Is our current EHR paradigm dated? Docs practiced for years with paper. Pencil evolved to ink, both inscribed on compressed wood. Housed in manila folders, stickers provided the index and retrieval involved sight-based interpretation based on patient names. Then, we introduced computers. Initially similar to the paper paradigm, full summaries in ANSII or images are stored in a paradigm that still resembles folder-based paper storage. From the images and full ANSII summaries came discrete data points. Ink on paper had now evolved to data capture as unique field based database storage. Over time, these discrete data points will become much more comprehensive.
With all the technical advances where is the industry going? Will the paradigm shift from practicing medicine on discrete data points to something else, and when? Will medicine be able to shift? Is multimedia the next frontier? Just like the initial paper to electronic chart paradigm shift, when will computer science convert images and video to discrete data points? We all know the value of discrete data.
Fan of Dr. Jayne from the Deep South
Dear Southern Fan,
You pose some interesting questions. Given the fact that physician recordkeeping didn’t change much for hundreds of years, the relative pace of records evolution at present is staggering. We’re already becoming fairly adept at converting spoken language into discrete data, allowing physicians to document patients’ stories not only with codified data points, but with the rich narrative that frames individual patient circumstances and situations.
In my opinion, the biggest barrier to the kind of documentation that can be envisioned is unfortunately the proverbial hand that feeds us. The regulations, policies, and requirements of CMS are still stuck in the paper paradigm. And as we all know, as CMS goes, so go the rest of the payers. Despite federal mandates to take the technology forward — such as HIPAA and HITECH — healthcare providers are still being scored based on documentation standards that have not evolved in more than a decade.
Physicians can’t get “bullet point” credit for documenting a cancerous skin lesion with a photograph. They say a picture is worth a thousand words, but in an audit, a picture is worth nothing.
I remember sitting in medical school watching a video of a child with whooping cough. No written description could ever take the place of that. When you see and hear that kind of pathology, it’s etched in your brain forever. Nevertheless, embedding a video clip of a patient isn’t worth anything, either. I can look at a photograph of a diabetic foot and tell you a lot more about a patient’s illness and status than I can glean from a multi-page nonsense note generated from a poorly-implemented EHR.
I once heard someone say that our thinking is constrained by the technology of today. I don’t think that’s the entire problem; our vision is also constrained. And it’s not the technology that locks us in, but also the auditing and payment paradigm that hobbles us.
I was initially hopeful that the rise of Accountable Care Organizations with their risk-sharing and outcomes orientation would help us move to a more modern way of thinking and documenting. It doesn’t look like the fact that providers and payers are sharing risk is going to move us away from the incessant and costly paradigm of documentation for documentation’s sake.
The promise of telemedicine and other technology ventures such as real-time electronic patient communication was exciting. However, lack of payment and increased regulatory burden continue to keep it from realizing its potential. I’d like to think the future’s so bright we’ll have to wear shades, but I’m not sure CMS agrees.
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!
Structured and Unstructured Data, I Adore You Both By Deborah Kohn
Calling all electronic patient record systems (EPRS) structured data! Yes, all you electronic health / medical, administrative, and financial systems’ data elements that are binary, discrete, computer-readable, and, typically, are stored in relational databases with predefined fields … you tidy, typically core, transactional and mined elements. Hello? I’m talking about all you digital, patient demographic, financial, and clinical health data that are sitting in master patient indices, insurance claims, clinical histories, problem lists, orders, test results, care plans, and business intelligence reports — to mention just a few.
Meet unstructured data! Yes, all you EPRS data that are non-binary, non-discrete, sometimes only human-readable, and sometimes not stored in relational databases. This means all you digital, bit-mapped images, text, videos, audios, and vector graphics that are harnessed in word-processed summary reports, electronic forms, diagnostic radiology images, scanned document images, electrocardiograms, medical devices, and web pages – again, to mention just a few.
I know this might be an awkward introduction. However, I’m really happy to finally get you two data formats together. And, while this might be jumping the gun a bit, I really hope one day you two will get married! I know, I know. That is, after you’ve carefully sorted out all your differences and learned how to live together in peace and harmony for the betterment of patient care.
After all, I’m certain you heard the rumor that the “adoption” and “Meaningful Use” of “certified” diagnostic image-generation and management systems, such as a PACS for one or more of the “ologies”, might be included in Stage 2. In addition, heaven help if, given the revised Federal Rules of Civil Procedure Governing Electronic Discovery that became effective December 1, 2006, a patient’s electronic health/medical, administrative and financial episode-of-care records (I mean x-rays, bills, ECGs, orders, progress notes – the works!) are subpoenaed for that Weird News Andy case we recently read on Mr.HIStalk! So, don’t you think it’s time at least to begin acknowledging one another in public?
Who am I, you ask, to be so bold to introduce you to the other? I’m just one, frustrated HIT professional who specializes in most of the EPRS unstructured data and who observes that these data are rarely considered in EPRS strategies and purchases … until after the fact. Once considered, they divide provider organization departments right down the middle; those working with you, structured data, vs. those working with you, unstructured data. Don’t even get me started about integration and usability issues!
Come close, structured data, so I can tell you that I do adore you – especially when I search a database for one or more of you, and, quickly and easily, the search engine finds, retrieves, and even manipulates parts or all of you. On the other hand, what often makes me want to delete you is when you insist on snubbing unstructured data. I’ve even watched you try to convert some unstructured data, such as rich-text or video data, to your popular religion, using pretty-good-but-not-perfect artificial intelligence and recognition tools … just so that you can brag about how you were able to generate the complete health story with your qualities.
Unstructured data? After so many years working with you, you know that I love being able to retrieve your gorgeous, bit-mapped, raster images generated by that digital chest x-ray or computed tomography (CT) scan stored in a diagnostic image management system; or, listen over and over to your brilliant sound bytes generated by that digital stethoscope; or, fast forward your streaming videos / frames generated by that important cardiac catheterization study; or, admire the perfect lines connecting the series of points plotted by that fetal trace recording. On the other hand, what I can’t tolerate is when I am required to search, for example, a valuable narrative text for one or more of you, and after hours I still can’t find you!
Today there is no complete electronic patient health / medical, administrative or financial record system without both of you. Let me see a hand shake.
Problem Lists: Avoiding the Tragedy of the (Coded) Commons By Dr. Jim
If we want to take better care of patients, we have to know what we did. To know what we did across a whole group, we need computers to crunch concepts that computers understand.
But here lies a paradox. While we need structured data entry to enable useful analysis, too much structure complicates both data entry and analysis. The splitters (and payors) among us can create use cases that force the lumpers to accede to ever finer divisions until, for instance, a single ICD-10-PCS procedure code represents nearly an entire chart summary: “ICD-10-PCS 027334Z Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Approach” e.g. There are upwards of 1,000 more angioplasty codes within ICD-10-PCS, all with a General Equivalence Mapping to a lesser number of ICD-9-CM Volume 3 codes.
Are my fellow clinicians napping off yet? If so, put on a hazmat suit before you do. What is hitting the fan now will be splattering you shortly if it is not doing so already. In the interest of being able to use our electronic records meaningfully, the movement is toward collaborative problem lists with structured entries documented by clinicians. This would be a good thing—an excellent thing—were it not for the concomitant explosion of “structure” detail, the de facto requirement that clinicians do the structured entry as part of their workflow, and the variety of workflow places and coded sources that potentially populate the “Problem List.”
These sources include the SNOMED-CT and ICD-9/10-CM libraries for diagnoses. I won’t be surprised if a typical Problem List ends up including Procedural Codes as well from the ICD-10-PCS and CPT/HCPCS libraries. While these procedural codes are not technically “problems,” and not currently Meaningfully Used (the current standard is for “ICD-9 and SNOMED-CT” pending the swap to ICD-10), it does not take a Workflow Scientist to predict that a clinician who documents a percutaneous angioplasty as a CPT code will have an expectation that the Problem List is automatically populated with that (coded) “diagnosis.”
We are about to see electronic record-generated collaborative Problem Lists that are essentially a repository for the “workflow” output of every clinician who touched the patient. Diagnoses attached to ordered tests; diagnoses entered during a Hospital stay; ED diagnoses; prescription diagnoses; ambulatory diagnoses; imported diagnoses carried by CCDs … perhaps even diagnoses entered by billing services after discharge. It will be the plethora, and not the dearth, of finely-split coded data, which renders the Problem List less functional and the analytics related to it problematic.
The challenge is to find ways to get to Meaningful Use without letting it prevent the record from being used meaningfully. It’s a great idea to have a collaborative Problem List from which every workflow can read and to which every workflow can write. But we must also focus on finding ways to preserve a Problem List which readily communicates a plain-English problems summary for all caregivers so that Meaningful Use does not morph it into an unnecessarily long and noisy collection of all the code-speak entered on a patient.
There is a need in the electronic record for good, coded, structured data. This does not mean it should replace clear communication.
Real-World Epic from the Ground-Level View By Informaticist RN
I have worked as a nurse with Siemens Invision, Cerner, and Meditech and an implementation consultant for a leading HIS vendor (not Epic). I’ve also worked as an IT analyst at a major medical center implementing Epic ambulatory.
We had two Epic employees assigned to the ambulatory application, an application coordinator (AC) and an application manager (AM). Both were fresh out of college and obviously green to healthcare.
Our AC/AM would come out for a week at a time, with no agenda given in advance. When they were here, it was disorganized. Whether this was the hospital’s fault or Epic’s, I’m not sure.
Usually, the two Epic people would be typing away on their laptops and not meeting with anyone from the hospital. When I did have one-to-one meetings with them regarding the build we were working on, they were constantly on "Epigoogle" (Epic’s search engine) because they did not know answers to what seemed to me like basic questions.
After their visits, we received no follow-up on outstanding issues or status reports of things they were working on for us. Reaching them was always a challenge. Either by voice mail or e-mail, it could take days or weeks to get questions answered. Generally, it took escalating issues through our project manager just to get a response. We didn’t even get, "Saw your e-mail, working on issue, will get back to you." Nothing! Very poor customer service from them.
During what Epic calls validation sessions, we ran into many problems where scripts weren’t sent ahead of time for our review. Some sessions ended up with last-minute cancellations because Epic wasn’t prepared or hadn’t shared the necessary info with us. Very frustrating.
When build questions arose, the Epic AM preferred to fix the problem in our system herself rather than explain the answer to us so we could learn the system. Frustrating again!
These same AC/AM were also responsible for grading projects for certification. When clarification was needed for me to understand what I got wrong, they were unable to. That was actually a final answer I received from our AC — "I don’t know," and no offer to find who might know more or send on my project to someone more senior for grading.
It was really very disappointing because I was a better IC at the vendor I worked for than either of these two, but everyone at the hospital acted like they were so great because they come from Epic.
From THB: “Re: Cheyenne Regional Medical Center. Going Epic.” The 218-bed hospital gets board approval to replace McKesson Horizon with Epic in a $19 million deal, saying it will cost about $5 million over five years to implement Epic. It says Meaningful Use money will offset that amount, and after that, Epic will actually be cheaper that McKesson. Epic doesn’t usually sell to hospitals that small, so either CRMC is affiliated with a larger Epic customer or Epic is started to push down into Meditech territory.
From WSDiner: “Re: HCA. At a Credit Suisse Healthcare conference investor dinner Thursday night, HCA’s management said they piloted Meditech 6.0 this year and will pilot Epic next year. They said that no other vendors (i.e., Cerner) were under consideration.” The reader provided a Credit Suisse contact to confirm, but he didn’t respond to my e-mail. This will be interesting if it’s true – my read has always been that HCA just wants to scare Meditech into better pricing by bringing in competitors, but Epic doesn’t walk away without a contract in most cases. HCA is Meditech’s largest customer, contributing 8% of the company’s revenue in 2010.
From Commodore: “Re: Cerner running poorly on the iPad. Do other inpatient vendors have native apps?” The only one I know of is Epic, which has Canto (above.) There may well be others. I tried using a couple of my hospital’s clinical apps the iPad using the Citrix portal and that’s definitely not something that’s workable for clinicians. The shrunken screen is impossible to comfortably read, you have to constantly zoom to hit tiny drop-downs with your finger, and the clicking doesn’t feel sure-footed at all. I think it’s safe to say that for most vendors, there’s not much to brag on if your iPad capability consists of running an emulated desktop screen. Only your marketing people will be impressed.
From The PACS Designer: “iPad viewer. The FDA has now approved an iPad viewer from Carestream called Vue Motion. The application permits the viewing of image files from many different PACS platforms, including cloud-based offerings, and can be integrated into EHR solutions to permit viewing of image files and patient records through a single sign-on.”
Here’s my summary of business lessons learned from the Steve Jobs biography.
My Time Capsule editorial from October 2006: Economics 101 and the Healthcare IT Market (that’s a pretty lofty premise to cover in 500 words). A Sam’s Club tiny paper cup-sized sample: “Hospitals can be convinced by questionable claims of product superiority or patient risk, and even more so by seeking vendors just as prestigious as they fancy themselves (no Walmart shopping for big academic medical centers, even though patients are the ones paying.)”
Note the reduced number of animated ads to your left thanks to those overachieving sponsors who have already traded out their animated ads in advance of the January 1 target date. I always feel bad when requiring changes like that, but it will benefit sponsors as well since readers will pay more attention to more subtle ads. I’ll digress by saying that while few things surprise me these days, one that does is the non-financial support I get from sponsors. Not all of them, since a few are purely ad placements without much personal connection, but the majority have executives and regular employees who keep in touch, send me music recommendations, e-mail me a well-timed attaboy right when I’m feeling overwhelmed or under-accomplished, or send off-the-record snarky comments about one thing or another. HIStalk is an after-work hobby for me rather than business and I like that the connections aren’t always business related.
Venture capital superstar and billionaire Peter Thiel, speaking at Practice Fusion’s conference (he’s an investor), says highly paid salespeople can land big businesses as customers and relentless marketing can get consumer sales, but companies that can sell to small businesses (like most medical practices) are rare since those small businesess are reluctant to change. He gave as examples QuickBooks and PayPal (implying Practice Fusion as well, naturally.) Also at the conference: Practice Fusion rolls out its iPad app, although I’m not clear if that’s a new native app or just the LogMeIn remote control version that was announced at HIMSS.
Doctors and hospitals in Boulder, Colorado are questioning whether joining Colorado’s statewide RHIO (CORHIO) is worth the subsidized cost. Small practices say the upfront training costs and $85 per doctor monthly fee are steep, and doctors at Boulder Medical Center says there’s not much value to them since they’re already connected via their NextGen systems. CORHIO’s five-year business plan called for taking in $26 million in federal grants and $19 million in subscriber fees.
Polls that list companies always bring out ballot box stuffers, but they’re fun nonetheless. Epic wins this one handily, with a fairly even spread among the losers. New poll to your right: how will ONC respond to the IOM’s report that criticized patient safety efforts related to electronic medical records?
We already know what HIMSS thinks of the IOM recommendations since Steve Lieber quickly released a statement. He zoomed right past all the patient safety concerns, preferring to focus on one sentence that says paper records are also risky, thereby summarizing the entire work as “a strong endorsement for the path healthcare is on.” Well, OK. He also is somewhat dismissive in saying IOM looked at only at the patient safety aspect of HIT and it’s already fussed about that before (which is exactly what you’d want IOM doing given that there are plenty of loud voices, especially that of HIMSS, extolling the virtues of technology for purely commercial reasons and ignoring IOM’s previous recommendations). A critic might say, “Who’s this association executive with no credentials in medicine, research, or technology speaking on behalf of his unpolled membership to critique the work of a large group of unbiased and extremely well-credentialed IOM medical experts whose thoughtful opinions were commissioned by ONC?” but to question the authority (audacity) of HIMSS to weigh in on complex national matters is just not done. If you say anything even slightly negative about commercially sold healthcare IT, HIMSS is going to hit the PR airwaves, often cherry-picking a few HIMSS-friendly members to chime in for credibility support. Choose your side: an unbiased group of scientists vs. an exhibit hall-funded trade group. I like some (maybe even most) of what HIMSS does, but its predictable knee-jerk defense of the industry and federal grants just annoys the heck out of me as a dues-paying member, especially given that so many of us members pride ourselves in spotting and debunking shoddy research methods, investigator bias, and inconclusive evidence, all in the interest of improving patient outcomes and reducing healthcare costs just like IOM is trying to do.
Here’s Vince’s latest HIS-tory, highlighting Healthcare Information Systems. I’m cringing a little because he attacks someone at the end, to be named in the next installment. I don’t know who it is, but I’m hoping that person is (a) not a reader; (b) dead; or (c) one of Vince’s pals he’s just joking around with.
Thanks to the following sponsors (new and renewing) that supported HIStalk, HIStalk Practice, and HIStalk Mobile in April. Click a logo for more information.
Epic hosted a college team programming competition in its offices this past Saturday. You wonder how many of the geeky combatants left with job offers, and also how the reporter kept a straight face in writing up details: “Winners and awards will be announced after the 4:30 p.m. conclusion of the competition, which will be held in the Nebula room in the Heaven building. Parking is available in the Yoda underground garage.”
Jackson Memorial Hospital takes part in a quickly assembled telemedicine project that will connect Miami specialists with hospitals in Iraq, part of a $1 billion contractor’s project as the State Department takes over field hospitals and medical care when US troops pull out December 31.
Weird News Andy wonders how many EMRs have edits that would prevent documenting this. In Mexico, a 10-year-old girl gives birth. You have to either admire or detest the creativity of the UK-based newspaper’s accompanying photo of a girl packing a toddler along in some kind of serape, clearly desperate for a visual, yet struggling with the lack of an Enquirer-like picture of a 10-year-old: the photo has nothing to do with the actual story and was “posed by models.” Its readers are apparently so stupid that reading text without even an irrelevant picture is unthinkable.
WNA also notes that health conditions are leaning toward the Third World in the Occupy Wall Street encampment. The unfocused unemployed there are coming down with a variety of respiratory infections as they sleep among their trash, pee in bottles without washing their hands, pass cigarettes and alcohol mouth to mouth, and refuse free flu shots because they’ve concluded that vaccines are a government conspiracy. They have a volunteer-staffed medical tent, but it only stocks herbal remedies.
ONC’s blog (which is actually written by its contracted PR company – it’s not like Farzad’s going to bare his innermost thoughts or music recommendations there) highlights the VA’s Blue Button initiative in honor of Veterans Day.
As Dr. Jayne mentioned, Walmart is denying that it plans to develop some kind of national primary care program, but they might want to check with their RFI people they’re clearly looking for partners to “rapidly create a comprehensive healthcare solution to deliver low-cost, high-quality primary healthcare services nationally.” The RFI lists specifically that partners should be able to offer chronic care services (diabetes, hypertension, etc.), lab tests, vaccinations, physical exams, health screenings, and durable medical equipment support. They say they will consider vendors who offer only “enabling technologies” as well, and the RFI requires prospective vendors to describe their proposed information system and “data sharing model.”
Ed Marx updated his most recent post to respond to reader comments. He’s always gracious, even to his anonymous attackers. And here’s the secret I shared with Ed: I don’t usually delete negative comments because I’d rather let readers provide the majority opinion via their own responses.
Speaking of Ed’s pieces, a few folks howl if I dare run anything that’s not directly related to their jobs, but many (most, maybe, especially at the senior levels) enjoy a mental break with personal stories about patients, working in HIT, or life’s lessons learned. Yours are welcome.
An Investor’s Business Daily article notes that its medical software sector dropped from #2 a month ago to #67, mostly due to the huge drop in CPSI’s share price after it missed expectations. The article says Cerner beat estimates but profit margins slipped in the most recent quarter, while Quality Systems shot itself in the foot in its earnings conference call by implying (but later clarifying) that most of its new sales were coming from replacements, suggesting that the market was past its peak. Athenahealth is mentioned for beating expectations but not by enough (double expectations?) and took a 7% share price drop as a result. On the positive side, shares in MedAssets jumped 14% and later 17% after beating estimates and Allscripts share price took a slight turn north after reporting results. Above is a one-year price chart of the shares of all those companies: Allscripts (blue), Cerner (red), Quality Systems (dark green), athenahealth (yellow), MedAssets (brown), and CPSI (light green). Leading the pack are Cerner and athenahealth. Looking at just the past three months, the clear winner is Allscripts, with MedAssets and Cerner basically tied for #2 but pretty far off the pace. Looking back five years, your best return would have been Cerner and Quality Systems. Always amusing is that ever-vigilant stock analysts flip-flop their recommendations a day or two after unusually good or bad news is announced, providing no benefit whatsoever for the clients paying them for non-retrospective advice.
I’m beginning to be annoyed by research companies selling expensive reports under the headline, “XX Market to Reach $X.XX Billion by XX.” One of these days I’m going to check the accuracy of their past predictions, which I suspect is minimal. Inga loves to run those press releases like they’re real news, along with the splashy results of questionably conducted surveys that are favorable to the companies paying to have them done. She’s usually good natured about my edict that she’s allowed only one survey mention per post.
Inga notes that Sage’s new name, Vitera, is also a band’s name. She and I don’t usually like the same music, but they’re good for an unsigned band, a Latin-style pop with a harder guitar edge, like a Spanglish Guns N’ Roses. Check out this live video and the flying V fiddle, which sounds to me like prog rock meets Texas swing.
A Jacksonville, FL woman starts a booming business that provides scribes to do patient care documentation for ED physicians. The scribes, often pre-med or nursing students, are contractors billed out at $20-25 an hour, a bargain according to the company’s medical director. “For every hour we spend, we get about 15 minutes at the bedside of patients and 45 minutes of every hour documenting everything … part of it’s insurance. Part of it’s medical-legal. Part of it is a federal mandate to have everything documented electronically.”
Startup accelerator Rock Health signs on UnitedHealth Group as a sponsor. It joins Microsoft, Nike, Qualcomm, and Quest.
Outsourcer and iSoft acquirer CSC reports Q2 numbers: revenue up 1%, EPS –$18.56 vs. $1.19, cutting guidance. The ugliness was caused by a massive $2.69 billion write-down of goodwill and a settlement of a contract dispute with the US government. Shares predictably tanked.
Two nurses file a class action lawsuit against Aurora Medical Center (CO) after being written up for trying to clock in before putting on their hospital-provided scrubs. They say they should be paid for the time it takes to go to the scrubs room, find some that fit, put them on, then go clock in.
History Mingles with Innovation in Atlanta By Erin Sweeney, Director of Marketing The Friedman Marketing Group
Key takeaways from the eyes of this healthcare marketing guru include:
There is a whole new generation of healthcare IT experts ready to lead the charge.
Analytics are a key capability for all healthcare IT systems.
There are some really cool virtual reality glasses being tested in Afghanistan to help military medics and other first responders save lives—may come stateside soon.
Vendors that enable ACOs through harmonization of multiple systems will be winners.
Vendors that are behind can easily get ahead using new technology.
Cloud computing is here to stay, on-premise is antiquated.
Patients will spur providers to innovate.
Boards will be more involved in quality improvement.
Interoperability must happen between states.
Average venture capitalist investment in healthcare IT is $3 – $5M.
VCs are more interested in companies where technology is driving a service; and the two are not treated separately.
Amidst all the innovation, attendees did hear one reality check offered up by a panelist and based on research from Cigna Health: the average patient has 200 documents located in 19 different places.
And finally, Justin Barnes from Greenway Medical painted a gloomy picture for physician reimbursement and suggested groups ask themselves, “Do we interoperate or join an ACO?” Another panelist encouraged groups to look around and decide who they’ll affiliate with instead of waiting until the best dance partners are taken.
Overall, the Summit was interesting and a bit eye-opening. The TAG speakers and panelists added some fun and humor to the discussions. Dr. Dente pointed out that women are caregivers for not only their own elderly parents, but also their in-laws. Doctors’ appointments, prescriptions, transportation to and from check-ups — the women do it all. Looks like the upcoming holiday gatherings will be a walk in the park compared to what’s in store for this gal.
An HIT Moment with ... is a quick interview with someone we find interesting. Stuart Long is president of Capsule Tech, Inc. of Andover, MA.
What’s new in the world of medical device connectivity?
I think the biggest change is that more and more hospitals understand the need for device integration and have moved on to the realization that clinical workflow improvement is a significant factor. This means that when hospitals are evaluating connectivity, that they are not only looking at the technical components, but are really investigating whether the solution fits the way the nurse works. They realize that doing so not only ensures successful adoption, but ensures that the benefits of device integration are truly realized.
We’re seeing actual data from our customers indicating their clinical staff gains as much as one-fourth of their time back to bedside caring of their patients. This is significant. I also think this is why you see the role of CMIOs and CNIOs increasing in the industry — understanding the importance that IT plays in the evolution of improved clinical care. They are leading the way at bridging the gap between IT and clinical and ensuring that the technology not only fits technically, but clinically as well.
Why is vendor-neutral device connectivity important?
There are hundreds of devices throughout a hospital. There are dozens of receiving systems that want data from those devices. Without a vendor-neutral solution, hospitals end up with vendor-dependent solutions that only solve connectivity for one device or one system and can significantly drive up the cost of deployment, management, and upkeep. The result of this type of connectivity is multiple points of integration that are nearly impossible for the hospital to manage and that offer no flexibility to add, change, or upgrade their devices or IT systems. As connectivity evolves, there will be even more points of integration to manage.
Vendor-neutral connectivity is the optimal way for a hospital to ensure that their architecture is as clean as possible, that it minimizes points of integration for easier management, that it helps manage costs, and that it offers the flexibility and scalability to allow hospitals to add and change devices or IT systems as needed.
However, we consider this basic vendor neutral connectivity. Customers want to connect more devices, but they also want a visual status display at the bedside. They want a solution that allows them to validate and send vitals from the bedside in lower acuity areas such as med-surg. They want to expand their solution to do more advanced connectivity, such as reporting and analytics, that could result from the collection and comparison of all collected data.
Many of our customers understand the burden of managing many third-party applications on a PC not originally intended for this type of use. They tell us with FDA being a priority, “We want you to own it cradle to grave.” This way there’s no ambiguity as to who owns what. The point of demarcation between what is our responsibility and what is the customers is crystal clear.
Our product is a medical grade platform that delivers basic connectivity and enables connectivity across the hospital, fits into workflows, is dedicated to connectivity management, and is field-upgradeable. Customers can realize the benefits of improved patient care, workflow efficiency, and patient safety today and grow without having to overhaul their solution to add features and applications later.
Are we at a point where our ability to collect medical device data exceeds our ability to do anything useful with it?
There is always a need to automate the basic charting process. Manual vital sign collection and charting is simply a waste of nursing time. Even if the only goal for a hospital is to implement the basic connection of devices to systems to automate this charting process and improve patient care at the bedside, this in and of itself justifies the implementation.
However, I think the industry is in the early stages of the next big growth cycle for device connectivity. Clearly the connection to the EMR is still the biggest driver for connectivity today, but there are many applications that have been emerging over the past few years that require not only the discrete device parameters, but also the alarms and waveforms from devices. Some of the emerging drivers are decision support, remote surveillance and monitoring, mobile devices, alarm management, and device-to-device interoperability.
There are definitely many current and future uses for all this device data. The challenges are in being able to process, format, and ultimately serve up the data to these applications. We are experts at doing this. Providers also need and want to get more useful data to help improve decision making. In fact, there is already much progress on the BI and analytics aspect of healthcare.
Do you have examples of providers that have demonstrably improved patient outcomes by using medical device data integration?
Yes. The key benefits of medical device connectivity are improved workflow efficiency and patient safety. Our customers have documented amazing progress in this area and reported improvements in the amount of time vital signs are now available in the patient’s record.
One customer nearly eliminated the delay of vital signs to the patient record, going from six hours to just seconds. Another customer recognized an annual savings of $265k in reduced waste previously caused by vital sign delays. Another reported a 23% reduction in documentation time post medical device connectivity. Ultimately, this translates to more time in direct care activities and supports improved patient care and satisfaction. This leads us to the results of one customer that reported a 61% Gallup improvement in their nursing satisfaction pertaining to their job.
Patient safety is positively impacted by medical device connectivity as well. Charting errors are reduced and patient data errors are avoided. Accurate vital signs are available in the EMR and accessible to physicians and clinicians, which improves patient care coordination. One of our customers is linking near real-time vital signs with their early warning system and using it as patient surveillance to track deterioration of the patient status and the need for rapid response intervention. They are also using the benefits of device connectivity to monitor the potential for sepsis in lower acuity environments.
Exact metrics on errors and omissions are hard to come by since hospitals are sensitive to report this information. However, we are seeing our high reliability customers more willing to study this metric so they can continuously improve and initiate actions to create a safer environment for all their patients.
What changes do you predict over the next few years that will affect your products?
The largest changes will be related to improvements in clinical workflow and the use of data. This includes the collection and management of alarms and waveforms and the ability to integrate smart pumps. Closely related to all of this is the industry shift from collecting data based on the patient’s location to a workflow, whereby the data is directly linked to a confirmed patient ID. All of these areas are huge challenges for hospitals.
We have been working with our customers and our device and information system partners to solve these needs. There are a lot of technical details to sort through to make it happen and a lot of testing that needs to be done end to end. But that work has started and connectivity will, in my opinion, be rapidly changing in the years to come.
November 11, 2011Time CapsuleComments Off on Time Capsule: Economics 101 and the Healthcare IT Market
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 October 2006.
Economics 101 and the Healthcare IT Market By Mr. HIStalk
You’ll remember this example from your MBA economics class. If sports tickets are priced perfectly, the venue will sell out precisely, leaving neither disappointed fans nor empty seats. Since the tickets aren’t priced perfectly, scalpers provide a valid economic function by ensuring that seats are available to those who value them more than others. The intersection of supply and demand is the correct price, which as scalpers know, is sometimes higher than the face value of tickets. That arbitrage goes right into their pockets.
Software isn’t a perfect model for supply and demand. Its incremental cost to the seller is nearly zero and those sellers work hard to dispel the “commodity’ notion that all products are equally acceptable.
Still, signs seem to point at some rationalization of supply and demand in the PM and EMR business in physician offices. Pricey vendors are getting squeezed hard by new entrants with cheaper products. Doctors aren’t as easily enamored with “Cadillac” offerings as hospitals seem to be. Another economic principle is working there, too – when companies make excess profits, newcomers will come in and undercut them, thereby shaking out inefficient players.
Hospital system vendors haven’t felt that pressure yet. The choice of enterprise systems is limited. Marketing-issued smoke and mirrors have kept hospital prospects thinking that Product A is far superior and/or acceptable than Product B, thereby keeping prices high. The cheapest vendor doesn’t always win and neither does the most expensive one. Neither does the “best” one, for that matter.
One explanation is that maybe hospitals aren’t a price-sensitive market. There’s some evidence of that: expensive drugs and medical equipment sell just fine even when cheaper alternatives are available. Hospitals can be convinced by questionable claims of product superiority or patient risk, and even more so by seeking vendors just as prestigious as they fancy themselves (no Walmart shopping for big academic medical centers, even though patients are the ones paying.) CIOs trying to keep their jobs and to develop a marketable resume are suckers for the “bigger is better” approach, even when the bigger vendor has a horrendous failure rate in hospitals just like theirs.
Hardware and services costs also skew the market. Even free software comes with a high price tag because hardware costs are similar for all products and hospitals demand lots of fixed-cost, on-site help. A vendor that can develop a turnkey product with low hardware costs should theoretically do very well, at least if they can overcome the marketing spin of the big boys.
Yet another anomaly is that the HIT market isn’t perfect. Hospitals don’t necessarily know what everyone else is buying, how it worked for them, and what they paid.
I’ve advanced my “Big Three” theory of broad-line systems vendors. Could the also-rans move more product if they cut software prices? Should they give their systems away just to start earning maintenance fees? Hospitals area always starved for capital, so maybe a monthly fee paid out of operational funds would be appealing.
We’ll learn by watching companies like Medsphere, which has a heavy R&D product that costs them nothing since Uncle Sam already paid for it. They can succeed only if they can find price-sensitive hospitals who believe that information systems are a commodity. They’ll also have to compete with Meditech, whose products are already relatively low in cost and whose huge customer base throws off recurring revenue that will let it meet any price threat.
It’s interesting to review the healthcare IT market using what you learned in economics and marketing. Vendors and upstart competitors should be doing that. HIT 2.0, anyone?
Comments Off on Time Capsule: Economics 101 and the Healthcare IT Market
National Coordinator Farzad Mostashari says ONC will beat the IOM’s suggested 12-month deadline in rolling out a program to accept and analyze patient safety reports related to computer systems.
Reader Comments
From Duck Hunter: “Re: West Johnson. West Johnson, vice president for healthcare revenue cycle consulting at Huron Consulting Group, is leaving at the end of December. He was an original Stockamp person.” West sent me a note confirming his departure.
From Phone Geek: “HIT Policy Committee meeting. This afternoon I have been listening to the HIT Policy Committee meeting. There’s now a rah-rah session about consumer access to their EHR records. President Obama wants every person to access his personal health record by 2014. I keep wondering if we should be more concerned about every person having access to healthcare and ensuring that rural America has access. And maybe making sure that we have good EHR implementations delivering systems that clinicians like to use and that they and their delivery systems receive value from.” Well, the HIT Policy Committee really has no influence on healthcare accessibility, however important the need. On the other hand, isn’t there a workgroup that focuses on EHR adoption and certification – and presumably considers usability?
From B.S. Walks: “Re: Cerner finally fulfilling the façade prophecy. Look at the stock dump that happened 10/27 and 10/28, dropping from $72.88 to $63.67. They are going counter-market, which isn’t a good sign unless you’re a short seller.” Above is a three-month share price graph of CERN (blue), DJIA (red), and Nasdaq (green). The trend line definitely looks better over a full year, but there was a big dip in August and the second starting in October. It could be more of a reflection on the sector since some of the HITECH luster seems to be wearing off as some companies haven’t met lofty expectations that were built into the share price.
From Horned Frog: “Re: Epic. Salaries are in line with what most new college grads get, or better I suspect since many of them are liberal arts majors. However, their incomes rise quickly, often exceeding what the typical med tech, nurse, or hospital IT person might make, although they typically work more than 40 hours a week. And with regard to requiring everybody to live in Madison, there’s a lot of advantage in having people show up at corporate, sharing knowledge and networking. Corporate offices often had the greatest product expertise, and vendors allow road warriors to travel from wherever. It doesn’t necessarily cost more to travel across the company than to take a shorter trip.”
From Porcini: “Re: Vince’s article on Epic. Hiring fresh grads isn’t new – Cerner started that. I doubt you can attribute cost overruns to training cost since organizations plan for those and it’s a good investment. Regarding ‘the Epic way.’ how do you define success in allowing user to customize – inefficient workflows? Unhappy clinicians? Epic charges so much because it can, and because it delivers what it promises in a timely fashion for a price that customers seem to find justifiable. And if Epic brainwashes its users to earn high KLAS scores, why aren’t other vendors doing that? I’ve never seen anything like Epic’s most collegial user group meeting. The amount of education and information sharing is absolutely astounding.”
From Buffalo Tom: ”Re: IOM report. Maybe I’m reading too much into it, but organizations with internally developed software fall under this definition, at least with regard to certification. I’m involved in the certification program and have seen firsthand how good ideas and intentions can create a lot of extra (and arguably unnecessary), like developing EHR modules that will be never used beyond earning certification. Compounding these recommendations is the discussion of mobile healthcare applications falling under FDA purview. Imagine if all of our clinical projects required certification or FDA approval before go-live. That might push hospitals to third-party solutions exclusively and we know there is no vendor that has a solution for every provider and scenario. I’m for safety checks and resources to help develop safer software are needed and valuable, but with regard to in-house development, I don’t think they need to jump through additional regulations imposed because of some shop that popped up last month to hurry up to get into the healthcare space.”
From Hat Creek: “Re: TEDMED 2012. Are you going?” Probably not – registration is $5,000, the attendee list is “curated” (meaning you don’t automatically get to come just because you have $5,000 to wave around), and it’s not all HIT-related. They had fun speakers last time around, including Dean Kamen, Michael Graves, Tim O’Reilly, Loudon Wainwright III (I could have sworn he was dead, but he’s not), Steve Wozniak, and some semi-celebrities.
From Lugubrious: “Re: Health IT Leadership Summit in Atlanta. SoloHealth won the Intel Innovation Award for their health and wellness kiosk. Bart Foster, the CEO and founder, was a very nice guy who accepted the award with a lot of humility and brought his team up on stage with him.” I found the above video on YouTube. The touch screen kiosk checks vision, blood pressure, weight, and BMI and lists doctors and “valuable offers from healthcare partners” (meaning ads, I assume.) I’d skeptical that a glorified, electronified scale and eye chart can have a significant impact on health (the people who need to hop on the scales tend to steer a wide berth, no pun intended, around them), but the technology itself seems interesting and the direct-to-consumer approach is different. I like the idea that users can create an account and access their information from any of the company’s kiosks. Maybe it should include a one-click connection to a nurse-staffed telemedicine center where you swipe your credit card to get a consultation for $20 or something. Ask Walgreens – they are clearly the leader in putting technology and innovative services right in their existing stores, turning what used to be “the pharmacy” into a “health center.”
HIStalk Announcements and Requests
Wondering what treasures await you on HIStalk Practice? A few gems from the last week: 52% of office-based doctors are e-prescribing. Greenway Medical is named a preferred EHR vendor for at least 10 RECs. MGMA’s Rosemarie Nelson provides great recommendations on improving EMR adoption. athenahealth earns a spot on a list of Top Places to Work in Boston. Brad Boyd of Culbert Healthcare Solutions tackles ICD-10 and 5010 readiness. Sign up for your HIStalk Practice e-mail updates because you never know what booty you may find there (and I mean the treasure kind, though the foot kind often makes an appearance on HIStalk Practice as well.)
I perused my calendar last night and realized that HIMSS is just over three months away. Wow! Mr. H mentioned that HIStalkapalooza is on the calendar for February 21, which means it’s time to start shopping for the perfect party outfit (new shoes!) Returning this year: our always-popular “Inga Loves My Shoes” contest, sashes for the sassy, and the crowning of our HIStalk King and Queen (for the best-dressed partygoers.) Of course we will name the winners of the HISsie awards and hope that Jonathan Bush will return as emcee (Neal Patterson has agreed to step in if JB is unavailable.) We’re also considering a few new things for both the party and HIMSS in general, so stay tuned.
Friday, which contains the 11th hour of the 11th day of the 11th month that marked the end of World War I hostilities, is Veterans Day. Unlike Memorial Day, which is set aside to honor those who died in military service, Veterans Day is when we honor all American veterans (hopefully we do that on other days as well.) It’s a refreshingly non-commercial commemoration that involves no Hallmark moments, mandatory gifts, or heavily sponsored sporting events, so why not start your own tradition and take the opportunity to tell a veteran that you appreciate their service and sacrifice? If you served, are serving, or have loved ones in the military, thank you.
Listening: reader-recommended Ratatat, a couple of Brooklyn guys with a spare bedroom full of synthesizers (and a few guitars) that somehow make rocking instrumentals that are real songs (not background music) that sound like a non-computerized mad stew of Genesis, Boston, and Muse with some hip hop drum loops for rhythm. Sometimes the occasion calls for soaring, dramatic music free of unskilled singing of uninspired lyrics and these fellas deliver. Like most reader recommendations, this one was spot on with what I like. If I were making a movie, I’d want them to do the soundtrack.
Inga, Dr. Jayne, and I work day jobs, so we do the best we can with HIStalk given the time we have, trying to compete with well-funded armies of full-timers running around and reporting for various magazines and sites. You can help by reading, telling others, and supporting our sponsors. We can always use guest articles, insightful comments, and news tips. There’s the usual stuff I always mention (friending, liking, connecting, and signing up for e-mail updates) but we’re open to ideas if we can figure out how to find the time to do them.
Acquisitions, Funding, Business, and Stock
Emdeon reports Q3 numbers: revenue of $282.1 million (14.7% increase); non-GAAP adjusted EBITDA of $76.7 million (15.3% increase.)
Siemens AG announces that it ended its fiscal 2011 with record operating results that included several orders worth over $100 million for Soarian Revenue Cycle. Siemens Healthcare also just finalized a $28.7 million contract with Hawaii Health Systems.
Millennium HealthCare Inc. completes its acquisition of medical billing and consulting firm Premier Technology Resources.
Vista Equity Partners completes its acquisition of Sage Healthcare Division and renames the company Vitera Healthcare Solutions. Matthew Hawkins, previously CEO of library software vendor SirsiDynix, is named CEO, replacing former Sage Healthcare President Betty Otter-Nickerson. The ambulatory product line remains intact.
Sales
Northwest Michigan Surgery Center selects the Versus Advantages RTLS to automate process flow management for the clinical staff.
SUNY Upstate Medical University (NY) signs an agreement with TeraMedica to implement Evercore Enterprise Vendor Neutral Architecture, which will support integration for SUNY’s Epic EMR.
John C. Lincoln Health Network (AZ) selects iSirona to connect medical devices to its Epic CIS.
Lakeland Regional Health System (FL) chooses RelayHealth for its enterprise HIE.
Twelve-bed Sedgwick County Health Center (CO) selects the ChartAccess Comprehensive EHR from Prognosis.
Four-hospital Lifeline Hospital Group will partner with Optum to bring that company’s billing and collection systems to Lifeline’s hospitals in United Arab Emirates and Oman. Optum says it will take what it learns there to aid its expansion in the Middle East.
People
Merge Healthcare appoints Peter Urbain (IBM) SVP of partner sales and Steven Tolle (OptumInsight, Allscripts) SVP of solutions management.
Omnicell founder and CEO Randall Lipps is named to the board of outsourced radiology provider Radisphere.
Announcements and Implementations
The Tri-State REC announces that it has met its enrollment goal of 1,739 primary care providers in Ohio, Indiana, and Kentucky.
North York General Hospital (ON), the first hospital in Canada to go live on CPOE and bedside bar code scanning of medications, earns the Innovation in the Adoption of Health Information award from Canada’s Health Informatics Association. The Cerner customer had been previously been recognized as HIMSS EMRAM Stage 6 hospital.
LSU Health Shreveport goes live on electronic medical records (Epic?) The implementation moves on to E.A. Conway and Huey P. Long hospitals.
Web-based PM/billing vendor Kareo launches its electronic patient statements and payment portal for practices.
Government and Politics
HHS’s Office for Civil Rights will begin conducting HIPAA compliance audits this month for office-based physicians, hospitals, and health plans. Twenty audits will be performed in the initial round and selected entities will be notified in writing within 10 days. Officials will visit the audited sites within 30 to 90 days of notification.
A Senate technology subcommittee chaired by Sen. Al Franken (D-MN) frets over recent healthcare data breaches at Minnesota hospitals, with Sen. Franken saying, “The same wonderful technology that has revolutionized patient health records has also created very real and very serious privacy challenges.” Ranking committee member and physician Sen. Tom Coburn, MD (R-OK) opines that maybe electronic records aren’t all that great. “They gotta get into my office to get it when it’s on a piece of paper.” Above is the Senator in his former life as a comic with partner Tom Davis (old timers will remember them from SNL) in an excellent Rolling Stones parody. Franken should get the band back together and run for governor with Davis as his lieutenant.
Technology
Steve Jobs gets his first posthumous nod for being right yet again: Adobe is abandoning its attempts to make Flash work on mobile browsers, and in fact, may be admitting that Flash is obsolete for the Web in general. Steve refused to allow Flash to run on Apple’s mobile devices, saying it’s proprietary, buggy, full of security holes, a CPU pig, incapable of responding to a touch screen interface, and a battery-eater. He said Apple mobile users enjoy videos and games just fine without Flash and that Adobe should dump Flash and focus on HTML5, which they apparently are now doing. Adobe canned 750 employees this week with the usual “restructuring to focus on core business” excuse, taking a $94 million charge for eliminating 7% of its work force.
Indigo Identityware announces iDNA for the iPad, which it says offers password-free strong authentication via a four-digit PIN to access a virtual desktop (including Citrix.)
A CIO article reports that a few clinicians at Seattle Children’s Hospital tested the iPad for running a virtual desktop in patient care areas. The verdict: every one of them returned their iPad, saying Cerner apps that were designed for desktop-and-keyboard users sucked big time on the small touchscreen.
Several states and technology vendors in the EHR/HIE Interoperability Workgroup define standards by which EHRs connect to HIE in a plug-and-play (their words) fashion.
Other
Epic goes before the Verona (WI) Planning Commission to present an expansion project that will add 900 offices and 700 underground parking spaces. Three buildings will make up the “Farm Campus” and may feature barn siding rather than brick, and possibly a silo. Epic, by the way, expects 2011 revenues to reach $1.1 billion, up from last year’s $825 million. A Verona city administrator estimates the new project will cost Epic $75 million.
Kudos to the eClinicalWorks employees who spent time this week volunteering with Habitat for Humanity in Boylston, MA. The eCW folks helped with painting, laying down floors, and assorted other projects.
The rate of healthcare employment fell from 45,000 new jobs in September to only 11,600 in October. Physician offices accounted for 8,000 of the new opportunities in October.
A new report estimates that the combined ambulatory and inpatient EMR market will grow to over $8.3 billion by 2016. Allscripts hold the largest share of the ambulatory EMR market while Meditech leads in the acute care segment.
The Clark County Commission (NV) considers a $30 million proposal for a McKesson EMR system for University Medical Center. The contract includes a one-time fee of $27 million, $4 million in annual fees for the next four years, a $1 million reserve, and $1.3 million to backfill employees and perform ongoing system maintenance.
A three-year study from the RAND Corporation concludes that providers are interested in bundling payments to cut health costs, but find the strategy difficult to implement. Technical challenges include deciding what problems should be subject to bundling and providing clinicians with the information needed to improve care. Cultural issues include convincing providers that cost cutting measures will not reduce the quality of care.
Elected officials urge residents of Freetown, MA to show their support for a proposed Meditech facility to be located in their town, an option Meditech walked away from in September after tangling with the state’s historical commission over preservation issues. Given that the unemployed citizenry vastly outnumber the archaeologically astute, just about everyone is trying to neuter the commission’s authority in their pleas urging to Meditech to reconsider.
Notorious patent troll Acacia Research Corporation announces that EMR vendor Aprima has decided to pay the company off in the form of a “license agreement” rather than spend money defending itself against a nuisance infringement lawsuit. Acacia’s intellectual property is, “The generation of a document utilizing user-modifiable document structures, a database including information to be placed into a particular document structure, and a computing device which combines the particular document structure with relevant information stored in the database.” Legal chest-puffing is good business: Acacia booked $63 million the most recent quarter. The company owns patents for such medical innovations as catheter insertion, cardiac stents, performing laparoscopic surgery, medical monitoring, PACS, and wireless physiologic monitors.
Sponsor Updates
On the first day of its go-live, Baptist Healthcare System’s (KY) ED exceeds Meaningful Use thresholds using T SystemEV.
Passport Health releases its November schedule of live demonstration webinars.
Trustwave’s security and compliance portal TrustKeeper is named a 2011 Chicago Innovation Award winner.
MED3OOO announces upcoming dates for its webinars featuring InteGreat EHR with Quippe technology. MED3OOO will give away an iPad 2 at each session.
e-MDs and TMF Health Quality Institute offer free assistance to Texas e-MDs customers interested in earning incentives under PQRS 2012.
Covisint releases a report on three PQRS misconceptions that could prevent providers from obtaining CMS incentive dollars.
Scott Besler and Jonathan Besler of Besler Consulting will presentMedicare Hot Topics at the HFMA NH/VT Annual Health Care Reimbursement Seminar December 8.
The Kansas and Missouri regional extension centers select Greenway Medical’s PrimeSUITE EHR for their combined 2,548 providers.
Wolters Kluwer Health announces the addition of general surgery to its UpToDate clinical knowledge system.
Baptist Hospital (TN) is using MyHealthDIRECT to schedule community provider appointments for its discharged patients.
Healthcare Integration Strategies enters into a Provider Consulting Organization agreement with CapSite, enabling Healthcare Integration Strategies to offer the CapSite service as part of its consulting engagements.
An Aspen Advisors case study covers its engagement by Indiana University Health to analyze the personal health record market and best practices use of PHRs by health systems.
EPtalk by Dr. Jayne
It seems as though we’ve had a couple of slow news weeks lately, but the past few days have been what you could call a target-rich environment. Of course, the Institute of Medicine report is tops on many colleagues’ minds. Mr. H did a great job with his digest, which thankfully gave me enough talking points to look as if I had read the whole thing, when in fact I had spent my time watching Fast Five rather than doing actual work in the evening at home as I usually do.
Personally, I’m intrigued by the comments about regulating software, but I also think we need to hold users accountable for certain behaviors. I have physicians who regularly strive to defeat EHR safety features and others who complain about every safety feature which is introduced. No matter how non-intrusive the code, they take it as an assault on their profession. Maybe for those physicians who demand to wear the mantle of medicine as it used to be rather than living in the present, I say adepto super is: get over it.
Merritt Hawkins releases the 2011 Survey of Final-Year Medical Residents, which looks at career preferences and plans of those completing their training. Not surprisingly, over the last decade there has been a ten-fold increase in the number of physicians who are looking for hospital employment. Solo practice continues to be a non-starter. The number of residents who owe between $200,000 and $250,000 in student loan debt has grown from 7% in 2003 to 19% in 2001. My take on it: more validation of the impending primary care shortage. It’s much harder to pay off that kind of debt as a PCP than as a radiologist or dermatologist.
Speaking of the primary care shortage, the headline “Walmart wants to be your MD” certainly caught the eye of THIS medical doctor. Just when you thought that we’d seen the worst of the worst ideas in healthcare reform, this one comes along. Apparently Walmart requested information from partners looking to reduce healthcare costs and then had to issue a statement correcting its position, stating it was “not building a national, integrated low-cost primary health care platform” even though that’s what the statement said.
Walmart’s track record of driving jobs out of the economy in the name of low prices is well known. I hardly think a company that hasn’t even figured out how to offer affordable health insurance to its own employees has any business getting into the healthcare fray. Within days of this request, they also announced that they will no longer offer health insurance to new part-timers. As the article states, primary care isn’t what is driving up the cost of healthcare in America. My favorite quote from the article summarizes this as just another retail clinic attempt to gain market share: “If you get someone in the door, you can also sell them milk and a shotgun.”
Speaking of great quotes, I love this one from an article on transitioning from paper to electronic records. When asked what data should be transferred to the EMR, one physician answers, “depends on how anal-retentive you are.” This absolutely hits the nail on the head.
A friend of mine just went through the grueling process of prepping all of her charts for bulk scanning. She quickly discovered that her practice had kept every scrap of paper that ever came into the office, regardless of relevance or utility (and independent of liability as well.) She falls into the “slash and burn” camp and quickly rid her charts of duplicate and meaningless information, but not every provider is that motivated or has that much free time. Most want to keep everything, which often results in simply converting a messy paper chart (where nothing can be found) into a messy electronic chart (where nothing can be found.)
An interesting survey finding mentioned in the article: 44% of organizations are not explicitly measuring the effectiveness of productivity of their scanning process. My final quote of the day comes from Pretty Woman: Big mistake. Big. Huge.
Considering the massive effort involved in converting from paper to EHR, scanning is one of the places where the work is reproducible as well as being amenable to applying lean manufacturing principles. Unlike work with patients or families, you can look at cycle time, accuracy, and per-page outputs when you look at scanning. Charts CAN be treated like widgets. Unless you just want to spend more money than you actually need to or prefer to be scanning for years, this process should be looked at carefully.
Have a question about milk and shotguns, takt time, or what’s next in my Netflix queue? E-mail me.
The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.
The No Nice Guy Rule
I interviewed with University Hospitals on November 23, 1998. I recall the date for two reasons. One, it was my birthday. Second, I encountered Zoya (name changed to protect her privacy), an analyst on the employee interview panel.
Zoya embossed herself on my memory with her questions. She pitched hardballs, fastballs, and curveballs while the nice people on the panel tossed softballs. Although professionally polite, Zoya hovered on borderline offensive. I was taken aback by her persona, yet her disruptive approach was about to make me a strong leader.
Let me explain.
My first day on the job, Zoya walked into my office and welcomed me. Before I could hang my coat, she asked if I had time to talk. She was alive with ideas and energy and aspired to transform the IT culture and increase our value to our customers. Although overwhelmed at first, I appreciated her hunger to influence and shape our organization.
The customers loved this analyst. If no one kept watch, some customers would bypass our intake process and go directly to her. She tackled the most difficult assignments and notoriously challenged our processes. Zoya took great pride in consistently delivering results and delighting her customers. A workhorse! And … she was tough to manage.
While the customers loved Zoya, the team did not. One by one, each complained to me about her, and their observations had merit.
I recall Zoya’s first review. She gave herself a perfect score. In discussing career goals, she stated her expectation to be the best analyst in the world, but agreed she hadn’t reached that goal. Nevertheless, her drive to be the best showed in her outcomes, which inevitably raised the bar for the other analysts.
I invested in Zoya, an immigrant from Russia. She and her husband had packed up their kids one day and sought a better life in the USA. Sympathizing as a person of European descent, I coached her. I pointed her toward specific changes and how to better handle situations. I sent her to a speech pathologist to help her communicate more clearly. She made headway, slowly.
Still exasperated, the team now came into my office as a group to lay out complaints. I listened and then asked: Who can tell me the names of Zoya’s children? Silence. Who can tell me the names of her dogs, whose pictures she had plastered all over her cube? Silence. Who can tell me her passion (Russian folk dance)? Silence. Who can tell me her defining moment? Silence. Who can tell me her background and why she left Russia? Silence. Who can tell me what drives Zoya? Silence.
My response: Once you’re able to answer these questions, we’ll revisit Zoya’s future with us.
I endeavored to kill the notion that every instrument in the band had to be a clarinet. Collegial yes, but as long as behavior did not violate organizational values, every employee had the freedom to express themselves uniquely. Sure, it’s cozy when the team can sing Kumbaya in harmony, but who thrives under constant coziness?
I’d rather work with a team of challenging personalities that adds value to the business than a team who liked one another, but performed with mediocrity. I would argue that the conflicted team—dare I say disruptive and non-complacent—produces superior individual and team performance. Iron sharpens iron.
Better to celebrate individual differences than succumb to the tragedy of nice guys. Which reminds of a scene on conformity from Dead Poets Society. I want people and leaders who walk their own path, even if it’s not nice.
The team never came back with another complaint. Instead, they engaged Zoya on a personal level. Mutual understanding and acceptance grew. They became a team. They gleaned from her, and although she never sang Kumbaya, Zoya did learn to be more collaborative and collegial.
The team developed into the shining star for University Hospitals IT and launched me to where I am today. Thanks to FaceBook, many of us remain connected after all these years.
Not all of my experiences with my teams have been positive. I’ve made mistakes. A couple of times I invested energy into helping a staffer turn the corner and be successful, but that person refused to change.
Before you think I’m endorsing dirty players, let me balance my message. Consider the bestseller, “The No Asshole Rule”, by one of my favorite professors, Stanford’s Robert I. Sutton. You also have to protect your team. Get to know the fine line between a “not nice guy” and an asshole.
Yes, Zoya rocked our world and made us uncomfortable. But it didn’t surprise me when our team rallied around her after she was diagnosed with Stage IV cancer. We cried together over her death, for she had left a legacy in her own unique way.
Thanks Zoya, for not being nice, but for being true to yourself.
Update 11/12/11
Thank you for your responses (yes, even “Marxism”).
I don’t mind Marxism’s character attacks, but I would disagree with the implication that excellent leaders work only at the largest organizations. Great leaders can be found in organizations of any size. The size of the organization is not important. The size of the leader’s capabilities is important.
Finally, the story of Zoya is true. For those of you on FaceBook, you can see the positive responses left by some of Zoya’s former team.
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.
A remarkably frank Institute of Medicine report commissioned by ONC, Health IT and Patient Safety: Building Safer Systems for Better Care, urges significant government intervention with regard to the safety of healthcare IT systems. It takes shots at both HIT vendors and HITECH incentives, saying in the preface,
Stories of patient injuries and deaths associated with health information technologies (health IT) frequently appear in the news, juxtaposed with stories of how health professionals are being provided monetary incentives to adopt the very products that may be causing harm.
On the committee were researchers, academics, and practicing physicians. Vendors were not represented, although John Glaser of Siemens was a reviewer. These are the most interesting points from my quick read of the report.
The report recommends that ONC require all health IT vendors to publicly register their products with ONC, starting with certified EHRs.
It urges HHS to eliminate non-disclosure and limited liability clauses in vendor contracts that discourage users from sharing patient safety-related software concerns.
It suggests that reviews of software applications be published publicly.
It recommends that HHS form a council to develop criteria for the safe use of information technology.
It urges HHS to require software vendors to report IT-related patient safety harm or concerns to a central organization and also encourage users to voluntarily report to that organization as well.
Software-related problem reports would be reviewed by a new group that would be the HIT equivalent of the National Transportation Safety Board. The report says FDA is not up the task since it’s an oversight body, AHRQ is too research-focused, CMS is mostly good at threatening the income streams of providers, ONC doesn’t have the expertise, and Joint Commission and related organizations are so dependent on income from special interests that they can’t be objective.
It observes that “poor user interface design, poor workflow, and complex data interfaces are threats to patient safety” and “lack of system interoperability is a barrier to improving clinical decisions and patient safety” once you get beyond lab-related terminologies such as LOINC. Overall, it is quite critical of system usability and observes that vendors don’t have much incentive to make their products interoperable with those of their competitors.
The report says that the industry has done a poor job of regulating itself with regard to patient safety and suggests turning the whole thing over to the FDA to regulate if the foot-dragging continues: “These and other recommendations would comprise the first stage for action, greatly advancing current understanding of the threats to patient safety. However, because the private sector has not taken substantive action on its own, the committee further recommends that HHS monitor and publicly report on the progress of health IT safety annually, beginning in 2012. If progress is not sufficient, HHS should direct the Food and Drug Administration (FDA) to exercise its authority to regulate health IT.”
Reader Comments
From Pachelbel: “Re: Vince’s article on Epic. Cache’ is not proprietary to Epic as it is owned by InterSystems. It can be an extremely fast database if implemented properly. Ask QuadraMed or any of the hundreds of other HIS vendors that use it. I suspect your gripe is with the way Cache’ was implemented. No database works well if the data structure or queries are malformed. Full disclosure: I’m a Cache programmer who has seen the good, bad, and plenty of ugly implementations of Cache’.” Cache’ is one of few technologies developed for healthcare that was adopted by the financial industry for mission-critical applications, with organizations such as Credit Suisse, Ameritrade, and a couple of stock exchanges using it.
From SouperDooper: “Re: Vince’s article on Epic. I agree with the points made about the Epic way, rookie staff, and high costs. But to say that GE and McKesson have equal functionality is beyond ridiculous.”
From Astrid: “Re: Vince’s article on Epic. This feels like ‘nobody ever got fired for buying IBM.’ I know a hospital where the VP had Epic where he came from and wanted Epic there, so it was a total rip-and-replace without a business analysis or needs analysis. I understand that a strict implementation keeps clients from shooting themselves in the foot, but that usually speaks to their lack of business sense, discipline, and management ability. Having an implementation guided by people without healthcare experience and knowledge seems to guarantee rework later.”
From Lorenzo’s Oil: “Re: Catholic Healthcare West. Hear they’ve scrapped their dual Cerner/Meditech strategy and are moving forward with Cerner system-wide after Meditech problems, with Cerner picking up about 20 sites once they’re done. I also heard Epic tried to jump into the fray, but CHW didn’t like the exorbitant price tag.” Unverified.
From Unbiased Consulting Firm: “Re: Epic. They clearly have a huge lead in implementations over the last 24 months, but the talent pool is not available to support those implementations, nor does the application support this market advance. Meditech, Cerner, and Allscripts … there is much to do with marketing and creating awareness. If you purchase Epic, you need to be able to support and implement it successfully. Each of these applications are market leaders – do not be taken by the media. Make your choice, but consider all the factors.”
Acquisitions, Funding, Business, and Stock
Grant Thornton, LLP acquires Computer Technology Health Associates’ Health Solutions division, including five military healthcare contracts and the staff supporting them.
HMS Holdings Corp. announces plans to buy RAC contractor HealthDataInsights for about $400 million. HMS expects HDI to contribute $85 million in revenue next year.
Days after the SEC releases new guidance on the matter, HCA revises its accounting for the recognition of income from HITECH incentive payments. Last week the SEC indicated that the “gain contingency” accounting model was the appropriate income recognition model for payments. Under this model, HCA will “recognize HITECH income when its hospitals have demonstrated MU and the cost report information for the full cost report year that will determine the final calculation of the HITECH payment that is available.” HCA expects to recognize HITECH income of $100 million to $130 million in Q4 and $190 million to $220 million for the full year.
San Diego-based Perminova, which offers SaaS-based applications for managing cardiac electrophysiologic labs and cardiovascular surgery, gets $7 million in venture funding. Its software is used by UC Sand Diego and Mount Sinai in New York.
Sales
UC Health (OH) selects Ciena Corporation’s 4200 Advanced Services Platform to provide network connectivity across four hospital buildings and its data center facilities.
Iowa Health System chooses Jardogs’ FollowMy Health Universal Health Record to provide online access to its patients.
Conway Medical Center (SC) purchases PatientKeeper’s clinical suite of applications to automate physician workflow and drive physician adoption of HIT.
Kindred Healthcare signs for practice management and revenue cycle tools and services from MED3OOO.
People
IT service provider Systems Made Simple hires Viet Nguyen, MD as CMIO to advance technology initiatives to improve continuity of care and enhance patient safety. He was previously with KForce eGovernment Solutions and the VA Office of Information.
Optum’s Accountable Care Solutions team, led by Todd Cozzens, now includes over 700 cross-functional team members focused on aligning hospitals, physicians, and health plans for integrated care models.
Fast Company profiles Zynx Health Chief Nursing Officer Pat Button EdD, RN.
Announcements and Implementations
Cedars-Sinai Medical Center (CA) launches Voalte’s point-of-care communication solution following a year of research and testing.
Platte Valley Medical Center (CO) goes live on eCareNet, powered by Soarian Clinicals.
Rochester General Hospital (NY) and seven affiliated practices go live on Epic. They will spend $65 million over the next two years to convert the entire health system, which includes two hospitals and 40 practices.
Kronos announces its InTouch time clock that features a color touch screen, gives employees access to their accrual balances and schedules, and supports off-peak use of apps such as employee surveys or streaming of informational videos.
Technology
Panasonic expands its Toughbook line of ruggedized laptops, popular in hospitals, to the Android-powered Toughpad, initially available in 2012 in a 10-inch form factor ($1,299) with a 7-inch version to follow.
Other
CCHIT announces that AOD Software’s Answers EHR and HealthMEDX Vision are the first EHRs to earn its Long Term and Post Acute Care certification.
Home health agencies, by the way, will see a 2.3% decline in Medicare payments next year under a newly released regulation. Opponents claim the cuts will leave half of Medicare home-health agencies operating in the red in 2012.
Community hospitals are progressing with their EMR implementations, with 69% saying they have acquired the technology and 39% of those reporting that their EHR project will cost over $8 million. The same report finds that almost all community hospitals have begun the conversion to ICD-10, though only a quarter are currently undergoing remediation. Forty-three percent of the hospitals say they are participating in HIEs.
The local paper provides an update on Cape Code Healthcare’s (MA) $20 million HIT investment, which includes a replacement of Meditech Magic with Siemens Soarian. Mr. H. interviewed Cape Cod VP/CIO Sheryl Crowley last year.
The HIMSS EHR Association announces its support of iHealth Alliance’s EHRevent, an online system for reporting adverse events. It’s part of the PDR Network, whose CEO Edward Fotsch MD was interviewed on HIStalk a year ago.
Eighty-three percent of clinical informaticists participating in a Billian’s HealthDATA survey report an improvement in quality outcomes from using EMRs.
CMIOs, CNOs, and senior nursing executives believe their roles and responsibilities will continue to evolve as new technologies are developed, according to a research report by Capsule. CMIOs indicate their most basic job function is to bridge the gap between clinical needs and IT, while CNOs and senior nursing execs see their roles evolving to be more inclusive of departments outside of nursing.
The EHR/HIE Interoperability Workgroup issues technical specifications to standardize connections between providers, HIEs, and other data-sharing partners.
Rival health systems HealthPartners and Allina Hospitals and Clinics (MN) claim their collaboration allowed them to shave $6 million in medical costs for patients across two counties. The organizations are participating in a seven-year “learning lab” that involves the pooling of resources, sharing of EMRs, and mining of insurance claims data for about 26,700 people with private insurance.
Kevin Lasser, CEO of JEMS Technology, compares Ford’s smart phone app for owners of the Focus Electric to his company’s own telemedicine app in My Ford Magazine, distributed to 4.7 million recipients.
I featured Aventura in one of my Innovation Showcases and at least two readers have told me they’ve gone to work for the company. CEO Howard Diamond writes a post for Boulder Startups urging entrepreneurs to jump into healthcare IT: “The software and other tools that are supposed to be building efficiencies, reducing errors, and building collaboration and trust across caregivers are actually having the opposite effect; they are creating barriers to efficient quality care.” I like the list of information sources he provides for those interested in the healthcare revolution: Clayton Christensen (the Harvard professor who wrote The Innovator’s Dilemma), Regina Herzlinger (the Harvard professor who wrote Who Killed Health Care?), HIMSS (which needs no introduction), and HIStalk (the non-Harvard, non-professor known mostly for goofy music recommendations and HIT rumor-mongering.) Howard’s just being nice since I profiled his company.
I bet the Harvard people have more time after their day jobs to pursue their side ventures than I do, though. Mrs. HIStalk keenly observed this weekend that “whatever it is you do upstairs all the time won’t get done when you kick the bucket.” That’s the extent of her knowledge about HIStalk.
New York’s state controller nixes a proposed $22 million deal with Allscripts that would have created a call center for SUNY Downstate Medical Center. Allscripts had reserved the right to send work offshore, raising confidentiality concerns.
Practice Fusion is named top EMR for ePrescribing and helping practices achieve Meaningful Use by Brown-Wilson’s Black Book Rankings.
I’m not an attorney, but this ruling by Colorado’s Supreme Court seems to uphold a previous verdict that a man suing Kaiser for malpractice can’t claim physician-patient privilege in denying Kaiser’s lawyers access to his electronic medical records. He had a heart attack while taking a treadmill stress test and is suing Kaiser and one of its doctors, but didn’t want the defense to be able to study his medical records. A footnote in the ruling sounds like a HealthConnect (Epic) commercial: “Kaiser’s integrated electronic medical record is instantaneously accessible by any and all Kaiser healthcare providers and is a hallmark of the services Kaiser provides.”
Next month’s mHealth Summit has added as keynote speakers Surgeon General Regina Benjamin MD and HHS Secretary Kathleen Sebelius. HIStalk (in the form of HIStalk Mobile) is a media partner, so our own Travis Good, MD will be providing daily reports. He’s outstanding at understanding and explaining the business of mHealth, so he’ll provide both health and business perspectives. It’s December 5-7 at the Gaylord National Resort and Convention Center in the DC area. Full registration is $525, or $195 for federal government employees. I had a pretty good time there last year and the venue looks much better than last time, although I’d miss the proximity to the National Mall and all the fun sites and restaurants nearby.
Sponsor Updates
Mike Marvin of CareTech Solutions and Kara Wingerter of Blessing Health Systems (IL) will present a case study on increasing revenue with online pre-orders and sales at this week’s Greystone.net Healthcare Internet Conference.
OptumInsight launches additional capabilities for its Netwerkes EDI service, including integration with Epic PM Systems claim administration and clinical information workflows.
Facilities of Vitalité Health Network (Canada) will go live next week with a pharmacy medication order management system connected to its Meditech system and powered by Perceptive Software’s ImageNow enterprise content management system.
ICA releases a white paper entitled All Health Information Exchanges Are Not Created Equal.
Mac McMillan, CEO of CynergisTek and chair of the HIMSS Privacy and Security Policy Task Force, will serve a panelist for Clearwater Compliance’s HIPAA-HITECH Blue Ribbon Panel webinar How to Prepare for HIPAA Audits.
Tee Green, president and CEO of Greenway Medical, will host a November 15 webinar on future trends in healthcare.
You all know how much I love things from South Carolina, so it’s with an extra smile that I congratulate Pink Glove Dance winner Lexington Medical Center of West Columbia, SC. Their entry really does have it all – from the early morning cleaning crew to pink glow sticks at the end of the day. I’m particularly impressed because they captured parts of the hospital that some of us forget about – like the engineering department (the guys with the umbrellas) and the child care center – with plenty of other clever bits in between. In honor of the win, $10,000 will be donated to the Vera Bradley Foundation for Breast Cancer. BTW, don’t miss the biohazard ninjas at 2:23.
From my comments on shoes and finding the best martini, some of you might think Dr. Jayne’s idea of the great outdoors involves poolside cocktails at the Ritz Carlton. Big surprise though — I spent the weekend camping. Good, old-fashioned sleeping bag on the ground in tent-style camping. No electricity, no running water. The weather was chilly, but fantastic. It was great to be away from technology for at least a little bit (except for the guy in our group who was texting in his tent – I believe that’s a camping faux pas, but I wasn’t going to wriggle out of my mummy bag to tell him to quit.)
Camping can be a great equalizer. It’s hard to know whether you’re a Suit, a Doc, or IT staffer when you’re all wearing jeans and either a ponytail or a ball cap. (I didn’t go camping with work people, but I did go camping with an IT staffer, a postal carrier, and a project manager as well as other assorted folks, so it was an interesting mix.)
Watching people set up camp definitely reminded me recent IT adventures in the “you get what you pay for” category. The inexpensive vendor with the iffy support that you contracted with because you only needed them as a bridge technology? Very similar to the budget tent with the iffy instructions that took entirely too long to assemble and will never, ever go back into its stuff sack. (And a shout out to my tent provider – yes, you are correct, your tent IS the bomb, I’m sorry I ever made fun of how much you paid for it, and BTW you’re never getting it back.)
Being away from the constant electronic and political spin cycle was good and allowed for some time to think about where our tech-enabled lifestyle has gotten us and how far apart we are from the vast majority of people in the world. One of the women in my group mentioned that she had never eaten a breakfast that had been cooked over an actual fire. Considering that’s how many people in the world today still live on a daily basis, it seemed kind of sad that we’re so out of touch from what many consider true basic needs. Our near-worship of technology and making things easier and more efficient has also made us more prone to heart disease, diabetes, obesity, depression, anxiety, and stress-related illnesses, which add to the high cost of health care.
We’re spending billions on expanding, enhancing, upgrading, and turbo-charging health information technology when there are people in the world (and even in our own country) who have no access to health care. We forget that there are people who have to walk miles to access clean drinking water. Things like that kind of put some of our daily IT trials and tribulations in perspective when you’re considering that level of resource disparity in our world.
While contemplating all of this under a cloudless starry sky (after having confiscated my tent-mate’s iPhone and its fascinating but atmosphere-spoiling astronomy app) I started thinking about what it really is that I do for a living. When I left solo practice to begin my journey at the Big Hospital and in academia, I was motivated by how many patients I’d be able to impact by moving to the next level. Moving next to the Large Health System and now to my current position, the potential for impacting patients’ health should be even greater. It’s a long way from three thousand patients in a private practice to several million patients across a multi-state organization, but some days it doesn’t feel very impactful.
I know from the numbers (which I crunch daily thanks to software, reports, registries, and endless dashboards) that we are moving the needle. On a month-to-month basis however it is agonizingly slow. We’re building a better mousetrap, but is a mousetrap what we really need? Where is the true innovation? Do we instead need an ultrasonic way to repel the mice from the area, obviating the need for a mousetrap? Or maybe we’ve over engineered, missing entirely the fact that if we’re living on a farm, we’re going to have mice, and we need to be focusing on something else entirely?
The people who deal with the mice on a daily basis feel like they’re no longer stakeholders in the process. Putting it in healthcare terms, insurers, large health systems, and federal entitlement programs are driving legislation that pushes us away from individually focused care and into a widget-making mentality. Patients aren’t the same and neither are providers. Among large health systems, there are great differences (and for some, differences even within their own organizations.)
We’re exactly a year from the next presidential election and I think it will be interesting to see where we are when the big day rolls around. By November 2012, we’ll know who’s been naughty and who’s been nice in the game of Meaningful Use attestation. We’ll watch some vendors bomb and some victors emerge. The big question: will we actually be making more of a difference in the lives of the patients we serve? Or will we ourselves be mice reaching for cheese and hoping to avoid the snap of the trap? Only time will tell.
Have a question about healthcare expenditures, CPOE, or which knot to use to hang your bear bag? E-mail me.
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!
The Other Side of Epic By Vince Ciotti
It’s almost gotten boring to read about another large hospital or multi-IDN picking Epic. It’s as if they have no competitors in the high-end market, which is silly. Mckesson Horizon, Siemens Soarian, Cerner Millennium, GEs Centricty, and Allscripts / Eclipsys Sunrise all have equal or better functionality. What they don’t seem to have is a back door to sell a hospital’s C-Suite through the medical staff, an insurmountable advantage Epic has due to its ambulatory roots.
Having assessed a number of Epic hospitals and having several CIO friends relay their Epic experiences recently, I think it’s about time someone listed the many weaknesses of Epic instead of just more glowing testimonials (to be sure, every vendor has their strengths and weaknesses: one could list many things wrong with other vendor systems too.) This “other side” is intended to open the eyes of those who are considering Epic just because everyone else is.
Rookie implementers. Epic hires fresh college graduates for their implementation consultants (IC), a practice that saves them a fortune in salaries and gives them malleable candidates to learn “the Epic way.” Unfortunately, these ICs are terribly naïve when it comes to hospitals and do poor work on site, mainly sitting in their offices and looking up questions in “Epigoogle,” their search engine. A hospital would be far better off with veterans that have many installs under their belt, plus several years working in healthcare, to know the many challenges that make hospitals one of the most difficult industries to automate.
“Epic” costs. Epic charges huge sums for their software and implementation services, just like most other vendors — equal to or greater than license fees. However, there are internal costs that make an Epic budget just that: dozens of hospital FTEs from IT and every user department who need to travel to Verona for many weeks/months of training and testing. Factor in their salaries and the cost for replacement temps and the re-training for inevitable turnover and you can understand why clients like Kaiser and Sutter reported budget overruns of 2-3 times their initial cost estimates.
The “Epic Way.” Time and again I have heard from CIOs who have gone through an epic install (lower case intended) that the only way to make an Epic implementation successful is to not change the system, but rather adopt your workflow to EpicCare. This is silly in light of the mega-bucks Epic charges. Vendors like Cerner and Siemens pride themselves in adopting their system to their clients’ workflow through screen painting and workflow engines. How can Epic dare charge so much, yet be so inflexible?
What hardware? Like Meditech (which Epic seems to have copied many bad ideas from, like all employees having to live near headquarters, running up hospital travel costs), Epic does not sell hardware. It is your responsibility and good luck that you buy enough to achieve decent response times. Any problems, just call Dell or IBM and buy more servers. Contrast that with more sensible vendors like Eclipsys and GE that sell hardware and negotiate reasonable system response time guarantees where they will buy more servers if needed. And Epic’s proprietary Cache’ database does take many minutes to run even simple reports.
Interfaces. What, you thought Epic was integrated? Well that’s true, except for “minor” applications like ERP (AP, GL, PR, HR and Materials). Even the smallest vendors in the industry — such as CPSI, Healthland and HMS — include functional, totally integrated ERP suites, let alone leaders like Meditech and Paragon. CPSI even offers totally integrated PACS and time and attendance modules. Many of Epic’s ancillary department systems are relatively weak compared to specialty vendors. For example, their Beaker LIS can’t hold a candle to SCC Soft Computing or Sunquest, and their ED suite pales in comparison to A4 or MedHost. So, you better add an interface engine, servers, and analysts to that bloated budget.
Physician training. Physicians love the fact that they see the same Epic EHR in their practice as they see in the hospital, but for two minor problems. First, the Epic build is different for ambulatory versus inpatient order screens, so physicians have to learn two ways of entering orders, responding to alerts, etc. Second, they have to sit through 12 to 18 hours of training classes – factor those hourly expenses into your budget (physicians are not exactly low paid!) At least they don’t have to fly to Verona for weeks of indoctrination like your poor users and IT staff.
High ratings. Epic has the highest ratings KLAS has ever seen, but think back to all the dozens of IT and user department staff who spend weeks and weeks getting brainwashed on the Epic way. How do you think QuadraMed or Keane’s scores would look if they required their clients to send dozens of FTEs to their headquarters for months of training or testing? And it they didn’t cooperate, they wouldn’t qualify for “good” software maintenance rates, running up their budgets even more. Is it cause or effect?
Well, I could go on, but I doubt Mr. HIStalk will publish much more heresy. Indeed, if he even publishes this, I’ll admire him even more than I do today, as no one in HIS circles seem to challenge Epic these days.
Again, every HIS vendor has their strengths and weaknesses. I could go on for pages of weaknesses about any vendor, not just Epic. It is just sad that everyone seems to conform to only praising Epic while ignoring these and other weaknesses. Anyone else have the nerve to join me in calling for more rationality when dealing with the Epic “cult?”
They’re Killin’ “Me” by Richard E. and Joy Goodspeed
My colleagues present themselves with an air of professionalism both in dress and in conduct. However, they look sloppy when they forget some grammar basics in speech and emails. My biggest pet peeve is that they are killing “me.”
They don’t understand what happens to the first person singular personal pronoun (“I”) when it follows a preposition. If the pronoun is alone behind that preposition, they get it right, but when it is part of a group of two or more, it is usually wrong.
Grammar rules may be a little hard to understand, so I’ll illustrate with some examples.
Say I invite Tim to go to HIMSS with me. I tell you, “I invited Tim to go to HIMSS with me.” Good. Inga decides to come along to keep us out of trouble. I say: “Inga went to HIMSS with Tim and me.” My colleagues would say “Inga went to HIMSS with Tim and I,” and that’s bad grammar (killing “me,” . . . get it?). How do I know it’s bad? Take Tim out of that last sentence. Are you going to say “Inga went to HIMSS with I”? Of course not. “Inga went to HIMSS with me.” Sticking Tim into the middle of the action doesn’t change the need for “me.” The pronoun is the object of “with” (a preposition), so it’s got to be “me.”
Now you’re on a project, and you’re telling your partner about a physician who came to a project meeting to make a complaint. “The radiologist complained to the project team and me.” Right! Now you’re catching on. It’s not “the project team and I,” as it would not be “to I” if you were the only one there. “To me” and “to the project team and me” are both correct.
This discussion is all about the “objective case.” It makes sense that you use the objective case for the object of a preposition. However, “I” also changes to “me” when it is the object of a verb.
Suppose you are going to take Tim to the new ER. “I’m taking Tim to the ER.” There’s nothing hard about that. Along comes Inga. She’s going to take Tim to the ER, and you can come along. You tell Jane about it. “Inga’s taking Tim and I to the ER” Oops! No, no. You’re killing “me” again. You and Tim are now the object of a verb (to take), and you have to use the objective case. “Inga’s taking Tim and me to the ER.” We use the same criterion for the case of that pronoun that we used when it was the object of a preposition: take “Tim and” out of the sentence. In your most ungrammatical of moments you wouldn’t say “Inga’s gonna take I to the ER.”
Keep thinking about objective case (and quit killing “me”).
Joy Goodspeed is a senior integration analyst with Sarasota Memorial Healthcare of Sarasota, FL.
Passionate People Perform By Peter Longo
Another day, another conference call. “OK, we have everyone on the line and we are ready to review our ACO strategy that will affect v5.5 and the ICD 10 but we can’t forget the FFS model or the FQHC needs as we build the HL7 exchange. With the eMPI not ready, the focus should still stay on the CSI program and promote the current CCD standards that hopefully won’t affect the DR on the COF for client CPHR or the CPQs …” (do we use too many acronyms?)
With all this work selling software that enables physicians and nurses to deliver high-quality healthcare, we still can feel removed from the impact on a patient’s life. Yearning to be reminded, a group of dedicated sales professionals felt the need to get directly involved with delivering care and service to people in need, volunteering at Wheels For Humanity.
Wheels For Humanity (I guess that is WFH) is an organization that is dedicated to supplying wheelchairs to incredible people who are unable to walk for many reasons and who can’t afford mobility. Generally, they spent their young lives being carried from place to place. Painfully, the time comes when they no longer can be carried, and they are left to stay in their rooms. Recipients of these chairs are given the joy of mobility, but equally importantly, they are given dignity.
We work in an industry that is focused on the patient. This live experience stands as a pivotal reminder that the patient should be the center of everything we do. Many of the wheelchairs will be sent to places like El Salvador, Indonesia, and beyond. This whole operation is possible through donations and volunteers wanting to make a difference. Volunteers with a passion to help others.
The one thing our industry is not short on is passion. It is incredible to see so many individuals passionate about improving healthcare. I don’t think anyone can find an industry with a rivaled passion toward helping others. I am pretty sure there is no acronym for passion.
From The PACS Designer: “Re: iPad. A new, free iPad application called Line2 HD turns your iPad into a phone. This extended feature could increase the penetration of iPads into healthcare environments.” It’s very cool, but it should be noted that while the app is free and so is the service for a seven-day trial, the ongoing cost is $10-15 per month depending on the options chosen. That gets you a new or transferred number, voice mail, and conference calling, all over Wi-Fi or cell. A cool feature: if you’re not connected, it will forward incoming calls to up to six other numbers. This CNET review is positive.
From Lobstah: “Re: Meditech. New executives.” Meditech promotes Chris Anschuetz to SVP of technology and Scott Radner to VP of advanced technology. They’ve been with the company for 36 and 21 years, respectively.
From Ralph Hinckley: “Re: NextGen. Drops MEDSEEK as a white-label enterprise portal, developing its own.” Unverified. Ralph sent over an e-mail saying that NextGen will release its own enterprise patient portal in 2012, integrated with its HIE platform and physician portal. The companies signed their agreement just three months ago.
Speaking of Meditech, the company releases its Q3 report. Revenue was up 19% to $141 million, EPS was unchanged with profit of $32 million for the quarter.
My Time Capsule editorial this week, gasping for air after being entombed journalistically for five years: Leapfrog’s Leap into Irrelevance. I looked back to Leapfrog Group’s founding: “Predictions were dire back then in the post dot-bomb nuclear winter. Hospitals would be wildly overbedded. Savvy baby boomers, emboldened by buying books and dog food online, would be calling the shots, making shrewd healthcare decisions and choosing providers based on stringent quality measures that would be plastered all over the Web. Unfocused, change-resistant hospitals, which included all the ones I’d ever worked for or heard of, would be road kill. ”
Listening: Frosting on the Beater, a 1993 album by The Posies, alt power pop from Washington with a big, radio-friendly guitar sound. You either found it a guilty pleasure on VH1 or missed it entirely.
Welcome to new HIStalk Platinum Sponsor Henry Elliott & Company of Wellesley, MA. The company operates in a fascinating, high-demand niche: providing certified experts in InterSystems Cache’, M/MUMPS, and Ensemble for almost 20 years. The company offers experts in those technologies (contract, temporary, remote, and direct placement.) Or, if you are skilled in those areas and are feeling under-appreciated, review the plethora of opportunities in case you’re in the job-changing frame of mind and want to connect with a company that understands and values your highly specialized talents. If you need or have Cache’ or MUMPS expertise, Henry Elliott & Company would love to hear from you. Thanks to those folks for supporting HIStalk.
Also supporting HIStalk is Acusis, a new Gold Sponsor. Pittsburgh-based Acusis offers clinical documentation solutions in the form of outsourced medical transcription. Customers choose whether they would prefer US or global CMT-certified transcriptionists. Their Six Sigma-driven processes include a separate Quality Control editing step, and medical language specialists are paired with the customer’s dictating clinicians to give consistently high quality and fast turnaround time. The company’s team of 50 software engineers created dictation options that include telephone, VoIP, digital recorders, and smart phones, also supporting rules-based report distribution (network printing, fax, e-mail), multiple electronic signatures, and integration with just about every HIT system. Back-end speech recognition is offered, providing customers with a lower-cost solution for their more consistent clinicians. An iPhone-based, Dragon-integrated front end speech dictation option was announced a few weeks ago.Customer testimonials are here. Thanks to Acusis for supporting HIStalk.
It’s a 60-40 split that today’s healthcare software cannot or can, respectively, support needed improvements in cost and quality. New poll to your right: a quick read on which vendor is “doing things right” more than the others, which you can define however you like (quality, vision, business, etc.)
Financial performance solutions vendor MedAssets reports Q3 numbers: revenue up 50%, EPS –$0.02 vs. $0.14. Excluding integration costs from its Broadlane Group acquisition, earnings of $0.26 handily beat expectations of $0.16, sending shares flying on Friday to close up 16.7% as Nasdaq’s seventh biggest percentage gainer. I’m not much of a stock-picker and I own no shares in MDAS, but after a year of not-so-good performance (MDAS in blue, Nasdaq in green, and the Dow in red), it looks as though MDAS is moving up out of its trading range on increased volume, which is usually a good thing (duh). Market cap is $712 million.
Weird News Andy can’t decide whether this is a trick or a treat. A man walks into a hospital complaining of leg pain. Astute clinicians postulate that a potential etiology is the bullet lodged there from a Halloween shooting three days earlier. The patient said yes, he did recall that unfortunate eposide, but didn’t think it was a big deal.
New York-based Netsmart Technologies, run by former Cerner COO Mike Valentine, will relocate to Kansas City, creating 130 jobs with plans to hire up to 520 total employees. CEO Valentine never moved from Kansas City since he left Cerner in April 2011 and joined Netsmart in May 2011, so he gets to make all the employees move so he doesn’t have to (those handful willing to leave New York to go to Missouri, anyway, although the company will keep a New York office.) Netsmart sells solutions that include behavioral, public health, substance abuse, and social services.
Here’s Vince’s Part 2 HIS-tory of Computer Synergy.
Medicare’s pilot projects for commercially run disease management programs actually cost taxpayers more money and didn’t improve quality, a study finds. Five of the eight participating companies were losing so much money they paid an exit fee to drop out early. The conclusion is that just calling or visiting elderly patients occasionally doesn’t really accomplish much, and health coaches in such a program need to be given access to hospitals and practices and their patient information to coordinate care.
News I missed: Meditech co-founder and original president Mort Ruderman died October 12 at 75. A tribute video is here.
The DC RHIO is shut down when the city declines to continue funding it. The mayor apparently wants to take the federal grant money and start a new HIE.
The Louisiana Health Information Exchange launches after conducting pilots with Lafayette General Medical Center and Opelousas General Health System. They’re trying to recruit Ochsner, LSU, and Franciscan Ministries to sign up. Orion Health is providing the technology. The HIE received $10.6 million in federal taxpayer dollars in March 2010.
UCLA Health System notifies 16,000 patients that their personal information was stored on a hard drive that was stolen in a burglary of the home of one of its doctors. The drive was encrypted, but the doctor had written the password on a slip of paper near the drive and that appears to have been taken as well.
Lawrence Memorial Hospital (KS) warns that patient billing and credit card information was exposed on the Internet for more than a month due to “failed security measures” by the Web host of the hospital’s online bill-pay vendor.
Blue Cross Blue Shield of Delaware offers to spend $30 million in charitable projects, including donating $1 million a year for the next five years to support the Delaware Health Information Network, in an attempt to convince regulators to allow it to merge with Pittsburgh-based insurer Highmark. The state’s attorney general says Delaware citizens have subsidized BCBS to the tune of $181 million and he wants at least $45 million set aside to benefit Delaware.
Massachusetts plans to allow casinos to operate in the state, earmarking 23% of the hefty license fees involved, or around $50 million, toward encouraging the use of electronic medical records in hopes they will help control the state’s rising health costs.
November 4, 2011NewsComments Off on HIStalk Innovator Showcase–Caristix
Company Name: Caristix Address: 1400 St-Jean-Baptiste Avenue, Suite 204, Quebec City, QC G2E 5B7 Web Address: www.caristix.com Telephone: 877.872.0027 Year Founded: 2009 FTEs: 5
Elevator Pitch
The Caristix HL7 software suite helps healthcare IT vendors and hospitals reduce interface deployment from months of work to a few days.
Business and Product Summary
Caristix develops software for healthcare IT analysts and developers. With a focus on HL7 and data mining, Caristix streamlines the delivery of interfaces that support the flow of data in healthcare. If we look at innovation in this space, we took a leap forward about 15-20 years ago with the introduction of interface engines. The next leap forward is going to come from automating the manual scoping and configuration work involved in interfacing, leaving integration analysts free to add value on other more complex data integration topics.
With our software offering, we help vendors and providers scope HL7 interface requirements more quickly before coding, test more thoroughly before go-live, and troubleshoot over the interface lifecycle. Benefits to vendors and providers include lower interfacing costs, faster time to value, and reduced process waste and risk. We provide annual licenses that include support and maintenance releases. We also offer services, such as creating interface specifications for our customers, and getting them started on documentation and interfacing best practices.
Target Customer
HIT software and service providers, hospitals and IDNs, and HIEs.
Customer Problem Solved
The biggest bottleneck in HL7 interfacing isn’t coding or setting up the interface. With modern interface engines, that’s easy. What’s hard is figuring out what to code. In other words, which data should you handle and what does each piece look like in the real world (not on paper in the spec)? Our software figures out what to code automatically.
The way the industry solves this problem today isn’t going to work for much longer, especially with volume of data enabled through Meaningful Use. Right now, folks are essentially using trial and error. In other words, you set up an interface based on a site survey form and a broad product spec, connect up to a test system to get some data coming in, see what’s broken, then fix it. Rinse and repeat. If you’re lucky, you’ll make your schedule. If you’re not, you might be six months out. If you decide to go live anyway, the vendor and/or the hospital’s IT team will be facing one heck of a support backlog, which in turn, can tank adoption rates.
Trial and error is increasingly problematic with today’s interfacing volumes. It’s certainly going to get tougher to sustain once Meaningful Use forces real data integration, with multiple sources of clinical data coming into and going out of the EHR and other information systems. We’re seeing early-adopter vendors and hospitals moving away from trial and error. We think we’ve hit a sweet spot with our software. We’ve come up with a way to not only get proactive on scoping, but also keep scoping documentation up to date for future integration projects.
Competitors
Our competitors are niche tool vendors and a few of the interface engine vendors. However, that second category includes a little overlap: we also complement interface / integration engines and are working with two vendors in this space. But our biggest competitor is the status quo, folks just going along with business as usual.
Advantages Over Competitors
We integrate data mining so analysts can easily grasp their data and what it means. This can drive up interface quality while driving down project risk. The functionality we provide around HL7 data helps interface analysts to grasp sending and receiving system specifications easily. This enables analysts to identify gaps to be bridged by interfacing and integration early during a project. With complex interfacing and integration projects, project leaders can increase interface quality and confidence without jeopardizing timelines.
Fast Facts
KISS (Keep It Simple…) If our spouses let us, the founders would tattoo “KISS” on our respective foreheads. At Caristix, we really want to keep things simple for our customers.
We’re concentrating on HL7 for now. But keep an eye on us for other data standards over the next year.
We’re an experienced healthcare IT team and we have a shared work history. Some of us even go back 12 years, and our team brings over 50 years of combined experience, in both technical and business areas in healthcare IT.
The company has a product management focus. In other words, our products reflect market and user needs and where we think the market is going. As a startup, the last thing we’re interested in is the tech fantasy of “build it and they will come.”
Here is a customer quote: “This is the only tool that provides me with the filter functionality needed to successfully dissect thousands of transactions and find all of the deltas, without jeopardizing timelines.”
Pitch Video Created Specifically for this Showcase
Customer Interview (a system analyst for a large healthcare IT software vendor)
What problems have you solved using Caristix products and what impact has that had on your organization?
We are seeking ways to continuously improve our customer enablement process for our product. An activity in that process is understanding the customer environment. The Caristix Conformance product assist the SME knowledge of their environment and not to rely on outdated documentation and assumptions. Conformance gives us (and the customers) a great visual of their environment.
With this improved visibility, we reduced the rationalization logistic interactions – a lengthy Q/A process (i.e. what systems are involved in the project? what data comes from that system? <<…implementation period…>> Are you sure? Well, we’re seeing this type of data and it does not agree with the initial statements. Are there any more surprises? etc.). This form of interaction occurs over weeks or months and creates much re-work as information becomes known. Knowing upfront the true reality not only mitigates loss time (and financial expenditures), but also improves customer satisfaction and overall product experience.
Caristix also has other products which we review:
Cloak, which de-identifies data – another great product in the making. One colleague commented, “… this is the simplest interface I’ve ever used…”
Pinpoint, which enables what I call “finding a needle in a haystack” simple. Pinpoint cut so much time out finding what’s occurring within the data flow, it’s amazing! One colleague said, “…I wish I had this product when dealing with customer ABC — it would have saved me days of work.”
Although we have not looked at their other products, based on the ones we did, I’m confident they pointedly address the intended concerns.
What alternatives or competing products did you consider and why did you choose Caristix?
We searched for products that address our specific concerns, but didn’t find any. Also, as we began to use the product, the company was open to our product improvement suggestions. And the most amazing thing occurred — they not only implemented the suggestions, but also saw the general benefits to other users as well. Their turnaround time to implement was truly Agile. We saw results in weeks, not months or worst, year(s). As Conformance continues to mature with new features, plus the incorporation of the suggestions, I foresee retiring some of our legacy tools.
How would you complete this sentence if speaking to a peer? "I would recommend that you take a look at Caristix under these circumstances:"
If you are looking for a company who really wants to work with you to solve the problems that their product set addresses, then certainly call Caristix. They truly try to understand the customer use cases, see how (and which product(s)) can meet those needs. And on the rare occasion when their isn’t a “match,” they are upfront to let you know, but still try to see if it’s possible within their reach.
Their response is impeccable, from showing you mock-up to real running code. They are willing to see how your suggestion can make their product better. The proof is when you see the implemented result! Now that’s amazing! Their Say:Do ratio is on par.
They have a good idea where the market is progressing and are making plans to be there as you review their product roadmap. I believe they are flexible enough to make the necessary course corrections as they occur.
An Interview with Stéphane Vigot, President, Caristix
HL7 interfacing sounds simple, at least on paper. Why do organizations need your products?
HL7 is called a standard, but it’s more of a framework. It’s extremely flexible. You’ve got some guidance regarding the way you could organize the data, but each and every hospital adapts the organization of the data to its clinical workflows.
For example, if you consider the admit status sex of a patient, you can have up to six different possibilities. There are very, very few systems that would use those six possibilities. Most of them will use three or four, and even when they pick only three or four, let’s say for a male and a female, one could say, “OK, a male is designated as an M and a female as an F,” or another will say, “In my organization, we’d rather use an 1 and a 2.” That’s a real example.
For any kind of field, you’ve got a type of flexibility. Even though two hospitals are using the very same ADT system, let’s say – admission, discharge and transfer — and they use the very same vendor, the very same version of the system, the data will most likely be organized in a different way.
Thanks to our technology, instead of having an interface analyst looking and reading, literally, HL7 messages, we get the feed from the system that you have to connect. In a matter of a few minutes, we do some reverse engineering on the metadata and then we issue a document that will very precisely tell you how the data is organized within a system.
With interfaces, you often just play back a bunch of messages and try to figure out all the exceptions and rules, with an application expert on one side an an interface expert on the other. How would a hospital use your product to create their own interoperability?
They would get the software platform that we have. They would get HL7 logs, so basically several HL7 messages, and they can deal with tens of thousands of different messages. They would put that file into our platform, and then automatically the platform will do a reverse engineering process. It will read the data and issue a Word document that will tell you precisely how the data is organized.
Then the technician, either from their vendor side or from the hospital side, will know exactly how to configure the interface engine. They will know exactly what data is what and how it is organized — the length of the field and everything. That’s basically it. It’s a very straightforward application that saves hours and sometimes days or weeks of work for an interface analyst. We’ve got a customer testimonial where a task that usually took up to eight hours is done in three minutes, thanks to our platform.
Does the typical customer buy your product just for a specific interface problem they’re trying to solve, or is it in their tool chest of things that they end up using a lot?
They end up using it a lot, because an average hospital in the US will usually deal with more than 100 interfaces. Every single time there is an update to any of the systems they’re using, then the interface will need to be adapted to the update. We know hospitals that have up to five persons dedicated to managing the interfaces. That’s what they do all day long. That’s why our platform can be used on a daily basis.
How would a customer use your product to validate the integrity of an interface, either a new one or an existing one to make sure nothing has changed?
They will just get the logs, do a reverse engineering on the new or existing system, and perform gap analysis between the current interface, or on the old interface if you will, and then the new interface that they want to build. There’s a built-in functionality within our platform that allows you to perform in a matter of a few minutes a gap analysis between two specifications.
You’re based in Canada. Do you see any particular challenges that you’ll face when working with the US?
It’s our target market. In fact, 80% of our customers are in the US. Historically, the team of Caristix worked for a major US vendor for a number of years. The genesis of Caristix was because of a reduction of forces — we had to let go several software developers that were working for that US vendor, so our expertise was really in the US.
Who is it you market to and how do you reach those people?
We market to two segments: hospital vendors and hospitals. We are currently working on a free application for hospitals that will allow the hospital’s IT teams to document the specification of the different systems, again, in a matter of a few minutes.
We use a lot of white papers, we use a lot of reference, if you will. Since we’ve been working with US companies for years, we know a lot of them, so that’s how we reach out to them. We’re now getting more visibility and we’ve got some consultants — or I’d say gurus — in healthcare IT that are also talking a lot about us.
The nice thing about our platform is that once you see how it works, you automatically understand the benefits and you automatically understand the savings that as a vendor or even as a hospital you’re going to be able to make. I’d say it’s an easy sell. As soon as you talk to people who know and understand the complexity of HL7 Interfacing, it’s almost – and I hate to use this term – but it’s almost a walk in the park from a sales standpoint.
What do you hope to gain from the exposure on my site?
Any hospital is dealing with HL7. You’re extremely visible in the HIT world. I was at HIMSS this year – I’ve been attending for the past seven years – and a lot of people know Mr. HIStalk. You’ve got quite some followers there. I think that’s going to provide us a lot of visibility.
Most of the people who are dealing with HL7 interfacing will definitely take a look at our website. When they take a look, we’ve got a great response and they automatically understand what we do. The savings are very positive. That’s where we see a lot of potential, and thanks to your help, we see a lot of lead generation, thanks to the HIStalk blog.
The feedback we’re getting from existing customers is that within their first interface project, the return on investment is immediate. You don’t have to be using our platform for months to get to see the benefits. It almost pays for itself with the first project.
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November 4, 2011Time CapsuleComments Off on Time Capsule: Leapfrog’s Leap into Irrelevance
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 October 2006.
Leapfrog’s Leap into Irrelevance By Mr. HIStalk
I sat in a hotel ballroom back in 2001 or 2002, hearing about The Leapfrog Group for the first time as an IT director in a large IDN. Like most people in the room, I was both energized and concerned. I liked the idea of a short list of evidence-based hospital quality standards. However, I worried that my hospital might have a tough time meeting them, thereby raising the ire of the big-employer healthcare dollars that were supposedly backing Leapfrog to the hilt.
Predictions were dire back then in the post dot-bomb nuclear winter. Hospitals would be wildly overbedded. Savvy baby boomers, emboldened by buying books and dog food online, would be calling the shots, making shrewd healthcare decisions and choosing providers based on stringent quality measures that would be plastered all over the Web. Unfocused, change-resistant hospitals, which included all the ones I’d ever worked for or heard of, would be road kill.
If the IOM’s “To Err is Human” was embarrassing to hospitals, Leapfrog was threatening. Their mandates were prescriptive, concentrating on “just do it” guidelines. If you didn’t like their requirements, that was just too bad. Cisco and GM and other big employers had already decided you’d have to play ball their way for a change. Medical experts in fields that were covered by the Leaps howled, demanding to see the evidence supporting them, but it was not forthcoming. Leapfrog wasn’t looking for a debate.
Somewhere along the line, Leapfrog fizzled, surprisingly but decisively. Nowadays, they’re a quaint anachronism. The “news” on their site is mostly press releases applauding the accomplishments of other groups. Their 2004 website listed 152 members; now it has just 44. Among those that bailed were most of the HIT vendors: Allscripts, Cerner, Eclipsys, McKesson, Misys, and Siemens. I hope no one got hurt in the stampede for the exits.
I hadn’t even thought of Leapfrog for months until they issued a press release last week. Instead of containing major announcements of accomplishments or new guidelines, it described their self-commissioned survey that, ironically, laid bare their astounding lack of clout. Hospital compliance with their much-feared CPOE mandate was less than 10%. Over 90% of hospitals don’t meet Leapfrog standards for two surgical procedures. Intensivists in the ICU are used by only 30%. Apparently the risk of retaliation from the tiny band of surviving Leapfrog members isn’t much of a threat.
Maybe the timing wasn’t so good to name Methodist Hospital of Indianapolis as one of their Top Hospitals of 2006, sharing headlines with a string of medication errors that occurred there, some of which killed three newborns. Got CPOE? Check.
CPOE prevents errors, but rarely prevents significant patient harm, making it a bottom-feeder in the “bang for the buck” category of patient safety technologies. Documented successes are nearly non-existent. Still, Leapfrog pushed it as a must-have above all else, undoubtedly with few objections from its HIT vendor members who were happy to move some low-demand product, even if customers signed up out of fear alone.
It’s ironic that hospitals are stuck with white elephant CPOE systems because Leapfrog insisted on them. It’s sad that hard-won capital was diverted from better, cheaper, easier technologies that might have saved some patients instead of just keeping a now-irrelevant trade group happy. I think of those dead babies a lot, trying to decide if just maybe Leapfrog’s CPOE tunnel vision did more harm than good.
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November 4, 2011NewsComments Off on Siemens To Acquire MobileMD
Siemens Healthcare announced this morning that it will acquire HIE solutions vendor MobileMD of Yardley, PA.
John Glaser PhD, CEO of the Health Services Business Unit of Siemens Healthcare, was quoted as saying:
The goals behind many of our country’s broad, health reform initiatives are intended to improve the quality of care by doing two basic things: increase utilization of electronic technology, for a variety of benefits, and improve the coordination of care among entities that had previously not shared data well. Patients come into the healthcare system expecting physicians to help them get well by coordinating their care. Patients generally should not need to be concerned with the logistics of how their care is coordinated – they should rightfully expect that it will be coordinated. Siemens was impressed with MobileMD’s capabilities to enable this level of data sharing while maintaining an impressive focus on customer satisfaction. MobileMD customers can expect to continue to experience this same level, or an improved level, of service, commitment and partnership.
MobileMD’s HIE service is used by 110 hospitals and 2,000 physician practices, according to the announcement.
HIStalk interviewed MobileMD CEO Todd Fisher this past January. He named Axolotl and Medicity as MobileMD’s main competitors, both of which had been recently acquired at that time.
Terms of the acquisition, which is expected to close promptly, were not disclosed.
Citing the need for more time, ONC announces it will delay the launch of the permanent program for EHR certification until mid-2012. The timeframe coincides with the anticipated final rule of Stage 2 of Meaningful Use and standards and certification criteria. ONC says it can’t make the original January 1 deadline to approve testing labs and authorize certifying bodies.
Reader Comments
From Viking: “Re: doctors, texting, and HIPAA. This video on how to make a ‘pager scanner’ shows how easy it is for anyone to listen in and breach via texting.” Though I was distracted by the painful-looking lip piercing on the geek chick, I need to get someone to build me one of those. Go to about the 2:45 mark to see her computer screen filling up with pager messages. It’s definitely a target-rich environment at my hospital, although I expect the messages are amazingly dull.
From Megan: “Re: HIStalk page loading improvement. Thank you! I’m new to the industry and like to stay on top of news, but that one little fix made this site so much more reader-friendly.” I’m embarrassed that it was a relatively simple change once Dave Dillehunt suggested it. I wish I’d done it sooner. I find myself pulling up the page several times a day just because I like watching it snap to attention on my command. The beauty of it is that everything still displays, sponsor ads and all, but just in a slightly different order.
From AnotherDave: “Re: HIStalk page loading improvement. I second, third, and fourth the shout-out to Dave Dillehunt. Instant access to HIStalk: priceless.” This may well be Dave’s finest hour. I mean, sure, he’s a CIO and everything, but how many times do strangers publicly sing his praises?
From NoSleepTillEpic: “Re: Kadlec Regional Medical Center. Live with Epic inpatient, ambulatory went in August, One of Epic’s smallest customers, a PlaneTree hospital with a reputation for doing technology right. JCAHO showed up the week before go-live!” Nice.
From Anon: “Re: ONC budget. Is this something to be concerned about?” I don’t know the source of the attached material and I don’t understand all of it, but it says ONC’s 2011 budget was $61 million and the President requested $78 million for 2012. The Senate Budget Committee recommended holding the budget to $61 million, but supposedly (and this would be the big news, if true) that figure would also include ONC’s HITECH allocation, which was $57 million in 2010 and was scheduled to increase to $499 million and $874 million in 2011 and 2012, respectively. A House subcommittee has proposed only $28 million. If you know more about this, please share since it sounds important if it’s true.
Unrelated, but while Googling the subject, I came up with ONC’s 2012 budget justification, which has key indicators that include the percentage of practices and hospitals using EMRs and receiving Meaningful Use payments. ONC requested 189 FTEs for 2012 with an average cost per FTE of $148,000.
HIStalk Announcements and Requests
This week on HIStalk Practice: Dr. Gregg enlightens readers on the behind-the-scenes coordination for AAP’s Pediatric Office of the Future. A reader comments on providers who seem overwhelmed by Meaningful Use-fueled EHR purchases and rushed implementations. MGMA calls on CMS to establish a 5010 contingency plan in case practices and their trading partners can’t meet the looming deadline. Physicians believe EHRs are safer than paper, but patients disagree. CMS advises providers to report on all clinical measures in their EHR, even if the data is incomplete – and thus meaningless. Shuffle on over to HIStalk Practice, get your ambulatory HIT fix, and sign-up for e-mail updates. Thanks for reading.
Welcome to new HIStalk Gold Sponsor New York eHealth Collaborative. The not-for-profit, formed in 2006, strives to improve healthcare for New Yorkers through the use of healthcare IT. It helps develop policies and standards to help providers move to electronic health records and coordinates connecting providers statewide. It runs a Regional Extension Center and the Statewide Health Information Network (SHIN-NY). They’re presenting the NYeC Digital Health Conference 2011 December 1-2 at Pier Sixty on the Chelsea Waterfront in NYC, with keynotes by HHS CTO Todd Park and journalist T. R. Reid. Registration is $395 general and only $195 for practicing physicians and government employees. I’m running a text ad for them over to your right just in case you want to check it out later. I would loved to have gone, but it was just too hard to get time off from the hospital, which left Mrs. H deprived of the opportunity to enjoy New York near Christmastime. Thanks to New York eHealth Collaborative for supporting HIStalk.
Suggestions on how to spend your extra minutes of free time each day now that HIStalk loads faster: (a) seek Inga, Dr. Jayne, and me on Facebook and LinkedIn and consummate our electronic union by Liking, Friending, and Connecting; (b) sign up for spam-free e-mail updates on HIStalk, HIStalk Practice, and HIStalk Mobile; (c) send me scandalous rumors, squelched news, and anything that would interest readers like yourself by clicking the atrocious-looking green Rumor Report box to your right that sends your secure message and an optional attachment right to my inbox; (d) peruse the friendlier-loading sponsor ads to your left and click those that seem fun, or check out the Resource Center to browser and search, pausing to marvel that polished and powerful executives command their underlings to mail a check to a PO box to support an anonymous hospital guy’s amateurish blog; and (e) look yourself in the mirror while giving yourself a little nod and a Bill Clinton finger-pointing recognition gesture to acknowledge your role in reading and doing all of the above, which keeps the vivacious and erudite Inga and Dr. Jayne smiling.
Acquisitions, Funding, Business, and Stock
HealthGrades signs a definitive agreement to merge with CPM Marketing Group, a provider of customer relationship-management services for hospitals.
Mediware announces Q1 numbers: revenue up 24% to $15.5 million and profits up 42% to $1.49 million or $0.18/share.
Medical practice documentation management software vendor Updox gets a $500K loan from the state of Ohio to develop a mobile version of its product, to integrate with more EHR products, and to promote its free secure messaging service.
Advisory Board Co. reports Q2 net income of $5.2 million ($0.30/share) compared to $4.9 million ($0.30/share) last year. Revenues grew 30.7% to $92.9 million.
Allscripts reports Q3 numbers: revenue up 13%, EPS $0.11 vs. $0.01, beating expectations. The company raised guidance on both revenue and earnings. The earnings call transcript is here. Interesting snips from it: (a) CEO Glen Tullman says the new January 1 readmission rule in which hospitals eat the cost of patients readmitted for the same condition within 30 days is driving interest in care management and discharge management applications; (b) he says Allscripts beat Cerner and Epic at Flagler Hospital (FL) because the hospital wanted to connect to a variety of EMRs used by community-based physicians (c) several new hospitals signed up for the EPSi performance management system, among them UC-Davis and Stanford; (d) Glen sees big opportunity from ICD-10 (“you’re going to have to replace every practice management and revenue cycle management system out there”) and analytics; (e) he says Sunrise Clinical Manager is used by “all the best names out there,” saying it’s “open” and “not outdated” and “what the market wants, what physicians want, is one comprehensive patient view, not one database, because they realize you can’t do that”; (f) their most frequent ambulatory competitors are Greenway and eClinicalWorks.
UPMC Health Plan and The Advisory Board Company formEvolent Health, which will offer the Identifi population and health management software developed by the health plan and used by UPMC to manage the health of its 54,000 employees. Each organization capitalized the venture with $10 million. Its first customer will be MedStar Health. Former Advisory Board CEO Frank Williams will serve as CEO of Evolent Health.
Merge Healthcare reports Q3 results: revenue up 33%, EPS –$.01 vs. –$0.06, missing consensus estimates by a penny.
Sales
Health Care Authority for Baptist Health selects MEDSEEK for clinician and patient engagement tools.
Lompoc Valley Medical Center (CA) will deploy Allscripts’ Sunrise Clinical Manager EHR and offer the Sunrise Clinician Portal to it physicians. Also, DMC Children’s Hospital of Michigan selects Allscripts EHR for its employed and affiliated physicians.
Houston Healthcare (GA) selects Wolters Kluwer Health’s ProVation Order Sets for Houston Medical Center and Perry Hospital.
Wake Forest Baptist Medical Center chooses RelayHealth’s RelayCare for readmission management.
Intermountain Healthcare signs a five-year agreement with Accretive Health to manage its revenue cycle. The organizations say they will create a Salt Lake City-based revenue cycle Center of Excellence that will provide best practices, technology, and education.
Harris Corporation wins a $4.5 million VA contract to develop Web-based mental health self-documentation tools for the MyHealtheVet personal health record.
People
Apixio names Darren Schulte MD as chief medical officer. He was previously with Anvita Health.
Availity promotes Russ Thomas from COO to CEO, succeeding Julie Klapstein, who will remain on the board of managers.
Recombinant Data Corp. hires Jason D. Oliveira as managing director of health system consulting. He previously led the healthcare BI practice at Kurt Salmon Associates.
AMIA President and CEO Ted Shortliffe MD, PhD announces that he’ll be leaving the job he’s held since mid-2009 to pursue other interests. The board will initiate a search for his replacement, expected to be in place by early 2012.
Main Line Health (PA) promotes Karen Thomas to SVP/CIO. She was previously VP/CIO.
Announcements and Implementations
Physician practice marketing and communications company Medley Health partners with athenahealth to integrate its physician-patient communications platform with athenahealth’s suite of offerings.
Guam launches the first phase of its HIE with the deployment of secure messaging and clinical document exchange using the ApeniMED HIE platform.
The Wichita HIE signs up its first two physician practices.
New Hanover Medical Group (NC) goes live on Epic, the first step in a system-wide, $53 million upgrade. The local TV station covers its rollout of MyChart.
Inland Northwest Health Services (INHS) announces that 12 client hospitals have successfully attested for Meaningful Use.
Trustwave introduces its Web application security offerings, including an enhanced version of Trustwave WebDefend.
Three rural Adventist Health hospitals in California will share a $1 million Blue Shield of California grant to implement electronic medical records.
Healthcare IT services provider Anthelio will add 200 jobs in Detroit and Flint, MI to support its area customers, which include Detroit Medical Center and McLaren Health Care Group.
Innovation and Research
Stanford’s Lucile Packard Children’s Hospital publishes a NEJM article describing its use of patient information from its electronic medical records system to choose drug therapy for a patient’s rare disease. The 13-year-old patient had lupus complications and was a candidate for anticoagulants, but cases are so rare that a literature search came up with nothing on the risk-benefit profile. Jennifer Frankovich MD (above) used a research tool to query de-identified EMR data and found the records of 98 patients over a five-year period who had similar conditions and determined that the risk of clots was high enough to justify starting anticoagulants right away. Their conclusion is that a physician probably couldn’t have figured it out otherwise since there were so few patients, recall is sometimes biased, and EMRs have so much information that it’s hard to pick out the important data elements. They also expect that aggregated patient information will be used during rounds to make treatment decisions in the not-too-distant future. I assume the EMR in question was Cerner, which Packard is supposedly having to give up despite publishing extensively about its patient safety benefits (parent Stanford Hospital uses Epic.)
Technology
Toyota announces that it will start selling mobility robots in 2013, one of them being Independent Walk Assist, a computer-controlled mechanical exoskeleton. It was developed at the University of California at Berkeley, where one of its students who is paralyzed was able to walk across the stage to receive his diploma with the help of the technology. Toyota is working on another version that will lift and move patients.
Mobile healthcare apps tools vendor Diversinetis awarded a patent for encryption technology that prevents data from being transferred from one mobile device to another.
Other
From KLAS: over the next five years, almost half of providers will replace their RCM system; 87% of those will make the switch in the next three years. Most providers are looking at a new RCM in terms of how it fits in with a single-source enterprise strategy, often driven by the clinical vendor. Epic and Siemens top the list of considerations for over-200 bed providers, while McKesson and Meditech were the most considered by community hospitals.
A Richmond TV piece covers the use of AirStrip Cardiology at Bon Secours St. Francis Medical Center, in which one of the doctors sheepishly admits that the previous standard of practice for ED doctors to get cardiology consults was to send them an iPhone picture of the EKG.
A Virginia psychiatrist avoids becoming the first physician to be prosecuted for HIPAA violations when the judge dismisses charges against him. Prosecutors claimed the doctor retaliated against a patient who had complained about him by telling her supervisors that she had been involuntarily committed. The doctor says “it could have collapsed the entire system” had he been convicted since doctors would become reluctant to provide such warnings.
The Rhode Island Department of Health investigates four Lifespan hospitals after getting reports they gave 2,000 discharged inpatients prescriptions for immediate-release drugs instead of the timed-release versions ordered by the physician. Lifespan blames “software used to generate medication instructions provided to discharged patients.” State Senator Jamie Doyle says he is “shocked” and wants a review of all Lifespan hospitals and the Rhode Island Department of Health.
Weird News Andy is positively lyrical over this story, which he titles “Crystal Gayle, where are you?” A California doctor (and former entertainment lawyer) develops a laser procedure that can permanently turn brown eyes blue in 20 seconds. WNA provides the soundtrack: “Colored contacts, with you I’m through; That laser beam oh, it’s so brand new; Doctor Gregg now, let your aim be true; And don’t it make my brown eyes blue.”
Sponsor Updates
Medicomp Systems announces that Quippe, powered by the MEDCIN Engine, is now embedded into MED3OOO’s InteGreat EHR. Medicomp, by the way, exhibited at MGMA and trained seven people every hour on Quippe.
The latest newsletter from TELUS Health Solutions includes several articles on using data to drive transformational change in heath systems.
Virtelligence is participating in this month’s VA and Midwest HIMSS conferences.
Orion Health CEO Ian McCrae calls out his company’s continued success, calling Orion Health the leading healthcare IT software vendor in health information exchange.
MedAptus President Larry Hagerty discusses the company’s use of Internap’s cloud solution.
Carefx will participate in the Midwest HIMSS 2011 Fall Technology Conference in Indiana.
CareTech Solutions is recruiting 60+ people for installation and support of hospital IT systems.
Concerro opens registration for its November 29 Webinar entitled, “Achieving Compliance with the Joint Commission’s Staffing Effectiveness Requirements.”
CynergisTek CEO Mac McMillian is presenting “Data Security – Eliminating Imaging Informatics Risks” at the virtual AuntMinnie.com RAD Expo 2011 November 2-3. He will also present a Health IT Capstone Course at the American College of Physician Executives Fall Institute 2011 November 8-9.
MyHealthDIRECT CEO and Founder Jay Mason will discuss the changing landscape for Medicaid health plans at the upcoming Medicaid Health Plans of America Annual Meeting in Washington, DC.
EPtalk by Dr. Jayne
This time of year as it starts to get a little chilly, I think fondly of places where sassy CMIOs can go for some fun in the sun. News from the sun belt: Cigna purchases HealthSpring, which runs the Medicare insurance plan for Miami-based Leon Medical Centers. The $3.8 billion dollar deal brings the plan’s 37,000 Medicare beneficiaries to Cigna and is seen as a major move into the Medicare Advantage market.
The AMA claims a win for helping to extend the deadline for providers to file for hardship exemptions to prevent penalties for not ePrescribing. Not a huge win in my book — the previous deadline was November 1 and it was very well publicized.
Mr. H usually reports on health IT vendor earnings calls and I rely on his summaries because I’m usually looking at pharmaceutical and other industry outlooks. Pfizer admits to its plan to work towards marketing an over the counter version of Lipitor. As the company’s best-selling drug goes off patent, they’re obviously trying to resuscitate their cash cow. The concept of bringing this class of drugs OTC comes up periodically – Merck asked the FDA three times over a seven-year period to allow them to take Mevacor OTC and was rejected every time.
When most people think of healthcare IT, they think of hospital and ambulatory documentation software, revenue cycle, laboratory information systems, and the like. In my opinion, one of the more fascinating breakthroughs is the computing power that helps scientists sequence the genome of various organisms. The journal Nature reports success in sequencing the DNA of Yersinia pestis, the agent that caused Black Death in the mid-1300s. Researchers extracted the DNA from teeth of victims buried in 1348.
I hope the HIPAA compliance zombies don’t hear about this one. The Defense Advanced Research Projects Agency (DARPA) challenges techies to reconstruct handwritten documents that have been shredded. Screenshots of shredded documents are on the Shredder Challenge website. Get your decoder rings ready – winners will be announced on December 5. Should emerging technology make it easy to piece together these puzzles, I’m sure we’re all in for compensatory advances in document destruction technology.
In the weirdest research study of the week, Israeli researchers conclude that drinking cold water increases the resting energy expenditure of overweight children, helping them burn calories. The patients drank water cooled to 4 degrees Celsius while watching a movie lying down. Not exactly my idea of a good time, but just illustrates how desperately people are looking at the obesity problem. I’ve got an idea: how about asking the kids to do stretching exercises or even calisthenics while watching? Bet that would work too.
Bad news for social habits favored by the ladies of HIStalk: a study published in this week’s Journal of the American Medical Association documented a statistically significant increase in breast cancer risk among women who drank small to moderate amounts of alcohol – the equivalent of three to six drinks per week. The data comes from the Nurses’ Health Study, a prospective observational study of over 100,000 women which has produced a multitude of findings.
Pat Hampson is chairman and CEO of MED3OOO of Pittsburgh, PA.
Tell me about yourself and the company.
I was a business major in management. My mother was a hospital administrator and my brother was a lawyer who litigated against physicians, so I chose the middle ground of working with physicians. I started a practice management franchise back in 1987 and expanded that into revenue cycle management.
In 1995 when we got our first capital raise, I started MED3OOO. I’m the chairman and founder of the company. Historically during that period of time, I was lucky enough to be befriended by John McConnell, who was the CEO and founder of Medic, and was able to invest and be on the Medic board. Then the same thing with A4 Health Systems. Conversely, John McConnell’s on my board. I think you could say it’s incestuous to some extent.
A lot of people, including the ONC folks, are talking about the usability of physician software. How are MED3OOO and the industry in general doing in that area?
I don’t know anybody that’s like MED3OOO, for two reasons. One, we’re in the physician practice management business, so basically we were born and raised as operators. Whether it’s an Allscripts system or a Sage system or our own systems, we know what we want these systems to do to better manage a practice.
Conversely, we’re also system-agnostic, so if the physician group or the hospital who has employed physicians already has a system, we’re able to use their systems. It’s like BASF — we don’t make things, we make things better. We use their systems to improve how they run their physician practices, or if it’s an independent group, how we run the practice.
Separately, we have InteGreat, which is our proprietary, Web-based PM system. If we’re talking to physicians for the first time about EHRs, it reduces the barrier to the sale. We let them look at all the EHRs and then hopefully they’ll pick InteGreat, but if they don’t, we’re fine with them picking one of the other vendors and we’ll install it and service it and manage it for them.
How do you separate those lines of business within the organization?
MED3OOO has three lines of business. The first business is physician services. That has three components. One component is where we manage a physician’s group, whether it’s hospital-owned or they’re independent-owned, on a turn-key basis. We do the accounting, the finance, the administration, the billing, the collections. We do the managed care contracting. Usually those are long-term contracts, but it’s turn-key.
Separately, we actually own physician practices in some states where you’re allowed to own them. We have large physician groups that are actually owned and operated by MED3OOO.
Third, we have the revenue cycle management. I think we’re one of the largest private RCM companies in the US. That all falls under physician services.
Separately, we have an ACO division, which is accountable care, and that houses our IPA business. In California, Illinois and Florida, we’re a TPA and we manage large IPAs. Some of our IPAs are taking global risk and some of the IPAs are taking professional risk, so now that the word ACO has come about, we’ve been taking reimbursement risk on patients and quality for quite a few years. We have our own systems for that.
The third division is the technology division. It can either be agnostic and utilize the non-proprietary systems like Allscripts, Sage, or GE, or we’ll sell our own proprietary system, which is InteGreat PM, EHR, and data warehousing. It’s really the physician’s choice. As you know, physicians like different bells and whistles, depending on their specialty. But we try to stay agnostic as much as we can, even though we believe the product that we built with InteGreat has much more capabilities than some of the older legacy systems.
I’m glad I asked you that question because I didn’t realize the scope of what you do. Are you the only company offering physician systems that actually owns physician practices and performs TPA duties?
I think we’re the only company out there that has all three of those divisions, which is kind of interesting because the market’s now come to us. Again, there’s a lot of hospital groups, there are a lot of hospitals, there are a lot of physician groups that now want to … you know, they’re worried about getting into the ACO business. If you think about it, we can walk in and we already have the risked-base experience because we’ve been doing global risk for 10 years for our clients. We have the technology, because we’re a TPA. Then we have the electronic health records, whether it’s the system that they’re using or developing a community model, and we have data warehousing. So we’re pretty much a plug-and-play for folks that want to go to the next step and partner with someone to become an ACO.
How big is the company?
In 2012, our run rate will be about $200 million in revenues. We have 14 operating centers across the U.S. and about 2,500 employees.
Wow, it’s huge. I’m sure there’s going to be a lot of folks other than me who are going to do a little double-take when they read that. There are potential acquirers out there looking at revenue cycle, different kinds of companies, and you’ve got several sweet spots. Are you getting a lot of interest from folks who see your very large footprint and are interested in participating with you in some way?
Where we get a lot of interest is from companies that want to invest in MED3OOO and then for it to go public. We’ve been in business since 1995. I have been on public boards, Medic being one of them. Historically, because we are privately held, we’ve been able to pretty much put all the capital back in the company, so we’ve been able to build internally. We already have population health management. We have predictive modeling. All the tools that we need to manage our physician practices or our own risk-based IPAs — we built these things internally, so it’s not vaporware. It’s things that really work in the field of fire, not selling a product and then running off to the next client.
Recently, it’s kind of exciting for us, but we signed the state of Florida to do their children’s Medicaid services. That’s not only a nice contract for us because it’s across the whole state of Florida and it’s a state contract, but they’ve also signed us to build a continuous quality of care modules, which no one else in the industry is trying to do because they might have the software expertise, but they don’t have the operating expertise to actually build it so that once it’s up and ready to go, then it works at the point of care.
I know that you’re a big user of Quippe and jumped on that pretty quickly. How important is that and its acceptance to the strategy on the EHR side?
Quippe’s pretty important because the thing it does that others – I think we’re one of the first to use it – but it’s template-free documentation. The way it’s set up, you don’t have to build templates. It really thinks like a physician. You can really fly.
I think why that’s important is it feels like the market is now down to where it’s the one doctor to the 25-doctor practices. Most of the larger groups have already been saturated with technology. We think there’s a big difference between putting systems in onesy-twosy practices than there are for these large clinics that have tons of infrastructure, they might have their own CTOs, they might have a training group.
The smaller practices don’t have that. You really need to have something that’s low-cost, that’s easy to use, and at the same time, moves the way the doctor moves, not have the doctor move the way the vendor built the system. Last but not least, it’s also cloud-based with our technology, so we don’t need a VPN or network, so it also keeps the pricing down for folks.
You mentioned the small to mid-sized practices. How much of the practice market are you seeing that’s being driven by hospitals that are choosing single-vendor offerings, like from Allscripts or from Epic or whoever, and then subsidizing those offerings to their affiliated physicians?
I’d say the majority of cases, from I can see. The hospitals are choosing their select vendor. We’ve got a lot cases where we have hospitals and we’re not the main vendor for their employed physicians. I’d also say that if you’re a large group, an independent physician group, the problem that you have is that you’re in a marketplace where you want to connect to all the other physicians that affiliate with your hospital or your practice group. In most cases, we might go into a market and there’s 600-700 physicians on staff and they have all the different systems you’d every want to know.
We’re a little different as, again, we’re agnostic. We can work with that hospital system, that group system, or we can help them connect with the marketplace where you’ve got 16-20 different vendors out there that have already sold systems. I think the Web-based technology for us is important, too, because the majority of systems out there are legacies. You’ve got a few Web-based systems, but there’s going to be over time a large capital cost for the folks to get off the legacy systems because they’re just not going to be able to do what they need to do easily. We believe that InteGreat is pretty well positioned for that second phase in the market.
There are people that predict that the small practice is an endangered species, and especially with all the emphasis on technology and affiliations, that it’s going to be tough to survive. Do you see that happening, and how do you see the technology needs either helping them go away or helping them not go away?
I think that the industry is cyclical. In 1995, back when we were first named MED3OOO, you had companies like PhyCor and MedPartners and you had hospitals and everybody employing physicians. From 1995 to 2007, they lost a lot of money on their employed physicians. The physicians weren’t happy, the hospitals looked at the P&Ls of physicians and weren’t happy.
I think you’ll still see employment models strategically in certain areas like Pittsburgh, for example. Highmark and UPMC are battling, so there’s more competition there. What we see more of is hospitals and/or large physician groups and/or IPAs trying to figure out different methods to align with physicians versus just employ them.
In some states like California, you can’t have a non-compete. Even if you pay the physician a lot of money for his practice, they can go six doors away and reopen a practice or go to someone else. We think the smartest move that people are making is just figuring out different ways to keep the physicians to align with them, not necessarily just use the employment model.
You mentioned the ACO market in general. How do you think hospitals and practices will address that need to collaborate and integrate their delivery, especially with IT?
Right now today, ACO to me means “awesome consulting opportunity.” Everybody is running around, everybody wants one, but very few really know the details. The government just came out with their new set of regulations and I’m not aware of any of the pilots in the ACO realm that have made any money. I think the jury is still out.
Do I think there’s any need for a different reimbursement model that’s based on quality and based on access to care? Sure. But is it the ACO model? I’m not sure but – this is a sales pitch for MED3OOO – if somebody wants to become an ACO, now again, what do you need? You need heavy technology on the reimbursement side, the payer side. You need ways to align physicians and hospitals. You need expertise, somebody that’s actually handled global payments. We believe we’re the best partner, whereas the hospital or physician group to make him successful in whatever the new ACO world is. It’s just not having it, and so it’s not being a vendor. You have to be a partner to make this really work for a hospital or a physician group.
As a developer of systems, what are the challenges that you see with managing population health?
Right now we have about 2% of the U.S. population in our data warehouse. Getting data is easy. Sorting data and making sure that it’s viable data is much more difficult. then doing it on a real-time basis so that people have that data at the point of care.
But in our world, population, health management, predictive modeling — these aren’t new terms. We’ve been doing it for five years and doing it successfully with our groups. It’s more of an issue of access to the data. Will the states continue to fund HIEs and deploy them so that everybody can share data? With the economy, will that funding continue? And if it doesn’t, what’s the solution were everybody can share data?
The government did a great thing by saying everybody had to be interoperable, but that’s a technology term. It still doesn’t mean that you have to share data. I think this will shake out in the next three or four years, but it’s those that have the data and then those that know that it has to be processed before it’s usable are the ones that will have a leg up.
You mentioned interoperability and HIEs. What customer demand are you seeing for that and what are your strategies in those areas?
InteGreat is certified for Meaningful Use, and interoperability is one the components of Meaningful Use. We’ve got two things. We’ve got the EHR that has Meaningful Use and interoperability, but separately, the data warehouse will let you extract data from disparate systems. Then we can turn that data into actionable information for the physicians.
You need to have a strategy that has different parts, because if you’re a vendor, all you care about is selling your system. If you’re in management, you care about what systems you’re using, but you also care about what system the other 60% of the market is using and how you get access to that data. That’s where we made an investment 10 years ago into the data warehousing piece. I you think about it, because we are a large user of Allscripts and NextGen and Misys and Sage and InteGreat, we got the data warehousing so we could manage our own disparate systems. Now it’s a plus, because in these communities, we can manage the disparate systems that are in that community and an HIE can’t do that. An HIE can connect them, but it’s really not a place to house data and then turn it into information.
Every executive makes bets about what’s going to happen in the future, making company decisions today that won’t realize fruition for years. What are some of the bets you’re making about what the industry is going to look like down the road?
I’ll be really different. I don’t think we’re making a bet. I think what we decided years ago is that the industry is cyclical, so we wanted to have expertise in technology. We wanted to have the expertise in management and operations. We wanted to have the expertise in data.
When these markets shift, for example, you might assume that if everybody’s employing physicians, the revenue cycle management business would be less. But if hospitals are employing physicians, that practice management piece accelerates, because they usually don’t know how to manage physicians. What we’ve decided to do is have the components, and then as the industry shifts, two of our components, two of our divisions might be on fire right now. I think just four years ago the IPA market was kind of flat — there wasn’t anybody developing new IPAs. Now the IPA market has become the ACO market and everybody wants one, but very few have the tools and the knowledge on how to really do it. While physician employment might be saturated or systems might be saturated, the knowledge base in our ACO division … it’s tough to keep up right now.
Any final thoughts?
You’re going to have to get to scale, whatever you do as a company. I truly believe that if you want to make a difference — where it’s quantifiable, you’re making a cost improvement and a quality improvement on the clinical side — you really need more. You can’t just be a vendor. You’ve got to provide people with a stepping stone and a map to get to disease management and population health management. There are a lot of people today that are just starting and are not sure where they should start. I think we would be good partners for them, because we’ve been doing it. That’s the core of the company and we’ve got all the tools and services, but more importantly, we actually do it for a living. We’re not a vendor to most of our physician clients or hospitals.
Hospitals are becoming more optimistic about their Stage 1 Meaningful Use readiness compared to seven months ago. About 41% now say they are well positioned to meet Stage 1. The HIMSS Analytics report also finds higher adoption rates among academic medical centers and larger hospitals.
Reader Comments
From Marquis: “Re: Dr. Jerry Stonemetz. He’s a world-famous anesthesiologist, an expert in anesthesia information management systems, and head of anesthesia services at HCA. All told, he is a very cool dude. He writes a blog about AIMS, but recently incorporated his other passion (wine) into the blog. It’s not exactly HIT, but it is kind of fun. And our industry could use more fun.” I agree that HIT needs fun, as well as more wine. Dr. Stonemetz’s first post includes tips on how to create a wine cellar and is geared to those of us who lack the discipline to accumulate wine ahead of consumption.
From Lee: “Re: new Siemens announcement about Soarian for small hospitals. Looks like the death knell for MedSeries 4. I’m sure they will deny it, otherwise they would be sending 200+ clients to the RFP mill.” One big lesson learned from reading the Steve Jobs biography and Vince’s HIS-tory of failed HIT vendors: companies should not offer products that overlap each other or confuse customers (not to mention products that force a company’s own salespeople to compete with each other).
From LeBronze: “Re: Meaningful Use. Good thing CMS is there to answer our questions.” LeBronze forwarded the transcript of auto-generated responses he received in response to a question he posted on CMS’s EHR Information Center about criteria for maintaining a problem list. His question was filed on August 18. Nine auto-responses and escalations later, he still doesn’t have an answer after more than two months.
From Flow: “Re: Endo Pharmaceuticals. It acquired Urochart recently, and now has acquired its major competitor in the urology EMR space, meridianEMR. Meridian had filed an infringement lawsuit against Urochart.” Verified, apparently. According to Endo’s earnings announcement last week, it has made “strategic investments in Intuitive Medical Software (IMS) and meridianEMR, Inc., two providers of electronic medical records for urologists. Together, IMS and meridianEMR provide access to approximately 1,800 urologists using data platforms that will enhance service offerings in urology practice management.” I always like to read the executive bios and found some fun facts about the folks who run meridianEMR: CEO and Chairman Michael Custode was the designer and architect of the Medic Vision PM product that Misys bought; CMO Herschel Jackson MD developed the ScriptLetter prescription writing system; CTO William Bartlett is a Certified Ethical Hacker; and Chief Software Architect G. Ralph Kuntz MD, MS wrote the link-editor and dynamic linker for the UNIX C compiler for Bell Labs.
From Kaity: “Re: sales job. I’m an avid reader of yours and I LOVE your blog. I’m a software sales rep who likes listening to customers and understanding how the products I’m selling can make their lives better. If you were going to sell software to hospitals, what are your Top 3 target companies? (probably not EMR since that ship has sailed with everybody buying Epic).” I’ve spent almost my whole career working in non-profit hospitals, so I have only limited experience working for a vendor and none working in sales. Luckily, what I do have are smart readers who have my back – if you’re one, feel free to leave a comment giving Kaity some ideas. She put “love” in all upper case, so I figure I owe her.
HIStalk Announcements and Requests
Here’s a shout-out to Dave Dillehunt, CIO of FirstHealth of the Carolinas, who gave me a brilliant idea. He said nobody would mind how long it takes the main HIStalk page to load if there was a way to display the article itself first, with the sponsor ads and other sidebar content loading in the background. I didn’t think that was possible, but after some Googling and fun Javascript programming (not me – I hired it offshore) it’s magic – the article scrolls out almost immediately and everything else quickly follows. Sounds minor, but it’s much more satisfying to start reading so quickly. I may create a HISsies category just for Dave to win.
Acquisitions, Funding, Business, and Stock
Fortuneprofiles appointment-booking site ZocDoc, which is now available in 12 cities. The company, which has raised $95 million in funding, hints that it collects enough patient information that it could create an application that would allow them to self-register at practices and hospitals.
Sales
Orlando Health’s Physician and Professional Services Group expands its relationship with VisiQuate, a provider of enterprise performance management tools.
Spartanburg Regional Healthcare System (SC) contracts with Wellsoft for its EDIS, which it will integrate with its McKesson systems.
Brown & Toland Physicians (CA) selects the Allscripts Community Record, powered by dbMotion, for its 1,500 physicians.
Central Ohio Primary Care Physicians chooses eClinicalWorks for its 230 physicians.
Centracare Health System’s St. Cloud Hospital (MN) selects Merge Healthcare’s iConnect vendor neutral archive (VNA) and iConnect Share. Also, HealthPartners chooses iConnect VNA for its enterprise-wide imaging strategy.
People
MedHOK appoints Rahul Singal, MD as its chief medical officer. He’s a former president and CEO of WorldDoc and was VP and medical director of Southwest Medical Associates.
Announcements and Implementations
Oakland Physician Network Services (MI) extends Michigan Health Connect’s HIE solutions to its 425 physician members.
Healthland EMR client Glacial Ridge Health System (MN) becomes the first hospital in Minnesota to achieve Meaningful Use under Medicare’s EHR incentive program.
Cerner implements Oracle Enterprise Manager to support cloud-based services.
Children’s Hospital and Health System (WI) begins training users on its new Epic system in preparation for a go-live in late 2012 or early 2013. The project will cost $120 million over five years.
Convergent renames its RCM division Convergent Healthcare (formerly AHC) and introduces its Convergent CARE product line.
Ohio State University Medical Center goes live on iSirona’s device connectivity solution, connecting 700 wired monitors and wireless ventilators to Epic.
Iatric Systems launches EasyConnect Jaguar, an advanced healthcare interface engine.
Denver-based virtual clinician desktop vendor AventuraHQ hires 15 new employees, most of them in sales and marketing, following its first round of institutional venture funding.
Innovation and Research
The Robert Wood Johnson Foundation announces its Aligning Forces for Quality (AF4Q) $100,000 app challenge, designed to encourage the development of easy-to-use online tools that consumers can use to find quality information on their local physicians and hospitals. The deadline for the competition’s first phase is December 31, 2011.
Technology
Penn Medicine adds a second pilot using its Penn Research Trial Advisory software, a homegrown application that flags candidates for clinical trials. It’s programmed to look for specific patient criteria that fit current clinical trails and delivers a pop-up alert when medical staff enter patient data into the hospital’s EMR.
Other
Peirce College (PA) will use software applications from QuadraMed and 3M in its new Health Information Administration bachelor’s degree program.
A Wolters Kluwer Health survey of physician finds that search engines like Google and Yahoo are second only to professional journals and colleagues as a source of information for diagnosing and treating patients. The same study lists physicians’ top barriers to technology adoption: too expensive, too much data and not enough actionable information, too hard to learn, and too hard to use at the point of care.
Siemens Healthcare announces its commitment to deliver its Soarian solution to small community and rural hospitals. Siemens recently implemented Soarian Clinicals at the 70-bed Platte Valley Medical Center (CO) and at the 202-bed Palisades Medical Center (NJ).
George Reynolds, VP/CIO and CMIO of Children’s Hospital and Medical Center of Omaha, tells me they’ve decided to go with Epic (displacing Allscripts on the inpatient side, I assume.) They were already using Epic ambulatory. Phase 1 will go live in early 2013 with inpatient, ED, pharmacy, and surgery. If you don’t know George, check out his credentials: he’s an MD, has a Master’s in Medical Management, was director of pediatric critical care at University of Nebraska Medical Center, and now is both CIO and CMIO at Children’s. Not to mention that he’s a funny guy. I need to interview him sometime.
What might have been: as Steve Jobs was near death, he was sketching plans for an iPad holder for hospital beds and designs for other hospital equipment.
Doctors know that text messaging patient information from smart phones may violate HIPAA, but it’s so efficient that they do it anyway.
Researchers find that gastroenterologists who listen to Mozart during colonoscopies improve their precancerous polyp detection rates from 27% to 36%. Other bodies of research has found that listening to Mozart’s music may result in significant short-term improvement in spatial temporal reasoning.
Weird News Andy finds that this sad story sets the pace. A man living in a Chicago group home tells staff he’s having chest pains and asks them to call an ambulance while he waits in his room. Paramedics arrive, and noticing a puncture wound to his chest, think someone stabbed him. Someone did: the man himself, who cut open his own chest to try to remove his pacemaker. He died in the hospital.
Sponsor Updates
The Advisory Board Company will host a conference on transforming physician talent development on November 14 in Washington, DC.
Encore Health Resources will participate in this week’s Louisiana HIMSS 2011 Fall Conference.
DIVURGENT is attending the Virginia HIMSS 2011 Fall Conference and the Midwest HIMSS Fall Technology Conference.
API Healthcare will participate in the HealthcareSource User Conference in Las Vegas.
Florida Hospital Celebration Health implements the GetWellNetwork solution in its new patient care tower.
Cumberland Consulting Group promotes Lindsay Lopez to executive consultant.
Hayes Management Consulting announces its new inpatient consulting division, which will be led by Amitav Hajra, formerly of Epic Systems.
Stockell Healthcare Systems receives ONC-ATCB certification for its InsightCS Revenue Cycle Information System.
Eastland Memorial Hospital (TX) and Hamlin Memorial Hospital (TX) qualify for Meaningful Use money using the Prognosis ChartAccess Comprehensive EHR. Eastland signed their contract in February, went live in June, attested in September, and got their check in October.
Heard that all of our sites are moving to Epic. We have started hiring internally already. Don’t know if this…