on PCs.

Musings

• Post-op patients are usually coherent and can report their own medical situation, so this is more like ambulatory telemedicine than remote ICU monitoring.
• Using iPads is a smart idea since they are portable and cheap. Installing telepresence hardware in individual patient rooms would be ridiculously expensive, and the enhanced video quality would offer no advantage when the intention is simply to chat with the patient. Observers often overlook the iPad’s price and maintenance advantage – it does a lot for $500.
• Cynics might say that a phone call would work just as well as a video call, but physicians like seeing and not just hearing.
• Once the iPads are in the hands of patients, their use could be extended to video-based patient education and self-documentation.
• Once again Apple products prove their medical value not because of more in-depth technical capabilities over PCs, but because they are easy and fast to use, especially since a lot more people know how to use iOS products like the iPhone than have Windows expertise.
• It’s easy to see how this project could be translated into home health or skilled nursing care, where it’s just not practical to have an ongoing physician presence. For that matter, a nurse could round with a single iPad as the physician participates by video.

Time Capsule: Brailer’s Santa Barbara RHIO Baby Goes Down the Tubes

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.

Brailer’s Santa Barbara RHIO Baby Goes Down the Tubes
By Mr. HIStalk

The nation’s first RHIO is officially defunct. The Santa Barbara County Care Data Exchange (SBCCDE) locked its doors and quickly took down its website last week. David Brailer’s child star died an ugly, lonely death at age nine.

SBCCDE was a “big hat, no cattle” kind of project that left two sad legacies: (a) it blew millions in grant money,  and (b) it seduced politicians and reporters into thinking they’d seen the Second Coming of CHINs, only destined for success this time. They were half right.

It wasn’t for lack of trying by the California HealthCare Foundation (CHCF). That organization gave CareScience, of which Brailer was then CEO, $10 million to create and run SBCCDE. Uncle Sam chipped in a few more bills along the way.

CHCF bragged, incorrectly as it turned out, that SBCCDE had solved the funding model issue, based on the assumption that providers would happily pony up to keep the lights on. They were wrong. With only two organizations sharing data, neither was willing to fund SBCCDE’s ongoing operation.

Actually, SBCCDE left one other lasting legacy. It focused nearly all the government’s interest in healthcare IT on interoperability to the exclusion of everything else. That’s hardly surprising since Brailer got the healthcare IT czar job riding his SBCCDE credential, with few critics remembering CareScience’s 2001 struggles, shareholder lawsuits, and eventual sale to Quovadx for just $14 million over its cash reserves in 2003.

Perhaps Brailer provided some hints of a cloudy future for his RHIO. In an early SBCCDE presentation, he listed “substantial first-mover disadvantage” as a concern. He was right: new entrant CalRHIO is hot stuff now, planning to spend $300 million to blanket California in interoperability. SBCCDE was suddenly yesterday’s news, falling behind even upstart RHIOs in actually moving data around to anyone’s benefit. For that reason, no one is mourning the dearly departed SBCCDE very much.

Brailer also hinted more than once that the entire RHIO movement could be a throwaway technology, an interesting experiment to kill time until the massively more expensive Nationwide Health Information Network comes online. We’ll have to see if he was right about that.

In any case, I predict that at least one-fourth of RHIOs will fail within 1-2 years. Not because they don’t have noble goals or sound technologies, but because reality is working against them just like it did SBCCDE and CHINs before them.

• Like the many other misaligned incentives in healthcare, providers have to pay for the common RHIO plumbing, but get little value from it. Patients and insurers get a free ride in many cases.
• A mishmash of federal and state privacy laws ensures that expensive lawyers will guarantee nothing when it comes to avoiding HIPAA violations, opt-in guarantees, and privacy lawsuits.
• Back-end interfaces are expensive and difficult to maintain.
• The lack of an information sharing pipeline wasn’t the only reason competitors didn’t hold hands and sing Kumbaya before.
• The primitive state of most provider computer systems means that information is often not available electronically. The least-capable hospital or practice reduces the value for everyone else. Clinical information is always of suspect quality and completeness.
• Providers have many more projects that are more fundamental to their survival that will always take precedence.

In other words, RHIOs have all the same threats that CHINs had, other than the advantage of using the Internet for connectivity.

Perhaps the best lesson from SBCCDE’s flameout is the one we’ve already learned from failed physician order entry, enterprise resource planning, and physician electronic medical records system implementations. Technology is rarely the problem.

News 3/30/12

Top News

Vocera shares gain 40% over the $16 offering price in the company’s Wednesday IPO. Shares were up another 19% Thursday to $24.91, giving VCRA a 56% jump in the company’s first two days of being publicly traded.

Reader Comments

From Max: “Re: Microsoft/Sentillion. The bloodbath is in full effect. Employees received either a 60-day notice this week or an offer to move to Caradigm. I’ve heard losses on the Amalga side were significant.” Unverified. I asked my Microsoft contact, who says that like most companies, Microsoft doesn’t comment publicly on HR-related questions.

From HMSUser: “Re: HMS CEO. ‘Resigned’ last Friday, rumor that more high-level people will be shown the door.” Unverified, but Tom Stephenson’s bio has vanished from the executive team page. HMS’s parent company, HealthTech Holdings, has been owned since 2007 by private equity firm Primus, whose other healthcare IT-related investments include InSite One, Medhost, and Passport Health Communications.

From Epic-urious: “Re: Epic leading the market and gunning for the big guys. I’ve only read a few new customer updates. Where are all of these new customers?” Just to be clear, Epic is the big guy now, so there’s nobody left to gun for in terms of penetration of patients and providers (not necessarily in  number of hospitals since it’s a lot easier to dominate the market selling to one 1,000 bed hospital than ten 100-bed ones.) The company doesn’t announce sales, so new customers come to light only casually, like at conferences with mostly large-hospital attendees, where just about everybody finds out simultaneously that they’re all implementing Epic. Another way to look at it: the lack of significant sales announcements from Epic’s competitors, who do indeed happily announce new sales when they can get them.

HIStalk Announcements and Requests

This week on HIStalk Practice: a physician being sued by his former practice resigns over “technology troubles” and “billing errors” that he claims were the caused by computer problems. CMS offers help to providers not deemed “successful electronic prescribers” in 2011. Nancy Pelosi’s connection (or lack of one) between Practice Fusion’s rapid growth and the Affordable Care Act as she cuts the ribbon at the company’s new building (above.) Brad Boyd urges providers to continue moving forward on their ICD-10 transition. In our reader survey, 85% said reading HIStalk Practice helped them perform their job better last year, so if you’re in ambulatory HIT and need performance enhancement, you should be reading.

Listening: new from The Mars Volta, complex, perfectionist progressive rockers from El Paso, TX. An Amazon reviewer said it well: they’re what Led Zeppelin would have sounded like time warped into 2050. Dead ringers for Manfred Mann’s Earth Band at the 4:10 mark of the video, but very Zeppelin-like at 5:00. And I’m reflecting on the amazing musical contributions of Earl Scruggs, who almost single-handedly gave non-hayseed credibility to both the banjo as a musical instrument and to bluegrass as a uniquely American musical genre and who died Wednesday at 88. Foggy Mountain Breakdown was the speed metal of its day and it still sounds amazing as I listen to it right now.

Acquisitions, Funding, Business, and Stock

ClearDATA Networks, which provides healthcare cloud computing services, secures funding from Norwest Venture Partners and several angel investors.

Seven-month-old hospice management software vendor Hospicelink of Birmingham, AL says it expects $50 million in sales by the end of 2012. Color me skeptical.

Ann Arbor, MI-based HIE vendor CareEvolution is expanding its 22-employee workforce to 38, expecting to hire three software developers per quarter. I notice from the company’s site that they claim a trademark on the term One Patient, One Record, which I would associate more with Epic than CareEvolution, which I’ve heard of only once when a reader said they did an impressive demo but still lost the West Virginia Health Information Network bid. UPDATE: the company clarified the newspaper article – it has 38 employees now (22 of them in Ann Arbor) and will add another 15. WVHIN did choose Thomson Reuters’ HIE Advantage, but that product actually runs CareEvolution’s HIEBus under an expanded agreement between the companies signed in February 2011, so CareEvolution is in place (and scheduled for go-live next month) even though the announced winner was Thomson Reuters.

BlackBerry maker Research in Motion reports sagging sales, a quarterly loss, and an executive housecleaning. The CEO says he won’t rule out selling the company now that he’s seen from the inside just how dire the situation is, although he’s hoping for a turnaround. The steep downward slope above is the one-year share price, down 75%.

Sales

Asante Health System (OR) selects iSirona’s medical device connectivity solution to populate patient data in its Epic system.

Memorial Hospital of Union County (OH) selects Wolters Kluwer Health’s Provation MD for its gastroenterology and pulmonology departments. In addition, Duke University Health System (NC) licenses ProVation Order Sets.

Duke University Health System (NC) selects M*Modal Speech Understanding technology to support the Epic system it’s implementing.

Two practices within the University at Buffalo School of Medicine select PatientKeeper Charge Capture, which will be integrated with UBMD’s GE Centricity Group Management PM product.

People

EMR vendor CareCloud appoints PowerReviews CEO Ken Comée to its board.

Online physician networking site Sermo names former Revolution Health president Tim Davenport CEO. He replaces founder Daniel Palestrant, who left the company in January to run Par80, a startup focused on patient referrals.

Aventura hires Brian Stern (NewsGator Technologies) as SVP of sales and marketing and Brandi Narvaez (Sentillion, Vitalize – above) as chief customer officer.

eMerge Health Solutions, a provider of voice-powered documentation systems, hires Trent McCracken as president and CEO. He was previously owner of a telecommunications software company.

Announcements and Implementations

St. Francis Hospital & Health Services (MO) will go live on Epic Saturday morning.

The Verizon Foundation donates $100,000 to launch a telemedicine pilot project at Children’s Hospital of Philadelphia. CHOP will offer community hospitals consults with its pediatric specialists.

Government and Politics

The New York eHealth Collaborative and the New York State Department of Health form the Statewide Health Information Network of New York Policy Committee, tasked with updating and creating policy measures to protect PHI while expanding the state’s ability to electronically share clinical data.

The White House announced Thursday that various government agencies will invest $200 million of taxpayer money in so-called “Big Data” R&D. A NSF/NIH project will look at large-scale health and disease databases.

It’s not healthcare related, but it’s another hugely expensive government computing foul-up: the State of California pulls the plug on a $2 billion court system that still isn’t fully rolled out 11 years after the project started. The project was originally supposed to cost $260 million, with a state audit last year finding that the massive overruns were due to poor management of contractors. An IT project failure expert said, “I am dumbstruck over the incredible waste and obvious poor planning associated with this system. This failure only adds to California’s reputation as the land of IT boondoggles”

Technology

Henry Ford Hospital (MI) implements telerounding, in which minimally invasive surgery inpatients are given an iPad to post-operatively communicate with their remotely located surgeons using the FaceTime video chat app.

Other

Weird News Andy likes this video story of a BYU nurse practitioner student whose professor, while observing her practice thyroid exams in her third week of class, happens to notice that she has a hard-to-spot tumor. The mass turned out to be highly aggressive, but she’s OK after fast-track surgery and radiation therapy. She will take a nurse practitioner job at the Thyroid Institute of Utah when she graduates this summer.

Hill-Rom joins Stryker and Zimmer in laying off hundreds of its employees to offset the cost of complying with a new medical device tax that takes effect next year. The 2.3% tax, enacted in the Affordable Care Act, is based on company revenue regardless of profitability. The industry estimates the tax will cost its members $30.5 billion and could result in the loss of up to 38,000 jobs.

Howard University Hospital (DC) notifies 34,000 patients that their health information was potentially exposed in January when a laptop was stolen from the car of a contractor who had downloaded the information in violation of hospital policy. The contractor had quit working for the hospital in December 2011, but reported the theft on January 25 of this year.

The government’s bet-the-farm idea of paying hospitals for quality didn’t move the needle on deaths or readmissions in its own demonstration project, a study published Wednesday in the New England Journal of Medicine found. The Harvard public health author says incentives are the right idea, but the metrics aren’t yet right. He also says it’s nice when processes are executed consistently, but the only thing that counts is that patients get healthier, and that didn’t seem to happen here.

It’s definitely not up to the high snark standards of The Onion, but this satirical article called Myanmar Embraces Facebook as Electronic Medical Record is kind of funny. “Whilst Facebook users can currently Add and Delete Friends, the updated site is going to allow users to Add Doctors, Nurses and other allied health professionals, who can be granted varying degrees of access to confidential medical data. ” You just know someone out there is working on this already.

I probably would find a new press release headline writer.

Here’s what HITECH has driven providers to. Physicians at Samaritan Healthcare (WA) gripe at a hospital board meeting about the hospital’s new Meditech system, which the hospital freely admits it implemented for only one reason: to get a $2.2 million HITECH check. According to one doctor, Meditech is “… time-consuming, it is frustrating, it is archaic, it’s hard to work with … It didn’t matter what we said, you were going to go ahead and implement this because there were the economic benefits being reaped by the hospital at our expense.” In response, the hospital CEO admitted that the system isn’t ideal, but says now that the money’s in the bank, Meditech is history, its replacement to be paid for by the HITECH money Meditech earned for the hospital.

Strange: two-thirds of respondents to an online poll run by the Chinese Communist Party’s newspaper choose a “smiley face” as their reaction to a story about a medical intern who was murdered by an enraged patient in a hospital, apparently because doctors are right up there with government workers in being hated for insisting on being paid bribes to do their jobs. The poll was quickly taken down. The government reported that over 5,000 medical personnel were injured by patients in 2006, the last year such statistics were published. Experts blame the anti-doctor mood to the lack of a medical malpractice system to provide compensation for errors, physician salaries that start at only $500 per month, and the fact that doctors are legally paid commissions for orders written. It was also reported that some doctors are taking kickbacks from funeral homes for promptly alerting them of the newly deceased.

Sponsor Updates

• EHRtv runs an interview with David Caldwell, EVP of HIE vendor Certify Data Systems, filmed at the HIMSS conference. We interviewed CEO Mark Willard last month.
• Salar and Transcend will participate in the Society Hospital Medicine 2012 Conference April 1-4, 2012, in San Diego, CA
• MedAssets launches its Population Health solution suite to support the industry’s transition to fee for service and accountable care.
• Greenway Medical Technologies announces the availability of PrimeMOBILE for Android and tablet devices.
• TELUS Health Solutions will license Get Real Consulting’s InstantPHRO to resell into Canada under the TELUS Personal Health Record brand.
• MEDSEEK announces that its eHealth ecoSystem V4.0 is 2011/2012 compliant and certified as an EHR Module.
• Queensway Carleton Hospital (Canada) is delivering ED records to more than 120 family doctors using TELUS Health Solutions’ CareShare technology. 
• GetWellNetwork announces its fifth annual users conference, to be held April 30 – May 2 in Orlando.

EPtalk by Dr. Jayne

All eyes are on the Supreme Court this week. Oral arguments for the cases challenging the Affordable Care Act concluded Wednesday. This has been a busy week at work so I haven’t been able to process the transcripts as quickly as I’d like. Stay tuned for my detailed reaction in Monday’s Curbside Consult. I find the whole process fascinating. It wakes up the non-medical part of my brain with the interplay of the Justices’ personalities and the complexities of legal theories of intent, severability, and judicial restraint.

The focus on PPACA overshadowed dialogue on last week’s ruling that state workers cannot sue their employer for violating a part of the Family and Medical Leave Act. A 2003 decision allows suits against state agencies for violations related to leave taken to care for family members, this decision involves leave take by employees to take care of their own health. There are already many loopholes in FMLA due to multiple court challenges over the past two decades. Additionally, states have made their own requirements and definitions, turning it into a patchwork. It’s a great example of what might happen to PPACA over the next few decades should it be allowed to stand.

My other exciting reading this week has been the recently-issued NIST protocol on EHR usability. The three-step process includes EHR application analysis, user interface expert review, and user interface validation testing. There are some interesting points in the document. Check out Appendix A, which discusses the use of human factors engineering by the Department of Defense, the Nuclear Regulatory Commission, and the Federal Aviation Administration.

It also provides questions used to evaluate an EHR’s “aesthetic and minimalist design” and “pleasurable and respectful interaction with the user,” including whether the EHR has artistic value. I never found that documenting as required by CMS (and now other payers) is particularly pleasurable, nor do I find artistic value relevant to patient care. I don’t care how ugly it is — I just want it to be easy to use and comprehensive.

AHIMA announces the Grace Award, which recognizes excellence in health information management. Nominations are open through June 30 and the award will be presented at the annual meeting in September. I give this new award a thumbs up for aesthetic and minimalist design (NIST would be proud.) It would look great on my credenza.

Wireless medical monitoring devices are highlighted in an article published yesterday. I like the idea of an edible sensor integrated into a medication that can document when it was taken, although I don’t want to receive patient information on my phone so that I can try to interpret it “all without a visit to the doctor.” Let’s take it one step further and integrate a monitoring sensor into every Girl Scout cookie produced, and if too many are consumed at a single sitting, it can send warning texts to purchasers. Having just found a stash of Thin Mints at the back of my freezer, I could definitely use the moral support.

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 3/28/12

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

Caught, Not Taught

As a parent, the most frightening rite of passage for me to tackle was not the sex talk, it was the car talk. As in watching my kids head down the street solo in a two-thousand pound, steel and fiberglass projectile. They had attended classes, studied a manual, and passed a test. But were they really prepared?

Not fully. They lacked one critical element.

In the workplace, I advocate professional development and have witnessed the benefits of classroom teaching. When I began to analyze this process, however, I realized traditional training suffered a maximum effectiveness. Think about this. After reading a book on teamwork, were you able to convert all the learned lessons into action? Why do some managers respond to training while their classmates do not? Why do leaders take life-changing courses, yet nothing changes?

Critical skills can only be caught, not taught. My children, for example, had the head knowledge for driving, but that information didn’t come to life until they took it on the road. Experiencing the streets helped them to catch—or ingrain—the skills for successful driving.

How do you help your team catch? Ability to drive is a necessity that comes with an inherent motivator—drive or be stuck living under my roof with my rules!

How can you create this driving-like context that motivates your staff to live out what they learned in the books? The following methods have worked for me.

Never fly solo. Do your best to always have a sidekick with you. If I have a team member in the hospital or a funeral to attend, I take an emerging leader with me to provide comfort. When I walk around to visit the team, I have a manager with me. They learn from the experience through observation and active participation.

Be vulnerable. When I have tough decisions to make or challenges to contend with, I open the kimono. I don’t shelter my team or pretend to know the answers. I include them. The young leader learns there is no voodoo or secret sauce. Some day they will face a similar issue and it will be familiar.

Share the stage. When I’m invited to speak, write, or interview, I often have one of my leaders with me. Sometimes observing, and other times co-presenting. One of our young directors had not presented before, so I had him observe me at a local university. The next time, we co-presented. Now he speaks routinely on the national stage.

Be transparent. Leverage social and business media. I Facebook friend any of my team who has interest. I connect with any on Twitter or LinkedIn. In the work environment, I mircoblog daily about what I am doing and why. This allows multiple avenues for insight. For instance, I may share my thought process on how I deal with setbacks.

Engage a mentor. Ongoing, planned partnerships focused on helping a person reach specific goals over a pre-determined period. Unfortunately, the art of mentoring has rarely caught on in the business world, healthcare included. Mentoring can be a difference maker.

Connect to others. As a leader, how do I impact the heart of my team? How do I create an environment where we can cultivate compassion? How do I help them view their job as more than a paycheck, but as a contribution to a patient’s life?

Ask questions. Whenever I’m around people I admire, I fire off a number of questions, then just listen and learn. I soak up wisdom.

Create hang time. It’s easier to talk when we’re not disguised in stuffy work attire. A non-business setting encourages conversation, but you must create these situations. I have surprised my team with an ice cream fest and invited individual members to attend employer-sponsored professional sports with me. I attend their symphony performances or listen to their garage bands at a local bar. I invite them to join my family for Broadway shows (we always buy extra tickets.) Make it happen!

Offer social opportunities. Do you learn etiquette from a manual? Emerging leaders who seek to become vice presidents should know how to handle themselves in a cocktail party situation and know the difference between red and white wines. My wife and I purposely host parties in our home to create a safe place in which to practice so they can learn to be comfortable mingling among executives. It’s also another occasion to get acquainted with and show appreciation to their significant others.

Outcomes?

I’ve had the joy of watching my directs blossom in their careers. Although I invested greatly in their formal training, their development accelerated during active observation. In the last couple of years, several became CIOs. Others took senior leadership positions in professional organizations.

My kids turned out to be pretty good drivers. But if you ask them how they learned, they’ll tell you they caught it by doing it – by making wrong turns, slamming on the brakes at stoplights, and bumping over curbs while parallel parking. The manual finally made sense.

It was caught, not taught.

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

News 3/28/12

Top News

Clinical communications vendor Vocera prices shares for its Friday IPO at $16, above the originally announced range of $12-14. That price values the offering at $94 million, giving the company a market cap of around $300 million.

Reader Comments

From Midnight Son: “Re: ICD-10 implementation delay. I’m hearing rumblings that ONC is mentioning a possible two-year hold. Have you heard anything?” I haven’t, but I will listen attentively to any reader who has and who wants to share.

From Jay: “Re: Capterrra. Rates EMRs using a ‘popularity index.’” This is yet another example of coming up with information that looks impressive in eye candy form without really meaning much. Capterra decided that market share wasn’t useful because it favors more expensive solutions (not to mention that the company doesn’t have exclusive use of that data and it wouldn’t look as cool on an ever-so-trendy infographic.) They don’t like rating EMRs as “the best” since needs vary (which doesn’t stop companies that rate cars, colleges, and places to live.) Instead, they went with the lazy method of just grabbing a bunch of unrelated publicly available data and mixing it up to give a conclusion: number of customers, number of users, revenue, number of Google searches, number of Facebook and Twitter followers, and Web site popularity rankings. The end result may or may not reflect reality, but I would say this: any provider who lets a cute infographic influence their EMR choice is a fool (do you really want to change your professional workflow based on vendor Facebook likes?) However, in fairness to the company, healthcare IT purchasers do indeed often line up like docile sheep behind whatever everyone else is buying, so perhaps this reflects reality.

From Charlie Enicks: “Re: job change. I debated sending you a note before any rumor was posted — too late! I am leaving to go to Georgia Health Sciences University in Augusta, Georgia starting May 1. As you know the searches take quite awhile. Our Epic project is going well and is on schedule. My leaving for an opportunity that is on the East Coast and closer to family had nothing to do with the project. Happy to give further clarification if any questions arise. Keep up the good work!” Charlie, who is CIO at University of Mississippi Medical Center, will take over that role in Augusta. I told him it was too bad that he will just miss the Masters Tournament. He joked that he tried to get that included in his offer.

From Indigo: “Re: end-of-life decision app. Recommended by Forbes.” The Best Endings site, started by former entertainment reporter Kathy Kastner with input from healthcare professionals, guides people into living their lives optimally before dying. It includes HIT-related topics such as specifying wishes for DNR and life support. I didn’t get much from the site, but I did follow one of its links to Death 1, Medicine No Score from the Canadian Medical Association Journal, which was really good, though predictably not exactly upbeat.

HIStalk Announcements and Requests

Over on HIStalk Mobile, Travis has written an insightful post, Free isn’t Free, that has generated excellent reader response. Dr. Travis says he’s OK with having his personal information used by a free app vendor as long as he’s told upfront, although he’s uneasy with fast-growing startups who haven’t figured out a revenue model and may peddle data down the road. Cyndee has a problem with companies that sell claims data to carriers to help them dream up reasons to deny claims payment, while Margalit doesn’t like non-free apps that sell your data without your knowledge. Finally, HIT Project Mgr states that consumers should have all of their health information available without paying for it, no different than being able to check their previous Amazon orders whenever they want. Good discussion. Sign up for the e-mail updates while you’re over there if you want to keep up with excellent doctor-written news and opinion about mHealth.

Ross Martin MD, who actually has a day job (Deloitte) that doesn’t involve writing fun songs or appearing as Elvis at HIStalkapalooza, is recruiting industry folks to complete the 2012 Deloite-AMIA Health Informatics Industry Maturity Survey by April 20. They hope to conduct it each year as a benchmark about what’s going on with health informatics. I think it’s a great idea and I started the survey with enthusiasm, but I’ll be honest in admitting that I quit early – the estimated time to complete is 30 minutes and I just didn’t have it to spare.

Acquisitions, Funding, Business, and Stock

Home health software provider Kinnser Software secures $40 million in Series A financing from Insight Venture Partners.

Predixion Software will present at a New York venture summit this week, discussing its predictive analytics solutions for payors and providers. The California company claims its Readmission Insight can predict up to 86% of readmissions. I Googled and found the above video interview with the company, filmed at the HIMSS conference in Las Vegas.

Sales

Kern Medical Center (CA) selects EZ-CAP, EZ-NET, and EZ-EDI from MZI Healthcare for health benefit administration.

MD Anderson Cancer Center (TX) selects Health Language Inc.’s Language Engine to automate mapping of patient data collected in its custom-built EMR, ClinicStation.

People

EHNAC appoints Luigi Leblanc (Zane Networks) and Deborah Meisner (Emdeon) as commissioners.

Former Carefx Chairman and CEO Andrew Hurd is appointed president and CEO of Epocrates. He takes over for Peter Brandt, who will step down as interim president and CEO and assume the role of vice chairman of the board.

As rumored by reader HairClub earlier this month, Hackensack University Medical Center (NJ) hires Shafiq Rab MD as CIO. He was previously VP/CIO of Greater Hudson Valley Health System (NY).

Former CMS administrator Donald Berwick MD, MPP is named a senior fellow with the Center for American Progress, a DC-based liberal think tank with historically close White House ties.

Laurie Gehrt, former chief nursing officer of Cerner Consulting, is named SVP at B.E. Smith, where she will lead the company’s interim leadership and consulting groups.

Announcements and Implementations

Riverside Regional Medical Center (VA) implements Phytel Transition in its ED to follow up with discharged patients.

NextGen Healthcare will resell Dragon Medical speech recognition software to its ambulatory EHR clients in an agreement with Nuance.

Cone Health (NC) takes 25 affiliated physician offices live in its $120 million Epic project. Its five hospitals will go live in July.

Drug data vendor PEPID announces that it has added maximum pediatric and adult drug doses to its medication content, allowing hospitals to create overdose warning alerts.

Government and Politics

CMS reports that through the end of February, hospitals and EPs have been paid $3.9 billion as part of the EHR incentive program. That includes almost $1.2 billion to 84,005 EPs and $2.7 billion to 2,355 hospitals.

HHS awards $50,000 to the designers of THUMPr, an Web-based tool that allows users to create personal heart health profiles, as part of its One in a Million Hearts Challenge innovation program.

The Office of the Inspector General finds that Brigham and Women’s Hospital (MA) received $1.5 million in overpayments from 2008 to 2010, primarily because “the hospital did not have adequate controls to prevent incorrect billing of Medicare claims or did not fully understand the Medicare billing requirements.” The hospital’s official response notes that the organization has since implemented additional controls, performed training, and implemented a new pre-bill monitoring system and more robust claims scrubber system.

HIMSS lists the HIT-related effects if the Supreme Court finds all or part of the Patient Protection and Affordable Care Act to be unconstitutional. If the whole thing dies, with it go certain HIE provisions, ACO demonstration projects, extension of PQRI, and Center for Medicare and Medicaid Innovation. However, the court could also find that only parts of PPACA are unconstitutional (specifically the part requiring that everybody buy medical insurance) and the rest could remain intact. None of this would impact HITECH or the Medicaid EHR incentive program, both of which came from ARRA.

Contractors building the behind-schedule, 314-bed Orlando VA Hospital say the agency’s red tape and design errors could add $120 million to the original $665 million project cost. That would raise the final cost to $2.5 million per bed.

Other

A Texas newspaper picks up on the year-old policy of Citizens Medical Center (TX), which bans the hiring of employees whose body mass index exceeds 35 (about 260 pounds for a man who is six feet tall.) The policy says a prospective employee’s physique “should fit with a representational image or specific mental projection of the job of a healthcare professional.” I personally enjoy the specific mental projection of George Clooney.

SCL Health System will move its headquarters from Kansas to the Denver, Colorado area, creating 750 jobs in accounting, billing, IT, and systems services over the next four years.

Board members of the Tennessee chapter of HIMSS create their own HIT workforce initiative, pledging on behalf of their employer organizations to offer 50 internships and 500 hours of collaboration with educators and students.

The Tampa newspaper covers competing interoperability projects that are underway, one led by big hospitals and the other by big medical practices. The president of the medical association says hospitals are too profit-oriented to share data among themselves. One orthopedic surgeon who was interviewed says he doesn’t really care which group prevails – he just wants to use his two-year-old EMR to exchange records with somebody.

Medline kicks off its 2012 Pink Glove Dance competition at the AORN conference in New Orleans Monday, with 1,000 OR nurses participating in the company’s Breast Cancer Breakfast.

Sponsor Updates

• AirStrip Technologies EVP Bruce Brandes is interviewed by the Nashville Business Journal (subscription required.)
• Sam Lakkundi, VP of mobile strategies of Kony Solutions, discusses Bring Your Own Device models in a video interview.
• Regional Medical Center at Memphis selects MedAssets to provide strategic sourcing and clinical resource management services.
• CTG Health Solutions expands several of its large EMR project engagements.
• API Healthcare hosts a webinar on the importance of role-based practice in staffing.
• Regional Medical Imaging (MI) becomes Merge Healthcare’s first radiology customer to receive Meaningful Use payment.
• US Representative Nancy Pelosi participates in a ribbon-cutting ceremony at Practice Fusion, which recently moved into a new building after completing $1 million in renovations.
• T-System posts a video featuring Baptist Healthcare System (KY) and its go-live with the T SystemEV EDIS.

More news: HIStalk Practice, HIStalk Mobile.

Readers Write 3/26/12

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!

If You Did It, Enter It in the EHR
By Mitch McClellan

I was recently asked the following by a colleague:

We know that every organization has some physicians who just will not fully use the EHR. They will have nurses, MAs, and other clinical staff do all of the data entry. They may just hand the staff a piece of paper and have them enter the problem list. A specific example would be the MU requirement for weight counseling – do you think it is acceptable for an MA to indicate in the record that the physician did the weight counseling? Clearly it makes sense to have nurses and other clinical staff enter medications and even other orders and even start notes, but where do you draw the line?

This question certainly walks the line between facilitating accurate data entry vs.what is appropriate.

If an organization is truly going to embrace this much-needed change in healthcare, they need to enforce that their clinicians do the right thing. In this case, it would be physicians taking 100% ownership of entering the documentation specific to weight counseling. They are the ones actually provided the counseling.

I understand that is a black-and-white response, but I strongly believe that if an organization’s culture accommodates physicians who choose not to do their complete EHR responsibilities (e.g. not documenting the counseling that YOU provided), then it defeats the entire purpose of what we’re doing.

The EHR revolution is strongly driven by the fact that paper is not efficient and creates too many points of failure. Not only is the medium (paper) antiquated, so are many of the policies and processes that support those paper workflows (e.g. documenting a note that you then pass on to someone else to then "document a note" on your behalf).

Unfortunately, I believe most physicians are put into a "get it done now vs. a get it done right" scenario due to the payers’ stringent reimbursement policies. I completely understand the time demands on these physicians. But the rule I try to instill with all of my groups is that, "if you did it, then you must enter it in the HER." Otherwise, the effectiveness and efficiencies of an EHR are lost if the old way of doing things is still embraced.

The groups that I’ve worked with would require the physician enter that piece of documentation themselves instead of the MA. The only groups that I’ve worked with that would allow this scenario to happen would be if it was the physician’s nurse — not an MA –entering the documentation. To me, the issue is twofold. The first is workflow (reasons already stated), the second is the lack of credentials of an MA. I know I’d want a higher-credentialed healthcare provider entering that information if it’s not the physician themselves.

Mitch McClellan is manager of implementations at MBA HealthGroup of South Burlington, VT.

Optimization
By Dave Vreeland

Cumberland brought together a select group of HIT executives from some of the nation’s leading health systems for a recent breakfast discussion The topic: optimization.

Now that many are on track for Stage 1 Meaningful Use and other compliance deadlines, the focus is beginning to shift beyond go-live toward getting the most out of HIT systems. The panel, made up of Cumberland’s Brian Junghans, HCA’s Dr. Divya Shroff, and Memorial Healthcare System’s Jeff Sturman, shared how non-profit Memorial and industry giant HCA are tackling optimization.

The takeaway: success largely hinges on solid communication and the collaboration of two very different worlds – IT and clinical. Clinicians are arguably the keystone in achieving effective system adoption and long-term optimization.

Junghans points out that IT folks tend to think in terms of projects, which have a defined beginning and end. When it comes to IT implementation projects, the end is go-live. In contrast, optimization is an ongoing effort.

Dr. Shroff points out that clinicians have more of an optimization mindset, with a continuous focus on improved quality of care, optimal patient outcomes, and best practices.

With techies and clinicians in different mindsets, speaking two different languages, communication issues are common. HCA has success placing physicians and other clinical professionals like Dr. Shroff in clinical transformation roles. Valuable insight and hands-on experience makes these clinicians effective ambassadors for both the IT and clinical teams. 

Sturman and the Memorial team have incorporated clinical aspects into their approach to optimization. The team makes regularly scheduled rounds to observe workflow, system usage patterns and identify opportunities for improvement throughout each of their six hospitals, clinics, and ambulatory practices.

The importance of a clear distinction between IT support and optimization teams was also stressed. HCA trains the IT support team to triage incoming calls, address specific break/fix issues, and refer optimization matters to the optimization team.

Both organizations have seen success with various efforts to improve clinical/IT relations and are on track with current and long-term efforts toward optimization.

In addition to a number of lessons learned and critical success factors to consider during and after the implementation process (summarized in our presentation Beyond Go-Live: Achieving HIT System Optimization), it was interesting to hear this room of executives from diverse organizations, representing both the clinical and IT fields, reinforce the significant impact collaboration between the two worlds has on the success of end-user adoption and achieving true optimization.  

Dave Vreeland is partner with Cumberland Consulting Group of Franklin, TN.

Stage 2: The Vendor View
By Frank Poggio

On March 7, 2012, a draft for comment on the new Stage 2 rules was published in the Federal Register. Actually there were two separate parts to the rules. They are:

1. The CMS part that is aimed at provider requirements necessary to meet Meaningful Use, and
2. The ONC piece that addressed proposed changes to the certification process for EHR vendors.

On the provider side, there are innumerable blogs and Web sites that are covering the provider issues, which deal mostly with a few added MU criteria such as electronic medication administration records, menu options in Stage 1 that are now mandatory in Stage 2, greater emphasis on exchanging patent care information across care levels, and greater patient access to care information.

This article will focus on the “second side” of the regulations — the elements that most impact the system suppliers, with emphasis on the impact to niche or best-of-breed (BoB) vendors.

The full text of the new ONC Certification proposed rules can be found at here.

Before we hit the high (and low) points of the rules keep in mind these are proposed rules. If there is anything you don’t like about them, have suggestions for improvements, etc. you have from now until June 7 to post comments on the federal Web site. Speak now or forever hold your price! (No that is not a typo … see the Ugly).

Here’s the Good, the Bad, and the Ugly of proposed certification changes for vendors.

The good news:

Privacy and Security — will it go away?

EHR Module certification gets a little easier for niche and best-of-breed vendors (BoB). The big change here is that Module certification no longer requires you to address any of the privacy and security criteria. In the past, there were eight P&S criteria (number nine was always optional), and in our working through many ATCB tests, if you said the right phrase, you could get a waiver on three others (Integrity, General Encryption, and HIE.) Proposed under the Stage 2 as a niche/BoB vendor, you can ignore all the P&S criteria. To get certified under Stage 2, it would seem all you will need to do is pass any one Inpatient, Ambulatory, or General criteria, just ignore the P&S criteria, and you’re home free.

ONC said they made this change because many of the smaller firms complained that the P&S criteria did not apply or were too burdensome. This may sound too good to be true. Maybe it is. Read what ONC says in other parts of the document:

Finally, we propose to require that test results used for the certification of EHR technology be available to the public in an effort to increase transparency around the certification process. We believe that there will be market pressures to have certified Complete EHRs and certified EHR Modules ready and available prior to when EPs, EHs, and CAHs must meet the proposed revised definition of CEHRT for FY/CY 2014. We assume this factor will cause a greater number of developers to prepare EHR technology for testing and certification towards the end of 2012 and throughout 2013, rather than in 2014.

This is classic ONC. They say you don’t have to get certified. There is no law that says any vendor MUST – even a full EMR vendor. They believe the market will tell you. And by the way, ONC will be publishing the details of your certification so the world can compare you against your peers.

As we tell our clients, the MU criteria you choose to test on is dictated more by your competition and clients, not by the ONC.

Gap certification for Stage 2

A question that we have heard frequently was if I was certified on 20 criteria for Stage 1, under Stage 2, would I have to be tested again for those same criteria? Under the proposed Stage 2 rules, you would not need to get re-certified on Stage 1 criteria. You will only have to be tested on new criteria you select, and tested on Stage1 criteria that has changed or been revised by ONC.

A good example is the encryption P&S test. The focus now will be on encryption for data at rest. They state:

EHR technology presented for certification must be able to encrypt the electronic health information that remains on end user devices. And, to comply with paragraph (d)(7)(i), this capability must be enabled (i.e., turned on) by default and only be permitted to be disabled (and re-enabled) by a limited set of identified users.

So if you tested out on encryption under Stage 1 and want to carry it forward into Stage 2, you’ll probably have to show how you default encryption for user devices.

Component EHR vs. Complete EHR

A typical misunderstanding we came across many times during past year taking our clients through the certification process was a CIO at a hospital would say to the vendor that he/she believed they had to install a full EMR from a single vendor to meet all the MU criteria. In the proposed regulations, ONC has clearly addressed this question. On page 104, they say:

Certified EHR technology means: 1. For any Federal fiscal year (FY) or calendar year (CY) up to and including 2013: i. A Complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition EHR certification criteria or the equivalent 2014 Edition EHR certification criteria; or ii. A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition HER certification criteria or the equivalent 2014 Edition EHR certification criteria, and the resultant combination also meets the requirements included in the definition of a Qualified EHR.

In effect, a provider could meet the MU criteria using as many suites of BoB systems as they believe necessary. They do not have to be from one or the same vendor.

Now some bad news:

Criteria components

Many BoBs struggled with the make up of the criteria for Vitals and Demographics and several other clinical criteria. On the surface, they seemed easy to pass. The problem was they contained some data elements that were not typically found in BoB systems. For vitals, the hurdle was growth charts. For demographics, the hurdle is date and time of death. To pass these criteria, some vendors would use user-defined fields or create new inputs that they knew their clients would never use. Repeatedly I was asked by niche and BoB clients, “Why would you ask a patient during a registration process, ‘When did you die?’” Now there’s a comforting dialog!

Keep in mind several or the participants in building the HITECH/MU program were academics and researchers who would find that piece of information critical to their retrospective medical data analyses. Also, vendors of full EMR systems would easily have that piece of data readily available in their medical record abstract system. But for an ancillary or niche vendor, not likely. As far as I know, there were no niche or BoB vendors represented on any of the HITECH Policy or Standard Committees.

You may wonder why any firm would go through the trouble of adding a useless data element. Again, keep in mind what ONC said above: market will require certification. It can be virtually impossible to sell an ancillary system such as surgery, ICU monitoring, therapy, anesthesia, etc. if you had to tell your prospect your product was not certified for vitals.

Unfortunately this issue is still there for BoBs. The big change is on the provider side. ONC has greatly liberalized the granting of exceptions to providers for MU attestation if the MU criteria (or element of the criteria) do not apply to their practice of facility. As an example, a psychiatrist does not have to do growth charts for his patients — an exemption will be readily available. But the vendor who sold him the system still must!

Continuing this topic, in a recent interview Dr. Mostashari chided EHR vendors who "aren’t making meaningful use of Meaningful Use." Instead of attempting to seamlessly incorporate MU standards into their interfaces, Mostashari said "vendors did what vendors do—they slammed in the criteria and got certified.”

I submit that ONC slammed these regulations into being as fast as they could due to Congressional and Executive pressure, so one good slam deserves another. Maybe if ONC took a moment to look at the impact of certification on niche and BoBs — which are mostly the smaller, more innovative developers — and adjusted the criteria, we all could stop slamming.

And now the ugly:

As I mentioned in an earlier HIStalk post, ONC wants comments on vendor product price transparency. Here’s the ONC statement:

During implementation of the temporary certification program, we have received feedback from stakeholders that some EHR technology developers do not provide clear price transparency related to the full cost of a certified Complete EHR or certified EHR Module. Instead, some EHR technology developers identify prices for multiple groupings of capabilities even though the groupings do not correlate to the capabilities of the entire certified Complete EHR or certified EHR Module. Thus, with the transparency already required by §170.523(k)(3) in mind, we believe that the EHR technology market could benefit from transparency related to the price associated with a certified Complete EHR or certified EHR Module. We believe price transparency could be achieved through a requirement that ONC ACBs ensure that EHR technology developers include clear pricing of the full cost of their certified Complete EHR and/or certified EHR Module on their websites and in all marketing materials, communications, statements, and other assertions related to a Complete EHR’s or EHR Module’s certification. Put simply, this provision would require EHR technology developers to disclose only the full cost of a certified Complete EHR or certified EHR Module.

As a former CFO, I know that the through definition of ‘full cost’ would take at least another 500 pages in the Federal Register. After the vendors in the audience come down off the ceiling, you’d probably like to share your reaction with ONC. Just click here.

Frank L. Poggio is president of The Kelzon Group.

Curbside Consult with Dr. Jayne 3/26/12

I’ve been having a hard time sleeping lately. Maybe it’s the recent time change, or maybe there’s just too much going on at work. Maybe I’ve got spring fever or just a touch of unfulfilled wanderlust. I’ve enjoyed taking some long walks in the evenings and sitting out on the patio listening to mellow David Gray tunes as I deliberately wind down from the ever-lengthening days.

I suspect it’s the proverbial “too much going on” because I also developed a touch of writer’s block. A friend of mine works in the industry, so I asked him for inspiration with this question: as a person in the trenches, what kinds of things keep you up at night?

What he came up with was a question for me: will Meaningful Use really decrease the cost of healthcare and increase continuity of care, or is it just additional overhead where no one really knows how to administrate the benefit it could provide?

I’m going to take off my politically savvy “plays well with others” hat and put on my “doc in the trenches” hat for a bit here. The answer is I really don’t know. Many health systems have been practicing what Meaningful Use preaches for years prior to the incentive program. They’ve implemented patient portals, obtained unified data, and achieved transparency of the medical record. They conduct group visits, run non-traditional schedules, and encourage both patients and employees to use personal health records.

IT systems are in place which support evidence-based care and encourage disease prevention and health promotion. Providers are graded on the care they deliver and are presented with opportunities to intervene where care can be improved. Providers in these health systems are discouraged from ordering unnecessary tests and ineffective treatments through both payer and quality initiatives. In many organizations which are true integrated delivery systems, referrals are closed loop and carefully controlled as well.

Despite these efforts, many are not seeing overall costs come down. Patient insurance premiums definitely aren’t decreasing. We know that certain episodes of care can be made more cost effective and we can leverage technology to prevent many harms. We’ve all watched the recent debate over the Health Affairs article that showed that access to prior results didn’t decrease ordering of tests. We understand that test volume alone isn’t a reliable indicator of whether we’re successful. I have seen data on primary care practices whose ordering volume spiked after EHR implementation, but when you drill down, a large number of those tests were preventive. That seems to indicate that clinical decision support is working.

If you watch those practices over a few years or so, however, the ordering tapers off. It’s almost as if providers are playing “catch up” for the tests they missed while they were too busy addressing acute illnesses and complex chronically ill patients. If you look at labs that are ordered to diagnose illness or monitor chronic conditions, we didn’t see as many spikes. I wish hospitals and provider groups would have had the resources to do better prospective studies as they implemented, but unfortunately, most of us were focused on system build and implementation. It would be nice to look at it other than through the retrospectoscope.

I do think advances in healthcare IT have significant potential to increase continuity of care, but it is unclear whether MU is really a driver. Over the last decade, we’ve seen RHIOs fail despite significant clinical potential. I’ve seen the accessibility of information increase dramatically in both the ambulatory and acute spaces as well as between them. We have data at our fingertips instantly that would have taken hours or days to obtain previously.

We have the potential to avoid duplication of tests and therapies, with one caveat – caregivers have to be allowed the time to intelligently process the burgeoning amounts of information relevant to each patient and his or her care. Unfortunately, our payment system is still largely volume driven, often resulting in fewer and fewer minutes for each patient contact. Patients in the hospital are sicker and they’re going home sooner, making the task even more difficult.

Meaningful Use is certainly additional overhead. Of that there is no question. The cost to implement certified technology is significantly higher than the payments received. I hope anyone who actually believes differently is willing to share whatever psychotropic substance they’ve gotten a hold of.

Hospitals and providers are simply running to catch up and to make sure they avoid the payment penalties that are coming. Meaningful Use has derailed other initiatives as budgets have shifted to accommodate timelines which are faster than some groups were prepared to implement. I know that’s the point – to speed things along for laggards – but some groups and hospitals were simply proceeding at a more deliberate pace relative to their own goals and priorities.

I wonder how many people at ONC have visited a practice that has cut back on improvements to the physical plant, supplies, or clinical equipment due to the increasing IT budget? I know I’ve been to quite a few. I’ve seen state-of-the-art computers sitting on decaying countertops that can’t be properly sanitized. I’ve seen budgets for continuing education and clinical in-services eliminated in favor of application training and time spent in endless debate about the validity of various order sets.

I’ve seen much more, but it’s too depressing to put into words. The amount of money spent on MU consulting alone is absolutely staggering.

Physicians seem increasingly susceptible to burnout, and the cost of that unintended consequence can’t be readily quantified. This also applies to nursing staff, pharmacists, ancillary staff, and pretty much anyone who works in support of patient care. IT staff are also under increasing stress. We all know stress and burnout diminish productivity and put patients at risk.

Only time will tell whether Meaningful Use will be truly effective in changing the way we deliver healthcare and how much it costs. In the mean time, we’re all going to work longer and harder and get by with less in some respects. We’re going to do some amazing things, but not without a price. Fasten your seat belts, folks. It’s going to be a wild ride.

And for those of you who know your Disney history, remember this: Mr. Toad was only a C-ticket ride.

E-mail Dr. Jayne.

Monday Morning Update 3/26/12

From Fozzie Bear: “Re: University of Mississippi CIO Charlie Enicks. Resigned just a few months before going live with Epic.” Unverified. UPDATE: verified. Charlie tells me he’ll be the new CIO at Georgia Health Sciences University in Augusta starting May 1. He says Epic is doing fine at Mississippi – he just wanted to get closer to family.

From The PACS Designer: “Re: Epic at Yale. It appears that things are going well with Epic, according to Daniel Barchi, CIO at Yale New Haven Health System, who gives us his real experience using the new Epic EMR for a recent physician visit as detailed in the Yale Medical Group News. “

I’ll be making minor changes to HIStalk over the next year based on your reader survey responses, although there won’t be too many — most respondents urged me to not try to fix what isn’t broken. First up is the search function, which I’ve just replaced with a paid Google version that’s faster and cooler. Second: readers suggested bringing on two contributors if I can find them: (a) a frontline provider-side nurse with healthcare IT insight, and (b) a stock and business expert. I’m willing if I can find that rare combination of talent, insight, and the commitment to write even when life intrudes. Some other suggested ideas (new sites, new coverage, putting on conferences, etc.) were good, but not realistic to undertake as a part-timer. They do, however, give me a fall-back position if I ever get sick of my day job and need to scratch out a living on my own. Thanks to the folks who completed the survey – it’s important to me.

Listening: new from Nada Surf, catchy indie rock that’s more upbeat than some of their earlier stuff. They sound just as good in their acoustic performances, a rarity among bands who couldn’t sing Happy Birthday to someone without Auto-Tune help and whose high-ticket shows are more karaoke than concert. They’re on tour now.

Two-thirds of respondents side with Farzad Mostashari in predicting that physicians will order fewer unnecessary imaging tests when previous results are available and new orders are guided by electronic decision support. New poll to your right, inspired by my Pam Pure interview: what target market will offer the greatest HIT opportunity in the next 5-10 years?

Emerging confused and squinting in the first light it has seen in five years is this week’s Time Capsule editorial, EMRs: Free May Not Be Cheap Enough for Physicians, in which I opine, “Imagine what they’ll think when they first encounter hospital IT types, those grudging emissaries of a department built around rigid conformance to rules, perpetual understaffing, and a vision for the common good that squelches the individuality and self-determination that doctors thrive on.”

Cooper Health System (NJ) names Jayashree Raman, formerly of Stanley Healthcare Solutions, as VP/CIO.

Mr. Ciotti turns back the HIS-tory clock  to long-forgotten bedside system vendor MedTake.

Weird News Andy is fascinated by a $100 test that could predict heart attacks weeks in advance. It detects endothelial cells that have been loosened into the bloodstream by fresh artery damage.

Cerner will break ground on its new Kansas City campus this week, planning to start moving an eventual 4,000 employees into the new offices by the end of the year as required by state-provided incentives.

CMS will conduct a free webinar overview of MU Stage 2 on Monday, March 26 at 1:00 Eastern.

CVS Caremark blames a programming error for exposing the detailed medication and condition lists of 3,500 members of Tufts Health Plan to other members by printing the wrong addresses on the envelopes.

In England, Liverpool hospitals are running a “bring your own device” pilot for tablets, installing Kaseya’s device management software on them for security. The hospitals like the idea of cheaper alternatives to desktop PCs and are considering offering an employee subsidy for tablet purchases. Says the CIO, “Refreshing all that kit every three years is becoming cost-prohibitive. People already have really cool devices, which they do bring to work. They just can’t connect them.”

E-mail Mr. H.

HIStalk Interviews Pam Pure, CEO, HealthMEDX

Pam Pure is CEO of HealthMEDX of Ozark, MO.

Let’s get the obligatory McKesson questions out of the way. What are you proudest of from the time you spent there and what regrets do you have?

I look back at McKesson with great memories. I’m very proud of our team and I’m very proud of what we accomplished. 

We took a business that was basically going nowhere in the ‘98-‘99 time frame. We built a strategic plan and brought together a series of products — clinical products, imaging products — that we could deliver as a really robust solution to our customers. Over the eight years that I was there, we built great customer relationships, built a great working organization, and put some customers on the road to full clinical implementation and physician connectivity. It was a great time, a great experience, and I look back on it with a lot of pride.

In terms of regrets, I don’t really have any. I look at that as a great chapter in my career, a chapter that I’m very proud of. I learned a lot and it was a great launching point to this next chapter, which I recently started and I’m really excited about.

What led you to leave McKesson?

It was the right time, time for a new chapter. I left the organization and began thinking I was going to take a year off and just spend some time with my family. Things went on a whirlwind from there until I ended up HealthMEDX.

As you’re watching now from the sidelines, were you surprised by the announcement about Horizon Clinicals and Horizon Enterprise Revenue Management  being de-emphasized in favor of Paragon?

I know this is going to be hard for a lot of people to believe, but I really don’t spend a lot of time watching McKesson. I’ve made a conscious decision, like when you send your kids off to school. You have to let them go. A really important transition point for me was letting McKesson go.

There’s a lot of great people there, a lot of smart people there. I rely on them to make the best decisions for the company and for the customers. I hope they will continue to do that because I think we set a precedent of putting our customers and employees first.

But you know what? I really don’t follow it. I’ve tried very hard not to have an opinion on McKesson, but just to support their continued success.

What is it about HealthMEDX and the post-acute care market in general that simultaneously got you to come there and for investors to acquire the company?

I left McKesson and I had this grand plan that I was going to take off a year and travel with my kids and do things like exercise and get fit. Shortly after I left McKesson, my mom was diagnosed with a really serious Stage 4 cancer. She had a lot of surgery and a very long rehab, which she experienced in my home. 

And you know, here I am — I think I’m like Miss Healthcare, because I think I’ve been involved in healthcare for 27 years, so I must understand it — but here I was in the middle of helping someone I love recover from something very serious. It was the most challenging thing I’ve ever done, because it was very, very difficult to figure out how to manage her care.

My mom got back to the point where she could live at home with my dad. We went on a two-week vacation, came back, and my father had a heart attack in our driveway. He had quadruple bypass surgery and then he moved into the Pure Rehab Center, at which point over the door came up Pure Rehab Center the sign. We shipped him home about eight weeks later. 

Three months later, my mother-in-law had a stroke. In this very compressed eight-month period of time, I had three people — who are very independent, very successful in their own lives, very healthy — all go through these major post-acute events at three fabulous health systems. In every case, I was so disappointed and so stunned by the lack of follow-up support.

While I was at home dealing with the emotions of taking care of parents and in-laws, I had a very introspective time. I said, what am I going to do next? I don’t want to go back and do another very large company. I would really like to help figure out how to solve this problem in the post-acute space. 

I started spending time with my parents’ friends, my in-laws’ friends in trying to understand how they were dealing with managing their home care, moving to retirement communities, moving to assistant living organizations. As I started digging into this, I found that these organizations were very disconnected. It was confusing for my parents and their friends to deal with healthcare and follow-up. There are many people involved doing the same things, many different locations, and it was totally a paper system.

I approached the private equity firm and said, “I would really like to do something in the post-acute space to figure out how we can build a technology-enabled system that could be connected back to the health system. Post-acute care is going to be very strategic moving forward, and it’s got to be more connected and it’s got to be more automated.” That’s what began my journey at looking at companies in this space.

The question I should have asked you earlier but I was hung up on the McKesson questions is to describe what HealthMEDX does.

HealthMEDX provides an integrated technology platform that manages a patient in a post-acute environment. If they’re not in the hospital and they’re not in front of a physician, we automate it – home care, hospice, skilled nursing, assisted living, rehab, retirement communities, transitional care organizations moving from the hospital back out to the home. Anything that doesn’t occur in the hospital or doesn’t occur in the physician office — we can manage the patient through that experience.

What is most different about that client base compared to physician practices and hospitals?

For the most part, post-acute providers have more long-term patient care responsibility. I visit some of our customers that are skilled nursing homes. The patient might be there for 12 years. These post-acute providers or even a rehab center – these providers are kind of like the last check to make sure the patients gets as healthy as they can be. They finish the care. 

In the hospital or in the physician office, treatment tends to be very episodic — finish off and go. In the post-acute center, it’s more focused on how do we get the patient back, how do we get this person back as good as they can be, and where is the right end place? I think there is more focus on managing the patient back as opposed to managing an episode.

That’s changing in health systems, and obviously with risk-shifting and ACOs, there is a great focus on the patient. That’s why I think these post-acute organizations are going to become more strategically important.

That market wasn’t really considered all that sexy by most people, where institutions were perceived to have both financial challenges and technology challenges. How did HealthMEDX turned out to be the biggest vendor in it?

The uniqueness of HealthMEDX comes in two areas. Most technology players in the post-acute space focus on one segment. You’ll see a lot of home care companies, you’ll see a lot of rehab companies, you’ll see a lot of skilled nursing companies. Most of those companies do one thing.

I think the difference and the magic of HealthMEDX is it’s a patient-centered system that knows it has to manage the patients. Where they are doesn’t matter in terms of how the care is automated and delivered. 

If you look at our customer base, it’s very diverse. We do these large, national, senior living retirement communities. We automate the whole community. We do post-acute transition programs, where it’s a program for 14 days to get the patients from the hospital to home. We do home care, we do hospice, we do rehab. We have a large presence in all of the different segments of the post-acute market.

A big part of our strategic thesis was that post-acute care providers are going to diversify and consolidate. Nobody just wants to be a skilled nursing home or just an assisted living these days. They want to provide rehab services or home care services. The technology needs and the requirements of these organizations are changing.

Do you think federal reimbursement changes will encourage growth or consolidation, changing the way these organizations compete with each other as well as competing with hospitals?

We’re going to see a lot more networking between post-acute providers and hospitals. More sharing of the risk. When you look at readmissions and the health system focus on reducing readmissions, there are a lot of post-acute providers that can help them get there, in terms of managing the patient once they leave and trying to keep the patient form coming back. 

A lot of the changes in the regulatory environment and in the risk-shifting environment will cause the post-acute providers and the health systems to become more tightly integrated. Some health systems will acquire more post-acute providers. I see some purchasing nursing homes, assisted living, some building retirement communities where they’ll have full management of the patient. Then I see a number that are building very progressive networks with regional post-acute providers to manage their patients once they go home.

There was a time when hospital CIOs really knew next to nothing about physician practice systems because they weren’t relevant to their organizations. Do you think that they’re going to be pushed into gaining the same expertise in long-term and home care systems?

I absolutely do. It’s very interesting to watch, because we all watched in the ‘80s and the first half of the ‘90s as the hospital markets started to automate it. It started with financial automation, then clinical automation, and then connectivity. We watched the physicians go through the exact same evolution – financials, then EMR, and then a huge focus on connectivity. That became the continuum of care.

I think we’ll see an extension in the continuum of care. I think that extension will include the people who are responsible for the care of the patient after they leave the hospital and after they leave the physician office. I think we’re going to see the exact same thing. Those post-acute care organizations have billing today. They’re now beginning the journey for an electronic clinical record. I think the journey for that electronic clinical record and health system connectivity will almost occur concurrently because of their importance in an ACO environment.

Those of us on the hospital side might assume that we’re doing cool stuff that should find its way into nursing homes and home care. Are those organizations things that hospital people could learn from?

There will be a great deal of information shared and a great deal of learning on the health system in the post-acute side as we build this collaboration and extend the continuum. 

The hospital market today is much more experienced with implementing advanced clinical systems. The lessons learned in terms of process flow and workflow automation will be essential to the success of some of these post-acute care providers and will help us figure out the right way to make handoffs … what happens when a patient is discharged, what happens when a patient shows up in the emergency room. The health system and hospital clinicians are more system savvy and can help direct those handoffs, which I think will be great.

On the post-acute side, what’s very interesting to me is that the location of the patient is really insignificant in the care of the patient. For the most part, hospital systems and physician systems have been very visit specific and episodic in the way that the data is managed. Especially with HealthMEDX, the post-acute view is much more patient centered, just naturally patient centered in the way the product was built, with the assumption that the system has to follow the patient — the patient doesn’t follow the system. Just a lot more flexibility in how the technology can be deployed and the intelligence of the product to know the right way to bill.

Some of the biggest changes in healthcare IT have been driven by government changes, like reimbursement or Meaningful Use. Do you see that happening in the market that you’re in? Will hospital software companies need to build or to buy to get into that market or be left behind?

The post-acute market has similar regulatory requirements that are getting more complicated and more intense and I believe are driving the automation of the EMR in the post-acute market, very similar to what happened in the hospital and the physician market. Subtle incentives to automate, so you can electronically transmit clinical data and electronically transmit some more complex financial information. The regulatory push is definitely there.

Many of these post-acute organizations are selling “directly to patients,” quote-unquote, in terms of the value they can provide and the quality of care. In many cases, patients are making a very definite choice of where to receive their care and the technology infrastructure is becoming more important. Patients want families, want their parents in organizations that they feel are safe, with quality systems and services. Technology is becoming part of that decision process and the shifting reimbursement and relationships with hospitals.

We’re going to look back and see the next three years as a critical time in terms of hospitals and physicians being able to follow their patients home. To do that, the post-acute technology and post-acute connectivity is going to become essential. I think the progressive post-acute organizations realize that and are moving more rapidly than we expected.

How is selling and supporting customers in your market different than it was for hospitals and physician practices?

From a selling perspective, customers are very focused on three or four things that are very important to them. There is more clarity of what they are looking for. When you look at a hospital or health system, it is a very complex sales cycle with a lot of decision makers and a lot of stakeholders at the table. The post-acute environment tends to be more focused on exactly what’s required and is not as large and long.

When you look at the company over the next five years, what are your priorities?

It’s a great question, because I just really am excited about the potential to help build the technology-enabled post-acute world. 

When I look at the next three to five years, the first thing that we can do is help these post-acute care providers build an electronic medical record that includes all of the information for the patient, whether they’re receiving home care, whether they’re receiving rehab, or whether they’ve had to move to assisted living. We can build one integrated record to manage that patient. I think Job #1 is supporting the consolidation and the diversification that’s happening in the post-acute market with an electronic clinical record. It’s really essential.

The second thing that is going to happen — and it’s going to happen quickly — is helping health systems connect and build relationships with these post-acute organizations so they have the capability to follow patients home. That will require a lot of work with health systems in terms of setting up the infrastructure and the process flow of moving a patient home or moving a patient to an assisted living or a rehab organization. Also being prepared to take the patient back when they show up in the emergency room or have to come back for services. Health system connectivity supported by industry standards — I think that’s Job #2.

Job #3, once we get that going and these post-acute providers are automated and they’re connected, there will be great learnings in terms of analytics. Where’s the most cost-effective place to send a patient? How quickly do you discharge them into transitional care? How long should transitional care last?

I’ll tell you this great story. A post-acute customer who’s trying to develop a specialty in transitional care said, you know, if a patient comes in for hip surgery and it’s scheduled, and you look at that same patient is not scheduled — they fall down and they break their hip. The patient who falls down and is unscheduled spends 10 days longer in transition care. And you know what we figured out? They need mental health services, they need emotional support. The fastest way to cut those 10 days is support for dealing with the stress of the trauma and the unplanned medical experience.

I really believe, and what I’m most excited about, is once we are able to automate the post-acute space and connect it, we’ll be able to figure out questions like, where is the most cost-effective treatment location? How do you move patients through the continuum of care in a quality, cost-effective manner? Because now you really have the continuum.

Any concluding thoughts?

I’m very excited about the business. We’re about to open an office just outside of Boulder, Colorado, so we’ll be expanding to two offices. We’re growing quickly.

For me personally, I’m just thrilled to have the opportunity to focus on a segment of healthcare that I’m extremely passionate about after dealing with some very traumatic personal experiences. I wake up in the morning believing that a company like ours can impact the way that care is delivered in the post-acute environment. 

I would also say that I’m equally focused on building a company culture where people come to work and feel as excited and passionate about what they’re doing as I do. I’m really looking forward to that.

Time Capsule: EMRs: Free May Not Be Cheap Enough for Physicians

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.

EMRs: Free May Not Be Cheap Enough for Physicians
By Mr. HIStalk

Now that Stark restrictions have been relaxed, hospitals are rushing headlong into the ambulatory EMR business. It makes sense. Hospitals have a lot of technology expertise and private physician offices usually have none. The government wants to increase the embarrassingly small number of EMR-capable practices, so throttling back Stark is a free solution that makes almost everyone happy.

Are EMRs the peace pipe that will suddenly bring the traditionally wary partners / competitors together in a long-awaited passionate embrace? Probably not.

Community-based physicians are often scornful of hospitals, seeing them as a hotbed of meddling management, questionable quality, and carefully hidden profits. Imagine what they’ll think when they first encounter hospital IT types, those grudging emissaries of a department built around rigid conformance to rules, perpetual understaffing, and a vision for the common good that squelches the individuality and self-determination that doctors thrive on.

Hospital CIOs like service-heavy, expensive vendors that won’t get them fired. They also like standardization and vendors that offer the theoretical possibility of integrating office-based EMRs with inpatient systems and RHIOs. For those reasons, I expect most CIOs will favor EMRs from big-iron, old-line ambulatory vendors like Misys, Epic, and Allscripts.

These are the vendors that small practices studiously avoid in many cases. They dislike them for the same reasons CIOs love them.

I spoke about this with Jonathan Bush, CEO of athenahealth, at the HIMSS conference. He has an interesting perspective, although not surprising considering that his company sells simple, easy-to-use systems that increase physician income through reduced claims denials.

Bush described the EMR offerings of the big, inpatient-oriented vendors as “elephant’s ass systems.” The little two-doc practice sees the hospital IT truck back up and out comes a complex application with loads of customization options, stacks of thick manuals, and no direct support except whatever the providing hospital has decided to offer. Free or not, there’s training to attend, configuration choices to make, and conversion from existing systems to plan. Oh, goody.

Doctors aren’t that thrilled with EMRs. Most of their benefit goes to insurance companies, studies have shown. Until pay-for-performance kicks in, there’s not much incentive. Plus, docs are always paranoid that hospitals will see how much money they make.

Benefits aside, EMRs take more of the doctor’s time to use. Something that’s free but consumes an hour or two more of the doctor’s day is hardly a welcome gift. All the doctor has to sell is time, and suddenly there’s less of it available.

Bush predicts what he calls a “hairballing up” of these feature-rich EMRs. The hospital may spend the money, staff a support center, and hand-hold the implementation, but there’s still a good chance the doc will thrown up his or her hands and announce, “I’m not using this. I don’t have the time.” Then, they’ll either ditch the whole EMR idea or find an easier to use system that gives them a financial benefit.

Remember when insurance companies and hospitals gave away free PDAs with all kinds of supposedly doctor-friendly software on them? Docs lined up to get one. No one was smart enough to realize until afterward that asking for a free gadget was hardly a commitment to change practice patterns.

Perhaps hospitals have underestimated this hairball effect. They’re giving doctors systems that are mostly loved by hospitals: feature-rich, committee-designed for a large range of practice settings, and with extensive clinical capabilities that may or may not interest the physicians who are expected to use them enthusiastically.

It’s great that hospitals will help drive EMR adoption by private medical practices. Hopefully they’ll give the docs a voice in choosing systems that they’ll use before spending too much money on a monolithic system that may not fit all.