HIStalk Interviews Michael Weintraub, President and CEO, Humedica

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

Tell me about yourself and the company.

Humedica is a business that, in addition to incubation phase and the launch of the business, has been around for roughly five and a half years. We formally launched the business in 2008.

Our vision is around population health business intelligence solutions. The founders of the company, the members of the team, and I have been working within and around health informatics, health analytics for anywhere from 20 to 30 years. I’ve been in this space for about 30 years and have always been passionate around the need to get our arms around health information to drive value and change in the industry. That’s what this company is all about.

Our focus is in moving from electronic data to liquid access to information and doing that across the continuum of care longitudinally. Our view is that there are a lot of solutions out there that are brought to the industry, but there was a need for an organization that’s focused passionately and exclusively focused on bringing together all the disparate clinical financial and operational data across the continuum of care. That includes hospital information, and importantly, ambulatory clinic data in multi-specialty medical groups. Pulling that information together in a centralized business intelligence analytic way that allows a chief medical officer, VP of quality, CMIO ,and others in the organization to get their arms around the population that they treat across the continuum of care. That’s what we’ve been aiming to do since the beginning. That’s our focus, our vision and our mission. So far, so good.

Your timing must have been fortuitous. Not too many folks were interested in population health management back in 2008.

I’ve always said that it’s 51% luck at a minimum. You know the old saying about, “It’s heavily perspiration and a bit of inspiration.”

I’ve been working with claims-based information for quite some time and saw what the opportunity was with that data, as well as the limitations and the future need. I’ve always said with a smile on my face that when we started this company, Obama was a senator. If you watch the trends out there, we had a hunch of what was coming together.

Earlier in my career, I spent 10 to 15 years working with clinical data in the provider setting before EMRs. I was involved in companies that were successful when it was about chart abstraction and at grabbing that information using medical record coders and doing analytics on abstracted information. For me, it was the coming together of a distinct need around clinical information earlier in my career and then seeing the movement in technology and the availability of information as we moved from chart-based data to then, “What can you do with electronic data on the claims side?” to then coming full circle to, “What if that data actually was electronic?”

When we started the business, EMR penetration was somewhere in the high single digits. We saw what was happening in the industry with some of the leading EMRs starting to really accelerate. We were watching the technology and regulatory movement and thinking about the opportunity. If you think about what’s happened in the industry, health reform has really driven technology and EMR penetration based on the incentives and the ultimately the disincentives if you don’t have an EMR. Health reform has been a driver to technology adoption.

On top of that, from a regulation and finance perspective, i.e. healthcare reimbursement, there’s a real focus on operational efficiency and clinical effectiveness as key drivers,  more so than ever. Based on regulations and finance as a key driver and technology, we saw this coming.

The healthcare industry is really looking more and more like it needs to manufacture value at an operational level. The financial system, risk-taking, and reimbursement are all moving more and more into an alignment that – and perhaps I’m an eternal optimist of an entrepreneur — but I really believe that there’s an efficiency and effectiveness requirement as it relates to outcomes and the need to truly measure quality and cost. That starts from moving the needle to looking at data to truly transforming that data into information and ultimately into insight to drive action.

My 30 years in healthcare have all been focused on building – once upon a time we called it decision support tools, now we call it business intelligence tools – building analytics that leverage the transactional data that moves through the pipe and taking it to the next level. I think the DNA of an informatics and analytics company is very distinct, and that’s been our focus. We leveraged what we saw happening at the technology level and a regulatory and financial system level.  

We can all discuss and debate how long that will take to change and what the slope of that curve will be, but I’m optimistic more than I’ve ever been that the drivers are in place to force the focus. I think that the macroeconomics are such that sustainability is on people’s minds, more than ever before as the national spend on the healthcare industry … 20% of GNP is not out of the question anymore. The question becomes, what is sustainable? Are we getting to a true tipping point that creates the motivation for change?

Hopefully the regulatory drive and the changing economics create the focus. I’m sure it will take longer than we all want and I’m sure there will be a lot of bumps in the road, but for me, I felt that the opportunity was there to build Humedica into the kind of company that I felt could drive the value. The need is there.

The company was initially called HIT, Health Insight Technologies. When Obama and others started using that term more and more, we realized that that name would not survive, hence the focus on human medical, or Humedica, to understand to the patient experience in the healthcare delivery system across a continuum of care and be able to study it at the population health level.

A lot of companies offer business intelligence tools, including some big ones. Who are your main competitors and how are your solutions different?

I say this as a member of the healthcare industry, not criticizing it from the outside-in, that I believe that there’s a significant level of sorting out and confusion occurring now. The focus up until now and continuing for the next several years will be EMRs. Do I have the right one? Should I switch to a different one? Do I have one? Do I need one? How do I get one? There’s a huge focus on EMRs.

Certainly the next phase after EMRs is, “What do I do with the data?” There’s a big difference between transacting with the data at the point of care versus doing the analytics that we do. The industry right now is in a period of sorting out. There’s a bunch of major buckets of firms out there that all touch and talk about analytics.

What’s interesting is clinical analytics and business intelligence was a concept that was not anywhere near as strategic as it is today. The good news about health reform is it has made this strategic. The bad news about it is it’s made it so strategic that there’s a sorting out occurring that’s causing the provider industry to sort out what it does about this.

If you look at the buckets of firms that all touch this, there are EMRs, and more and more of the EMRs are saying, “Don’t worry, we’ll get to this.” We believe that there’s a distinct difference between a specific EMR, whether it’s touching some of the data or more of the data in a provider, but many providers have multiple EMRs, whether it’s within the inpatient setting or inpatient versus outpatient. Cutting across and pulling it all together is a very different value proposition.

But there are EMRs that are all suggesting, “We’ll get into this over time.” I believe that they have their hands full right now. It’s like Y2K for the EMRs. There’s so much activity. I don’t believe the providers can wait for that to be developed, nor do I believe that software firms — as opposed to analytics and informatics firms — have that as a distinct competency. There are claims-based firms out there that do analytics with claims, and many of them are now repositioning as population health, ACO, etc. but there’s a distinct difference in looking at this information for population health with claims versus clinical data.

There are firms out there that are systems integrators and data warehousing firms like Oracle, IBM, Accenture. They end up oftentimes being more our partners than our competitors for a variety of reasons. There are regulatory reporting tools that touch on population health, but they’re more focused on regulatory reporting. There are application-specific firms that provide clinical data that are very narrow and specific in application. There are health and information exchanges and vendors as well that are pulling all the data into a common pipe as opposed to doing the analytics. We are starting to partner more and more with many of the firms in each of the categories. There are business process outsourcing firms that are now building clinical process redesign competencies, again partnering with us more so than competing.

We were the first to purely focus on clinical analytics. I believe we have years of lead time from a development perspective and from a competitive advantage in that regard. Competition is good. It creates a focus on best-of-breed and advances the capability on behalf of the industry. But there is no single firm out there that is distinct with and purely focused the way we are, but there’s certainly a buzz where every major firm and lots of boutique specialty firms are all positioning and or repositioning as population health and ACOs. I’ve seen many of the firms eventually complementing with us, collaborating with us right now more so than competing.

Allscripts is now a Humedica partner. What competitive advantage led Allscripts to that decision?

It’s a tremendous and terrific partnership. It was driven by the leadership and boards of the respective companies. Many Allscripts customers have multiple EMRs, and Glen Tullman, CEO and Lee Shapiro, the president, and I have a very common vision on the need to move towards an analytics and informatics foundation. Allscripts has branded Humedica within their business as they go to market as, “Clinical analytics powered by Humedica.”

When they saw our offering, they saw best-in-breed capability that they felt would create value for their customers and our mutual customers. What we saw was an opportunity given the accelerated movement of the industry in focusing on this. They’ve got an inside and outside sales force combined of 600 people and growing. What we saw was an opportunity to go to market faster, better, more effectively and more efficiently.

We’ve been working on that partnership for several quarters. I believe you’ll see the fruits of that over the next one to two quarters in a very significant manner as we start growing some mutual customers together based on our products and their sales channel. It’s been phenomenally successful thus far.

What are clients doing with your real-time capabilities?

There’s one product on the market and there’s one product in development. In the inpatient setting, the product is being used for clinical surveillance. In the hospital setting from a CMS perspective, regulation is such that 30-day readmissions and preventable readmissions complications will not be reimbursed. From a clinical surveillance perspective, tools are up and running in a hospital setting and key therapeutic areas.

The product in development has the capability to provide real-time surveillance in a clinic or ambulatory setting focused on proactive patient management in chronic ambulatory areas, stratifying risk and focusing on a Patient-Centered Medical Home, which more and more of our multi-specialty medical groups and clinics are focused on.

Your recent financing around raised your total a pretty big number, over $50 million. How have you invested that money?

The first round of capital was used in the formative stages of the company’s development, the first three-plus years to devise, develop, and deploy what we believe is a world class product portfolio for the provider market and to get validation from our customers in that regard. We believe that’s a huge competitive advantage and a sustainable barrier vis-a-vis the competition.

As we’ve gotten that validation, a few months ago in KLAS’s market research 300-page report, we received the highest rating of any business intelligence firm, with a rating of 91.8. A new category was created, essentially a clinically powered category where a solution has clinical capability, based on their discussions with our customers. All our customers in that report said they would buy again.

The first round of capital was really focused on building the most innovative capability possible. The second round of financing is focused on commercialization in a very significant manner. We currently have customers in roughly 20 states, but our ambition is significant. We want to bring this offering to the market at large. That meant a sales force, field organization,  customer organization, managing our channel partners, which includes Allscripts as well as the American Medical Group Association. That round of capital was meant to exploit the capability and partner with a provider market in a broader way to accelerate bringing this to market and managing a growing client base.

You came from Leerink Swann. What experience did you gain there that will help you build Humedica?

Leerink Swann is an investor in the company and provided the organizational platform that we were able to incubate this business. I was there for a short period of time, only about a year and a half. The majority of my career has been focused specifically on entrepreneurial activities such as this one. Leerink clearly has an exclusive healthcare focus and they’ve provided tremendous value as an investor and a board member as well, but it provided the platform where we were able to incubate this business, pull together a team, and spend about a year to a year and a half prototyping and thinking hard about how to bring these solutions to the market.

Where do you want the company to be in 5-10 years?

We’re at an important point. We have a partnership with Allscripts, which is a leading EMR. We also have a phenomenal long-term partnership with the American Medical Group Association, which has members in almost every state in the country and its membership treats one on three Americans. What we would like to be is the de facto leader in bringing health informatics insight at a population health level to the provider industry as they get their arms around their organizations managing cost, quality, and risk and compete.

The pressure on these providers is significant. They’re making significant investment in technology and now they’re ready to harness, we believe for the first time, all of this information to study and enhance and improve their operation as they bring world class care to their customer, the patient. That’s our vision.

We’re very, very excited about what’s happening in the industry. The activity level is at an all-time high. We think 2012 is going to be a mainstream year, where clinical informatics and business intelligence become a significant initiative for more and more providers in the US.

Monday Morning Update 12/12/11

From Dr. Boogie: “Re: Gwinnett Medical Center (GA). Goes on total patient diversion due to a computer virus. Physician portals impacted, hospital systems shut down. News media says no patients were impacted. Using old fashioned paper until systems can be resurrected.” Verified. They’re using paper and runners, with campuses in Lawrenceville and Duluth still on trauma diversion this weekend after the virus was discovered Wednesday, meaning ambulances are being sent elsewhere. They hope to have the problem fixed by Monday. For the nerds among us, they were hit with SillyFDC, a worm that spreads on removable or mapped drives that have Autorun turned on. It supposedly spreads without doing harm, but having seen similar worms take down hospitals myself, I’d bet it generated so much TCP/IP traffic that the network bogged down, requiring field support techs to touch every PC with network nodes isolated to prevent the virus from propagating right back from another unfixed PC. One thing you learn: antivirus software on individual PCs can tell you if they are infected, but they don’t tell you at a network level which PCs are spreading it, so you end up looking for network traffic patterns and isolating devices one at a time. Thus, A/V tools are of limited benefit, especially if users just ignore their messages like they usually do.

From CC: “Re: Validus handheld e-prescribing tool. Has been acquired, but they won’t say by whom. An employee told me and said it was hoped the news would not appear in HIStalk, but loyalty to HIStalk got the better of me.” I assume that’s Validus Medical Systems, quietly acquired by Imprivata in July 2011. They offered a mobile order entry app for hospital physicians that Imprivata either isn’t marketing or hasn’t repackaged yet since I see no mention on Imprivata’s site. We can take joint responsibility for disappointing the folks who hoped not to see the news here.

From Petaler Dan: “Re: Quebec’s medical error registry. Here’s news on how hospital mortality rates have fallen, although it doesn’t cover Quebec. And here’s Montreal coverage on the report and how mortality rates have decreased significantly — scroll toward the end for quotes on surgical checklist implementation, which is reassuring.”

From McKesson Horizon Client CIO: “Re: McKesson. To employees affected by this latest turn of events, you worked very hard over the last several years and your dedication to the customer base did not go unnoticed. You are collateral damage from mismanagement and lack of a principled leadership. For the patients you helped me and my team serve, thank you and best of luck.”

From Uggams: “Re: GE and Microsoft. This is a Microsoft healthcare surrender flag. Somehow they convinced GE to help them bury the bodies. Michael Simpson’s only relevant experience was running Horizon Clinicals for McKesson, ironically mercy-killed the same day he was announced as CEO of the new GE-Microsoft home for dying products. Sentillion had solid, well accepted products, but was especially aggrieved by the meddling of its Microsoft masters, and now they are cast aside with products and vague ideas that nobody cares about.” That’s the biggest disappointment to me. Microsoft had insinuated that Sentillion’s products would find mainstream Microsoft use. Now it’s relegated to the group that includes some GE-Intermountain screwing around that never seems to provide any real, marketable products (are those Intermountain-led Carecast enhancements just about done?) and some GE products that, to be honest, I’ve barely heard of. I don’t think anybody really believes that Microsoft is growing its healthcare business rather than retreating from it, so that leaves GE’s track record as a nimble innovator to make something happen. But I’m going to stop being cynical and give them six months to show some progress, with my hopes that they really can do it. We need some new stuff to talk about since Epic and Meaningful Use are getting repetitive.

From Ex-Tele: “Re: TeleTracking. Anthony Sanzo, former CEO of AHERF, has stepped down as CEO of TeleTracking.” Verified by a company spokesperson. A search is underway for his replacement. The interim CEO is Michael Zamagias (above), board chair of the company.

From Booth Monkey: “Re: Meditech exhibiting at HIMSS. Something must have happened to get them back in. As a silver corporate HIMSS sponsor with mega-sponsor points, those of us who worked our way to the top of the exhibit booth selection process would start over by dropping out, so look for them back on the corner wall by the bathrooms. So it is with those who dare to thumb their nose at HIMSS, as it was in the beginning, is now, and forever shall be, HIMSS without end.”

Listening: I was in the mood for some slow-dance kind of doo-wop, one of my favorite musical forms even though it was popular only before my time and most of the original performers are dead now. Among my favorites: The Passions, Earl Lewis & The Channels, The Schoolboys, The Skyliners, The Excellents, and The Shields. I always plan to listen to just one song and end up playing them all afternoon. It’s a triumphant and truly American form of vocalizing, drawing from gospel and rhythm and blues and performed by untrained, uneducated, largely forgotten blue-collar part-timers crossing every ethnic and racial line who were working for nothing because record companies were robbing them blind (for many of the records, the performers are anonymous because nobody at the studio cared enough to even write down their names.) I defy you to listen to The Closer You Are, Just to Be With You, or  My True Story without joining in with your own background harmonies.

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

We can learn two two facts from my last poll:  (a) around half of respondents went to the most recent HIMSS conference, and (b) about the same percentage will attend the next one. Not exactly earth-shattering news. New poll to your right: what do you think about McKesson’s Better Health 2020 plan as described by MPT President Dave Souerwine in my Friday interview? The great thing about having a lot of well-informed readers is that companies can get immediate and broad feedback that’s not available anywhere other than HIStalk, so here’s your chance to provide it (and feel free to leave comments on either the interview or the poll if you’d care to elaborate).

I don’t want to get into the placement business for displaced McKessonites who are among the announced 174 employees who may lose their jobs, but another company has already e-mailed me looking for high-level marketing people from there. E-mail me.

Speaking of HIMSS, HIStalkapalooza is on: Tuesday, February 21 at FIRST Food & Bar at The Palazzo in Las Vegas. I’ll have more later, including opening up of the invitation list sometime after New Year’s. Our soon-to-be-named sponsor is doing a great job with the planning and has bought the place out. We’re going for a fun but networking-friendly vibe. The stage show will include our King and Queen contests with Lindsay and Greg again; people running around in beauty queen sashes for no apparent reason; some kind of contest or charity fundraiser that Inga and Dr. Jayne are cooking up to which I’m not really privy (I suspect shoe-related activities, which is great for the guys since the ladies come dressed to kill); and of course the HISsies awards. Put it on your calendar and watch for the announcement in a few weeks.

My Time Capsule editorial this week from five years ago: Sounds Like Somebody’s Industry Has a Case of the Mondays. “Nobody seems to be innovating anything. Everybody claims big R&D spending, but the products are starting to all look alike, kind of a no-nonsense 1980s Soviet Union version of software by committee. Or it could be their customers, blaming everyone except themselves for poor ROI.”

Here’s a scoop from our official friends at Cerner: the company (like Meditech) will be exhibiting at the upcoming HIMSS conference after sitting out for a few years. I’ll be talking more with them soon to get the story. They said customers wanted to see them there, which doesn’t surprise me.

Quest’s Care360 EHR is named the top standalone e-prescribing platform by Black Book Rankings. Above is a demo of its iPad version, just because I happened to see it on YouTube and it’s new.

Some of my favorite “why doesn’t every vendor offer this” tools are plain old Google-like EMR search tools that physicians can use to get quick answers from electronic medical records. Mass General goes one step further with QPID, a semantically driven variant that can perform searches by concept and not just keyword.

Here’s an example of why you don’t want your company to go public: analysts warn Scottish CDM software vendor Craneware that if it doesn’t want to see its stock price drop, it needs to announce a big sale in the next three weeks. So is the message to give whatever ridiculous discount is required to convince a hesitant prospect to sign on the line which is dotted? Is that end-of-period timing so important that signing a money-losing contract quickly is still a good idea?

Here’s Vince’s latest HIS-tory, this time on boutique consulting firms. Dorenfest, Kennedy, Johnson, Weil, Levine … fascinating stuff. He names some 1985-era individual consultants and admits to never having heard of any of them – have you? It puts your own legacy and mortality in perspective when looking at names from just 25 years ago and wondering how their lives turned out, where they are today, and how their work fits against the backdrop of history.

Weird News Andy urges Hollywood to pay particular attention to this article since both smoking and breast enhancements are common there, fearing that the result during a strong wind could be “a nip in the air.” A plastic surgeon warns breast augmentation surgery patients to avoid smoking afterward since nicotine and carbon dioxide can disrupt blood flow and can “cause her nipples to turn black and fall off.” WNA also likes this story, even though he worries that patients might be admitted as brunettes and discharged as blondes: a new and promising method of room disinfection involves pumping ozone and hydrogen peroxide into a room to sterilize everything in it.

Inga asked our sponsors to share any charitable works, celebrations, or other notable holiday-related events going on at their places. Here’s one to get us started: BridgeHead Software and its 25 US employees donated $1,000 to Youth Villages Holiday Heroes, which matches the wish lists of disadvantaged children with sponsors who provide them. Kudos to them.

Employees of chiropractor PM/EMR vendor Redpine Healthcare Technology of Panama City, FL ask county commissioners to help them get overdue paychecks. The company’s CEO says he’s trying to find an investor, but employees were last seen packing up their cubes and nobody’s answering the phones. The county says it’s going after the $350K it gave the company to relocate there, which came with a guarantee the company would add at least 150 jobs over three years. The county has a lien on the software.

Struggling New River Behavioral HealthCare (NC), behind on payments to the guy who wrote some Meaningful Use enhancements for its eNotes mental health records system, faces loss of access to all of its records if it can’t pay up quickly.

Here’s one of the dumber articles that attempts to explain the Microsoft-GE JV. The article itself is obviously a typical no-value-added rewriting of the press release to make it sound like authoritative reporting, but how about that headline?

E-mail Mr. H.

Time Capsule: Sounds Like Somebody’s Industry Has a Case of the Mondays

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 December 2006.

Sounds Like Somebody’s Industry Has a Case of the Mondays
By Mr. HIStalk

Is it just me, or is the industry in the doldrums? The news is boring, optimism is in short supply, and both provider and vendor people seem to be uncharacteristically cranky and burned out.

What happened? Just a few months ago, we were on what looked like an unstoppable, exhilarating ride. Everybody was talking about healthcare IT and momentum seemed to be building toward something cool. Now we’re just trudging joylessly along.

Maybe everybody is just hunkering down to get the jobs done that were promised back then, moving us into the less-sexy execution phase from all the high-profile jabbering. That’s good, at least for awhile.

No, I think I’ll blame RHIOs for the industry’s malaise. Like a furnace in winter, it takes a lot of energy to keep that RHIO hot air flowing. Even though most of us don’t have anything to do with RHIOs, it seems like our collective focus has swarmed around them like mosquitoes to a bug zapper.

Or maybe it’s ambulatory EMRs. It is apparently the 11th commandment that ambulatory EMRs are to be “hot” and “inevitable,” except for the vast majority of physicians who still refuse to use them. Once again, we ground troops who are locked in long, desperate inpatient CPOE and clinical systems wars that were started before this latest round of new ideas were conceived have been forgotten, but we’re still holding our own deep behind enemy lines.

Speaking of which, maybe the big hospital applications vendors are bringing us down. Nobody seems to be innovating anything. Everybody claims big R&D spending, but the products are starting to all look alike, kind of a no-nonsense 1980s Soviet Union version of software by committee. Or it could be their customers, blaming everyone except themselves for poor ROI. Nobody’s shaking anybody up.

Maybe it’s the government. Brailer’s gone and no one wants his job, Hillary’s threatening to run for President, and the politicians who promised big IT spending took their (our) money elsewhere.

Company mergers and acquisitions … that’s the problem! Instead of highly strategic, widely cheered absorptions of great little companies by bigger and better ones that energize employees and shareholders, it’s mostly one boring and struggling company being acquired by another, with misplaced expectations of synergy.

Maybe it’s poor management or lack of real strategic planning that’s forcing a “work harder and like it” mindset, just as a new generation of workers makes it clear they won’t be motivated by fear or the desire to help a few company insiders line their pockets.

Whatever it is, I’d like to see it fixed. Not enough people are having fun in healthcare IT. They’re taking themselves too seriously, stifling their own creativity and everyone else’s, and breeding a risk-averse culture that’s exactly what we don’t need just as the world realizes we’re 20 years behind. We’ve got a bunch of self-important stiffs in suits and no one wearing lampshades on their heads, more like General Motors than Google.

If you’re a person or a company with fresh ideas, a sense of humor, endless creativity and resourcefulness, and a passion for patient care, we need you desperately. Bring on your innovation, new ways of looking at old problems, and a passion for doing something other than propping up the company’s stock price.

Like the line from the movie Office Space, I think somebody’s having a case of the Mondays. Lately in healthcare IT, it’s been lasting seven days a week. Still, as it always does, this too will pass.

HIStalk Interviews Dave Souerwine, President, McKesson Provider Technologies

David A. Souerwine is president of McKesson Provider Technologies.

Tell me about the impact of the just-announced Better Health 2020 program on McKesson’s IT investments and portfolio.

I know you’re pretty conversant in this space, obviously, so I’ll tell you some things you probably know. If I was asked that question by a less-informed person, I think I’d give it some broader perspective.

There’s a huge amount of focus that a lot of people give to HIS/CIS, or what a lot of people call core hospital systems. A lot of what we announced in MPT was around products in those two areas. But more broadly, what McKesson has been attempting to do over a long period of time is to create an entire technology portfolio that’s second to nobody in the industry. We’re now very focused on trying to develop products and services that will best meet healthcare reform and all the various regulatory requirements that are hitting not only our hospital customers, but because of the blurring of settings of care, also for physicians, for long-term care, for home care.

We have a large payer business. We have a large connectivity business, both in clinicals and financials. We have a connectivity business in pharmacy, which a lot of people know, but a lot don’t. We handle about 90% of all the pharmacy transactions in the country on a daily basis, so it’s a huge volume business.

The announcements that you’re now familiar with and that some of your readers started to comment on yesterday wrapped underneath a broad McKesson Technology Solutions banner that we’re calling Better Health 2020. You can interpret the 2020 as either a decade from now, where we’re trying to help customers in a very uncertain environment navigate to the best financial and clinical endpoints they can, or you could also interpret as good vision, 20/20. We think we’ve got a good sense of where the market’s leading and progressing and what we need to do to help our customers get there.

The broad agenda, Better Health as a corporate communications platform, refers to better business, better care, and better connectivity. Those are the three broad planks. I’m sure you’ve undoubtedly seen either our employee letter or our customer letter, which are pretty similar. Underneath that, we went on in those letters to describe four areas that we believe are critical success factors.

The first one is the ability to improve patient safety and deliver better clinical and financial outcomes through fully integrated core clinical and revenue cycle IT systems with a highly competitive total cost of ownership.

The second one is a reduction cost of operations, which includes pharmacy automation, supply chain analytics, and performance management.

Third is better care coordination through connectivity across the healthcare ecosystem of diverse stakeholders and IT systems.

The fourth is the ability to manage increasing complexity and risk, bundled payments, and structural relationships, because our view is there’s a lot of experimentation that’s currently going on in payment solutions, but the risk is definitely shifting towards the provider and potentially hospitals. Our customers are going to have to survive on Medicare levels of reimbursement. There’s a shortage of personnel. They’re going to have to take costs out continually. We have to have a lot of assets helping them manage through that complexity and risk.

On Better Health 2020, the other major part of that announcement was a commitment that we have across our technology businesses. It’s not an investment in Paragon or Horizon or any particular application. It’s a commitment across all of our technology assets to invest a billion dollars in research and development over the next two years, which is a really big commitment in this area.

We are sunsetting no products. We have several products outside our core clinical suite. At one time, we had renamed a lot of our imaging products under the Horizon banner. We have several that now reside in a performance management business and in our analytics capability that are called Horizon. Over the next few months, which we already had underway before these decisions were made, we’re renaming them under the McKesson brand name, just so that there’s not confusion in the marketplace related to Horizon core clinicals.

The changes that we made in strategy were just around that core clinical suite, which we put into hospitals. It’s about 30 different products that we sell under that Horizon brand name. Those are the ones where we’re making a strategic shift away from Horizon to Paragon, but nothing is being sunsetted.

In fact, I’ve gotten several questions, including from my own employees, about the relative investment. We’re continuing next year to put more into the Horizon clinical suite than we are into Paragon. There’s still a big amount of money that’s being spent beyond Horizon. We want to leave our customers with options. If they want to stay on Horizon, they certainly can. If they want to switch to Paragon now, they can. If they want to wait and assess how that roadmap develops over the next 30-36 months, they can. That product will be around for a long time. We’ve made no firm decisions on end dates or sunsetting in any way, shape, or form.

You mentioned a reduction in total costs for customers. I got the impression that there might be some bundling of McKesson offerings under an umbrella that will collectively reduce costs.

I’m not sure what that reference is to. We would tell you that we believe with certainty that the total cost of ownership for Paragon as a hospital HIS will be less than Horizon and will be less than Cerner and will be less than Epic. There’s nothing that’s changed internally in terms of corporate structure or movement of products between or amongst divisions that would create any kind of bundling. The customer still has the ability to choose solutions that are right for either gaps in their current portfolio, or if they want more capability from one vendor, we would portray that we have the broadest selection. You can get connectivity, population management, risk management, care coordination, analytics, and your HIS from one place, which is McKesson Technology Solutions.

The billion dollars in R&D that you said was collective across all the platforms. How much more is that than you’re spending now?

The reason we positioned it that way is there’s a huge commitment that the corporation is making. It’s larger than what’s been spent in the past, but I want to draw the distinction that it’s not an incremental billion, it’s just larger than it’s been in the past. It encompasses McKesson Provider Technologies, RelayHealth, and our health solutions payer and physician business. It’s all the technology components.

That said, the majority of that expense will be in MPT. MPT includes six business units. The Paragon business unit. Health Systems Enterprise Solutions, which encompasses the legacy as well as Horizon Revenue Cycle and also the Horizon Clinicals business. It’s our enterprise imaging business, which is out of Vancouver. It’s pharmacy automation, which is out of Pittsburgh. It’s Health Systems Performance and Analytics, which is a separate business unit that we stood up at the end of last year to help customers get a cost efficiency and reduction. And then we have a managed services business, which includes hardware, outsourcing, and remote hosting that cuts across all of those offerings for MPT. It’s not a homogenous thing, it’s actually six business units that we put under the Provider Technologies banner.

Is the billion dollars double what it’s been, or something less? I’m trying to get a feel for the magnitude of increase.

It’s not double. It is an increase.

Sorry, I interrupted you there.

Within MPT, I would tell you that the five key messages that came out of the change from yesterday are the commitment in R&D underneath the Better Health 2020 banner . Within MPT, we’re planning to converge our revenue cycle core clinical solutions around Paragon’s Microsoft platform. We’ll significantly increase the investment in that platform. We’re finding it increasingly difficult and not in the best service of our customer needs to continue to develop two very complete clinical and revenue cycle systems. They’re on two very different platforms.

All the Horizon stuff is on Java and Oracle, so it has a higher total cost of ownership. The evolution of that product was around very fully functionally rich products in an environment where a lot of hospitals were making decisions on a best-of-breed basis. We’re finding today almost all customers are making combined decisions to get to an integrated clinical and revenue cycle platform. The decision was largely around how do we get more focus on our investment to reach product endpoints that will serve the needs of the customer better.

You know through a lot of the comments on your own blog that we have struggled with the Horizon upgrades and some of the product commitments over the past five years that we’ve made to the marketplace. We just believe we’re going to get to a fully integrated, lower total cost of ownership, fully functional solution for customers that’s completely competitive in the market with the Paragon solution as the basis rather than continue to invest in two completely functional HIS/CIS.

There’s been some question around when we say converge, are you really putting the platforms together? No. The convergence is really around taking the best capabilities from Paragon and the best capabilities from Horizon and creating one integrated system with a lower total cost of ownership than what we have today.

The third key message from yesterday was that based on that decision, we have stopped development on Horizon Enterprise Revenue Management, which was a separate R&D project that’s about seven years old, maybe eight. It’s been going on for a while. That was just based on we believe with the capabilities Paragon has today, plus some fairly minor enhancements, that we can get a capability that’s integrated with a lower total cost of ownership in a shorter period of time than we’d have gotten customers there under the Horizon architecture. We haven’t shifted away from next-generation revenue cycle, we’ve just shifted to putting it on Microsoft architecture. Most of the products under Technology Solutions, about 70% of capability today, is also on Microsoft architecture, so we’re just trying to get synergies and better integration points across all of our solution set and that will become a higher percentage in the future.

The fourth thing that we’re trying to make very clear, particularly to our Horizon customers, is that we remain fully committed to the Horizon base. There’s a huge amount of work to be done there, including getting those customers to be ICD-10 compliant and then getting them through the various stages of Meaningful Use, which we are continued to be committed to do. We’re not sunsetting anything. We will actually spend a huge amount of resource developing those capabilities and getting our customer base upgraded over the next three or four years.

The fifth message is that we’re more confident than ever that we’re in a position to get our customers through Meaningful Use and will better position them than we believe anyone else in in the market, in terms of capabilities from one company, to get our customers through Stage 3. We believe that with our R&D focus now shifting to what’s next, that we’ll be able to continue to invest and improve deployability and support for them today and much enhanced capabilities in the future.

The CIOs that I talk to say time and again when I ask them, “Why are you buying Epic?” — and cost doesn’t seem important to them — it’s because it’s the only vendor with a single patient record that not only crosses ambulatory and the inpatient sides of the house, but also has top-ranked modules on both sides. Can Paragon deliver that?

We believe so. There’s a detailed roadmap. Paragon today is probably a lot more capable than people realize. It’s been best in KLAS for the last five years. We suspect it will win shortly for the sixth year in a row. It has a really high customer acceptance and rating. It scales up, so they also have larger customers today.

We went through a lot of work over the last year to make sure that we had line of sight so that features and functions and just general capability, including technology, that was going to be necessary to be able to claim that this was competitive with Cerner and Epic’s capabilities in this space. We think we will get there. By the time anybody starting today would be able to convert to Paragon, even if they made an immediate decision, the emergency room and ambulatory features of Paragon will be completed. It’s very capable today.

If a customer wants imaging capability or automation capability or analytic capability or health information exchange capability, we can attach McKesson solutions directly to Paragon to do that. They have a very high attachment rate of our other solutions, and those will continue to be more integrated into Paragon as time progresses .

Is anything actually being created from scratch? It sounds like there’s some porting of functionality from Horizon to Paragon and adding some modules. The criticism of McKesson is that they never build anything, they just keep tweaking the same old stuff except for the example of HERM, which was a pretty expensive failure, at least other than the intellectual material from it that you can port to different technologies. Are you building brand new, from-scratch products?

Two different answers to that question. One is that a lot of the individual application modules inside of Horizon Clinicals were variations in products that had been purchased and put into the Horizon Clinicals suite. I think that’s where the perception comes from that we don’t build anything from scratch. Some of that stuff was built, but a lot of it was purchased and put into that suite.

The development of the current version of Paragon started 11 years ago and all those applications were natively created. That stuff was built. There’s been nothing that’s been purchased. It’s been built in a way so that it’s on one database. It is fully integrated. It’s what I’m sure you over and over have heard Horizon customers asking for — how do we get to true integration and how do we get lower total cost of ownership and how do we get to an easier upgrade path?

Our customers can download whatever upgrades they need from a capability that we have internally called Download Central. They put it into their test environment, they test it until they’re satisfied with it, it moves into production. It’s not an invasive process. It doesn’t require a lot of support people to be on site. You know the experience on the Horizon side is quite different from that.

I wanted to point to you too that when I was flying back from Colorado, I saw a comment, I don’t know if it was from you or one of your readers, but the HERM decision was not around the failure of that product. We actually believe we could have gotten to a successful solution, but with the capabilities and rev cycle that we already have inside of Paragon, we didn’t see a reason to continue to rewrite the Horizon version of that product.

For the people that were affected by that decision, there is a redeployment process inside the company that started with the announcement yesterday and goes through next week. There’s openings in many different parts of our technology businesses and we believe that we’ll be able to redeploy many of those people into other areas of the company.

Just like always happens, when jobs are open and an employee wants to move from Charlotte to Alpharetta or vice versa, or they want to relocate from Colorado to Alpharetta or vice versa, there’s a relocation policy that does that if they apply for an open position. We would consider them. The downsizing happened because of the strategic decision to just focus on the one platform, but that does not mean that the people that have good capabilities that want to stay with the company will be displaced.

Do you have a feeling for the specifics of how many people will be RIFed out and how the total headcount will change?

There was a public filing, which we’re required to make, that talked about how 174 people were displaced on that team. That’s how many were actioned that first day.

We have more than that many openings in our technology businesses. It’s going to be a matter of their level of interest, if they decide to stay, whether they’ve got requisite skills to fit into those areas. We have onsite hiring managers form the businesses with openings to talk to those people starting next Tuesday. We believe that we’ll be able to redeploy many of them.

From a timing perspective, it’s somewhat late in the Meaningful Use game and Epic pretty much owns the high-end market and seems to be quickly moving down the scale to the smaller bed ranges that most people thought they would never bother with. When do you think the results of these changes, both the product changes and the packaging changes to get them in front of additional prospects, how long will that take and what will the competitive landscape look like?

The technology roadmap that we’ve created is a 30-month development. The Paragon product has gotten progressively better continually over time, so a lot of the customers that made decisions made them at a time when we didn’t even have HEO or we didn’t have an order entry system for physicians. They bought it, it came out on time, it’s gone in, the adoption rate of the physicians is very high. Same thing with a lot of the other modules. The emergency room integrated module will be GA’ed around the end of our fiscal year, which is March-April of 2012. Ambulatory is about a year and a half out.

Logically, by the time customers could make decisions, either new customers or decisions to switch, when they got onto the full suite of products through the implementation cycle, those modules would be completed and ready. There’s a really solid track record of developing and delivering on that platform.

In terms of how the market’s going to evolve, I think most of the clinical decisions have been made. I certainly wouldn’t take anything away from Epic. We know what their success rate has been and they’re well respected in the market. We would also tell you, though, that we believe our analytics capabilities, especially as we head into Meaningful Use 3 — and we don’t know if there will be stages beyond that — our capability for health information exchange, our health management, population management, are some of the aspects that we think are going to be central to both later stages of Meaningful Use and health reform are capabilities that McKesson has that our competitors do not.

It’s a balance. There’s lots of Epic customers today that have our analytics. There’s lots of Epic customers that put in Epic and have Horizon Lab, because it’s a really robust system. They don’t offer imaging, so if you want radiology or cardiology, we’re going to be your best bet in this space. It’s a mixed bag. They clearly understood the dynamic of ambulatory and physician side of the market ahead of what other people did and did a really good job in capitalizing on that, no doubt about it.

You mentioned that lot of customers have already chosen their dance partner and spent a lot of money to be in an early stage stage of implementation. A strong selling point that you’re emphasizing is total cost of ownership, and people have questioned whether these hospitals can really afford Epic and Cerner long term. Do you think that to be successful you’ll need to take customers back from them based on price?

I think total cost of ownership is going to become an increasing issue as we go forward. You’ve got a lot of factors coming into play at the same time. We’ve got a really crappy macroeconomic environment, which in my view, whether you believe there’s going to be a double-dip recession or whether that’s already occurred, I don’t think anybody is optimistic about a strong recovery anytime soon. There will continue to be a lot of pressure on capital availability and deployment. You’ve got a shortage of personnel. You’ve got all of these health reform changes and regulatory changes coming at these hospitals. It will be difficult for them to navigate.

The modeling, the data collection that we’ve done shows that an ongoing clinical decision rate will continue in the market, if you look at all 5,000 hospitals, at around 3.5 – 4%.  It will continue to be 150 to 200 decisions a year in clinicals. Financials are likely to accelerate once people get beyond Meaningful Use 3 and ICD-10. A lot of customers are continuing to use whatever financial systems or revenue cycle systems they have in place because they’re focused on clinical, but there will be a point coming soon where they’ll be making a different financials decision, a lot of times in convergence with whoever they’ve decided on for clinicals.

What goals do you have for MPT in the next five years?

It’s really goals for MTS. I wouldn’t answer for MPT. I think the big shift, a lot of which has been driven by the market, is five years ago or maybe even three years ago, if you were talking to one of my predecessors in MPT, they would have told you that MPT is a hospital software company. I don’t think anybody can be segment specific. The blurring of the settings of care, all of the vendors are going to have to be a lot more aware of what the patient and clinician experience is wherever it is that either the clinician is delivering care or the patient is receiving it.

There’s going to be some mixed models. Who would have thought that Walmart would be getting into direct care? Who would have thought that payors would be purchasing physician practices? I think there’s going to be that experimentation over time and some form of consolidation. Our goal across the technology businesses is to deliver the most capabilities that we can to support what all these customers are going to need as health reform evolves.

I couldn’t for a minute tell you that McKesson or I have the answers. We don’t have a better Ouija board than anybody. We’re just trying to stay as close as we can to the trend. Accountable care is another great example. Whether or not accountable care organizations in the legal entity sense actually end up developing or not, customers are going to need the capability of accountable care just to meet health reform. We believe we’ve got most of that capability that they’re going to need today and it’s just going to get stronger in the future.

News 12/9/11

Top News

Microsoft and GE announce the formation of a joint venture company that will take over most of the people and assets of the Microsoft Health Solutions Group along with specific GE Healthcare products. See the HIStalk story from early Thursday, which includes insights from interviews with the key executives involved.

Reader Comments

From Curious Reader: “Re: Black Book Rankings. I am confused about Black Book’s results. Do they break out their ratings by hospital size? CPSI usually sells to community hospitals, not the same ones Epic sells to. I don’t know how those are comparable. How is Black Book even defining and EMR? Picis is a surgery and anesthesia vendor — they don’t really have an EMR system.” This report includes multiple categories including under 100-bed hospitals, community hospitals, large hospitals, health systems, and EDs. Per Black Book’s website, the rankings are based on survey results that cover 18 performance areas. To make the Top 20 list, vendors must have at least 10 unique clients participate. Results for these ratings were based on 12,075 validated responses. There is no mention on how an EMR is defined, though it may be included in the full report. In you need to further satisfy your curiosity, you can purchase a report for $3,250, but note it will only include details on a single category and not all the inpatient EHR categories.

From EMR Wannabe: “Re: GE and Microsoft. From trying to work with it, I know that Amalga UIS is an overly complicated hairball. I wasn’t sure about Qualibria, although last year when I asked a GE team how the knowledge project with Intermountain Health was going, they just broke into laughter and said, ‘depends who you ask.’ I said, ‘Well, I’m asking you,’ to which they took the Fifth (amendment, not bottle). Now with this announcement, we can see that Microsoft and GE decided to combine, and then bury, their respective dead or dying.” Amalga seems cool, but I don’t hear much from its customers once they’ve signed contracts, so NewCo should work to get the word out. I hope the companies really are planning to do something innovative like the announcement says. However, those with long memories will find it hard to forget (or forgive) historical examples of big, unfocused vendors who brashly stormed the HIT gates and then slunk off quietly shortly thereafter, unceremoniously dumping the charred remains of once-proud companies they had burned through and hoping the smell of utter failure would wash out of their Teflon-coated corporate suits. Recall when Baxter and IBM formed IBAX and quickly sold it off to HBOC, relieved to put distance between themselves and the albatross they had spawned from their passionate but short-lived union by creating a new company and not really caring whether it succeeded or failed.

From SmallMe: “RE: Microsoft HSG. Major RIF and re-org in advance of the HSG/GE joint venture announcement.” According to our Microsoft contact that I asked to confirm, “Like all companies, Microsoft evaluates our business priorities regularly. As we evolve HSG’s strategy, we’re concentrating more on building a compelling platform and have eliminated a small number of positions to align with current priorities.”  

From EthicsInHealthcareBusiness: “Re: RSNA. I’m surprised there isn’t more stringent hiring vetting by big vendors. Take the example of [vendor VP name omitted], who while at [vendor name omitted] was named in a federal lawsuit (CIVIL NO. 2004-116) accusing him of fraudulent pricing in dealings with government purchasing agents. The lawsuit was dismissed on a technicality, but it drove a parallel criminal investigation by the Defense Department and the US attorney’s office in Philadelphia. Why would a company risk this potential liability?” I omitted the specifics since, as you said, the lawsuit was dismissed and his innocence must be presumed. If he’s found guilty by the Feds, I’ll name names. His previous employer was known both globally and historically for shameful bribery. I blurred their name only a little above, but enough to say I didn’t unfairly name the company specifically.

From Erik: “Re: McKesson. Halting all development of Horizon Clinicals 10.3 and deployment of Horizon Enterprise Revenue Manager.” Unverified. I got several e-mails from MCK employees Thursday morning that a company call was in progress (our readers are so loyal I’m surprised they didn’t conference us in.) Inga asked what was up and I told her if I had to guess, I would say MCK is either killing off Horizon or moving its revenue cycle efforts from HERM to Paragon since both had been rumored previously. I’ll be crowing to her endlessly if both guesses are correct, although I must credit readers who reported those possibilities to me in the first place starting many months ago. I’ll know more Friday, as McKesson Provider Technologies President Dave Souerwine asked to brief me. Unfortunately it will be late in the afternoon since I have to get home after work from the hospital to do it (darned day job!), but I’ll recap in the Monday Morning Update if not before.

From MCKWorker: “Re: McKesson. All HERM staff essentially laid off. New direction for development, to combine with Paragon. HERM employees will have 60 days to interview for positions with that new strategy.” Unverified. It’s funny that Inga pinged a couple of her MCK sources and they told her company bigwigs had warned them that HIStalk would be probing for information. They were correct. Inga and I were flattered, even though the compliment was almost certainly unintentional. Apparently they weren’t too worried about anyone but us being on top of the breaking news and caring enough to dig beyond any official announcement.

 From Must Remain Anonymous: “Re: McKesson. It has finally happened! The call came today that McKesson will cease development of its Horizon product. All support will stop in seven years. Product development will now focus on the Paragon application instead. To be announced to their physician advisory council tomorrow morning. It is about time that McKesson drops the dead weight.” Unverified, until Friday anyway. If true, that would be truly remarkable given that Paragon has been close to being killed off several times, as Vince has explained in his HIS-tory lessons. Horizon has ample problems, but to think of Paragon as MPT’s flagship product is a mind-bender. If true, kudos to that little engine that could for hanging in there, excelling over and over, and giving the company an overachieving understudy for when its star couldn’t make curtain call.

And lest we forget among the corporate announcements from the several companies mentioned here, there are people behind these decisions, grunts like you and me who leave their families every day to do the best job they can, competently even though their expertise is related to products no longer in favor, who are torn with worry about their future livelihoods that are being manipulated invisibly by factors entirely beyond their control as corporate drones judge them unfairly on what they do today rather than their ability to contribute in a different way tomorrow (I hate that about corporate BS more than anything). Right now, they’re putting on a game face to try to make a nice Christmas or Hanukkah for their kids and families without seeming too preoccupied by work stuff that shouldn’t be intruding on their celebrations and religious observations, but at night when the lights go out, they are sleepless in contemplating what could change for them and those who depend on them. Join me in beaming some positive thoughts their way because I’m guessing they could use them right about now. I’ve been there and it sucks, but it eventually gets better.

From Kurt: “Re: McKesson. I’m hearing they announced that they are spending $1 billion in healthcare IT. Is this correct? If so, this is more than most other vendors combined.” I’ll let you know soon. That sounds like an awfully large number even for a company of McKesson’s size, but I’m not ruling anything out. If they asked me for advice (not likely), I’d say they should show some leadership (meaning spend money) in building innovative solutions that will make their HIT presence respectable (i.e., high KLAS scores and a growing customer base), unlike their fellow conglomerate vendors that seem to be happy milking the wrinkled, desiccated udders of their thinning herds of malnourished and badly aging cash cows. In McKesson’s defense, they did make a huge investment (and later write-down, unfortunately) in developing HERM, so give them some credit for taking action, even if the result wasn’t what they had hoped. Corporate management has changed since then (and probably for that reason), so perhaps the environment is more conducive to nimble innovation now. I’d have to see that to believe it since it’s a rarity in a huge, publicly traded company.

From Leotardo: “Re: Epic in the UK. Old news?” Two big-name English hospital trusts name their short list of potential post-NPfIT EMR vendors: Cerner, Epic, and Allscripts. The report says that “Epic is known to have invested heavily in the Cambridge procurement.” The Brits had better price out flights from London to Madison before finalizing a budget since they would be creating a massive carbon footprint for the endless mandatory training visits. Britain was one of few places where Cerner could pursue business knowing that Epic wouldn’t be sitting across the table, so news of an Epic win would not be celebrated in KCMO. And if Epic loses, that would be even bigger news since they usually don’t.

From Wildcat Well: “Re: Costco selling Allscripts MyWay. Isn’t that an insult to every EHR sales rep out there? What exactly will Allscripts sales reps do now? The EMR adoption bubble is developing a very short shelf life.”

From JB: “Re: Epic. I think this job would be humorous to highlight.” Epic hires only fresh-from-college greenhorns, so if you are experienced in healthcare IT, informatics, consulting, or process re-engineering, this is your one chance to get your foot in the Star Trek-themed door. I wonder how many Epic dishwashers have passed the company’s notorious MUMPS programming test?

From Poutine: “Re: Quebec’s medical error registry. Finally done after being promised in 2002, but not getting provider data.” Provider error reporting is mandatory, but a third of them submitted incomplete information, while nine hospitals claimed “technical difficulties” that prevented them from filing even one report.

From Skeptic: “Re: Micky Tripathi’s breach article. Part of me says. ‘Well done for a conscientious job.’ It’s not as if the folks involved had much of a choice in how to respond if they wanted to be law-abiding and careful stewards of the cards handed them by our system. The rest of me says. ‘This is insane.’ A street thief  steals a laptop and there is ‘an infinitesimally small chance’ the information would be accessed and/or abused. We spend $300K direct dollars and another large chunk of internal time — not to mention hours spent on the government regulatory side — addressing it, after which the thug still has the laptop and the exposure is still infinitesimally small. How much will we spend when the risk is real? And the lesson learned is that we all need to behave even more carefully and institute even more policies. This is great news for security companies, government agencies, and regulators. It’s horrible news for patients. Every dollar we spend on this kind of craziness is a dollar not available for patient care. At present, we’ve managed to construct a ridiculously expensive system relative to actual care delivered. This is an index case of how we’ve done it. (a) lesson one: no amount of anything is going to prevent this sort of thing. That’s not an excuse to be careless, but we need to use some common sense when applying blame. This blame falls on the thief. Period. (b) lesson two: the most sensitive data the healthcare system owns is financial. Identity theft is worth cash; PHI is close to worthless despite the paranoia surrounding it. We need to find ways to universally encrypt ADT/financial information and to not bind it so tightly to PHI. (c) lesson three: if we want to deliver better healthcare, there are better places to spend our patients’ money.”

HIStalk Announcements and Requests

Thanks to Micky Tripathi’s outstanding contribution on his organization’s patient data security breach, traffic on HIStalk Practice has been especially heavy this week. We’ve posted a number of other great items over the last week including Brad Boyd’s discussion on the need for clinically integrated organizations. Other news bits of note: CMS releases a well done MU toolkit for providers. Physicians are fairly unaware of ACOs and don’t know if they should join one. Only 4% of all eligible providers have been paid incentives for meaningful EMR use. Physician wait times are shortest in Wisconsin and longest in Mississippi. Requests: (a) read HIStalk Practice regularly because it thrills me to know that my father is not the only one tuning in; (b) next time you need to purchase something HIT-related, consider the offerings of our sponsors; and (c) sign up for HIStalk Practice e-mail updates because I love knowing that I am not the only one with an overflowing inbox. Thanks for reading.

On the Jobs Board: Manager of Professional Services, Senior Trainer, Senior Software Engineer. On Healthcare IT Jobs: NextGen Workflow Process Consultants, EMR Application Specialist, Technical Services Manager.

Inga, Dr. Jayne, and I take risks writing HIStalk. We could get fired from our real jobs if unhappy companies figure out who we are and complain to our bosses about something we’ve said about them. We could lose sponsors for reporting news objectively and stating our opinions honestly (GE, Microsoft, and McKesson are all HIStalk sponsors, for a current example, but we still have to say what we think or else we’d be just another rag that uncritically spews vendor-friendly non-news). We could lose long- or short-term significant others because we sit in front of computers way too much, or risk letting life pass us by as we fixate on the relatively tiny topic of healthcare IT after spending already-long days at work (tonight’s HIStalk took me 5.5 hours, so my total non-work time in the past 24 hours, including sleep, was about six hours.) If you want to provide some reward to offset that risk, (a) sign up for e-mail updates for HIStalk, HIStalk Practice, and HIStalk Mobile; (b) connect with us on Facebook and LinkedIn; (c) support our sponsors, especially those we have to occasionally say negative things about, by clicking their ads, checking them out in the searchable, indexed Resource Center, and sending them consulting RFIs; (d) send us rumors, news we might have missed, and updates on what’s going on where you work; and (e) help us find the good news of IT helping patients, IT people doing commendable work, and IT companies innovating and making a difference. Thanks for being part of what we do, which means you’re actually part of who we are.

Acquisitions, Funding, Business, and Stock

A day after we (and thus you) were tipped off by HIStalk reader Elroy, Streamline Health Solutions announces that it has signed a definitive asset purchase agreement to acquire Interpoint Partners for $5 million. We like to think they had to fast-track the announcement because of Elroy’s rumor report.

Humana acquires healthcare analytics company Anvita Health.

Sales

The federal government awards McKesson Provider Technologies its DIN PACS III contract, allowing it to sell PACS and related sub-systems to all branches of the US armed forces and civilian defense department agency facilities. The two-year contract has a potential value of $30 million.

Morehead Memorial Hospital (NC) selects Unidesk for desktop provisioning and application delivery for its VMware-based Virtual Desktop Infrastructure.

Meridian Health (NJ) to ICA’s CareAlign 3.0 for its 95 locations.

Group Health Cooperative of South Central Wisconsin and Group Health Cooperative of Eau Claire (WI) select McKesson Analytics Advisor.

Tidewell Hospice (FL) chooses Allscripts Homecare and EPSi financial management.

China-based diagnostic testing vendor Kindstar Globagene Technology chooses PathCentral’s anatomic pathology system for its 2,000 hospital customers in China.

Personal health record vendor MMRGlobal, which runs the MyMedicalRecords.com site, says Surgery Center Management has offered $30 million to license its patents for the PHR, patient video site, and document management system for providers.

CSC says it expects its NPfIT contract will be extended by an extra year through 2017, despite the company’s past problems delivering implementations on schedule that contributed to the cancellation of the $19 billion project. CSC expects to earn up to $3 billion for the 12-month extension. The former CIO said CSC would probably sue if its contract was cancelled, concluding that it might be cheaper just to pay them.

People

Medical documentation software provider Emdat hires Michael Grayson (Eclipsys, Sentillion, IDX) as VP of strategic partnerships.

HIMSS adds four members to its board of directors: Dana Alexander, RN, MSN, MBA, FHIMSS (GE Healthcare); Brian R. Jacobs, MD, MS, FHIMSS (Children’s National Medical Center, DC); Kenneth R. Ong, MD, MPH, FACP, FIDSA, FHIMSS (New York Hospital Queens); and Fred D. Rachman, MD, FHIMSS (Alliance of Chicago Community Health Services.)

Encore Health Resources expands its client services leadership team with the hiring of Greg Bluth, Ken Frantz, Jason Griffin, and Jim Kearns.

MED3OOO’s board of directors promotes Carl Smollinger from executive VP of ACO and employer services to COO.

Announcements and Implementations

NYU Langone Medical Center implements IOD’s release of information solution.

Wolters Kluwer Health releases its expanded IPhone app, UpToDate MobileComplete.

University Behavioral HealthCare (NJ) goes live on Stockell Healthcare Systems’ InsightCS Revenue Cycle Information Management platform.

DrFirst partners with Atlas Medical to offer physicians the ability to place lab/rad orders and review results via DrFirst’s Rcopia e-prescribing solution.

Government and Politics

Medicare and Medicaid have paid 2,868 hospitals and 21,425 EPs approximately $1.8 million for the Meaningful Use of EHRs through the end of November.

Dr. Jayne mentions below, but here’s a list of all Medicare EPs who have received HITECH money through September 30.

The State Department and the US Coast Guard sign an interagency agreement to share Epic’s EHR and access to VLER, the EHR used by the US Armed Forces EHR for its current and retired members.

Other

VA employee unions raise concerns that a plan to add RTLS technology will lead to staff monitoring. The VA is issuing a $550 million draft request for proposals for RTLS to interface with cleaning and sterilization equipment. The department claims it has no official plans to tag and track employees. One union representative views any plans to use RTLS to track employees as “the beginning of Big Brother” and “and invasion of privacy.”

Meditech announces it will return to the HIMSS conference this year as an exhibitor. In looking at the HIMSS conference site, it does not appear that Cerner will be following Meditech’s lead in coming back.

Programmers world-wide celebrated last weekend with Random Hacks of Kindness, where self-proclaimed hackers developed programs for humanitarian purposes. Among them were an emergency response system for the Samoan Islands, a real-time disease tracking system, and an app that can scan a photo of water-borne bacteria to determine if it’s safe to drink.

The FBI subpoenas several businesses in its investigation into the financial dealings of Wayne County, MI. Among the companies whose contracts are being reviewed is Strategic Business Partners, a Detroit IT company that has billed the county for $22 million over several years, some of that for developing EMR software for the county jail.

A hospital in Canada being sued for malpractice by a patient who suffered a stroke during surgery tries to convince a judge to give it access to the patient’s Facebook and Twitter accounts, her computer, and her iPhone. The hospital’s argument was that since the patient claims her health and enjoyment of life had been harmed, they should be able to look for evidence to the contrary. The judge said no, calling it “ a classic fishing expedition without the appropriate bait.”

Sponsor Updates

• The Advisory Board Company’s Crimson business unit wins the Best Booth award at the IHI forum in Orlando, with recognition of its employees for their knowledge and demonstration skills.
• GE Healthcare releases a white paper that highlights the use of Centricity Practice Solution to achieve Meaningful Use requirements.
• Healthwise launches Healthwise Spanish Knowledgebase, which includes evidence-based health information.
• Symantec Health and DrFirst will present at April’s EPCS Leadership Symposium.
• Blanton Godfrey, co-founder of the Institute for Healthcare Improvement, keynotes at TeleTracking Technologies’ 2011 Client Conference and predicts that better workflow choices will determine winners and losers after health reform.
• DIVURGENT releases a white paper on the selection of the right IT infrastructure for ACOs.
• The Irish Health Service Executive announces that four of its 35 hospitals are live on McKesson’s Horizon Medical Imaging PACS, with the remainder coming up within 20 months.
• T-System’s CMIO Robert Hitchcock MD and CFO Steve Armond CFO discuss how to use IT to make an emergency department profitable.
• Lawson Software introduces Infor10 Lawson S3, which includes integration between Lawson technology and products and applications from its newly acquired company Infor.
• e-MDs customer James F. Holsinger, MD, PC wins the 2011 HIMSS Ambulatory Davies Award of Excellence for the quality of patient care through practice’s Meaningful Use of EHR.
• MedVentive was selected to participate in last month’s Mid-West BluePrint Health IT Innovation Exchange Summit.
• Intelligent InSites posts congratulations to President and CEO Doug Burgum, who is also chairman of the board of the SuccessFactors, just acquired by SAP for $3.4 billion. He was also an early investor and leader of Great Plains Software, which Microsoft acquired for $1.1 billion in 2001.

Contacts

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

Microsoft, GE Form Healthcare Joint Venture

Microsoft and GE Healthcare announced this morning that the companies will form a joint venture, creating a new company that will offer software tools for managing population health to improve outcomes and cost.

Microsoft will move its Health Solutions Group employees and assets to the new company, effectively ending its direct involvement in provider healthcare technology. Corporate Vice President Peter Neupert announced his retirement from Microsoft.

The new company, which has yet to be named, will be launched in the first half of 2012. Microsoft will contribute its Amalga health intelligence platform, the Vergence context management and single sign-on solution, and the expreSSO enterprise single sign-on product to the joint venture. Those products had been acquired from MedStar Health (Azyxxi) in 2006 and Sentillion (Vergence, expreSSO) in 2009.

Microsoft HSG’s hospital systems product line that was acquired from Thailand-based Global Care Solutions in 2007 had already been retired, but was sold to Orion Health in October 2011.

GE Healthcare will provide its eHealth HIE and the Qualibria clinical knowledge application that it is developing with Intermountain Healthcare. 

In an interview with HIStalk, Neupert said the bulk of HSG employees will be transferred to the new company, joining those GE Healthcare employees who are assigned to the eHealth and Qualibria projects for an initial headcount of 700. The company’s headquarters will be in Redmond, WA.

Microsoft’s HealthVault will not be part of the joint venture, Neupert told us, explaining that HealthVault needs to remain “independent and consumer-facing.”

The announcement states that the new company will deliver “a distinctive, open platform that will give healthcare providers and independent software vendors the ability to develop a new generation of clinical applications.”

Neupert explained that Microsoft Amalga will be the base layer of the new offering, bringing in data from other systems and adding metadata. GE Healthcare Qualibria will provide advanced data descriptors such as clinical vocabulary and context (such as where a patient’s blood pressure was taken and whether the patient was sitting or lying down at the time.) External applications can then retrieve data, data meaning, and workflow context from the new system. “Provider and payor will become intermixed,” Neupert said. “Our customers already do cohort management. How do we get really good at making cohort groups discoverable and manageable in an interesting way?”

Neupert said the platform will have open APIs for developer access. Amalga’s services can manage healthcare-specific requirements such as access controls and auditability, allowing third-party developers to build solutions around large enterprise databases.  “In a patient-centric world, you want the data to be separate from the app,” he told HIStalk. “You want competition to be based on user interface and functionality, not a vendor’s ability to lock up the data. Customers want choice.”

The announcement indicates that the new company will market its products globally. Neupert said that there’s always a difference between ambulatory and inpatient care and that all governments want to tie in home care. He expects the new products to assist in those efforts, acknowledging that countries will evolve differently.

Michael J. Simpson, general manager of GE Healthcare’s Healthcare Knowledge & Connectivity Solutions practice, has been named CEO of the new company. He joined GE Healthcare in 2010 after a few months as SVP of product strategy for QuadraMed. Before that, he spent 5 1/2 years as general manager and chief technology officer of McKesson’s Horizon Clinicals business unit.

Simpson told HIStalk that he plans to enable customers to be amazed, opening up the user experience to caregivers and bringing the cultures of software development and customer relationship management to the patient. “Connectivity across inpatient and outpatient will require new platforms,” he said.

CIO Unplugged 12/7/11

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

Transformation Through the Written Word

My nephew Jordan, at the time a high schooler, was thinking about careers. Spring Break of 2009 found him shadowing “Uncle Ed,” exploring healthcare. He awoke with me each morning for 5 a.m. workouts and remained engaged until we returned home for 6 p.m. family dinners. Free time was spent developing content for an innovation workshop he would help me lead for one of our hospital leadership teams.

We nailed the workshop. The hospital president was so impressed with Jordan’s facilitation techniques that he offered him a job upon college graduation. We left that Friday session exhausted but high, ready for a Starbucks reward! Immersed all week in healthcare and spending time with physicians and leaders, his career decision crystalized. After graduating as class valedictorian, Jordan began an eight-year journey as a University of Colorado Medical School BA/BS-MD student, one of only ten chosen in the nation.

An elite runner, Jordan serves me humble pie each time we connect. We met up a couple months ago and put in a few hard miles. A college freshman, he asked me for my views on Gawandi’s The Checklist Manifesto and how it has influenced our culture. A month later he asked me about Johansson’s The Medici Effect; What Elephants and Epidemics Can Teach Us about Innovation.

We met up recently in Denver, and, during this run, he wanted to know my views on Johnson’s Fire in the Mind; Science, Faith, and the Search for Order. “Uncle Ed, where does science end and religion begin?” He loses me on the hill. Is this my nineteen-year-old nephew?

The more I learn about his medical school program and curriculum, the more impressed I am. They have something special going down at UC School of Medicine with their focus on stimulating personal and professional growth through book studies. Every other week, these future physicians tackle another book and debate.

Book and debate reinforced my IT department’s approach. I was not a reader in my youth, but as my hunger grew for leadership, I began devouring the written page. A causal correlation emerged. The more I learned, the more effective I became.

I asked my direct reports to read with me, and I observed the same causality. If these book studies were helpful for my teams, then what about my entire organization? Twelve years and counting, my desire to be a continuous learner has not abated. I have seen the transformative impact on my organizations. Hearing about Jordan’s medical school inspired me to continue pressing forward.

Many people stopped learning the day they graduated. Having book studies in the work place carries numerous benefits. Studies remove excuses and make learning convenient. The studies bring a cross-section of individuals together who might not otherwise meet each other. Cohorts ensure accountability, and nobody shows up to class unprepared. Relationships form. Engagement deepens. Leadership is honed. New ideas stimulate innovation. Sometimes we invite our strategic partners. Learning happens. People grow.

How to develop a program in your workplace:

• Charge a modest fee for the class. Return the fee for 80% attendance. Unreturned fees are donated to United Way.
• Lead the first set of classes yourself so you can model the process. Then delegate teaching to your direct reports. Expand to line staff as you find alignment between a person’s passion, ability to teach, and the general need for the topic.
• Classes early in the day have the most traction.
• Books with associated workbooks work especially well.
• Meet weekly and run each class 6-8 sessions for one hour.
• Offer a variety of classes quarterly.

Here is a sample listing of the books we have leveraged through the years. While we have our reliable classics, we always scan for new books. And yes, we have gone digital:

• 17 Irrefutable Laws of Teamwork
• 21 Indispensible Qualities of a Leader
• 21 Irrefutable Laws of Leadership
• 360 Degree Leadership
• 5 Dysfunctions of a Team
• A Long Obedience in the Same Direction: Discipleship in an Instant Society
• A Message to Garcia
• Accounting for Non-Accountants
• Application Stuff for Non Apps
• Axiom
• Blown to Bits
• Built to Last
• Business Etiquette for Dummies
• Checklist Manifesto
• Churchill on Leadership
• Clever: Leading Your Smartest, Most Creative People
• Competing on Analytics: The New Science of Winning
• Computer Factoids
• CPHIMS Prep Guide
• Creative Whack Pack Deck-Book Set, Success Edition
• Cyber Warfare
• Death By Meeting
• Developing the Leader Within You
• Disintegration
• Drucker on Leadership
• Emotional Intelligence
• Finance for Dummies
• Financial Peace
• First, Break all the Rules
• Fish
• Getting to Plan B: Breaking Through to a Better Business Model
• Good to Great
• Gung Ho!
• Hardwiring Excellence
• Heart of Change
• Here Comes Everybody
• High Five
• Higher Standard of Leadership
• Hospital Management
• Hospitals: What They Are and How They Work
• How to Give a Damn Good Speech
• How to Listen to God
• Human Sigma
• If Disney Ran Your Hospital
• Innovators Dilemma
• Innovators RX
• Inside the Magic Kingdom
• IT Risk
• It’s Your Ship
• Jack; Straight from the Gut
• James and the Giant Peach
• Judgment: How Winning Leaders Make Great Calls
• Kick in the Seat of the Pants: Using Your Explorer, Artist, Judge, & Warrior to Be More Creative
• Lead with Luv
• Leadership (Giuliani)
• Leadership Lessons Learned
• Leadership Secrets of Attila the Hun
• Lincoln on Leadership
• Making Teleworking Work: Leading People and Levering Technology for High Impact Results
• Medici Effect: What Elephants and Epidemics Can Teach Us about Innovation
• Now Discover Your Strengths
• Orbiting the Giant Hairball
• Outliers
• Overcoming the 5 Dysfunctions of a Team
• Please Understand Me (Myers-Briggs)
• Raving Fans
• Redefining Global Strategy
• Safe Patients, Smart Hospitals,
• Same Kind of Different as Me
• Servant Leadership
• Social Intelligence
• Strengths Finder 2.0
• Sustained Innovation
• Technical Stuff for Non Techies
• The Art of War
• The Big Switch: Rewiring the World, from Edison to Google
• The Black Swan
• The Element: How Finding Your Passion Changes Everything
• The Fifth Discipline
• The Five Temptations of a CEO
• The Four Obsessions of an Extraordinary Executive
• The Fred Factor
• The Future Arrived Yesterday
• The Future of Management
• The Innovator’s Prescription (Innovator’s RX)
• The Leadership Challenge
• The No Asshole Rule
• The Power of Pull
• The Purpose Driven Life
• The Shallows: What the Internet is Doing to Our Brains
• The World is Flat
• Thinking for a Change
• Today Matters
• True North:  Discover Your Authentic Leadership
• What Difference Do It Make Stories of Hope and Healing
• What Got You Here Wont Get You There
• What Were They Thinking
• Where Good Ideas Come Innovation
• Who Moved my Cheese
• Wikinomics
• Wild at Heart

Our next family reunion is in Seattle during the summer. If I want to keep up with Jordan, I’d better keep reading!

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 12/7/11

Top News

Costco announces its entry into the PM/EHR software and services business through its partners, Etransmedia Technology, Inc. and Allscripts, moving from a test phase to full launch after experiencing high demand. Costco will offer the Allscripts MyWay PM/EHR along with hosting maintenance, support, training, implementation services, and unlimited claims processing for $499 per month. The company will have a booth at HIMSS.

Reader Comments

From Unibroue: “Re: Kaiser MU-payment mishap. The doctor who did not receive her MU incentive because Kaiser mistakenly claimed it is now making progress towards collecting her money. After a couple of attempts, she connected with the right person at Kaiser, they have corrected the registration issue, and the doctor should now be able to have her payment processed correctly.” Many thanks to our great readers who offered advice and contact names to help this doctor straighten things out.

From Fancy Schneider: “Re: HIStalk’s reputation. I was recently in a meeting at a hospital and HIStalk came up. Someone commented that it was the only place where they could get real information in an industry that is swamped with vaporware.”

From Bob Coli, MD: "Micky Tripathi’s First-Hand Experience with Patient Data Security Breach. This is the best overview of a PHI security incident that I have seen to date. Every word is valuable to consumers, healthcare professionals, and everyone else in America striving to achieve maximally secure and efficient data portability and fully interoperable HIE.” Other readers concur with Dr. Coli, with some urging that Micky’s post be “mandatory” reading and naming it HIStalk’s “Post of the Year.” Even Mr. H, who is parsimonious with his praise, called Micky’s piece “outstanding” and suggested that if there were Academy Awards for blog posts, that this one would be a shoo-in. The cost of the breach (above) should get your attention, after which you can read the article here.

From Dave Miller: “Re: University of Arkansas for Medical Sciences. Some news for HIStalk. Our RFP scoring committee has recommended Epic. We still have to nail down funding and get the contract done, but the die is cast.” Dave, who is vice chancellor and CIO at UAMS (cool license plate) says they will replace Eclipsys Sunrise and Medipac on the inpatient side and Logician and Signature for ambulatory, plus a bunch of miscellaneous systems. Dave’s an old friend of HIStalk who has kept in touch since his days at University of Chicago Medical Center.

From Benzyl: “Re: PQRS. Do you see the number of submitting practices increasing or decreasing this year? What about hospitals? It seems that submissions slowed down after the incentive was reduced from 2% to 1% this year, or maybe other programs are getting the attention of practices.” Readers, chime in with your comment if you like.

From Long-Time Reader: “Re: HIT spending. I was wondering if you know what percentage of total healthcare spending HIT represents? Awesome site!” I’ll again go to readers who might a data source since I don’t know that I’ve seen an HIT-specific number that’s more precise than the typical “technology” that covers medical equipment.

From Gladys Kravitz: “Re: Cape Coral Hospital (FL). I was told by someone who works there that their Epic go-live didn’t go well, taking two hospitals down for several days. The person said administration was responsible since they didn’t go for the ‘deluxe’ Epic package from Epic and tried to manage the implementation on their own.” Unverified.

From Dadudadu: “Re: HIStalk. I hate to draw the comparison, but your statement about doing what you love and the money will follow sounds a lot like the philosophy of Epic. That intangible sense of purpose, unadulterated by the naked self-interest introduced by the pursuit of money or power or fame is, of course, what makes this website so great. And results, paradoxically, in more Money, Power, and Fame than you want. Be honest, what pays more at this point: HIStalk or your day job? Regardless, kudos to you for finding what you love, and doing it well so we all can benefit from it. Thanks.” One thing I should have added to my statement is that you almost have to work for yourself to either (a) do what you really love in the way you want to do it, and (b) reap money, power, and fame, since by definition, corporate employers fully expect to arbitrage the difference in what you’re worth vs. what they pay you, laying claim the great majority of that difference by rebating tiny raises and bonuses to encourage your occupational inertia for their continued benefit. I admire Epic for at least appearing to have something other than their corporate bottom line front and foremost, although it’s rare that good-sized companies can create and maintain a “we just want to do good work” philosophy, especially after the founders step aside (no different than when humbly wealthy self-made parents leave their fortunes to bratty, entitled children.) It’s probably empowering to have a lot of money, but I’m just as empowered by not needing much of it. If I ever quit my day job, which I admit contemplating on occasion, my questionably achievable goal would be to work for myself instead of someone else for a change.

From Elroy: “Re: Streamline Health. Acquiring Interpoint Partners, to be announced next week.” Unverified. Streamline does document management, while the Atlanta-based Interpoint Partners offers business intelligence and analytics. Streamhealth’s President and CEO Robert Watson, who took the job in February 2011, was previously a director of Interpoint. That adds credibility to the rumor.

From The PACS Designer: “Re: NPfIT Roundable. The UK’s NPfIT has had its ups and downs, but they are still looking to the future and have assembled a group to talk about it.”

From LanMan: “Re: Cerner. Buying IP blocks from now-defunct Borders? What for? And I heard this from a Brit publication?” Actually you could have heard it here since I mentioned it on December 2. At $786K, it was supposedly the second largest transfer of IPv4 addresses after Microsoft bought $7.5 million worth from also-defunct Nortel. IP addresses are about to become harder to obtain and more expensive with the advent of IPv6, which is replacing the current IPv4 as it runs out of available addresses. Cerner could be buying the addresses for resale, but I would speculate that it’s just ensuring that it will have enough for its own use for the foreseeable future, or perhaps to avoid expensive network infrastructure upgrades that IPv6 addresses will require.

From Lyssa Neel: “Re: native EMR apps for the iPad. Our app, VitalHub Chart, sits on top of Cerner PowerChart and makes data available to clinicians in a native iOS interface. Please take a look and let me know what you think.” Lyssa, whom I notice sports an impressive PhD in computer science from MIT, is CTO for VitalHub. Their product was developed at Mount Sinai Hospital in Toronto. Cerner users, what do you think?

From Early Girl: “Re: Microsoft Health Solutions Group. Some kind of announcement involving GE Healthcare will be made this week, either GEHC acquiring HealthVault and/or other MSFT products or some kind of marketing agreement.” Unverified.

HIStalk Announcements and Requests

Travis Good is on the ground at the mHealth Summit, so you can check out his reports on HIStalk Mobile. He says attendance is an impressive 3,500.

Acquisitions, Funding, Business, and Stock

Healthcare quality improvement firm Avatar International acquires HR Solutions, a human capital management consulting firm that specializes in clinical engagement.

Streamline Health posts a Q3 profit of $296,000, up 212% from a year ago. Revenue fell 4% to $4.3 million.

Health Tap raises $11.5 million in Series A funding, raising its total to $14 million. It provides an online community where anyone can ask questions to US-based physicians at no charge. The company says that 6,000 physicians are participating so far, attracted by the “gamification” of earning reputation points for answering questions or agreeing with answers provided by other doctors. Big-name investors in the 12-employee company include Eric Schmidt (Google) and Ester Dyson.

SAIC reports Q3 numbers: revenue flat, EPS –$0.27 vs. $0.46, but exceeding analyst earnings expectations by a penny after excluding one-time items. The company said it paid $190 million in cash to acquire Vitalize Consulting Solutions in July 2011.

Sales

QuadraMed RCM client Memorial Hospital of Sweetwater County (WY) chooses QuadraMed’s Computerized Patient Record and Quantim Electronic Document Management.

The San Diego Beacon Community selects Santech’s SanText SMS platform to send text messages to parents for appointment reminders and to inform them of their children’s immunization needs.

Lehigh Valley Health Network (PA) selects Orion Health’s HIE for its 50+ hospitals, clinics and health centers.

Association of Ontario Health Centres signs a 10-year contract with Canada-based EMR vendor Nightingale Informatix, which says it will earn $9 million in revenue in the first three years.

Mary Crouch joins Orchestrate Healthcare as its Meditech Practice Manager. She was previously with Laughlin Memorial Hospital (TN).

Tad Jacobs, DO, CMIO of Avera Medical Group (SD), is promoted to chief medical officer.

TriZetto names Pierre Samec, formerly of Expedia, as EVP/CTO.

Announcements and Implementations

The Greater Houston HIE announces the formation of its collaborative HIE network, which includes representation from over 60 hospitals across 14 counties.

St. Francis Hospital & Health Services (MO) announces plans to launch its Epic EHR on March 31, 2012.

Aintree University Hospital NHS Foundation Trust implements CCube Solutions’ electronic document management system, powered by Kodak production scanners and Kodak Capture Pro Network Edition imaging software.

gloStream will integrate clinical decision support from DiagnosisOne into its EMR.

Trustwave announces MyIdentity, a cloud-based two-factor authentication solution that supports five mechanisms (digital certificates, one-time SMS message passcodes, voice call-back, pushed login alert to mobile, and a mobile app that generates a one-time password.)

Caristix launches Cloak, which strips patient-identifiable messages from HL7 data for creating sample messages or clinically valid data for testing. The company, which was featured in HIStalk Innovator Showcase in November, offers a seven-day free trial.

Innovation and Research

Microsoft Research is applying spam-fighting techniques to the analysis of HIV cells, finding similarities in how viruses mutate as they attack the immune system and spammers who fine-tune their payloads to bypass spam filters.

mHealth Alliance announces its Top 11 in 2001 Innovators Challenge. Winning apps include pregnancy surveillance, voice-powered information retrieval, diagnostic tools for telemedicine, counterfeit drug detection, patient teaching, physician collaboration, patient communication, baby tracking, and care reminders. Above is a demo of an smart phone-based EMR developed by Martin Were MD, MS of Regenstrief Institute for HIV treatment and control in Kenya.

IRobot, the company behind the Roomba vacuum cleaner, applies for a patent for AVA, a five-foot-tall robot with a “head agonistic design” that can accommodate tablets or smart phones.

Other

The board chair for Maryland eCare says that mortality rates have fallen 30% across hospitals that have implemented its telehealth systems that supplement ICU coverage at rural hospitals.

CPSI pays $9.5 million for its new Mobile, AL corporate headquarters, which includes 16.5 acres and 135,500 square feet of office and warehouse space. The company had been leasing 13 buildings in the same office park.

EHRrtv publishes its MGMA interview with the always entertaining (and interestingly-attired) Jonathan Bush of athenahealth. He’s like no other CEO out there.

Aetna and ProHealth Physicians (CT) say that their four year Provider Collaboration program has resulted in 37% fewer inpatient hospital days on a risk-adjusted basis and 35% few hospital readmissions.

CPSI, Cerner, GE Healthcare, and Picis earn top client satisfaction scores in Black Book’s ranking of inpatient EHR vendors, obviously reaching vastly different conclusions than KLAS.

The Leapfrog Group includes 65 hospitals (including 18 Kaiser facilities) on its list of Top Hospitals, based on the delivery of quality care.

An article in Wired magazine called Apple’s Secret Plan to Steal Your Doctor’s Heart is not particularly focused or convincing, but a fun read. I couldn’t figure out its conclusion other than (a) doctors like using an iPad because it saves them time; (b) hospitals seem to be warming up to them; and (c) Steve Jobs had a small interest in healthcare after trying unsuccessfully to develop a Pixar CT imaging system. Like many articles these days, it seems  highly analytical and fresh until you think about precisely what you learned and realize that it wasn’t much.

Sponsor Updates

• Elsevier introduces Procedures Consult App for iPad, iPhone, and iPod Touch.
• Adler Hey Children’s Hospital and Liverpool Women’s Hospital (UK) select Perceptive Software’s ImageNow electronic document management system.
• Wolters Kluwer Health announces its acquisition of Medknow PVT Ltd, expanding its open access publishing business.
• Capital Health (NJ) goes live on Wellsoft EDIS in its four emergency departments.
• dbMotion announces the 2012 schedule for its Insights into HIE seminar series.
• Michael O’Neil, founder and CEO of GetWellNework, moderates a discussion on mHealth and the role of patient education and monitoring medical compliance at this week’s mHealth Summit.
• Qualcomm Life Inc. and AirStrip Technologies collaborate to offer mobile monitoring to home health providers and patients.
• Capario launches a streamlined payer enrollment process.
• Teradici combines Imprivata OneSign Virtual Desktop Access with its PCoIP Firmware release 3.5.0 to offer virtual desktop access via access cards and ID badges.
• A Practice Fusion press release discusses five top trends and surprises in HIT for 2011.
• In a December 12 Webinar, South Jersey Health System CIO Thomas Pacek  will share how MobileMD is helping his organization’s physician network to grow and coordinate patient care.
• Nebraska Health Information Initiative announces that physicians are now sharing patient immunization information with NESIIS through the HIE’s Axoloti-powered platform from OptumInsight.
• San Diego Business Journal profiles Awarepoint and its four new RTLS patents.
• Vibra Healthcare (PA) selects PatientKeeper Physician Portal and Mobile Clinical Results for its long term acute care hospitals nationwide.
• Forst & Sullivan awards AT&T its Competitive Strategy Leadership Award for its approach to mHealth.

Contacts

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

Curbside Consult with Dr. Jayne 12/5/11

For those of you who are my Facebook friends, you may have noticed that I’m at the National Finals Rodeo this week. (And if you’re not my friend on Facebook… well, you know what you need to do to keep up with all my travels and adventures.) Despite my love of all things technology, I really am a cowgirl at heart.

For those of you who are not rodeo fans, NFR is in Las Vegas. I’m amazed at how the city transforms itself for different constituencies. The casinos of the headquarters hotels are filled with the sounds of country music. Shopping areas are featuring cowboy boots in the window instead of rhinestone stilettos (although there are plenty of rhinestones on the boots.) The cocktail waitresses at one bar I’ve been to several times in the past have given up their leather bustiers and miniskirts in favor of tight jeans and white cotton shirts. If there’s any place on earth that’s a triumph of marketing, it’s Las Vegas.

So what does this have to do with healthcare and technology? A couple of things.

First, let’s talk about marketing. We always think about vendors when we think of marketing. Nearly every vendor’s ad campaigns these days prominently feature the twin terrors of Meaningful Use and Accountable Care. If those aren’t mentioned, then it’s revenue cycle or other financial aspects of health care.

I think we forget about the sheer amount of hospital marketing that goes on, however. Just like the casinos marketing to the cowboys (many of whom have wallets the size of their belt buckles – and trust me, Jayne and her crew have been checking out some jeans pockets on this trip) the hospitals, surgery centers, and physicians are heavily marketing towards whatever demographic they feel has the fattest wallets or deepest pockets.

Driving around most cities, you see plenty of healthcare-related billboards. One hospital I passed recently boasts a Heart Hospital. What does that mean? Do they do more heart cases than anyone else? Are their outcomes better than others? Or do they just want the perception of being specialized to try to garner business when their volumes are the same as the hospital across town?

Everyone is tweeting their emergency department wait times. I’d like to see them tweeting their nurse-to-patient ratios or their infection rates instead. That would really create some interesting discussion in the community about which facility is the best.

Physicians and other providers aren’t much different. Going after high-paying patients is an art form. Medical buildings (and some physician offices, too) are installing complimentary coffee kiosks to go with their waiting room check-in kiosks. Ancillary services including cosmetic and convenience offerings are proliferating faster than Medicare Wellness exams. Availability of after-hours physician access at premium prices is becoming more commonplace. Concierge-type practice models such as MD VIP are going mainstream. My travel companion noticed a special advertising section in the Southwest Airlines Spirit magazine this month that featured not only concierge medicine, but other specialty and alternative practices.

Hospitals and physicians have their own internal marketing campaigns as well. It may be as simple as signs in a primary care office reminding diabetic patients to take off their shoes prior to seeing the physician or as complex as a multi-hospital multimedia hand washing campaign (complete with Big Brother surveillance, as we’ve seen recently) or promoting desired behaviors such as vaccine compliance through viral videos.

The medical establishment is increasingly marketing technology to patients. Not only emergency wait times, but also patient portals, secure messaging with providers, lab results online, bill pay, and a host of other services. Many of these offerings not only add value to patients and families, but also have the potential to significantly increase the bottom line for healthcare organizations. Payers are in the game as well as employers, with many offering health promotion and disease prevention as well as online enrollment, updating, and claims management features.

Many agree there are health benefits to increased patient education and empowerment. But the jury is still out on some of these marketing efforts. I’m interested to hear what HIStalk readers think about marketing – on the vendor, client, and patient sides. Have an opinion? I promise to read your comments just as soon as I’m finished watching the action. Tonight is “Tough Enough to Wear Pink Night.” I’ll let you guess what color my boots are.

E-mail Dr. Jayne.

Readers Write 12/5/11

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

Note: this special edition of Readers Write features a special contribution from Sam Bierstock, for which the length limits were waived.

A 19th Century Perspective on Physician Adoption
By Sam Bierstock, MD

I first recognized that there was a pattern to the challenges of physician adoption of information technology in 2001. At that time, I convened a meeting of CMOs and clinical IT champions for hospital clinical information systems of all sizes, and quickly learned that they were all facing similar challenges. Basic human nature does not differ much, even in organizations that feel they are unique.

When I wrote about the importance of supporting what I called “Thoughtflow” as opposed to “workflow,” I was surprised by the widespread endorsement of the concept by clinicians, but disappointed by the sluggishness of vendor design processes to truly support the way clinicians think and work in an age of real-time data availability. I’ve been around long enough to start to see that begin to change, although I am not sure that this is because of vendor enlightenment or simply a generational turnover. The Israelites had to wander in the desert for 40 years to wait for a new generation of people to enter the Promised Land. Perhaps adoption is improving because of generational turnover as much as from demonstrable value.

A historical perspective dealing with the way healthcare was practiced during the second half of the 19th century, considering the patient safety issues of the day and the political climate, is intriguing. It says much about human nature, resistance to change – and the physician adoption champion of all champions, Joseph Lister.

In the 82 years between 1841 and 1923, six United States presidents died in office – four in the space of 40 years, five in 60 years. William Henry Harrison died of pneumonia and pleurisy in 1841. Zachary Taylor died of acute gastroenteritis in 1850 (with subsequent conspiracy theories suggesting that he was poisoned.) Abraham Lincoln was assassinated in 1864. James Garfield died after being shot by Charles Guiteau during his fourth month of service as president in 1881. William McKinley was assassinated by Leon Frank Czolgosz in 1901. William Harding died in office in 1920 of a “heart attack.”

We’ve had 10 presidents during the last 50 years. Comparing the timeframes, this rate of loss would be equivalent to us losing Kennedy, Nixon, Carter, Clinton, George Bush, Sr., and Obama while they were in office. Of the six presidents that died between 1841 and 1923, three had their fate tied to assassin’s bullets. Those occurred over the span of just 37 years (Lincoln 1864, Garfield 1881, and McKinley 1901.) One can only imagine the impact on the national psyche of these serial attacks on the lives of our presidents. One man in particular must have suffered a heavy emotional toll, for Robert Todd Lincoln bears the unique distinction of being the only person ever to be present at three presidential assassinations.

Regardless of the precipitating event, in many cases, the direct cause of death of these presidents was due to medical care that ranged from abysmal to totally incompetent.

In the later half of the 19th century, hospitals were not viewed as a place to go to recover from an illness or to have surgery. Hospitals were where you went to die. Surgeries were performed at home or similar environment. Illnesses such as influenza, mumps, diphtheria, or pneumonia – and especially infected wounds – were death sentences. In the absence of antibiotics, for instance, the vast majority of Civil War wounds resulted in death from infection.

Doctors’ standard operating garb were black smocks that they rarely washed or changed – if ever. A blood-encrusted smock was something of a status symbol and an indication of experience, and therefore presumed expertise. Surgical instruments were carried about in bacteria-laden, velvet-lined cases, and were not cleaned between operations beyond a quick wipe with a much-used handkerchief. If an instrument was dropped during a case, it was picked up off the filthy floor and used to continue the procedure (boots and shoes were not routinely cleaned off before entering the operating room). At Jefferson University in Philadelphia, the same table was used to dissect cadavers as was used to perform operations on live patients.

Things were so bad that the leading cause of death for hospitalized patients was termed “hospitalism.” Some thought that hospitalism was the result of toxic ether that surrounded hospitals.

In the 1880s, there were approximately 60 medical schools in the country – none certified by any organization – and students often had only one year of training. Until Lister came along — and for many years after he began to promote his theories about microbes causing infections — the idea of invisible organisms that could cause infection was laughable and readily dismissed by the vast majority of physicians.

Talk about a physician adoption challenge and patient safety!

In a political context, the state of presidential medical care went far beyond patient safety and had a direct impact on national policy and survival. This was a time when vice presidents were not hand-picked by the presidential candidates. They were selected by their party at their respective conventions, often by virtue of having the second largest number of nominating votes. As a result, the vice president and president were often of widely differing political views if not polar opposites, and often didn’t like each other very much.

James Garfield hardly ever spoke to his vice president, Chester Arthur. Garfield was vehemently opposed to the patronage system that infested national politics and Arthur was a product of it (although to his credit, he underwent a significant change in attitude once he assumed office.) Grover Cleveland and his second vice president, Adlai Stevenson, Sr., differed markedly on the key issue of the day, the gold standard versus the silver standard in our monetary system – an issue that had dire implications during a period of severe economic crisis. Woodrow Wilson and his vice president Thomas Marshall did not see or talk to each other while Wilson was incapacitated by a massive stroke until the day that Wilson left office.

None of these presidents relinquished power while ill or unable to perform their duties. Not until 1967, when the 25th Amendment to the Constitution was enacted after the death of John Kennedy, was the country assured that the vice president would assume presidential powers in the event that the president became unable to exercise his duties.

The death of a president during these times, therefore, had enormous impact on the direction of the country. Physicians caring for ill presidents were under enormous pressure to be sure that they could save their patients.

To avert public panic, presidents often went to great lengths to hide their human frailties and illnesses from the press. Unlike today, they were generally successful at doing so. Unknown to the populace, Abraham Lincoln became extremely ill with influenza for one month shortly after delivering the Gettysburg Address and lingered near death. Garfield did not die until two months after being shot, and aside from being subjected to the most barbaric care of any president, was reported to be in good condition and recovering steadily in bulletins issued to a nervous public several times a day. Chester Arthur suffered from “Bright’s Disease” (chronic nephritis) which he persistently denied publicly, but which took his life within two years of his leaving office.

Grover Cleveland underwent a secret operation to remove a presumed squamous cell carcinoma on his palate shortly after beginning his second term. (He is the only president to be elected twice in non-contiguous terms). In order to maintain secrecy, the procedure was performed on a friend’s yacht by a team of doctors who removed about a third of his palate, four teeth, and a portion of his upper jaw. He simply disappeared from public view during this time. He even kept his surgery secret from his vice president. When Adlai Stevenson wanted to know where the president was, Cleveland sent him on a length trip to the West Coast to keep him in the dark and to avoid the possibility that Stevenson would muster support for his position on the silver standard. In 1967, pathologists were finally allowed to examine the tissue removed from Cleveland’s mouth, which turned out to be a verrucous carcinoma – tumors that do not metastasize, but which can cause death local extensive local invasion.

Nor did the public know that Woodrow Wilson was rendered non-functional by a severe stroke toward the end of his presidency. In fact, few people knew that he had suffered several strokes prior to being elected for his first term. For the remainder of his last term in office, virtually all presidential decisions were made by his wife Edith – who, as a result, is often referred to as our first female president.

Warren Harding’s doctor, Dr. Charles Sawyer, was undoubtedly the most incompetent of presidential doctors. Appointed as the president’s private physician because of a long personal relationship, Sawyer had only one year of medical school training. Sawyer liked to prescribe medication based upon the color of the pill – once prescribing a dose of soda water with two pink pills for the president. Even though Harding was hypertensive and had significant orthopnea, exhaustion, and shortness of breath, Sawyer failed to recognize the clear symptoms of congestive heart failure, which he dismissed as “a touch of food poisoning.” Harding died in the Palace Hotel in San Francisco in 1923 at age 57 after a grueling trip to Alaska.

The most egregious care administered to a president by far was that applied to James Garfield – a man who would have undoubtedly been destined to greatness, but having served only 200 days in office, has been delegated to historical footnote status. Garfield was popular, exceedingly capable, honest, and brilliant. A man of natural congeniality, he withstood the most unimaginable procedures without complaint and generally in silence.

Garfield was shot by Charles Guiteau in the Baltimore and Potomac Railroad Station in Washington, DC on July 2, 1881 (now the site of the West Building of the National Gallery of Art.) He did not die until September 19 of the same year. During the assassination attempt, he was hit by two bullets, the first grazing one arm and the second entering his back. As he lay vomiting on the filthy station floor, his doctor inserted an unwashed finger into the back wound in an effort to locate the bullet. This was repeated multiple times by a series of doctors (16 physicians gathered), after which the wound was repeatedly probed with unsterile instruments. At one point, a probe became lodged between fragments of Garfield’s eleventh rib and removed only with great effort and resultant pain to the president. Dr. D.W. Bliss then used his finger to widen the wound so he could probe further. Over the next two months, Garfield was subjected to repeated probing of the wound with unsterile fingers and instruments, non-aseptic incisions to drain abscesses, and other invasive procedures in an effort to locate the bullet, which was, in fact, located harmlessly in fatty tissue behind the pancreas. Eventually, the original three-inch deep wound was converted to a twenty-inch long contaminated, purulent gash stretching from the president’s ribs to his groin.

Garfield’s original wound was entirely survivable even in the 1880s, and he would almost certainly have survived it had his doctors not repeatedly introduced sources of infection which ultimately resulted in his having systemic abscesses and resultant septicemia. Thousands of civil war veterans lived long lives with bullets embedded in their bodies. Garfield ultimately died of a ruptured splenic artery.

It is an interesting sidelight that a Herculean effort was made by Alexander Graham Bell to perfect his newly invented metal detector in time to save President Garfield. He worked tirelessly on the device day and night and devoted endless hours to this cause. X-rays had not yet been invented and it was deemed essential to locate the position of the bullet for possible removal. Bell was finally permitted to try his device on the president, and did so on two occasions. Garfield himself was apprehensive of the new device and was fearful of being electrocuted. Bliss, allowed Bell only to examine one side of Garfield’s body, being convinced that that was where the bullet was lodged (in fact, it lay on the opposite side.) To his great dismay, Bell detected a constant series of signals indicating metal over a diffuse area and could not understand why. He later learned that Garfield was lying on a brand new type of mattress – a coil mattress filled with metal springs.

And then there was the matter of facial hair.

In the second half of the 19th century, it was considered the norm for presidents to have facial hair, something unimaginable in our current image-conscious times.

Although John Quincy Adams and Martin Van Buren had extensive sideburns, presidents were clean shaven until Abraham Lincoln grew a beard when an 11-year-old girl suggested that he do so. For the next 52 years, facial hair became the trend, so much so that it became unimaginable for a president to be clean shaven. Beards were thought to prevent pulmonary problems and throat disease. The last president to serve with facial hair was Taft (who left office in 1913.) His successor Woodrow Wilson had a white beard during his illness and just prior to leaving office.

Beards and facial hair were almost an expectation of the day. One can only wonder about the magnitude of iatrogenic disease caused by the introduction of infectious agents by uncovered beards on physicians wearing blood-encrusted smocks and using filthy instruments during these times.

Enter Joseph Lister.

Lister spent much of the 1870s and 1880s trying to convince the world that germs existed and were the cause of wound infection. He was received with derision and frequent outright hostility. One medical journal editorial stated that, “We are as likely to be as ridiculed in the next century for our blind belief in the power of unseen germs as our forefathers were for their faith in the influence of spirits.” Doctors could simply not accept that microbes might be lurking in the air and on their hands.

In many cases, doctors might be persuaded to try antiseptic techniques by boiling their instruments prior to surgery, and at the same time be completely unaware of the need to maintain asepsis. If a previously sterilized instrument fell to the floor, it would be picked up and wiped off with an unsterile cloth and used to continue the operation. If infection resulted, the doctor would then dismiss Lister’s ideas.

Lister lectured and promoted his theories tirelessly, pointing to his own remarkable success in reducing post-operative infection. Gradually he began to gain a following, when doctors such as W.W. Keen began to use aseptic techniques in Philadelphia’s St. Mary’s Hospital after hearing Lister speak. The infection and mortality rates plummeted almost immediately, and other hospitals rapidly followed suit. Antiseptic techniques became the norm within a decade.

Lister died in 1912, having lived to see universal adoption of his aseptic techniques. He did not live to see the introduction of a household product bearing the unauthorized use of his name just two years later– Listerine mouthwash.

This historical perspective says much about human nature and resistance to change. Lister was committed to his cause, but encountered a 19th century version of the physician adoption challenges of the first decade of the 21st century. The possibility that a universal conversion to digitalized medicine will have the same impact on saving lives that aseptic techniques had seems unlikely, but it is clear that breaking through the boundaries of embedded practices has never been easy in our industry. Current day champions have a big set of shoes to fill.

Samuel R. Bierstock, MD, BSEE is the founder and president of Champions in Healthcare, LLC, a strategic consulting firm specializing in clinical information system implementation and healthcare IT business strategies.

Bottomline Technologies Acquires Logical Progression

Financial software vendor Bottomline Technologies announced today that it has acquired the assets of Logical Progression of Cary, NC, which sells the Logical Ink mobile provider documentation solution for hospitals and large clinics. Terms were not disclosed.

Logical Ink is an interactive paperless forms platform that the company markets as an intuitive, workflow-based alternative to traditional computer documentation. Bottomline Technologies will offer that product as part of its healthcare product portfolio.

Logical Progression was featured in the HIStalk Innovator Showcase in June 2011.

Monday Morning Update 12/5/11

From It’s All Good: “Re: [vendor name omitted]. In post-acquisition happenings, staffers have been required to sign a highly restrictive non-compete agreement or face termination, with a number of 10+ year veterans opting not to sign and accepting termination instead. Next up, aptitude tests for those who remain. Pushing out seasoned veterans without having ready replacements is not a best practice.” At least it’s a free country, where the employment commitment works both ways. I admire those who took their walking papers instead of sticking around if they were really that unhappy. Complaining about your job while staying in it is like telling everybody how your spouse mistreats you – if you truly feel demeaned or endangered, stop talking and get out of the situation immediately. The bad thing about company belt-tightening is that you first lose the people with marketable skills and experience, leaving you stuck with those who don’t have anywhere else to go. Update: I concur with a reader’s comment that my “spouse” comment sounded insensitive, so I reworded to be clearer what I meant.

From Farina: “Re: being anonymous. It’s a shame you’re anonymous as you know more than pretty much all of the people that I talk to at vendors, VCs, or healthcare orgs. You’d also make a great advisor for a lot of companies.” I’m happy keeping a low profile, which also keeps me as focused and honest as a monk in a locked-down monastery. Not to mention that “knowing” is different from “doing,” obvious since I still toil in the salt mines of a non-profit hospital. Sometimes I’m envious of those with greater ambition and different skills who create and run large organizations and make names for themselves, but this is still the best “job” I’ve ever had (and the longest held at 8.5 years and counting.) I’m not motivated by money, power, or fame, so I’m fine. I firmly believe that if you do something you really enjoy for reasons other than making money, the money will find you anyway.

It surely cannot be possible that Christmas is just three weeks away and the HIMSS conference is just eight weeks after that. I get slammed every year in January and February doing the HISsies, gearing up for HIStalkapalooza, setting up our little HIMSS sponsor appreciation lunch, handling a big surge of e-mails of all kinds, and running around the conference anonymously and telling you about what I’m seeing (and trying to keep up with my real job at the hospital, of course.) If you need anything from me, this is a great time to let me know since I’ll be heads-down from New Year’s until March.

Nearly half of respondents say they have a problem buying into healthcare-related ideas that are presented by someone who’s overweight. New poll to your right: did you go to HIMSS last time and will you be going in February? I registered and made travel arrangements last week. This past year on February 20, Las Vegas was sunny with a high of 46 degrees compared to the normal high of 64. Exhibitors are going to hate the location since they’ll be competing for attendee attention with casinos and showgirls.

Our own Travis Good MD of HIStalk Mobile will be reporting from the mHealth Summit in the DC area starting Monday. Here’s his preview and links for following along with him this week (sign up for updates and you won’t miss anything). HIStalk Mobile is a media partner, meaning Dr. Travis gets to play intrepid reporter and prowl around areas that are off limits to regular attendees (OK, I’m not sure there really are any of those, but that makes it sound more exclusive than just taking notes along with everybody else.) Big-name keynoters include the Surgeon General, the chairman of the FCC, Kathleen Sebelius of HHS, and some notables from Qualcomm, Apollo Hospitals Group, Verizon, and West Wireless Health Institute.

I’ve just posted on HIStalk Practice Micky Tripathi’s gripping, highly educational account of having his organization’s patient data breached. It’s long, detailed, full of documentation and like nothing you’ve ever read since nobody has ever talked so openly about their own organizational mistakes. We all know data breaches are potentially embarrassing, but you’ll be surprised (unless you’ve lived through a breach yourself) at the gray regulatory areas, the “who’s really responsible” question (shocker: legally, it wasn’t Micky’s organization, Massachusetts eHealth Collaborative), and just how much money and effort is required to go through the required steps. I’ve preached for years about encrypting mobile devices, so if budget is your barrier, send a copy of the article to your CEO and I bet the project will be quickly funded. I always enjoy Micky’s regular HIStalk Practice columns since he’s not only an expert, he’s also one of the most engaging writers I know. In this case, has served the entire industry, for which we should all be grateful. I consider this piece to be mandatory reading for just about everybody.

Listening: Odessey and Oracle from The Zombies (and yes, I spelled it correctly). This is the innocence, psychedelia, and British Invasion fascination of the 1960s captured permanently on vinyl like a prehistoric bug in amber. By the time this album came out in 1968 the band was broke and disbanded (they could barely afford studio time and had to record it in mono.) Time of the Season climbed the charts and the group still declined to tour, so fake groups gave concerts using their name, with one even grabbing the band name’s trademark that had expired. For my money, I’d take this album over Sgt. Pepper’s and Pet Sounds as the best of the decade (right up their with Love’s Forever Changes and either The Doors or Strange Days from The Doors).

I had some major upgrade work done on the site over the weekend. Most of it is behind the scenes, but if you read HIStalk, HIStalk Practice, or HIStalk Mobile on a smart phone or iPad, you may see some improvements. I noticed that the iPad display was sometimes fuzzy for reasons I could never figure out and that seems to be fixed, plus there’s new support for Apple’s Retina display.

My Time Capsule editorial this week from five years ago: HBOC 1, Everybody Else 0, in which I opine, “Among those involved were certainly some crooks and some fools, but let’s not forget those who suffered most, those McKesson lifers who had stashed away years’ worth of shares of their unexciting company’s stock instead of risking their future on flaky fads like Microsoft and Dell. When lonely old conservative widower Dad McKesson brought home a sexy young step-mom named HBOC, she stole the kids’ piggybank.”

Welcome to new HIStalk Platinum Sponsor Etransmedia Technology. You may recall that the Troy, NY company facilitated the offering of Allscripts MyWay nationally through Costco, but they’ve created quite a few products of their own related to PM/EHR, patient connectivity, physician mobile, revenue cycle, and clinical documentation. The SaaS-delivered EtransConnect ACO product suite has tools for connectivity, patient identity management, a clinical data repository, and an orders report portal for providers, rounding those solutions out with a community patient portal and back-end analytics tools. The company’s ambulatory EHR toolkit provides a full-function patient portal (appointments, health histories, messaging, refills, consents, online statements, and structured data exchange such as by CCD). Also offered is custom reporting modules and a mobile charge capture app that lets physicians document their hospital rounding activities to send charges back to their own EHRs for billing. The company just announced that it’s  #155 on Deloitte’s Technology Fast 500 with a 647% revenue growth over the past five years. Thanks to Etransmedia Technology for supporting HIStalk and its readers.

Thanks to Intelligent InSites for supporting HIStalk as a Platinum Sponsor. The Fargo, ND company’s tagline is Enabling the Real-Time Enterprise, which it does with an extensive list of RTLS-powered solutions (asset management, patient flow, bed management, infection control, patient and staff safety, environmental monitoring, and mobile information access.) The company just announced its enterprise Big Data analytics solution that uses the wealth of information it captures to identify trends, track key performance indicators, and call out process improvement opportunities. Also just announced is a consulting service that helps hospitals identify specific areas (and hard-dollar impact) in which RTLS-powered solutions can improve outcomes, patient satisfaction, and cost. I was intrigued that the company’s largest investor and interim CEO is Doug Burgum, who bootstrapped and ran fellow Fargo company Great Plains Software until Microsoft bought it for $1.1 billion in 2001. Thanks to Intelligent InSites for helping me do what I do.

I like to get the big-picture view of a company by checking out an introductory video (I’m lazy and have a short attention span), so I found the one above for Intelligent  InSites on YouTube.

The new Plano, TX office of MedAssets will consolidate over 1,000 employees in a building covering 225,000 square feet. The company’s corporate headquarters is in Alpharetta, GA, which I note has a population around 60,000 and about the same number of HIT-related company offices (slight exaggeration.)

The IT team behind the US Army’s MC4 battlefield EMR wins the top IT team award from the Association of Military Surgeons of the United States. Receiving the award above is Lt. Col. William Geesey, project manager (on the right.)

Vince Ciotti takes a slight detour from his ongoing HIS-tory of HIT software vendors, this time leading off a series on consulting firms. Vince is looking for your first-hand stories, so if ampersanded names like Coopers & Lybrand and Ernst & Whinney cause one of those TV dream bubbles to appear over your upraised head as you dreamily recall the glory days of dark-suited Big Six accountants descending on your hospital with their weapons of choice (legal pads, expense accounts, and blank RFPs for selling add-on work), then feel free to reminisce with him for future installments.

An ED doctor in Canada admits that he looked up medical information on his girlfriend’s former husband during a child custody dispute. The hospital’s computers have a 10-minute logout period, so the doctor would go behind users who left their PCs logged on to look up records under their user ID. The hospital’s SVP of medicine says it hopes to implement a card-based computer system that automatically logs users off, so there’s a sales opportunity if your company offers those.

Ed Marx has a big go-live at Texas Health Resources and found this signage amusing.

A fascinating Forbes article called The Bomb Buried In Obamacare Explodes Today – Hallelujah! says the only truly important part of the Affordable Care Act took effect on Friday. That’s when the medical loss ratio part of the law kicks in, requiring insurance companies to spend 80% of the premium dollars they collect on medical care (if they underspend, they have to write customers a check.) The author says this marks the slow but sure death of for-profit insurance companies because they know they can’t do that and still make a profit, so they are already moving to more profitable businesses (but read the comments at the end for some interesting counterpoints, with a notable one being that insurance companies make most of their profit from investing the money until it’s spent anyway and that’s not changing.) A snip from the article:

So, can private health insurance companies manage to make a profit when they actually have to spend premium receipts taking care of their customers’ health needs as promised? Not a chance – and they know it. Indeed, we are already seeing the parent companies who own these insurance operations fleeing into other types of investments. They know what we should all know – we are now on an inescapable path to a single-payer system for most Americans and thank goodness for it. Whether you are a believer in the benefits of single-payer health coverage or an opponent, mark this day down on your calendar because this is the day seismic shifts in our health care system finally get under way. If you thought that the Obama Administration chickened out on pushing the nation in the direction of universal health care for everyone, today is the day you begin to understand that the reality is quite the contrary.

Raul Recarey, president and CEO of the Missouri Health Connection HIE, quits after eight months on the job.

HCI’s USA-built Android-powered RoomMate Healthcare TV for hospitals includes a patient and visitor whiteboard, a web browser, video and music options, a pillow speaker, an an optional hard drive for video streaming. It comes in screen sizes from 22 to 42 inches and includes just about every kind of connectivity available. It integrates with the company’s MediaCare2 product, which allows hospitals to send “information prescriptions” to specific patient TVs, such as educational videos, images, and announcements. It also allows hospital staff to control patient TVs from a central location.

Stupid lawsuit: a prisoner sues his former hostages, a newlywed couple whose home he broke into while evading police on suspicion of murder. The couple agreed at knifepoint to hide him, but called police when he fell asleep. He brandished the knife again and was shot by a SWAT team officer. He’s suing the couple for $235,000 worth of medical costs and emotional distress, saying they breach breached  an oral contract by turning him in.

E-mail Mr. H.

An HIT Moment with … Ramsey Evans, CEO Prognosis Health Information Systems

An HIT Moment with ... is a quick interview with someone we find interesting. Ramsey Evans MBA, is president and CEO of Prognosis Health Information Systems of Houston, TX.

What’s on the minds of small hospitals these days with regard to operational challenges, healthcare IT, and Meaningful Use?

Executives at small hospitals are thinking about the same issues that their counterparts at larger hospitals are struggling with: financial challenges associated with shrinking reimbursements; the relentless need to improve quality; and, of course, the rush to achieve Meaningful Use in order to qualify for government incentive funds.

However, the obstacles faced by healthcare providers and patients in rural areas are vastly different than those in urban areas. Rural hospitals are smaller in size, have limited assets and financial reserves, and a higher percentage of Medicare patients due to their populations being older than urban populations.

The desire to achieve Meaningful Use is exacerbating a frustration that hospitals have been struggling with for years — the time and money that it takes to implement EHRs. It’s the No. 1 headache out there, but it is especially vexing for rural hospitals as they simply don’t have the same financial and human resources that larger providers have. Our Web-native technology enables rural and community hospitals to move from signing to implementation to the realization of Meaningful Use in less than 120 days, which translates into a significant time to value as well as the lowest total cost of ownership.

The big-hospital market has shaken out to just two or three vendors that regularly sign new customers. What’s the competitive landscape in the smaller hospital market?

A similar shakeout is underway in the smaller hospital market. Vendors are realizing that it takes special product offerings and service to meet the needs of the rural and smaller community hospitals. Some of the large vendors are trying to bring their systems into the smaller hospitals, but they are finding that the solutions and the service model just don’t mesh with the way critical access and smaller rural community hospitals operate. Simply repackaging their monolith systems into a smaller box with a slightly faster implementation is not what’s required for this unique market.

Realizing that smaller hospitals simply cannot afford the multi-million dollar, client-server based systems that take years to implement, we focus on disruptive innovation. In his seminal book The Innovator’s Dilemma, Clay Christenson explains that a disruptive innovations improve a product or service in ways that the market does not expect, typically first by designing for a different set of customers in the new market and later by lowering prices in the existing market. His follow-up book explains how the disruptive innovation concept could play out in healthcare by delivering capabilities formerly only available to large providers with huge budgets to smaller providers that can then leverage such solutions to improve care delivery. That’s what we are trying to do.

How advanced are your client hospitals in their use of your clinical documentation, ordering, and clinical ancillary applications?

Our clients don’t have the same level of complexity as large tertiary hospitals with a range of specialties such as cardiology, oncology, and pediatric departments or Level Four trauma centers. So IT system utilization is in line with their charter. But they still have to provide quality care  and document it.

They should be able to leverage an EHR that will enable them to do that as well as larger hospitals. That’s really the issue we are addressing. Take a look at the inequities. According to the National Rural Health Association, Medicare patients with acute myocardial infarction who were treated in rural hospitals were less likely than those treated in urban hospitals to receive recommended treatments and had significantly higher adjusted 30-day post AMI death rates from all causes than those in urban hospitals.

Our system can help to close this digital divide. Our “clinical visual pathway” makes it easy for nurses and physicians to deliver the best care by simply following a visual map that walks them through standard best practice scenarios while treating a patient.

How are your customers and you as a vendor affected by the push toward alignment with physician practices and the developing ACO market?

With our target market of rural, critical access and smaller community hospitals, we haven’t seen much focus today on ACOs. These smaller providers traditionally focus on defined requirements, instead of those that are in a constant state of motion such as the ACO requirements were in the past several months.

With defined ARRA regulations for Stage 1 and defined incentives, leaders at these hospitals have been keenly focused on identifying a way to meet the requirements. With the final ACO rules recently published, though, these hospitals are likely to begin to add ACOs to their list of challenges and it will start to become a concern.

What’s the future of interoperability among hospitals and practices?

There is an ever-increasing interest in evaluating both hospital and physician EMR systems at the same time. Providers in rural communities understand that there is real value in sharing records, as patients frequently receive care from various providers across a region. And providers really want all of this sharing to be seamless. They want to make it possible for patients to go from facility to facility and simply have their medical information follow them.

To make good on this notion, we are working with a number of our hospital clients to help support the West Texas RHIO, where eight hospitals across a region are accessing records via a shared EHR. The RHIO enables clinicians to access patient records at any of the hospitals, such as when a patient shows up in an emergency room or is transferred. As such, doctors and other clinicians can provide care with access to complete information, which, in turn, enables them to make the best care decisions and save lives in the process. 

This arrangement makes it easy to create a virtual health information exchange. That’s because authorized physicians can retrieve patient records from any of the hospital databases once they are verified with user name and password. In contrast, most emerging health information exchanges across the country involve competing organizations, usually with different records systems, creating a network from scratch to share certain patient information. It’s just an example of how innovation can make it possible for healthcare organizations to go beyond what was possible with the formerly dominant technologies.

Time Capsule: HBOC 1, Everybody Else 0

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

I wrote this piece in November 2006.

HBOC 1, Everybody Else 0
By Mr. HIStalk

I didn’t even know Charlie McCall was on trial. The former HBOC chairman was acquitted of a securities fraud charge last week and got a mistrial on six more counts as a lone juror’s holdout deadlocked the jury. I feel deprived that I missed a blow-by-blow report of his being grilled and then left to await his fate. All these years of waiting: “Wonder when they’ll get Charlie?”

In case you’re a newbie, HBO & Company was the pre-Enron corporate malfeasance poster child, a prodromal symptom of dot-coms in waiting that used its optimistically valued stock to buy everything in its path. The frenzied transacting caught the attention of drug wholesaler McKesson like the mating dance of a spider, which paid a mind-boggling $14 billion for the company in January 1999.

Industry long-timers chuckling knowingly, having watched similar companies take it in the shorts for the same expensive, ill-advised, and dispassionate dabbling in healthcare IT. Investors scratched their heads after running their calculators and finding no possible way that HBOC was worth that kind of money. The general consensus of all interested parties: what the hell was McKesson thinking?

Three months later, McKesson’s stock tanked on charges of book-cooking by Charlie’s crowd. Shareholders lost $9 billion of wealth in a single day, thereby unwillingly participating in the ultimate assessment of HBOC’s value.

McKesson’s executives were perhaps the only people on the planet who weren’t suspicious about the Atlanta high-flyers. Everyone was swapping insider horror stories. I sent two anecdotes to a healthcare IT publication in 1998 (who missed out on the scoop of the century by ignoring them.) First: I’d heard from an HBOC employee that he was ordered to mail out empty tape boxes to customers for not-ready enhancements so revenue could be recognized anyway. Second: HBOC programmers, all of whom in some areas had revenue targets, griped about booking their estimates long before any work was done. Recognizing revenue on the basis of a shipping receipt? Oh, my.

You know how it ended. HBOC’s brass were indicted, McKesson’s were fired. Charlie went off sailing (so the story goes.) The reeling McKesson lost employees, came up with strange ideas like co-CEOs, jumped on the dot-com era right as it imploded (taking with it hastily conceived names like i-this and e-that), and retired the stench-ridden Pathways name.

Cipher in the nearly $1 billion they eventually paid to settle shareholder lawsuits and the grand total for those few weeks of financial fornication is $10 billion. What they got for their trouble was a mongrel pack of products HBOC had hastily snapped up for financial growth without any real plan except to keep the printing presses busy running off stock certificates.

Among those involved were certainly some crooks and some fools, but let’s not forget those who suffered most, those McKesson lifers who had stashed away years’ worth of shares of their unexciting company’s stock instead of risking their future on flaky fads like Microsoft and Dell. When lonely old conservative widower Dad McKesson brought home a sexy young step-mom named HBOC, she stole the kids’ piggybank.

The stock went from the mid-80s to the mid-teens. People I knew glumly tried to estimate how many more years they’d have to work until retirement with 80% of their investment gone. Even today, after eight years and with good company management, McKesson’s stock has recovered by only about half.

Only the jury can decide whether Charlie McCall and his associates are guilty or innocent, but I can say one thing: if they are found guilty, then I hope the pain they receive is commensurate with the pain they caused.

News 12/2/11

Top News

EDIS vendor Forerun will acquire substantially all the assets of competitor Emergisoft, including customer contracts, product rights, software, and services. Emergisoft President Jordan Davis will be the new VP of sales and CTO Godson Menezes takes over as director of operations. Forerun was formed in 2006 to commercialize ED software developed at Beth Israel Deaconess Medical Center in Boston. John Halamka is on the company’s advisory board.

Reader Comments

From Ralph Hinckley: “Re: Pat Cline of Quality Systems. Has officially left.” He announced in July that he would be retiring this year.

From The Tom: “Re: Carrier IQ. PC World has an article about Android devices that should raise concerns for folks using them in healthcare. I would think this has HIPAA implications.” A security researcher finds that performance monitoring software vendor Carrier IQ, which says its product is running on 150 million phones, is apparently installing virus-like software on Android, BlackBerry, and Nokia smart phones that logs every keystroke, screen touch, and Web search. The company got nasty with a quick denial and a cease-and-desist letter to the researcher, but after he put out a video showing what he had found, Carrier IQ suddenly gritted out an apology. Maybe their software can log how many times cell phone users call the dozens of law firms that are no doubt filing class action suits as we speak.

From Giselle: “Re: Medical Justice. Have you heard about the questionable agreements they sell to private practice physicians? The Center for Democracy and Technology has filed a complaint with the Federal Trade Commission arguing that the company itself was engaged in ‘deceptive and unfair business practices.’” Medical Justice is mostly known for applying a heavy legal hand to anyone (especially patients) who posts less-than-stellar comments about physicians on public sites, especially those of physician rating services (some of those sites claim Medical Justice also plants fake glowing reviews of its own.) Medical Justice also files counterclaims against expert witnesses with their state licensing boards and encourage physicians to make their patients sign contracts (a “Mutual Agreement to Maintain Privacy”) promising they won’t say anything negative about them. Every one of these services is of question legality (or at least questionable enforceability), but I can’t say that I don’t agree at least a little with what they do given absurd malpractice lawsuits.

HIStalk Announcements and Requests

Here’s what we have been up to at HIStalk Practice over the last week: Dr. Gregg preps for his audience with HIT’s Queen and King, aka Secretary Kathleen Sebelius and National Coordinator Farzad Mostashari. MU attestation figures from Greenway, athenahealth, and meridianEMR. AMA intros My Medications, a consumer app to track meds and allergies. CDC reports on ambulatory EMR adoption rates. Coming soon: the best “best practice” article you may ever read on how to handle a security breach, courtesy of Micky Tripathi of the Massachusetts eHealth Collaborative. If you aren’t yet a HIStalk Practice subscriber, this is the time to do it because Micky has some great stuff coming our way.

Thanks to Cindy for her nice post covering the various flavors of post-acute care (and thanks to the classy readers who posted their appreciation in comments on her article – she’s new at this, so she can probably use the encouragement.) Cindy will be following up shortly in a post about the IT systems used in those organizations. She and others have offered to keep HIStalk readers informed about developments in the post-acute areas, which I guarantee will soon be hitting the radar of CIOs as their hospitals start getting penalized for readmissions that might have been preventable by better care coordination and use of technology. It’s one of those things that the tea leaves (and experts) are telling me we should be talking about now rather than later.

On the Jobs Board: Java developer, IS Director – Hospital, Solutions Marketing Manager, Expert Communications Consultant. On Healthcare IT Jobs: SQL/EHR Programmer, Epic Certified ASAP Builders, Technical Services Manager.

I keep forgetting to mention these: the Resource Center lets you search for vendors or navigate through a rather slick index of product and service categories, with a nice description and contact information for each one you find. Brand new is the RFI Blaster (a working name), where you can enter just a few details about the consulting help you need, attach a document if you want, and then shoot the result off immediately to one, some, or all of HIStalk’s sponsors that provide consulting services, putting yourself in the catbird’s seat to sit back and wait for responses. We’re always trying to do cool stuff for sponsors, and cooler still is that both of these ideas came from provider readers who like giving business to those who support us.

Welcome to new HIStalk Platinum Sponsor Aventura. The Denver-based company’s technology provides doctors and nurses with near-instant access to the information they need at the place they need it, allowing them to spend more time with patients instead of pounding their keyboards in frustration and griping to the CIO about poor response time and convoluted logons. We found each other through my Innovation Showcase when my panel of reviewers voted them in (there’s a ton of information at that link, including videos, interviews, etc. that were part of their application.) CEO Howard Diamond has been really supportive in sending nice notes every now and then after our initial interview, also letting me know that he has hired three HIStalk readers recently. I was surprised and pleased to have the company support HIStalk as a sponsor, which I appreciate. Thanks to Howard Diamond and the Aventura folks (including those HIStalk readers who have just joined them) for supporting my work.

Here’s Alegent Health’s testimonial about Aventura, just in case you don’t feel like clicking over to the Innovator’s Showcase post.

We all have success metrics in our personal lives: the number of people who call us on our birthdays, how often our kids come home, and how many former flames turned just-friends still seem to harbor a bit of smoldering passion in remembrance of what once was. Out here in Internet-land, it’s a cold and inhospitable environment, so all Inga, Dr. Jayne, and I have as our feel-good accomplishment measures are numbers: (a) e-mail signups; (b) reader comments and rumor reports (c) shallow expressions of like via Face and LinkedIn;  and (d) clicks on the ads of sponsors who beam us into your living rooms. On the other hand, like a Pavlovian experiment, you can boost our mood using nothing more than your keyboard and mouse to increment those numbers by which we pitifully measure our self worth. And for that, we thank you.

Acquisitions, Funding, Business, and Stock

Tele-ICU program provider Advanced ICU Care closes on a new round of equity funding led by Trident Capital.

Hospital systems vendor eCareSoft will acquire Expert Sistemas Computacionales, a Mexico-based software developer. It’s an odd transaction given that eCareSoft is the US affiliate of the company it plans to acquire. Its SaaS-based, certified inpatient system was launched in January. The company signed Central Texas Hospital (TX) as a customer in April, claiming small hospitals can go live in as little as 120 days.

Sales

HealthBridge (OH) selects Clinical Architecture’s Symedical Server for its HIE infrastructure.

The Louisiana Health Care Quality Forum chooses Arcadia Solutions to help define its statewide quality improvement and measurement objectives and the HIT tools required to implement them.

The VA and DoD  award Harris Corporation two multi-year contracts worth $17.1 million to help their doctors operate an eye injury and vision registry.

Florida Memorial Hospital and Medical Center of Manchester (TN) select RazorInsights’ ONE-EHR.

Oakwood Healthcare System (MI) will expand its use of Streamline Health Solutions’ document management program through a direct licensing agreement and the purchase of additional Streamline Health solutions.

People

Myca Health, developers of Hello Health, promotes Steven Ferguson from VP of product management to patient management officer.

Health Revenue Assurance Associates appoints former Medical Learning manager Peggy Harper as its director of ambulatory services.

Cognosante adds Davis Foster (Evolvent, Vangent) as chief business development officer and SVP.

Healthcare robot maker Aethon names Peter Seiff as SVP of business development and product strategy. He was previously with McKesson Pharmacy Systems.

Nephrologist Thomas Stokes MD, medical informatics director at East Alabama Medical Center (AL), is recognized by the state hospital association for his involvement with the organization’s EMR implementation. The hospital says he donated money for employee education and also programmed a problem list that helped it qualify for $4 million in MU money.

Announcements and Implementations

The Kansas Health Information Network and ICA announce that KHIN has signed up its 1,000th provider to its statewide HIE that uses ICA’s CareAlign CareExchange and CareConnect technology.

Gateway Regional Medical Center (IL) goes live on Concerro’s ShiftSelect solution.

Nason Hospital (PA) implements the Access Intelligent Forms Suite to generate forms, wristbands, and medication barcodes for patients in its Siemens MS4 system.

McKesson will introduce RightStock, a usage tracking system for its AcuDose-Rx medication cabinets that helps prevent drug stock-outs, at the ASHP Midyear in New Orleans.

Nazareth Hospital (PA), part of Mercy Health System and Catholic Healthcare East, went live Thursday on CPOE with Meditech Client Server version 5.65. The reader-provided announcement from its internal Web site is above..

Government and Politics

The New York Times takes another look at Newt Gingrich’s Center for Health Transformation, which he insists isn’t a lobbying firm even though it works similarly (the difference, he says, is that he takes money only from clients whose positions align with his own). The newspaper found an unsecured backup of the members-only section of CHT’s site and turned up minutes of a conference call in which Gingrich had arranged joint meetings between his members and top-ranking federal officials on the topic of electronic medical records. Clients paid up to $200K annually for memberships, with CHT taking in $55 million over 10 years. One of the companies he pitched was HealthTrio, which he said could deliver a UK-type EHR for every US citizen for 10 cents per person per month (the company just named Gingrich to its advisory board this past June – above.) A Congressional staff member said off the record that Newt talked a lot about members of his center without disclosing that they were paying him: “It was a year before I even realized that the Center for Health Transformation was even a for-profit company because it didn’t sound like one.”

Former Massachusetts House Speaker Salvatore DiMasi starts his eight-year stint in federal prison after being convicted in June of taking kickbacks for steering state contracts to Cognos (IBM). He claims to be innocent and outraged.

Other

 CRN, a publication whose target audience is VARs and resellers, profiles Dell and its EMR VAR program. Dell has shifted its EMR sales approach away from direct to the customer after discovering that implementing a system from vendors like Allscripts or NextGen requires more integration than Dell initially realized. Of course, anyone who has been in HIT for some time could probably have advised Dell that implementing an EMR is not like installing Quicken. Dell is now partnering with local VARs that can provide onsite support and with application providers that offer solutions certified to run on Dell technology.

If you think you have mother-in-law issues, consider what it might be like to have Lisa Dawn Mack as your family matriarch. The former Valley View Hospital employee is arrested for stealing $178,000 from the hospital and another $47,000 from her daughter-in-law. She allegedly stole a portion of the money in a relatively mundane fashion by filing unauthorized mileage reimbursements. However, she also hired her daughter-in-law at the hospital, overpaid her for her consulting work, then had the daughter-in-law reimburse the overpayments  directly to Mack for the purpose of repaying the hospital. She also had the daughter-in-law give her a portion of her check to pay the IRS, but just kept the money for herself.

Cindy our post-acute care expert turned up this interesting article: an Irish hospital sends out male nurses in bicycles to the homes of senior citizens who are seeking to be admitted. The nurse approves the admission or is empowered to deliver the needed care directly in the patient’s home if they determine admission is not necessary. The patient avoids the stress of a hospital stay and society avoids the cost of it.

Cerner wants to buy all 65,536 IP addresses held by defunct Borders Books for $12 each.

Weird News Andy is showing a fondness for a 50-year-old cartoon in labeling this story, “Flying squirrel in the ER, no big deal. Now if they had a moose …” This particular version of Rocket J. Squirrel was found in an ED trauma room of Robert Wood Johnson University Hospital (NJ), where it repeatedly flew into a glass wall trying to escape. The fire department gently escorted it off property and released it in a nearby wooded area, possibly eliciting fan mail from some flounder.

Here’s a Medical Justice-type news item, although that organization isn’t named as being involved: an 83-year-old man fresh out of ICU after having a stroke is greeted by his neurologist, who breaks the ice by saying he “had to spend time to find out if you were transferred or died.” The family is appalled and the patient’s son posts negative comments about the doctor’s bedside manner on several websites, quoting one of the neurologist’s colleagues who called the doctor “a real tool.” The doctor files a defamation suit against the man, but the judge dismisses the case, saying “a real tool” is too vague to be considered defamatory.

Sponsor Updates

• Mountainside Hospital (NJ) achieves Meaningful Use using its clinical system from Healthcare Management Systems.
• Passport Health offers a white paper discussing the increased importance of patient payments in the healthcare revenue cycle.  
• Rita Russell, senior director of program management for RelayHealth, will present at NCPDP’s Education Summit in February.
• Melinda Noonan DNP, RN, NEA-BC, director of nursing operations for Rush University Medical Center, is quoted about how her organization uses data from TeleTracking Technologies to predict staffing needs, patient volumes, and other trends.
• Forbes names Shareable Ink to its list of America’s Most Promising Companies.
• The Greater Houston HIE appoints Encore Health Resources founder Ivo Nelson to its board.
• Sentry Data Systems offers a white paper on HRSA’s 340B drug billing audits that start in February.
• NetApp awards World Wide Technology Inc. two Partner Excellent Awards.
• CynergisTek and Diebold will host a December 13 webinar entitled Managing and Monitoring Healthcare Data.
• MEDSEEK announces that 1,000 hospitals are using its eHealth solution.

EPtalk by Dr. Jayne

Social media is increasingly used to gauge public health, according to American Medical News. It cites a study that appeared in Archives of Pediatrics & Adolescent Medicine that looked at Facebook posts to identify college students who may have drinking problems. I’d like to take this opportunity to remind everyone of the perils of friending co-workers and (gasp) your boss. And to my employees who are my Facebook friends, feel free to filter your drinking exploits from my news feed (unless there is a good martini recipe involved.)

In CMS news, the deadline for all Medicare providers to re-enroll has been pushed back to 2015. That’s an additional two years to try to ensure smooth processing without significant backlogs or other unintended consequences. Additional changes to the enrollment system including electronic signatures, document upload, “seamless” password resets, and other features are slated to be online by the end of 2012.

With physicians facing a 27% cut in Medicare reimbursement effective January 1, many are reconsidering their participation options. Although we’ve seen these threatened pay cuts several times over the last decade, this is the first time I recall seeing the AMA advertise a Medicare Participation Kit to guide physicians as they consider becoming non-participating providers. It includes sample letters to patients for providers choosing to opt out or limit their Medicare panels as well as informational downloads.

I mentioned recently a study that showed that physicians who own nuclear and stress testing equipment are more likely to order those tests. Presented this week at RSNA was a study looking at MRI imaging. Physicians who owned MRI machines had more than twice the number of normal results as physicians who had no ownership ties.

A study from the Department of Veterans Affairs looked at Internet-delivered provider education as a way to reduce cardiovascular risk in patients who have had heart attacks. Providers received educational modules, practice guidelines, literature summaries, and e-mail reminders for more than two years. Looking at seven clinical indicators, there was minimal difference in outcomes.

In non-technology news, Pfizer’s blockbuster drug Lipitor went generic Tuesday night. I wonder if patients were lined up outside the pharmacies at midnight like readers waiting for a Harry Potter installment?

For those of you who are probably like me and work in front of the TV, this article about infertility and laptop use was of interest. It seems that use of Wi-Fi connected laptops has been shown to decrease sperm quality. For the curious, the sperm were randomized and exposed to laptops after reaching the lab. Investigators conclude that actual human studies are needed.

A friend sent me this news item for Inga. The Rock ‘n’ Roll Las Vegas Stiletto Dash is set for this weekend at the Palazzo. Competitors must wear at least a 3” heel for the 50-yard dash, which ends (fittingly) at a champagne bar. Heels cannot be taped, tied, or adhered to the foot. I think Inga and I may have to do our own Stiletto Dash at HIMSS – I’ve already started looking for the perfect shoes for HIStalkapalooza.

WANTED: S&M Show Seeks Mosh Pit
By Dr. Gregg

Certainly you heard the word of the deadline pushback to ease the pressure on folks trying to decide whether or not to hit the Stage 1 starting blocks. Madam Secretary Kathleen Sebelius announced that little gem Wednesday at a meeting held in the Unified Technologies Center of Cuyahoga Community College in Cleveland. Along with this, she and Dr. Mostashari announced the new findings of a doubling of EHR adoption in just the past two years.

However, this was yesterday’s news, and I’m fairly sure you’ve already read enough diversity of opinion via tweets or blasts or blogs on it. So instead of yet another “what does this really mean” rehashing, I’d like to share a few thoughts I thunk while sitting in the crowd at the aforementioned Sebelius & Mostashari Show in Cleveland.

First off, Kathleen Sebelius moved up this year from 57th to 13th on the Forbes list of “The World’s 100 Most Powerful Women.” You can see why: she has a countenance that shows the ferocity acquired from uncounted political battles and the seemingly stern “hide” that comes from learning to slough off the daily barrage of slings and arrows that inevitably fly in that eternal battleground.

Yet, as I hear from folks who know her well, she is also approachable in public and attentive to the opinions and presence of those around her. Plus, according to Wikipedia, she’s a huge jazz fan and has an untarnished record going of attending thirty (30!) consecutive New Orleans Jazz Fests. Now, I don’t care how stern you may appear on a panel or in a board meeting: anybody who has ever been to NOLA’s Jazz Fest knows a little something about how to have fun and what some really, really good music is all about.

So, following the main act by Sebelius and Friends (i.e., the panel discussion,) up steps “The Mostashari.” I wanted to say that he was the opening act for Sebelius given her position, power, and the fact that she was the headliner. However, since his act followed hers — and especially because of the supreme “choreography” of his act — I’m not sure this is true. To say he stole the show would be absolutely true.

Even before the “show” had begun, Farzad was working it. He came into this roomful of some 100+ folks and glad-handed all around before the show started, grinning that infectious grin of his almost non-stop. He was engaging, but at all times obviously a man on a mission.

During the opening panel’s time on stage, Farzad would be very attentive-appearing, but with an almost unobtrusive manner and with an almost a rhythmic beat, he’d be checking e-mails or texts. (Both he and the Secretary would text or check e-mails off and on continually throughout the performance, of course. Even Ms. Sebelius was pretty discrete about it, I must admit.)

But, when the panel was done and break time was over, it was time for the real show to begin: “Farzad: The Champion Physician Champion.”

Originally, the “intimate discussion period” was supposed to be with Farzad and about 12 of us. But, some 50 or so folks were still hanging around after the break, apparently thinking they might be a part of this session. We had already started out into a hallway to head toward a smaller room for the chat when it became clear that there was some confusion as to just who was invited. With barely a skipped beat, Farzad says, “That’s great! Let’s just make it an intimate meeting with 50.” So, about face, back to big room we went.

Now, as many of you may have read here, I used to do sound engineering in the “big time” rock-n-roll world. I gotta tell ya’, I’ve never seen an act by any band or performer – especially by ANY geek, even the inimitable Steve Jobs – that had more true “rock star” quality than did Dr. Mostashari.

He steps down off the stage onto the floor to be at the same level as the crowd. He bounces from one side of the room to the opposite. He is charged with energy. He starts off the show with the requisite rock star proclamation: “Ohio, you’re my new favorite state!” (Hello, Cleveland!) He bounds back and forth. He actively engages the crowd. He applauds audience contributions at every opportunity. He sits on the dais, takes off his suit jacket, and rolls up his shirt sleeves, ready to get to work. He challenges the crowd. He unflinchingly accepts challenges from the crowd. He throws in a last “Ohio, I love ya!” before the show ends. He sticks around a good amount of time afterwards to talk to the masses.

Dr. Mostashari, you are, sir, without question, a rock star. You are the head cheerleader for all HIT physician champions and you are superb in the role. Thanks for the great show.

The only thing missing was the Mostashari Mosh Pit.

Contacts

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

Post Acute Care Market and Providers 11/30/11

I am a long-time reader of HIStalk. Even though I do not work in the acute care space, I find that monitoring what is going on in hospital and physician practice IT helps in planning for what might be coming down the road for post acute care.

A while back, there was a request for information about providers in the post acute care market, and I thought, “Hey, I know about that.” So, like the “long-time listener, first-time caller” that you hear on radio talk shows, I contacted Mr. H about a journalistic opportunity. He agreed, so here we go.

This article is the first of a two-part series about providers and technologies in the post acute care market. This is not meant to be an exhaustive analysis, but more of an overview to give you a bit more insight in to this part of the health care continuum.

Home Health

The term home health includes several types of providers, which can be quite confusing for consumers and healthcare practitioners alike. For purposes of this discussion, home health means a Medicare-certified agency that provides skilled care services. In 2009, 3.3 million Medicare beneficiaries received care from 11,400 home health agencies, for which Medicare paid $19 billion.

Population served

People who are under the care of a physician who require intermittent (less than eight hours per day), skilled (nursing, physical therapy, occupational, or speech therapy) home health aide, or medical social services. Almost exclusively, the payer is Medicare. Other payers include Medicare HMO, Medicaid, and commercial insurers. Home health eligibility is not dependent on a hospital stay; however, hospitals are by far the majority referral source for home health.

Special rules and regulations

The “patients” must be confined to their home in order to receive services. “Confined to home” is a misunderstood regulation in home health, even amongst the providers themselves. Essentially, what Medicare says is: the patient should leave the home only infrequently, and, when they do, it is a significant and taxing effort, usually because of medical reasons.

Medicare-reimbursed home health services are not for long-term custodial care. The services are focused on helping the patient become independent as soon as possible. The average number of visits (all disciplines) per patient for a 60-day episode of care in 2008 was 37.

Reimbursement structure

In 2000, Medicare changed from “we will pay you what it costs you” per-visit reimbursement to the Prospective Payment System. Patient acuity (clinical and functional) is measured at specific points in a patient’s episode of care. These skilled assessments are performed using the OASIS assessment tool. The result of the assessments is a Case Mix Weight (acuity) that determines how much money the home health agency will receive for a 60-day episode of care. Patients do not pay a co-payment or deductible to receive home health services.

Regulatory environment

Post acute care is highly regulated, with regular on-site surveys by state and federal regulators. Many home health agencies have achieved accreditation through the Joint Commission or other accrediting bodies.

Ownership

Home health agencies can be affiliated with a hospital, free-standing, for-profit, or not-for-profit.

Private Duty

Private duty home care agencies provide home care aides, companion care, homemaker services, and possibly nursing services in the client’s home or place of residence.

Population served

This varies tremendously from agency to agency—from newborns to seniors. Some agencies provide only unskilled (aide and companion care) and some provide highly skilled nursing (infusion, ventilator) services.

When compared to the costs associated with a retirement community, private duty home care can be an affordable option for many seniors. The average annual cost for a nursing home is $69,715. The average annual cost for an assisted living facility resident is $36,372. (Source: MetLife Market Survey of Nursing Home & Assisted Living Costs). Seniors who want to remain in their homes can often do so cost effectively with a few hours of care a week. For example, 20 hours of companionship home care a week costs approximately $1,500 a month, or an average annual cost of $18,000.

Reimbursement structure

Many services are paid directly by the “client”. Some insurance models will pay for some private duty services — Medicaid, long term care insurance, worker’s compensation, and commercial payers.

Regulatory environment

This is all service dependent. If only companion services are provided, depending on the state, only a business license may be required. If personal care (home care aide) or skilled nursing services are provided, then state department of health services (or equivalent) regulations will apply.

Ownership

There are some national chains, but many are privately owned by individuals who tend to be active in their local communities.

Home Health Registries

The reason I specifically chose to discuss registries is because they many times are confused with home health agencies since their name or advertising may include “home health.” These businesses are essentially a referral agency. They are the middleman between certified nursing assistants, home health aides, companions, etc. and an individual looking for services.

Population served

No particular population—newborns to seniors.

Special rules and regulations

None, since they are only a placement resource.

Reimbursement structure

Cash. They take a percentage from the person that is able to gain employment from their referral.

Regulatory environment

Business license. May having a bonding requirement.

Ownership

Private.

Hospice

Population served

Individuals who are terminally ill, their families and friends, and the communities in which they are located. Most hospices accept payment from Medicare, Medicaid, and commercial payers. Some with excellent funding may not require the individual to pay and will not bill insurance.

Hospice services may be provided in the client’s place of residence (home, assisted living facility, and skilled nursing facility) or a dedicated hospice facility, many times referred to as a “Hospice House.”

Special rules and regulations

Specifically, I will discuss the regulations for a hospice that is reimbursed by Medicare. All of the “clients” must have a “Certification of Terminal Illness” signed by a physician that states that it is reasonable to believe that the individual has less than six months to live due to their terminal illness. When the individual elects the Medicare Hospice benefit, they are stating that they no longer will seek curative treatment for that specific ailment. This election may be revoked by the person at any time during their care in hospice if they decide to receive potentially curative treatments for the terminal illness.

A significant percentage of the services hospices provide must be performed by volunteers. The agencies are responsible for supporting their local communities with education about terminal illness and will provide counseling services to the community — for example, in a high school where a tragedy has taken place. Hospices must provide bereavement services for 13 months after the person has died to any person designated to be a member of the client’s “family.”

Reimbursement structure

Paid on a per diem basis for as long as the client is under Medicare-reimbursed hospice care. Medicaid and commercial insurers will pay differently depending on the state and the client’s policy.

Regulatory environment

Medicare regulations state that the care provided to the client is done by an “interdisciplinary team” made up of nurses, social workers, spiritual support, aides, counselors, and the hospice medical director.

Ownership

National chains, hospitals, foundations, and communities,

Skilled Nursing Facilities, Nursing Homes, Long-Term Care

A nursing home or skilled nursing facility (SNF) is normally the highest level of care for older adults outside of a hospital. Nursing homes provide what is called custodial care, including getting in and out of bed, and providing assistance with feeding, bathing, and dressing.

However, nursing homes differ from other senior housing facilities in that they also provide a high level of medical care. Each resident’s care is supervised by a physician, with skilled nursing care and rehabilitation services available on site. Some facilities specialize in stroke care, dementia and cognitive services, neurological disorders, etc. Many folks who have had orthopedic surgery (total joint replacements) will go to the skilled nursing facility to get rehabilitation services after their acute care hospitalization.

2011 statistics: 15,682 facilities serving 1.4 million residents. The average facility size is 109 beds at 80% of capacity.

Population served

Mostly frail seniors, the severely disabled, and individuals with cognitive disorders.

Special rules and regulations

It is said that outside of the nuclear industry, long-term care providers are the most regulated. There are local, state, and federal regulations. Under the federal Older Americans Act, every state is required to have an Ombudsman Program that addresses resident and family complaints and advocates for improvements in the long-term care system.

Like home health, a standardized clinical and functional assessment called the MDS must be performed at regular intervals to determine the resident’s acuity and the services they require, which drives reimbursement.

Medicare residents must have a qualifying hospital stay prior to admission in to the SNF. Medicare will cover 100 days of service for that “spell of illness.” If the resident is discharged from the facility prior to the 100th day, either to the community or the hospital, they can return to the facility within 30 days and continue that same 100 days of coverage. If they do not, they must wait for 60 days and have another three-day hospital stay in order for Medicare to cover another episode of care. So if they return to the facility between Day 30 and 60, Medicare is not paying.

Reimbursement structure

Medicare 14.2 %, Medicaid 63.6%, other/government 22.2%. There are some commercial payers, workers compensation, and long term care insurers.

Ownership

National chains, regional companies, private, for-profit, not-for-profit. About 6% are hospital owned.

Assisted Living Facility

Assisted living is a retirement housing facility that provides independent living while offering extra help where needed. Some common services are help with getting dressed, laundry assistance, transportation, housekeeping, cooking and preparing meals, and medication assistance.

Assisted living facilities can stand alone,or be a component of a senior living facility which includes independent living, assisted living, and skilled nursing facilities all on one campus. Many assisted living facilities have special secured (locked) dementia or “memory” units.

Population served

Individuals of retirement age.

Special rules and regulations

Have to meet many of the same regulations as a skilled nursing facility with regard to building, safety, personnel requirements, etc. Nursing oversight is required for personal care services and medication assistance. Ombudsman oversight occurs in this environment as well.

Reimbursement structure

Mostly reimbursed by the individual. Some long-term care insurers will cover.

Regulatory environment

Highly regulated, oversight by the state where the facility is located.

Ownership

National chains dominate the market, some affiliated with religious organizations.

Durable Medical Equipment

Durable medical equipment is special equipment for home use that provides therapeutic benefits or helps patients perform tasks they would otherwise not be able to accomplish. Durable medical equipment is defined as equipment that can withstand repeated use, serves a recognized medical purpose, generally is not useful to an individual without an illness or injury, is appropriate for home use, and is prescribed by a physician as medically necessary.

Typical equipment supplied: wheelchairs, hospital beds, lift chairs, scooters, diabetic supplies, canes, crutches, walkers, commodes, home oxygen, and traction. Many vendors will have a retail store front and equipment warehouse with home delivery service.

Population served

Newborns to seniors.

Special rules and regulations

Depends on the payer source and whether or not they are accredited. Medicare reimbursement brings special requirements.

Reimbursement structure

Cash, commercial payers, Medicaid, Medicare.

Regulatory environment

Recent changes to the DME landscape has turned the industry upside down. Section 302 of the Medicare Modernization Act of 2003 (MMA) established requirements for a new Competitive Bidding Program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Under the program, DMEPOS suppliers compete to become Medicare contract suppliers by submitting bids to furnish certain items in competitive bidding areas, and the Centers for Medicare & Medicaid Services awards contracts to enough suppliers to meet beneficiary demand for the bid items. The new, lower payment amounts resulting from the competition replace the Medicare DMEPOS fee schedule amounts for the bid items in these areas. All contract suppliers must comply with Medicare enrollment rules, be licensed and accredited, and meet financial standards.

Ownership

Some national chains, many private.

I hope this information helps you understand these post-acute health care services and providers. Part Two of this series will cover the information systems typically found in these environments, who the major players are, and what things to consider if looking to partner with these entities in shared payment arrangements, or ACOs.

Cindy Gagnon, RN, FNP has worked as a provider of post acute care services as well as a functional / clinical designer, implementation specialist, and manager of support services within the post-acute care information technology community. You may contact Cindy at: cindy.gagnon@comcast.net.

Meaningful Use Stage 2 Deadline Extended

Under a news release headline of “We can’t wait: Obama Administration takes new steps to encourage doctors and hospitals to use health information technology to lower costs, improve quality, create jobs” HHS announced today that providers starting participation in the Medicare EHR incentive programs in 2011 will not be required to meet Stage 2 standards until 2014, a year later than was originally announced.

The previous timetable allowed providers to sit out a year and begin participation in 2012, thereby automatically extended their own Stage 2 deadline until 2014.

The announcement includes an HHS reminder that “doctors who act quickly” (by February 29, 2012, according to previously published dates) can still qualify for 2011 incentive payments.

The announcement also cites a new CDC study that found that 52% of office-based physicians plan to seek HITECH money, with 34% of practices now using electronic records software with at least “basic” capability.

From the announcement:

HHS also announced its intent to make it easier to adopt health IT. Under the current requirements, eligible doctors and hospitals that begin participating in the Medicare EHR (electronic health record) Incentive Programs this year would have to meet new standards for the program in 2013.  If they did not participate in the program until 2012, they could wait to meet these new standards until 2014 and still be eligible for the same incentive payment. To encourage faster adoption, the Secretary announced that HHS intends to allow doctors and hospitals to adopt health IT this year, without meeting the new standards until 2014. Doctors who act quickly can also qualify for incentive payments in 2011 as well as 2012.

These policy changes are accompanied by greater outreach efforts that will provide more information to doctors and hospitals about best practices and to vendors whose products allow health care providers to meaningfully use EHRs. For example, in communities across the country HHS will target outreach, education and training to Medicare eligible professionals that have registered in the EHR incentive program but have not yet met the requirements for meaningful use. Meaningful use is the necessary foundation for all impending payment changes involving patient-centered medical homes, accountable care organizations, bundled payments, and value-based purchasing.