Time Capsule: Can EMRs Sweeten their ROI by Moonlighting as Research Databases?

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.

Can EMRs Sweeten their ROI by Moonlighting as Research Databases?
By Mr. HIStalk

I’d never heard of the Clinical Data Interchange Standards Consortium (CDISC) until last week. That’s when that group announced the kickoff of a new interoperability project, this one involving linking EMR systems to the information systems of clinical investigators who are performing drug or disease research.

The audience is researchers, the Centers for Disease Control and Prevention, or registries for patients or disease. The IHE is involved in the testing and will demonstrate the results at the HIMSS conference.

I’m not usually interested in this sort of project. I’ve seen first-hand what an insurmountable effort it can be just to get hospital systems to swap clinical data across the hall, much less with national third parties. Still, this is an exciting indicator of how quickly the now-common idea of interoperability has taken hold. If nothing else, RHIOs have made hospitals think about the value of their patient information and how to exchange it in standard electronic formats.

Getting and keeping drugs and devices on the market is expensive and information-intensive. Several small, highly profitable companies have sprung up to help enlist patients in studies, to do the rigorous paperwork required, and to design research methodologies. Their key commodity is information.

Hospitals have patient information that’s available nowhere else, the kind that arouses researchers and manufacturers that have far deeper pockets. Repurposing that existing information by making it available to those willing third-party customers, even when motivated purely by mission-supporting cash, is at least more beneficial to society than running a McDonald’s or building medical office buildings.

Let’s say your hospital implements a well-integrated, information-rich EMR system that can easily tie together everything about patients from medical history to demographics to procedure history. Suppose you add genomic data to the mix, storing information about family history, lifestyle, and a longitudinal history of disease, treatment, and outcomes. Your patients will benefit, but the information has an equally high value to those third parties trying to assemble or execute big research projects.

Drug companies and device manufacturers need the data that lives in your clinical systems. How else will they be available to target research to a very narrow range of patient types, maybe even those with a rare genomic profile? It could help them identify appropriate research subjects, design post-marketing surveillance, study population-based outcomes, and catalog adverse events. The information you provide could either be de-identified or made available only if individual patients opt in. The benefit to patients is access to a wider variety of treatments and protocols, most likely free to them if tied to a research project.

You wouldn’t just give that information away, of course. Hospital information is far deeper and more detailed than what’s available from any other source, with a wide scale to match. All you need is sophisticated EMR functionality and a relentless push to get every scrap of clinical information codified, categorized, and cross-referenced.

In the movie Wall Street, Gordon Gekko says, “The most valuable commodity I know of is information.” That’s true of clinical data, especially when those who value it can pay. Just don’t sign away too cheaply the rights to your treasure trove of data, even if the interested customer is a RHIO or third party data vendor.

HIT Vendor Executives – Part Two of Two 12/30/11

We asked several HIT vendor executives the following question: Where do you plan to invest your research and development dollars over the next 1-2 years?

Tim Elliott, Founder and CEO, Access

We are focusing on three technologies that every hospital needs: electronic signature, a data bridge between clinical devices and systems and EHRs, and paperless, online e-forms.

The next generation of e-signature not only enables patients to quickly and securely authorize e-form registration packets and bedside consents, but also offers administrators the convenience of a server-based model. A clinical data bridge can capture and standardize output from devices (such as EKG traces and surgery images) and systems (perinatal documentation, COLD feeds, etc), and interface these directly into EHRs – with no paper or manual indexing.

Finally, we’re giving hospitals a way to transform slow, inefficient paper-based processes – such as onboarding, capital requests and physician referrals – into fast, collaborative, paperless ones. Users will be able to access electronic forms from their browser, add attachments, apply digital signatures and send through the proper channels, and to track each stage of the process. Upon completion, a copy of the form is archived in the ECM system and data posted to business and/or clinical systems. With healthcare facilities shooting for full EMRs, we’re doing our part to create technologies that fill the gaps, and are focusing our R&D on removing paper from as many processes as possible.

Ray Dyer, CEO, Acusis

As a clinical documentation solution provider, we continue to look to our customers and healthcare IT market drivers. Given the many transformations underway, driven to a large degree by healthcare provider behavior, we are planning on investing our R&D funding in user intelligence tools including decision support and patient care analytics as well as mobile solutions development. We believe these areas will continue to be driven by customer need and demand, requiring data availability with strong privacy and security provisions. Acusis is poised and preparing to meet these challenges.

Dan Herman, Founder and Managing Principal, Aspen Advisors

Aspen Advisors’ investments will be focused on the expansion of our current services to address the needs of our clients:

• Adoption of EMR technologies and clinical informatics;
• Healthcare reform in support of “accountable care” delivery and financing models;
• Operational integration of Business Intelligence and Data Warehousing solutions to enhance care delivery, improve quality, reduce costs; and
• Improved reliability and cost effectiveness of technology infrastructure through the implementation of structured IT service management processes.

We will continue to invest in the development of structured, repeatable, yet flexible methodologies for planning and assessment, implementation management, and operational performance improvement.

We will also continue our investment in training programs for our consultants, so that our clients will continue to see the consistent application of expertise and delivery of service as our firm continues to grow.

Don Graham, General Manager, Billian’s HealthDATA

Our R&D investment will focus primarily on improving our data on outpatient care, and the better use of social media internally to communicate who we are and what we have.

With outpatient surgical visits now accounting for almost two-thirds of all surgical visits in the US, it is an area that our customers – healthcare vendors – are paying more and more attention to. We in turn must provide them with the data they need to best address this trend, which doesn’t show any sign of slowing down in my opinion.

As for social media, it’s proving to be the most effective way to distribute the news. That includes, of course, healthcare news. We realize that our customers and their provider customers are increasingly using social media as a means of communication and self-education, not to mention public relations and marketing. Patient referrals, good and bad, will have an ever-increasing influence on healthcare-related decisions made by the public, and the public’s migration to social media is obvious.

We, of course, want to be where our customers are, whether that be Twitter, LinkedIn, or blogs like HIStalk, so we’ll be ramping up our social media presence internally to make sure that staff are engaged and conversant in the healthcare discussions taking place online.

Stuart Long, President, Capsule

As the leaders in device integration, we’ve always been in the data business. Yet data needs are rapidly evolving. We are going well beyond the basic connectivity of data into information system(s). Basic connectivity is actually well understood as a necessity at this point; hospitals get that automating the vitals collection process is critical to recovering nursing hours, reducing charting hours and improving patient care. What they really need is better, more useful data to help improve decision making, to alert them to impending conditions faster and to improve the quality and safety of patient care overall.

We’ve reached a tipping point; hospitals are starting to scream “information overload.” Our customers are saying “we get so much data, from so many sources, that we need help sorting through it all; we need it presented in a meaningful way so we can act upon it faster.” We hear them loud and clear and will therefore be investing heavily on data; on how we increase the value of data so we can manage and disseminate the discrete data and communicate additional relevant context and meaning of that data to the right caregiver, at the right time, about the right patient. It’s a tall order and will take a lot of work with our EMR partners as well to make it a reality, but I think we are in the right place, at the right time to make it all happen.

Mac McMillan, CEO, CynergisTek

That’s easy — on the areas of privacy and security representing the greatest challenges for our customers.

We have always prided ourselves on staying out ahead and anticipating the needs of the industry and the needs of our customers in privacy and security. Five years ago, that meant attacking things like data leakage, encryption, and log management/auditing. Today it still involves finding better ways to monitor activity in the enterprise, but it also includes things like securing the cloud, defining managed security services for healthcare, managing the risk associated with the proliferation of mobile devices and medical devices that are not secure, and finding ways to better manage the security requirements with Business Associates.

Healthcare has enough complexity in its environment and more than enough on its plate with HIE, ACO, ICD-10, etc. It needs practical security strategies and solutions that work and are effective at stemming the tide of breaches like we have seen this year. We believe that in order for healthcare to win the battle with privacy and security, it’s going to take an investment in the right technologies and integration of Managed Security Services into compliance programs. We understand that technology alone is not the answer, and so the focus should be on implementation strategies and building the right processes around these technologies that enable them to be successful.

Michael O’Neil, CEO, GetWellNetwork

In recognition of the emerging reality that healthcare will be delivered anywhere and everywhere, no matter what the time, device or location, GetWellNetwork will sustain its investment in innovative Web-based, mobile phone and cable television technologies. When used properly, such technologies will support communication, education and even engagement throughout a patient’s care journey — from the home to the physician office, hospital, imaging center, or pharmacy and back to the home once again.

Platform-agnostic, technology-enabled patient engagement will be indispensable to providers, payers, and vendors as they work collaboratively to reduce hospital readmissions, promote self-care, boost patient and member satisfaction, and decrease cost per case. At GetWellNetwork, we are making significant investment in helping providers fulfill Stage 2 and 3 Meaningful Use requirements, and address the evolving challenges of medical home, accountable care and bundled payments.

Peter J. Butler, President and CEO, Hayes Management Consulting

At Hayes, we plan to invest R&D dollars in our hospital billing compliance software, MDaudit Hospital. It is designed to give auditors access to billing data to support revenue integrity, helping them to eliminate the errors for which CMS routinely recovers payments through its integrity programs such as RAC, MAC, and the efforts of the OIG.

However, we are finding that our clients are increasingly asking us about using this tool for other strategic projects such as ICD-10 documentation improvement, Meaningful Use, and data mining. Therefore, we are exploring related tools to use for these additional purposes. For example, via our recent integration with MediRegs clients can look up diagnosis and procedure codes and documentation requirements while in MDaudit. Additionally, some of our auditors are using MDaudit as a physician training tool on ICD-10 documentation.

Tiffany Crenshaw, President and CEO, Intellect Resources

Intellect Resources is investing in identifying and breeding new talent for the healthcare IT industry, with emphasis on training and go-lives.  In 2011 we debuted Big Break, a high-energy recruiting event designed to select an entire training and go-live teams in short period of time. Big Break is marketed towards individuals with no or minimal healthcare IT experience who have the right attitude, enthusiasm, and potential.  In an intensive one-day recruiting event, job applicants must complete a series of rigorous tests – one-on-one and panel interviews, extemporaneous public speaking, group work and classroom presentation skills – designed to identify only the best training and go-live talent.   

Once selected, Big Breakers complete an intensive course with classroom and hands-on learning, credentialing them in the appropriate EMR. As a result, a hospital system is able to select an entire training and go-live team in just a few days. Because Big Breakers do not typically have prior industry experience, they can often be secured at a fraction of the cost. As a result, hospital systems are able to breed and retain this new talent at a fraction of industry costs in a short amount of time.

Doug Burgum, President and CEO, Intelligent InSites

In our pursuit of improving care while lowering costs, we’ll be investing in three primary areas in the next 1-2 years.

First, one of Intelligent InSites’ most important objectives is to improve caregivers’ ability to spend more time at the patient bedside. To this end, we’ll be continuing our R&D investment in automating non-value-added manual tasks—including EHR data entry and finding available, clean equipment through easy-to-use applications—to give caregivers more time to spend with patients.

Second, as our solution utilizes RTLS and RFID technologies to know the location, status, condition, and interaction of all tracked equipment, patients, and staff throughout the hospital, we collect a massive quantity of operational data, every minute, every day, month after month, year after year. Through our Business Intelligence solution, we help our customers harness this “Big Data” to produce actionable insights critical to making sound and timely decisions, by utilizing flexible, high-impact, easy to create reports.

Third, because real-time data is generated from a wide variety of data sources, and because real-time intelligence can empower multiple healthcare IT systems, we’ll be continuing our investment in our partner ecosystem. We will continue to integrate with the expanding set of RTLS hardware vendors, and we’ll continue to expand our interfaces with EHR solutions, communications platforms, asset management applications, building management systems, and nurse call systems.

We are excited about investing in the future of RTLS, the “magic” of enterprise RTLS software, and helping our customers to truly improve the care they deliver, while simultaneously lowering their costs.

Tom Carson, CEO and President, MD-IT

MD-IT has traditionally developed and delivered software functions that provide or support practical use of technology for physicians and patients, and that will continue to be our focus. Like most vendors, we will keep an eye on Meaningful Use requirements and other market developments, but identifying specific features beyond the near term is tough, as the HIT market is quite volatile at this point.

We expect to see evolving demands as the industry moves from what we think of as effectively an EMR version 1.0 environment to a more mature EMR version 2.0 environment that is more sensitive to the needs of physicians and patients as the primary users of these systems. Certainly near-term efforts will be directed to expansion of our popular mobile functionality that streamlines physician workflows, as well as continued broadening of our interoperability functions that link providers, patients, and payors.

Patrick Hampson, Chairman and CEO, MED3OOO

We are focusing our investments and resources in numerous areas. MED3OOO has committed to focus our knowledge, products and services with a MED360 view of healthcare delivery. We are not like most vendors just supplying systems. Our investments will continue to expand our current operational and technical capabilities and offerings. We will continue to integrate our proprietary systems, and continue our investments in capturing and using data of populations. We will continue to invest in tools that providing information across the entire spectrum of care focused on: efficiencies wherever we can find them, the patient and provider experience, the cost and most importantly the quality of care delivery. We want to be the best partner to providers that is in the industry.

Our investments in point-of-care capabilities will also create a great differentiation for the providers using our proprietary systems. As part of this, we are investing in the area of clinical decision support. “CDS” in an Electronic Health Record can take many forms. It is certainly more than providing guidelines to a provider. We want to focus on the user experience and want to spend a lot of effort with physicians reviewing workflows to determine how CDS can truly add value to the provider and patient when care is being delivered. Our addition of Quippe is just one example of these efforts. Quippe is the state-of-the-art documentation tool in the industry and is the basis of enhanced CDS within our InteGreat EHR offering.

These efforts are also critical to the physicians and hospitals we have partnerships with, but who are on older technologies or legacy systems even though they come from today’s brand vendors. Physicians already have investments in these systems. They too, need these higher level capabilities and they too need knowledge-based solutions. While these systems may be older and not web- based, MED3OOO, as their operating partners we work to provide solutions to improve on the capabilities these older systems just do not have. A system agnostic approach allows us to not just throw them out and waste physician’s precious capital. We try to maintain those systems and it is somewhat like the BASF commercials, “We don’t make things, we make things better.”

Lastly we will continue to expand our significant M3IQ data warehousing capabilities, capturing data from disparate systems, continuing our focus on the promise of combining financial claims and clinical data, and turning that data into actionable, predictable intelligence.

Robert Connely, Senior Vice President, Medicity

We are going through a period of enormous change in healthcare, and it’s clear that healthcare IT will play a critical role in that change. Medicity is focused on a strategy that will enable rapid adaptation to changing requirements while realizing a more cost-effective model that we believe will lead the next generation of information technologies.

Today, we’re building out the underlying IT infrastructure required for tomorrow’s healthcare, including integrating EHRs, building data exchanges, and standing up repositories. We are expanding our analytics capabilities and are involved with developing standards like ONC Direct. 

Many of our R&D efforts are targeted at integrating and improving our family of products. The strategy levers common technology platforms, modular apps, and cloud services. We believe that by porting much of our current functionality into apps designed to run on a platform like iNexx (Medicity’s individual network exchange), we can reduce time to market for new features, control development costs, and provide a greater opportunity to adapt to new needs quickly. 

We believe that technology is evolving to the point that it can adapt to people as opposed to people adapting to the technology.  Towards this end, we continue to invest in emerging technologies and markets.  For example, our efforts range from pioneering pervasive analytics that employ software agents to better analyze information at the source, to enabling consumer platforms to drive better health.  We are also focused on building solutions that leverage payer, provider, and consumer interactions to create more effective care.

Peter Kuhn, CEO, MEDSEEK

MEDSEEK has always been ahead of the curve, developing strategic patient engagement and management solutions that help healthcare executives realize cost savings by improving care collaboration within existing workflows and find new revenue streams by finding and engaging patients. We were among the first to deploy our enterprise solutions to assist hospitals in finding, engaging, activating, and managing patient populations, and we’ll continue to invest in developing those solutions to allow hospitals to better prepare and position themselves in the rapidly changing world of healthcare reform.

Additionally, the strategic use of predictive analytics will ultimately become the market differentiator for hospitals, which is why we acquired Third Wave Research, Ltd, in 2011 and have been working on integrating their advanced predictive analytics expertise into our existing solutions. We will continue to invest in analytics technology that enables our clients to position for patient engagement, wellness and disease management. The rapid adoption of patient portals and the shift away from fee-for-service in favor of outcome- and quality-based reimbursement models will place more emphasis on finding new cost savings and revenue streams. To differentiate themselves from the competition, hospitals must find ways to personalize the patient experience and better manage the patient population. Effectively promoting profitable services to high-value patients and engaging them in wellness programs will influence healthy behaviors to positively impact outcomes.

Jay Mason, CEO, My Health DIRECT

It has been painfully obvious over the years that our solution was a bit ahead of it’s time. While very successful in directing patients to appropriate care settings in an ER, there wasn’t a pressing need to interact “outside of the walls” broadly or routinely. What we have seen in 2011 and see as our chief role moving forward is to serve as a health scheduling exchange. We will continue to invest our R&D in staying ahead of the curve. Today we can provide true Enterprise  Application Integration (EAI) with any willing trading partner via our own platform’s ability to leverage HL7, API, or CRM-based communication protocols.

So the next year will be more of the same for us — creating the integration tools, onboarding methodologies, and consumer engagement services that will allow our clients to redefine the way they interact and guide their patients and members.

Janet Dillione, Executive Vice President and General Manager, Nuance Healthcare

Going into 2012 the pressure is on for healthcare organizations to increase the quality of care delivered while reducing cost and complying with federal mandates. Nuance could not be better aligned to help healthcare organizations succeed in light of such pressures as Meaningful Use and ICD-10 and to ensure that clinical data is created in the most efficient way possible and is built from rich information that can be analyzed and intelligently used to drive broad healthcare enterprise change and improvement.

Over the next 1-2 years, we’ll continue to invest in areas that fundamentally improve the capture phase of clinical documentation, by which I mean empowering clinicians to document anytime, anywhere on any device in the most effective, natural way possible – via voice.  In 2011 we went to the cloud, offering SpeechAnywhere services to development teams across the industry.  Speech-powered clinical documentation is widely in demand and will continue to expand to encompass the complete healthcare enterprise and the mobile clinician workflow.

We’ll also continue to heavily invest and innovate in the area of language understanding and analytics technologies, which make it so clinical data can be extracted from unstructured documents and intelligently leveraged to drive better clinical and business decisions. Through work with 3M, IBM and UPMC, Nuance is making tremendous traction against its mission to transform patient stories into high-value information. Our speech-driven clinical understanding solutions will increase the quality of documentation, improve efficiency and drive better care – all while putting less burden on clinicians.

Todd Cozzens, CEO, Accountable Care Solutions, Optum

I heard someone say the other day that ACO = HMO 2.0 But With Data. It is indeed all about the data. I empathize with health system CEOs who, after spending anywhere from $100 million (average medium size IDN) up to the $3 billion Kaiser spent on installing EMRs in the last ten years that all they really achieved was computerizing paper records. Little has been achieved in actually doing something with the data. That’s what the next ten years is all about.

• Population Analytics: EMRs and the early data warehouses being developed on top of them are good at managing a census – sick people that visit hospitals and doctors. Population Analytics manage entire patient populations across all of their interactions with the health system. EMRs rely mostly on clinical data and some financial data. Population Analytics incorporate claims data, clinical data, financial data and actuarial data across ambulatory, in-patient, post acute and home care. We are in the top of the first inning of the biggest wave of change in our healthcare system any of us will see in our lifetime. These tools are also in their 1.0 versions and will evolve. Optum was almost purpose-built to bring all of these capabilities together into one cloud-based, integrated solution.
• End-to-End (E2E) Financial Efficiencies: Hospitals leak revenue more than any other business in any other industry – with the average health system collecting only 33% of what they actually bill under the current fee-for-service (FFS) system. And on top of this we’re now going to burden hospital finance departments by introducing new fee-for-value (FFV) payments starting with bundled payments and pay-for-performance measures right on up to full risk-bearing entities. In the forward-thinking health systems, we’re seeing the realization that they cannot do this all themselves. Many see FFV as the future so they want their current finance teams to be the experts in the new system. These same health systems are increasingly outsourcing their FFS financial systems to experts who know how to recover lost revenue, realize much higher collection rates and know how to drive cost takeout. We acquired Executive Health Resources to help hospitals drive revenue integrity for the big potential loss area of reimbursable admissions. The Lynx ED coding tool returns an average of $2.5 million lost revenue per medium size hospital. We combined those tools plus others around collections, billing, and Financial Health Record (FHR) to form our E2E solution set and we will invest more in these capabilities in 2012.
• ICD-10: Health systems are so encumbered with Meaningful Use compliance, RAC compliance, and facing the coming huge cuts in Medicare/Medicaid that they have largely been in denial about the impending ICD-10 deadline. With the introduction of up to 155,000 new reimbursement codes and less than 10% of healthcare providers halfway to ICD-10 readiness, ICD-10 could be an insurmountable challenge. We made a large investment in what we believe to be the best technology available to meet this new challenge. Because of the time caregivers will spend hunting for the right code, ICD-10 will actually make the health system much less efficient unless groundbreaking new technologies emerge. The natural language processing technology that we acquired from A-Life is exactly what’s needed to automate this laborious process. We’ve seen tremendous traction for this solution in the last six months and expect that to continue. Our R&D investment has increased so we believe we will keep and extend our technology lead here.
  

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  Paul Brient, President and CEO, PatientKeeper Inc.

  PatientKeeper’s number one priority is to deliver healthcare applications that improve the physician workflow. This means that we save physicians time, we help them provide higher quality care, and we help them get paid for more of the services they deliver.  

  We are still spending heavily in R&D to round out our suite of 13 fully integrated applications. Our near-term focus is to continue to add features to our CPOE product, complete our Medication Reconciliation product, release a next-generation charge capture application, and give our tablet/iPad applications feature parity with our desktop applications. The emergence of the tablet as a “first class” device has been eagerly anticipated by the healthcare IT community for nearly a decade and is finally here.  In fact, we have a small but growing number of our 40,000 users who use their tablet/iPad as their only computing device.

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  Todd Johnson, President, Salar

  While we have always been focused on "the physicians experience," the merger between Transcend Services and Salar has intensified this focus. In the months ahead, we are going to be able to address a physician’s workflow in ways never before thought possible. Understanding all of the external pressures applied to physicians, how remarkable it will be to offer solutions that offer either zero impact on their day-to-day, or better yet, offer drastic improvements to their workflow that they didn’t even realize were achievable? Not only will we be able to satisfy a physician’s interests for time, speed, and efficiency, but we will also be able to free the physicians from those same external pressures. By offering to our hospital customers clinical documentation solutions that meet the needs of coding, compliance, quality, billing, RAC audit mitigation, communication, and patient safety while doing so in a zero impact methodology to the delivery of care, we truly meet the needs of all parties at the table.

  To realize the benefits of this "enhanced physician experience," we will be investing heavily in our web-based platform to complement our existing thick client solutions, natural language processing tools, front end speech solutions, ICD-9 and ICD 10 GEMS mapping solutions, front end computer-assisted coding features, and even an improved workflow for traditional transcription services. We will continue to deliver all of the above through our "have it your way approach," thereby meeting the needs of both our physician users and our hospital customers.

  It’s been a long-time objective of Salar to become the de facto clinical documentation module within a host of HIS systems. We are closer to realizing that objective than ever before. Through some new and unique customer engagements, we will be integrating our platform into industry-standard information systems and, in turn, reaching out to an even broader customer base. The marriage of these solutions and the seamless nature of their delivery are incredibly important to us. Our customers count clicks–and so do we. We will continue to work over the next 1 to 2 years to streamline usability across systems and, ultimately, enhance a physician’s day-to-day experience.

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  Stephen Hau, CEO, Shareable Ink

  Everyone wants innovation, but no one wants to change.

  It is well understood that the healthcare industry must become more electronic and data-driven. However, we also know that change is hard. Market data reveal that, while most clinicians enjoy the accessibility of patient information that EHRs deliver, the majority does not prefer the Windows 95-style “point and click and drop down list” style of documenting that the standard EHR user interface requires.

  We believe that there must be a better way to extract information from a physician’s head without forcing them to become typists, tap a screen or mouse 30 times to create a “cookie cutter” note, or hire prohibitively expensive scribes out of desperation.

  As such, we have begun to invest aggressively in machine learning and natural language processing. Our system does not require user training. Instead, it has begun to learn from clinicians’ handwriting, gestures, and other natural inputs. The ambitious goal is to deliver innovation without requiring clinicians to alter time-tested workflows.

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  Ed Daihl, CEO, Surgical Information Systems

  Our R&D focus supports improving the management of perioperative services, the area of the hospital that continues to drive the financial success of the hospital. A recent survey by SIS shows an increased focus on reducing perioperative costs, with 78% working on cost reduction efforts – a 34% increase since 2010. Additionally,  the survey indicated another shift from 2010 with cost reduction efforts being prioritized over reimbursement concerns. In 2010, 25% of hospitals cited maximizing reimbursements as their top financial concern. In 2011, that number dropped by 56%. We believe that perioperative specific analytics is a powerful tool to help hospitals control costs — their top concern — and will continue to work to improve this management tool.

  Additionally, we see the adoption of anesthesia information management systems as a growth area in the industry. Electronic anesthesia documentation streamlines this process and provides accurate and legible anesthesia records. This equates to significant benefits, such as more accurate charge capture, quality improvement, and allows for the anesthesiologist to spend more time with the patient and less time documenting.  The addition of clinical intelligence with anesthesia analytics provides even more value to hospitals and anesthesia providers by unlocking powerful decision making data to help improve both care quality and financial return.

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  Evan Steele, CEO, SRS

  Over the next couple of years, SRSsoft will evolve to accommodate the acquisition and sharing of increasingly greater volumes of patient health information, as relevant to our specialist and primary care clients.

  We will remain focused on productivity (naturally!) as we evolve our data capture interfaces. This means that user interfaces will be implemented using techniques that are both ergonomic from a personal user perspective and accommodative of the actual workflow that takes place in the clinical office environment.

  We have put into place, and will continue to enhance, our own dedicated platform for data sharing and interoperability. Our Continuity of Care Exchange (CCX) platform manages connectivity and the physical transport of files, while our Discrete Data Exchange (DDX) components handle the import and export of discrete data to and from our system. We will continue to evolve CCX and DDX over the next couple of years to support increasingly higher levels of interoperability.

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  Rick Stockell, President, Stockell Healthcare Systems

  Over the next 1-2 years, Stockell Healthcare Systems will be devoting a significant amount of R&D to ongoing regulatory compliance.  In addition, we will continue our ongoing focus on client business process improvement through the development of advanced analytics and information management solutions.

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  Richard Atkin, President and CEO, Sunquest

  Sunquest is increasing its investment in product development across the board. We now have over 35% of our total resources dedicated to product development and product quality. We will have a particular focus over the next 24 months on developing new functionality in the converging areas of molecular pathology, anatomic pathology, and digital pathology. As a founding Gold Sponsor of the Digital Pathology Association (DPS) and through our partnership with Massachusetts General Hospital, we will be building the next generation of pathology workflow solutions.

  The incorporation of digital images of all sorts into the pathology workflow will drive significant growth, change, and efficiencies throughout our clients’ operations. Sunquest will work closely with our clients to enable them to take advantage of the coming changes in science, medicine, and technology. The ongoing evolution of molecular testing is driving a convergence between anatomic and clinical pathology. As healthcare delivery evolves to a more integrated, regional model and incorporates more personalized data, Sunquest will provide the solutions required to thrive in a new age.

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  Sunny Sanyal, CEO, T-System

  To meet clients’ current and evolving needs, T-System in the next 12-24 months will focus R&D investment on enhancing our emergency department information system, The T SystemEV. Our top three R&D priorities are as follows:

  • Support for regulatory mandates, including Meaningful Use and ICD-10. T-System will seek ONC-ATCB certification for Stage 2 Meaningful Use measures as soon as HHS finalizes the requirements. T SystemEV, already certified for 2011/2012 criteria for Stage 1 Meaningful Use requirements, will be compliant with ICD-10 in 2012, a year before the deadline. Our goal is to give clients maximum flexibility to address clinical, business and regulatory needs
  • Enhance interoperability. T-System will continue to invest and partner with other vendors to ensure that clients can seamlessly connect T SystemEV with disparate inpatient EHRs and other information systems outside the ED.
  • Continue to provide innovative and new functionality. As the care transition hub and starting point for a high volume of patient handoffs, the ED plays a critical role in ensuring the continuity of care. Supporting smooth patient transitions with efficient communication will become even more important as facilities and practices form accountable care organizations (ACOs). T-System will develop solutions and functionality that will help EDs lead the ACO model of healthcare delivery. Additional offerings will continue to improve clinical and financial outcomes that start in the ED and benefit the entire hospital and community.

News 12/30/11

Top News

CSC says it will have to write off almost the entire $1.5 billion it spent trying to install iSoft’s Lorenzo in the defunct NPfIT project in England. The government has apparently declined to give CSC the new scope of work the company had requested. CSC has also withdrawn its financial forecast and stepped up plans to replace its CEO. It posted a loss of almost $3 billion in its Q2 report filed September 30, mostly due to a write-down of goodwill. The company’s market cap is $3.7 billion. Shares are at $23.68, off more than half since the beginning of the year.

Reader Comments

From Zafirex: “Re: hardship exemption for e-prescribing. Looks like so many providers are claiming it that CMS is having difficulties. Wonder how many are truly hardships? I doubt CMS could ever verify since it looks like they’re having trouble even producing a list.” Exemption categories include a practice area with no broadband coverage or that has too few participating pharmacies, practices that applied for Meaningful Use before requesting an exemption, practices that prescribe mostly narcotics that are not eligible for e-prescribing, practices that don’t prescribe regularly, or practices that e-prescribe but not for qualifying visits.

From Search Boy: “Re: searching HIStalk. Thanks for the explanation to King Salmon. Is there a way for retrieved searches to be indexed chronologically rather than as a percentage of keyword match?” I haven’t figured out how to do that. Since the pages are stored in a database, I don’t think the search function can determine the original publish date even though it’s in the title.

From Lilies: “Re: Epic. They’re #17 on the list of 25 oddball job interview questions, with ‘You have a bouquet of flowers. All but two are roses, all but two are daisies, and all but two are tulips. How many flowers do you have?’ There are two distinct valid answers.” Three is the obvious answer (one of each flower) that took me about two seconds to get. I assume the second answer depends on the question not stating explicitly that there are no other kinds of flowers in the bouquet (i.e., you could have two Venus fly traps only, making two a correct answer.)

From Stats Fan: “Re: readership stats. You haven’t given your readership stats lately for me to track.” Good timing since I realized a couple of weeks ago that I’ve been undercounting all along. I had forgotten to add the hit-counting Javascript to the mobile display that you see on iPhones and iPads. That hit me a couple of weeks ago, so I dug around the code and figured out how to fix it, also noticing that a surprising 30-50% of readers use Safari, most of them presumably on iPhones and iPads, which is a lot more mobile readers than I would have guessed. So far for December, it’s 96,250 visits, 148,218 page views, and 22,029 unique people reading (but that’s lower than the real number since I didn’t make the change until the middle of the month.) January and February will be good indicators since the HIMSS conference really pegs the needle on readership. Inga pays a lot more attention to the numbers than I do, so I will await her analysis. Above is where the visitors are from, just in case you are interested. Among cities, it’s Madison, Stone Mountain, Atlanta, New York, and Chicago making up the top five, but the major metro area is Boston with 8.41% of visitors. It’s a 62% male audience, so ladies, tell your friends.

From HIMSS Envy: “Re: HIMSS points. Got me wondering – it would be nice of HIMSS published an annual report for public review. It might not change a thing, but transparency is a powerful motivator. Come to think about it, Mr. H, how about you, too?” I thought HIMSS did a report, but I couldn’t find one. You can get their Form 990 from GuideStar, which always has interesting factoids (like that HIMSS FY 2009 revenue was $44 million and CEO Steve Lieber’s total compensation was $711K). I don’t know what I’d put in an annual report that isn’t already on the About page or contained in the list of sponsors … other than my hospital job, I don’t have any ownership in anything, I have no other income, and I don’t shill stuff like speaking or consulting under the delusion that I have value beyond what you’re reading right here.

From Peds Envy: “Re: tired of writing only good things about Epic. Private practice peds are the worst type of users for Epic. No surprise there. Someone who knows Brown & Toland told me the reaction is 100% unanimous – they hate it.”

From Anonymous Epic Fan: “Re: tired of writing only good things about Epic. Here are a few issues with their implementation methodology and support that even the Kool-Aid drinkers would have a hard time disputing.” Here’s the list from AEF:

• Epic’s implementation planning materials are weak. They have to be re-worked for each new application / scope mix, and after that is done, little to no effort is made by Epic to customize them based on organization specifics. If you want the project plan to be useful and to have sufficient detail, expect to spend a lot of time and effort re-working what gets initially delivered.
• Epic suggests you go live on Model workflows as quick as possible. As painful as it may be, it is definitely better from a cost perspective. Then, you plan to do the bulk of the ‘real’ implementation after getting live. This can/may work if the bulk of the existing documentation / orders workflows are paper based and you are implementing all of Epic’s applications, but this approach is suicide if the existing system being replaced has been customized for the end-users and they are happy with them or if you have to rely on the timelines of other vendors to build/test/implement interfaces and data conversions.
• The Epic Model does not work well for any hospital or outpatient units that are more complicated  then the most typical med/surg units and general practice specialties. Specifically, hospital outpatient departments that bridge the inpatient and outpatient void.
• The Epic Model completely breaks down if you are not implementing all of Epic’s applications and workflows rely on interfaces to/from legacy systems.
• With Epic’s implementation team constantly turning over, being spread across more and more customers, and the increasing pressure to implement faster, attention to detail is lacking. In my experience, they are over promising and under delivering more than they did years ago.
• Time estimates are always low. Everything takes much longer than anyone anticipates. Medication build, consolidating charge masters, cleaning up supply/pick lists, mapping lab components, consolidating multiple sources of payor/plans, cleaning up the provider / credentialing information, getting physicians to agree and sign-off on order set/documentation template content, and working down duplicate patients in your EMPI or mapping data elements for conversions etc.
• Epic implementation tools / deliverables are often shared just before an upcoming trip for when they are to be used. Though effort is made to customize them based on application mix/scope, they never really get updated to reflect the actual workflows discussed and validated early in the process – especially if they differ in any amount from the ‘model’ workflow. The delivered product if very inconsistent from application team to application team and integrated areas/workflows often get overlooked. So just like the implementation planning materials, expect to spend a lot of time re-working these deliverables to make them useful.
• All application teams involved in the implementation are siloed, and in addition, the Epic implementation teams, technical support teams, and development teams are also siloed. This causes issues for organizations live on one set of applications, rolling out another set, and implementing a third set.
• The silos mean that there are application experts, but very few Epic staff have cross-application experience / knowledge and if workflows are interface-dependent, very few have true integration experience.
• Epic’s training only scratches the surface. The true training is the implementation process and go-live. The shorter the implementation timeline, the more unprepared the customer IT staff is to support the applications when they go live – thus the demand for lots of consultants.
• The system documentation is very inconsistent and virtually impossible to search on the UserWeb. Unless you know where to find what you are looking for, you often have to e-mail Epic to ask if documentation exists. I is not uncommon to be sent an ‘unofficial’ document created by a frustrated Implementer not being able to rely on the system administration guides themselves. In fact, all of the implementation documentation / guides were historically written and maintained by implementers, but due to the inconsistency between applications and un-sustainability of keeping it up to date. no implementation documentation/guides exist today.
• Epic’s end-user training materials are great if you are implementing all of Epic’s applications and you are using all Epic model workflows. If anything changes, these are not so great – expect to have to overhaul them.
• Same goes for the testing scripts. An OK start, but definitely not something that can be used out of the box.

HIStalk Announcements and Requests

How Apple wins customers for life: I had a five-year-old, first-generation, 1 GB Nano that I only used for the gym. I heard Apple was recalling a few of them because of some explosion-prone batteries, so I put in the serial number on their Web page and darned if mine wasn’t on the list. They sent a postage-paid Fedex box to return it. Today I got back a brand new sixth-generation, 8 GB Nano, which now comes with a color display, gestures, FM radio with live pause, pedometer/accelerometer, and a bunch of other features, all in a package barely bigger than a watch face (in fact, you can buy a watchband that holds it, turning it into a watch.) It’s super cool, and so is Apple. You did good, Steve Jobs – RIP.

It’s time to wrap up the HISsies nominations soon, so contribute yours now to the blank slate that will be distilled into a handful of choices for the real voting that starts shortly. I’m particularly happy with one nomination for Smartest Vendor Action Taken: “HIStalk sponsors that replaced blinking ads before the deadline.” Well done, and a good observation. My sponsors really are the best – as much as I hated to spring the change on them since it requires work and expense on their end, they’ve been great about it. I’ve enjoyed the nominees for the Beer and Pie categories, as always, and there are some good nominees for the Lifetime Achievement Award.

Speaking of the HISsies, full details and signups will go up next week for HIStalkapalooza in Las Vegas. And also speaking of the HISsies, if you plan to vote (and I hope you do), sign up for the e-mail updates since I e-mail the voting link out to prevent ballot box stuffing that was as rampant as in a third-world dictatorship until I took that step. For that reason, if you aren’t on the list, you can’t vote.

Listening: new from The Roots, which even though I’ve only sampled it so far due to limited time, is just blowing me away. It’s extraordinarily music in the form of a concept album, making it impossible to label as rap, soul, or hip hop even though it includes strong elements of all of those. The accompanying short film is here. Their talent is mind-boggling. Down it goes to the new Nano, which contains only my latest favorites since I intentionally started from scratch: Genesis And Then There Were Three, two albums from Gooder, one from Metric, and Luminiferous Ether by the never-gets-old Zip Tang.

It’s just Dr. Jayne and me tonight as Inga is sojourning in the mythical Land Without Broadband. She will return soon. But in the mean time, Dr. Jayne is doing her usual fabulous job. I’m pretty darned lucky to have two smart, funny, hard-working, and undeniably cute ladies with whom to share the page, don’t you think? I will raise a glass in their honor for New Year’s (probably of Duvel beer since I got some for Christmas and I like it a lot.)

I’m not telling you Happy New Year yet because I’ll be posting a Monday Morning Update this weekend as usual, even if nobody’s around Monday to read it.

Acquisitions, Funding, Business, and Stock

Board members and executives of document management vendor Streamline Health Solutions will buy $400K worth of the company’s stock, news of which sent shares up 9% on Wednesday.

Healthcare alerting system vendor Extension, Inc. announces what it says is record quarterly growth, adding 17 new hospitals in the third quarter and quadrupling its headcount to 40 over the past two years. They might want to budget for a public relations or media person next since this is easily one of the worst-written press releases ever, starting off with a clumsy opening sentence that sounds as though someone whose native tongue was not English (or at least not good English) sweated over it until nothing interesting remained. It doesn’t get better as you read on.

Announcements and Implementations

Tampa General Hospital (FL) goes live on its $120 million Epic system, which works out to $118K per bed. The hospital says $40 million of that was for hardware and software, with the rest going for staffing and training.

Other

Weird News Andy sounds like a fortune cookie in summarizing this story as, “Foot in mouth results in mouth in foot.” A man shows up in the ED with a swollen, infected foot, claiming he stepped on a piece of glass on the beach a couple of weeks before. The beach and timeline part of his story were accurate, but not the glass part: doctors removed a tooth embedded between his toes, lodged there during a beach fight when he kicked his opponent in the jaw while wearing flip flops.

Several readers were interested in John Halamka’s post about his wife Kathy’s newly diagnosed breast cancer. The first of regular updates, posted Thursday, is here. Reading his thoughts and analysis of their situation makes you realize that HIT stuff aside, he’s probably a fine doctor as well, not to mention the kind of supportive partner we would all want if faced with a life-changing diagnosis and gearing up to fight it.

A big health-related software sale you probably didn’t hear about: General Cannabis, which operates the medical marijuana dispensary finder WeedMaps, acquires MMJMenu, whose software for marijuana growers and dispensaries tracks inventory “from seed to sale,” basically an ERP for pot growers. General Cannabis had revenue of $10.4 million in the first nine months of the year and paid $4.2 million last month to buy the Marijuana.com domain.

John Newman, MD PhD, a UCSF physician and legal scholar, worries that medical copyrights will threaten patient care, citing a recent case in which a company offering a licensed cognitive screening tool threatened legal action against a similar but free online tool. The implication is that tools based on published research, which could be anything from a pain scale to a hip fracture risk predictor, could be claimed as proprietary by a fast-moving company. The author speculates that without new forms of copyrights, “… as physicians walk down the hallway interviewing patients, they’re tallying up the licensing fees they need to pay for doing their day’s work, and hospitals are suing each other or making cross-licensing arrangements to manage each other’s intellectual property.”

A power surge caused by monthly back-up generator tests at Aspirus Wausau Hospital (WI) takes all communication and computer systems down for five hours, forcing the hospital to go on ambulance diversion. As is always the case, the hospital says patient safety was never at risk, which you might interpret as meaning that those systems contribute nothing to patient safety. They’re on Epic, I believe, not that the hospital’s Wisconsin location didn’t already make that fairly likely.

GE Healthcare agrees to pay $30 million to CMS to settle a False Claims Act charge that it encouraged hospital and cardiology laboratories to overbill Medicare for Myoview, its form of technetium 99 that shows areas of decreased blood flow in the heart.

Sponsor Updates

• Rockford Orthopedic (IL) announces that 21 providers have successfully attested for Meaningful Use using eClinicalWorks EHR suite.
• Baptist Health Line (KY) receives its third ICARE award from RelayHealth for work with Western Baptist Hospital’s transfer center.
• Paul Rooke, CEO of Lexmark, discusses how the company’s acquisition of Perceptive Software and Pallas Athena puts them in a unique position in his interview with All Things D.
• Health Choice Arizona, achieves a 44% improvement in its completion rate for preventive services pilot program using MyHealthDIRECT.
• AmkaiSolutions will offer revenue cycle solutions from ZirMed to its outpatient surgery provider software customers.

EPtalk by Dr. Jayne

Where have all the drug reps gone? With significant cuts in the budgets for Big Pharma, many reps have been “made available to the workforce,” as they say. It seems hospitals and health systems are hiring former drug and device reps to sell their facilities to physicians. A recent article discusses how they’re using infection data and patient satisfaction scores to drive business rather than the drug pricing and formulary data of yore. In my book, this is just another thing that sucks up valuable time that we need to care for patients, not to mention sucking up budget dollars that could be better spent on those patients.

I wonder how many physicians who refuse to see drug reps also refuse to see these new “physician liaisons?” And how many health systems place rules around having these reps in the office? At some large integrated health systems, policies ban providers from seeing reps or liaisons from any facility or service provider that competes with a system-operated service line. This includes home health agencies, remote cardiac testing providers, reference labs, and the like. Other health systems restrict the hospital privileges of their employees (prohibiting credentialing at competitor hospitals,) so I’m not sure how big of a target pool these new reps have.

Weird News from one of my favorite places: South Carolina sports a giant mound of tires that can be seen from space. At least it’s not burning like the one in my favorite fictional town. But kudos to Lee Tire Company, Inc. of Jacksonville, Florida for waiving the usual fees to shred and recycle the tires in an attempt to clear the 50-acre mess.

Inga and I are well into our pre-HIMSS preparations. As you’re thinking about traveling to fabulous Las Vegas, consider this recent article that discusses continued concerns about backscatter scanners at the airport. Until I read this piece, I didn’t know they had been banned in Europe. As someone who has to wear a badge to track my exposure to radiation in the hospital, I do worry about frequent flyers. Many of my friends who work for vendors fly two to four times a week. There’s enough radiation from just being in a plane, let alone adding to it with scanners. I’d love to see the cumulative dose numbers for some of those flyers. Maybe frequent flyer programs should start issuing radiation monitoring badges with their airlines’ logos as a promotional item.

Each time I sit to write for HIStalk, I’m still amazed to be part of this team. It’s particularly amusing when I’m just reading through my “normal” e-mail and find a mention of us – most recently a blurb from MED3000 regarding Mr. H’s recent piece asking vendor leadership about the biggest HIT-related news items of 2011. I hope I don’t have facial leakage when I see these blurbs (yes, I have a bad habit of multitasking during meetings) because I know I feel like smiling.

Speaking of multitasking, one of my Facebook friends shared another article on docs multitasking during critical procedures. Medical schools are apparently having to actually instruct students to focus on the patient instead of the smart phone. Looking at some of the examples given in the article, it sounds like some IT teams need to revisit the websites they allow users to access. I can’t think of too many medically legitimate reasons to be on Facebook, Amazon, or eBay in the operating room or in the ICU.

I mentioned earlier this month about my inability to keep up with Inga where shoes are concerned. I think I win this round though – I seriously doubt that Santa left a glass slipper filled with Cosmopolitans at her house.

Have a question about managing pesky sales reps, maintaining the perfect poker face, or the best way to garnish a Cosmopolitan? E-mail me.

Contacts

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

CIO Unplugged 12/28/11

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

The Connecters

For six-year-old Herbert, a train ride was nothing new. But this train was different. Cold. Smelly. No seats. Conductors wore helmets, carried guns, and yelled. Shrouded in darkness and smushed between people’s legs, Herbert clung to his mother and aunt. Passengers wept and prayed. Days later, they disembarked at Gurs.

Horrid scarcely described the inhumane conditions in the “relocation” camp. Herb dug through the trash each day, foraging for crumbs. Six months into the torment, a soldier grabbed him and carried him outside the camp gates. The French Resistance, hiding in the night, whisked Herb into the woods.

Dodging armed patrols, they traversed the countryside and came to a convent near Lyon—Herb’s new home. During routine inspections, the nuns would hide him, the only Jew amongst gentiles. A year later, the Swiss underground led him on foot over the Alps into Switzerland, where he found solace in a group home for Jewish boys.

Herb never saw his family again. While he scaled mountains to freedom, they boarded trains for Auschwitz.

After the war, Red Cross officials connected Herb with relatives that had immigrated to the United States years prior. A young adolescent, fluent in French and German, Herb sailed across the Atlantic. Lady Liberty greeted him in the New York harbor. He learned English. Five years later, Herb returned to Germany as an American soldier.

He fell in love with a young fräulein. They had seven children. I am the youngest

At the end of each year, I reflect and give thanks for many things in my personal and professional life. I’m grateful for what I call The Connecters: the beautiful people who held my dad’s hand. From the German guard at Gurs who led him through freedom’s gate, to the hands of the men and women of the underground. For the nuns who loved a boy of a different faith. For the schoolmasters who hid my father in defiance of the law and for the hands of my immigrant uncle who welcomed him into his New Jersey home. They connected my father to his future. In my heart, I kiss those hands.

This year, my gratitude focuses on my personal Connecters — those who helped enabled my then-future career. While hiring me didn’t affect life or death, I am thankful to those who took a gamble on me. Here are my Connecters and what they taught me:

Pastor Rick Olmstead. In a small but growing church, Pastor Rick invited everyone from the congregation who had an interest in leadership to visit his home for a barbeque. He had hoped for gray heads of wisdom, but ended up with four young-in-their-faith sophomore college students. Trusting in a higher power, Rick pushed forward and invested in us. We eventually became part of the team that enabled multi-year, double-digit growth. His exceptional mentoring and leadership formed the foundation of who I am today.

Major Loomis. The Executive Officer of the 244th Army Reserve Engineer Battalion. This officer’s additional duties involved overseeing the Cadet program. As a nervous nineteen-year-old combat medic, I interviewed with him for one of the few coveted Cadet slots. I knew others had interviewed better than I did, but he took a chance and showed me unmerited favor. I went on to become a combat engineer officer. Upon earning the rank of Captain, I served as the battalion motor officer and battalion movement officer. I learned much about organization, leadership, and process.

Mary Hein. She agreed to interview me because she had misread one of my degrees. She thought I had a Masters in Computer Science when in fact it was a Masters in Consumer Science. When I brought this to her attention, she let it pass and continued the interview. I had very little experience to speak of, yet she offered me my first salaried professional position. I cried (not in front of her, of course.) Mary taught me poise, communication, and brand. She helped hone my leadership.

Mike Gogola. I was interviewing for a director of physician relations position when I realized it was actually an IT position. “You have the wrong person,” I told Mike. While I was good at physician relations and marketing, IT was not my forte. To this day, I’m not sure if he was desperate or sincere, but Mike assured me I had the right stuff for the position. He surrounded me with good technical people and I learned on the go. Mike took me with him to networking opportunities and conferences. He taught me project management and IT.

Kevin Roberts. Kevin believed in me before anyone else saw my executive potential. He took a major risk in supporting my bid to become a CIO at a young age and without requisite experience. He shielded me from naysayers as I learned to walk and then run. He pushed me to become increasingly independent, which grew my confidence. He believed in me.

I’m thankful for those men and women who saved my dad and made my life possible. And I’m thankful for the men and women who connected me, took a risk, and enabled my career.

Who are you thankful for? Take time this holiday to let them know your appreciation. But don’t stop there. Ask yourself who you can help connect. When is the last time you took a risk to help an eager wannabe advance?

Leaders are called to Connect.

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 12/28/11

Top News

UPMC’s Cerner systems go down for 14 hours at most campuses last Thursday and Friday, forcing them to go back to paper. The PR person blamed “a database bug,” which makes the above Oracle press release from this past summer a particularly fun read. Cerner and UPMC have an atypical vendor-customer relationship since they’ve invested big money together in innovation projects and UPMC runs a Cerner implementation business overseas.

Reader Comments

From King Salmon: “Re: search. Is here a way to search HIStalk by keyword?” You can use the search box that’s in the right column. It’s not visible on mobile devices, though, in which case you can do a Google search by keyword, then click the gears icon at the upper right of the results screen (that’s where Google has moved the advanced search options, which used to come up on the main search screen.) Then, qualify your search down to the specific HIStalk site as shown above.

From Booth Boy: “Re: MEDITECH and Cerner. As I predicted, see the attached Las Vegas floor plan. Since they lost their HIMSS points by sitting out a few years, they are way back in the corner by the freight doors. If it’s cold on setup day, they’re going to freeze their butts off because the doors never close.” Just about every year I run the link to the rules of how HIMSS awards its much-coveted Exhibitor Priority Points, which rewards vendors who spend a lot with HIMSS by allowing them to buy bigger and better located booth space. Points can also be earned by buying sponsorships, booking hotel space through their housing company, signing up for corporate membership and paying your dues early, and buying services from HIMSS Analytics. Because they didn’t exhibit, MEDITECH is way down the list in the #727 spot (behind mostly companies you’ve never heard of and even some universities) and Cerner is at #429 (two notches below University of Alabama at Birmingham.) Needless to say, prime exhibit real estate isn’t happening for them this year, so you’ll need to seek them out.  

HIStalk Announcements and Requests

Inga’s taking a short break, so it’s just me (Mr. H) this time around.

Sales

The board of 125-bed Powell Valley Healthcare (WY) approves the purchase of NextGen EHR to replace its “dysfunctional” and old Healthland system, saying the hospital is getting a bargain because the company offered to drop $400K from the $2.65 million cost if the hospital signed by December 31. The hospital plans to collect $1.5 million in Meaningful Use incentives, which it says it could not have done with Healthland because, according to the IT manager, “The system we have now is not good. It’s terrible. It crashes. I can’t imagine being a nurse or a physician and working with it every day.” The money-losing hospital says buying a new clinical system probably means that other projects, such as needed renovations in surgery and the ED, may not get done, but a board member says the new system is even more important. “This is a have-to. We have to do this. I remember going into the lab a few years ago, and the lab girls were crying, and it was over Healthland (the current system). It needs to be replaced,”

People

Saint Francis Care (CT) names Linda Shanley as VP/CIO. She was previously with Stony Brook University Hospital.

Announcements and Implementations

Pikeville Medical Center (KY) goes live on Wellsoft’s EDIS, which is integrated with its McKesson applications.

Innovation and Research

An Ohio ED doctor develops NARx Check, which calculates a drug abuse “credit score” using Ohio’s prescription monitoring program data and alerts ED staff of patients likely to be abusing drugs. The application has generated positive comments from the state pharmacy board and local hospital association.

West Wireless Health Institute says that less than 1% of hospitals have deployed fully functional tablets, mostly because clinical systems vendors haven’t developed iPad-native apps, but also because wireless connectivity is spotty, iPads don’t fit into the pockets of standard-issue lab coats, and typing on an iPad is a pain when PCs are always close by anyway.

Other

The western regional chapters of HIMSS are putting on the one-day Women in Healthcare Information Technology Conference in San Francisco on Friday, January 20.

An insurance company sues the former COO of Christus St. Vincent Regional Medical Center (NM), trying to recoup the $3 million it reimbursed the hospital for fraud losses. The COO allegedly funneled hospital IT payments through corporations that were run by a woman with whom he was having a relationship. He supposedly even paid a part-time student to impersonate an engineer with the phony company when the hospital got suspicious. The hospital fired the COO for cause in early 2008 and says it’s still waiting for authorities to charge him with a crime.

Jacob Goldman, the former chief scientist of Xerox who created the famous Palo Alto Research Center (PARC) in 1970, died last week at 90. Xerox was happy making money from copy machines and didn’t commercialize PARC’s research, but those discoveries, such as the graphical user interface and ethernet, created the personal computer industry when further developed by Apple, Microsoft, Cisco, Adobe, Sun, and other fledgling Silicon Valley companies.

A new KLAS report says that while only 10-15% of hospitals use real-time location systems, 95% of those that do say they increased operational efficiency.

Several readers sent over a link to this article, in which another conservative publication takes some unfocused political shots at Epic’s Judy Faulkner using healthcare IT as its weapon of choice (actually, they aren’t new shots, just the same old ones recycled yet again for a new audience.) Her oft-recited transgressions:

• She donates to Democratic political candidates.
• She represents vendors on the Health IT Policy Committee.
• She’s anti-competition and anti-innovation, at least according to the unbiased opinion of Allscripts CEO Glen Tullman, an Epic competitor, quoted from an interview we did with him on HIStalk Practice (being a conservative publication, they had to be grasping to quote a long-time supporter and friend of President Obama who had a lot more influence than Judy Faulkner in getting billions in HITECH money included in the stimulus package.)
• She could have benefitted from politician meddling in which a group urged the VA to buy instead of build systems, mentioning as their argument successful clients that happen to be all Epic users. That’s true, but perhaps a fact worthy of inclusion is that the VA ignored the unsolicited advice and is sticking with its original plan to develop an open source replacement for VistA, so the net benefit to Epic was zero.
• Epic clients (Geisinger and Cleveland Clinic) were named by President Obama as being good technology users.
• Epic clients, like those of all vendors, have had some unrelated IT incidents that were listed.

The article concludes, predictably and with no facts whatsoever to back it up, that Epic is preventing patients from getting good care because of “partisan politics” (meaning beliefs that differ from the ones held by the authors.) You would think instead of just Googling up some old articles they could have turned up an actual expert in a hospital somewhere instead of just quoting a competitor’s CEO and a reporter. I’m a conservative more or less (fiscally, anyway) but this is just lazy political editorializing pretending to be reporting, indiscriminately throwing out loads of unrelated mud in the hopes it will stick to someone of a different political persuasion.

Surely someone could build a better case against Epic, although it’s probably hard to write around the inconvenient facts (its customers are among the best hospitals, they are voluntarily buying Epic given the other available options, and Epic tops every industry statistic by a mile, such as big-hospital sales, KLAS rankings, and hospital customers that have been awarded HIMSS EMRAM Stage 7.) Or maybe they can’t. The anonymous anti-Epic comments I get are almost always long on emotion and opinions and short on facts and first-hand knowledge (and they often come from the same handful of posters using different names, which makes me suspect that they are unhappy former Epic employees, spurned job-seekers, or employees of struggling competitors.) I don’t know that I’ve ever seen a negative comment about Epic from someone who actually uses it in a provider role, and I don’t recall hearing remorse from any of those users about losing the systems that Epic replaced. I get tired of writing positive things about Epic and keep hoping someone who’s actually in the game and not on the sidelines will provide an intelligent and convincing counterpoint to why they aren’t as great as the Kool-Aid drinkers say. I’m still waiting.

Sponsor Updates

• Weed Army Community Hospital (CA) chooses T-System for paper-based ED documentation.
• Salar suggests three New Year’s resolution in a blog posting.
• Nuance releases a case study on Emerson Hospital’s (MA) use of Nuance Transcription Services powered by eScription.
• Digital Prospectors Corp., which offers embedded systems engineering and healthcare information systems consulting services, is featured in Bloomberg Businessweek.
• Jeff Wasserman, VP of Culbert Healthcare Solutions, discusses physician employment opportunities, job culture, and interview skills in an American Medical News article.

Contacts

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

Curbside Consult with Dr. Jayne 12/26/11

Technology: The New Scapegoat?

I’ve always been a bit of a tech junkie. If I wasn’t afraid of revealing my age, I could tell some pretty good stories. To me, technology is exciting and invigorating, but also something to be respected. Technology at any level can run amok – think about Lucy in the chocolate factory as a basic example of what can go wrong. And who wants the artificial intelligence to run amok like HAL 9000? 

In conversations with providers, hospital administrators, and end users, the problem is always “the EHR” or “the system” or “the computer.”

Having lived in an electronic practice for nearly a decade and having used computers in the hospital for almost a decade before that, I can say with a good level of confidence that it’s not always the technology that’s at issue. Systems are only as good as the users who operate them, in conjunction with the training they receive and the proficiency they demonstrate. A recent situation at UC Irvine Medical Center illustrates this.

Although the headline screams “drug pump issue,” a close reading of the Statement of Deficiencies document (it begins on Page Five) yields some interesting factoids:

• The hospital deployed new infusion pumps without hospital-wide training.
• No policy and procedure document was developed (let alone approved) for the safe use of the new pumps.
• A physician overrode a “soft stop” alert on the pump, leading to a patient receiving a high dose of medication. (I agree that the fact that there wasn’t a “hard stop” alert programmed in, but let’s remember a physician did override the alert.)
• The hospital was “unable to ensure that MD… was competent in accurately programming the medication infusion pump.” The pump didn’t have a drug library and was programmed with a dose over 30 times that of the prescribed dose.

After two patient-related incidents, the hospital took corrective action, including:

• Only allowing trained RNs who have documented competency to program the pumps.
• Ensuring that dose, concentration, and flow rates are chosen from a current drug library appropriate to the care area.
• Restricting the ability for users to enter dose/rate for non-library medications unless a second user verifies the programming.
• Requiring re-verification of orders and programming when soft limits are overridden.
• Instituting hard stops which cannot be overridden for certain medication doses.
• Instituting independent double check for programming of pumps that deliver certain high-risk medications

These seem like no-brainer fixes to me. I’m glad the hospital put policies in place that should have been there all along (regardless of the newness of the brand of pump, model, etc., these are just good patient safety procedures).

The document goes on to list several other fairly horrifying behaviors, including a director of pharmacy who admitted knowing that no policies were in place and that no one was overseeing pump safety. “We will in the future, but the pharmacy department needs to be trained first.” He/she also stated that the vendor provided inadequate training for monitoring of pump-related events. Blaming the vendor is always easy – it takes a steadfast leader to halt a go-live when adequate training has not yet taken place.

Other scenarios mentioned in the document:

• A resident physician involved in a pump-related incident that involved infusing a medication over one hour instead of the recommended six hours was “unaware or unwilling to accept the hospital pharmacy directive to infuse the medication over six hours.” The resident’s anesthesia record stated that he was aware that he dosed the medication to infuse over one hour. The resident also violated Department of Anesthesia rules by not paging his attending physician to be present for the end of anesthesia as was required. Oh yeah – he also “overlooked” the patient’s low oxygen level and didn’t take corrective action. When the attending arrived after the resident finally paged, the attending called a Code Blue because the patient “had poor color and was not breathing.”
• Residents examining patients but not writing progress notes (even after a nursing supervisor notified the attending physician) on several occasions.
• An oncology staff nurse (whose job duties included validating chemotherapy doses) who was unable to calculate the dose when given a patient’s weight in pounds and a dose in milligrams per kilogram.
• Contract nurses allowed to operate infusion pumps without training (one with an ungraded proficiency exam in the personnel file — if you made him take it, why not grade it?)

I had to quit reading after a while because I’m extremely compulsive about patient safety and it was just making me increasingly agitated.

Despite the potential harm involved in the pump-related incidents, I’m actually glad they happened. Why? Because the incidents acted as a trigger to expose some significant issues and deficits in patient safety. Patient safety is a culture that requires education and support. It doesn’t happen in a vacuum.

I wouldn’t let an adolescent operate a lawn mower independently without appropriate training, safety gear, and close supervision. We don’t allow teenagers to drive cars (aka operate deadly weapons) without proving a minimum level of proficiency. Yet in this situation, users were allowed to operate equally dangerous machinery without training. The documentation doesn’t mention whether the nurses were forced to operate the pumps over their objections, but the point is they shouldn’t have been asked to use potentially lethal equipment they weren’t qualified (by training and demonstrated competency) to use.

I hope this case serves as a wake-up call for some institutions. I hope end users continue to speak up when they’re asked to do things that are unsafe and that someone listens. Lives depend on it.

E-mail Dr. Jayne.

HIStalk Interviews Bobbie Byrne, VP/CIO, Edward Hospital

Bobbie Byrne MD, MBA is VP/CIO of Edward Hospital, Naperville, IL.

Tell me about yourself and the hospital.

Edward is a really the quintessential community hospital. We have 400 beds over two hospitals, one of which is behavioral health, and we have an acute care hospital. It’s the backbone of Naperville, which is a suburb outside of Chicago. We are making efforts to move into tertiary care and trying to bring tertiary care into the community so that we don’t have to have our residents going to the downtown hospitals.

We’re really so typical. We’re in the middle of America, in the middle of the suburbs. What we’re doing, I think, is reflective of what a lot of other people are doing. 

I’m a pediatrician. My husband says I got hit in the head with a computer and I’ve never been the same. I was practicing and made the connection between quality of care and automation of care, and that if we were going to stay on paper, then we would never have any data to figure out what we were doing well and what we were doing poorly. Maybe 10 years ago, I ended up moving into IT on a part-time basis at the beginning, and then with increasing depth. It’s always been about, “Get it in the system so that we can measure it and track it and improve it.”

You just chose Epic. What is it about their story that’s making them dominate all the new sales?

A completely integrated record – inpatient, emergency, and ambulatory, clinical, and revenue cycle. They are the only company that offers this. It is exactly what our envisioning session showed us that Edward wanted. 

I shouldn’t say that they’re the only company that offers it. They’re the only company that offers it with strength in all of those product areas. Very often when you’re making a decision, there’s some department that thinks that they’re getting screwed, and they usually are. There usually is some really significant weakness in one section of the product from any of the other vendors. In Epic, there just isn’t. Everybody feels like they’re getting a best-of-breed product, but they’re getting the integrated product that the organization needs. The only compromise was on the price. [laughs] That was the only negative.

Are you expecting a hard-dollar return on investment, or is it just a leap of faith that there will some quality and strategic alignment benefits that will make it net out in the long run?

My sarcastic response is that when electricity came into the hospital, were people expecting a hard-dollar return on electricity? I don’t know if they were. I don’t think they were. To me, the electronic medical record is becoming a utility. It’s the, “What is the implication if we do not put this in?” as opposed to, “What’s our return on investment for installing it?” I think in the Chicago area, it could be seen as a competitive disadvantage to not have Epic.

I assume that Epic was a lot more expensive than … well, I shouldn’t assume that, but in a lot of cases they’re a lot more expensive than the systems you didn’t choose.

The actual check that we send to Epic is a very small percentage of our budget. The difference in price between Epic and the other vendors on the software cost is, I think, pretty small.

Cache’ is expensive. That’s a cost that the other vendors mostly do not have. But the difference is in the people and in the requirements for implementation and the recommendations around pulling people off of the floors, sending them to training, having them come full time to the project. That’s really where the big dollars are.

It makes me wonder that if you use the Epic staffing and methodology, would the other vendors be giving you the same kind of outcomes that Epic is getting? I mean, is it really the product? I do think it’s a superior product, but is it really the product or is it the entire implementation methodology that makes the difference and the incredible success of Epic customers?

You’re in an unusual position in that you saw Epic as a competitor when you were with Eclipsys and now you’re on the provider side and have chosen them as a vendor. From your two perspectives, are they invincible, and if you were a vendor again, what would you do to mount a challenge to Epic?

At that time I was at Eclipsys, Epic and Eclipsys were formidable competitors. There were certainly deals that Eclipsys won and deals that Epic won. At the beginning of my time at Eclipsys, Eclipsys won more. At the end of my time, Eclipsys won a lot less, so there was a progression there.

I would say that at this point the only way to beat Epic is to find prospects where they’re not looking for a comprehensive system. One patient, one record, one bill is what we were looking for. If you have somebody who’s got that enterprise vision, single source of truth, I don’t know how you could beat Epic.

There would be huge time lag in building a new system. Where does that leave the pie of business that Epic might want vs. how much they’re going to get? People keep saying, “Well, the pendulum will swing back, it always does.” But what would it swing back to?

When I first got to Edward, we had this combined system where we had MEDITECH on the inpatient side and Allscripts on the employed physician group. People would say, “Well, shouldn’t we buy Epic?“ just because all the hospitals around had bought Epic.

I said, you know, if we’re really going to do that, maybe we should really wait for some transformational technology. Maybe we should wait for a pure Web-based solution. We should be looking for that really disruptive technology. Maybe an EMR that’s so intuitive it requires no training or something like that. That’s really what I was thinking that the hospital enterprise system really needed.

Athenahealth in the physician office is a disruptive technology. They have a completely different business model and they do things very differently. They’re not a standard electronic medical record. If we could have something like that on the enterprise scale — not specifically their business model, but something that is just as disruptive. That was the thing I was thinking would be able to beat Epic. And it would be good for our industry, right, to have some fresh technology.

With healthcare reform and with the need to understand the patient across the continuum of care, it wouldn’t be prudent for us at Edward to sit here and wait for some theoretical disruptive technology to come forward. We have to run our business. We have to do what’s right based on what we have today.

I suppose it’s possible that Epic might be able to be the disruptive technology. Typically it would come from something outside of healthcare or from a new company emerging on the scene, but maybe Epic will be the one to be able to provide us with this next wave. I certainly think they probably would have a greater chance of doing that then anybody. Well, I shouldn’t say that …

You’ve going to have a lot money invested in staff training, salaries, and travel. You’ve written in the past about IT turnover. How will you create a culture that makes those expensive employees want to stay?

We actually have very low turnover, which is why when I have any, it’s a challenge. We are not always able to compete on salary, of course. I don’t think there’s any not-for-profit hospitals who can compete on salary all the time.

We have a really strong culture that has a very nice work-life balance. We tend to promote from within whenever possible so that individuals have a career path. We are increasing the number of career paths, so that people feel like when they complete the projects, that they would have the next step and they can see that somebody has gone ahead of them and advanced at Edward. We try and be really accommodating when people say, “I like to work on these types of projects versus these types of projects,” we try and adjust based on that.

It’s just a really nice place to work. People are very nice. Individuals really like their co-workers. 

Those are the kinds of things that we do. We of course have work from home and provide the tools through all of your standard electronic communication so that people can work from home or work from anywhere.

I don’t fear the turnover as much as some people do. We will have some, I know we will. But we’re also then going to have an opportunity to get other terrific people into the organization. In the proximity that we are, we also live in a really nice community, so people like to live here and they like to work here.

Epic, both as an employer and as a vendor, tends to like to bring people in who don’t have much IT background. They almost seem to have an anti-IT bias, working around IT instead of with them. Do you see that as a challenge?

I don’t know that we’re going to have as much of a challenge. I believe that our IT department is really integrated into the hospital. We don’t have a big “us–them” kind of issue with our operational owners. I’m sure there’s a little bit of that everywhere, but I think the idea that we’ve always had to have a physician – and it was important to Edward to have a physician in the CIO position, because they really wanted to make that this wasn’t — that we were very connected to the business and very connected to the clinical workflows. We have former accountants who have moved over and have come into IT and vice versa, so we’ve had some people who’ve been in IT and then moved back into the business piece of it. 

This was a decision that was not an IT decision. I mean, everybody says that about Epic. This really was a complete grassroots, bottom-up user decision to choose Epic, so right now, people are feeling really collaborative and feeling really close together.

The majority of our project is not being staffed by consultants or IT people. We’re pulling people off the floor, sending them to training, and then they will be full time on the project. We will end up during the project having fewer IT people working on it than we will users;. There’ll be more users working on the project than IT people and they’ll just be working side by side.

You are a CCHIT commissioner. Do you think certification has done what it was supposed to do in reducing provider risk and do you think that role is still important?

Well, that may be the most controversial question.

If you think about certification, I’ll divide into two phases. One is the formation of CCHIT, which was to help increase adoption of health information technology by removing some of the risk on the buying side, and that CCHIT certification really meant something and that when if you were buying a CCHIT-certified product, it wasn’t going to be perfect, but you could be assured it was going to have some baseline interoperability security and functionality.

I do think that that changed very much the way that people purchased systems. For example, the days of the scripted demos to make sure that you could do long lists of specific feature-function ..  those days are gone, and mostly because if it’s a CCHIT-certified product, you can already pull out the long list of feature-function, security, interoperability items that you know the product can do. I really believe very strongly in CCHIT moving the market forward.

My concern is that certification for ARRA is a significantly lower bar than CCHIT certification was. There is absolutely zero requirement for anything related to workflow in the ARRA certification. An implementation doesn’t fail based on any particular nit of functionality. It succeeds or fails based on whether it fits the workflow of the user — the doctor, the nurse, the scheduler, the accountant, whoever is doing that.

For example, in the office-based setting, tasking between physicians and nurses is a huge workflow component. That’s part of CCHIT certification, not part of ARRA certification. But you know if the physician or nurse in the office can’t affectively communicate and task patient follow-up back and forth, the implementation is going to fail. 

I am afraid that we are going to hear a wave of stories of failed implementations of ARRA-certified products. I fear that we will have physicians and offices saying, “I bought a certified product. Why can’t it run my office? Why doesn’t it do these basic things in the office?” It may do it, but the certification doesn’t guarantee that you’re going to have a product that’s actually going to work for the environment that you’re buying it.

There’s that argument to be made that CCHIT-type certification is for the product and maybe ARRA is the certification of the implementation, which are really unrelated because you can do some pretty amazing things with some pretty crappy products and you can take a really good product in the wrong hands and turn it into a disaster. Do you see any influence of the Regional Extension Centers in trying to close that gap between what the product can do versus what the users try to make it do?

I think that it’s exactly the right idea, you know, put experienced people feet on the street in the areas that people are trying to implement. I have not seen a lot of real impact of the Regional Extension Centers. I think there’s a lot of regional variation. I know that some here are doing really great things and really helping, and then I think that some others are not.

I’m not saying it’s easy to get into these small doc practices and make it work. I think it’s really hard. I’m not so sure that the Regional Extension Centers have really checked the box or been successful yet as a whole.

Everybody who’s trying to predict the next hot trend thinks it’s going to be data warehousing and business intelligence based on electronic data that these electronic medical record systems will create. What are you looking forward to or planning for at Edward Hospital as far as what kind of data you’ll have and what you’ll do with it?

We’ve had a data warehouse for quite a while. I think it’s because we were running a different system in the inpatient as in ambulatory as in operating room. We really needed to have a data warehouse in order to get any kind of basic information to run the business.

I do think that that’s going to deepen, but I find it very interesting. The biggest thing we’re working on other than Epic is a clinical integration project. What I mean by clinical integration is clinical integration in the FTC definition, where groups of hospitals and groups of physicians who are independent come together to work on cost and quality metrics and then therefore can come together to contract with commercial payers. I think a lot of people will consider it a steppingstone to an ACO, perhaps not with Medicare, but with the commercial payers and with not quite as much risk as there would be in a full ACO. It’s a way to learn something about aligning physicians.

While we have this really nice robust data warehouse, the data that we’re looking to rely on from our independent physicians is billing data. I can’t believe we’re still doing this, but if we’re trying to say, “What can our independent physicians give us that will allow us to track our cost and quality metrics so that we can present to commercial third-party insurance companies that we really deliver better service,” the kind of data that they can give us is the claims feed. We’re looking ICD-9s and CPT II codes.

And you know what? I don’t feel great about it, but it’s better than having no data. I can’t expect these small physician practices to be … you know, they don’t have data warehouse, a business intelligence person. They can only give us what they can give us and that’s that.

I think we can be really hospital-focused and think about all of our big IT resource staff, but when it comes down to it, the majority of care is being delivered in the ambulatory setting by physicians. Even though physicians are becoming employed at a very rapid rate, there still are a whole lot more independent physicians out there delivering care. They have the data. Ten years after being in IT, I never thought I’d be back to a claims feed.

When you look at the important trends and challenges with the ones you see at your hospital and in the industry overall, which ones do you think are most significant?

If you have like five number ones, they can’t be number one? I think the pressure on declining reimbursement just impacts everything, because it’s across the board and impacts everything you do — new program expansion, investment in technology, investment in training, all of those things. It creates an enormous amount of pressure.

The increased patient-consumer empowerment. The idea that well, physicians refer a lot of patients to Edward and physicians are a very important customer of mine. There are times when the patients pick the hospital first and then they pick their physician, so they’re coming to Edward first and then they’re looking for an Edward physician. I think that that’s just going to continue to increase.

Any final thoughts?

I have to tell you I’m super-excited about what we are doing here. I feel like the entire time that I was at Eclipsys and the entire time I was at CCHIT, I was working towards this really comprehensive, patient-focused electronic system. I’m now getting to implement it. I’m pretty excited about it.

Monday Morning Update 12/26/11

From Hospital IT Guy: “Re: HIStalk. I don’t know how you produce such insightful and well-written news and comment as a part-time gig. Your posts give me a reality check and enhance my position as an HIT expert charged with leading us into a very uncertain future. Thanks for the body of work you produced this past year and for the work you hopefully will continue to produce in the year to come.” Thanks for those nice comments – they made my day. I have the luxury of being subsidized by hospital day job, which allows me to do whatever I want without pandering for a buck. New Year’s Day is a good time to take stock of where you are, so if you have ideas of how I could provide a better service to the industry (especially providers and patients), send them my way. I’m constrained by time (not to mention by being rather lazy and risk-averse) but I’m fairly creative in getting help and other resources when I need them. I don’t want to be sadly reflecting back from a nursing home bed, “I could have done so much more” and having only my bank account to produce as evidence that I wasn’t a total waste.

One of the first to-dos of the yet-unnamed HIT spawn of Microsoft and GE Healthcare should be to communicate to a skeptical market audience, with only 12% of poll respondents finding the announcement positive. New poll to your right, inspired by John Gomez’s article: if there’s a healthcare IT bubble, when will it burst?

My Time Capsule editorial from five years ago: 2006 Product Rankings – Pay Some Attention, But Not Too Much. It inadvertently highlights just how much Epic has changed the industry with its lengthening roster of top-ranked applications: “The most discouraging point is that no vendor does everything well, if you believe the scores. If you look at KLAS’s 15 main general solutions categories, you’d find 13 top-ranked vendors. If you’re a best-of-breed shop, you’ll end up with a lot of interfaced systems if you chase the winners. If you’re a single-vendor organization, some of your departments are going to be stuck with systems far short of being the best. And of course, in the next survey, they may all shuffle around anyway. ”

Weird News Andy wonders how much the patient was charged for the tape. Two ICU nurses at Utah Valley Regional Medical Center (UT) are fired for telling a moaning patient to shut up, then taping her mouth and laughing about it.

Listening: new from Phoenix-based Gooder, a cross between the infectious power pop of Gin Blossoms with hard-driving guitar and drums (Rush? Van Halen?) They have a really big, well-produced sound for a three-piece. The reader who recommended them has a relative in the band and didn’t really talk them up much (“I’m obliged to like them”) but I really like their sound.

Here’s the latest from Vince, who takes a break from profiling long-gone companies (and sadly, sometimes long-gone people who worked for them) and addresses how HIT vendors throw down at holiday party time. I like Slide 3, in which Vince, one of his company buds, and their wives are dressed to the nines in their hideous 1960s party fashions ready for a big night on the town. If you’re a 20-something industry noob, you will in 20 years or so look back with an equal mix of nostalgia and a little tinge of sadness when faced with images from your long-gone youth, which involved fewer wrinkles and pounds and visually obvious humble surroundings, yet beaming with both delight and surprise to have found a place in productive society and brimming with optimism about the endless future that lies ahead. You’ll know you’ve done well if looking back now is just as satisfying as looking ahead was then.

BIDMC CIO John Halamka announces on his blog that his wife Kathy has been diagnosed with breast cancer. He’s approaching it as you would expect for someone who’s both an engineer and a physician: he is reviewing her medical information, he has assembled a team of renowned experts, and he will be documenting the process with a weekly blog post. I had two immediate reactions: (a) I was surprised that I was affected by the news since I don’t know either John or his wife. I used to assume he was a self-promoting gasbag since he kept popping up everywhere, but the couple of times I’ve met him for a few seconds (as myself, not Mr. H) and interviewed him, he seemed to be a nice guy without much ego. Hearing about his wife was a bit of a blow. (b) as much as I’m happy that he has limitless resources available to him as a Harvard physician with a vast industry network, I kept thinking – what if it was my wife or mother? Why does his wife get better odds because of where he works and where they live?

That’s not a criticism of him at all, but rather an observation about how US healthcare works – it unfortunately helps to go to renowned facilities, to have enough time and money to demand the best when nobody’s offering it to you, and to challenge physicians for the best, personalized answers since healthcare is a cottage industry that is primitive if not indifferent with regard to standardized processes, best practices, and outcomes. Those of us who work in the system know that, while the majority of Americans get their care in undistinguished hospitals from undistinguished doctors whose treatment choices are often anything but evidence-based. I say that having worked in small-town hospitals that had the most incompetent physicians you could possibly imagine with a handful of pretty good ones thrown in, but all of them running thriving practices with patients who lived and died never knowing the difference. To this day, if I were to keel over in the waiting room of a small-town, for-profit hospital, the only medical instrument I want touching me is an ambulance gurney that’s taking me somewhere else in a hurry.

Update: John replied to me Christmas morning. I don’t know if I was clear in my brief writeup above, but he’s been very cool in my brief dealings with him, never too busy despite a superhuman scheduled to drop a few words of encouragement or deflect credit for some HIT development to someone else, which I think is the ultimate mark of a leader – he’s more than happy to let someone else have the limelight. He took the time (as did his wife Kathy) to respond to my comments above. Think about what must be going through their minds if you think this is trivial. There’s never a good time to receive sobering medical news, but imagine having it delivered just a few days before Christmas, with the expectation of being cheery around friends and family.

John writes:

At the same time I’m focused on Kathy’s care, I’m also deeply committed to quality, safety, efficiency, and equity in healthcare across the country.  In the upcoming weeks, I’ll describe how the electronic records that coordinate Kathy’s treatment provide the same protocols to every BIDMC patient, regardless of insurance status, profession, or income. My goal is the "right care" – not too much nor too little – that follows best practices from evidence. Decision support driven "right care" is the only way we can hope to improve outcomes while bending the cost curve of healthcare spending that threatens the US economy. Universal healthcare supported by universal adoption of electronic  and personal health records must be our guiding vision.

Kathy writes:

My life with John has been entwined for 32 years, so to say "we have cancer" cannot be more completely and utterly correct. True that physically, only one of use has the obvious organic symptoms, but our close partnership has been irrevocably changed by the diagnosis. Whatever lies ahead, it is impossible to go back to that innocent moment before hearing the word cancer.

I am luckier than most – I have health insurance, and access to a major urban medical center that is also a teaching and research hospital. But, in encouraging John to follow our progress publicly in his blog, I am keeping the memory of a friend close to my heart. She did not have health insurance (as a part time adjunct instructor of art). With this financial barrier, she unwittingly waited until the cancer had spread before seeking medical care, and although she fought bravely, she lost her battle with breast cancer.

Throughout my life, I have not needed medical care beyond occasional primary care visits and the birth of one child.  My first weeks negotiating the barrage of new terminology, new tests, new doctors has been significantly eased by my access to a complete electronic medical record. Even more important to me, my doctors can work as a team with open access to all the same instant information to help me make the best decisions for my health. As I think about my lost friend, I also am thinking of all others with a breast cancer diagnosis, or other serious illnesses, and about how they manage to work toward their cure if they worry about health insurance, or have no access to an electronic medical record.

Health Information Partnership for Tennessee releases some well made HIE videos that anybody who needs to talk up the HIE concept can use. CEO Keith Cox sent over the link.

One more update about sponsor charity work. Iatric Systems can’t bring its dispersed workforce together for a company party, so it allows employees to payroll deduct charitable contributions that the company then percentage matches. More than $19,000 was donated this year to Save-a-Limb, Relay for Live Japan Earthquake, Alzheimer’s Association, and London Marathon (since they have UK employees.) |

The 21-year-old who posed as a surgeon while counseling patients in the public areas of two Oregon hospitals is sentenced three years in prison. He also claimed to be a Microsoft employee, porn producer, and credit counselor.

A point I’ve been pondering for years, fanned back to life by a reader’s comment. Hospitals enjoy quite modest (if not negative) revenue increases each year, almost wholly driven by what the federal government decides it’s willing to pay them. The country is insolvent and there’s no political will to fix that, so it’s a certainty that the government will be paying less. How, then, can hospitals afford to lock themselves into IT contracts, especially maintenance ones, whose percentage cost increase each year exceeds the revenue increase the hospital expects? That’s especially true of IT systems (most of them) that generate minimal return on investment. I guess that’s why someone had to invent the “IT is like plumbing” argument to justify buying technology without questioning return on investment, but I’m wondering how that rationalization will stand as the going gets tougher. IT departments have the same challenge – how do you justify a 10% IT budget increase when the organization is only expecting a 2% revenue increase, or why does IT keep growing when front-line employees are having their hours flexed or their jobs eliminated? The folks at the top who approve IT purchases and budgets often forget that there’s an ongoing cost to the systems they want to buy.

The pending absorption of Alamance Regional Medical Center (NC) by Cone Health raises IT questions: what will happen with Alamance’s Allscripts Sunrise system given that Cone and the other big systems nearby (Wake Forest Baptist, Novant) are on Epic? The respective CEOs say they’ll probably just try to connect the systems in some way since it’s too expensive to implement Epic at Alamance.

Both MEDITECH and Cerner announced that they will be returning as HIMSS conference exhibitors after an absence of several years. I asked both companies about that decision, with responses from Paul Berthiaume (public relations manager of MEDITECH) and Zane Burke (EVP of Cerner’s client organization.)

Cerner and MEDITECH stopped exhibiting at HIMSS at about the same time and announced their return at about the same time. Were the companies expecting competitors to follow their lead and are coming back now because they didn’t?

MEDITECH
MEDITECH’s decisions regarding HIMSS participation were and are influenced solely by our needs and the needs of our customers. We don’t concern ourselves with our competitors, and we’re not trying to set nor follow any "vendor trends." We’re doing what works for us. This year, we have a particularly compelling story to tell as a leading EHR vendor. We want to share our customers’ successes reaching Stages 6 and 7 as well as achieving Meaningful Use Attestation, and we want to congratulate another Baldrige Award winner. Best of all, we’re going to debut an exciting new Web-based ambulatory product.

Cerner
When we made the decision to not exhibit at HIMSS, we shifted to other strategies to engage with our clients and the marketplace. Since then, one consistent request across our client base was to have a presence at HIMSS for a more personal interaction with our executives, IT support staff, and other clients. Over the years, we continued our HIMSS engagement across the Interoperability Showcase, demos with our industry partners and by supporting the educational components of HIMSS. This year, we will participate in these activities again, and we are excited to be able to meet our clients’ request and have a presence on the exhibit floor.

What will the company’s exhibit hall presence be? Do you have enough HIMSS points for the big, prime location booth, or do you have to work your way back up?

MEDITECH
We’ll be unveiling a new 40×40 booth at HIMSS, which we are excited about, and we’ll have members of our physician team in the booth meeting with customers. We encourage everyone to visit us at Booth #774.

Cerner
We have confirmed a sizable amount of floor space. We’d be happy to share additional details closer to the event.

Both companies say their customers wanted the company to return to the exhibit hall. If that’s the case, was it a mistake to pull out in the first place? What influence did a tough, competitive market and the peaking of HITECH-related system decisions have?

MEDITECH
I believe you’re referring to an earlier interview I gave, where the emphasis of our return was placed on customer demand. The focus is truly more on the timing being right for us; it’s the right time for us to allocate these resources and dollars. Our customers did miss us, and we certainly paid attention to that. In particular, our return to HIMSS gives our customers an opportunity to see our new products and to meet our team of physicians.

Cerner
Cerner and our clients have made significant advancements over the last few years and we are looking forward to participating at HIMSS to showcase these advancements with our clients more broadly. Our decision to come back to the HIMSS tradeshow floor is driven by many factors, including what we all can acknowledge is a strong health care industry making huge strides to improve quality and reduce cost. The diverse HIMSS audience gives us a chance to reconnect with our current clients and showcase to the broader health care community some of the exciting advances we’ve made in recent years.

Merry Christmas, Happy Hanukkah, and a belated Happy Festivus to all. Thanks for everybody who reads, sponsors, or otherwise supports HIStalk. I hope your holidays are amazing and that 2012 is your best year ever.

E-mail Mr. H.

Time Capsule: 2006 Product Rankings – Pay Some Attention, But Not Too Much

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.

2006 Product Rankings – Pay Some Attention, But Not Too Much
By Mr. HIStalk

The 2006 Best in KLAS Awards were just announced. I know a lot of folks wait anxiously for those, especially vendors.

KLAS has its critics, of which I’m occasionally one. I like the idea of surveying customers, but having taken KLAS surveys myself, I’ve seen first-hand how poorly designed some of their questions are. A respondent can’t complete the survey without in-depth knowledge of product functionality, support, documentation, executive relationships, hardware, and so on.

In other words, either the person cares so much that they carefully enlist the assistance of 3-10 colleagues, or they just wing the damn thing so they can get back to work instead of wasting time on yet another hard-to-finish survey. You guess which. At least KLAS sometimes follows up by phone.

All of that data collection and interpretation imprecision is masked by a numbing array of graphs, charts, and tables in the final product. No one pays attention to those, recognizing them as a way of padding out the sometimes-skimpy data to make it more impressive and convincing.

The scores tend to wander a lot from one report to the next, which KLAS attributes to swings in vendor or product performance. It’s much more likely to have been caused by the imprecision of the survey methodology. Do you really believe that Meditech’s client-server EMR was improved so much that it earned itself a move from sixth in an eight-horse race all the way up to second place in just one year? Me neither. KLAS marks it as having a low confidence level, so how do you interpret its score?

Still, I’d definitely pay attention to the top-ranked product and be careful with the last-place finishers. I wouldn’t try to overanalyze products in between, especially when the scores are close. Read the customer comments instead, the best part of the KLAS reports if you ask me (although you don’t know what kind of organizations and employees are being represented.)

The most discouraging point is that no vendor does everything well, if you believe the scores. If you look at KLAS’s 15 main general solutions categories, you’d find 13 top-ranked vendors. If you’re a best-of-breed shop, you’ll end up with a lot of interfaced systems if you chase the winners. If you’re a single-vendor organization, some of your departments are going to be stuck with systems far short of being the best. And of course, in the next survey, they may all shuffle around anyway.

My takeaway is this: somebody has to be last, and if the scores are tight, it may not mean much. On the other hand, why can’t a #1 ranked vendor in one product area use that knowledge to excel in the others? Or, do vendors selectively invest in some strategic lines and allow the others to languish? What does the #1 vendor know or do that everyone else doesn’t?

You don’t have to be a KLAS subscriber to see who’s #1. Just check out the HIMSS booth walls and vendor marketing material. You will need to pony up, though, to see who earned worst in KLAS and which vendors did well in important categories like “would you buy it gain.” That’s where the subscription is worth it. Use it like Consumer Reports for car-shopping – at the beginning and end of your selection process. The work in between is on your own.

John Gomez 12/23/11

Since establishing JGo Labs, I have had the opportunity to speak with many of the key decision makers in the world of HIT. It has been a rather eye-opening experience, one that has created a new understanding and appreciation for the challenges this industry faces long term. My discussions have involved hospital leadership, physicians, nurses, employees, leaders of HIT companies, and industry analysts.

One of the consistent things I hear from everyone I speak to is, "You know John, we just aren’t sure about this market. When we talk to the vendors and industry analysts, they all paint this awesome picture of their companies with strong financial performance and huge upside. Yet when we talk to the clients and ask about their future plans, they don’t match up with the vendors’ and analysts’ views. What do you think?"

This polar view of HIT, specifically in the EMR sector, may seem typical of the client / vendor perspective. But when you dig deeper, you find that it is all but typical. Vendors will paint rosy pictures and clients are going to be cautious of vendor claims. That is normal.

What isn’t normal is that when you probe clients (IDN, academics, community and physician groups) you quickly learn that their hope is to get through Meaningful Use certification as fast as possible and then get back to what they know best. That often means not investing in EMR products.

Most clients I speak with state that the biggest issue they have with HIT products is that they don’t deliver on the promises. They may improve patient safety to some extent and help streamline some processes, but clients aren’t seeing those products as a means to cut their operating costs or improve their revenue. Why this is the case would make great content for another article, but what is important here is that there is a general feeling among clients that the EMR is a distraction, not something they want to continue evolving over time. Simply stated, they want to meet the guidelines and focus on the things in their business which drive real revenue and change.

In speaking with the vendor leadership side of the HIT world, what I typically find is a world of fear, with many leaders confidentially stating that, “I am not sure how we survive the long term.” Keep in mind that my discussions are with middle and senior managers, not the executives. My experience is that speaking to those on the ground gives you a much more realistic view of what is happening in a company than what you learn from executives, boards of directors, and financial filings.

The last area of input is the sector analysts. Although they typically focus on public companies in the HIT sector, many of them will evaluate all companies as means to gauge opportunity and test the claims of those companies in which they are considering investing. More and more analysts are finding that over the long term, the return on investment for HIT companies is not as promising as hoped. There are some shining stars and if you use diligent tactics you will make a return, but if you compare HIT ROI for public companies versus other industries, the return is not glowing.

As you can see, this doesn’t paint a really exciting picture of the market. Although I believe we are seeing a mini financial bubble, I do think there is hope, and I’ll address that shortly. Right now, I want to continue to flush out why a bubble may exist and provide some insight into the dynamics of this market and how it affects vendors, which ultimately affects healthcare institutions and their decisions.

Most healthcare vendors operate in a US market, or at least their portfolio is dominated by US clients. The US healthcare market, from an HIT perspective, does not grow each year as do other industry sectors. There are more patients every year, but unless the vendor’s licensing model increases their payment for each patient visit or transaction, the majority of HIT vendors don’t see this upside.  

The market size for the vendors is typically the number of beds in the US.  If we want to translate this to a math formula, it would be

Total US Hospital Beds – Already Committed Beds

That is your market. Committed beds are those where the institution has already selected an HIT vendor for that line of business offering.

Most hospitals have made a commitment to, say, an EMR vendor (with Epic and Meditech having the lion’s share) and are facing sheer difficulty in successfully implementing the systems. This is not a very transient market — clients will stick with their choices for years or decades. This makes vendor growth difficult and impedes new vendors from entering the market.  

Secondly, not many new hospitals are being added each year. Not only is it a limited market opportunity, it is also a limited market in terms of its organic expansion.

Those two points alone are cause for concern. We have companies struggling to make their way in a rather limited market. Just like in the real world, if you put a few predators in a pond that exhaust the food supply, they either turn on each other (merger) or they die off (stalled growth, no innovation, go on life support.) These foundational characteristics  establish the foundation for our bubble. Lots of excitement, sudden infusion of growth, tons of market hype, very limited market.

The next challenge is that many of the companies in HIT are experiencing extremely rapid growth. You might be thinking, “Wait, John. Isn’t rapid growth a good thing?” It is if the growth is balanced.  

If a company is growing its top side (new profitable sales) while slowly expanding its costs (people, infrastructure) then growth is great. But if you pay attention to the vendors in HIT, they are growing their costs at a rate that outpaces their top line.They are adding tons of people for services and support, yet you don’t see a tremendous number of net new sales. They are offering this expanded capacity as proof that they are in demand, but without net new sales, it is probably because they misjudged their products’ quality and capabilities, not because the company is gaining market share.

Secondly, if you aren’t seeing a company hire an incremental number of engineers and product people, then they aren’t adding new products to fuel the future. Healthy companies have a long-term focus, which is critical for surviving a bubble — growing and investing in their future products.

The concern here is that eventually, given a limited market (pond), vendors will eventually need to slash costs to continue operations ( the first pin prick in the bubble).

Slashing costs can be termed many different things: optimization, efficiencies, consolidation, synergy, and reorganization. Fancy terms aside, it is simply good old fashioned cost-cutting in hopes of making a financial plan  People lose their jobs and the company is in the first throes of trouble.  

As an industry, we have seen a few companies begin to take this tack and go into maintenance mode. Others will not cut costs so as not to signal the market that they are having challenges, but their margins will dwindle or their stocks will stagnate. No matter how you slice it, these are the outcomes of a limited market and companies with limited innovation.

So what does this mean to you? What should you be thinking or asking?

As a client, investor, or employee of an HIT vendor, you need to make long-term bets and evaluate whether a particular vendor is truly positioned for the long term. Now more then ever, you need to verify that your vendor is transparent about their finances, operating plans, and roadmaps.  

A vendor shouldn’t just talk about their history. It’s more important to know how they are financed and structured for the future. Be careful of fancy talk regarding reorganization, the use of external consultants, or restructuring. This is often the first sign that a company is in flux, either poorly positioned for growth or unable to understand their own market.

(Also, as important as cash reserves are to any company, if any company continues to point to their cash reserves as part of their long-term survival strategy, I would be concerned, but that’s just me.)

If the company is publicly traded, look at how Wall Street has rewarded their stock over several years. A stock that doesn’t have a history of long-term incremental and sustained growth reflects a company that hasn’t earned Wall Street confidence, but rather is a company that most analysts use to do short sales. This is not a company whose products you want to own for the next decade. 

Consider also that many companies put a lot of time and thought into their analyst calls — to the point of scripting them, hiring PR firms, and using other tactics to paint a glowing picture of poor performance. Don’t get fooled by fancy words and great presentations. Look at the long-term stock performance and discount what you hear on analysts calls. They are like first dates — everyone is on their best behavior and most analysts don’t ask hard questions. Your time is better spent elsewhere.

Simple math can give you clues to your vendor’s position for the future. Ask how many new new sales they have made in the past three years. 

I am defining net new sales as those that bring completely new clients to the table — clients with which the vendor has no preexisting relationship. Many vendors will classify a new sale as any new item bought by an existing client. If you listen to the analyst calls or sit in a vendor presentation, you might hear them say, “We had 50 new sales last year.” You think, “Wow, these guys and gals are on fire. Let me get some of that!” 

In actuality, they may not mean “net new sales,” they mean, “We sold stuff to the clients we already have.” This is important. You want existing clients to buy from their vendors. But if a vendor isn’t breaking out sales between net new clients and existing clients, it’s sleight of hand, often used to hide that the vendor isn’t expanding their market. That isn’t good.

Vendors love to talk about their sales pipeline and product roadmaps. This is good, but in a market with limited number of clients, a vendor needs to really talk in detail about their product pipeline. What products are they bringing to market? Who will buy them? If they are just offering the same products they have for the past several years or decades, be wary. If they are talking about new products in the pipeline but aren’t hiring tons of engineers and domain experts, be wary.

Look for details about when, how and why. Does their pipeline make sense? How much are they investing? Is it a committed investment? What do they need to do keep investing in the pipeline?  I bet it is linked to net new sales. If new sales stop rolling in, the company will either cut their costs or cut the product. Neither is good for you.

Why do cuts matter to you? If a vendor is cutting people, you may be in for a bumpy ride when it comes to service levels, which affect you the client directly. It also may mean that the vendor couldn’t predict accurately how to manage their business through the economic challenges of the industry.  

Look behind the marketing and get a clear understanding of why the vendor is cutting costs. Cost-cutting because of a new process may make sense. Adding robots to an assembly line would provide the same level of service with a need for less humans and less costs over time, but just cutting people or taking a quarterly write-off are not signs of a healthy company.

Listen closely to your vendor for signs of cannibalization. Be wary if they plan to grow their business by going after the business of stagnant companies that are closing, downsizing, or freezing their products. What the vendor is saying is, "Thank God those other guys screwed up, because without that, we would be in trouble."

Again, look for the totally net new sale. If clients are buying the vendor’s products without a sentient event — such as other companies going into maintenance mode — chances are the vendor is doing great. If a vendor is relying on the failure of others to keep growing, that’s a big warning signal.

Look over there and ignore the man behind the curtain. The industry relies on KLAS, Gartner, and others to evaluate vendor performance, client satisfaction, and overall product quality. I don’t believe any of these organizations is perfect. They should not be the ultimate voice of your decision. Still, when any vendor asks you to ignore these reports, you should have serious concerns.

No consumer or vendor reporting agency is perfect, but you can make it close to perfect. Take the report cards offered by these agencies and do your own analysis. Ask your vendor to answer the questions in the report. Randomly sample their client base, employees, and partners. It’s just like buying an appliance or car — if you bring the Consumer Reports article with you and ask about the report on your own, you will get better facts to help you make a decision.

So what’s the net?

I believe that we are in the early formation of a bubble. Whether it bursts or not, I don’t know. As an industry, we need to be wary and proactive. At the end of the day, the companies with strong product pipelines, net new clients being added to the roster, and growing conservatively will be the ones left standing. 

We will see consolidation, experimental business models, and some vendors fading away as the market settles and government funding levels. Don’t get taken in by mergers and consolidations. Most vendors don’t have the ability to successfully pull them off, although some have succeeded.

I have been wrong about more things in my life then right. I hope I am wrong about the future of HIT and the landscape of companies. There are real people that walk the halls of those companies, with families and dreams. My hope is that the leadership of those companies think long term, put aside vanity and ego, and do the right things to weather the storms.

Is there hope?

Yes. I don’t believe that this industry is doomed. I do believe there are going to be some serious growing pains, some flushing out of the industry (which has already started – Google, Microsoft, etc.) and unfortunately, many people losing their jobs as Meaningful Use levels out.

Once the industry works through that, I think we will be left with a really strong base of companies that are highly innovative, financially stable, nimble, and led by really smart professional leaders who truly understand the needs of the client and have a long-term focus. There is tremendous opportunity in this industry. We just need to separate fact from fiction.

John Gomez is CEO of JGo Labs.

News 12/23/11

Top News

It was announced Thursday evening that the 27% Medicare physician pay cut that was scheduled to take place January 1 will be delayed for at least two months.

HIStalk Announcements and Requests

Mr. H and I are already working on our HIMSS-related details, including our Must-See Vendor listing, our sponsors-only luncheon (where Mr. H, Dr. Jayne, and I will make personal but disguised appearances if we get brave,) our first-ever HIStalk Booth Crawl, and HIStalkapalooza. And then there is the charity shoe drive, which I hope results in hundreds of pairs of donated shoes. Mr. H says he also wants to schedule a HIStalk flash mob doing The Wobble, but who knows if he is serious. If you are a sponsor, look for my name in your inbox so you don’t miss any important details. And if you enjoy dressing to the nines and winning fabulous prizes, keep reading here for HIStalkapalooza details. In the mean time, shop those after-Christmas sales to find some hot new shoes and your party attire.

Looking for last minute gift ideas? You won’t find them on HIStalk Practice, but you will find plenty of other goodies to stimulate your mind as you nourish your body with fruitcake and other treats of the season. Some highlights: Canadian EMR Nightingale Informatix purchases US-based PM company Medrium. A troubling headline. A CIO seeks recommendations for EHRs suitable for surgery-based practice (send your recs my way.) ARHQ releases a guide for EHR implementations. Still on the naughty list? If you sign up for e-mail updates on HIStalk Practice, I promise to put in a good word for you with the jolly guy in red. Merry Christmas, Happy Hanukkah, or best wishes for whatever holiday you may be celebrating!

You may have noticed considerably less visual assault when reading HIStalk lately, as sponsors are busily swapping out their animated ads by the January 1 target date. We appreciate their support of the new policy and hope you do as well.

We need your HISsies nominations. It’s like a primary election: those with the most votes get on the final ballot to run for Most Influential, Most Effective, Worst Vendor, etc.

On the Jobs Board: Clinical Systems Analyst, Cerner and Epic Resources. On Healthcare IT Jobs: Pharmacy Business System Analyst/SME, McKesson STAR Analyst / Consultant, Cerner PathNet Consultant.

Online life is not a cabaret, old chum. What good is sitting alone in your room in front of an HIStalk keyboard if you can’t hear the music play, in the form of the pathetic metrics that Inga, Dr. Jayne, and I focus on in the absence of any other source of validation of our questionable societal worth? Right this way, your table’s waiting: (a) subscribe to the e-mail updates; (b) Friend and Like us in the appropriate places (on the Internet I mean, not our actual bodily places); (c) send us news and rumors; (d) give the Resource Center and Consulting RFI Blaster a look if you are in need of products or services; (e) admire and occasionally click the decreasingly animated sponsor ads to your left, marveling along with us that real companies with suit-wearing employees working in fancy offices support pajama-clad, crotch-scratching spare bedroom bloggers not only financially, but personally as we toil deep into the night after working hospital day jobs. We’re not naïve or full of ourselves , though – we fully understand that we’re just the convenient conduit for our desirable readership, so thanks for being included in that number.

Listening: jangle rockers The Connells, which flamed brightly but briefly over the 1980s global skies from Raleigh, NC. Even less appreciated than the band is Bandwagon, the tune-filled 1996 movie they had a hand in. I strayed on it and loved it this week on Netflix. Its total gross was $22,000, so it’s a safe bet you haven’t seen it. 

I will be working as usual this weekend, so there will indeed be a Monday Morning Update even though few folks will be reading it Monday. My handful of readers and I will be huddled like weary travelers making small talk in an out-of-the-way diner during a Christmas Day snowstorm. I don’t expect much news to report, but you never know. Regardless, Merry Christmas, Happy Hanukkah, or a joyous whatever it is you celebrate this weekend. If you’re out next week, Happy New Year as well (not to offend those who follow the Chinese calendar, who won’t be celebrating until January 23.)

Acquisitions, Funding, Business, and Stock

Citing challenging economic conditions, Thomas Reuters announces that it has changed its mind about selling its healthcare business.

Nuance Communications signs an agreement to acquire rival Vlingo, a Siri alternative for Android smart phones that offers better social networking capabilities. That company was found not guilty of infringing on a Nuance patent earlier this year and later sued Nuance for unfair business practices, alleging that Nuance’s CEO offered three Vlingo executives $5 million each to persuade their boards to approve an earlier acquisition offer. All pending lawsuits are now “stayed.”

PatientKeeper raises $6 million in growth capital from existing investors to support product development. Chip Hazard of Flybridge Capital Partners has been named chairman of the company’s board.

The company behind MyMedicalRecords.com announced a $30 million sale of its patents last week, but the newly filed 8K indicates that the transaction is not quite that straightforward (not surprising given that the company’s market cap is only $16 million and its products don’t seem particularly innovative.) Expert interpretation welcome.

Sales

Biggs Gridley Memorial Hospital (CA) selects the Prognosis Health Information Systems ChartAccess EHR and HIE.

INTEGRIS Health (OK) selects MedVentive Population Manager and Risk Manager to manage risks and quality performance.

People

Charles Anastos, Jr. joins PwC US as a principal in PwC’s Health Industries Group and co-leader of the firm’s EHR/HIE practice.

The Indiana HIE appoints Josh Nelson, MD as CMO. He was a physician executive fellow at WellPoint.

Announcements and Implementations

Bayada Nurses completes implementation of Homecare Homebase across its 50 home health service offices.

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Government and Politics

The VA announces that it has established Facebook pages for all 152 of its medical centers. It has also created 64 Twitter feeds, a YouTube channel, a Flickr page, and the VAntage Point blog.

CMS warns that its computer systems could crash under to a backlog of claims unless Congress stops the scheduled Medicare pay cut at the end of the year. The agency is advising contractors to hold physician claims for the first 10 business days of 2012.

ONC will build an online database to measure the effectiveness of grants given for a variety of HIT purposes, including those to individual physicians and hospitals, RECs, state HIEs, community colleges for HIT training, and vendors tracking HIT adoption.

The government project to develop a single EMR system for the VA and Department of Defense gets a $100 million appropriation even though the agencies’ request came in after the deadline. The VA gets $3.11 billion to spend for IT in FY2012, of which $580 million is for software development that includes a benefits management system ($107 million), veterans relationship management ($70 million), Virtual Lifetime Electronic Record ($50 million), and miscellaneous applications ($48 million.)

FDA goes on record in suggesting that it’s not really a good idea to buy another mother’s breast milk for your baby, even though Web sites offer it and some mothers make up to $2,000 per month selling their excess supplies. Breast milk is theoretically healthier for babies, but only if it doesn’t come from HIV and hepatitis-infected crack addicts anxious to feed their habit by selling whatever body product commands street value. Hospitals get sued regularly for mixing up breast milk, to the point that several vendors offer bar code scanning solutions to match milk to baby.

Other

athenahealth’s Jonathan Bush takes some direct swings at Allscripts and CEO Glen Tullman, calling him a symbol of “atrophy” and likening Allscripts to an “Orwellian bureaucracy.” In an article in the online investor publication Minyanville, Bush positions athenahealth as nimble and cutting edge, compared to the behind-the-times Allscripts. I’d say it’s pretty safe to assume that Tullman will not be sending Bush a Christmas ham this year.

The local paper writes up the self-implementation of the VA’s VistA by Oroville Hospital (CA), which earned it a $2 million Meaningful Use payout. We wrote earlier about that project, citing Roger Maduro’s Open Health News, which said Oroville spent $10 million on the project (which included hardware, replacement lab and medical equipment, and iPads) and $500K to have VistA enhanced to meet its needs.

Lee Memorial Health System (FL) gets a story in its local paper for implementing Epic’s bedside barcoding.

A network switch outage at Upstate University Hospital (NY) forces a several-hour return to paper systems and hand-rung patient bells.

An article says Cleveland Clinic’s fifth-highest-paid employee made over $1 million in each of the last two years despite having left the organization under “cloudy circumstances” in 2009. The Clinic declined to answer questions about David Strand’s severance or whether he’s still on the payroll. He and his also-resigned wife founded patient satisfaction and quality consulting firm ExperiaHealth (sold to Vocera) and he’s now CEO of LifeNexus, which sells consumer PHR smart cards.

KLAS says more providers are taking advantage of application hosting services to reduce capital expenditures and to tap into a higher level of technology. At the same time, more hosting providers are providing hosting services to applications other than their own.

All 69 IT workers in Louisiana’s Department of Health and Hospitals are notified they will lose their jobs early next year. The University of New Orleans and the University of Louisiana at Lafayette have been contracted to provide IT services for the state agency and may hire 50 of the displaced workers.

The sale of the Chicago Sun-Times to an investment group led my Merge Healthcare chairman Michael Ferro, Jr. has been completed.

A new non-profit, Patients for Fair Compensation, proposes a worker’s compensation-like system that would replace lawyer-enriching malpractice lawsuits with an administrative process by which patients would receive reasonable compensation quickly without turning most of the money over to attorneys.

Weird News Andy says he had a friend with an experience similar to that of this story, in which a man partying hard with two hookers at a Knights Inn motel in Orlando takes an AK-47 round to the chest. Doctors treating his wound find a large mass, removing part of his lung but likely saving his life.

WNA calls this story “Crack Cocaine.” Police car video records the back seat conversation of two handcuffed brothers as the older one implores the younger one to eat the one-ounce cocaine stash hidden in the older one’s rectum, telling him, “I can’t get no more strikes. Eat that sh*t so I can get out.” The younger brother eats the cocaine, tells the older brother he loves him, and dies of cocaine intoxication.

A Chicago malpractice law firm, cheered by the recent article suggesting that doctors are screwing around on their smart phones during critical medical procedures, says anyone who suspects they were injured by “distracted doctoring” should give them a call (probably while driving.)

Sponsor Updates

• Healthwise offers a white paper entitled Patient Response: Giving Voice to the Patients.
• Tom Stephenson, president and CEO of HMS, discusses healthcare technology as a tool for better patient care in a blog post.
• Passport Health Communications will participate in next month’s MEGA and HFMA MA-RI conferences.
• eClinicalWorks and the American Society of Plastic Surgeons (ASPS) announce a three-year initiative to provide eCW’s products to ASPS members.
• HealthStream and GE Healthcare announce a partnership to offer Centricity University, a subscription-based service for online and classroom training on Centricity products.
• Microsoft will participate in the 2012 Military Health System Conference January 30 – February 2 in National Harbor, MD.
• Brian Woods MD, chief medical officer of NorthStar Anesthesia, wins a magazine’s award for implementing Shareable Ink in the hospitals that his group serves. Prognosis CEO Ramsey Evans was also named for his work creating the Prognosis HIS.

EPtalk by Dr. Jayne

The hot news around the doctor’s lounge the past few days (other than the fountain soda machines that were recently purchased to feed the habits of those non-coffee drinkers on the medical staff) is the Medicare pay rate debacle. As most of you know, the House of Representatives rejected a Senate bill this week that would have avoided the pending 27% cut in Medicare rates. As a result, pay rates are in limbo and CMS responded by saying it would suspend claims processing for the first 10 business days in 2012 to avoid having to deal with retroactive reprocessing should Congress remedy the situation.

Make sure you don’t use it as an excuse to slack on your charges, though, because come January 17t, CMS will start processing those claims (at the reduced pay rate if Congress doesn’t act) on a first-come, first-served basis.

And for the curious, they installed both Coke and Pepsi dispensers, but my southern sensibilities are highly outraged by the lack of respect shown to my esteemed colleague, Dr. Pepper.

Interestingly, one of the stories I read that covered this issue was right next to an article titled Physicians Must Make Any Changes to Medicare Participation by December 31. That means if you’re tired of all the shenanigans, you have the opportunity to opt out of Medicare if you wish. The AMA offers a Medicare Participation Kit that offers more information on the various options.

I love it when Inga sends me snarky comments about stories she’s reading, and this week she didn’t disappoint with this one. To Get Meaningful Use Payments, Urologists Must Address Workflow. I wholly agree with her that the words “flow” and “urologist” should never go in the same headline.

Sending more happiness our way, CMS also released a proposal for rules around the Physician Payment Sunshine Act. The rules require that gifts, consulting fees, travel reimbursements, payments, grants, and pretty much anything worth more than $10 that is given to physicians or teaching hospitals be disclosed by manufacturers annually. For those of you who may not know, this is part of the Affordable Care Act, which really does seem to be the gift that keeps on giving. CMS also announced a comment period open through February 17, 2012, so be sure to weigh in. HIMSS has also released a fact sheet and plans to convene a working group to formally respond.

NCQA releases a “save the date” for the 2012 Health Quality Awards to be held March 27, 2012 at the National Building Museum in Washington, DC. Nothing on their website yet that I can find, but I did get a nice e-mail soliciting sponsors.

The Wall Street Journal runs a nice piece on researchers who are using “virtual patients” to leverage technology to test medical devices and procedures when real patient testing isn’t practical. Computerized modeling can help with estimates of radiation exposure to a fetus or with technologies which may perform differently in children (who aren’t typically the subjects of very many research protocols) as compared to adults.

Sometimes low-tech is best: Archives of Dermatology publishes a study that shows that maggots debride non-healing wounds “significantly faster” than traditional scalpel-based techniques. Additionally, there were no differences in pain or crawling sensations between the two treatment groups. Maggots have been approved for medical therapy since 2004, but availability of so-called “bagged larvae” varies. Out of curiosity, I checked with our pharmacy and am happy to report that yes, we’ve got maggots in our arsenal.

I’ve enjoyed seeing the pictures of holiday giving and charity activities submitted by our readers. I recently heard about WorldScopes, a philanthropic project of the AMA Foundation that distributes new and gently used stethoscopes to clinics and hospitals world-wide. If you donate more than 20, the AMA covers your shipping costs. My package is already on its way. If you decide to participate, put HIStalk on the shipping label since we’re a lot more fun than the other choices for identifying where you heard about the project.

That’s it for me tonight. I’m off to bake some holiday cookies with my main man. Have a question about automated patient recalls, why baking soda and baking powder aren’t interchangeable, or what those little silver metallic balls are on holiday cookies? E-mail me.

Contacts

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

HIT Vendor Executives – Part One of Two

We asked several HIT vendor executives the following question: What was the biggest HIT-related news or event in 2011 and why?

Ray Dyer, CEO, Acusis

The industry has experienced continued mergers in 2011 (Allscripts/Eclipsys and Medquist/M*Modal, to mention a couple), the federal government has come to a ruling on how ACOs should work, MU payments were issued, and we have seen a rise in the use of and demand for mobile devices in healthcare, including new medical students being issued iPads.

I don’t think a singular event could be identified as the biggest moment in HIT in 2011. However if mapped across a timeline, we could certainly mark these as significant highlights during this past year.

Dan Herman, Founder and Managing Principal, Aspen Advisors

McKesson Provider Technology (MPT) division’s Better Health 2020 strategy announced on 12/9/11. MPT has publicly announced what has been rumored for some time – that it will curtail further development of its Horizon software product line and invest heavily in its Paragon product. This decision affects hundreds of hospitals throughout the country. Some long-term McKesson customers have already seen the writing on the wall and have made strategic and financially significant decisions to move away from McKesson’s non-integrated Horizon clinical platform. However, many other customers (medium-sized community hospitals and multi-entity integrated delivery networks) are faced with a critical decision: do we stay the course with McKesson or rethink our EMR strategy and pursue an alternative course?

Reading between the lines, this change in direction will have a huge financial impact on current McKesson Horizon customers, and it brings McKesson’s credibility in the EMR market into question. Although the market for EMR technologies has grown, the Horizon product line has experienced decline in market share, system development delays, poor product integration, and significant customer dissatisfaction.

On one hand, I laud MPT for coming clean on the challenges it has had with the development and support of the Horizon product. However, it appears that MPT’s go forward strategy is “déjà vu” – a poorly thought out approach to integrate disparate platforms, enhance a product that has experienced success in a focused market place (Paragon), and promise customers that MPT is committed to delivering “a fully integrated core clinical and revenue cycle IT system.”

Regardless of McKesson’s direction, healthcare providers need to evaluate their needs against the software available to support them and make decisions that are in their best interests.

Jay Deady, CEO, Awarepoint Corporation

The biggest HIT-related news of 2011 is that 1,211 eligible hospitals and 21,425 eligible professionals (EPs) have successfully attested and collected $1.84 billion from Medicare and Medicaid through the end of November for meeting Stage 1 meaningful use of electronic health records (EHRs).

The news, disclosed at the December 7, 2011 meeting of the Health IT Policy Committee, is significant for several reasons. First, it indicates the transformation of the health system and national commitment to improve access, quality, coordination, and efficiency of care through information technology have begun in earnest.

Second, it ensures providers adhere to baseline quality standards that can be measured and compared, including: using CPOE for medication orders, implementing decision support rules, exchanging key clinical information, and protecting electronic health information.

Third, attesting hospitals and EPs had to meet reporting requirements that some providers have characterized as challenging, onerous and time-consuming. Those that haven’t attested or plan to attest to Stage 1 in 2012 will benefit from lessons learned by early attesters.

Fourth, the payments demonstrate the meaningful use program is real, which will motivate providers to automate sooner rather than later in order to subsidize or recoup the cost of an EHR. As they automate, however, providers must remember that EHRs alone won’t address every problem afflicting healthcare. To accomplish that and aid throughput, they must complement EHRs with other technologies such as real-time location systems.

Don Graham, General Manager, Billian’s HealthDATA

I would have to say it’s been the extreme focus providers seem to be putting now on enterprise healthcare analytics and business intelligence, especially when coupled with the recent release of final ACO regulations. They realize that healthcare transformation requires more than the implementation of an EMR. As providers move more towards the coordinated care model (PCMH, ACOs and beyond), the challenge will be to meet the analytical needs to support this model. It will be critical to deliver an integrated view of clinical, financial and operational data not only across the enterprise, but across the community as well. Access to this data will enable providers to move into new areas of care.

In acknowledgement of the importance of analytics and its role in healthcare transformation, Billian’s HealthDATA and affiliate Porter Research have decided to focus one of our Provider Perception studies on Enterprise Analytics early next year. It’s something that our healthcare vendor customers are in turn paying more and more attention to, and appreciate the insight into.

Stuart Long, President, Capsule

I think the biggest HIT-related news this year is ARRA. It seems that all hospitals are just looking at how they are going to meet the criteria and qualify for the stimulus dollars. They are looking for any and all news on the topic. They are looking for help in sorting through and interpreting the legislation and what they specifically need to do to qualify. They are setting up cross-functional teams within the hospital to sort through it all. And they are looking to their vendor partners to prove how their technology and solutions fit within ARRA and therefore whether or not they will make it to the hospitals short list or not.

In fact, it’s one of the biggest areas we’ve been working on at Capsule and with our EMR partners — to help define where device integration fits within meaningful use and CPOE. I believe that ARRA and CPOE have hit all areas of the HIT space, from hospitals, to vendors, to system integrators, and to the publishing community at large – whether that be new publications, journals, trade shows, blogs, and even social media.

I just believe that the entire healthcare IT world has been turned upside down with ARRA. And of course it’s not over. We will all continue to be focused on it as Phases 2 and 3 roll out in the years to come. It might be a bumpy ride, but all we can do is hold on tight and keep on moving forward.

Mac McMillan, CEO, CynergisTek

I’m sure from an overall HIT perspective the answers will be quite different, but from a privacy and security perspective, it had to be one of two announcements from the federal government.

The first is OCR announcing it will finally initiate its regular audit program to conduct routine, random compliance audits of organizations accountable to HIPAA. The initiation of the audit program completed OCR’s menu of compliance and enforcement-related activities by adding to its existing practices: investigation of breaches and response to complaints. The OCR will likely disclose more information about these audits and their outcomes next year.

The second candidate for the biggest HIT-related event is the ONC announcing a delay in Meaningful Use Stage 2 in order to give organizations more time to meet Stage 1 requirements and to further support adoption of EHR technologies.

Both of these have a direct impact on the industry and its move to privacy and security readiness. We at CynergisTek are working with a lot of healthcare organizations to achieve compliance goals and improve their overall security posture. We’ve seen Meaningful Use increase attention to security and work to provide the support covered entities need to accomplish their risk analysis and implement the security features of their EHR/EMR effectively. This approach is consistent with OCR’s guidance on risk analysis and produces a step-by-step action plan that guides remediation efforts. In addition to that, we understand the partnership model desired in healthcare and we provide ongoing advice and assistance throughout the remediation process and beyond.

Michael O’Neil, CEO, GetWellNetwork

2011 was the year that the healthcare industry fully recognized patient engagement as a business imperative. Driven generally by the reality of a shift to a value-based US health system — and specifically by the requirements for patient engagement in Stage 2 Meaningful Use and the push by ONC to support consumer health IT adoption — leading providers moved aggressively to develop strategies, find partners, and adopt solutions to help.

Due to the confluence of regulatory, business, and technology transformation underway, patient engagement emerged as a core strategy for performance improvement for providers. Leveraging HIT, patient engagement solutions can take the form of Web-based portals and interactive patient care (IPC) education and communication solutions, or as simple as an online patient guide or patient bill of rights. It’s education. It’s entertainment. It’s empowerment. In fact, it’s all aspects of being involved in care.

One thing is sure: providers must work to ensure that the principle of patient engagement permeates clinical and business workflow and every aspect of care delivery. In 2012, there is no doubt that a focus on patient engagement will take greater hold throughout the continuum of care.

Peter J. Butler, President and CEO, Hayes Management Consulting

Attempting to identify the biggest HIT-related news item is difficult. However, based on research from the Ponemon Institute, which  conducted detailed interviews with executives at 72 healthcare organizations, the economic impact of information breaches can be far reaching and should be considered one of the top news items. Consider the following breach survey results:

• On average, organizations surveyed have had four data breach incidents in the past two years, up from three in last year’s study.
• The average number of lost or stolen records per breach is 2,575, up from 1,769 in the previous study.
• The top three causes for a data breach are lost or stolen computing devices, third-party mistakes, and unintentional employee action.
• Insufficient budgets and inadequate risk assessments are cited as the two greatest breach prevention weaknesses.
• Some 81% of those surveyed use mobile devices to collect, store, or transmit patient information, but 49% say they’re doing nothing to protect these devices.

There hasn’t been a slow news day in healthcare this year, but the topic of breaches is the alarm bell for the industry. With the onslaught of new technology, the most important data – patient health information – is not safely secured. It reflects the cracks in the frantic attempt to catch up with all the unintended byproducts of the industry changes.

For example, just when the industry secured all its laptops, mobile technology took off. Now, smart phones, mobile carts, tablets, and thumb drives need to be monitored and secured. Not a day goes by where a laptop has been lost or stolen. HIPAA’s reporting policy means that the clock is ticking when the breach happens, organizations are responsible for business associates’ breaches, and the fines pale in comparison to the impact on reputation.

Healthcare organizations must put privacy and security at the top of their 2012 priority list. They must develop policies and procedures for reporting in a timely manner on breaches. Further assessments need to be conducted on a timely basis – annually at least.  This protocol must be understood by every employee and monitored to ensure compliance across the enterprise. Training and communication of HIPAA regulations need to incorporated within each healthcare organization and monitored. Micky Tripathi’s blog post on this topic gives a stunning insider view to what it’s like to have a breach happen in your organization. No one is immune – and it takes a village to rectify it.

Tiffany Crenshaw, President and CEO, Intellect Resources

Meaningful Use and ICD-10 are what everyone is talking about, but surprisingly, no one is talking about what Meaningful Use and ICD-10 mean from a human resources standpoint.  Incentive deadlines have created an industry-wide shortage of experienced healthcare IT professionals, specifically those with Epic experience. Think about it — everyone in the industry is working towards the exact same deadline!

Countless planning hours are put forth to ensure a successful go-live and meet incentive deadlines. Technology, equipment, infrastructure, training and other task related functions are all meticulously planned in advance with the intention of those tasks being carried out by future experienced healthcare IT hires. But what if you can’t find those future hires? What happens to your plan then?

Meaningful Use and ICD-10 have created a huge demand for experienced healthcare IT professionals and there simply aren’t enough experienced individuals to fill these much-needed positions. Now is the time to think creatively about hiring solutions and start planning.

Doug Burgum, President and CEO, Intelligent InSites

The biggest healthcare IT event in 2011 was the Department of Veterans Affairs’ decision to improve healthcare efficiency with a national investment in Real-Time Location Systems (RTLS.)

The VA has the nation’s largest integrated healthcare system: over 150 medical centers, almost 1,400 community outpatient clinics, and 53,000 independent licensed healthcare practitioners, serving more than 8.3 million Veterans every year. Eric K. Shinseki, Secretary of the VA, has identified 16 transformational initiatives for the VA. One of these initiatives, Health Care Efficiency, directly includes RTLS to improve care while lowering costs.

The Government Executive reports that the VA views a planned $550 million National RTLS implementation as a way to improve efficiency, track equipment, and properly sterilize medical instruments.

We are thrilled that our industry has the opportunity to contribute to this groundbreaking effort. Intelligent InSites’ customers have improved patient satisfaction and patient safety, while decreasing hard-dollar expenses, through their use of RTLS solutions for asset management and patient flow. They do this by automatically collecting real-time data from throughout the hospital, processing that data, then using actionable intelligence to make fundamental improvements to how they run their hospitals. By using RTLS, they can process the location and status of every critical piece of medical equipment, patient, and staff in a healthcare facility, then use this data and intelligent workflow automation to improve their healthcare processes.

The next few years are going to be amazing—not just the RTLS industry, but also for the transformational benefits to the delivery of care.

Mike Sweeney, President and CEO, maxIT Healthcare

This was such a busy year in the HIT industry, it would be difficult to name just one event, so I will limit myself to three.

First, Epic’s continued dominance in new account sales along with the recent trend of their customers’ rolling the Epic applications out to their affiliate networks (acute and ambulatory) has had a major impact this year. Second, McKesson’s announcement of their product direction with Horizon and Paragon will have a significant ripple effect in the market as we get into 2012. Finally, the government mandates and programs surrounding Meaningful Use, ICD-10 and ACOs are driving so much demand and activity in the market, those can’t be left out of top events for 2011.

It’s definitely an exciting time to be in our industry, and I can’t wait to see what’s in store next year.

Tom Carson, CEO and President, MD-IT

The clear emergence of physician preferences for mobile applications to interface with their HIT systems has huge implications for systems criteria and future workflow demands. Most legacy HIT systems were developed with the idea that physicians would sit in front of desktop computers for their documentation and care-planning tasks. After years of physician reluctance to adapt to these defined work processes, the relatively rapid increase in popularity of applications for smart phones and tablets suggest that doctors are beginning to participate on their terms in EMR adoption and use, and that HIT vendors are due for a re-think in their approach to product solution design and delivery.

This is significant because it marks a maturing of the EMR industry in that products will have to be more customer-driven going forward, as opposed to regulatory-driven to succeed.

Patrick Hampson, Chairman and CEO, MED3OOO

The biggest news related event was just recently announced by the Kathleen Sebelius, the HHS secretary. By relaxing the time frame for meeting Meaningful Use Stage 2 requirements, physicians, EHR vendors, HIE projects, and most all operators of healthcare will all get more time to adapt to the rapid expansion of electronic health care delivery.

Changing healthcare to a more seamless, interconnected health system in the US is absolutely critical. Doing it right and not just doing it fast is even more critical. Why have providers go from a paper mess to an electronic mess? Why just add technologies without the strategy, knowledge, and planning needed and the provider level knowledge necessary to actually get a return on your investment? How about a return in care for your patient?

Physicians and hospitals were forced to scramble to adopt new work flows, new processes of care delivery, and at the same time, implement new technologies (EHR systems) and install patient portals to meet the requirements for Stage 1. If these same providers want to stay viable, they have to maintain productivity, fight competitive forces in their markets and pre-pay, for most of this while the government gives them an IOU. Throw in the current economic conditions of our depressed economy and it is all too much for providers. Great for vendors, not so great for providers.

Relaxation of the Stage 2 requirements deadline is less about not wanting to get somewhere, but it is more about getting there efficiently. A pet peeve of mine is why have financial penalties should you not do it fast? Why not financial incentives for doing it right?

Hopefully we will all take this delay as a continued opportunity to improve the designs of technology, not just to process a bill or serve as expensive transcription, but provide technology that can really support providers and the coordination of care across the populations they serve. While Accountable Care is touted as the next big step for many, MED3OOO as a healthcare management and technology company has provided technologies and operations for physicians and hospitals and communities are already accountable for care and for managing risk and been doing it successfully for more than 15 years.

For those that haven’t, the learning curve and the costs are steep. These organizations will require more than just production systems like accounting systems, practice management systems, and electronic health records. Organizations will require and we will provide strategies, systems, and operations economically. Organizations will need to have capabilities that include integration of disparate systems and disparate centers of data. Organizations will need the ability and systems to disseminate population data and then distribute that same data efficiently back to the point of care for its best use.

MED3OOO is uniquely position to partner with providers and provide our existing packages of system, software, and knowledge infrastructure to make this next journey a successful one for new Accountable Care providers. In doing this, we will continue our mission and make absolutely sure that the patient has a better outcome. We do believe that outcomes matter!

Peter Kuhn, CEO, MEDSEEK

With Microsoft partnering with GE, Google exiting the PHR market, and more payers entering the provider market, the events of 2011 have significantly changed the healthcare industry. How patients respond to payers acquiring providers depends on whether they perceive an improvement in care coordination or feel that quality of care is mitigated by payers influencing physicians. With access to both risk models and clinical information, how well these acquisitions work also depends upon the ability to analyze that data to create effective business strategies.

Analytics, particularly predictive analytics, has been in the healthcare news this year. At MEDSEEK, we understand that analyzing data and creating actionable strategic plans will help our clients set themselves apart. That’s why we made the decision to acquire Third Wave Research, Ltd. We’ve subsequently integrated what we believe to be the most advanced predictive analytics technology into our strategic patient engagement and management solutions.  With the commoditization of patient portals and patient outcomes and wellness driving revenues, the major market differentiator will be how well hospitals engage new and existing patients, manage costs, and coordinate care.

Hospitals’ success will increasingly hinge on using predictive analytics to match high-value patients with appropriate, profitable services when and where they need them and make informed investment decisions based on population health propensities. Combined with factors such as demographic, financial, and insurance data, predictive analytics will play a larger role in executing cost-effective, personalized marketing campaigns that influence patient behavior and improve population health.

Jeff Surges, CEO, Merge Healthcare

With new federal policies to reduce reimbursement and foster information sharing, the question is not if, but when a healthcare system should implement an enterprise imaging strategy that focuses on providing electronic access to medical images. Hospital CEOs, CIOs and physicians can no longer ignore:

• Patient safety issues around radiation exposure
• Competition to attract and retain the best physicians
• Compliance with Meaningful Use guidelines
• Support for an ACO strategy
• The push for interoperability in EHRs across healthcare systems and HIEs

These issues are driving the need for a new paradigm of image sharing and enterprise-wide imaging strategies.

An enterprise imaging strategy must focus on image storage, the ability to ingest images from outside of the enterprise, and provide accessibility to any type of medical image, anywhere across the continuum of care, anytime, by anyone. It should include three components:

• Storage. A vendor-neutral archive (VNA) to create a patient-centric record of images across all sites and modalities.
• Gateway. An intelligent DICOM gateway, capable of receiving and morphing studies from outside the enterprise.
• Viewer. A universal viewer that can be used in any environment on any device and is accessed via the browser, thus requiring no software to be downloaded.

There really is no wrong way to proceed with an enterprise imaging strategy as long as decision-makers fully understand the capabilities of each technology component, relate the capabilities to meeting their top business challenges, and look at the enterprise imaging strategy as a solution that can grow and evolve over time.

Jay Mason, CEO, My Health DIRECT

I see the roll-out and clarification for Accountable Care Organizations this year as being a significant event or turning point. While there is yet to be much to determined in how they will play a role in reimbursement and delivery, it has forced organizations — both payers and providers — to rethink how they function and how they look at themselves. Infrastructure, resources, and relationships will be reshaped.

This means they must commit to new ways to work together as providers, as well as how they are engaging, informing, managing, and directing patients. The silos that have been built up over the past decades will soon come crashing down.

Janet Dillione, Executive Vice President and General Manager, Nuance Healthcare

ICD-10 came onto the scene in 2011 in a big way. It received enormous attention throughout the year and has even been compared to Y2K. In short, it’s a monumental shift from what is documented, coded, and billed against today in healthcare and what level of specificity will be expected to be documented, coded, and billed against come 2013.

As a result of this major transition in medical coding, the reimbursement process will get more complicated and will expand. At Nuance, we believe that ICD-10 success begins with the physician at the point of documentation. In turn, over the past year we’ve allocated resources to develop, in partnership with 3M, next generation ICD-10-ready clinical documentation and coding solutions. In 2012, we’ll bring to market Computer-Assisted Physician Documentation, a new category of solutions that will interact with physicians at the point of documentation to review and prompt for the level of specificity required to achieve reimbursement in correlation with ICD-10 standards. Simply put, it turns clinical language (doctor’s spoken words) into codable language.

By combining Nuance’s speech recognition and Clinical Language Understanding (CLU) capabilities with 3M’s experience in developing and implementing coding products and services around the world, we’re well positioned to deliver solutions that will substantially improve physician workflow and will facilitate more precise, complete coding, and more accurate claims.

Todd Cozzens, CEO, Accountable Care Solutions, Optum

This past year has been filled with game-changers – from Meaningful Use to ICD-10 – but the biggest milestone in healthcare IT had to be the CMS final rule on the Medicare Shared Savings Program, which I believe will be looked back at one day as the event that spawned a whole new generation of health information technology.

Notice that I’ve not include the “care” ending to health. This next generation of IT solutions will focus not just on patients currently seeing doctors and being admitted to hospitals. It will cover a much broader spectrum of wellness and prevention products to comprehensive management of patient populations. The final regs set the tone for the industry and made a statement: accountable care is here to stay.

When I talk about accountable care these days, I am quick to point out I’m talking about the general idea of healthcare providers taking on some form of risk – i.e. being responsible for the outcome AND the cost of that outcome. McKinsey thinks there will be around 750 MSSP ACOs within five years. That sounds about right. But when we at Optum talk about the broader concept of sustainable health communities, we believe that every health system in the country will adopt some form of risk taking – whether it be bundled payments or new risk-sharing health plans with payors, all the way up to fully capitated networks.

Healthcare reform was the catalyst that started the dialogue. The budget deficit, with its inevitable cuts in entitlements, created the sense of urgency. The Medicare MSSP program signaled that CMS is 100% behind the effort. We all know that when CMS coughs, the US healthcare industry has a cold, and that’s why this final rule is such a game changer.

Paul Brient, President and CEO, PatientKeeper Inc.

One of the biggest HIT-related news stories in 2011 was the extension in the effective date of Stage 2 Meaningful Use. At some levels, this was a non-event. ONC’s decision to push back the Stage 2 start date for Stage 1 “early attesters” by a year (to Oct. 1, 2013) corrected a flaw in the original plan that effectively penalized hospitals for being on the ball and attesting for Stage 1 early. Yet the move created a fair amount of confusion in the market and headlines in industry media, and paused some Meaningful Use activity.

That is largely behind us now. The Stage 2 proposed rule will be published in the next month or so, and many hospitals are beginning to focus on the challenge of getting widespread physician adoption of CPOE and documentation software that will be required by Stage 2 and 3 objectives.

Todd Johnson, President, Salar

In a conference this past summer with chief medical information officers and physician informaticists, a physician’s panel was convened to consider the next big challenge for their hospitals. Without question, the conversion to ICD-10 topped the list. As discussed in that conference in Ojai, California, and paraphrased here: “ICD-10 is entirely a physician documentation issue.” While this statement does not to suggest a minimized importance for consultative services, back-end billing systems, or payer reform, it does call to light the critical nature of a physician’s clinical note. All coding starts from the note. Indeed, the note itself justifies all other pieces in this puzzle.

Going into 2011, we believed (as did many others) that Meaningful Use would continue to dominate all discussions. In retrospect, we’ve been surprised to see how quickly ICD-10 has become a front-burner issue though so poorly addressed by the healthcare market. Both hospitals and the vendor community alike seem woefully ill-prepared to address this issue which simply fuels the anxiety and paranoia of this “great unknown.” Just as Meaningful Use taglines blanketed the banners at HIMSS this year and MS-DRG coding dominated the banners in years before, you won’t be able to walk 10 paces without seeing ICD-10 lingo at HIMSS 2012.

Stephen Hau, CEO, Shareable Ink

The growing acceptance of enterprise cloud computing in healthcare has been a persistent and recurring theme of 2011. We are excited by this development because it will help accelerate much needed innovation in healthcare IT.

Hugely successful IT projects in our industry are relatively rare. Some may feel that this reputation is unfair and not deserved. However, who can deny that the industry has a track record of protracted implementation projects, lengthy development / release cycles, and expensive hardware investments that can quickly become obsolete?

Enterprise cloud computing represents an approach that is compelling for small physician practices (with no in-house IT support), large health systems (that require scalability, minimal administrative burden, and stringent uptime commitments), and organizations in between. We have observed shorter deployments, transparent and non-disruptive updates, and removal of hardware obligations from the customer. A cloud-based distribution model allows software providers to respond to market demands more nimbly – and healthcare organizations to take advantage of rapid innovation.

Taken together, enterprise cloud computing has the power to provide a very positive IT experience, allowing healthcare organizations to focus on the benefits of technology and creating a better environment for innovation.

Ed Daihl, CEO, Surgical Information Systems

Hospitals and anesthesia providers are facing reimbursement changes, shifting payment models, increased regulatory reporting, and Meaningful Use. We believe that hospitals will continue to focus on achieving ARRA funding to help combat these challenges.

It is important to us at SIS to ensure that we help our clients respond and prepare for these changes. We were the first perioperative healthcare software provider to achieve ONC Meaningful Use certification in 2010, and more recently, our Anesthesia Information Management System (AIMS) achieved Meaningful Use certification as well.

Evan Steele, CEO, SRS

One of the biggest HIT-related events was the recent announcement by HHS that it was postponing the implementation of Meaningful Use Stage 2. It was important, not because it will directly and significantly impact very many providers, but rather because of what it acknowledges and the positive message it sends.

All that the delay does is to reward early adopters by giving them access to three years’ of incentives under the easier rules of Stage 1 and to remove one of the reasons that might have discouraged some of them from attesting in 2011. Contrary to Secretary Sebelius’s contention, it can do nothing to speed adoption since the announcement came too late to impact any providers who have not already implemented—and been successfully using—a certified EHR.

What the delay does accomplish, however, is to send a heretofore unheard message—one of flexibility and of an acknowledgment of the significant challenges that Stage 1 is posing for many providers and vendors. By delaying the schedule for Stage 2, the government has let them know that the rules are not set in stone, that some things are negotiable, and that it is willing to work with providers and vendors in the interest of accelerating EHR adoption. If this same message is conveyed in the release of the actual rules for Stage 2, the likelihood of the program’s ultimate success will be greatly enhanced.

Rick Stockell, President, Stockell Healthcare Systems

As we have seen and experienced with our customers, the impact of prepping for and addressing Meaningful Use and ICD-10/5010 compliance on the healthcare industry was certainly significant in 2011, and it will continue to be a major factor into 2012 and beyond.

Richard Atkin, President and CEO, Sunquest

Over the past several years, structured reporting of laboratory results has been promoted as a public health priority. Its inclusion as a Meaningful Use objective is helping to drive the accelerated adoption of EMRs.

This past January, Sunquest Information Systems became the first and only dedicated laboratory information system vendor to achieve 2011/2012 Meaningful Use compliance and certification as an EHR Module by the Certification Commission for Health Information Technology (CCHIT.)

Sunquest continues to lead the industry with regard to the HITECH Act and Meaningful Use regulations. Meeting with government officials and continuously monitoring client preparedness are just two of the ways that Sunquest helps its clients complete the three steps for earning incentives: adopt certified electronic health record (EHR) technologies, achieve Meaningful Use objectives, and apply for incentive payments.

In addition to meeting many of the Meaningful Use modules, Sunquest solutions provide the capability to improve the overall safety, quality, and efficiency of healthcare. Our comprehensive Meaningful Use plan includes expanding the use and management of LOINC and SNOMED-CT codes. This initiative is a critical priority for our clients as they plan their LOINC strategy.

Sunny Sanyal, CEO, T-System

The recent decision by the US Department of Health and Human Services (HHS) to delay by one year the start date of Stage 2 Meaningful Use of certified electronic health records (EHRs) is by far the biggest HIT-related development of 2011.

By pushing the compliance deadline from Oct. 1, 2013 to Oct. 1, 2014, HHS recognized that the original timetable was too aggressive. Many hospitals planning to be ready for Stage 1 in 2011 or 2012 would have faced little lead time to prepare for Stage 2 requirements, which will not be finalized until July 2012. This deadline would have made it extremely difficult for both facilities and vendors to upgrade and install Stage 2-compliant EHRs by October 2013.

Prior to the delay announcement, we were beginning to hear rumblings from hospitals about potentially abandoning efforts to qualify for Meaningful Use incentives, instead waiting to attest until 2015 to avoid Medicare reimbursement cuts. The one-year grace period will enable providers who attest to Stage 1 Meaningful Use in 2011 to qualify for three payment years and those attesting in 2012 two payment years. It will give them and their EHR vendor partners additional time to develop a plan for Stage 2 compliance and design and implement optimal software. More importantly, it buys hospitals time to drive adoption of EHRs intended to improve the quality, safety and cost-effectiveness of care.

News 12/21/11

Top News

HHS names the 32 healthcare organizations selected to participate in the Pioneer Accountable Care Organization model. The Pioneer ACOs will test the effectiveness of several payment models to support better care and outcomes at a lower cost.

Reader Comments

From Unicorn Hunter: “Re: IT resources. I need people or a company who can extract, transform, and load data from popular ambulatory EMRs to EpicCare, with skill in Oracle programming and Epic Bridges.” We don’t usually get involved with recruiting, but leave a comment if you have suggestions.

From Curious Reader: “Re: Medicomp. Interesting interview with Dave Lareau. Which vendors are using Medicomp?” I checked with Dave, who unfortunately can’t help. “Because of the proliferation of patent trolls in the marketplace and their ‘bulk litigation’ approach, Medicomp does not publish its customer list.” But if you go to HIMSS, I bet he will tell you, and if it’s like last year, several vendors will be bragging on their use of MEDCIN and Quippe.

From Music Man: “Re: your frenetic schedule. Know that your efforts are appreciated by me, my team, and many others. You’ve liberated us from the pay-for-play, outdated, and hopelessly out of touch hegemony of the publications put out by HIMSS and others.” Not only was that a nice comment from a sponsor, it uses a word not often heard. I had to check the pronunciation and definition: hee JEM uh nee, meaning dominance. I’m pretty sure the old guard is still dominant, but we’re happy heel-nippers.

From Harold the Barrel: “Re: [vendor name omitted]. The head of its demo team resigned today. Also, rumor has it that [name omitted], a well-liked executive from before the acquisition, has resigned. Also, [name omitted], who was responsible for driving new acute care sales, has parted ways.” I’m leaving out specifics since I know from experience that the company doesn’t confirm personnel issues and I’m uncomfortable running the names of people without verification.

From Big Sigh: “Re: Cleveland Clinic. Despite its health technology savviness, it still orders tests without regard to best evidence.” The top five tests ordered there are of questionable value, says this article.

From The PACS Designer: “Re: Withings. Since it’s the holiday season, TPD thought it would be nice to highlight a potential gift for someone you know. If that recipient has health issues, the gift of Withings may help start the improvement process. Withings is Wi-Fi enabled, can monitor blood pressures and other body parameters, and also has a baby monitor application.”

HIStalk Announcements and Requests

I keep mentioning the Resource Center and Consulting RFI functions, so I finally got around to having banners made that link to them (to your left, below the Founding Sponsor ads). I decided to make it confusing by calling the Resource Center “Vendor Catalog” (actually, even though it’s inconsistent, I thought that label was more immediately understandable.) The Resource Center lets you find HIStalk sponsors by category, which is pretty cool, or you can look them up by name or do a full-text search. The Consulting RFI Blaster lets you fill out a really simple form and send it with a click to one, some, or all HIStalk sponsors who offer consulting services. CIO readers came up with the idea for both of these functions, asking for a way to make it easy for them to give sponsors a chance to earn their business.

It’s that time again: HISsies nominations are open. Name the best and worst vendors, choose the Industry Figure of the Year, and of course give thoughtful consideration of your nominee for Industry Figure in Whose Face You’d Most Like to Throw a Pie. The most-nominated winners advance to the final ballot in a couple of weeks, so don’t assume someone else will nominate your candidate. The winners (who, paradoxically, are losers in some categories) will be announced grandly at HIStalkapalooza in Lost Wages on Tuesday, February 21, amidst an embarrassment of jollity, eating, drinking, and edgy entertainment (by healthcare IT standards, anyway, where the 30-year-old third cousin of a former roadie for The Temptations with questionably legal rights to their name can cause near-pandemonium by covering their modest hits that charted decades before he was born). Even if you’re a button-down stiff who doesn’t find The Pie award funny, give some thought to the Lifetime Achievement and Industry Figure of the Year awards, which are serious. That’s athenahealth CEO Jonathan Bush above doing his one-man HISSies awards show at HIMSS 2011 in Orlando, decked out in the beauty queen sash we provided that read, “I’m In the Cloud.”

Acquisitions, Funding, Business, and Stock

VeriTeQ Acquisition Corp. signs a non-binding letter of intent to buy the non-core assets of PositiveID Corporation, including the company’s VeriChip and Health Link businesses that PositiveID has not marketed  for over two years.

Intel’s investment arm makes an investment in Pixeon, a Brazil-based PACS vendor.

Chicago healthcare technology accelerator Healthbox names its inaugural class of 10 startups that will receive seed capital, work space, and mentoring:

• CareHubs (healthcare enterprise social platform)
• CareWire (patient text message for appointments)
• Corengi (matches patients to clinical trials)
• The Coupon Doc (drug discounts)
• DermLink (teledermatology)
• Iconic Data (cloud-based patient list manager for physicians)
• PaJR (identifies readmission risk by self-reported patient status)
• PUSH Wellness (wellness incentives)
• SwipeSense (hand hygiene)
• UnitedPreference (prepaid preventative health cards)

Sales

Silverton Health (OR) contracts with Summit Healthcare for interface and connection tools to facilitate its migration to the Meditech 6.0 platform.

Adena Health Systems (OH) awards a five year contract to Precyse for transcription services and various aspects of HIM administration.

Crescent City Beacon Community (LA) selects Mirth Corporation’s interoperability products.

The Delaware HIN chooses ABILITY Network’s DIRECT Messaging tool for the secure exchange of health information between providers.

Baystate Health (MA) selects ATLAS to provide outreach and connectivity services to manage Baystate’s lab, radiology, and other ancillary orders and results requirements.

East Tennessee Health Information Network will use the Axolotl HIE platform from OptumInsight to connect regional providers, hospitals, labs, and pharmacies.

St. Vincent’s HealthCare (FL) selects Orion Health HIE and Clinical Portal.

Shannon Health (TX) chooses the Rothman Index for patient surveillance.

People

Harrington HealthCare System (MA) names Harry Lemieux as CIO. He was previously with Morton Hospital and Medical Center.

Craig Joseph MD, is named CMIO of Agnesian HealthCare (WI). He was previously with Epic.

Jim Milligan, previously with Antek Healthware, has joined Baltimore-based PM/EMR vendor Software Unlimited, Inc. as CEO.  Readers voted him as “Best Non-CEO Executive” in the 2006 HISsies when he was with QuadraMed.  

New Zealand businessman Andrew Ferrier, formerly CEO of the country’s dairy co-operative, invests in Orion Health and takes a seat on the company’s board.

Announcements and Implementations

Hoboken University Medical Center (NJ) gets a Meaningful Use check for its use of Medsphere’s OpenVista.

Ohio-based HealthSpot will market its Care4 Station primary care telemedicine kiosk to military facilities. It includes software for scheduling appointments and managing health records.

Government and Politics

MGMA calls for HHS to immediately issue an expanded six-month contingency plan for the Version 5010 transaction standards. MGMA reports that less than a third of its members have completed all the upgrades and testing required for the 5010 transition and is encouraging HHS to allow physician practices to continue submitting Version 4010 transactions

Technology

Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute will provide clinical expertise to WellPoint as the insurance company develops a commercial application using IBM’s Watson technology.

Other

The Apple App Store names AirStrip CARDIOLOGY the best US medical application for the iPhone.

A just-published article in Annals of Internal Medicine finds that users of the VA’s My HealthVet are overwhelmingly interested in sharing their PHR information with family members or other providers. Another article finds that primary care providers are mixed about sharing electronic progress notes, with a significant number expressing concern that increased patient worry might outweigh the benefit of improved communication and education. An editorial discusses the two articles, but mostly just asks a lot of cautious questions about what patients might do with the information in their records. 

Rumors say The Chicago Sun-Times will be sold to an investment group led by Michael Ferro, CEO of Merrick Ventures and chairman of Merge Healthcare.

A hospital CEO alerts colleagues that his Facebook friend requests are actually coming from an imposter who set up a Facebook page using his name and photos. The scammer has friended several hospital employees, with at least one of the requests saying, “I love you.” The CEO e-mailed Facebook for help and got the usual prompt, personal service: they changed something so that he can’t see the fake profile, even though everybody else still can.

The laptop of a terminally ill woman in Canada is stolen from her apartment, and along with it the only copies of the farewell message videos she had recorded for her five children under 18 to remember her by.

The New York Times runs an article taken from Micky Tripathi’s HIStalk Practice post describing the experience of his Massachusetts eHealth Collaborative in dealing with a lost laptop. In his own blog, he mentions his annoyance that the paper didn’t credit HIStalk Practice (since corrected, and notice that he still had preemptively slipped it into the photo they asked him for), the article implied that an increasing number of breach reports must mean that more breaches are occurring, and it suggests that electronic records are more susceptible to inappropriate exposure. Most importantly:

Finally, I found it a little ironic, that while the NYT article itself is an important step toward educating the public about the real issues surrounding the loss of electronic patient information, it glossed over the steps we’ve taken to educate the industry – like writing the post that lead the Times to the story in the first place. I think it was a bit of a missed opportunity to encourage organizations that have similar experiences to follow the path of full disclosure that we did.

Weird News Andy is doing his own end-of-year retrospective, targeting this “high-caliber story” from Italy. A man hit in the head by a bullet fired by a New Year’s reveler is lucky when it lodges in his nasal passage without causing serious damage. His luck got even better as he waited to see a doctor in the hospital: he sneezed the bullet out of his nostril, requiring only eye surgery before being discharged.

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Sponsor Updates

• Providence Holy Family Hospital (WA) uses the Access e-Forms Repository to standardize surgery documentation.
• CBSMedTech joins MD-IT as a Medical Transcription Service Organization associate.
• Practice Fusion releases an infographic to share its record growth and accomplishments for 2011.
• API Healthcare offers a case study on MemorialCare Medical Centers’ (CA) successful integration of staffing, time and attendance, and payroll software.
• Concerro hosts a free January 24 Webcast  on how to avoid burnout in the healthcare management workplace.
• Vermont Information Technology Leaders partners with CapSite to assist its physician practices in adopting EHRs.
• Joel French, CEO of SCI Solutions, discusses four proven methods to improve hospital revenue in 2012.
• Gateway EDI releases a free webinar on how to effectively build a revenue management strategy.
• T-System publishes a white paper on the advantages and disadvantages of ICD-10 and the effects on EDs and hospitals.
• The American Hospital Association exclusively endorses Imprivata OneSign single sign-on.
• Orthopaedic Center of Southern Illinois selects SRS EHR for its nine providers.
• TeleTracking Technologies announces that its Capacity Management Suite is now iPad compatible.

Contacts

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

Curbside Consult with Dr. Jayne 12/19/11

I really struggled with what to write about for this week’s Curbside Consult. I thought about being witty or trying to come up with some clever HIStalk version of “Twas the Night Before Christmas,” but the things I saw today top anything I could ever come up with. So listen, dear readers, to the cautionary tale of why each and every one of you who work in health IT can never forget the importance of your role, whether large or small.

As you may have picked up from my columns, when I’m not in the CMIO trenches, I work in various clinical environments. I don’t have to (it’s not part of my contract,) but I discovered during a year-long sabbatical from patient care that I really did miss taking care of people. I missed the simple joys of being able to make a new parent confident that their baby will eventually sleep through the night or helping patients come up with a plan to manage chronic health conditions. I missed the patients who came to me with lacerations because they knew I could patch them up faster than the local emergency room.

I did not, however, miss dealing with insurance companies, RVU compensation models, and administrators who didn’t know beans about running a medical practice.

When I was ready to see patients again, I had to find opportunities that wouldn’t interfere with my CMIO duties and that were flexible enough for me to still have plenty of time to cultivate my hobbies (can one really consider martini drinking a hobby?) I chose to be a non-employed physician. Sometimes I work for a staffing company, covering urgent and emergent care facilities. Sometimes I work as a locum tenens to cover docs who are on medical or family leave. Today was a little of both and to compound the “perfect storm” that was brewing, it was a place I hadn’t worked before.

You know you’re in trouble when you pull up to the designated employee parking garage and it’s essentially a chain link cage with a badge-swipe entry portal that looks like a sally port. As a last-minute fill-in for a physician out on leave, I didn’t have a badge, so I had to phone a security guard, who had to find my name on a list. Of course they didn’t have me on said list, but I must have looked fairly non-scary, so they buzzed me in.

I parked (next to a Corvette and a Jaguar, safe in their cage – go figure) and headed in. The staff was friendly and I had enough time to get fully caffeinated before the patients started rolling in, both of which are usually good signs.

The Emergency Department Information System (EDIS) was one I had worked with before, so I was pretty confident that I was going to be able to roll along without incident. Boy, was I wrong. Today was a veritable textbook of “lessons learned” on what can go totally wrong with software, hardware, and workflow. As I mentioned, this is why it’s so important for everyone who works in health IT to take their jobs seriously. Information Services leadership take note and hold on tight, because here we go:

1. I was given a stock password and told to change my password the first time I logged in. Unfortunately, my security classification doesn’t permit password changes, requiring me to call the help desk, which told me I could tell them what I wanted and they’d load it on their end. Really?
2. Better yet, the PACS system has a generic login and password left on a sticky note taped to the monitor. When I asked about this, I was told they had gone to a generic login because the doctors couldn’t remember their passwords. I can’t imagine what their HIPAA audit policy looks like for figuring out who viewed what data with generic logins.
3. To make things more exciting, the IT team scheduled a planned upgrade of the financial and registration system during the day shift. There were no printed downtime procedures available for staff and no clear communication plans. We were alerted to upgrade status by random people who would walk through the ED shouting “it’s back up” or “it’s down again.” Eventually we figured out that the patients whose names appeared in mixed case were registered using the integrated system, and patients whose names were all lower case were manually registered in the EDIS. That might have been nice to know since those manually registered patients had no outbound orders stemming from their accounts. We figured this out after radiology never showed up to do films on our patients – apparently we were supposed to call radiology to schedule those manually registered patients.
4. I’m usually obsessive about hand hygiene before and after touching patients. Today I actually felt an uncontrollable urge to wear gloves to touch the keyboard. You may have noticed I said “keyboard,” as in singular. There was one computer for me to use in a 10-bed emergency unit and it was a fixed desktop. That means no documenting in a patient-facing manner, thereby leading to rework, possible memory errors, and potential transcription errors. The nurse also had a single fixed workstation. Interestingly, the registrar had a really nice new computer on wheels (wireless) to go with their spanking new financial and registration system. So much for enabling patient care.
5. The software had not been updated to a Meaningful Use-compliant version. Not that being MU certified has anything to do with usability or efficiency, but it has become at least a minimum standard for software to meet. Basic demographic information is required to meet MU and this system had some major holes. I know the vendor has a MU compliant version (I’ve used it before,) but this was not it. The users were unaware of any planned upgrades.
6. I’m fairly certain the EDIS was not JCAHO compliant or remotely adherent to the precepts of the Institute for Safe Medication Practices, either. For prescribing, it was almost entirely hard-coded with physician “favorites.” Unfortunately, many of these favorites included “do not use” abbreviations as well as medications that have been off the market for several years. Users told me the prescribing system was hand-built and doesn’t import data from any of the respected formulary vendors. It was pretty clear no one was updating it, either. There was no appropriate way to prescribe current weight-based pediatric prescriptions. In order to get a non-ambiguous medication order for the pharmacy, I had to find the closest “canned” medication I could then print it on safety paper, finally crossing out the confusing parts and handwriting a traditional script below to clarify the confusing computer-ese. To the pharmacists on the receiving end – mea culpa, I didn’t know what else to do.
7. There was no ability to save any kinds of defaults or templates when documenting patients. I had the choice of either a “brief” history/ROS/exam, which was basically a canned jumble of findings (which I’m sure some committee somewhere worked really hard to agree on, rendering it individually useless) or the ability to check each individual finding box individually. After a full complement of ED patients, I’m seeing individual checkboxes when I close my eyes.
8. Customizations had been placed into the system without logic, resulting in duplicates and user brain fatigue. Most of the follow up clinics were listed as “Clinic – Specialty” but every now and then I’d see a rogue like “Derm Clinic” (even though Clinic – Dermatology was in there) but there was no consistency.
9. Clicking for Spanish patient education materials occasionally printed documents in a language which was distinctly not Spanish. Thank you, Señor B for gently educating the gringa that the discharge instructions were muy mal, because you’re right, I didn’t look at them before I handed them to you or I would have known. Shame on me and my apologies to those who taught me during eight years of Spanish classes.
10. Printers were non-configurable. I could print the discharge summary for the patient, but when I wanted to print additional information (such as sources of free medication for uninsured patients), my only choice was “print to file.”

I could keep going but I won’t. Hopefully you get the point.

As an outsider, the confluence of all the various decision streams at work here created a veritable maelstrom in which we tried to deliver care. It would be tempting to refuse to go back if I’m ever asked to staff that facility again. What’s interesting, though, is that I probably won’t refuse if I’m called. Why? Because the patients were genuinely needy, the care provided was solid despite the challenges, and the staff worked their tails off as a team to get through the shift. Everyone did his or her part and then some.

By the end of the day, it was like we had worked together forever. Hugs were exchanged (as well as recipes for Christmas cookies and empanadas – thanks for introducing me to things I never thought possible with chocolate and coconut) and high-fives given. I learned a nice trick for removing the proverbial rusty nail from the bottom of a foot, courtesy of a provider who shoes his own horses in his spare time. I did a little bit of education on Meaningful Use and information security.

Last, but most important, I helped some people. And that, my friends, is what it’s all about.

Feliz Navidad, próspero año y felicidad.

E-mail Dr. Jayne.

Readers Write 12/19/11

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!

View from the Healthcare Recruiter’s Chair
By Don Calhoun

Happy Holidays! As this year comes to an end, I thought I’d share some insight into the job market, hiring trends, tips for candidates, and tips for clients. Not to mention some observations that may or may not have anything to do with any of the above. The following are educated opinions with some fact sprinkled in.

The Job Market

We continue to see strong demand for implementation consultants, project managers, and practice directors. Shocking, right?

Instead of just trying to find one of the 1,000 Epic Certified “X” consultants to fill one of the 4,000 Epic Certified “X” consultant openings, we have employed a new strategy. Starting in 2012, we will be working with George Lucas on a controversial project. I can’t say a lot more at this time, but DNA will be involved.

Tips for Candidates

You may be looking for a better position, going through RIFs, or just putting EMR on your resume in the hopes that will create a bidding war for your services.

Tip #1. Recruiters see hundreds of resumes per week. They can become lazy. If you have experience with a vendor product, a particular system, or an integration tool, make sure it is on your resume. This is a world of keyword searches. If you don’t list these, you could be missing out.

Tip #2. If you have been at the same firm for sometime and have a feeling that they are underpaying you, talk to a recruiting firm. Some companies pay below-market value, and if you get comfortable in that role, you may be shortchanging yourself.

Tip #3. If you don’t mind travel, put that on your resume. If we stick with the theory that recruiters see hundreds of resumes per week and need to prioritize who to call first, the biggest slam-dunks will get that call. The slam-dunk has all of the pertinent information available – skills, software, general idea of rate/salary, and ability to travel.

Tips for Those Laid Off

Tip #1. Get on LinkedIn and make it known that you are looking for a new position. Put all of your skills, training, etc. on your profile.

Tip #2. Network like crazy.

Tip #3. If you have the drive and ability, think about starting your own firm. It doesn’t cost much to get incorporated in most states. You may be surprised about local work you can pick up.

Editorial Comment Section

When are large companies who think they can buy their way into healthcare going to learn that they are five years late to the dance? And that IT NEVER WORKS?? I wouldn’t be surprised if General Motors is a “healthcare” firm next year. Sorry – had to be done.

Clients

(Not ours — they already know this.)

Tip #1. Being thorough and expedient is a difficult trick to pull off when hiring, but it is a must in this market. Whoever dies with the best healthcare consultants wins. You must make this a priority in order to grow, create a great reputation, and have a happy work force. A couple of phone interviews are great, but at some point it is time to lock all decision-makers in a room with the candidate and make a decision. Some companies are hiring people two weeks after starting the process. Are you able to compete with that? If not, talk to HR/Recruiting and figure out a way to streamline your process. You will save yourself lots of recruiting dollars, disappointment with candidates you missed out on, and will ultimately have a stronger workforce.

Tip #2. Before deciding on a hiring initiative, reach out to some people in the recruitment business to see what the market is commanding in terms of salary, bonus, travel, time off, etc. Salary surveys run by third parties don’t seem to be in line with the real healthcare market (just my opinion). Ensure that you are making strong offers. I view the current healthcare market like NFL free agency. The best players want the top teams, the most dollars, and the best situation. Everybody wants the top free agents. Playing the lowball and hope they accept game isn’t going to get you anywhere.

Tip #3. If you decided to engage a search firm, make sure you know who is actually conducting the search and talking to candidates. You need experienced healthcare people talking to these candidates. I may get threats for saying this, but some firms put the big gun on the phone with you to sell you their services and then turn the search over to a “just out of college, took a recruiting job to pay the bills until my band makes it” recruiter. Make sure you talk to the people that are going to talk to your future employee.

I hope some of this provided some value. We’re off to an undisclosed location to meet with Mr. G. Lucas. An update should be coming soon.

Don Calhoun is founder and managing director of Executive Search Recruiting, LLC of Cornelius, NC.

Breakfast of Physician Champions!
By Daniela Mahoney

Culture eats strategy any day.

I think we have all heard this saying. More than ever, it proves to be true when I think of any initiative that involves providers, changes to their workflow, perceived loss of autonomy, and the sacrifice of something very, very precious — TIME.

Yet when introducing a new initiative, hospital and project leaders must somehow get everyone on board in a relatively short time frame and also convince them to embrace the new way of doing business.

So, you ask, where are the challenges?

Unwritten Rules

The relationship between organizations and their providers varies based on structure, history, leadership culture, and vision of the future. Therefore, for any organization, every new initiative is challenged by implicit unwritten rules that define and govern certain expectations, organizational design and behavior.

And moreover, initiatives that involve the introduction of advanced clinical systems to providers — particularly CPOE — are subject to the greatest scrutiny. These projects subsequently pose serious challenges to the unwritten rules because they raise a very fundamental question from providers: “If our present rules will no longer support what we know and feel comfortable with, what will it take to change these rules so we can create an environment that better aligns with the new vision of the organization?”

These days, most hospital leaders encounter this challenge when implementing a new system. Regardless of motive —whether implementing CPOE because the organization is on the fast track to meeting Meaningful Use or, more nobly, because “it is the right thing to do” to improve patient care and outcomes— the reality is that the unwritten rules must be rewritten upfront and early to successfully transform the staff culture and ensure quality and predictable patient outcomes with the new system in place.

Great Expectations

It’s about inclusion from the get-go. The staff culture has to be given serious consideration and be honestly and fully included in implementation plans from the time you begin talking about these new initiatives to the time they are executed and realized. I have witnessed noticeable and successful changes in culture only when the majority of the providers are aligned with the vision of the organization (I say “majority” because in most cases, non-academic organizations have difficulty achieving 100% buy-in from all providers.)

How do we go about learning what is important to your providers? What are their expectations and what are their fears? The answers to these questions are the elements that eventually create the adoption strategy map. And the pursuit for these answers is a concerted effort executed in the early phases of the implementation (although sometimes we get pulled in at the tail end of an implementation when things do not go as planned. This makes the recovery efforts more difficult and at times delays the initiatives!)

If done well, this initial Q & A or interview exercise yields a fairly clear plan, yielding one strategic decision to make about it:

• Should things be mandated and, if so, when and how?

Or,

• How will the support and training strategies need to be structured to make things manageable?

Constant Compromise

To me, the decision is a basic balance of give and take, a constant compromise where the art of negotiation reaches amazing peaks. This is when it is important for the CEO to have a close relationship with the medical staff and be actively involved and visible with these new initiatives. The CIO needs to think outside the box and not lead with the technology as the value proposition. A strong CMIO or physician champion should truly understand his/her peers and their workflows and master the art of negotiating.

The unwritten rules have to be explored. These are the rules that might imply that “nothing can be mandated to physicians”, that “physicians must always have individual choice and prerogative”, that if “I am not involved in a decision, I will not support it”, or that “variability is desired.” It reflects the true art of medicine and the uniqueness of every individual patient, that the art of medicine always trumps the science of medicine.

Understanding the unwritten rules from the beginning helps establish the appropriate path to implementation. For example, in one of our cultural assessments this year, we learned that the initial plans included a very aggressive deployment of CPOE, house-wide at once, with rapid expectations toward universal adoption (“mandate” is an ugly word.) As much as this approach is desired, it is more important to know if it could be executed successfully. In this particular case, the expectations of the medical staff were not integrated into the original plan. During the cultural assessment process, these expectations surfaced and were far from being consistent with the original plan.

Now, one can push and try to keep the plan as defined initially but, in the long run, this would alienate many (or probably most) of the providers. Why not take another look at the plan? And by employing a much more collaborative approach, see how it can be adjusted and eventually executed —successfully — while still attaining the same goals. Also, by doing this, the unwritten message from the CMO and other organizational leadership would be clear: “We do care about what you [providers] are telling us. We know it will not be easy to implement CPOE. But we are committed to working with you for all of us to succeed.”

Personal to Us, but System Agnostic

Culture is something personal to all of us —to any organization. CPOE touches clinicians at many different levels and inarguably creates significant disruptions in everyone’s routine. I truly believe that CPOE is the best thing we can do for our patients, but as I say this, I know that not all CPOE outcomes are the best. With a failure rate somewhere in the neighborhood of 30%, along with a long list of unintended consequences, it makes us realize that technology is only 15-20% of the challenge. The rest is all the change and optimization that needs to be done for this to work as intended.

We should also recognize and accept that provider culture is system agnostic. We can hope that the more advanced systems become easier to design solutions that support clinical processes. But it is naïve to believe that CPOE will be an easy project simply because you install the Cadillac version of a system. We have seen many successes with more modest versions of clinical systems and failures with very sophisticated ones and vice versa.

A system alone does not guarantee a successful outcome. It needs much more than that. As part of the team planning clinical initiatives for your hospital, please listen to your providers and understand your organizational history and its culture. Many of the answers to what it takes to succeed are right in front of you— you just have to look to see them.

Time for Breakfast!

I just returned from a visit oversees and came across this wonderful blini (Russian pancakes) recipe. I guarantee the entire family will love them, especially on cold winter mornings. I serve mine with 1 cup ricotta cheese, 1 tablespoon sugar, 1 teaspoon vanilla extract, and a scant ½ cup golden raisins added at the end once all other ingredients are mixed well.

Till next time, when we will talk more about the CPOE value proposition to providers. Safe and happy holidays to all!

Daniela Mahoney, RN BSN is vice president of Beacon Partners of Weymouth, MA.

iPatients?
By Vince Ciotti

An interesting week of news for our EMR world.

On Tuesday, the National Transportation Safety Board (NTSB) called for the first-ever nationwide ban on driver use of personal electronic devices while operating a motor vehicle. According to NHTSA, more than 3,000 people lost their lives last year in distraction-related accidents. NTSB Chairman Deborah A.P. Hersman stated, "It is time for all of us to stand up for safety by turning off electronic devices when driving. No call, no text, no update, is worth a human life."

The heart of their argument can be found in a few statistics:

• Globally, there are 5.3 billion mobile phone subscribers, or 77% of the world population. In the United States, that percentage is even higher – it exceeds 100%.
• A Virginia Tech Transportation Institute study of commercial drivers found that a safety-critical event is 163 times more likely if a driver is texting, e-mailing, or accessing the Internet.

Hersman concluded, "The data is clear; the time to act is now. How many more lives will be lost before we, as a society, change our attitudes about the deadliness of distractions?"

On Thursday, an article on the front page of The New York Times caught my eye while driving my RV down I-4, As Doctors Use More Devices, Potential for Distraction Grows. Wow, doctors? That’s our business! Reading on (while occasionally checking my mirrors before changing lanes), I read these amazing factoids:

• A peer-reviewed survey of 439 medical technicians published this year in Perfusion, a journal about cardio-pulmonary bypass surgery, found that 55% of technicians who monitor bypass machines acknowledged to researchers that they had talked on cellphones during heart surgery. Half said they had texted while in surgery.
• Scott J. Eldredge, a medical malpractice lawyer in Denver, recently represented a patient who was left partly paralyzed after surgery. The neurosurgeon was distracted during the operation, using a wireless headset to talk on his cell phone. “I’ve seen texting among people I’m supervising in the OR,” said Stephen Luczycki MD, an anesthesiologist and medical director in one of the surgical intensive care units at Yale-New Haven Hospital. “Amazon, Gmail, I’ve seen all sorts of shopping, I’ve seen eBay,” he said. “You name it, I’ve seen it.”

So who am I to pontificate on this seeming bit of common sense? Some of you may know I am also an avid vintage motorcycle buff (not loud Harleys, but quiet Hondas) and have published a few articles in bike magazines. My most recent was last year in Motorcyclist entitled Driven To Distraction. In it, I admonish my fellow bikers to wear bright clothing, flash headlights, etc. — anything so their 500-pound motorcycle gets the attention of the driver of a 5,000-pound SUV.

So after all our Herculean efforts the past few years to get our RNs to use BMV and eMARs and to coerce our MDs to use CPOE and EHRs, now some of them are over-using the technology! I guess it had to happen in this world of cell-phonies.

What’s a CIO to do? My suggestion: send the Times article to your CMO and CNO. They’ll do the rest. Clinicians are such consummate professionals, all they need are a few facts like the above and they will caution their staffs in a hurry. Will it be a total cure? No more than I’m likely to stop keying on my GPS while dodging semis. But it will make them aware of the problem, which is always the first step to addressing one.

Vince Ciotti is a principal with H.I.S. Professionals LLC.

My Christmas Wish
By Chip Perkins

I’ve been reading quite a bit lately about how important sharing data is to improving healthcare quality and outcomes, and reducing costs. The ability to share health data between patients, providers, specialist, and health plans is a key building block for patient centered medical home (PCMH) or accountable care organization (ACO) initiatives. 

But there is one more thing about data to consider. The data needs to be discrete. The data needs to be actionable. The data needs to be standardized. The data needs to be semantic. 

As healthcare systems ramp up their efforts to transition to ICD-10-CM/PCS, launch clinical documentation improvement projects, report Meaningful Use quality indicators, implement electronic lab reporting (ELR) to public health, and build analytic tools to monitor improvements in health outcomes, organizations will recognize the importance of leveraging controlled clinical vocabularies and terminologies such as SNOMED CT, LOINC and RxNorm. 

The standards exist. The standards turn raw data into semantic data. Now we have to build the use of standard terminologies into our health information technology infrastructure. 

I’m hoping Santa will put a little semantic interoperability into everyone’s stocking for Christmas.

Chip Perkins is managing director, CAP STS of College of American Pathologists of Deerfield, IL.

Monday Morning Update 12/19/11

From EpicNews: “Re: HCA. Any rumors about HCA signing with Epic?” I’ve mentioned here several times that HCA is putting up an Epic pilot as they choose between that option and upgrading Meditech. I haven’t heard anything more than that, although a couple of less well-placed rumors seem to think Epic is the likely choice (I’m guessing that’s due to Epic’s track record rather than any real insider knowledge.)

From CIO Lookin’: “Re: company that has a contracts database. One of your sponsors offers a database of vendor contracts with full details about pricing and terms. I don’t remember the company’s name. Can you help?” It’s CapSite. Very useful. It’s cool looking at the actual scan of the contracts but also having all the numbers broken out into a worksheet for easier review.

Aetna reveals at an investor conference Thursday that it acquired mobile app developer Healthagen “about a month and a half ago.” Aetna says it will add cost estimation functions for patients to its iTriage app. Aetna’s chairman, president, and CEO also told investors that the company will make the software development kit for the Medicity iNexx platform available free so that anyone can write apps for it.

Micky Tripathi’s breach article on HIStalk Practice has raised the interest of The New York Times, which will apparently be running a story about his experience in Monday’s business section.

My Time Capsule editorial from 2006 for this week: Embrace FDA Oversight If You Want Clinical — not Clerical — Systems.  A snippet:

It’s like Lucy working on that candy assembly line – reams of often irrelevant information are unceremoniously dumped faster and faster into the laps of physicians and nurses, who are expected to manually figure out what’s useful and then “process” it, often by entering even more on-screen information. Eventually, the administrivia buries someone who ought to be making patient care decisions instead of romancing a keyboard.

TPD has updated his list of iPhone apps.

A reminder for McKesson folks whose jobs will be eliminated in February: check the comments left on the past few posts since I invited companies who might have jobs for you to leave their contact information.

Another newspaper picks up on Newt Gingrich’s dichotomy on stimulus money, which he called a “pork-laden bill” that should be stopped even as he cheered the $19 billion it contained to pay providers to use EHRs sold by clients of his consulting firm, Center for Health Transformation. It mentions his participation in 2009’s EHR Stimulus Tour, where his company helped its clients Microsoft and Allscripts encourage providers to use federal incentives to buy their products. Gingrich also pressed his former House colleagues to block efforts to dismantle Stage Children’s Health Insurance Program while being paid by drug companies and insurers that would have lost profits, as well as urging them to support the expansion of Medicare’s prescription drug benefit, which benefited his center’s $200K per year founding member, drug maker Novo Nordisk. Novo listed their payment as a lobbying expense, although Gingrich says that’s not the case.

In related news, the former CEO and VP of the Center for Health Transformation and Gingrich Group join Leavitt Partners to create Health Intelligence Partners, a membership organization that will offer advice to healthcare executives. The founder and chairman of Leavitt Partners is Mike Leavitt, former HHS secretary and Utah governor. The president and CEO is his former HHS chief of staff and the managing director is Leavitt’s former HHS senior executive advisor.

Some readers are getting their HIStalk e-mail blasts long after I’ve sent them out. It’s a worsening problem, primarily affecting users of free e-mail services (Hotmail, Google, Yahoo) since those are apparently ramping up their inspection of incoming e-mails for spam. Those services are also slowing down my sending speed since my server has to wait on theirs and they have throttled back their connection rates. My web host has taken a couple of steps to hopefully reduce the scrutiny and therefore increase the delivery speed, but it’s somewhat out of my hands.

Here’s my latest pet peeve (I know you were anxiously awaiting it): publications that refer to doctorate holders as “Dr. John Smith.” It’s perfectly legitimate (but damned obnoxious) to introduce yourself socially as Dr. John Smith, but that form should not be used in a publication of any kind since it provides no clue to exactly what kind of doctorate is held (MD, non-research based EdD, mail order fake PhD, etc.) Honorary doctorate holders should never be addressed either as (a) Doctor, or (b) listing their unearned PhD. If you see a professional advertising their white-coated services as Dr. John Smith instead of stating their actual degree (it’s usually chiropractors who do that) or using bookended vanity titles on both ends of their names (such as Dr. John Smith, MD) run fast and far since at least in my experience, these folks are often seriously incompetent, insecure, ill-informed, or all of the above.

Welcome to new HIStalk Gold Sponsor Macadamian, a global firm headquartered in Quebec that provides user interface design and software innovation services for clients that include HP, Cisco, and Adobe. They help product management executives turn ideas into market-ready products, including working with mobile apps. The company offers design services, usability consulting and testing, and user services (focus groups, task analysis, and field research). Healthcare IT vendors they’ve worked with include Sage (updated Intergy’s encounter note function), Cardinal Health (designed a touch-screen interface for a bedside patient information system), and Elsevier (developed a fresh user interface for the online Mosby’s Nursing Consult). The company offers a one-day EHR Usability Workshop to help vendors understand the implications of NIST’s usability draft and to develop a usability plan. Thanks to Macadamian for supporting HIStalk.

I’m getting an increasing number of requests from companies and organizations that want to get me involved in their projects in some way (conferences, education, contests, etc.) I almost always turn those down, and just to save future time all around, here are my standards, which I don’t think I’ve explicitly stated until now:

1. I have almost no time between work and HIStalk and I have no employees, so I will always turn down anything that would require much of my time.
2. I won’t do anything to compromise my ethics (endorse products, further a hidden agenda, or write anything that I don’t believe.)
3. The only item I offer is sponsorships. I don’t rent my e-mail list, run paid article placements, or shill my services for speaking or consulting (easy since I don’t do those things anyway).
4. I don’t entrust HIStalk’s reputation to anyone else, so I don’t get involved with activities unless I’m offered control over them (HIStalkpalooza being a good example.)
5. I’m not very motivated by money, so it’s easier to raise my interest for projects that will benefit HIStalk’s readers or that involve undeniably good deeds, education, industry enlightenment, or something offbeat and fun.

Only 22% of respondents reacted positively to Mckesson’s Better Health 2020 product realignment plan. New poll to your right: it’s the same as this one, only regarding Microsoft and GE forming a new HIT company.

Here are some products from HIStalk sponsors that topped out their respective category in the Best in KLAS report that just came out:

• 3M Codefinder (medical records coding)
• 3M APCfinder (medical records other)
• Allscripts Sunrise EPSi Decision Support (decision support – business)
• API Healthcare Time and Attendance (time and attendance)
• CareTech Solutions (IT outsourcing – extensive)
• Cerner CoPathPlus (anatomic pathology)
• Cerner Millennium PharmNet (pharmacy – community)
• Cerner (application hosting CIS/ERP/HIS)
• Clairvia (staff/nurse scheduling)
• Cumberland Consulting Group (planning and assessment)
• eClinicalWorks Electronic Health eXchange (private HIE)
• GE Healthcare Centricity Perioperative Anesthesia (anesthesia)
• GetWellNetwork PatientLife System (interactive patient system)
• Greenway Medical PrimeSuite Practice (practice management 1-10 physicians)
• Greenway Medical PrimeSuite Practice (practice management 11-75 physicians)
• Hayes Management Consulting (staff augmentation)
• Iatric Systems MobiLab (specimen collection barcoding)
• Impact Advisors (clinical implementation principal)
• iSirona DeviceConX (medical device integration system)
• McKesson Paragon (community HIS)
• McKesson Paragon Clinicals (acute care EMR – community)
• McKesson Paragon Financials (patient accounting and patient management – community)
• MedAptus Professional Intelligent Charge Capture (mobile data systems)
• MedAssets Contract Manager (revenue cycle – contract management)
• MedPlus ChartMaxx (document management and imaging)
• Merge Healthcare Hemo (cardiology hemodynamics)
• Nuance eScription (speech recognition)
• Nuance EXText (dictation and transcription)
• Orchestrate Healthcare (technical services)
• Passport BatchSource (patient access – eligibility checking)
• RelayHealth ePREMIS (revenue cycle – claims management)
• TeleTracking Capacity Management Suite (patient flow)
• Wolters Kluwer ProVatation MD (clinical procedure documentation)
• ZirMed (claims and clearinghouse services)

Ignis Systems releases EMR-Link ResultsAnywhere, which works with the company’s lab outreach solution to create patient-friendly lab results. It meets the new guidelines under which patients can access their own lab reports. Video here.

Weird News Andy says he has a nose for news with this article: Louisiana’s state health department warns consumers about the use of neti pots, a pitcher-like container (aka “nose bidet”) used to flush the sinuses with salty water to relieve nasal congestion. Two people have died from amoeba infection of the brain after apparently using tap water instead of the manufacturer-recommended distilled water. WNA also finds this Grinch-like story: a UK hospital cancels more than 80 surgeries, some of them involving cancer patients who had waited for months to get on the schedule, after the broad daylight theft of the copper cabling from the hospital’s backup electrical generator.

An interesting item came up at athenahealth’s stock analyst day this past Thursday. The company is trying to turn its athenaCoordinator product (from its acquisition of Proxsys in July 2011)  into a private HIE so that practices in a given geographic area can manage referrals through it, something that was hinted at in this request from an unnamed (but easily identified) vendor for an HHS ruling that was rendered on December 7. Athena would charge fees for use of its network, with a somewhat complex set of rules deciding which practice (referring or receiving) gets the bill. Athenahealth would reduce the monthly subscription cost of athenaClinicals, using the new referral transaction fees to offset its reduced revenue.

Meanwhile, it was a wild ride for ATHN shares this week, with guidance below expectations sending shares down 15%, but conflicting investment opinion pushing it partly back up (Leerink Swann and Oppenheimer upgraded, Piper Jaffray cut its price target, Morgan Stanley stuck with its Underweight rating.)  

Rep. Tom Price (R-GA), an orthopedic surgeon, says paper medical records are insane and practices should be using technology to communicate and to give patients access to their own records. He’s not a fan of HITECH, though:

Instead, what does the federal government do and think it’s getting high tech? It is defining every little thing, every box that the physician or nurse has to check every time you see a patient, in order to get an extra 1.5% of reimbursement from the government. Or, not getting dinged for an extra 1.5 or 2%. These are the Meaningful Use things.  Washington always has these great lines, right, these wonderful Meaningful Use standards. They’re neither meaningful nor useful and they’re so ridiculous that they actually incentivize pathologists to have to ask on every single patient that they care for how old they are, how many allergies they have, what medications they’re on, when was the last time they saw their primary care physician, on and on and on, including of a slide of a patient … the pathologist never actually sees that patient … or a corpse for an autopsy. This is no lie. The federal government wants the pathologist to determine whether or not a corpse has any allergies. How you feeling today, right? This is nonsense.

So what do you do with technology to make it so it actually works for healthcare? I think the proper role of government in the area of technology in healthcare is to say, OK, this is the platform we will use. This is the highway upon which we will ride. Everybody needs to have a system that allows it to speak to another system within these parameters. And not dictate what the docs are doing on a day-to-day basis for a given patient, because it doesn’t make any sense. It’s a waste of time. They can never, ever put in place the right standards for a bureaucrat to determine whether or not the doctor’s doing the right thing.

An MSNBC article says aides of former Massachusetts Governor Mitt Romney arranged to buy the hard drives of their office computers for $65 as his term ended, thus eliminating the only record of official e-mails and details about his health insurance mandate since they had also had the servers replaced. Romney says the hard drives might have contained personal information, such as medical records and job applications, but reporters noted that government officials could use that excuse to keep every paper record from the public eye by just writing their Social Security number on the bottom of every page.

Here’s the latest HIS-tory from Vince, which contains the answer to this trivia question: what hospital programmer started a one-person consulting practice that eventually grew into a company of over 1,400 employees?

Zach Mortensen of CareFusion picks up on Barry’s comment on HIStalk about a possible change in Epic’s sales strategy, speculating that Epic may be willing to sign ambulatory-only contracts because they’ve hit capacity, run out of new customers, or fear low-cost ambulatory competitors. I’m not convinced Epic is changing strategy at all just because a couple of unnamed consultants speculated as such (Epic has always sold ambulatory-only deals), but if they are, I’d infer the opposite. Epic has not hit the predicted wall on scalability, customers keep giving its products industry-leading KLAS scores, nobody is de-installing or grumbling about value, and prospects keep signing up in droves despite high project costs. Each time Epic sells an ambulatory-only deal, it (a) deprives a competitor of a new sale, and (b) plants a flag that has a decent percentage chance of yielding an easy inpatient sale down the road. If anything, I suspect Epic is gaining confidence given the near absence of significant competition and is willing to ramp up sales, which by definition means they will be selling to smaller hospitals and practices. The company’s favorite statistics involve not the number of hospital customers it has, but rather the percentage of physicians and patients using its systems. I think they want that number to keep rising for reasons beyond financial, and any change in strategy can be attributed to unchallenged dominance rather than newfound desperation.

Analysts speculate that Research in Motion (BlackBerry) may be on its last legs, with bad earnings, grim forecasts, delayed new products, and a continue share price slide (down 77% year to date).

Allina Hospitals & Clinics is involved in an unusual but minor patient privacy breach. It sends an e-mail blast to 250,000 patients promoting Epic’s MyChart, but eight of those e-mails bounce back as undeliverable. Its mail software then tries to re-send the message to those eight recipients, but mistakenly blasts it back out to the 250,000 original recipients, only this time including the name, employer, and e-mail address of the eight patients (whited out above).

A California patient opens up her medical records to an investigative reporting agency to show how medical upcoding happened at Shasta Regional Medical Center (CA), which claimed that almost 20% of its patients suffered from the mostly third-world nutritional disease kwashiorkor. A DRG coding firm analyzed the records, which mentioned nothing about nutritional issues, and found that the correct payment was $4,708. Adding the kwashiorkor diagnosis raised the payment for the same stay to $11,463. Irrelevant but interesting: the patient’s daughter reviewed her mother’s bill and noticed charges that included $273 for a cloth sling and $22 for a 4×4 gauze.

Texas Health Resources is holding a Nursing Informatics Boot Camp April 28-29 in Arlington, TX to prepare nurses to take the ANCC certification exam.

The Alaska State Medical Association is providing DocBookMD to all physicians in the state to allow them to share information, including referrals, using mobile devices.

A jazz singer unhappy with her new nose job creates a Web site criticizing the work and credentials of her plastic surgeon, files complaints with the state medical board, and posts negative reviews on several Web sites. The doctor says his practice went from $4.5 million to two patients a week. He files a defamation lawsuit against the patient and is awarded $12 million. That’s a lot of jazz.

Every year about this time (when we remember it, anyway) we like to get in the Christmas spirit by asking our sponsors what holiday and charitable activities they’re involved with, preferably with photos since the usual half-hearted hospital door decorating contest just doesn’t stir up much Christmas spirit.  Here are a few.

DIVURGENT sponsored a Winter Wonderland event at Children’s Medical Center at Legacy (TX) last week for children hospitalized there. Every child got a teddy bear, shown being delivered above.

Hayes Management Consulting donated $1,000 worth of toys to Toys for Tots and sent an equal amount of money to the Susan G. Komen Foundation.

Surgical Information Systems held its Coins for Kids fundraiser contest, where each of its departments decorated a piggy bank to collect money (the above entry from sales and marketing was branded as Miss Barbie-Q). It has raised $6,000 so far for The Giving Tree, EduNations, and the Westlake Estate Home for Girls. Employees also donated time and supplies to stuff 50 stockings for the troops and collecting DVDs for Children’s Hospital of Atlanta. Employees also held coat and winter weather drives and continued their support for Cool Girls, Inc.

maxIT sponsored the Beads of Courage Beads in Space Tour to honor Childhood Cancer Awareness Month. It’s a non-profit that works with children experiencing serious illnesses to use beads to tell the story of challenges they have overcome during their treatment, such as spending a night in the hospital or undergoing chemotherapy treatments. The organization took its program on the road, stopping at 10 hospitals to show a display of beads that few on the space shuttle, with one design from each being incorporated into a real bead and the top ten to be featured in a book.

Software Testing Solutions donated $10,000 to Heifer International, a non-profit that focuses on long-term sustainability and self-reliance by purchasing llamas, sheep, goats, chickens, and honeybees and providing agricultural education for poverty-stricken communities around the world.

The business development team of World Wide Technology volunteered at Kingdom House, a neighborhood community center in downtown St. Louis, where they repaired tables and chairs, cleaned the food pantry, and reorganized the thrift store.

Aspen Advisors held a fun walk/run at its annual all-associate retreat in Fort Lauderdale, FL and raised $1,500 for Broward Health.

Quality IT Partners supported Habitat for Humanity, the American Heart Association, Special Olympics, the Scott Hamilton CARES Initiative, the American Cancer Society, the American Association for the Study of Liver Diseases, and local schools and food banks.

Sunquest held its annual fundraising barbeque this month, this time supporting Tucson-based Aviva Children’s Services, which provides support services to children under the care of Child Protective Services after experiencing abuse, neglect, or poverty. Employees received lunch in return for their donations of toys, gift cards, and money, raising $3,500 for Aviva’s Christmas giving program.

Cynergis Tek supported OPERATION Hug-A-Hero and its Holiday Hugs program. It provides children with dolls that contain an image of their deployed service member parent or other relative, providing a tangible, comforting connection with their loved one.

E-mail Mr. H.

HIStalk Interviews Dave Lareau, COO, Medicomp Systems

David Lareau is chief operating officer of Medicomp Systems of Chantilly, VA.

Tell me about yourself and the company.

I was in Baltimore in the late 1980s and had my own practice management reselling company. One of my customers in 1990 came to me and said, “Dave, we’re real happy with your services, your billing system — we want to start looking at EMRs.” I said, “What’s that?” He said, “We think they’re going to be the thing of the future. Would you help us look at them?” 

We set up a process where once a month they would come into my office and I’d bring in a vendor. After a few months, they said, “Nope. All this makes us data entry clerks. It’s all template-based. We hate it, can’t use it. Thanks. Here’s what we need you to find.”

A couple of years later, maybe ’92, I happened to see Peter Goltra and his team at Medicomp and I was intrigued. I thought, “This sounds like what those guys were talking about. Let’s bring them in.” They looked at it and said, “That’s exactly the way this stuff needs to work, but it’s just ugly as hell.” It was a Unix-based system, the old green screens and stuff dropping down. They said, “If you put a decent user interface on that and integrate it with a billing system, that would really be something.”

I talked Peter into letting my little company do that. I eventually came home to my wife one day and said, “Honey, I just found what I want to do with the rest of life. Can we move to Virginia? I really want to work with this company. I love what they’re doing. I think it’s the thing of the future.” I figured at that point, yeah, 10 years from now everybody will have an EMR. You know how it was in 1992. 

I joined Medicomp. I found that they provide clinical content for documentation and patient care that thinks and works the way a physician does. It’s just simply that. We’ve been doing that ever since, with changes along the way in response to the markets, technology, etc.

You said you had to find Medicomp. I always got the feeling that both the company and Peter Goltra aren’t as widely recognized as they ought to be. Is that low-key approach intentional?

The low-key approach is somewhat intentional. We provide a really critical component to about 10 to 12 different vendors in the space. That’s growing all the time.

We leave it them to do a couple of things. Differentiate themselves from each other. And, we want to make it clear to the marketplace that if you want an EMR that uses our content, you need to go to our customers, not to us. 

We’re very low-key at industry events. We really only concentrate on going to industry events like HIMSS and MGMA, where we’re there primarily to support our customers, who are EMR vendors, and educate their potential customers about the benefits of an EMR that uses MEDCIN.

The other way we stay in the background is when a new vendor decides to license our technology and put it into their product, we leave it to them to time the announcement to let their installed base know. As you know, once somebody announces a change in direction, even if it’s a good thing – which we think implementing our MEDCIN engine and Quippe is — it still tends to freeze what is then perceived as a legacy product, and these people need to maintain that revenue stream.

For readers who don’t know, describe the MEDCIN engine and how it’s used.

MEDCIN at its core is a clinical knowledge base that has about 280,000 clinical concepts in it. For the most part, they are pre-coordinated. The purpose of the engine is to present the relevant information to the physician at the point of care given a specific clinical scenario. 

For example, there are 293 concepts in MEDCIN whose relevance is scored for a patient with asthma. In that case, adding more concepts to MEDCIN doesn’t do anybody good. We can focus on the relevant items given almost any clinical situation, which is what makes it valuable for a providers treating a specific patient for a specific problem or a set of problems at a specific point in time.

What’s nice is is that it thinks and works like a clinician, and then all those concepts are mapped to ICD-9, ICD-10, SNOMED, CPT, LOINC, RxNorm, and all the 44 Meaningful Use criteria. All the nonsense — from the doc’s point of view — is taken care of in the background. The engine presents to the physician the things that they would care about for a patient with that condition.

We came up with that in 33 years of working with physicians saying, “OK, here’s the presentation. What would you want to be in your note? What will you want to look at? What kind of lab results would you want? What are potential orders? What would you do for the review of systems? What history? What physical?” It presents the things that real docs who are treating patients every day tell us they would want. We’re not trying to tell them what to do – we’re presenting to them what they said they would do.

Describe where your content comes from.

We have at any point about 20 to 30 active clinical consultants. We tried in the mid-80s having medical MDs on staff and nurses on staff to do that, but we found that when we brought guest experts in — consultants to help us build the data engine — all they did was argue with each other over, “You were trained here, you were trained there. I wouldn’t do it that way, I wouldn’t do it that way.”

We ended up saying, OK, we’re going to be clinical knowledge management engineers. Let’s engineer an editing system, where we can bring these people in and we have editing facilities. Now with the Web, you don’t have to do it locally, but when we did, we had an editing facility in Martha’s Vineyard, we had one in New York, whatever’s convenient. We’d typically bring somebody in for two or three days at a time. Some of these guys come in regularly, some come in every six months, some once a year for a week or so.

We sit with them and say, you’re seeing a patient with asthma. What would you normally expect to have to think about or address? They’ll say wheezing, difficulty breathing, is the wheezing episodic. What do I see in the lungs? Auscultation. Family history. Do they have exposure to dust mites? What’s the spirometry? What’s the O2 sat? Do they have any other conditions, maybe nasal polyps?

We say, is they’re anything else that might help you differentiate asthma from something else that we should put in the asthma – we call them indices – in the asthma index that you’d need for rule-out? So there’s things in there that have both a positive and a negative correlation. 

We put those in, and then we’ll go back and say, now for each one of those things, wheezing … somebody comes in wheezing, it doesn’t mean they have asthma. Means they might, but what else might it be? Let’s built out the index for those things.

You do this in an iterative process over years. We’ve ended up with about 293 items in the asthma index, one of which is wheezing, which has 260-some links of its own to diagnoses other than asthma. You can attack it from either point. This is iterative. Then we’ll have pulmonologist come in and say, we just did this recent work with somebody who was a specialist in asthma. How does this intersect with other things that you see? Does it raise the risk factors for pneumonias? 

It’s iterative. It’s one of the reasons why it’s so hard to replicate this with a template system, because we’ve been at it so long. Everybody says you can’t take nine women and have a baby in a month. That’s sort of what we’re dealing with here.

Does the MEDCIN engine have competition other than templates and text-based literature look-ups?

In terms of what we do and the way we do it, no. But in terms of competition, there’s tremendous competition all throughout the marketplace for our approach and any other approach. We define competition as anything that causes somebody to say, “Hey, your stuff looks great, but I don’t really need it.”

You can fake some of this activity for a single-problem patient with loads of templates, but eventually it doesn’t scale up when you start to have multi-problem patients whose conditions progress over time with clinical sequelae, complications, comorbidities, etc. Nobody really does or is close to doing what we do, but as long as people think that there are reasonable alternatives … sure, we have competition, and now you’re hearing about Watson’s going to do this and Zynx has protocols and Wolters Kluwer is getting into the market. 

One of the things that we do that those folks don’t do is we actually have the concepts for documentation linked to E&M, linked to all the other stuff designed for use at the point of care. It’s not a knowledge resource — it’s a documentation and patient care resource. In that regard, there’s really nobody else that I know of that does what we do.

Explain the advantages of Quippe and why physicians like using it.

When we first started designing this stuff, we were a little bit limited by the current technology at that time, by the state-of-the-art of user interfaces, and that kind of stuff. We made the decision in 1997 to make the knowledge engine its own component without a UI. When some of the browser-based technologies and some of the performance stuff for cloud type services came along in 2002 to 2005, that enabled us to think about a completely new way to deliver two things to the user at the point of care: deliver the content and give them control over the presentation of it.

What we’ve managed to do with Quippe is take 25 years — from 1978 to about 2003 — of clinical content development and what would now be looked on as rather primitive user interface options, and bring a bunch of docs in here and say, “We can deliver any of this content anywhere you want in millisecond time. What is it you really want, and what control over it do you want at the point of care in a user interface?

We had docs come in here over a period of about two years, probably 10 different sessions, and just say “Give me what I want to know when I need to know it. Give it to me in a format that I can control, that can learn from me as I go along, adapt to my needs, and not fix me into a template, but actually push the information to me that I want to see for any condition I treat without me having to go and find it or ask for it.”

Quippe is a note-like user interface that has all this data behind it ready to serve whatever action the clinician takes and give it to them on almost any device. Right now tablets are the hot new thing, but it doesn’t have to be that way.

How is it different selling to vendors rather than end-users? You had a significant presence at HIMSS, including sponsoring HIStalkapalooza. You have to develop interest by the user, but through their vendors.

There’s two ways to do it, and we have to do a little bit of both. Going with MEDCIN and Quippe as your platform is a major strategic and management decision. You have to get the interest of probably the busiest people at HIMSS, who are the CIOs, the CEOs, the clinical people of the vendors who are there to do business with their potential customers. They’re not there to talk to me. We have to get their attention and we have to prove to them that we can provide value. 

One of the reasons we do the iPad giveaways at HIMSS that we just did at MGMA is to show these vendors that we can provide to them something that I can train their customers to use in 20 minutes on a busy show floor. They look at that and say, “Wow. That means I can scale up. I can get implementations up. The docs seem to love it. Tell me more about Medicomp and MEDCIN.”

It’s a two-pronged strategy. We’ve got to appeal to the end user, but we’ve got to also get the attention of the busiest people at HIMSS and MGMA.

I knew nothing about documenting an encounter or using an iPad, but it really was just that easy to use Quippe. What response did you get and are getting at conventions where you just sit people down cold in front of it and say, “Here you go?”

They can’t believe it. It looks so easy they think we’re faking it, which is why we have to put it in their hands. 

I don’t know anybody else that puts software with the complexity underneath it and power in a user’s hand on the show floor at HIMSS and just says, “Have at it.” That’s a very powerful message and one we’ll continue to use over the next couple of years. 

That all comes from those docs coming in here. Every time I had an idea for the user interface or somebody here did, the docs said, “No, no, no. Just give me what I want and get out of my way because I already know how to treat patients. I already know what a note looks like. I know how to document. Just give me the information I want and a format I’m used to looking at it.”

That’s really all that we do. There’s a tremendous layer of technology underneath that, but MEDCIN is like the wizard behind the curtain of Quippe, except there’s really something there, not just some guy pulling strings. The only way to prove that is to put it in somebody’s hands and let them do it.

Like the iPad it runs on, that’s an Apple-like strategy to replace complexity with elegance, but let the user do what they need to do efficiently.

Exactly. One of those light bulb moments for me was I went out to visit the end user of one of our customers about five or six years ago. She was not happy with how much the user interface that we had in the old VB6 days slowed her down. She was vocal about it, but she made some really good points. She gave me a lab coat and said, “You’re an intern for the day. You’re following me around. Let’s go see two patients.”

We went into see one. Lights were on, computer, etc. She did what she did using the software of one of our vendors, who will go unnamed. She went to document and do all this and do all that. At the end of that and said, “Did you see how excruciating that was? Let’s go in to the next patient.”

She pulled up the shades so that light came in. She unplugged the computer and pulled out a pad. Saw the patient, did what she did, gave the patient a prescription, walked out, and she said, “I already knew how to do everything. Without your technology, it took me 11 minutes. With your technology, it took 15. Don’t slow me down. Get out of my way.”

I came back to the guys and I said, “We’ve got to kill the idea of fixed templates. We got to kill the idea of checkboxes on forms. We got to come up with a different model for this. What do physicians know? They know medicine, they know what they’re thinking, and they know they have to produce a note. Let’s marry all that together.”

As it turns out, our engine was almost perfect to serve up that sort of solution. We brought the docs in here and said, “Help us do this.” They just kept saying simplify, simplify, simplify. That’s how we did it. That’s what makes it possible for us to teach people to document on an iPad on the show floor in 20 minutes.

That gets into the area of EHR usability, which is, along with ICD-10 and Meaningful Use, is a hot topic. What is Medicomp doing to address those?

A couple of things. Back in 1997, when the National Committee on Vital and Health Statistics decided to set up a standards committee, we were very involved in that. One of the big decisions they made in maybe 1999 or 2000 was ,”We’re going to set reference terminology standards for the exchange of information between systems. We’re not going to dictate user interface terminologies. We think those have to adapt to users and it’s not going to be the same for everybody ,so let’s establish standards.”

In July of 2003, they said that LOINC, RxNorm, and SNOMED were going to be some of the voluntary standards for this. We immediately said everything we do from now on is geared at making sure we maintain that layer of usability and map to all these standards in the background. We probably added 30% to our staff, we added consultants, and we just started cranking out those mappings, just doing them reiteratively over and over again.

When we saw that ICD-10 was going to happen eventually, we prepared for it. We’re now implementing that. We did the same thing for E&M, which is another kind set of coding mappings back in 1999, 2000. We continue to do all that mapping in the background.

We adopted Virginia Saba’s clinical care classification system for nursing and built a nursing engine and documentation index that integrates with the physician index that we’ve been talking about, so that nurses and allied health can both treat the patient based on the same information in the note, but their documentation overlaps in some cases, but is very different in other cases. That’s what’s getting us now into the enterprise market more deeply.

So you think you’ll have an inpatient clinical documentation system for nurses?

We do have it. I expect that we will make … as I said, we let other vendors make the announcements. I’m virtually certain we’ll make an announcement of a major vendor in the next six months and possibly two by the end of next year. They don’t announce until they’re almost ready to deploy. I think it’s going to stun people.

These are vendors that are committing to retool their product to have your version of the MEDCIN engine as the front end?

Yes. We found an interesting thing. We did a project in Asia about three years ago. I went to Asia and I demo of Quippe in English and they said, “Forget about that. Let’s see it in Mandarin, in simplified Chinese. When will you have that done?” We hadn’t even started and that wasn’t my intention. What would be acceptable? They said, “If you can document 95% of what you do in Chinese, that’ll be fine.”

We pulled the MEDCIN index out for the top 500 diagnoses, all the index records for those, plus 200 other areas of our clinical hierarchy that weren’t represented in the 500. We merged them all together and it came 10,104 of our 285,000 items. We got translations for those done in less than three months for positive and negative. I went back and did a demo — 98% of everything came out in Chinese.

That was pretty cool, but when we started dealing with the enterprise vendors and they said, “You know Dave, we’ve got existing content that covers most of what anybody does” – this is two different vendors independently – and I said. “How many others do you have?” They said just over 10,000.

How weird is that? It pretty much told us that even in a large population, 10,000 to 15,000 of our elements constitute 97 to 98% of total data occurrences, but the struggle that the continue to have to add items, they continue having to map them. The more items you add without some intelligent way of presenting them, the more templates you have to build and maintain over time. 

The big vendors, for the most part, are coming to the conclusion that they do not want to be in the clinical content business. There’s a couple of big exceptions, one located in the Midwestern state south of Chicago.

You’ve been good at predicting the future and being ready for it. Where do you go from here looking down the road a few years?

We have to be ready for a couple of things. Whether anybody likes it or not, if you’re a clinical provider and you’re treating a patient, you have to be prepared to deal with what we think of internally as the coming data tsunami. Once these HIEs are in place and once these standards are in place and people are required to send this as LOINC or RxNorm or SNOMED or ICD-10, and I’m treating a patient and they’re under my supervision now – maybe I’m their caretaker under an ACO model — I’m responsible for that data coming in. I’ve got to be able to make some sense of it.

I might have a patient with the classic big three in America — hypertension, obesity, and diabetes — plus two other things. Maybe today I just want to deal with this.  I’ve got to find the relevant information in there, because I’m probably going to be held responsible for it, and I’m probably going to be held responsible for whatever I do and making sure that patient, once I treat them, if I admit them to a hospital or I discharge them from ambulatory care; if we got to outcomes-based reimbursement, I’ve got to take that data in, treat them, and keep them from coming back.

All of our tools are built to enable that. That’s one of the reasons we got into integrating the nursing care. If somebody gets discharged or somebody comes in even to an ambulatory practice with an open wound, I’m going to be responsible if they show up with an infection coming back. I’ve got to teach them hand hygiene, I’ve got to teach them wound care, I’ve got to teach them signs of infection. I’ve got to do all that. That’s why we built that stuff and then integrated it, because whether it happens or not – and I think it will, I think it’ll take longer than people think – we’ve got to be ready for that data tsunami that’s coming.

We also have to be ready to make it possible to scale up – and I’m including implementation and training and updates of software – quickly as medical knowledge changes and get it deployed out to the places where care happens, which is why we started building our cloud-based model about six years ago. Whether or not ACOs push integrated care, information is going to increasingly be … you’re going to need to be able to integrate it quickly, absorb it, find what you want, treat the patient successfully, and manage them on an ongoing basis.

We’re building all of our tools as if we have to do that. We also know from our experience, now with about 100,000 people using MEDCIN everyday, that training consists of, “You’re new here. Let me show you how I use this.” They get about 20 minutes of training, it’s done, and they’re on they’re own. That thing had better push the information they need to them. It better be intuitive. It better be easy to use, maintain, train, deploy.

That’s what we’re focused on. It’s a lot, but it’s really one problem. Giving them the information they want when they want it so they can do what they need to do and not require massive support to do that.

Any concluding thoughts?

We think there are going two be major challenges. How do enterprises handle data and account for their outcomes? How do you get the tools to do the individual clinicians on the front lines to do their job, which is patient care, and take care of all of that other stuff in the background? That’s what we’re trying to do.