Curbside Consult with Dr. Jayne 10/31/11

Today is Halloween, which is without a doubt my favorite day of the year. It’s one of those days where even adults can act like kids and playing dress-up is OK. People love to mark the occasion by visiting haunted houses, watching scary movies, and telling ghost stories.

So everyone grab a popcorn ball and some of those little peanut-buttery candies in the orange and black wrappers and turn the lights down low, because it’s time for Dr. Jayne’s Top Ten List of Horrifying and Frightening Things.

10. HIPAA compliance zombies. You know the type — those that cite HIPAA as the reason for everything, regardless of relevancy. I had a run-in with one of these who told me (as the referring physician) that she couldn’t fax me a copy of a consultation note (which was addressed to me, but had only arrived with one of three pages present) unless I sent a release signed by the patient. Reason: HIPAA. (I bet in her head it was spelled HIPPA.)

9. Physicians who demand that allergy checking and other EHR decision support be completely disabled because they “know all that stuff already.” I understand (and loathe) alert fatigue as much as the next gal, but seriously, I can’t imagine that there’s a physician who has never accidentally prescribed a medication to someone who was allergic to said medication. I know I’ve done it and you know you’ve done it at least once in your career, too. If that doesn’t scare you into leaving the allergy checking active, it should.

8. Shortages of common medications, including vaccines and chemotherapy drugs. Often these are low-profit margin generics and are made by only a handful of manufacturers. If one of them experiences production issues, the entire supply is threatened. Something to think about the next time you read about all drug makers being branded as greedy.

7. Celebrities and politicians dabbling in the public health sphere by adding to vaccine hysteria. Want to see something really scary? Pictures of vaccine-preventable diseases. I wish they’d spend their time advocating anti-drug and anti-obesity propaganda instead.

6. Patient-facing software vendors who do not have licensed physicians on staff (or at least as consultants.) I’m not sure how they evaluate usability, let alone suitability for patient care. The only thing scarier is the hospitals and health systems that actually purchase this software.

5. Hospitals and ambulatory organizations that implement patient-facing software without physician leadership or oversight. I recently moonlighted at a JCAHO-accredited facility that had an allegedly certified system. However, for some reason, the prescriptions printed without a medication route. The system also had “never use” abbreviations on the prescribing screen. I’m not sure why they were printing on paper in the first place, but with obvious patient safety and regulatory issues to address, I didn’t pick the eRx battle that day.

4. Congressional rule-making that increases health care costs in the name of balancing the budget. I’m talking about the ridiculous change that made patients obtain prescriptions in order to use flexible spending accounts to reimburse over-the-counter drugs. Let’s see, the reason they’re over-the-counter is because they don’t require a prescription. But now, to save money, I have to get a prescription for my OTC med (after paying a co-pay), take it to the pharmacy, waste their time submitting it to my insurance to get the denial because it’s OTC, then pay cash for it and submit it to my FSA overseer. If they thought this process was going to deter patients, they were wrong (I’m not sure they thought it that far through the process, though) because patients are coming in droves for these scripts and some offices are charging fees for preparing these extra prescriptions. There’s a whole lot of spending going on here and it’s your fault, Congress. Next time you’re going to do this kind of thing, can you please ask a primary care doc his or her opinion first? I’d rather be counseling the obese, hyperlipidemic, hypertensive diabetic about his cardiac risk than writing another prescription for little Johnny’s diaper cream.

3. The fact that the item above is only a teeny, tiny, microscopic piece of what Congress has done or is trying to do with healthcare. I’ve got an idea: Let’s form a Congressional HMO, enroll all the legislators and their families in it, and use it as a pilot site for health care reform proposals. Once they prove efficacy on a captive population, only then should it be allowed to see the light of day. Muahahaha!

2. The emergency department at almost any urban hospital and quite a few suburban and rural ones, too. Overcrowding is often the norm, and due to fright-inducing Acts of Congress such as EMTALA, everyone is treated regardless of the ridiculousness of their chief complaint or its appropriateness for the emergency department. I know some hospitals were (and still are) guilty of patient dumping, and that is indeed a crime, but having to perform a medical screening examination on a patient who presents with “wants to know if I’m dyslexic” at 11 a.m. on a Saturday is a waste of resources. And yes, I really did see this patient, but only after the nurse had to spend his time assessing the patient’s pain score and asking him if he had an advance directive. This was in an ED that sees about the same patient volume as that of Massachusetts General Hospital, so it’s not like we were just sitting around shoe shopping on the Internet.

1. Watching providers adapt to ICD-10. I’m hearing lots about ICD-10 readiness and how software and billing systems will handle it, but am hearing very little about how organizations are actually going to train their providers to identify the appropriate new codes for old diseases. Word in the Doctor’s Lounge is that providers think EHR vendors will just automagically map the codes for them. They apparently missed the fact that it’s not a 1:1 conversion. If your vendor is telling you they’ll do this, you should be as frightened as if you just ran into Jason Voorhees and Freddy Krueger chatting at the coffee machine.

I hope after all this you’re not too scared to open the door to trick-or-treaters tonight or to do some candy hunting of your own. Maybe you’ll stop by Casa Jayne and not even know it. I’m one of the “good candy” houses and my office at work is also well provisioned. I stocked up on Sweet Tarts and Sprees should a certain sassy sales exec decide to stop by. I’ll be in costume (of course!) but I’ll give you a clue — you’ll be able to figure me out by my shoes. I’ll bet Inga doesn’t have a pair of these!

E-mail Dr. Jayne.

HIStalk Interviews Farzad Mostashari MD ScM, National Coordinator for Health Information Technology

Farzad Mostashari MD, SCM is National Coordinator for Health Information Technology of the US Department of Health & Human Services.

Has HITECH spurred EHR adoption to the level anticipated?

I think so. I think the EHR marketplace had been kind of growing, but slowly. After 20 years, we were at 20% EHR adoption. Then, with the passage of HITECH, I think it is undeniable.

You talk to practically any provider out there and they have either acquired, they are shopping for, or planning to get an EHR. The ice has broken run a very real way. The survey results from last year found that among primary care providers, it went from 20% to 30% in one year for having a basic EHR. I expect this year to be 40%. Next year, 50%.

That is pretty remarkable. As the Secretary put it, HITECH has been successful at “lighting the spark” that is now ignited in terms of getting this modernization of healthcare to happen. I think it had its intended effect.

Now for the long term, this is not a one-year or six-month or 18-month story. The longer test of HITECH will be: are we able to serve as a foundation for healthcare that costs less, that has higher quality, that is more patient centered and safer? We are going to have a little bit longer time before we can answer that definitely. But so far we, are hitting the milestones.

What do you think? Do you think HITECH has had its intended effect on EHR adoption?

Yes, it has had an effect, but what has been the benchmark? Was there a specific goal on the onset as to where we would be in Year One, Year Two, Year Three? There is still is obviously a lot of resistance out there for one reason or another.

Healthcare doesn’t change very quickly. It can take four years to get one hospital to go through an implementation. People who have done actual implementations of EHR know how hard it is to get one hospital to move. We did not say,” If we hit this number, we are successful. If we do less than that, we are unsuccessful.” But, I think by any metric, the early indicators are extremely positive.

Usability is one excuse that providers use for not adopting EHR. Is ONC doing anything to try to do to improve usability in the marketplace?

I think it is more than an excuse. I think that there really is a frustration on the part of many providers with usability of the systems they purchased. I was recently at my reunion for my residency class in internal medicine. Someone came up to me and said, “Thank you for what you are doing, but the EHR that we have is really lousy.” And I said, “I am really glad I didn’t choose it for you!” [laughs.]

That is one difference between the approach we took in the States versus what the UK did. They said, “We are going to do the procurement. We are going to choose the systems and that is what you are going to use.” We said no, providers are going to choose what system is right for them. I love that market-based approach.

The only problem is that providers consistently say, “I didn’t know what I bought until three months after I bought it. I didn’t know what the usability of the system was really going to be, because all I saw was these demos I had from people who knew their way around the system and knew spots to avoid.”

I do think usability is a serious issue for us — vendors, doctors, academics, and the government — to tackle together. The right question that you asked was, “What do you think you can do about it?” I think it starts with having some baseline expectations around user-centered designs, around user-based testing.

I hope we’ll have some common sense, consensus-derived standards for what are some aspects of usability that you actually can measure. I think if we can bring that to the industry and to providers, we will have done a great service.

Would that involve making usability a requirement in certification?

No. I think the first step is simply just to say, “This is how you would measure usability,” and vendors are free to test their products against this. There will be more transparency. People, when they are purchasing systems, they can say, “What is your usability on this or that metric?” and incorporate that into their decision-making. This is something we will have to monitor and adapt as we go along.

We are very aware of the policy balance between the protection of the safety of the patient, certainly, and responding to what we are hearing from providers that usability being a major sore point for them, but not stifling innovation and not saying, “You shall do design this way,” which is a sure way to not get the innovation that we want.

As the bar continues to be raised in Stage 2 and Stage 3, what happens if providers aren’t able to meet those requirements? Does the money not get spent? Does the stick not get used?

What we heard from the Policy Committee and the vendors and providers was that people are going to need more time in Stage 1 before they do step up. We have heard that. We agree with the logic of the Policy’s Committee recommendations on that. Under that scenario, people would have 2011, 2012, and 2013 at Stage 1 before they would have to move up to the Stage 2 requirements.

One of the things that we are going to be doing in rule-making is around what Stage 2 is going to look like. If you look at what the Policy Committee recommended, it is going to strike the same sort of balance we struck in Stage 1. Where Stage 2 requirements are ambitious, they do they move the ball forward, but they maintain connection and continuity with what went before. So, it is not a dramatic departure from what Stage 1 is. It is more evolutionary than revolutionary in terms of what Stage 2 is compared to Stage 1.

Our goal is for it to be achievable, but ambitious. I am sure will hear plenty of feedback as to whether we hit the target.

When is the last time you used an EHR?

Wow. I have had the great fortune of seeing a lot of different EHRs, but the last one was when I was in New York City, when we were not just using them, but actually helping create more usable public health than prevention-oriented functionality in the systems that we worked with there.

Was that with a variety of systems, or was that when you were implementing eClinicalWorks?

We were implementing eClinical, but also Epic at the Institution for Family Health and NextGen, so working with a number of different products to particularly implement decision support quality measurements.

Much of the country is critical of the Obama Administration and many feel that perhaps there’s been failure there. What is your opinion?

I am very proud of the work that we have done on HITECH and in this administration. I think a lot of what we have done sets the foundation for doctors and hospitals to provide care that is safer and more effective, and that is more affordable and more patient-centered. I have no second thoughts about the rightness of the approach this administration has taken on this issue that I am working on.

I also want to make clear that I think the Affordable Care Act is greatly underappreciated, in terms of how beyond what it does for prevention and beyond what it does for coverage. There are really, really fantastic aspects of the Affordable Care Act that people don’t know about and just don’t understand — around care delivery, around giving options for providers who want to deliver care differently and have different payment models.

There is a lot of attention focused on the ACO regulations that just came out. I think there is widespread opinion that they are greatly improved, and I absolutely agree. There are a whole host of different payment models that are enabled. Also, the Innovation Center, that can test different models and roll the out to the rest of Medicare.

I just think people think the Affordable Care Act is just about insurance, but it is about so much more than that. There’s a lot of good stuff there.

When you met with the HIT standards committee, you urged them to move forward on the HIE piece of it. Are you encouraged that we are moving forward?

I think we are, absolutely. I think the message was heard and they made recommendations for moving ahead on standards that are not going to be perfect, but will be good enough, and we will continually improve them. I felt that unless we move on moving data — not just structuring it within systems, but actually having standards for how that information gets transported — we are going to be me missing a big opportunity.

This is the most important question of all. In the last couple of years, Dr. Blumenthal earned HISsie awards for Industry Figure of the Year. If you should win it for 2011, are you going to accept your award in person at HIStalkapalooza?

I would be happy to.

Monday Morning Update 10/31/11

From What About Bob?: “Re: HIT Stack Exchange. Took a year to get enough people to commit, now we need the masses to ask and answer questions so the site can survive. Give us nerds some love.” HIT nerds or nerd-wannabes should take a look.

From Orlando Cepeda: “Re: Dr. HITECH’s Rainbow Button Initiative Rap. Lyrics are here.” Ross did great with these. Here’s a section where he lyrically explains the VA’s Blue Button medical record download:

I been to far-off lands, tryin’ to do what’s right, I had dreams and plans, when I got caught in a firefight.
Now back in the states, I’m a wounded warrior, all my doctors are great, but sometimes I ain’t sure,
Exactly how to keep it straight, or know just how to navigate, all my meds and lab results, and how they relate,
But now I push the Blue Button, and it’s all there to see, just a click of the mouse, and it all comes to me. 
And it’s not just for this vet, heck that ain’t nuttin’, just see what stuff *you* get, when you hit the Blue Button.

From Arcturus: “Re: exposure. You recently mentioned our company on HIStalk. We got several inquiries from companies wanting to be a VAR for us, several VCs inquired, and it caused some buzz. Very much appreciate your doing this.” My pleasure. If I’ve heard about something and it interests me, I’ll almost always mention it. It does get a bit tough when companies try to press me to write about them and (a) I don’t find their product or service all that interesting, or (b) I’m too busy. People sometimes forget that HIStalk is an after-work thing for me, meaning I can’t chat on the telephone during hospital working hours and I’m not usually willing to give up some of my handful of free hours each week to watch a demo or comment on a white paper, especially if it’s a company or person I’ve never heard of.

Three-quarters of respondents say it’s silly for docs to be required to crank out engaging, unique narrative for every repetitive patient encounter, but a fourth don’t want HHS paying for encounters described in boilerplate. New poll to your right: can healthcare reform’s needed improvements in cost and quality be realized with today’s IT systems?

My Time Capsule editorial from 2006: Misys Lesson: Mama, Don’t Let Your Vendors Grow Up to Be Conglomerates. I don’t like to show paternal favoritism toward my editorial offspring, but I admit this is one of my favorites, with hyper-caffeinated ramblings like, “Why did a British financial software company get into the US healthcare IT market in the first place? Well, let’s just say it wasn’t a noble desire to better humankind. From their Web site, ‘The main objectives were to reduce the Group’s exposure to a single market (insurance) and to increase its size in an already consolidating software sector.’ That’s about as unemotional as an accountant’s nimble calculator fingers determining the net present value of three dinners with Myra the secretary vs. the potential passion-filled payout.” 

Unrelated (mostly, anyway – it does involve exercise and personal motivation) but for a guaranteed Monday morning smile, check out this brilliant commercial for Contrex mineral water, which I can’t get out of my head. I know Inga will like it.

The merry pranksters at Epic put up a Halloween-inspired Web page that includes interactive spider-smashing. I’m sure it will be gone after Monday, so last call.

Encore Health Resources announces that Joe Boyd has replaced co-founder Ivo Nelson as board chair. Boyd has been advising the company for the past 18 months and has worked with Ivo and CEO Dana Sellers before at Healthlink, where Joe was board chair, Dana was president and COO, and Ivo was CEO until they sold the company to IBM in 2005. Encore has been quickly ramping up revenue and headcount and was named the #2 best HIT advisory firm by KLAS. Ivo will remain on the board.

Coincidentally, I’d been thinking for several days about something Ivo told me in my 2009 interview, reminded of it while reading the Steve Jobs biography:

This is nothing more than me doing what I love to do. If it leaves a legacy, I think that’s OK, but I’m not sure what you really get out of that. When I’m hopefully up in my 80s or 90s and I pass away, the people that are going to come to my funeral are going to be my family. It’s not going to be clients. It’s going to be people that are close to me personally in my personal life, my kids and my sisters and a handful of friends probably that I have. That’s a legacy. You say, "What kind of legacy would I want to leave?" and it would be a legacy that’s more related to being a good father to my children and being a good husband to my wife. That kind of stuff. Not anything I do professionally.

Inga encroaches on Weird News Andy air space in summarizing this story as, “I guess the guy wanted the doctor to give him a hand.” A homeless man with a history of mental problems rushes into a urologist’s office gushing blood, saying he had just accidentally chopped off his arm on a homemade guillotine. Nurses call 911 (probably the best course of action for a urology practice dealing with an amputation,) and when police check out his wooded camp, they find a huge guillotine built from scavenged timber, along with his recently severed arm. One world-weary police officer observed, “My goodness, a lot of thought went into this.” One can only imagine the intended purpose of his handiwork given that his self-amputation was accidental.

Vince’s HIS-tory covers a company I’m not familiar with: Computer Synergy. He says its product was so progressive that its still running in dozens of hospitals and its successor firm was just acquired a few months ago, with details coming next time.

Shareable Ink CEO Stephen Hau is named Innovator of the Year by the Nashville Technology Council. They haven’t posted pictures of the winners yet, so I’ll go with a company team lunch pic that I found on Facebook, with Stephen on the right.

CHIME Foundation gives Allscripts CEO Glen Tullman its 2011 Lifetime Achievement Award.

Omaha-based transplant systems vendor HKS Medical Information Systems is acquired by an investment group led by Argenta Partners LLP. Louis Halperin is named CEO and Paul Markham COO.

AventuraHQ names neurosurgeon and venture partner Teo Dagi MD as CMO. How about these educational credentials: Columbia undergrad, Hopkins MD/MPH, Harvard MTS, Wharton MBA, Queens University DMedSc. I profiled Aventura, which offers a virtual desktop for efficient clinician access, in July.

Small hospital systems vendor CPSI announces Q3 numbers: revenue up 2.8%, EPS $0.54 vs. $0.45, missing expectations by quite a bit and falling short of previous guidance. System sales were down, which is not exactly cheery news knowing that the HITECH effect is close to peaking. Shares were hammered, taking a 28.5% haircut at Friday’s close as the Nasdaq’s biggest percentage loser by far. Above is the one-year chart of CPSI (blue, straight vertical line on the right) compared to the Nasdaq (red) and S&P 500 (green). The stock had been climbing nicely, but tanked enough in a single day to barely put it above the indices for the year. Market cap is $564 million.

Speaking of stock, shares in MedAssets jumped 14% Friday, with an analyst attributing “weakness across the rest of the health IT group” that includes Cerner, Quality Systems, and CPSI. Michael Cherny of Deutsche Bank Securities says MedAssets “has no exposure to electronic health records” like those previously mentioned EHR vendors whose earnings reports this week were “disappointing” or “confusing.” That may just be a reaction, however, since after-hours trading shows MedAssets, which reports earnings Thursday, giving back the full amount of its Friday gains. And while MDAS shares had a nice Friday, the past 12 months haven’t been nearly as kind, with shares down 40%. The one-year share price graph shows compares MedAssets (blue), Cerner (green), and Quality Systems (red).

The Rockford, IL paper covers the HITECH status of local hospitals. OSF Saint Anthony uses Epic and has been paid $2.5 million in MU money. SwedishAmerican, with Meditech and Epic, has earned $7.5 million for the hospital and $4.5 million for physician practices. Rockford Health is installing Epic in its practices and hospital and will attest in 2012 and 2013, respectively.

For my techie brothers and sisters: Tom Munnecke (software architect, VistA) has an after-dinner chat with Ward Cunningham (inventor of the wiki) and Ralph Johnson (computer science professor and author) on the subject of “refactoring",” specifically with regard to VistA. Tom’s iPhone made a darned nice video with good audio. It’s kind of like Live from Daryl’s House for geeks. I got myself thinking about my techie sisters reference – nothing’s more attractive than a smart, cynical female programmer, of which there are sadly too few.

Meaningful Use and Beyond, a book by Fred Trotter (healthcare open source expert) and David Uhlman (CEO of open source EMR vendor ClearHealth), is published by O’Reilly.

The Federal Trade Commission will require the parent company of prescription data vendor IMS Health to sell two product lines of its acquisition target SDI Health to receive FTC’s approval for the sale to occur. SDI’s tools for promotional audits (estimates drug marketing costs) and medical audits (analyzes physician prescribing by condition) would give IMS Health a monopoly, according to the complaint by FTC, which must approve the buyer of the two product lines.

I feel like a Facebook stalker for posting this, but I will anyway. I noticed a “Like” for a recent post from Mark Work, IT director at ProMedica Health System in Toledo. Checked out his info, it linked to a site for Madison Avenue Band, a ten-piece cover band with horn section and no computers (thank goodness.) Check the video above – these guys (including Mark, I assume – looks like him on keyboard, but I’m not sure) are real-deal rockers. Check out this smokin’ version of “Vehicle” and here of “Wild Nights.” Not only do I love the music, Mark’s Facebook pics are a trove of cool 70s music history – Foghat, Uriah Heep, ELP, Queen, Foreigner, Heart, Styx, and Yes. Well worth my half hour to watch the videos and check out the pics. My arms are tired from air-drumming.

Cisco CEO John Chambers and the King of Jordan launch the Jordan ICT Task Force, which will promote Jordan’s HIT vendors.

GetWellNetwork is named Emerging Business of the Year by the Montgomery County (MD) Chamber of Commerce, which featured the company in a three-minute overview video.

A state-mandated Web site that allows Ohio consumers to compare hospital performance is apparently going down the tubes. The Ohio Hospital Association is supporting a bill that would eliminate the requirement that hospitals provide their data for the Ohio Hospital Compare site, saying they already send the same data to CMS’s Hospital Compare site that anyone can use.

Texas Health Resources runs an ad campaign around its use of AirStrip Cardiology that includes billboards (“Now Your EKG Gets Here Before You Do”) and TV commercials (above).

Merge Healthcare says 11 radiology practices have bought its RIS v7.0 to achieve Meaningful Use. One of its customers brings up the Complete vs. Modular HER issue, saying, “If you utilize a modular system, you as the provider, the onus is on you to find another product or combination of products that meet the remaining criteria before you can claim to be using a certified EHR and qualify for MU funds.”

Chiropractors are getting their HITECH payments, too.

Medtronic hires Symantec to assess the security of its insulin pumps after a McAfee team demonstrates how a hacker could control them from up to 300 feet away. 

In England, a terminally ill, mostly blind 14-year-old boy has his iPad stolen from his hospital bedside, which had been donated my Make-A-Wish Foundation so that he could enjoy it for the short time until he goes fully blind. All is well, however – a local supermarket was touched and bought him a replacement, with his reaction to it pictured above.

A new poll finds that only 34% of Americans like the Affordable Care Act, while 51% view it unfavorably, the worst numbers since it was introduced last spring.

A Massachusetts court dismisses a lawsuit against Tufts Medical Center, sued by a patient who claimed their faxing of her hysterectomy surgery records to her employer’s fax machine violated her privacy because co-workers read them. The patient had given the doctor instructions to send the records there, but still feels her lawsuit was justified.

E-mail Mr. H.

Time Capsule: Misys Lesson: Mama, Don’t Let Your Vendors Grow Up to Be Conglomerates

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.

Misys Lesson: Mama, Don’t Let Your Vendors Grow Up to Be Conglomerates
By Mr. HIStalk

I doubt most Misys Healthcare customers are following the company’s corporate drama as it plays out in England. They want to go private. Wait – no, they just want to sell it to someone! The CEO will lead a takeover group. Hold on, he just resigned! Their board chair is optimistic about their prospects. Shhh … did I just hear him say the company’s software was old and non-competitive? What’s that smell? Shareholder torches burning outside the castle door!

Healthcare makes up about a third of the Misys portfolio. Within that, the lineup is a salad bar of old, mixed-heritage applications from Per-Se, Medic, Amicore, Payerpath, and Sunquest. Sometimes the blended family gets along, but often they don’t (and I’m speaking both technically and culturally.) If you know of any healthcare IT conglomerates in which any of the above isn’t true, that makes one of us.

Why did a British financial software company get into the US healthcare IT market in the first place? Well, let’s just say it wasn’t a noble desire to better humankind. From their Web site, “The main objectives were to reduce the Group’s exposure to a single market (insurance) and to increase its size in an already consolidating software sector.” That’s about as unemotional as an accountant’s nimble calculator fingers determining the net present value of three dinners with Myra the secretary vs. the potential passion-filled payout. At least they were honest.

With just two software sectors, Misys is focused, at least compared to bigger conglomerates that dip 1% of their corporate body (a toe) into the healthcare waters. Since Misys is the only company actively considering deconstructing healthcare IT out of the soup, what are we learning from their troubles?

• The best way to make money as a conglomerate is to break it up into parts that are usually worth more than the whole and are more affordable to more prospective bidders.
• Conglomerates often reduce corporate value unless they can harness some elusive benefit in supply chain management, reproducible management excellence, or marketing, which few can.
• Conglomerates are fine until you want to sell to someone else who doesn’t share your unconditional love for some of the uglier corporate children.
• Product investment matters more than that impressive brand name. You may be getting free milk every day, but at some point, you better start saving up for a new cow.
• In most cases, button-down corporate management saps out the innovation that made formerly independent companies interesting and successful in the first place.
• Healthcare IT divisions of big companies live and die by the quarterly (or twice-yearly) numbers. Ambitious division executives will sell their souls to avoid being called out as company laggards among their peers. Long-term planning goes out the corporate window.
• Healthcare IT customers carry little weight with toe-dippers. Are GE brass more worried about the flatlining former CareCast or sagging toaster sales at Wal-Mart? Does patient safety come up in Siemens corporate meetings as often as power generators?

Just about every outcome suggests that Misys Healthcare will be carved off and sold. If you’re a foot soldier, hang in there at least long enough to see if the change benefits you. If you’re a suit, Misys publicly labeled its healthcare unit as underperforming, which isn’t a highly valued resume bullet for the new owners, so you might want to beat the traffic out. If you’re a customer, anything or nothing could happen, but you’re stuck either way. If you’re a prospect, there’s a lot of uncertainty ahead, so act accordingly.

And if you’re a vendor focused only on healthcare IT, especially if you’ve resisted the urge to cash out by going public, I say thank you.

HIStalk Innovator Showcase–OptimizeHIT 10/28/11

Company Name: ImplementHIT
Address: 4001 S. Decatur Blvd., Las Vegas, NV 89103
Wen Address: www.optimizehit.com
Telephone: 888.457.3332
Year Founded: 2009
FTEs: 20

Elevator Pitch

OptimizeHIT provides an innovative training platform that enables both pre- and post-implementation training to significantly drive clinical adoption via a more comprehensive, yet easy way for physicians to access the training curriculum.

Business and Product Summary

OptimizeHIT offers a sophisticated, physician-friendly, dynamic EHR training portal. OptimizeHIT’s staff, comprised of MD EHR experts and PhDs in education, have developed innovative, patent-pending learning technologies that integrate seamlessly with any practice setting or specialty. With proper EHR training significantly impacting the success or failure of any implementation, OptimizeHIT’s training suite delivers powerful and relevant training that is easy for physicians to access, significantly reducing the time they spend out of clinic to learn how to use the EHR.

With this technology, organizations are realizing higher rates of clinical adoption beyond Meaningful Use, with a bonus of significant cost savings via a reduction in trainer hours consumed during live training time and time physicians spend out of clinic for training. Management can view learner progress on training as well as their productivity in graphical form, using real-time implementation statistics, and objectively understand the status of each site’s implementation. The solution can also allow on-site support to customize each physician’s learning curriculum to their specific knowledge gaps, keeping their learning time focused on what is most needed for them to learn.

Our cost model is based on per month/per user charge, which can accommodate a small physician’s practice or clinic as well as large, multi-location hospitals. Furthermore, we recently introduced a new no-risk pricing model, where there is no cost per user till a user actually completes their basic EHR training. Once a user becomes an intermediate or advanced user, the EHR benefits to patient safety and ROI quickly climb in to the $1000s per provider.

Target Customer

Large academic hospitals all the way through two-physician practices use this solution successfully.

Customer Problem Solved

Clinical adoption. It is when physicians achieve intermediate- and advanced-level use of an EHR that the greatest patient safety benefits and cost savings are realized. Our portal is built specifically for health IT training, recognizing the unique challenges of training physicians and other healthcare professionals with very little spare time. We are not only getting physicians ready for Meaningful Use Stage 1, but later phases and beyond. Customers live with the portal can easily distribute system upgrade training, new best practices, and even ICD-10 training when the time is right.

Competitors

Other groups that provide standard EHR training with go-live being the end point, like most EHR vendors and a few specialized service consultant groups. However, no one else offers a solution that targets post-implementation training, and that is where you achieve the most efficient leaps in EHR use.

Advantages Over Competitors

We don’t recommend moving all pre-implementation training online, but through a hybrid approach that was featured at HIMSS this February in a presentation by one of our customers. We want to minimize the amount of time physicians must spend out of clinic to learn. Furthermore, we know that physicians learn more advanced features of the EHR a lot faster once they have had an opportunity to use an EHR, which is why our portal integrates the more comprehensive post-implementation training. By providing one integrated solution for pre- and post-implementation training, along with enabling implementation management to see learning and productivity progress in real time, we are much better than any competitor.

The system is also task-based, which means it is more relevant to the learner instead of talking about EHR modules that are abstract for beginner users. Furthermore, because it is task-based and since we deliver standard EHR tasks from beginner to advanced — including Meaningful Use for 10 specialties — the effort to customize the learning content down to the physician specialty is greatly reduced, which makes the content far more relevant and meaningful to the learner.

Pitch Video Created Specifically for this Showcase

Customer Interview (an applications trainer for a large orthopedic practice)

What problems have you solved using the OptimizeHIT technology and what has been the overall impact on the practice?

The first problem solved by using OptimizeHIT’s computer-based training (CBT) modules was improving our training model as we began to prepare our EHR rollout. We were looking at hours of preparation and actual classroom training time with users who were all over the map in terms of PC skills. It was a daunting project and would have required users to be out of clinic and coming in for Saturday training classes as well, which would have meant overtime for some employees. While we still had a few Saturday classes, it was held to a minimum. Our providers never had to take time out of clinic and the overtime was also kept to a minimum.

Anyway, then I was introduced to Andres by a friend, and as soon as I started talking with him, I knew we would work together. His company created customized CBT modules for us using our workflow and screens so that our users were learning how to use the EHR on screens that were our screens – it wasn’t a generic or canned version of training. They worked closely with us to make sure the training modules included great detail. We were able to put much of the responsibility for basic training on the users and they rose to the challenge. We did have to manage the process, checking to see that they were completing the CBTs and where they were weak so we could do focus training with them. But for the most part, our employees did a great job. For those who needed a bit of encouragement, they got “the e-mail” reminding them their CBTs were mandatory.

As far as the impact on the practice, I would say that our users, especially our medical assistants, were well prepared on their first day of live. By the end of the first week, they were fairly confident users. We intentionally designed the training process so that the medical assistants could act as a resource for their providers and they do just that.

If you were talking to a peer from another practice, what would you say about your experience with OptimizeHIT?

To be honest, I’d say don’t even try to train your users without really well designed CBTs, and that you can’t go wrong with OptimizeHIT. They are professional, efficient, epitomize customer service, and even more, they are kind and are comfortable with humor. It was just fun to work with this company and we ended up with an excellent product. I have said exactly that to other organizations.

For those of us who have been in this field for a few years, we have recognized for years that end user training/education is the great hole in the process of implementing healthcare software. Vendors have not, historically, educated the clients (there’s a difference between training and education) and in turn, the clients do not understand the importance of educating their users. With healthcare records, you want confident, accurate users and that means educating them to use the system, but to also think about their use of it critically. Andres and OptimizeHIT focus on exactly that – they are combining adult educational concepts with technology and offer it to sites. 

We call it the gift that keeps on giving. Besides training users for our rollouts, we now use the CBTs for new hire training, upgrade training, user review etc. We are also looking forward to using their new tool to create a post-implementation educational process as a continuing education requirement for our clinical staff and providers.

How would you complete this sentence in summarizing for them: "I would recommend that you take a look at OptimizeHIT under these circumstances:"

If you are a mid- to large-size organization and have a small EHR build/training team, you will simply not be able to meet the demand of build, workflow design, workflow validation, and training. And if you don’t have anyone on staff that has a background in adult education, then you need to consider using this company.

If you’re planning on taking your users through a set of screens and allowing them to do hands-on once or twice – you cannot really consider them educated, and it will show when you take the system live. They will have no confidence and won’t even know when they are making a mistake, so they won’t be able to report it. It could be months or longer until you see that your users are failing to use the system accurately or efficiently.

An interview with Andres Jimenez MD, CEO, ImplementHIT

What’s wrong with the way organizations train physicians to use technology?

There are several issues. Implementation is typically the endpoint of most training curriculums designed for health IT implementations. The challenge is that without the user ever using a system, it’s impossible to teach them everything they will need to know to become an advanced user. Maybe not impossible, but extremely difficult and inefficient.

The challenge with trying to move your training over time to extend it beyond implementation is having a vehicle or a platform like ours to deliver just-in-time training that’s convenient, relevant, and very powerful for end users and extends beyond implementation and builds upon the experiential knowledge that users gain after the first week or two of using an EHR, where learning more advanced features is far more efficient.

Tell me about the technology that you use. I know you have or are seeking a patent.

It runs on Google Web Toolkit, Google Apps Engine. It’s kind of like Gmail for training. It essentially is real-time, Web-based technology. We’ve structured it in a way where it provides real-time statistics to management. It allows us to plug into practice management systems so we can deliver to learners who may be physicians. We can deliver to them real-time productivity metrics, like how many patients are they seeing per day, how is their increase in learning affecting the number of patients they’ve seen per day, how they’re billing, their level of coding. We’re able to pull that data real time. That’s one of the ways that’s very, very unique.

Very often, training and on-site support are two different processes going on in an implementation. We try to combine them, because we feel on-site support is a great opportunity to further the user’s knowledge on the system. We’ve provided input so that the on-site support personnel can continue to assist learners and then they can fine-tune or focus their training curriculum. If the doctor has 10 minutes or an hour to log in to the training programs late at night, they can focus in just on their specific knowledge gaps instead of starting from scratch. That’s another thing that I think is very innovative about the program.

We really feel that it’s going to become the future of health IT training, where it’s task-based, it’s not necessarily module-based. We can assign specific task-based skills that are usually on the two- to three-minute timeframe or are using bite-size training clips. We can assign specific ones to learners based on their role, based on their specialty, and even within two specialties that are different sites. We can customize training at that level. That makes it very relevant, and that’s very important for adult learners.

I’m sure one of the things that you’ve experienced both as a physician and an entrepreneur is that physicians typically don’t like to sit in a classroom with other physicians. Either they get frustrated with the pace or they just don’t feel like they’re being treated individually enough. Is what you’re offering an alternative to that, or is classroom training still a part of their experience? How do you feel about how classroom training works with doctors?

You’re absolutely right. That is one of the challenges that we hear from other physicians. I think on-site training still has an important role. One of our customers at HIMSS this past February presented some results where they were able to reduce the amount of training time, to cut training time in half because they had a Web-based component and a live training component.

Another one of our customers was able to train their physicians without any time out of clinic before the implementation. Now that doesn’t mean that they didn’t do any on-site live training, but what it means is that they were able to move a significant component of the pre-implementation curriculum to a Web-based component through our platform. Then they were able to focus in the on-site session just what the learner needed to go live and do well those first two weeks. Then, since they have the platform, they can allow the users to progress in their use and start learning more advanced functions at their own pace.

So I agree, the traditional on-site training approach has its weaknesses. A curriculum that only relies on that is part of the reason that you see so many implementations failing, because you can’t get that customization. But even on other types of computer-based training, we’re not the only ones that deliver a training online, but our platform allows to do it in a way where it’s very easy to customize it.

One of the other challenges that we see is that many vendors offer e-learning that is just a number of clips by modules in the EHR that are geared towards one specialty. If you’re a cardiologist, the last thing you want is sit down and watch training – especially when you’re having a busy day – with the clinical context of a kid with an ear infection and how to take care of him with the EHR. We make it easy to inject that relevance in training with our platform, which is extremely important for adult learning to get their interest piqued and  their attention level is high. They really learn, and when you want them to perform, they’re able to recall that information.

How do you convince a prospective client who plans to do their own training or pay the vendor to do it to that they need you instead?

We partner with many vendors, so we never want to go necessarily head-to-head with the vendors. They certainly have their place in providing training, but the challenge for most vendors is that they’re scrambling right now just to acquire market share. They haven’t necessarily been able to provide the focus needed on a very specialized approach on training. Not just training that gets them to use the basics, but that drives to Meaningful Use and beyond, where you get the advanced features and the greatest safety benefits for your patients and the greatest return on investment.

We typically tell our customers that we’re providing a platform that is very innovative. It will help your users get to advanced clinical adoption faster with less of an impact on overall productivity. One of our customers was able to get their physicians to full productivity about a week after implementation. That had a huge impact for them. They’re an orthopedic group and some of their physicians see 60 patients per day. We combine our training with the phased rollout approach to make sure that they can return to full productivity. Those are the things that are very important to a lot of customers.

Obviously cost is a factor. We’ve been able to show, for instance at HIMSS this past February, a return on investment of $6 for every $1 invested in our training. 

It’s important for our customers that this platform stays around for awhile. While they may have a cost incurred on just the implementation training, they’re working with the vendors, etc. our platform can stay around. They can start with Meaningful Use functionality and the platform, but right around the corner, there are updates from the vendor, ICD-10, and many other initiatives. They can build into the platform additional training. That’s been very important to our customers. They can do that on their own.

What do you hope to gain from this exposure?

We really feel that our platform is going to be future of health IT training. The fact that not all computer-based training is created equal, that our training specifically drives adoption, gets folks to full productivity faster, and we have a number of customers that have really appreciated and seen the benefits of that. 

What I’m hoping to get from the exposure is actually people getting the chance to hear about us. We’re a small organization, so we don’t have the advertising budgets or the large-scale sales team that existing companies have. Because we’re a smaller group and very innovative, we’ve been able to produce a platform that’s very cutting edge. We’re hoping with this exposure that we can get the word out and more people come on to our site and learn. We’re happy to provide more demonstrations and happy to connect prospects with existing customers, because they’ve been our greatest sales force to date.

News 10/28/11

Top News

Cerner announces Q3 numbers: revenue up 24%, EPS $0.45 vs. $0.36. beating estimates excluding one-time items and raised guidance. The conference call transcript is here. Cerner says customers of an unnamed competitor (Epic) are concerned about their vendor’s ability to keep up with Meaningful Use requirements beyond Stage 1. It also says Epic’s customers are vulnerable to Cerner poaching because of Epic’s deficiencies in ACO readiness, lack of analytics capabilities, and poor total cost of ownership. Recently announced products were mentioned, as was the company’s acquisition of Clairvia and hints that other acquisitions may be forthcoming as “the clock is ticking” in acquisitions starting to look less attractive. It’s also implied that competitors (again, that would have to be Epic) may be getting bottlenecked in their ability to start implementations promptly.

HIStalk Announcements and Requests

This week on HIStalk Practice: daily reports from Las Vegas on MGMA’s annual conference. Mr. H declared I was “full of myself” (harrumph), but you will have to read the updates and make your own assessment. The posts include impressions on various speakers (Dr. Farzad Mostashari and Intel’s Eric Dishman were my favs); assessments of the hottest topics (connectivity, communication tools, and more); the exhibits (nice booths, annoying Elvises, a bit of technology, and the best giveaways); and, of course, hot shoes. Thanks for reading.

Listening: The Black Keys, an Akron-based white nerd duo whose Brothers album sounds like bluesy soul from the early 1960s (but they really rock out on earlier stuff in no-frills ‘70s Ted Nugent fashion). Excellent. And “Not Listening” despite a reader’s calling it to my attention (“Holy Shatner,” he said): yet another hideous and uber-hammy William Shatner non-musical recitation, this time to the tune of Queen’s Bohemian Rhapsody, making his previous masterwork Lucy in the Sky with Diamonds sound like Beethoven by comparison. If you like Star Trek, Queen, music, or your sanity, you’ve been warned because it will bore into your skull like an earwig (entomologically incorrect, I know, but an apt metaphor.) I suppose we can all only dream of being as cornily popular and scorn-immune when we reach Bill’s age (80).

Jobs on the sponsors-only Job Board: Project Specialist I, Account Manager, RVP Sales – Ohio Valley Territory. On Healthcare IT Jobs: Lab Information Systems Analyst, Regional Sales Executive, Epic Security Analyst, Network Administrator.

Acquisitions, Funding, Business, and Stock

Perceptive Software increases its Q3 revenues by about 15%, but less than parent company Lexmark says it expected when it acquired the company last year. Perceptive contributed $23 million of Lexmark’s $1.03 billion in quarterly revenues.

UPMC announces Q operating income of $155 million on operating revenue of $2.4 billion. A year ago, operating income was $93 million. The gain includes $36 million for demonstrating Stage 1 Meaningful Use.

McKesson’s earnings call transcript is here. There wasn’t much new about the technology division, other than profit was up 25% excluding an impairment charge. Analysts who asked questions were more interested in Lipitor and flu vaccine.

Healthcare billionaire Patrick Shoon-Shiong’s NantWorks acquires Ziosoft, a Japan-based vendor of supercomputing software that merges data from a variety of medical images (CT, MR, ultrasound) to allow 3D, 4D, and 5D analysis for diagnosis. The company will be renamed Qi Imaging everywhere except in Japan, where it has 2,000 of its imaging workstations installed.

NextGen parent Quality Systems Inc. reports Q2 numbers: revenue up 32%, EPS $0.35 vs. $0.23. A two-for-one share split took effect Thursday.

Sales

Meditech announces eight new clients.

The Virginia Department of Health awards Community Health Alliance a contract for the statewide HIE. CHA’s strategic and technology partners include MEDfx (IT services), MedVirginia (support services), Troutman Sanders (governance), and Verizon (HIE platform.)

The VA gives Harris Corporation a two-year, $5.3 million contract to transition its billing to ICD-10.

Tucson Medical Center selects MethodCare’s Charge Recovery application to improve coding compliance and identify missed charges.

Shamokin Community Area Hospital (PA) selects ProVation MD for gastroenterology documentation and coding.

People

BridgeHead Software appoints Jim Beagle CEO and president. Former CEO and founder Tony Cotterill will serve as executive chairman of the board and as EVP and chief products officer.

Allscripts appoints Catherine Burzik, president and CEO of Kinetic Concepts, to its board of directors.

MGMA and ACMPE name David Bowman, MD Physician Executive of the Year for outstanding leadership to achieve exceptional performance in healthcare delivery. He is executive director of IPC The Hospitalist Company.

HealthTech Holdings, the holding company that owns HMS, MEDHOST, and Sentry Healthcare Services, names Alan MacLamroc CTO and Geoff Roten CIO.

Announcements and Implementations

Houston Healthcare goes live on Meditech on October 31. CIO Robert Rhodes indicates the organization has invested about $6 million to implement the system.

Springfield Service Corporation and its subsidiary Laguna Medical Systems rebrand into a single organization named SPi Healthcare. The company specializes in RCM, health information management, and ASP hosting.

Piedmont Healthcare (GA) partners with TeleHealth Services to implement TeleHealth’s TIGR system for on-demand patient education and interactive communication.

Aetna President Mark T. Bertolini tells investors that its Medicity subsidiary has a $200 million contract revenue backlog and recently launched its iNexx application store. On supporting the ability of consumers to pay for medical services at the point of sale, “We also can now real-time auto-adjudicate a claim on a smart phone at the doctors office, by the consumer or the provider should they choose to do that, because we’ve now been able to create real-time auto-adjudication connection mobilely. The real issue, the ultimate issue here is whether or not people have the incentive to use it. And I think that’s where plan designs and the accountable care organizations and how they link to these platforms — that’s why we bought Medicity, will create people’s ease-of-use in using the system and using this technology to make decisions at the point-of-sale. And that’s ultimately where this needs to head.”

Olympic Medical Center (WA) signs on as an affiliate of Swedish Medical Center, with OMC’s CEO touting as a key benefit its access to Swedish’s Epic system. He said Epic is “the best” EMR and that 75% of Seattle-area hospitals will be running it.

Government and Politics

US Representative Tom Marino (R-PA) introduces legislation to create a system for reporting potential medical errors that occur when using EHRs. It would include protection that provider-supplied information could not be used as a legal admission of wrongdoing.

The VA announces plans to remove an inappropriate restriction on data sharing with the Department of Defense. The update would allow the VA to share information about treatment for drug abuse, alcoholism or alcohol abuse, HIV status, and sickle cell anemia.

CIO Roger Baker talks up the VA’s use of iPads, starting with access to VistA, but  potentially expanded to include tablet-based access to physiologic monitors, blood chemistry results, and full-motion video to support telehealth.

Innovation and Research

The folks from Project HealthDesign (a project of the Pioneer Portfolio of the Robert Wood Johnson Foundation) sent over an “early findings” presentation on using patient-sourced data in treating chronic conditions. They’re testing apps to determine how to collect “observations of daily living” (ODLs) from patients and how clinicians can use that information to help them manage their health. The five projects involve a smart phone-based inhaler study, iPad tracking of Crohn’s disease ODLs, sensor-based tracking of senior citizen task completion, smart phone collection of ODLs related to high-risk infants and their caregivers, and an iPod Touch study of activity and exercise in obese teens. Caregiver challenges: clinician workflows need to be developed to use the incoming information and EMR limitations make it tough to store information there.

Technology

Finally, a legitimate HIT shoe story. GTX Corp and Aetrex Worldwide are designing an GPS-enabled shoe to keep track of Alzheimer’s patients. If a patient walks outside of a certain geographic region, a device automatically sends an alert to the patient’s caretaker. Hopefully by the time I am completely demented the shoes will be a little more stylish.

Other

Though shoes are my first love, I also have quite a fancy for lattes from Starbucks. Maybe so does Alvin Mingczech Yee, a California doctor who preferred to meet most of his patients in various Starbucks outlets. A federal grand jury just indicted him on 56 counts of prescribing drugs “outside the usual course of professional practice and without a legitimate medical purpose.” It turns out hat Yee’s patients preferred oxycodone and other addictive opiates over espresso drinks.

Less than 10% of providers believe they are over halfway prepared for ICD-10, with most still in the strategy and planning phases of preparation.

Kaiser Permanente takes the top spot on Computerworld’s list green IT organizations. It earned high marks for data center cooling and its “Keep IT Green” program for brainstorming energy-saving initiatives.

HP changes its mind and says it won’t sell its PC division after all, with new CEO Meg Whitman saying the plan of her predecessor, the fired Leo Apotheker, “makes no sense.”

I ran my interview with Aetna’s Charles Kennedy the same day Emory Healthcare announced that it will operate a Patient-Centered Primary Care pilot with Aetna for its employees and some Medicare patients, which he described in general in the interview.  

I ran a link to a Kirby Partners survey on job satisfaction a few weeks back, so they sent over some of the findings. More than two-thirds of hospital CIOs work more than 51 hours per week, but still grade their job satisfaction as 7.2 on a 10-point scale (managers and directors scored 6.8 and non-management staff 6.2.) An amazing 96% of IT employees said their working conditions are stressful, and 74% of the non-CIO respondents say they’ll be on the lookout for a new job in the next 12-18 months. Short-term departmental turnover, however, is expected to be only 0-3%.

Weird News Andy concludes that there’s no good answer to this problem: an uninsured illegal alien who was paralyzed in a Texas workplace accident has been treated by UTMB for three months, but the hospital says it’s time for him to go back to Mexico since their only obligation was to stabilize him. They’ve offered him a free flight back, but he’s not leaving. A local aid group says Texas has the highest level of uninsured residents in the country, Galveston and UTMB are still reeling from 2008’s Hurricane Ike, and financially strapped state government has cut the hospital’s funding.

Here’s a Disposable Film Festival submission involving puppets, the Rainbow Button Initiative, and music by our cult favorite (and puppetized) Dr. HITECH. It would have been better with on-stage microphones (or maybe some directional shotguns), but it gets easier to hear when the music starts. The idea is that in addition to the government’s Blue Button for one-click patient downloading of their health information, there should be a Red Button (lock your record as private), a Green Button (make your de-identified information available to researchers), and White Button (send your information in CCD format directly to a chosen provider).

Yet another study finds few lives are saved when normal-risk women get a mammogram each year.

An anecdotal article picked up by MSNBC concludes that the use of outsourced radiology services can cause miscommunication and patient harm. It cites the example of an ED patient in a small Pennsylvania hospital who had a contrast CT performed. The digital copy was sent to the hospital’s contracted radiology service in a city four hours’ away, but since they were closed, it auto-forwarded to a radiologist in Hong Kong. He found the problem and noted it in his report, but neither the ED doc nor the radiology service followed up. The patient was discharged, her brain abscess ruptured, and the ensuing 11 weeks in a coma left her brain damaged. The article lists several potential problems since nobody actually talks to each other while looking at films in a dark room these days: outsourced radiologists may just rubber stamp their reports, offshore companies may fraudulently sign reports without having them read by a licensed radiologist, and Indian companies offer cut-rate radiology reads of unverifiable quality for radiologists to pass off as their own when billing.

Google donates 100 Web-only Chromebooks to the American Red Cross, to be used by wounded military members being treated at Walter Reed.

Hartford Hospital (CT) is elated to find its name used in the first iPhone 4S commercial, where a woman is shown asking its Siri personal assistant function, “What’s the fastest way to Hartford Hospital?” Says the hospital’s SVP of strategy on being asked early on by Apple to use its name, “We didn’t even know what the product was. We’d never even heard of Siri before. Knowing it was part of Apple, I knew it was going to be a quality commercial.”

A Massachusetts man convinces his doctor and others to invest in his thriving software company, which he said was about to be acquired by IBM. The company was fake — he spent the money of his investors on a second home and a fleet of luxury cars, supplementing his fraud revenues by forging prescriptions for narcotics. He’s been indicted on a long list of charges. The man says he’s the real victim even though the doctor is out $3.5 million.

Sponsor Updates

• Carefx and Tracline will showcase their technology partnership at EHI Live 2011.
• Inland Northwest Health Services (INHS) goes live on its Spokane Connection project, enabling the exchange of information with the Social Security Administration. The initiative is part of the Electronic Disability Benefits Eligibility Determination pilot project and connects data through the Nationwide Health Information Network Exchange.
• GE Healthcare, McKesson, NextGen, Practice Fusion, and Sage Healthcare will participate in a two-year Medical Economics EHR study to determine best practices for PCPs.
• The Great Lakes HIE and University of Michigan Health System announce a partnership to share patient health information using the Axoloti HIE platform from OptumInsight. Also, Optum and Lifeline Hospital Group (Abu Dhabi) launch Optum Middle East LLC to improve RCM processes and performance.
• Imprivata introduces its OneSign Virtual Desktop Access for Citrix XenDesktop at Citrix Synergy Barcelona.
• St. Peters Health Care Services (NY) adds Thomson Reuters Pharmacy Xpert.
• ZirMed introduces SimpleResponse to simplify payer rejection messages.
• TeleTracking Technologies receives designation as a Support Staff Excellence Center by the Technology Services Industry Association.
• Practice Fusion will host a “Doctors of the Future” photobooth during the Bay Area Science Festival.
• eClinicalWorks says its 2011 National Users Conference set a new attendance records with over 3,000 participants.
• Baylor Health Care System (TX) creates an enterprise HIE using AT&T’s Healthcare Community Online platform.
• St. Peters Bone & Joint (MO) says it will save $30K annually by improving its Sage EHR workflow using EMR Optimization software and services from MD-IT, which added dictation solutions and an iPhone app.

EPtalk by Dr. Jayne

HIMSS submits comments in response to FDA’s draft guidance on Mobile Medical Applications. Its key point: lots of groups, including hospitals and health systems, are developing mobile apps while having no experience with the FDA’s regulatory processes. HIMSS calls on the FDA to help educate developers.

Health Services Research publishes an article about readiness for Patient Centered Medical Home initiatives, concluding that nearly half would qualify for NCQA recognition. It cites lack of infrastructure and notes that small practices will need assistance at achieving recognition.

CMS issued guidance last week clarifying attestation requirements for eligible hospitals. I’m not sure it told us anything we didn’t already know, but I give them full credit for trying to make sure that hospitals understand what’s involved in attestation. I continue to be surprised when I speak with colleagues who really have no idea what Meaningful Use is about or how it will impact them.

I’m a little behind in my reading, but a piece in the Journal of the American Medical Association caught my eye as I flipped through my ever-rising stack of paper. Automated Identification of Postoperative Complications Within an Electronic Medical Record Using Natural Language Processing compared coding-based identification of complications to data identified by natural language processing. The authors concluded that natural language processing analysis of electronic medical records at a VA hospital had higher sensitivity “compared with patient safety indicators based on discharge coding.” Contents of EHR notes were mapped to SNOMED for analysis. The authors propose that natural language processing could be used to better identify complications by analyzing documents while the patient is still hospitalized, as opposed to the coding approach, which typically occurs after the patient is discharged.

Weird health technology story of the week: a study in the American Journal of Cardiology suggests that pacemakers recycled from funeral homes could assist patients in the developing world. Although the study involved a small number of patients, 38 of 40 recipients improved after receiving a donated pacemaker. Since pacemakers are approved as single-use devices, researchers are seeking FDA approval to perform a more extensive study.

One of my organizational duties is to work with providers who are struggling with EHR adoption. Usually this involves a fairly painful session with a colleague who really wants nothing to do with the computer and who doesn’t see any benefit to learning. These visits showcase interesting behaviors — avoidance, denial, whining, begging, anger, and hostility. Today I had the privilege (and pleasure) of shadowing one of the most proficient EHR-using physicians I’ve ever seen. He seamlessly integrated the EHR into the patient experience and delivered care far more comprehensively than he could have done with a paper chart. An added bonus: his patients love having their charts in the EHR and are active participants in reviewing their records and assisting with updates. It gave me hope and was a nice recharge for my seriously depleted CMIO battieries.

Bedtime reading: The Final Rule for the Medicare Shared Savings Program, aka Accountable Care regs. Quite the page-turner, with nearly 700 pages of risk-sharing bliss, if you ask me. Changes include a rolling application process, reduced numbers of primary care providers who need to meet Meaningful Use requirements, and fewer required measures. Of course I’ll have to read the whole thing if I want to stay employed, but I’m interspersing sections of it with chapters from my newest chick lit find. I’m pretty sure the cover model is Inga, but it’s hard to know for sure without the shoes.

Contacts

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

HIStalk Interviews Charles Kennedy MD, CEO, Aetna Accountable Care Solutions

Tell me about yourself and your job.

I’m the CEO of Accountable Care Solutions. This is the part of an Aetna that deals with building ACOs on a national basis. I’m also an internist and have had a variety of roles over the years in informatics, health information technology, comparative effectiveness, and research. I also sit on the HIT Policy Committee, which developed the Meaningful Use regulations.

What do you see as the biggest challenges facing the HIT Policy Committee?

Right now, I think there’s probably three challenges I would point to.

The first challenge is that the number of physicians who have gone through the self-attestation process to say they’ve met the requirements for Meaningful Use is substantially lower than what CMS had forecast. At the Policy Committee, we’re keeping our eye on that. As things evolve, we need to may come up with some nuances that allow more physicians to qualify.

The second big challenge is when we developed the regulations, they were largely based off the existing technology, which is electronic medical records, At times, electronic medical records in and of themselves are insufficient to get the kinds of quality and cost improvements that we want to get from technology deployment. Translating the technology deployments to measurable value, I think, is the next big challenge the policy committee faces.

Thirdly, I would point to the technical challenges. Clinical ontology, semantic interoperability is still very uncommonly found in any of these solutions, and in my view, it’s foundational to getting value — or the kind of value that we want to get –from HIT deployments.

Do you see any threat that Congress will pull back some of the HITECH money?

I’m not aware of any threat. Health information technology has generally enjoyed broad bipartisan support, primarily because if you’re going to try and attack the cost equation, HIT is one of the few tools that doesn’t involve benefit reductions or eligibility reductions or some other unpalatable — especially politically unpalatable — approach. I think the House and Senate still very much want to see it successful and I think we’ll stand behind it.

What is Aetna’s perspective on accountable care organizations and how do the Medicity and Active Health Management acquisitions play to that?

Aetna looks at accountable care solutions as the best business model and operational structure to deliver high-quality care efficiently. Because in order to make that successful, you have to have a structure where physicians can operate, work together, and achieve the team-based approaches to managing the patient, which is so common in clinical care today. ACOs gives you a structure.

You have to have alignment of the incentives. It is very difficult to deliver healthcare efficiently when you’re getting paid on a volume basis. ACOs have the right kinds of incentives around gain-sharing, which makes it much more likely that physicians will be rewarded for high value of care rather than volumes of care.

Health information technology is foundational to ACO successes. If you think about many of the things that ACOs are doing, there’s not that much that’s completely new. Many of these things were tried in the ‘90s and had varying degrees of success, but what’s different this time is health information technology. I was in the industry out in California when many of those IPAs and medical groups and capitated agreements were formed. One of the most important predictors of success was the level of IT sophistication for the group accepting financial risk for a set of patients. I believe that the tools we have today are far better than what the best tools of the ‘90s could offer, and I think that gives us a strong chance of making ACOs successful.

Along those lines, to what extent do you think the ACO model will encourage or even require greater levels of interoperability, business analytics, and population management tools, and how well do you think today’s provider information systems can meet those needs?

All of those needs — analytics, applications which support the care process, knowledge bases which allow you to apply the best in medical thinking to each individual patient within the context of the care … is an absolute requirement. The challenge is primarily a data challenge.

Most of the data that is found today is derived from claims data, which has inaccuracies. It has timeliness issues, and it may not always reflect the actual clinical care process. When you get into the realm of clinical data, you find that much of the information is in textual reports. It may be sent in a structured message, but the pieces of information you need to derive from that structured message are often free text. 

Without that clinical data being in a discrete form that we can run algorithms against, that we can data mine, we can write reports against … until that happens, we’re going to be limited by the depth and breadth of the data available to it. That will cause significant challenges in getting the value from health IT that we would like to get in order to make ACOs work.

I really look at from the perspective of we must improve the quality, breadth, and depth of the clinical data and allow that to be fed into engines, repositories that you can apply mathematical operations to. That’s the challenge.

Ours is very much a collaborative business model with the providers, hospitals and physicians. As we see hospitals and physicians needing to take on a certain amount of risk in managing the populations that are associated with an ACO, Aetna’s business model is one to say, how can we provide our intellectual property knowledge to help hospitals and doctors figure out how to do that truly in a collaborative way, as opposed to it somehow being taken offshore or taken back to a big company like Aetna where it’s all being managed by us. That’s absolutely not our model in any way, shape, or form.

What people are trying to achieve in the structure where clinical care can be delivered more efficiently and effectively, that structure must deliver a better foundation for the care management process to be executed. One way is to actually buy practices. We’ve seen various health plans do that. That’s not our approach, because we believe the delivery of care is sufficiently different from the IT tools, the risk management, the actuarial functions, and all the things associated with what a traditional health plan does. We believe those businesses are sufficiently different that it doesn’t justify acquiring practices. Our model is a collaborative model.

It seems the accountable care model may be affecting the viability of the small independent physician practice and maybe even physician autonomy in general. Do you see that being an unintended consequence?

There will certainly be opportunities for physicians to align themselves with larger organizations. Many will choose to do so for the reasons you are citing. They’ll need help with information technology. They’ll need help with reporting and analytics. They’ll need help with risk management. These are all functions that an individual or small group practice simply doesn’t have the bandwidth or the infrastructure to take on.

However, again with our partnership model, we believe we can preserve the look, feel, and operations of an independent practice, but through technology, bring them all the capabilities they need to be successful in an ACO world. We don’t think it’s an inevitable result, but we believe there will certainly be organizations who go down the integration path and look to individual and small group physician acquisition as a way to get it.

How does the partnership model work and who pays for it?

We have a variety of ways of working with delivery systems. They generally fall into three buckets.

The first bucket is what I’ll call a clinical integration focus. Let’s say you’re a hospital and there are 500 physicians in the community who admit to your facility. What we’re finding in the marketplace is that many hospitals are interested in a clinical integration strategy, because they recognize the benefits of having the physicians more closely aligned with their facility as both benefits from the hospital as well as in improved care process.

One approach that we use is to simply say, we will work with you in a collaborative fashion to allow physicians in your community … so this would be to market and sell a Medicity-style solution, which could include health information exchange, it might include an electronic medical record. Through our ownership of Active Health, it could include analytics and reporting as well. What it allows us to do is to offer a seamless set of tools that allow the community physicians to begin to operate as a virtual ACO with a very light footprint. This is not massive EMR implementations, this is not any kind of rip-and-replace type of approach. This is a lightweight, small-footprint approach to allow health information exchange to occur.

Once you do that, there are significant benefits from both the quality perspective as well as an efficiency perspective in simply getting everyone connected. That’s one way we would start interacting with them. We generally charge for those services, but we have very competitive rates and services may be paid for either by a sponsoring organization or by the end users themselves.

The second approach is what we call a population-based approach. This approach is for organizations that do not want to form an ACO yet, but want to take some steps toward forming an ACO. Two combinations that we commonly use in this style are the employees of the hospital. Frequently a good-sized hospital will have 5,000 or more employees. We use that population as a way to deploy some initial tool sets generally centered around chronic disease management and patient empowerment.

Let’s say you have a hospital with 5,000 employees. We might deploy a part or all of the Medicity solutions, connect all of their various systems, and expose that information — to the patients, the employees — and incorporate it as part of a disease management program. We’re typically paid for these services as well, but these services create a financial benefit in terms of lower utilization of healthcare costs, healthier, more productive employees, and so the hospital can realize a net gain from the deployment of these services. Further, it’s really good way for the hospital to be able to see the employer’s perspective of what their healthcare service offerings might look like, and that can be helpful if you want a commercial health plan itself as an ACO.

The third model is a private label health plan. In these types of circumstances, what we’re doing is we are enabling a delivery system to have their own health plan, powered by Aetna. They go to the market, they use their name, their local market reputation. We provide the same types of services that we do today, but the difference is that it’s done under the direction of delivery system in consultation with us and allows for complete transparency. The delivery system sees direct results from the cost initiatives and those flow directly to their bottom line through all of the members that are associated with their private label health plan. It’s very powerful from a transparency perspective and drives the delivery system’s interest in the using more data, more analytics to become more efficient and as competitive as they can be in the marketplace.

From your comments on the HIT Policy Committee as well as Accountable Care Organizations, it sounds as though the EMR systems of individual practitioners aren’t as important as they once were, becoming more of a tool to feed the network, the analytics engines, and population management tools. Do you think that will change the healthcare IT industry?

I think the healthcare IT industry has largely grown up around the customers that they served. When physicians were largely in solo and small group practice, the EMR industry tended to sign the larger organization because they have the capital and infrastructure to be able to adopt an EMR. Most of the vendors have struggled to profitably serve the solo and small group segment.

Now that we’re seeing more and more physicians become acquired by hospitals or in some way, more tightly aligned with systems, I think you’re going to see the EMR industry change. The organizations that are going to become more employed are the ones that are doing health information exchange, because that’s what’s going to be more important to ACOs and integrated delivery networks, as well as organizations that are very sophisticated with their data management capability. Here I’m talking about semantic interoperability, clinical ontologies, and similar ways of being able to use the data in a way influence the care process.

I do think you’ll see a bit of a shakeout. I really have no idea when. I think those with the more sophisticated data management capabilities will be the winners.

When the smoke clears after Meaningful Use, healthcare reform, and Accountable Care Organizations, how do you think the healthcare industry will look compared to today?

I’m going to give you the optimistic answer, which is I hope that the healthcare industry has transformed from an industry that rewards participants based on volume to one that rewards participants based on the value of the services that they provide.

I would expect that ACOs will become commonplace and will become successful and will allow patients, through the use of health IT, to take better care of their chronic disease. 

I hope we begin to see more effective chronic disease management. Chronic disease is responsible for 60-70 cents on the dollar of our healthcare expenditures. If we can begin to use the data that gets generated through the Meaningful Use deployments and digest it and turn it into a form that is actionable both by the individual physician as well as the individual patient, I think there’s a reasonable chance to think that people will get their diseases in better control and that will help us keep healthcare costs more manageable.

Any concluding thoughts?

As a society, we’ve been very concerned about healthcare reform.  I think part of that is because it so big and so complex and so important, But I think we are starting to see preliminary signs in the industry that healthcare reform may in fact work, and may in fact give us better quality care at a lower price. I see reasons to be optimistic about the future in healthcare.

News 10/26/11

Top News

ONC names Judy Murphy, RN, FACMI, FHIMSS as deputy national coordinator for programs and policy, the position Farzad Mostashari held until being named National Coordinator. She was previously VP of EHR applications at Aurora Health Care and has served on the boards of HIMSS and AMIA.

Reader Comments

From Legal Beagle: “Re: MedAssets. Cook County, IL is suing them for a salesperson having a laptop containing PHI stolen from his car.” Unverified.

From ShareBear: “Re: Continuity of Care Document. Does Canada use it as well? Just wondering if US patients could carry and delivery a CCD from their ONC-certified vendor.” I thought it was US-only, but experts can chime in.

HIStalk Announcements and Requests

Inga is all full of herself running around at MGMA in Las Vegas (or “Vegas,” as the logo annoyingly states), trying hard not to compromise her stealthy Inga identity while composing her daily summaries for HIStalk Practice, so I’ve given her the HIStalk day off. I’ll still put my little blue icons here and there since I’d miss them otherwise. The red ones will be back Thursday.

I’m a good way through the Steve Jobs biography (reading it on the iPad, not too ironically), so I’m sure I’ll have something to say about it by the weekend. My impression so far: he was an brilliant, rebellious, insensitive jackass who had amazing ideas and who didn’t hesitate to use his overpowering personality and caustic scorn to streamroll over anyone who stood in the way of seeing them realized, either by their intentions or their lack of equally shared enthusiasm. But it definitely worked for him and for Apple. I felt sorry for Steve Wozniak after reading how he was treated, but even Woz admits that there would be no Apple without Jobs. He should be the next to write a book (I have no doubt it’s coming, if for no other reason than for him to tell his side of the story.)

Save the date for HIStalkapalooza 2012: Tuesday, February 21, 7:00 to 10:00 p.m., at the HIMSS conference in Las Vegas. I was losing interest since I had too little time to figure out the details, but a fun sponsor stepped forward to take the load off my shoulders. Actually, several companies volunteered to foot the bill and meet my attendee-centric requirements (which I really appreciate) and in the interest of fairness, I simply chose the first one that met my checklist. We’ve chosen the venue, menu, and entertainment, so now Inga and I have to work out the stage show (shoe awards, beauty queen sashes, HISsies, etc.) Remember that everything is a day behind in Las Vegas: Monday is the old Sunday (pre-conference workshops, opening reception) and Tuesday is the old Monday (opening session, exhibits open). We’ve always had HIStalkapalooza on Monday, so this year is no different except it will be Tuesday (that makes no sense, but neither does the HIMSS schedule.) We’ll get all the registration stuff together later, probably right after New Year’s. Ladies, start your fashion shopping engines.

Admire the animation-free ad of new HIStalk Platinum Sponsor Passport Health Communications of Franklin, TN. The company, founded in 1996, offers business operations and payment certainty solutions to hospitals and providers. It serves over 1,900 hospitals and 8,000 practices and processes 300 million transactions each year through its eCare revenue cycle solutions, making it one of the fastest-growing SaaS service companies in the country. Its eCare NEXT Patient Access Suite is a single solution that handles patient information verification, address checking, and payments, offering (as the animation-free ad says elegantly) Payment Certainty for Every Patient. The company just announced a big deal to provide 27-hospital Providence Health & Services with payer eligibility connectivity services. You can read case studies on its site from organizations such as Vanderbilt Medical Group, UNC Health Care, West Virginia University Hospitals, Meriter, and Advocate Health Care. Thanks to Passport Health Communications for supporting HIStalk.

Speaking of Passport Health Communications, this is a first. To celebrate their HIStalk sponsorship, they got together with their customer Quorum Health Resources and put together the video above, which is pretty darned funny (my favorite part was the last few seconds). As I watched, I was thinking that the guy who played the boarding pass taker was a good actor, then I saw at the end that it’s actually Passport CEO Scott MacKenzie. I’m impressed.

Acquisitions, Funding, Business, and Stock

Health business intelligence vendor Analytix On Demand acquires Integrated Revenue Management Inc. and changes its name to CentraMed, which will offer a BI platform and professional services.

McKesson announces Q2 numbers: revenue up 10%, EPS $1.63 vs. $1.25, beating analyst expectations by $0.24 (excluding a $118 million one-time contribution to litigation reserves related to the drug pricing lawsuits it faces). The company also beat revenue expectations and raised guidance. Technology Solutions had revenue of $825 million, up 7%. The conference call was this afternoon, but the transcript hasn’t been posted yet.

Long-time IBM CEO Sam Palmisano steps down, replaced by sales and marketing SVP Virginia Rometty. Palmisano will remain as chairman.

HealthStream announces Q3 numbers; revenue up 24%, EPS $0.08 vs. $0.04, beating expectations for both. The Nashville company, which offers healthcare learning and staff competency solutions, has a market cap of $317 million. Shares were just mentioned in a Forbes article called Fifteen Small Company Stocks To Buy Right Now. 

A Japanese company says it saved Italy-based pharmacy IV automation vendor Health Robotics from a hostile takeover by unnamed US companies by acquiring a minority stake in the company. Health Robotics and McKesson sued each other after their distribution agreement went sour.

Sales

Seton Healthcare (TX) selects dbMotion Collaborate as its interoperability platform to cover 11 counties.

Walsall Trust (UK) chooses TeleTracking Technology’s TransportTracking system to replace an existing patient transport system.

Scripps Health (CA) selects Allscripts Community Record powered by dbMotion for its 2,600 affiliated physicians and five hospitals.

Memorial Hermann Healthcare System (TX) selects the T-SystemsEV EDIS to automate physician documentation in its nine EDs, including integration with the EMR and computer-assisted coding solution.

St. Peters Healthcare Services (NY) chooses the Pharmacy Xpert clinical intelligence dashboard for pharmacists from Thomson Reuters.

People

Awarepoint Corporation hires Merrie Wallace, RN, BSN, MN (McKesson) as EVP of product solutions; Chris Cosgrove (McKesson) as senior VP of sales; Greg Arthur (Microsoft) as VP of client management; and Carla Gallegos (Cisco) as VP of national account sales.

Healthcare data exchange vendor Proficient Health of Greensboro, NC names Dennis Barry to its board. He is a pharmacist, CEO Emeritus of Cone Health (NC), and a former educator and administrator for the University of North Carolina at Chapel Hill.

Announcements and Implementations

RelayHealth wins the VA’s “Blue Button for All Americans” contest. Its one-click Blue Button download of a patient’s information was implemented on the required 25,000 physician sites. VA Secretary of Veterans Affairs Eric K. Shineski says, “We wanted to give Veterans and their families easy access to their health data with the Blue Button so they can have greater control over the health care they receive. RelayHealth’s contribution to this goal is more than commendable.” The company will donate its $50,000 prize to the Wounded Warrior Project.

Froedtert Hospital implements NCR Wayfinding to improve the patient experience.

El Centro Regional Medical Center (CA) implements the PatientSecure palm vein scanning patient ID system from HT Systems.

Kansas Health Information Network and eHealthAlign merge their two ICA CareAlign HIE contracts to increase efficiencies and reduced cost to providers.

Fujitsu and Osmosyz announce a scanning product suite that converts paper charts to interoperable documents that meet HL7 Clinical Document Architecture standards. They’re demoing the solution in the booth of partner Aprima at MGMA.

In India, Wipro announces a new version of its Hospital Information Management System that’s used by over 100 customers in India, the Middle East, and Africa.

Government and Politics

Rep. Tim Huelskamp (R-KS), in an interview with reporters from The Heritage Foundation, is asked about Epic CEO Judy Faulkner’s role on the Health IT Policy Committee:

Reporter: Congressman, we at Heritage have done some reporting about, specifically, one member of the Health IT Policy Committee sort of controlling where these federal funds are being spent, who seems to be using her position — this is Judith Faulkner at Epic Systems — to advance her company’s interests, using $20 billion in stimulus funds. Have you looked into how the people who are directing this policy stand to gain from this potential conflict of interest, the sort of cronyism at play here?

Huelskamp: We discussed that in our office just yesterday, and saw an article this morning … I appreciate your work about exposing that. You know, you roll back a little bit of history to the Hillary Clinton era, and that’s helped kill that when that was being put together. Given the closed nature of the process … and I’ll tell you, for Congress to say it’s not transparent on that end, while down the street we’ve got 12 folks around a table dictating the entirety of policy, it rings hollow. 

But the point being, I think most Americans are saying, "Hey, wait a minute. That just doesn’t smell right." So I think that’s an angle to talk about and continue to push on that. We don’t have anything to add. You guys have done great research. We’re going to continue to push on that. We are looking for soft spots, and we just talked about that yesterday — where we can find those. Because there’s somebody in there, without a doubt. If I know Governor/Secretary Sebelius as well as I think I do, there’ll be plenty of other places. You follow the money, and you’ll find out where.

This is a multi-billion dollar initiative. I served on the information technology committee in the state legislature for about 10 years. They couldn’t put together a Medicaid system — am I right on that, Brian? I mean, it was millions and millions of dollars. It would fall apart every year, and then they’d start again and again. This is a cash cow, without a doubt. There’s only, in my understanding, two or three companies that could potentially pull that off and they’ve got connections to the administration.

And later in the interview:

Huelskamp: I’m just thinking about Judith Faulkner and her appointed group. They’re not for sure who appointed them? Yeah, surely you’re joking. We know it’s all political appointments, and that’s how it works, and we understand that.

Australia creates an oversight body to identify and manage patient safety risks related to its national electronic medical records rollout. The group will determine the severity of risks and provide guidance on how quickly to resolve them.

Innovation and Research

Graduate students at University of California Merced are developing an avatar-led virtual physical therapy software application to provide physical therapy services to the elderly.

Partners Healthcare Center for Connected Health gets a $25,000 Verizon Foundation grant to develop a wireless pedometer (a sneaker chip) for teens and a text messaging program that sends them health and nutrition suggestions based on their activity. That’s a pretty brilliant idea and the execution looks good.

Sponsor Updates

• Robert Hitchcock, CMIO of T-System is interviewed for a podcast on the survival of hospital EDs and the necessity of EHRs.
• CareTech Solutions is recognized with “Outstanding Website Developer” and “Information Services Standard of Excellence” awards from the Web Marketing Association, while 13 of its clients win WebAwards of their own.
• Modern Healthcare’s Best Places to Work in Healthcare names Aspen Advisors, Encore Health Resources, Hayes Management Consulting, Iatric Systems, Impact Advisors, maxIT Healthcare, and The Advisory Board Company among its top 100.
• Cumberland Consulting Group promotes Jessa Sprenkle to executive consultant.
• Orthopaedics of Steamboat Springs, PC (CO) selects the SRSsoft EHR.
• ZirMed announces the release of its Patient Payment Developer Kit at MGMA.
• ADP AdvancedMD announces cloud integration between its practice management system and Modernizing Medicine EMA-Ophthalmology EHR.
• Carondelet Health and Ascension Health Information Services (KS) select eClinicalWorks PM/EHR and Electronic Health eXchange.
• Coastal Medical (RI) announces that 47 providers have achieved MU using eClinicalWorks.
• MedVentive Inc. closes a $12 million offering of Series D preferred shares.
• Billian’s HealthDATA affiliate HITR.com launches a blog called Nurse Tech Talk – Bridging Nursing and IT.
• Health Language Inc. launches its LEAP I-10 claims analytics module at the Workgroup for Electronic Data Interchange Fall 2011 Conference.
• Greenway Medical releases an analysis of Medicare’s final ACO rule, authored by VP Justin Barnes, who also is co-chair of the national Accountable Care Community of Practice.
• Intelligent InSites will present Getting the Most out of an RFID/RTLS Implementation at the Northeast Healthcare Technology Symposium in Groton, CT next week.

Contacts

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

Thoughts on NIST’s EHR Usability Document 10/24/11

NIST’s EHR usability report, Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records, can be viewed here. It is in draft status and available for public comments. Comments can be sent to EHRUsability@nist.gov.

ONC has also pledged to review comments left HIStalk. Cllick the link at the end of this article to add yours.

My Disclosures

• I’m not a usability expert, but I have attended usability workshops and possess some familiarity with how software usability is defined and measured.
• I’ve used badly designed software.
• I’ve had to tell clinical users to live with badly designed software and patient-endangering IT functionality because we as the customer had no capability to change it and our vendor wasn’t inclined to.
• I’ve designed and programmed some of that badly designed software myself, choosing a quick and dirty problem fix rather than a more elegant and thoughtful approach.
• My hospital job has involved reviewing reports of patient harm (potential and actual) that either resulted from poor software design or could have been prevented by better software design.
• I’ve seen examples from hospitals I’ve worked in where patients died from mistakes that software either caused or could have prevented.

First Impressions

My first impression of the report is that it was developed by the right people – usability experts. Vendor people and well-intentioned but untrained system users were not involved. Both have a role in assessing the usability of a given application, but not in designing a usability review framework. That’s where you want experts in usability, whose domain is product-agnostic. 

My second impression of the report is that it is, in itself, usable. It’s an easy-to-read overview of what software usability is. It’s not an opinion piece, an academic literature review, or government boilerplate.

The document contains three sections:

1. A discussion of usability as it relates to developing a new application.
2. A review of how experts assess an application’s user interface usability after the fact.
3. How to bring in qualified users to use the product under controlled conditions as a final test to analyze their interaction with the application and their opinions about how usable it is. This is where the user input comes in.

A Nod to the HIMSS Usability Task Force

I was pleased to see a Chapter 2 nod given to the HIMSS Usability Task Force, which did a good job in bringing the usability issue to light. They were especially bold to do this under the vendor-friendly HIMSS, which has traditionally steered a wide berth around issues that might make its big-paying vendor members look bad. I credit that task force for putting usability on the front burner.

In fact, the HIMSS Usability Task Force’s white paper is similar to the NIST document, just less detailed. I’ll punt and suggest reading both for some good background. I actually like the HIMSS one better as an introduction.

Usability Protocol

A key issue raised early in Chapter 3 (Proposed EHR Usability Protocol) is that it’s important to understand the physical environment in which the software will be used. This is perhaps the biggest deficiency of software intended for physician use.

User interfaces that work well for users who are seated in a quiet room in front of a desktop computer may be significantly less functional when used on laptops or other portable devices while walking down a hospital hallway, or on a laptop with only a built-in mouse. That’s a variable that programmers and even IT-centric clinicians who spend their days riding an office chair often forget. The iPad is forcing re-examination of how and where applications are actually used and how to optimize them for frontline use.

The document mentions that ONC’s SHARPC program is developing a quick evaluation tool that assess how well an application adheres to good design principles. Three experts will review 14 best practices to come up with what sounds like a final score. It will be interesting to see what’s done with that score, since it could clearly identify a given software product as either very good or very bad. In fact, the document lists “violations” that range from “advisory” to “catastrophic,” which implies some kind of government involvement with vendors. Publishing the results would certainly put usability at the forefront, but I would not expect that to happen.

The document points out that usability testing “does not question an innovative feature” that’s being introduced by a designer, but nonetheless can identify troublesome or unsafe implementation of the user interface for that feature.” That’s the beauty of usability testing. It can be used to test anything. It doesn’t know or care that what’s being testing is a worthless bell and whistle vs. a game-changing informatics development. It only cares whether the end result can be effectively used (and with regard to clinical software, that patients won’t be harmed as a result of confusion by the clinician user.)

Methods of Expert Review of User Interfaces

Chapter 5 covers expert review of user interfaces. When it talked about standardization and monitoring, I was thinking how valuable a central EHR problem reporting capability would be. Customers find problems that either aren’t reported to vendors or aren’t fixed by them, meaning patients in potentially hundreds of locations are put at risk because of what their caregivers don’t know about an IT problem.

If the objective of improving usability is to reduce patient risk, why not have a single organization receive and aggregate EHR problem reports? It could be FDA, Joint Commission, ONC, NIST, or a variety of government or non-profit organizations. Their job would be to serve as the impartial intermediary between users and vendors in identifying problems, identifying their risk and severity, alerting other users of the potential risk, and tracking the problem through to resolution.

The NIST document cites draft guidance from FDA on usability of medical devices. It could be passionately argued either way that clinical IT systems are or aren’t medical devices, but the usability issues of medical devices and clinical IT systems are virtually identical. Since FDA has mechanisms in place for collecting problem reports for drugs and devices, making sure vendors are aware of the issues, and tracking those problems through to resolution, it would make perfect sense that FDA also oversee problem reports with software designed for clinician use. This oversight would not necessarily need to involve regulation or certification, but could instead be more like FDA’s product registration and recall process.

The document highlighted some issues that I’ve had personal gripes about in using clinical software, such as applications that don’t follow Windows standards for keystrokes and menus and those that don’t support longstanding accessibility guidelines for the disabled.

Choosing Expert Reviewers and Conducting a Usability Review

Chapter 6 talks about the expert review and analysis of EHR usability. So who is the “expert” involved in this step? It’s not just any clinician willing to volunteer. The “expert” is defined as someone with a Master’s or higher in a human factors discipline and three years’ experience working with EHRs or other clinical systems.
 
The idea that clinicians are the best people to (a) design clinical software from inception to final product, or (b) assess software usability ignores the formal discipline of human factors.

Validation Testing

Chapter 7 describes validation testing. It explains upfront that this refers to “summative” user testing, meaning giving users software tasks to perform and measuring what happens. It’s strictly observational. “Formative” testing occurs in product development, where an expert interacts collaboratively with users to talk through specific design challenges.

Validation testers, the document says, must be actively practicing physicians, ARNPs, PAs, or RNs. Those who have moved to the IT dark side aren’t candidates, and neither are those who have education in computer science.

How many of these testers do you need? The document cites studies that found that 80% of software problems can be found with 10 testers, while moving to 20 testers increases the detection rate to 95%. FDA split the difference in proposing 15 testers per distinct user group (15 doctors, 15 nurses, etc.)

The paper notes that EHRs “are not intended to be walk-up-and-use applications.” Their users require training and experience to master complex clinical applications. The tester pool, then, might include (a) complete EHR newbies; (b) those who have experience with the specific product; and (c) users who have used a competing or otherwise different EHR.

Tester instructions should include the fact that in summative testing, nobody’s asking for their opinions or suggestions. They are lab rats. Their job is to complete the defined tasks under controlled conditions and observation and nothing more. They are welcome to use help text, manuals, or job aids that any other user would have available to complete the defined tasks.

The NIST report listed other government software usability programs, including those of the FAA, the Nuclear Regulatory Commission, the military, and FDA.

EHR Review Criteria

Appendix B is a meaty list of expert EHR review criteria. This is where the report gets really interesting in a healthcare-specific way. It’s just a list of example criteria, but if you’re a software-using clinician, you can immediately start to picture the extent of the usability issue by seeing how many of those criteria are not met by software you’re using today. Some of those that resonated with me are:

• Does the system warn users when twins are admitted simultaneously or when active patients share similar names?
• If the system allows copying and pasting, does it show the viewer from where that information was copied and pasted?
• Does the system have a separate test environment that mirrors the production environment, or does it instead use a “test patient” in production that might cause inadvertent ordering of test orders on live patients?
• Does a screen require pressing a refresh button after changing information to see that change fully reflected on the screen?
• For orders, does the system warn users to read the order’s comments if they further define a discrete data field? (example: does a drug taper order flag the dose field to alert the user that the taper instructions are contained in the comments?)
• When a provider leaves an unsigned note, are other providers alerted to its existence?
• Do fields auto-fill only when the typed-in information entered matches only one choice?
• Can critical information (like a significant lab result) be manually flagged by a user to never be purged?
• Are commas automatically inserted when field values exceed 9999?
• Are “undo” options provided for multiple levels of actions?
• Is proper case text entry supported rather than uppercase-only?
• Do numeric fields automatically right-justify and decimal-align?
• Do error messages that relate to a data entry error automatically position the cursor to the field in error?
• Do error messages explain to the user what they need to do to correct the error?
• Do data entry fields indicate the maximum number of characters that can be entered?
• Are mandatory entry fields visually flagged?

My Random Thoughts

Usability principles would ideally be incorporated in early product design. To retrofit usability to an existing application could require major rework, which may be why some vendors don’t measure usability – it would simply expose opportunities that the vendor is unwilling or unable to undertake. 

On the other hand, improving usability doesn’t require heavy duty programming or database changes. The main consideration would be, ironically, the need for users to be re-trained on the user interface (new documentation, new help text, etc.)

Usability can me measured, so does that mean there is “one best way” to do a given set of functions? Or, given that users are often forced to use a variety of competing CPOE and nurse documentation systems, is it really in the best interest of patients that each of those vendor systems has a totally different user interface?

Car models have their own design elements to distinguish them commercially, but it’s in the best interest of both the car industry and society in general that placement of the steering wheel and brake pedal is consistent. With PC software, this wasn’t the case until Windows forced standard conventions and the abandonment of bizarre keystroke combinations and menus.

I always feel for the community-based physician who covers two or more hospitals and possibly even multiple ambulatory practice settings, all of which have implemented different proprietary software applications that must be learned. This issue of “user interoperability” is rarely discussed, but will continue to increase along with EHR penetration.

From a purely patient safety perspective, we’d be better off with a single basic user interface for a given module like CPOE, or even a single system instead of competing ones (the benefits of the VA’s single VistA system spring immediately to mind.) It’s the IT equivalent of a best practice, Usability can be measured and compared, so that means if there are 10 CPOE systems on the market, patients of physicians-users of nine of them are being subjected to greater risk of harm or suboptimal care.

Usability testing does not require vendor participation or permission. Any expert can conduct formal usability testing with nothing more than access to the application. Any third party (government, private, or for-profit) could conduct objective and meaningful usability assessments and publish their results. It’s surprising that none have done so. They could make quite a splash and instantly change the dialogue from academic to near-hysterical by publicly listing the usability scores of competing products.

Conclusion

Read the report. It’s not too long, and much of it can really be skimmed unless you’re a hardcore usability fan. If nothing else, at least read the two-page executive summary. 

For the folks who express strong reaction to the word “usability” while clearly not really knowing what it means, the report should be comforting in its objective specificity.

Even though the document is open to public comment, there really isn’t much in it that’s contentious or bold. It’s just a nice summary of usability design principles, with no suggested actions or hints of what might future actions are being contemplated (if any.)

I’m sure comments will be filed, but unless they are written by usability experts, they will most likely be unrelated to the actual paper, but rather what role the government may eventually take with regard to medical software usability.

It should also be noted that no product would register a perfect usability score. And, that humans are infinitely adaptable and will learn to work around poor design without even thinking about it. In some respects, usability is less of an issue with experienced system users who have figured out a given system’s quirks and learned to work capably (even proudly) around them.

This document really just provides some well-researched background on usability. The real discussion will involve what’s to be done with it.

Let’s hear your thoughts. Leave a comment.

Curbside Consult with Dr. Jayne 10/24/11

A reader recently sent me a link to a blog by Dr. Joe Heyman titled We Can’t Fix All of Medicine with Meaningful Use. He calls out two serious problems with Meaningful Use – measurement for the sake of measurement and the introduction of unintended frustrating inefficiencies that offer no noticeable improvement in patient care.

Heyman states:

It has been my experience that most physicians involved in policy making in the health IT field are unrepresentative of people like me. They are either not practicing at all or they practice one day a week in a huge institution or network. They never do their own coding and billing and have a buffer in place when it comes to measures as well. We little people have no buffers, no counters, no billers, and no paramedical people to help with our workload. Most physicians in this country are in small practices, and most patients in this country are cared for by those physicians. So when a policy maker who has never been in our shoes sets requirements for measurements, a red light and siren should go off to remind people to be sure that the measure is so important that it is worth decreasing efficiency and making technology less attractive to the folks who take care of most of our patients.

Unfortunately, this is entirely true, not just in Meaningful Use, but in various facets of healthcare. Although there are many areas where care can be dictated based on robust study of the evidence, we have entered uncharted waters in knowing whether the dictates of Meaningful Use will actually deliver quality care outcomes. Personally, rather than a hodgepodge of measures thrown together in the guise of Meaningful Use, I’d love to see demonstration projects on each of the measures to determine whether they are indeed valid.

We see this kind of evidence in the Quality Measures portion. Many of these are well-researched disease management elements that have been shown to reduce the burden of disease, improve quality of life, and reduce health care costs. I’m all for these types of measures.

What I’m not for, however, is mindless box-clicking such as Dr. Heyman describes when having to “remember to put a check mark in place saying the patient has no problem every time I would have left the problem list blank.” Playing devil’s advocate, of course one could argue that physicians left the problem list blank because they were lazy, or thought a problem unimportant, etc. Instead, however, we’re going to make everyone check a box instead so we can measure it.

As someone who has spent a great deal of her career in process improvement initiatives, I do fully embrace the concept that what gets measured gets managed. In this case though, I fear that all we’re going to manage is to have providers leverage staff to simply check the box so they don’t have to, potentially increasing inaccuracy rather than what was probably intended, which is to make sure patient charts have accurate and complete problem lists.

He also shares his frustration with requiring collection of ethnicity on each patient, with which I heartily agree. A good chunk of patients out there have no idea of the difference between race and ethnicity – frankly, how many healthcare providers can accurately explain it? – and quite a few patients are offended that we’re even asking. This requires someone in the office (often the physician, who hears the patient complaint even after staff has tried to address it) to explain the goals are of gathering the data, wasting precious time that could have been spent on health counseling, taking a detailed history, and undertaking more clinically relevant pursuits that have been shown time and again to improve outcomes.

For many providers, Meaningful Use is too much, too fast. I know that my staff, regardless of technology, prompts, and reminders, can only focus on so many elements at a time (and we were early adopters, so the distraction of the technology itself is long gone.) In a perfect world, we’d like them to be able to spend their time focusing on issues that will really make an impact with an individual patient rather than gathering individually irrelevant data for broad population initiatives. I’d like my staff to spend that explanation time making sure the patient has resources to pay for her medication so she can even take it, rather than worrying about discerning what my patients call “where my people come from.”

Patients want us to be present in the moment – in the exam room with them, focusing on individual issues and getting to know our patients as people. That is increasingly hard to do when providers are being graded on whether those same patients actually do what we ask them to do and also whether we checked the appropriate box to correctly document it. We’re no longer paid for patient rapport, cognitive ability, or compassion. We are, however, paid for playing a game where checkboxes and regulations rule. This is sad.

I close with another great comment from Dr. Heyman:

We cannot fix everything in medicine with Meaningful Use, and we should stop trying to do so. We can fix lots of things with technology and innovation, but let’s stop micromanaging physician practices. Let’s move from Meaningless Documentation Measurement to Meaningful Care! We can be so much more innovative than Meaningful Use.

And from the back pew of my hospital’s chapel, Dr. Jayne says “Amen!”

E-mail Dr. Jayne.

Monday Morning Update 10/24/11

From Mintonw: “Re: NorthCrest Medical Center (TN). It’s the first hospital to receive a Medicaid EHR incentive payment by just using ED patients and an EDIS, in their case Allscripts ED 7.0, the only EDIS certified as a Complete EHR.” The hospital’s press release is here. SVP/CIO Randy Davis says the 109-bed hospital was already in the high 90s percentile and didn’t need to change much. The hospital says it will meet Medicare’s MU requirements later this year.

From Tommy Tune: “Re: Jim Fitzgerald. Definitely no longer at Dell. My source says it was his choice.” Unverified.

From Rigoletto: “Re: GE Healthcare. Says Centricity Practice and EMR can’t generate accurate Meaningful Use reports. See link here to its letter to customers.” It sounds like basic technical stuff, made interesting only because the company admits that there could be problems for clients who have already attested – the corrected reports may show that they didn’t hit the required thresholds after all . GE says they will provide “further instruction on how to work with CMS related to any changes related to attestation.” The recommend changes in practice are: (a) choose specific race/ethnicity codes instead of free text and don’t choose “multi-racial,” “Hispanic,” or “other;” (b) use specific options for describing smoking status; and (c) us prescribing to measure patient medication education since issuing handouts that the EMR did not suggest doesn’t count toward Meaningful use. I don’t see any of this as a slam on GEHC other than they are awfully late in identifying the problems, which seem pretty obvious. Let’s hope the triggering event wasn’t an eligible provider getting in trouble with CMS.

From Dr. Nurse: “Re: McKesson CEO John Hammergen’s $131 million one-year compensation. Their products are a patchwork of jury-rigged acquired code which has never been upgraded and they clearly have no idea what a usability standard is (the joke is, ‘just keep scrolling down and to the right and you’ll eventually find the right checkbox.’) They perform paper-based billing for specialty practices (Fedexing boxes of paper forms to Pittsburgh – really?) and use antiquated reporting systems that cannot be altered (you can’t add columns due to system limitations). His compensation package is obscene considering McKesson’s ongoing loss of market share, discernible lack of innovation, and adherence to outdated methodologies and business practices. He’s not alone – the CEO salaries of third-party payers are off the grid, too.” Above is the five-year performance of MCK (blue), the Dow (red), the Nasdaq (green), and the S&P 500 (yellow). A big chunk ($112 million) of that compensation was from stock options that he won’t get to exercise every year. At least shareholders (including employees) got to make money along with him. Not to mention that IT isn’t the company’s bread-and-butter business, although that product line is still profitable.

From Por Favor: “Re: WNA. I totally love Weird News Andy, but as a Canadian, I’m appalled by the actions of the clinicians at the hospital. There once was a time where it didn’t matter how you came to be in the ER. I was in the ER several years ago when a young man of about 17 was brought in with a terrible leg break. He was from England on a rugby tour with his school. I remember him crying and trying to tell the doc he had insurance and hoped the doc would take care of him even though he couldn’t produce the documents right there. I’ll never forget what the doc said: ‘Son, I don’t care if you have insurance or not. I’m going to take care of you. Rest easy, try to relax, and do not worry. You’re in Canada and under my care.’ That demonstrates why doctors became doctors in the first place – to heal the sick. It is so sad that somewhere along the way, we have lost this. Please tell Andy to keep the weird news coming – it’s always fun!” The example was from Canada, but I’m certain we have at least as many such cases on this side of the border.

From Neil Louwrens, MD FACP: “Re: physician’s malpractice award as a patient at Northwestern. I’m vehemently opposed to the current tort system, but passionately for justified litigation, including substantial earnings to injured patients. I’m equally and passionately against trivial pestering from the legal profession, claiming wrongdoing and pain-and-suffering that runs up ridiculous tabs at this nation’s expense. The physician in this case is a patient and the case must rest on that. When we fight for tort reform, we are asking for some sense of sanity to be infused back into the system. Nowadays, even the best doctors doing the right thing are still sued. It’s a lottery mentality and the nation picks up the tab. Most physicians who have wronged someone are remorseful and wish they could compensate the patient for their wrongdoing, but to watch the lawyers walk away with 50-60% of the winnings is a travesty. Give patients their money back! Wall Street’s wrongdoings pale in comparison with what the Association of Trial Lawyers of America has managed to carve out for themselves in the current system, backed and perpetuated by the preponderance of lawyers in Congress. Tort reform will reform this inequity, but will not touch the earnings to the injured for their costs, such as justified pain and suffering. We need tort reform – not ‘we’ as physicians, but ‘we’ as patients.”

Thanks to Jacob Reider, ONC’s new usability guy, for taking the time to interview. A reader had tipped me off that he’d taken the job, I e-mailed him, and he asked me to hold off for a couple of days (the details weren’t quite finalized, I surmise.) He not only gave me the first interview, but didn’t tell anyone about his new job until I could get back from vacation so we could do the interview and have the scoop here. Above is another interview he did on usability before he took the ONC job. ONC is interested in reaction to NIST’s usability paper, which I’ll be providing once I’ve had a chance to read it over. Hopefully those readers who constantly gripe about poor EMR usability will channel some of their energies into reviewing the NIST document since it’s the best hope so far (short of some super-secret vendor development project that nobody’s seen yet) to improve the healthcare IT usability landscape.

Listening: reader-recommended Elizabeth Cook, who sounds a good bit like Dolly Parton. The youngest of 11 children, moonshiner dad in prison, took dual degrees in accounting and computer information systems, and worked as an auditor for PWC.  She writes most of the songs, which have brilliant lyrics and range from the good old boy rowdy (“Say Yes to Booty”, “Sometimes It Takes Balls to Be a Woman”) to the starkly moving (“Heroin Addict Sister”).  Modern country is one of my least-favorite genres because it’s been taken over by industry-groomed, overproduced pretty faces faking credibility in the pain and loss department while fronting pop music that has the absolute barest minimum of mandolin or steel guitar, but this is the real deal.

My Time Capsule editorial this week, squinting its eyes upon seeing its first daylight since October 2006: GM and Intel are Right: Healthcare Is Too Expensive, but Technology Alone Can’t Fix It. A taste: “Most US job growth since 2001 was in healthcare, and that’s not something to be proud of. We’re leaving an expensive mess for our children to clean up just as Baby Boomers suck the system dry with healthcare demands. If GM doesn’t like it today, they’ll hate it tomorrow, unless they’re watching from China or India.”

Good stuff on HIStalk Mobile, where Dr. Travis Good covers How to Make Money on Consumer Health Tools and Enterprise Provider Apps. He started out covering straight news, but now that he’s comfortable, he’s putting together some really good analysis and opinion posts that I appreciate since I’m learning from them. Sign up for the e-mail update over there if you like what you see. Thanks to our sponsors there, too: founding sponsors AT&T and Vocera and platinum sponsors Voalte, 3M, Thomson Reuters, Patientkeeper, Kony, and Access.

I’ve said before how much I like using speech recognition for certain tasks (composing e-mails and sometimes writing HIStalk, for example). I was about to upgrade my Dragon Naturally Speaking when I found about Windows Speech Recognition. Like DNS, it’s great for dictation and controlling Windows by voice. Advantages: its system performance seems to be better, its accuracy is almost as good (96% vs. 99%), and it’s included free in Windows 7 (you’ll find it in Control Panel.) Well worth experimenting with since everybody can talk faster than they can type and sometimes your fingers just get tired.

Here’s the latest HIS-tory from Vince, this time with Part II of JS/Data, with lots of info about its eventual (many-named) acquirer.

Most respondents (some of them with considerable skin in the game) think HITECH should pay providers for starting their EHR use even before HITECH started. New poll to your right: should HHS require doctors to generate personalized, unique documentation (i.e., no boilerplate or macros) in order to be paid?

Dr. Jayne brought up an interesting point in her latest post: the government seems to want everybody to be fooled into thinking that Medicaid is insurance rather than a social program that takes money away from taxpayers and gives it to non-taxpayers (all warm-and-cuddly positives aside, that’s what it is.) We’ve already taken the shame out of being on the dole courtesy of the ever-fewer working Americans (Social Security and Medicare being the big drains among many), so unless you have a lot more faith than I do that either politicians or voters will start exercising responsibility instead of acting in their own self-interest, keep an eye on what’s happening in Greece because we’re getting close to that point of non-sustainability. Politicians won’t stop handing out financial lollipops and the taxpayer/non-taxpayer ratio keeps shrinking, so something has to give regardless of the indignation and injustices involved. Our lavishly funded healthcare system isn’t exactly helping as it sucks up an ever-increasing chunk of GDP.

ProHealth Care (WI) finishes its implementation of Epic.

GE announces Q3 numbers: revenue flat, EPS $0.31 vs. $0.28, meeting expectations.

Interesting revelations from the Steve Jobs biography, hitting stores Monday: (a) he apparently lied about the extent of his medical problems; (b) he initially resisted having surgery for his pancreatic tumor, so he tried diets, acupuncture, a psychic, and remedies he found online, to his apparent eventual regret; (c) he claimed Google stole iPhone features in creating its Android phone, saying he would “spend every penny of Apple’s $40 billion in the bank to right this wrong.”; (d) his last ambitions, possibly involving Apple products yet to be released, involved developing an integrated TV and taking on the textbook monopoly. He also told President Obama that he was destined to be a one-termer because he is business-unfriendly; described Microsoft as “mostly irrelevant” and struggling like most other companies that put salespeople in charge; and said HP is being “dismembered and destroyed” by poor leadership. Nobody quoted him all that much while he was alive and he stayed out of the limelight for the most part, but now every scrap of writing and video is being assembled into the Gospel According to the Recently Canonized Steve (and I admit being just as fascinated by it as everybody else.)

Speaking of Apple, here’s the first commercial for the iPhone 4S and its Siri voice command system.

Kaiser needs to dig into its Epic database to evaluate this study from Canada. Overweight people (BMI of 25 to 29.9) were found to have the same risk of health problems as normal-weight patients. The study found that the big health problems start with a BMI of 35 (defined as “obese.”) Hopefully the study looked longitudinally at patients rather than just current weight. You can calculate your BMI here.

Washington Hospital Center (DC) and AT&T develop CodeHeart, a mobile collaboration app that provides real-time audio and video contact in critical care situations, such as for ambulances in transit.

A lawsuit against Abbott Northwestern by a kidney stone patient alleges that a drug-addicted nurse stole his ordered narcotics for herself, leaving him to suffer excruciating pain through the procedure. The patient says the nurse told him she couldn’t give him very much medication and that he should just “man up.” During the procedure, he says the nurse was unsteady and slurring her words as she coached him for his pain, telling him, “Go to your happy place, Larry. Go to your beach.”

E-mail Mr. H.

HIStalk Interviews Jacob Reider MD, Senior Policy Advisor, ONC

Jacob Reider MD is senior policy advisor of the Office of the National Coordinator for Health Information Technology of Washington, DC.

Tell me about yourself and your new job.

I’m a family doctor from upstate New York. I’ve been involved in health IT for a couple of decades. I started off as a medical educator in the Department of Family Medicine at Albany Medical College and moved on to leadership roles in health IT there and at Albany Medical Center, obviously in Albany, NY. Left there and joined a group called CapitalCare Medical Group, which is the large primary care group in Albany, doing EHR implementation.

There’s a sort of funny story to that one. Early in our EHR implementation, I posted this thing to this new communications platform called a blog. I started blogging in 1999. In about 2004, I put this post up about usability, which was a word people thought I made up, and how the usability of the EHR that I was using was missing the mark. About six months later, the president of the EHR vendor that I was complaining about contacted my boss and indirectly asked me to take down the post, because it was apparently costing them sales. That was Misys Healthcare, and the guy was Rob Kill, the former president of Misys Healthcare. I told my boss that last time I checked, this was a free country and I didn’t really have any intentions of taking the blog post down.

Then I actually started a dialogue with this guy, Rob Kill, and eventually he hired me to help them look at themselves in the mirror and try to improve the user experience of the EHR product. That may be answering your question about my background, because I eventually moved on from CapitalCare to Misys Healthcare, where I was medical director. Then we merged with Allscripts and I was CMIO of Allscripts for the last handful of years.

Then started interacting with folks from the government, and started to go back to my roots of idealism and thinking I could help solve really big problems. Got enticed to join Farzad’s team, because I was really inspired by the work that folks here are doing and the people who are here, who are just great folks who have the right vision and passion for getting things right. Sorry if I sound like a TV commercial.

What is your title and area of responsibility?

My title is senior policy advisor, which sounds very government. I tried on Luke Skywalker and Jedi Master, but so far we’ve got senior policy advisor on my business cards.

How much of the problem to get physicians and clinicians to use systems is because of usability issues?

Are you familiar with the NIST draft usability publication that was put out about a week ago?

I didn’t read it, but I heard it was out.

In that document, NIST calls out some fairly good evidence that user experience / usability is a barrier to broad EHR adoption. That’s not my opinion – that’s been stated by NIST in the publication. That was my callout in 2004, that these things were not optimal to use. I like to think of usability as kind of a milestone on the continuum of user experience. I’ll burden you with a little bit of my view of the world.

As a very basic component, if we think about any new technology, new tool, new anything, you’ve got at the basic end, functionality. Does the thing do what it was intended to do?  It’s something functional.

Beyond functional, you’ve got reliable. Does the thing do what it’s supposed to do every time? An example of functional is a Model-T car. It works, but Model-T cars came with toolkits because they broke, so they weren’t reliable. EHRs years ago – I can vividly remember that the system would go down at midnight every night for backups for four hours. They weren’t reliable. They were functional, perhaps – they did what they were intended to do – but they weren’t reliable.

I think we’ve nailed functionality, we’ve nailed reliability, so as the maturity of any new technology evolves, you evolve up the continuum, so you get functional, reliable, and usable. Usable implies that you can accomplish tasks efficiently; you can do things in an intuitive way. NIST’s document does a great job outlining how you can quantify usability. There’s an argument that it’s subjective, but I think they’ve documented that it’s quantifiable.

Beyond usability, you’ve got meaningful, so it does stuff that’s important. And then pleasurable, that it does stuff elegantly. Apple is a great example of a company that has reached the maturity pinnacle of pleasurability and not just usability, functionality, and reliability. Longer than I intended to blab about, but does it make sense?

People tend to react emotionally to the term usability, thinking it means somebody else designing their screens or taking away their competitive advantage, but in fact there is a usability science that has its own body of literature and its own professional groups. How do you take emotion out of what people think usability means and turn it into something that can move ahead constructively?

I think it’s about using terms carefully. Often I’ll talk to people about what I just described, because we can measure each of those components. I also talk about best practices, so as we think about the industry, we can think, “What are the best practices?”

I think the NIST document outlines best practices that are not just from our industry. If you want to design an airplane or an iPad or a coffee pot, there are methods that you use, and one of those methods is called user-centered design. As you mentioned, there’s a whole field that’s devoted to this. If we talk about using the right method and using the right processes, very frequently that disarms some of the emotional response and we can start to talk collaboratively.

That is what everyone wants to do. I don’t think anybody’s opposed to better usability. You’re not going to hear a user or a vendor or anybody from the government say, “We’re opposed to that.” It’s just The question of who should do what as we look to lever or accelerating that evolution of usability as it has evolved well, obviously, in the consumer electronics space.

How do you see your role specifically and ONC’s role in general affecting usability of software?

There are two areas that I’m really focused on as we move forward. One is clinical decision support and the other is usability. I actually think they are tightly linked. If you look at some of the great design literature from professionals like IDEO, who do a lot of innovation design, and Neilsen Norman Group, these are folks who were involved with the original Apple product and many other things that you’re familiar with.

You see how the design actually guides the actions of the user. A really well-designed door handle guides what I do. I think clinical decision support is not about alerts and reminders and hitting docs over the head with two by fours when they do things wrong. It ‘s about guiding care providers to more easily do what’s right and less easily do what’s wrong. Usability and CDS in that way – and that’s why I’m blabbing about this – fit together really nicely.

My role is to listen to the market, to end users, to eligible providers, to hospitals, and to vendors, and learning about all of these perspectives. Right now that’s the place that ONC is. We’re listening. We’re listening to the experts.

This report that NIST produced just a week ago is open for public comment. We’re very interested in the reaction to that document. It’s in the 30-day comment period and they’ve got a Webinar coming up. The more feedback they get — and by extension, we get –about that, the better, so we can learn more about what other folks think ONC’s role is in terms of facilitating the evolution of user experience in health IT.

Why hasn’t there been a market for usability, where somebody comes up with a more usable product that takes business away from less-usable products?

I think there are a couple of answers to that. We talked about Apple a little bit. In many cases, Apple Is a great example of great usability, great user experience, etc. Raise your hand if you owned or have a friend who owned the Newton. Did you have one?

I did not.

But you remember them, right?

I do.

Apple, of course, had some failures, too. If you look at that company, they’ve been through 30 years of fairly rapid evolution. They’ve succeeded in the long run because they’ve iterated over and over and over. Steve Jobs talked about how he just picked himself up and tried and tried again. Three decades of evolution from Apple that’s created that. And of course, the replacement cycle of a Mac or an iPhone is much more rapid than the replacement cycle of a $50 million electronic health record.

I think part of the answer to your question has to do with the maturity of the market. The market hasn’t matured as we know, with maybe 50% of this market is now penetrated, which means it’s still a young market. We’re not nearly as mature as the consumer electronics market. The other is the replacement cycle is slow, so you don’t have folks saying, “Oh, I can do that in three clicks in one system and 17 clicks in another, therefore I’m going to buy System A.” It’s just not as easy to rip and replace as it is your iPhone.

In your writings, you’ve said that usability guidance is what’s needed, not guidelines or set requirements. How do you see ONC positively affecting usability?

This summer, ONC, NIST, and FDA had a usability workshop. Along with the release of this document from NIST, the federal government will have have a wiki, where we’re going to invite participation from all communities and collaborate so that we can all openly discuss what the opportunities are.

If you’re asking me, “What’s ONC going to do next?” I can say honestly that I don’t know the answer, because what we’re trying to do is be intentional and/or deliberate about what we do next, why, and how, so that this isn’t something that anybody in the market perceives as reactive in any way. What ONC does will be product of dialogue and not something that we just pull out of the seat of our pants.

If we understand the concept that usability can be measured, do you see it either becoming a certification criterion or there being government-sponsored publishing of usability scores of software?

I can’t really answer that question. Sorry.

I did forget to ask you one important question. When did your job start?

I started here on October 3. I’ve been here, gosh, almost three weeks, and it’s flown by in a millisecond.

Any final thoughts?

The NIST document is a good thing to link to. 

The dialogue is important. Even if you solicited comments and you said something pithy and got your readers to throw in feedback, we would definitely pay attention to that – what people are saying on HIStalk about this topic. If you link to that and say, “Hey, what do people think about the NIST document and what’s the reaction to it?” That would be very interesting to us.

Time Capsule: GM and Intel are Right: Healthcare Is Too Expensive, but Technology Alone Can’t Fix It

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.

GM and Intel are Right: Healthcare Is Too Expensive, but Technology Alone Can’t Fix It
By Mr. HIStalk

Big-company CEOs have healthcare on their minds. I know that because they keep insulting us in the national media. We’re too expensive and we underutilize technology, they say. In fact, it’s our fault that jobs are moving offshore, not their own corporate greed or inefficiency.

My first reaction: who do they think they are? We’re getting lectures on innovation, productivity, and cost control from GM? If I wanted that kind of advice, I’d go to Toyota.

Quibbles aside, they’re right. Healthcare cost increases have to stop eventually. Most US job growth since 2001 was in healthcare, and that’s not something to be proud of. We’re leaving an expensive mess for our children to clean up just as Baby Boomers suck the system dry with healthcare demands. If GM doesn’t like it today, they’ll hate it tomorrow, unless they’re watching from China or India.

Businesses want to force computers on us, dragging us kicking and screaming out of the dark ages. Unfortunately, software doesn’t automatically bring increased productivity and lower cost. If it did, we’d be using it already. Think of all of those hospital dollars spent on Microsoft Office and Windows, which were supposed to have made us stunningly more effective, but instead gave employees something to screw around with instead of working.

I’d like to think that computerization can really reduce costs, but I haven’t seen that happen anywhere so far. Showcase sites keep buying the latest and greatest, but the correlation to bottom line and quality outcomes is murky at best. Where’s the average 100-300 bed hospital that has seen its overall costs drop 30% because of software? You’d know them, because every other hospital in their town would be out of business.

Hospitals can cut expenses in three ways, all of them at their local level. They can manage labor, which is by far their largest expense. They can go after the utilization and the cost of drugs and supplies. They can control physician practice variation. I’m glad I said “can” instead of “do” because, for various reasons, these things don’t happen. Software can only do so much.

I’m glad much of our recent IT investment relates to patient safety and outcomes. I hope electronic medical records really do become a standard, with all the information sharing that the RHIO people keep yapping about.

But when it comes to drastic cost reductions driven solely by buying and implementing software, I’d say that’s wishful thinking. There’s a lot of work to be done fixing the system and its underlying misaligned incentives before we try to automate it. No business became a world-beater just by installing SAP, even if they weren’t one of those that went bankrupt trying.

I do see a ray of hope in being called out by big-company CEOs. As hard as it is to have change forced on you, that’s the only way it will happen. I work in a hospital, but I’m also the occasional patient and medical and insurance bill-payer. When wearing those hats, I’m just as mad and frustrated with the system as those CEOs and I bet you are, too.

Healthcare is too expensive, too bureaucratic, and too unimpressive in benefits delivered compared to its horrendous cost. I’m pretty sure fixing it will require more talents than a software guy like me can offer, even if GM and Intel believe otherwise.

News 10/21/11

Top News

HHS announces its Accountable Care Organization rules (Medicare Shared Savings and the Advance Payment Model.) Some differences between the preliminary and final versions:

• Quality measures reduced from 65 to 33
• Use of an EHR is not a requirement to participate
• Introduction of a savings-only track without financial risk during the initial contract period
• CHCs and rural health clinics now have an option to lead ACOs
• A longer phase-in for reporting and performance measures
• Multiple start dates established
• CMS will provide approved marketing guidelines and language (so ACOs don’t have to wait for CMS approval, as was stated in prelim)

Reader Comments

From EHR Geek: “Re: Joel Diamond. I love your posts so much that sometimes I feel like a stalker. With the current healthcare environment, it seems like you could make so much more money (just by dropping your malpractice alone) by doing standup comedy. Please?” Like EHR Geek, I love Dr. Diamond’s posts, which I find laugh-out-loud funny. This week, he discusses all that is good in healthcare. The topic only sounds benign.

From WhatTheDell: “Re: resignation. Jim Fitzgerald recently resigned from Dell’s Meditech Solutions Group. Big loss given his role of all things Meditech.” Unverified. There is no change in his LinkedIn profile or on Dell’s “About Us” page.

From Colorado Kid: “Re: University of Colorado Hospital. Went live on Epic in September, including physician documentation, CPOE, RN barcoding and charting, OR, anesthesia, inpatient pharmacy, labor and delivery, radiology, and ED. Outpatient clinics are 70% deployed, to be completed with Beacon oncology and Phoenix transplant by mid-2012.”

From Lady Pharmacist: “Re: National Pharmacy Week, October 16-22. It’s time for the annual shout-out for pharmacists and pharmacy technicians. Healthcare informatics plays a vital role with and for these clinical and medication distribution folks who make medication usage safe in our institutions!” As I usually say, a hospital is a very clean hotel that offers only three interventions: surgery, treatments, and drugs. Pharmacists and techs manage that last set of interventions with extraordinary skill given the complexity involved (not to mention that most of the country is taking a plethora of pills – a new study found that 11% of Americans over the age of 12 take antidepressants, which is in itself depressing.) Congratulations to those folks behind the counters, down in the basement, and (increasingly) out on the floors.

From MM: “Re: Dr. Jayne on cloned documentation. Did we really expect anything else? If you have been around medical reimbursement rules for any amount of time, you know that when the rules begin to be met by the majority of providers, the rules will change. It is really all about who gets to keep the money. We used to bill by diagnoses, then by time, now by documentation. All these rules were created by the insurers, and each time we achieve competence at following the billing rules, they change them.” I’ve said that for years. Payment is a shell game, where there isn’t enough money to stick under every shell. It is inevitable that when some individual or group starts winning too often, the dealer will move the shells around and change the rules, sometimes drastically altering the lifestyles of professionals along the way (nurse anesthetists and physical therapists come to mind if you look back 25 years or so). That’s really the problem with healthcare – providers flock to profitable services like bugs to a zapper, but patients don’t usually benefit. Expecting healthcare providers, even theoretically non-profit hospitals, to just keep doing the same work without regard to what they’ll get paid is just silly.

HIStalk Announcements and Requests

I am heading to MGMA in Las Vegas this weekend and will be posting updates on some of the action. If you are attending, be sure to take a look at HIStalk’s Must-See Vendors for MGMA 2011. The guide includes some tips on vendor giveaways (hint: you don’t want to miss a visit to Allscripts, MED3OOO, and Culbert Healthcare.) And if  you see one of these desktop signs in a vendor’s booth, please take a moment and thank them for supporting HIStalk, HIStalk Practice, and HIStalk Mobile.

Listening: reader-recommended The Heard, rootsy Southern rockers from Reading, PA. Sounds kinds of Allmans-meet-R.E.M. to me. Also reader-recommended: BluesMotel, some guys from the Netherlands that play Chicago blues. I can almost smell the smoke and beer.

This week on HIStalk Practice: in addition to our MGMA guide and a post from Dr. Joel Diamond, athenahealth reports that pediatricians are under-reimbursed for certain vaccines almost half the time. CalOptima REC names its preferred EHR vendors. The Department of Pathology at the Medical City Dallas Hospital (TX) goes with McKesson for billing and RCM. Emdeon expands the capabilities of its Office Suite solution. Radiology Medical Group (CA) announces plans to outsource its billing and lay off 24 employees.  If you are interested in the ambulatory HIT world,  highlights from MGMA, shoe fashion, and/or Inga’s mental health, please sign up for e-mail updates while visiting HIStalk Practice. Thanks for reading.

Thanks to NexJ Systems of Toronto, ON, now supporting HIStalk as a Platinum Sponsor. The company is all about eHealth, offering its Health Information Exchange solution that includes its Universal Health Connector (global messaging and controlled vocabularies and terminology) to facilitate interoperability among providers, ACOs, payors, and public health agencies. They also offer tools for chronic disease management, disease registry, electronic referrals, patient portal, provider credentialing, and a wellness platform. Other offerings include platforms for provider health, consumer health, and analytics. Click the image above to check out their October 28 Webinar on next-generation, open-architecture HIE technologies that are fast, flexible, and cost effective. Thanks to NexJ for supporting HIStalk and its readers. 

Pardon me while I communicate in techo-gibberish with my fellow geeks (non-nerds, hands over ears, please). You may have noticed that HIStalk loads faster now. Reason: I replaced Apache with the Litespeed WebServer. It’s hard to picture a Web server that’s running *NIX without Apache, but you’re soaking in it. I also had the PHP handler changed from DSO to SUPHP to improve security and to fix some CHMOD problems. (end of nerdspeak)

October is Breast Cancer Awareness Month, meaning it’s time to watch those cool Pink Glove Dance videos. My favorite so far is from Victoria Hospital – Prince Albert Parkland Health Region, Prince Albert, Saskatchewan (although they’ve disabled putting the video directly on HIStalk this time around, so you’ll have to click.) Check out all great videos and vote for your favorite here.

On the Jobs Board: Senior Business Analyst – Salesforce.com, HL7 Interface Developer, Account Manager. On Healthcare IT Jobs: Director – Epic and Clinical Systems, Security Engineer, Business Continuity Analyst, Clinical Nurse Analyst.

Don’t let Inga’s swaggering online demeanor fool you. Those of us who know her recognize that she’s sensitive (sniffles at movies), self-doubting (always convinced she doesn’t know enough to write authoritatively about topics she’s followed for many years), and fragile (I’ve quit telling her to stop double-spacing after a period because it devalues her). You can imagine the emotional harm wreaked by those who don’t sign up for e-mail updates; who fail to connect with us on LinkedIn and Facebook; who don’t support our sponsors and click their ads and Resource Center listings occasionally; and who hurtfully neglect to send her newsworthy scoops and fun information so she can at least temporarily feel confident about her knowledge base (cue emotion-tugging Sarah McLachlan warbling). In lieu of giving her a hug, consider checking off the items on the list above, ‘cause when Mama ain’t happy, ain’t nobody happy.

Acquisitions, Funding, Business, and Stock

TransUnion acquires Financial Healthcare Services, a provider of a patient payment estimation solution.

Microsoft announces Q1 numbers: revenue up 7%, EPS $0.68 vs. $0.62, beating and meeting expectations, respectively.

Athenahealth announces Q3 numbers: revenue up 33%, EPS $0.15 vs. $0.11, beating expectations on both and raising fiscal year guidance.

San Diego’s West family, who made their $2 billion fortune from telemarketing and who established the West Wireless Health Institute in 2009, create a $100 million venture investment fund to invest in early-stage technology companies that can reduce healthcare costs. They pledge to invest any profits in medical research.

Sales

Alexian Brothers Health System (IL) expands its relationship with athenahealth by selecting athenaClinicals and athena Communicator for its network of 150 employed providers. In addition, athenaCollector client Harbin Clinic (GA) adds athenaClinicals for its 210 providers. Both are Allscripts replacements.

People

The Hay Group consulting firm promotes Bill Quirk from director of business development to national director of its US healthcare practice. He was previously with Sullivan, Cotter and Associates and Towers-Perrin.

The TriZetto Group names President and CEO Trace Devanny as the company’s chairman, succeeding TriZetto founder Jeff Margolis, who will serve as chairman emeritus. Devanny was president of Cerner until last year.

Streamline Health hires Tom Dean, formerly with CareCentric, as VP of product engineering.

Robert J. Bunker joins the board of directors of T-System. He is chairman and CEO of The Medical Staffing Network Inc. and started his work in healthcare as Humana’s COO in 1994 after serving 20 years in the US Air Force Medical Service, retiring with a rank of lieutenant colonel.

Joan Bishop, formerly with Lockeed Martin, joins Encore Health Resources as principal of its government client services business.

Announcements and Implementations

AtlantiCare (NJ) announces plans to to launch AtlantiCare Health Solutions, an accountable care organization.

Aprima Medical certifies GFI Software’s FaxMaker for use with Aprima’s EHR and PM solutions. Which reminds me of a recent need I had for a copy of certain medical records. My doctor’s office said I had to fax them a request form. Since I don’t have a fax machine, I asked if I could e-mail the form. They responded that they didn’t have e-mail. I had to double check the year to make sure I wasn’t in some sort of time warp.

ONC validates the South East Michigan Health Information Exchange (SEMHIE) for conformance and interoperability testing, allowing SEMHIE to go live on the Nationwide Health Information Network Exchange.

Intelerad Medical Systems launches InteleSuite, a RIS/PACS solution that combines Interad’s standalone PACS and RIS offerings.

University of Michigan Health System and Great Lakes Health Information Exchange sign an agreement to exchange information. Other members are Michigan State and Sparrow Health System.

A Detroit jury finds that Beaumont Hospital (MI) and an OB doctor let a woman deliver a 10-pound, 12-ounce baby vaginally instead of by C-section, causing brain injuries in the newborn girl. Despite the hospital’s claim that the disabilities of the child (now a teenager) were caused by the mother’s gestational diabetes, the jury awards the family $144 million.

I received an e-mail from Steve Pelton, VP of enterprise applications for Ministry Health Care (WI). They have completed their EHR certification tests through Drummond Group (“tough, but fair,” he says) and expect to demonstrate Meaningful Use and attest early next year after the 90-day demonstration period. He raises an interesting point:

From the CHPL web site, it appears that only 16 hospital and health systems have achieved either modular or complete EHR certification. While many or even most hospitals will wait for their vendors to provide updated, certified products for them to install, it does seem surprising that so few of the over 5,000 hospitals in the US have not gone through the self-certification process. Like Ministry Health Care, most of the 16 hospital and health systems achieved modular certification, which allows for the Meaningful Use of a collection of certified products. The most common modules that are self-certified seem to be homegrown data repositories. One would expect that many hospitals that have either homegrown systems or uncertified niche systems would attempt to certify them. One would also expect hospitals to self-certify their existing systems while they are working to replace or upgrade to a certified version. What is everyone waiting for?

Weird News Andy summarizes this story as, “Socialized medicine. Gotta love it.” An 82-year-old woman visiting her dying husband in a Canadian hospital falls in its lobby, breaking her hip. Two ED nurses and a security guard observe her lying face-down on a metal grate and bleeding, but refuse to help until an ambulance arrives. The  top executive can’t explain why a code wasn’t called. The same hospital made headlines last year when a woman who had stopped breathing was driven to the hospital by her boyfriend, but the ED staff refused to help since the couple were in their car in the parking lot and told the boyfriend to call 911 instead. The 39-year-old woman died a few days later of a heart event. The employees thought they wouldn’t be covered by malpractice insurance if they helped someone outside the four walls of the hospital.

Government and Politics

ONC adds a principal deputy position to its organization, tasked with duties similar to that of a COO in the private sector. The yet-unnamed deputy will report to ONC coordinator Farzad Mostashari.

The VA gives Harris Corp. a two-year, $200 million blanket purchase agreement to develop VistA-connected outreach tools, including creating a point-of-service kiosk, redesigning the VA’s quality Web site, supporting the National Utilization Management Integration project, and developing a replacement bed management system.

The government’s Substance Abuse and Mental Health Services Administration (SAMHSA) awards 29 grants totalling $25 million over three years to increase access to behavioral health services with information technology.

Federal prosecutors file an $8.1 million fraud suit against Kernan Hospital (MD), part of the University of Maryland Medical System. The government says the hospital intentionally changed its billing system to create a diagnosis of severe malnutrition, looking for the words “protein malnutrition” and pressuring physicians to add that condition as a secondary disease.

Other

Nearly 300 GE Healthcare employees in Salt Lake city form a human pink ribbon in recognition of Breast Cancer Awareness Month. The company has scheduled similar displays across a couple of dozen cities.

The hospital EHR market is expected to peak in 2012, with revenues of $6.5 billion.

Twenty-six percent of CHIME CIOs say their organizations have qualified to receive Meaningful Use funding, with 13% actually having been paid. About 93% expect to achieve the Stage 1 MU during the first three years of the program.

An Internet outage in a small North Carolina town leaves a medical practice that uses a Web-based EMR out of luck. “We’re electronic medical records, and neither one of our softwares will come up because we’re Internet-based. If the Internet goes down, we have to just call patients back to get appointments re-scheduled.”

An Illinois physician claims his health system employer placed him on administrative leave because he has “no computer skills.” Steven Kottermann MD, who was a family physician with Memorial Health System, admits that he fell behind on his electronic charting after the health system’s implementation of Epic. The doctor believes that Memorial is at fault because “they bought a lousy system.”  The hospital’s chief medical officer says the issues go beyond the doctor’s EMR proficiency.

Sponsor Updates

• GE Healthcare recognizes Frederik Memorial Hospital (MD) and Northeast Georgia Medical Center (GA) as winners of its 2011 Leaders of Change Awards at the Centricity Perinatal Users’ Group National Conference.
• Sentry Data Systems earns a spot on the South Florida Business Journal’s Top 25 Fast Tech Awards for significant revenue growth.
• Khalid Moidu, MD, PhD (Orlando Health) and Stephen Claypool, MD (Wolters Kluwer Health) will present Innovation Lab: Evidence Based Order Sets Tools from a Dynamic Hospital-Vendor Partnership at AMIA 2011.
• NVISION Laser Eye Centers (CA) selects NextGen for its 10 eye centers.
• NexJ Systems will host a free Webinar entitled The Next Generation of Health Information Exchange October 28th. NexJ Systems, by the way, was recently named the sixth fastest-growing company in North America on Deloitte’s  2011 Technology Fast 500.
• AdvancedMD receives the Healthcare Hero Award for Innovation from Utah Business Magazine.
• OptumInsight releases a guide for physicians to minimize security risks entitled Keep Patient Data Secure: Simple Actions for a Digital World.
• dbMotion and Allscripts will co-host a webinar on physician EHR connectivity on November 16th featuring dbMotion CMIO Joel Diamond MD and Ryan Winn, VP and CIO of MidMichigan Health.
• Perceptive Software will showcase its enterprise content management solutions at the Gartner Symposium/ITexpo in Spain.
• Newton-Wellesley Radiology Associates (MA) boosts its financial performance and prepares for ICD-10 using McKesson’s Revenue Management Solutions.

EPtalk by Dr. Jayne

Now that we’re in the last quarter of 2011, Physician Quality Reporting System (the artist formerly known as PQRI) data is available through the CMS quality portal. Groups can access data by taxpayer ID and individual providers can also request reports based on their NPI. Next year should be a little different, with CMS agreeing to provide interim feedback reports to those who use claims-based reporting. Too bad for those of us who are Meaningful Users of our EHR technology and are reporting through registries rather than claims.

Speaking of CMS, regulatory reforms are on the table, with two proposals being introduced and a third being finalized this week. Modifications to the Medicare Conditions of Participation would allow multi-hospital systems to have a single governing body for multiple hospitals rather than requiring each have its own governance structure. Hopefully combining governance structures will help those of us on staff at multiple hospitals within a health system to reduce the number of committees on which we are forced to serve.

Proposed modifications for non-hospital providers address durable medical equipment suppliers and dialysis providers. Also addressed are outdated e-prescribing technical requirements. Hiding towards the end of the document is language to end the use of the term “Medicaid recipient” and replace it with “Medicaid beneficiary.” Although this makes it parallel Medicare, I can’t help but think there are political games afoot, with this being one more move to make people think that Medicaid is insurance rather than an entitlement program.

We all know we live in a society that’s increasingly saturated by technology, specifically audiovisual media. The American Academy of Pediatrics Council on Communications and Media releases guidelines stating that children under age two should avoid television viewing. This also includes passive viewing while playing in a room where an adult or sibling may be watching.

There’s an app for that: Mobile MIM is one of a growing number of apps to receive FDA approval. It allows viewing of diagnostic images, including MRI and CT scans. Although the app (one version for physicians, one for patients) is free, physicians must pay $1 to upload each image to its cloud-based repository. Viewing the study costs $1 to $2 depending on the receiving device. Earning FDA approval took more than two years and included modification to the app to detect poor lighting conditions that are inappropriate for the interpretation of radiologic studies. Maybe the FDA should also include logic to detect whether it is being used in a bar, as my colleague was attempting.

Recent data from social media analytics firm Amplicate shows that over the last year, 69% of Facebook and Twitter users reported hating a particular insurance carrier. Data from over 2,500 posts is aggregated by payer. In contrast, the other industries the firm tracks were more positive, with 56% of users loving their grocery store chain and a 70% expressing a love connection for fast food chains. More negative than health insurers: banks.

The FDA approves Hologic’s Trident specimen radiography system. The system is designed for intraoperative specimen imaging during minimally-invasive, stereotactic, or ultrasound-guided breast biopsies and includes the ability to export to PACS.

October is Breast Cancer Awareness month. I first saw the Pink Glove Dance on HIStalk. It’s always good to see healthcare workers having fun and raising awareness about a disease that impacts so many people. More than 100 organizations are competing for thousands of dollars to donate to their favorite charities, so get out there and vote. Here’s a shout out to my co-workers who are fighting this disease and a special nod to all the women in my family who have beat it, including one 20+ year survivor. Love you, Mom!

Contacts

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

CIO Unplugged 10/19/11

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

This is the fourth in a short series of posts on “The CIO’s Best Friends,” those BFFs who are critical in ensuring CIO effectiveness. This time we cover the CNO – CIO relationship.

Got Clinicians?

The CNO and I started our jobs about the same time. We knew we needed one another to be successful. With an electronic health record implementation looming, our partnership would be imperative.

As organizational rookies, we became kindred spirits. We commiserated, encouraged, and partnered. Through my CNO’s coaching, I learned we needed more clinicians inside of IT. “Got clinicians?” he prodded often. “If you don’t, you should.”

I wondered how many credentialed clinicians a healthy IT department should have. I now think 25% is a good target. Whatever your starting point, push to raise the percentage. Include a mix of MDs; RNs; radiology, medical, and pharmacy techs; pharmacists; therapists; and a smattering of other less common specialties. While many organizations have a CMIO, equally critical is a CNIO.

My CNO taught me that once you have clinicians on your team, you’ve got to ensure their successful transition into IT. Here are some things to think about in order to succeed.

Challenges for Clinicians Moving Into IT

Adapting to the office environment

• Cubes vs. nursing station reduces the sense of teamwork
• Use of meeting rooms is equated with loss of casual social interaction
• Taking work home
• Going out to lunch vs. grazing between patient care tasks

Difficulty recognizing accomplishments/results

• Need to understand the bigger picture (see beyond the patient)
• IT systems are configurable with gray areas; reduced workflow focus
• No more rapid results (average patient LOS is three days)
• Used to implementing changes quickly
• Giving up precision and timing on tasks

Loss of familiarity generates stress. The clinician must:

• Learn new tasks, find new resources, and create a new employee network
• Learn basic IT software (no more IVs)
• Fight pressure to already understand IT on the first day of work
• Assimilate IT language/acronyms

Facilitation skills are not in the typical nursing repertoire

• Scheduling appointments
• Creating agendas
• Taking minutes
• Using a meeting room to solve problems instead of on-the-spot interactions

Common Conflict Areas and Issues of Concern for Clinicians

• IT staff is generally unaware of clinician’s former environment and the required adjustments
• Lack of training for clinicians in IT subjects
• Clinicians are expected to already know what to do
• Downtime scheduling affects issues regarding patient care
• Clinicians have an inherent desire for more testing on software applications (like testing a drug before giving it to a patient)

Bridging the Gap and Investing in Clinicians

Preceptor program

• Increase depth of typical IT orientation
• Pair new clinical staff with experienced IT person; identify future clinician leaders
• Document and publish referable guidelines
• Create Web-based training on IT tools
• Ensure clinicians don’t get sucked into traditional IT mentality

Project management training

• Create project management processes that nurses can relate to
• Help clinician visualize the big picture and break it down into tasks

Professional development

• Develop a facilitation/leadership class
• Provide continuing education credits (CEU)
• Create internal training opportunities specific to clinical IT
• Develop clear development pathways, like a clinical ladder
• Clarify the position’s responsibilities

Spend time with your CNO. Actively partner. If you can’t afford a CNIO to bridge the nursing and IT gap, assign another clinician as a part-time liaison.

Over the years, we moved from 5% clinical staff to nearly 25%. I believe one reason we successfully implemented and adopted clinical applications was due to our staff mix.

Embrace the significance of melding clinicians with IT. Be intentional with it, maximize the value, and encourage further adoption. A healthy mix leads to a high-performing healthcare IT organization. I’m so glad I listened to my CNO.

Got Clinicians?

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

News 10/19/11

Top News

A newly signed California bill will require electronic medical records systems to maintain a record of changed or deleted information. The Confidentiality of Medical Information Act, which will become law on January 1, requires systems to log the user’s identity, the date and time of the change, and a record of the information that was changed or deleted.

Reader Comments

From Sole Food: “Re: shoes. This conversation is from the Late Late Show last week. Craig Ferguson to Monica Potter: ‘Oh, nice shoes.’ Monica Potter: ‘Yeah, I heard you like shoes.’ Craig Ferguson: ‘No, I like women, and I know that women like shoes.’ So don’t let anyone give you a hard time about posting pics of women’s footwear.” I couldn’t agree more. Inga likes cute women’s shoes, I like how women look in cute shoes. HIStalkapalooza is a lot classier now that many of the ladies come dressed to the nines. Women like dressing up, men like seeing dressed-up women, everybody wins.

From The PACS Designer: “Re: Ethernet – Fibre Channel convergence. TPD is celebrating the 10th anniversary of the design of the first Windows/UNIX based PACS that relied on Ethernet, and a Fibre Channel RAID to permit downloading of 500MB image files in under 30 seconds. Now, 10 years later, you are going to be hearing more about the convergence of 10-Gbps Fast Ethernet, and Fibre Channel storage arrays using a new term ‘Data Center Bridging Exchange’ as it tries to become the new standard for data storage.”

Acquisitions, Funding, Business, and Stock

Lexmark, the parent company of Perceptive Software, acquires Netherlands-based Pallas Athena for $50 million in cash. Pallas Athena, which is a provider of business process and document output management solutions, will become part of Perceptive.

TransUnion Healthcare, which offers revenue cycle tools, acquires Financial Healthcare Systems, the Denver-based vendor of the ClearQuote software that estimates out-of-pocket patient responsibility at the point of service.

Sales

BloodCenter of Wisconsin, Community Blood Center of Kansas City, and the US Department of Defense contract with Mediware for its InSight Performance Management platform for blood management.

DeVry University signs a five-year agreement with QuadraMed to incorporate its Quantim suite of HIM coding, compliance, and record management solutions into the school’s health sciences curriculum.

Eastern Connecticut Health Network selects MobileMD’s 4D HIE solution.

Riverside Health System (VA) selects the EMR-Link solution of Ignis Systems for lab and radiology order integration for over 200 physicians. The company differentiates its product as making all labs equal to physicians and their EMRs, which it says differs from the lab-funded, lab-centric integration model.

Sheridan Healthcare, the country’s largest anesthesia group with 1,200 providers and 100 hospitals and ambulatory surgery centers, chooses Shareable Ink as its standard documentation and charge capture tool.

CapitalCare Medical Group (NY) chooses ImplementHIT’s OptimizeHIT training platform to prepare its 110 providers for an Allscripts EHR upgrade.

People

Healthcare Information Xchange of New York (HIXNY) names Mark McKinney as CEO, replacing Dominick Bizzarro, who joined InterSystems earlier this year. McKinney is the former director of integrated services for SXC Health Solutions. HIXNY merged with the Adirondack Regional Community HIE earlier this month.

MED3OOO hires former Tenet Healthcare executive Jeffery E. Flocken as EVP of accountable care and hospital services.

Ingenious Med appoints Jim Keener as CTO. He was previously VP of development of Verisign.

Clinical decision support provider DiagnosisOne names Francis X. Campion, MD as VP of clinical affairs. He’s a member of the Department of Population Medicine at Harvard Medical School.

Announcements and Implementations

Meditech client Aspen Valley Hospital (CO) implements Summit Healthcare’s Downtime Reporting System to address business continuity.

Blue Shield of California will distribute $20 million in grants to 18 California hospitals, health systems, and physician groups to help them develop ACOs.

The University of North Carolina Hospitals implement the RF Assure Detection System for preventing and detecting retained surgical items in patients.

New York City’s Department of Health and Mental Hygiene (DOHMH) implements NextGate MatchMatrix Terminology Registry to standardize data shared by EHR systems.

Imprivata announces that six additional hospitals using McKesson solutions have implemented OneSign, Imprivata’s single sign-on solution.

Enterprise RTLS vendor Intelligent InSites integrates active RFID readers and tags from RF Code into its solutions.

Government and Politics

New York’s state development agency grants eHealth Global Technologies $750,000 in tax credits to support the company’s expansion. eHealth Global, a medical record retrieval and diagnostic image exchange service provider, will invest $3 million in the expansion and will increase its staff from 75 to 155 over the next five years.

CMS adds WellCentive as a qualified Registry provider for the 2011 PQRS program.

The VA will solicit bids for a WiFi-based real-time location system for tracking assets, employees, and patients its 152 hospitals, with an RFP to be issued by the end of the year.

Bill O’Toole of O’Toole Law Group has expanded his HITlaw article about EHR vendor certification into a white paper called EHR Certification Alert for Providers, summarized as: “The absolute heart of the issue is recognizing that in some cases multiple products that are marketed individually by a vendor are grouped together for testing and ultimately certified together and not separately.”

An Associated Press review finds that Medicare often suspends bogus providers, but then quickly reinstates their payments even after their prosecution. The review found that appeal hearings often have nobody in attendance from CMS or their contractors, leading to a rubber stamp reinstatement of billing privileges. The article says pay-first policies (“pay and chase”) have made fraud so easy and lightly penalized that drug dealers and mobsters have given up their previous scams in favor of Medicare fraud. Disjointed government processes are blamed: contractors don’t share information, provider ID revocation doesn’t automatically initiate criminal proceedings, Medicare’s lawyers don’t show up at hearings, and nobody’s collecting surety bonds required of medical equipment providers when they skip town.

Innovation and Research

A good Business Insider article lists eight healthcare startups that are “shaking up” the industry. Among them: ZocDoc (online doctor appointments), Cake Health (medical expense tracking), Avado (doctor-patient relationship management software), and Sharecare (consumer Q&A with medical experts).

Technology

Dell ends its 10-year storage reseller agreement with EMC. The move was not a surprise, given Dell’s multiple acquisitions of data-storage technology over the last three years.

HP and Lucile Packard Children’s Hospital (CA) announce a real-time patient status system that uses EMR data to represent patient status, rather than traditional handwritten notes on whiteboards. During a trial period, researchers found that the Patient-Centered Dashboard prompted a change in care in one out of three patients.

Other

HealthGrades reports that Washington DC, New York City, and Kansas City are the top communities on a per capita basis in which consumers look for healthcare providers online.

Orion Health says it could hire up to 200 employees New Zealand following its acquisition of the former Microsoft Amalga HIS hospital information system.

At least 255 communities are attempting to support health information exchanges, but only 12% of them are self-sustaining. That’s still 33% better than 2010 estimates.

The 2010 Annual HIMSS Conference is recognized as “The Show with the Most Innovative Practices” at the Trade Show Executive Gold 100 Awards & Summit. HIMSS10 also ranked 33 on the Gold 100 list.

The Commonwealth Fund releases its annual National Scorecard on US Health System Performance. Some highlights (or perhaps lowlights):

• Despite big gains in EMR usage among primary care providers, the US lags far behind leading countries in EMR adoption.
• Although the US is showing promising improvements on several key indicators, quality of care remains uneven, with evidence of many inefficiencies and inequities in care.
• Other advanced countries are outpacing the US in providing timely access to primary care, in reducing premature mortality, and in extending health life expectancy. At the same time, these other countries are spending considerably less on healthcare and administration.

Readers have occasionally speculated about the EMR status of Lehigh Valley Health Network (PA), with a couple of them saying LVHN has chosen Epic. Not true, according to SVP/CIO Harry Lukens, who was kind to provide an update. LVHN, a GE Healthcare customer, is looking at GEHC, Allscripts, Cerner, and Epic. Scripted demos for all interested staff have begun, with those of GEHC and Epic completed (with similar combined scores of functionality and comments.) Harry says LVHN is planning to eliminate one vendor in November and another in January after site visits, then come to a final decision by March, although he’s philosophical in expecting the unexpected: “Keep in mind I also planned on attending the World Series to watch the Phillies play, which is my way of saying ‘stuff happens,’ a simple observation that planning is filled with things that happen for no reason.”

Central Vermont Medical Center and Fletcher Allen Health Care create a corporate affiliation that will allow them to share centralized services, among them Fletcher Allen’s Epic system.

Weird News Andy says, “I can see right through their plan,” as three Delaware Valley hospitals report the theft of scrap X-ray film, apparently by silver-seeking thieves posing as employees of a company hired by the hospitals to recycle their old film. And in a story WNA finds simultaneously weird and sad, a 47-year-old man appears on Howard Stern’s satellite radio show hoping to generate donations toward the $1 million he needs to pay for corrective surgery for his elephantiasis-swollen scrotum, which weighs 100 pounds.

Sponsor Updates

• Texas Regional Medical Center enhances its medication barcoding initiative with the implementation of the Access Intelligent Forms pharmacy labeling solution.
• Southeast Alabama Medical Center reports that its deployment of ProVation Order Sets has yielded cumulative benefits of $1.7 million.
• McKesson launches Episode Management, which automates bundled payments for episodes of care.
• Mac McMillian, CEO of CyngerisTek, will participate in a telebriefing on HIPAA privacy and security audits, hosted by Law Seminars International.
• T-System CMIO Robert Hitchcock, MD,  addresses critical issues in EDs in a podcast entitled Hospital Emergency Departments in Crises.
• Carefx Corporation releases a white paper entitled Patient Portals – The Pathway to Patient Engagement and an Enhanced Patient Experience.
• Hayes Management Consulting issues a white paper and Webinar on achieving Meaningful Use.
• Crittenden Regional Hospital (AR) meets Stage 1 MU utilizing the EHR and consulting services of Healthcare Management Systems,
• Merge Healthcare’s RIS v7.0 receives Complete EHR certification for MU.

Contacts

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

Curbside Consult with Dr. Jayne 10/17/11

Dear Dr. Jayne,

What’s your take on the following Medicare position?

When documentation is worded exactly like or similar to previous entries, the documentation is referred to as cloned documentation. Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient.

After doing cough/cold/flu clinics where patient after patient presents with similar symptoms, similar exam findings, while the HPI documentation may be different, there are only so many ways to document “nasal turbinates red, erythematous, swollen, lungs clear” and the advice to the patient nearly always remains “Rest, fluids, Tylenol, ibuprofen, return if condition worsens.”

Additionally, much documentation remains unchanged at a routine 3-6 month visit for diabetes, HTN, hyperlipidemia where a physical exam is performed thoroughly. Medicare requires the documentation for payment, but is now placing providers in a catch-22 where the documentation cannot be even similar. How different can one make an exam if little changes?

Must we now ditch those time-saving macros that document routine education in the chart, such as “Counseled patient regarding risks and benefits of medication, including the possibility of sedation and advice to avoid driving or operating power tools while on narcotics?”

Clone Trooper

Dearest Trooper,

My secret fear is that Medicare is building its own Clone Army of Recovery Audit Contractors to continue to torment and confuse physicians. If they’re now going to go after so-called cloned documentation, they’re going to have to go back to every History and Physical and every Discharge Summary that every resident has done since the invention of the Dictaphone.

I remember being trapped in Medical Records (before it became Health Information Management) with a stack of my cruel attending’s charts, dictating notes on patients I barely remember seeing. Unless they had a significant finding, everyone was “regular rate and rhythm no murmur, rub, or gallop; lungs were clear to auscultation bilaterally.”

I absolutely agree with you – there are only so many ways to say, “Patient is not a smoker.” Let’s see. PATIENT is not a smoker. Patient is NOT a smoker. Patient is not a SMOKER. Let’s try this: STOP smoking pot. Stop SMOKING pot. Stop smoking POT.

If I use the same simple sentence on every patient, does that make me guilty of cloning? Will the stem cell activists come after me too?

Frankly, I think Medicare shares responsibility for creating this kind of documentation. This isn’t a new problem with use of EHRs. It has been prevalent every since transcription services started charging by the line. Physicians learned to say the same thing in fewer and fewer words. This ultimately evolved into dictation macros and the concept has continued as voice recognition slowly takes the place of transcribed dictation. EHRs just jumped on a train that was already rolling at a good clip.

Medicare’s cousin, Medicaid, has also driven us to this. Has anyone ever seen an EPSDT form? This is a required form for pediatric well visits. It is required that providers fill out the same form (specific to age) for each patient. You are required to document mandatory anticipatory guidance by placing an X in a box. Thus, the forms look pretty darn identical when they’re done. Should I start doing cursive X on some forms and print on others? Should I alternate right and left facing check-marks? Why is Medicaid’s form OK but my own form causes cloning?

I do a lot of sports physicals, sometimes at a sports physical clinic. There is a mandated state form. Almost all of the teens I see are healthy. So what constitutes “patient specific information?” Maybe I should start finishing them up with “This blonde surfer dude in an Abercrombie t-shirt is cleared for contact sports,” or include “Patient has braces with alternating pink and green elastics” on the oral exam. Would this meet the CMS standard for unique documentation?

Then, what about the patients who have the same visit month after month? I have patients whose office visits are straight out of the movie Groundhog Day. Except for the vital signs, the visit never changes. The patient continues to be non-compliant. The murmur is identical from visit to visit (which is a good thing!) The assessment and plan are the same. I keep prescribing the same medications that the patient continues to not take correctly.

Let’s not even talk about group visits, which they want us to do as part of Patient Centered Medical Home initiatives. Of course your counseling is going to be identical for every patient – you only said it once because they were sitting there in a group, for goodness sake. If you try to change it up for the sake of making less uniform documentation, isn’t that fraud?

I think if Medicare wants to avoid cloned documentation, they should start paying physicians to document using well-crafted prose – or at least an incentive payment for complete sentences with reasonably correct grammar. For the ability to collect a higher fee, I’d even consider writing notes in the form of the Shakespearean sonnet. But with dropping reimbursements and rising costs, CMS is going to be lucky if they get a Haiku out of me.

Have a penchant for an Ode, some Tanka, the Jintishi, or maybe the anapestic tetrameter of Dr. Seuss? E-mail me.

E-mail Dr. Jayne.