Monday Morning Update 2/4/13

From HIStalk Fan: “Re: HITPC/HITSC testimony of Karen Van Wagner, executive director of North Texas Specialty Physicians. The Pioneer ACO shares results of its community HIE.” She talks about successful efforts to increase EMR usage (eCW, Allscripts, NextGen) and the results of the exchange (Sandlot Solutions), which was launched in 2006. She says traditional healthcare IT isn’t providing cost and quality improvements because it focuses on retrospective data, often from claims databases, and the optimal solution involves both retrospective and current clinical information. They did a discharge transitions project study that exceeded targets for PCP follow-up, having discharge summaries available for the follow-up PCP visit, and readmissions. Her specific recommendations to the government: (a) simplify consent and disclosure rules; (b) expedite adoption of IHE standards; (c) require laboratory diagnoses to delivered by LOINC standards; (d) require hospital EMRs to send a “just admitted” notice to community providers via their own EMRs; and (e) require pharmacy systems to communicate with HIEs and provide their information at no charge.

Hospitalist DZA MD left an insightful comment on my Time Capsule article about doctors getting lost in the barrage of generally useless information cluttering up EMRs. Excerpting:

Anything that is templated has exactly zero clinical information value to me. I don’t care if Osler himself dropped in “dyspnea improved,” “no diarrhea” … If I want to know the validity of that kind of thing, I will look at the narrative part of the nursing note … The only data I look at that actually represents signal is the vital signs and lab data. The rest of the discrete data is noise … The narrative and visual graphics (including graphic displays of lab and vital signs data) are for us (clinicians). The templated stuff is for the suits and insurance grifters. QED.

From The PACS Designer: “Re: Microsoft Office 365. Microsoft is making a dramatic switch by selling its enhanced Office products in the cloud. They are calling it Office + Office 365, and will be offering a monthly subscription service with pricing based on business size and features selected by the customer. It’s a big gamble on users satisfaction with cloud services which as we know can experience interruptions in service at inappropriate times of the business cycle.” The good thing about Office is that the once-touted Office killers, especially Google Apps, are vastly inferior flops. The bad thing is that home Office users aren’t likely to lock themselves into a $100 ongoing subscription for something they formerly bought or stole once, although it’s a pretty good deal if you have a bunch of PCs since the home license covers up to five (less likely now that everybody’s using iPads and phones instead of extra PCs). And, you can temporarily load and run it to a non-licensed PC. I think it can work – antivirus software moved subscription software for home users to the mainstream, not to mention that Microsoft can just jack up the price of the box version to move people toward the cloud-based offering,  which would also kill the bootleg business (possibly their primary motivation). It won’t help that Office 365 had an outage almost immediately after its launch, allowing the boxed software users to work merrily along while the leasers couldn’t even get to Outlook.

From Godzilla: “Re: [hospital name removed]. Filing suit against [vendor name removed]. Unhappy with the products, implementation, and project management.” A hospital media spokesperson replied on the record to my inquiry, “Nothing could be further from the truth. Inaccurate on all counts.”

From Unbeatable: “Re: [vendor name removed]. Laid off 31 developers and outsourced all work to India and the Ukraine. The Chicago office lost the largest number of staff.” I’ll see what I can find out.

From IndustryBnkr: “Re: OptumHealth. Rick Jelinek is leaving as CEO to pursue another opportunity outside the company, with Larry Renfro taking over.” Unverified, but his former “About Us” page has been deleted. He took the CEO job a year ago.

From HITEsq: “Re: MMR. Made good on its threats to sue someone for patent infringement in January, going after Walgreens. MMR’s theory is that displaying a list of your prescriptions infringes on its patents. I seem to remember having access on Walgreens before 2005 when the MMR patent was filed.” Patent trolls love the US system because (a) the Patent Office is overwhelmed, they don’t have the knowledge required to understand highly technical patent requests, and will approve just about anything and let the courts sort it out later; and (b) lawyers are so expensive that mounting a legal defense can bankrupt a defendant even when they are clearly right since our legal system requires the winner to pay their own legal costs. Unfortunately lawyers often morph into politicians and are predictably loathe to bite the hands (as inserted into the pockets of others) that once fed them and may again, so we are required to be collectively complacent about the status quo.

Speaking of despicable patent trolls, let us hear from our new hero, Lee Cheng, Newegg chief legal officer and extortionist squasher. 

In related patent troll news, billionaire bad boy Mark Cuban endows “The Mark Cuban Chair to Eliminate Stupid Patents” at the Electronic Frontier Foundation, which he funded because, “Dumbass patents are crushing small businesses. I have had multiple small companies I am an investor in have to fight or pay trolls for patents that were patently ridiculous.” Mentioned in the article is Acacia Research, which I’ve railed about here many times, which claims to own the process of sending medical images over the Internet.

Yale-New Haven Hospital (CT) went live with Epic on January 31. Above: Sue Fitzsimons, RN, PhD (SVP, patient services); James Staten (EVP, finance); Marna Borgstrom (CEO); Daniel Barchi (CIO, health system and medical school); Lisa Stump (VP, Epic project); Peter Herbert, MD (chief medical officer); and Richard D’Aquila (president and COO).

The stock-pickers among us like Cerner and athenahealth just about equally. New poll to your right: did you go to the HIMSS conference last year, and are you going this year?

Speaking of those stocks I listed, I decided to see how they’ve done in the past year: athenahealth (up 40 percent), Allscripts (down 45 percent), Quality Systems (down 57 percent), Cerner (up 34 percent), and Merge (down 49 percent).

Thanks to the following sponsors, new and renewing, that have recently supported HIStalk, HIStalk Connect, and HIStalk Practice. Click a logo for more information.

Psychology scientists from Brigham and Women’s Hospital perform an interesting study in their research into “inattentional blindness.” Radiologists were asked to examine the CT scans of five patients and click on whichever of the 10 known nodules they could find. The final case included a gorilla image that was 50 times the size of the nodule, which 20 of the 24 radiologists did not notice even though eye-tracking instruments showed they had looked right at it. I don’t see this as necessarily bad – a lot of the work in medicine is tuning out the noise to focus on what you’re looking for. However, it does reinforce the idea that in general it’s good to get a second opinion from someone less focused on the problem at hand, and if you’re a patient or lesser expert, you still might detect the forest that the tree-obsessed people have missed. It may also touch on confirmational bias, where people tend to place higher value on information that matches what they already believe (like brains not containing gorillas).

A New York Times op-ed piece observes a “casual lack of transparency” in that drug and device companies make sure that only positive studies are published, with the trigger being Johnson & Johnson’s recalled artificial hip that was marketed despite known problems that the public wasn’t told about. It observes two attempted fixes that have failed: (a) the FDA requires new clinical trials to have summaries posted on a federal site, but an audit found that 80 percent of the trials ignored the requirement and no fines have been levied; and (b) the medical journal industry promised to publish only pre-registered studies, but an audit found that more than half of published articles involved trials that weren’t registered correctly and one-fourth covered studies that weren’t registered at all.

Good luck explaining healthcare pricing to the public. A graduate student’s gallbladder removal was billed at $60,000 by an out-of-network provider. His insurance paid what it defined as a reasonable rate: $2,000. The average commercial price is $12,292, while Medicare would have paid $958. An advocacy group stepped in and the surgeon accepted $340. The article says the Affordable Care Act does nothing to limit out-of-network fees, which are almost always a surprise to patients since buildings and white coats don’t come with “I’m in your network” labels. I’ve known people burned by in-network EDs that used out-of-network doctors or lab companies, and of course nobody volunteered that information, not that you really have a choice in the ED anyway. The comments left on the New York Times article are fascinating and often insightful. The graphic above is from a new AHIP report.

A foundation employee of Fairbanks Memorial Hospital (AK) is charged with diverting $12,000 in donations that had been collected online via PayPal.

GE Healthcare is working with the VA to develop surgical robots that can locate, sterilize, and deliver instruments.  

Meditech files its annual report. For the year, revenue was up 9.7 percent, EPS $3.55 vs. $3.41. Neil Pappalardo owns nearly 39 percent of the company, holding shares worth around $650 million. CEO Howard Messing’s shares are valued at around $18 million. Share values are probably low given that the company is not publicly traded – I just used the most recent per-share acquisition price, but if the company were to be sold or IPO’d, the value would probably be a lot higher.

Nuggets from the McKesson earnings conference call late last week:

• Technology Solutions revenue was flat
• Margins of the Technology Solutions numbers was hurt by a required revenue recognition change for the System C UK business McKesson acquired in 2012
• RelayHealth and the payor software business contributed more than half of the profits of Technology Solutions
• More legacy customers than expected have either already moved to Paragon or have committed to do so instead of moving to competitor systems
• The Paragon ED solution is close to being generally available
• Both Horizon and Paragon will support Meaningful Use Stages 2 and 3

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis.

More news: HIStalk Practice, HIStalk Connect.

Readers Write: Students in the HIT Spotlight

Students in the HIT Spotlight
By Lisa Reichard RN, BSN

Inspiring! That was the word that ran through my mind when I heard that the HOSA team of Harris County High School, Hamilton, GA had won the second annual Student HIT Innovation Award at the Health IT Leadership Summit for its Type 1 diabetes mobile health app.

As a former pediatric nurse who has worked with children newly diagnosed with diabetes, I was thrilled to see an app that can aid in the education and training of newly diagnosed patients developed by 11th grade high school students. Best of all, right here in my own back yard.

In my experience, this can be an isolating disease with challenging daily management. According to the Center’s for Disease Control (CDC), Type I diabetes has spiked 23 percent among children, with a 21 percent increase in Type II diabetes also reported.

The student team from HCHS rose to the challenge and was chosen from 12 semifinalists followed by a final four selection. HIStalk Connect’s own Travis Good, MD was on the judging panel.

Left to right: Todd Bell, senior VP at Verizon; Brooke Grantham; Aleah Harris; Hank Huckaby, chancellor of the University System of Georgia; Christopher Keough; Brittney Wilkins; and Cheryl Batts, Harris County High School HOSA Advisor

I had a chance to chat with team member Christopher Keough to hear more about the experience.

How does your Type 1 Project app work and how does one download it?

Our Type 1 Project app has several links to choose from that provide general information about Type 1 diabetes, informational videos, a link to our website and Facebook page, and even a link to a carb counter. To download our app, search for “Type 1 Project” in the Google Play store, or to access it on your iPhone, visit type1project.conduitapps.com and just add to your home screen.

How will the app help kids recently diagnosed with diabetes?

We feel that kids would rather use a mobile application than receive information from a doctor or a book because most of them own some form of technology. Children and young adults can relate to how to best calculate the amount of carbs in food on the go with the link that we’ve provided through the app. They can also learn more about their condition through our website and the informational videos that we’ve provided.”

What are the plans for the product?

This mobile application started as a project for the Health IT Leadership Summit award, but we plan to keep it live for a limited time and try to make more users aware of the app through Facebook and other methods. We also plan to make ongoing improvements to the mobile application.

I also had the chance to ask Cheryl Batts, Keough’s advisor, how those of us in the health IT community can encourage students to foster future creativity in application development, and succeed in pursuing future IT careers.

“We can start in our classrooms,” she explained. “Last year, the health IT project was directed toward middle school students. Although an estimated 95 percent of students in my classes have cell phones, and this is where our mobile app can come into play, I believe many students have no idea what healthcare IT is. I know when I mention the number of job openings in Atlanta in my classroom, they all start thinking hard about it.”

“The mobile app we developed had a monetary award for our HOSA organization. HOSA, a national student organization, used to be an acronym for Health Occupations Students of America. However, it now stands for just Future Health Professionals. The chapter is for any student interested in a career in healthcare. The mission of HOSA is to enhance delivery of compassionate, quality healthcare by providing opportunities for knowledge, skill and leadership development of students. HOSA provides competitive events and leadership training at conferences that include knowledge and skill competencies through a program of motivation, awareness and recognition as part of the Health Science Education instructional program. Of course, these conferences cost money, so earning money for the organization helps reduce student expenses. The offering of scholarships is a big help to our students as well.”

Congratulations to Harris County High School on the receipt of this milestone award. Let’s all do what we can to support our local students. Who knows? We may start seeing more students demoing apps at trade shows. The future is looking bright!

Lisa Reichard, RN, BSN is director of business development of Billian’s HealthDATA of Atlanta, GA.

Readers Write: It’s a Matter of “Over Promise and Under Deliver”

It’s a Matter of “Over Promise and Under Deliver”
By Mike Silverstein

As a recruiter in the healthcare IT industry, I attend HIMSS every year and make it a point to know what vendors are hot and what products and solutions are being purchased by the healthcare community. I am always shocked when I walk into the HIMSS exhibit hall and see massive booths of vendors I have never heard of. Even more shocking is the number of these massive booths that were at HIMSS the previous year but are not at this year’s show. I ask myself, “How does this happen?”

The answer took me to the biggest complaint I hear again and again when talking with hospital executives about their feelings toward vendors. It’s a matter of “over promise and under deliver.”

I am not using the over promise and under deliver adage when it comes to the performance of these seemingly fleeting companies’ products. Frankly, as a recruiter in this business, I have no idea what differentiates a good product from a bad one. The lens I look through is that of a search consultant who on occasion gets a call from one of these startup companies which has just received a considerable round of funding and is looking to recruit the top sales talent in the industry.

Their game plan is often the same: spend a bunch of money to hire salespeople who can go out and sell something, then hope something sticks and figure out the rest later. According to these same salespeople, the problem quickly becomes: (a) the product isn’t ready for prime time; (2) the company can’t implement what they sold; ( 3) they don’t get paid until go-live and it doesn’t look that’s going to happen in the next decade, so Mike, can you help me get out of here?

I recognize that the industry is primed for PE and VC investment. As a guy who makes a living by helping companies hire, I’m not going to complain. That being said, I think that the healthcare community could cut down on wasted IT spending, vendors could maintain better relationships with their customers, and I could cut down on the number of candidate resumes I have on my desk who took a chance on a startup. In fact, in the time it took me to write this piece, I received four more of these resumes in my inbox.

If everyone would more appropriately manage expectations and think about building an infrastructure and not just a sales team, the result would stop the over promising and under delivering circumstances.

Mike Silverstein is director of healthcare IT of Direct Recruiters, Inc.

Time Capsule: Put Down That Computer and Listen: Why Filling Out and Reading EMR Data Screens May Cause Doctors to Shortchange Patients

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 May 2008.

Put Down That Computer and Listen: Why Filling Out and Reading EMR Data Screens May Cause Doctors to Shortchange Patients
By Mr. HIStalk

I’m a fan of an interesting learning concept called the Illusion of Knowing. Here’s what it says: you’ve read something carefully, sometimes more than once, so you’re confident you’ve mastered whatever it says. Later, however, when hard-pressed to put the information to good use, you blank out. You didn’t know it after all – you just thought you did because you had passively read it.

(Cue sweat-inducing college final exam dream. You couldn’t find the exam room, and when you finally did, you realized you hadn’t attended any of the classes … you know the rest).

Anyway, some Harvard doctors made me think of that with their recent NEJM report on EMRs. They question whether EMRs really improve care given their emphasis on creating reams of bland and predefined information, but with no capability to encourage fresh, individualized thinking to diagnose and treat patients.

(Note: I’m reading between the lines since the actual lines themselves require a NEJM subscription, which I don’t have because I’m cheap and they use a lot of big words when little ones would do fine).

The authors cite a doctor colleague who said that hunting for useful information in an EMR is like the Where’s Waldo? games of a few years ago. The kicker is this: that colleague is so frustrated with all the meaningless junk in EMRs that he makes index cards to track what’s important.

That’s where I thought of the Illusion of Knowing. A doctor could read all the EMR screens and figure, “Everything I need to know is right there, so if I study it long enough, I’ll figure out how to improve this patient’s life.” That’s EMR Nintendo: recognize and react to some event, which may seem like practicing medicine to a programmer since that’s how logically programming works.

Here’s a problem: doctors don’t have the time to conduct scavenger hunts for vital facts in the handful of minutes per encounter that the benevolent insurance companies and practice managers allow them.

Second problem: EMRs aren’t set up to allow automatic or manual grading of individual factoids, so everything looks potentially important.

Third problem: EMRs try to turn freeform and sometimes tentative thoughts into dropdowns and template-driven generic verbiage that may destroy their original context (that’s what programmers do: impose order and create retrievable database information, so it’s not really their fault).

Another article that was published at about the same time extols the virtues of speech recognition systems. Those create more voluminous and anecdotal information, but the context is perfectly preserved. Unlike discrete data, doctors could re-read a narrative and glean new information after the fact. Programmers hate bunches of text that don’t lend themselves to convenient database structures (although natural language processing can reverse engineer some of it back into data fields).

We in the industry could debate the merits of templates vs. narrative, but that discussion is moot. The real problem is medicine itself. A table of dry patient facts can help support diagnosis and treatment decisions, but even fresh-faced doctors know that patient care isn’t a video game of spotting a symptom and blasting it with drugs or surgery. The first thing they learn in medical school is not how to read charts or write orders, but to go into the patient’s room and look and listen. Sometimes the least-obvious information is the most useful.

Perhaps a redesign of EMRs is in order that takes semantics and metadata into account to better reflect the physician’s thought process and judgment rather than just trying to force those thoughts into a convenient data structure that looks good in a table and uses classification tools that say in black and white what might be better expressed in not just shades of gray, but in rainbows of colors. Or, maybe a well-designed study (not financed by EMR vendors, most likely) would find that chatty paper records lead to better outcomes than terse and categorized electronic ones.

The bottom line is this. EMRs have affected patient outcomes only modestly, if at all. If doctors still have to make index cards, maybe legacy EMR design should be revisited.

Morning Headlines 2/1/13

McKesson Q3 Profit Misses Estimate; Cuts FY13 Adj. EPS View

McKesson reports Q3 results: EPS $1.41 compared to last year’s $1.40, missing analyst estimates of $1.63. Revenue was up one percent, ending the quarter at $31.2 billion. The company lowered its guidance for FY 2013 by 20 cents, to $7.10-$7.30. The stock closed down 0.4 percent on the day.

Computer Programs and Systems, Inc. Announces Fourth Quarter and Year-End 2012 Results

CPSI reports year-end results, with revenue up five percent at $183 million. Net income increased 16 percent to $30 million, but EPS missed the $0.88 analyst estimate by $0.05 and shares dropped nearly nine percent in after-hours trading.

Clancy stepping down as AHRQ director

After 10 years on the job, Carolyn Clancy, MD, is stepping down as the director of AHRQ.

Piedmont Newnan transitioning to electronic medical record system

136-bed Piedmont Newnan Hospital goes live on Epic this Friday, the first within the five-hospital Piedmont Healthcare system’s network-wide implementation.

News 2/1/13

Top News

McKesson announces Q3 results: revenue up one percent, non-GAAP EPS $1.41 vs. $1.40, missing earnings expectations of $1.63 and guiding earnings slightly down for FY2013. Operating costs rose 10 percent, while technology solutions revenues were flat.

Reader Comments

From AphexTwin: “Re: Allscripts. Laid off five percent of its workforce (350 people) in testing and development roles. All remote development staff are being forced to relocate or be terminated.” An Allscripts spokesperson provided this response:

We internally announced the creation of R&D Centers of Excellence to enable us to better serve our clients, reduce complexity, and save costs. By making this move, we’re aligning with industry best practice and will be more agile in delivering results for our clients. Many team members will have the opportunity to relocate and some to work remotely. Unfortunately, there will be some team members whose positions will be adversely impacted, and they will be offered a severance package. In addition, we anticipate there will be Development jobs created in the North American locations with the majority of those in our Raleigh and Boston locations.

From The PACS Designer: “Re: iPad with Retina display. Apple keeps making the iPad more brilliant and powerful with the announcement of the iPad with Retina display. This new version also has 128GB of storage and a selling price of $799. The communications options now include both Wi-Fi and iPad with Wi-Fi+ Cellular as added features.”

HIStalk Announcements and Requests

Highlights from HIStalk Practice this week include: Epic, Allscripts, and eClinicalWorks accounted for 42 percent of all EP MU attestations through October, 2012. iPractice Group confirms that it has ceased operations. AMGA says it now represents 430 group practices and 130,000 FTE physicians. The HIStalk Practice Advisory Panel shares details of their practices’ social media policies and privacy and security measures. As always, thanks for reading.

On the Jobs Board: Director of Marketing, Epic Experienced Providers, Product Marketing Manager.

January, which isn’t quite over yet as I write this, will set an HIStalk record for the most monthly visits ever at 140,000, up 25 percent over January 2012.

Welcome to new HIStalk Platinum Sponsor VitalWare, a market leader in healthcare intelligence and regulatory compliance. The Yakima, WA company’s offerings include VitalView (ICD-10 planning and status between hospitals and vendors), VitalSigns (supports real-time retrospective coding to ICD-10 for starting efforts now to estimate impact on reimbursement and cash flow), VitalCoder (next-generation coding and revenue cycle resource), the just-announced CDM Navigator (charge master maintenance), and ICD-10 consulting and implementation. The company also offers VitalVendors, a vendor ICD-10 readiness rating system that’s part of the HIMSS ICD-10 Playbook. A guest post by Founder and CEO Kerry Martin provides a sobering update on the stage of vendor readiness for the October 1, 2014 ICD-10 compliance date. Thanks to VitalWare for supporting HIStalk, which thanks to its support will be fully ICD-10 ready.

Acquisitions, Funding, Business, and Stock

CommVault announces Q3 numbers: revenue up 24 percent, non-GAAP EPS $0.39 vs. 0.27.

Aetna announces Q4 numbers: revenue up 16 percent, EPS $0.56 vs. $1.02.

CPSI announces Q4 results: revenue up 14 percent, EPS $0.83 vs. $0.59, falling short of consensus estimates of $0.88. Shares are down nearly nine percent in after-hours trading.

Sales

Wenatchee Valley Medical Center (WA) and Central Washington Hospital select NextGate’s EMPI and provider registry systems.

Huron Valley Physicians Association (MI) chooses eClinicalWorks EHR for its 600 providers.

People

AHRQ Director Carolyn Clancy, MD announces plans to step down.

API Healthcare expands General Counsel Hayden Creque’s role to include vice president of human resources.

Announcements and Implementations

The VA completes integration and testing between VistA and Authentidate’s Electronic House Call and Interactive Voice Response telehealth systems.

The 24-bed Melissa Memorial Hospital (CO) completes implementation of its EMR.

Piedmont Newnan Hospital (GA) goes live this week on Epic.

Welch Allyn will distribute the EarlySense proactive patient care solutions to US hospitals.

Good Samaritan Hospital (NY) goes live on Epic March 9.

The University of California at Irvine uses the dbMotion interoperability platform to connect with  the Orange County Partnership RHIO.

Quantum Health integrates the Healthwise Care Management Solution into its Patient Information Virtual Integration Tool to provide real-time healthcare education to its members.

Stellaris Health Network (NY) goes live on PatientKeeper Charge Capture at five of its clinical practices group.

Government and Politics

The VA enhances Blue Button to give patients access to their Continuity of Care Document and the VA’s OpenNotes provider documentation.

Innovation and Research

A University of Washington graduate student develops FoneAstra, an Android phone app that monitors the pasteurization of donated breast milk. It’s being tested in South Africa. Other versions are used to ensure that vaccines remain refrigerated in developing countries.

Technology

Lt. Dan summarizes what the BlackBerry10 announcement means for mHealth and healthcare on HIStalk Connect.

University of Missouri-Kansas City’s Innovation Center will launch the partially federally funded Digital Sandbox KC IT accelerator on Friday, with officials from Cerner and other businesses on hand.

Other

Fifty-seven percent of Canada’s primary care physicians are using EMRs, which is almost double 2006’s adoption rate. Almost half routinely e-prescribe compared to 11 percent six years ago.

KLAS and EHI, a UK-based HIT research firm, partner to improve transparency and performance measures for the UK health technology market and to cross-market their research products.

Michael Dell’s family foundation donates $50 million to build Dell Medical School in Austin, TX.

The Minnesota Supreme Court rules that calling a doctor “a real tool” on a doctor rating site is protected speech.

Here’s an example of how technologically backward healthcare is. A body shop in Canada has been receiving faxed medical information for three years because its fax number is one digit different from that of the local health center. Says the body show owner, “In this day and age, why are they still using fax machines? It seems odd to me.”

I’m fascinated that this happens regularly in India. Twelve angry relatives of a teen who died after a bicycle accident trash the ICU and beat doctors and security guards. Medical residents then go on strike to demand better security and the arrest of the family members, which requires patients to be diverted and surgeries to be cancelled when only 20 doctors remain to care for 300 inpatients.

WNA thinks a hospital parody video makes him wonder whether ACO stands for Abridged Care Organization. Fox Business News says the video “mocks how health reform can make more money for doctors and hospitals” by showing staff blocking the admissions department door, handing out stacks of cash, and giving free laptops to employees. I didn’t see it that way – it looked like fun way to get the ACO idea across to otherwise learning-indifferent employees. The hospital says the video was a contest winner. Fox claims the video was “leaked,” which apparently means “posted to YouTube under the hospital’s name and still there but copied to Fox’s servers and covered with self-promoting graphics to make it look like the result of crack investigative reporting.”

Sponsor Updates

• ESD joins ANIA as a Gold Level member.
• dbMotion hosts a February 7 seminar in Dallas on connecting communities through clinical integration.
• Laura DeBusk from White Plume Technologies will co-present an ICD-10 session at the Becker’s Hospital Review Fourth Annual Meeting in Chicago in May.
• 2012 highlights for Aspen Advisors include the addition of 26 clients and the development and deployment of a population HIT planning methodology, a data governance maturity model, and an EHR value realization maturity model.
• DynaMed showcases how Memorial Hermann Healthcare System (TX) utilizes technology to allow physicians to practice evidence-based medicine in a journal article.
• Emdat Mobile usage has quadrupled from January 2012 with the rapid adoption of smartphones.
• Lucca Consulting Group posts new client, consultant, and trainer testimonials on it website.
• Macadamian CEO Frederic Boulanger says he is impressed with the new BlackBerry 10 and the company has developed 10 apps for it.
• Truven Health Analytics announces that staff members Eboney White and Jillian Thomas have been presented with the unique credential of Accredited Health Care Fraud Investigator.
• CareTech Solutions added five Service Desk clients in 2012 and experienced a 75 percent uptick in the use of its help desk services overall.

EPtalk by Dr. Jayne

Earlier this month, Virginia Senator Stephen J. Martin introduced SB 1275, “Medical data in an electronic or digital format; limitations on use, storage, sharing, & processing.” As a medical informaticist, all I can ask is what was he thinking? It would prohibit anyone who stores medical data in an electronic or digital format from participating in the Nationwide Health Information Network; performing analysis or statistical processing on medical records for purposes of diagnosis or treatment, including population health management; processing medical data within Virginia where a majority of the patients do not live in Virginia; and storing data on more than 10,000 patients in a single database, It also prevents providers who refuse to implement EHRs from being penalized and prohibits Virginia from authorizing or operating a health information exchange. I’d be interested to hear from anyone in Virginia who can tell us more about what’s really behind this besides anti-ARRA posturing. It’s been sent to committee where it will likely die, but still makes for good cocktail party conversation (at least among HIT folks).

It’s about time: Medicare will look at the facility fees charged by ambulatory medical practices. Many feel that these hospital-owned practices are driving up the cost of health are with this billing practice. Many of the groups in my area are now doing this. It’s not only annoying, but also feels dishonest.

Lots of buzz this week about the HIPAA update and the impending September compliance date. Looking forward to reading hundreds of pages of fun during my free time, whenever that is.

Although I thankfully don’t have any direct reports, before our recent hiring freeze I was often asked to interview potential employees for other managers. I’m going to keep this list of bizarre interview questions tucked away for when administration figures out we’re dangerously short-handed on some of our teams.

Bad news for Inga: an increasing number of young women are having issues with their feet that require surgery. Some blame is being placed on genetics, but the phenomenon is at least partially attributed to high heels and pointy-toed shoes. She’s always telling me I’m too conservative in the shoe department, so maybe for HIStalkapalooza I’ll be more inspired this year.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis.

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 1/31/13

Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA

JAMIA publishes the recommendations of a year-long EHR usability task force that included representatives from academic settings and EHR design analysts.

Huron Valley Physicians Association IPA Selects eClinicalWorks

Huron Valley Physicians Association of Ann Arbor, Michigan, has selected eClinicalWorks as an ambulatory EHR solution for its 600 providers.

HIT 2012 Annual and Q4 Funding and M&A Report

A 2012 HIT market analysis shows significantly increased venture capital funding, with $1.2B in funding spread over 163 individual deals.

EHI and KLAS Partner to Improve NHS IT Measures

KLAS has partnered with EHealth Insider, a UK-based health IT news and research firm, to bring performance measures to the UK health technology market.

HIStalk Advisory Panel: HIPAA Concerns and Priorities

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: When you think of potential HIPAA isses, what parts of your health system’s operation give you the most concern? What are your top HIPAA-related priorities?

Our top HIPAA concerns relate to the use of personal devices such as smartphones to transmit pictures and unsecured text. While we can and do provide secure alternatives, there is really nothing we can do to prevent a medical student from snapping a picture of a patient or patient data and sending it to several hundred of his closest friends.

HIPAA is an interesting concept. How do you balance providing sufficient access to critical information that can impact a patient’s health and still protect their privacy? It’s not easy. For many of the children we care for, privacy is not just a regulation to follow, it’s life and death – for children in custody disputes and victims of violence. The most significant challenges we face involve the fact that both the rules and technology are changing at an ever-increasing pace. The people writing the rules aren’t always the ones with the most knowledge about how (and even if it’s possible) to implement.

It’s ironic that we are both demanding healthcare costs go down and simultaneously creating new and unfunded mandates that require enormous amounts of time and money to implement. The two things I worry about most: mobility of devices and data  and staying current on vastly complex laws. Small hospitals outside of a larger system are still required to adhere to the same rules and regulations even if they have a fraction of the resources with which to do so.

Top HIPAA-related priorities and concern for us center around secure communication between our staff with clients and providers. Ensuring that the proper processes and technologies are used to secure communications via e-mail, instant message, or any channel is paramount.

When it comes to protecting PHI, my biggest concern is the data that goes to our physicians’ offices for billing. There are many concerns, but how the practice and the billing services treat this data is my greatest. We have no way to audit how this data is used and disposed of. Practice adherence to HIPAA security and privacy is very minimal, as an independent practice has little knowledge or resources to dedicate to this requirement. 

HIPAA security requires complete control of PHI storage. There is so much distributed data acquisition going on that it’s difficult to ensure complete control. Example: digital photos taken in the clinic stored on memory cards. Clinical staff don’t see these cards as containing PHI, but they do. Thieves see the cameras as easy to pawn theft targets. When stolen, we have a privacy breach on our hands. In retrospect, we learned we lack procedures to wipe the cards of data once the images are stored in the EHR. These novel data stores continue to pop up and represent control risks.

I lay awake at night thinking about unencrypted laptops. With all the other projects, this one keeps sliding down the priority list. The CFO all but refuses to fund this. We have a policy against keeping PHI on the PC, but I know no one follows this policy.

I’m glad you’re running my comments anonymously because I don’t want to advertise how many potential HIPAA vulnerabilities we have in our organization, ranging from PHI routinely sent via insecure text messages (and the Web-based paging system), workstations that are visible to the outside world that don’t secure properly, shared common windows passwords, shared common remote login passwords, EHR printouts that aren’t shredded in a timely manner, etc. I’ll stop now before I trigger a subpoena coming your way.

Mobile device security and BYOD are probably our biggest concerns. We have a number of clinicians using their own devices, communicating and coordinating patient care. We are putting in place comprehensive mobile device management system that will provide secure communications options. We are in the process of encrypting laptops and securing USB ports.

General staff knowledge and awareness would be the first thing that comes to mind. We can write policy and implement all the controls we want, but people will find ways to circumvent if they don’t understand the whys. Our top priorities in the coming year include establish ongoing staff education, conduct annual policy review, create mobile device management strategies, and evaluate data loss prevention solutions.

We do a good job of educating our employees on HIPAA. We don’t see too many concerns with patients. We do get the occasional employee who looks at a relative’s records. Our greater concern is office staff of independent providers who have access to our patient database by necessity. We rely on the physicians in their office to provide initial and ongoing HIPAA training and this breaks down. We also have the issue of those employees leaving employment in the physician office and the office not informing us to cancel their access. We do a manual audit every 90 days.

There are really four classes of data we are charged with protecting. First, our current data, which may be stored locally or remotely. Second, the data we push out to others (patients, providers and organizations). Third, the data we receive from others and is received in various formats. Fourth, our archived data which might be scanned, paper, or legacy digital formats. The diversity of data itself poses its own challenges.

We often think of securing data through protection from security breaches such as device theft or hackers. Encryption has become the standard in this regard. However, the more common occurrence would be in the form of end user error — leaving devices without logging out or the dreaded exposed password. While much of our effort has to be on prevention of the "big event," we must still focus on end user HIPAA training and routine auditing as the first line deterrent to loss of PHI.

My biggest technical concerns are with mobile devices. We are pushing quite a bit of data to them in e-mail alone, and even with security policy in place, it is still a huge exposure. While internal threats like staff inappropriately accessing someone’s records may be larger, technical solutions to a threat like that are harder to address. Our privacy officer gets to lose sleep over those.

The inability to control what disgruntled employees can do with sensitive health information. Overly curious individuals are also a problem in terms of celebrities or people they know, but they typically would not compromise the sizable amounts of information that could be breached by someone with a grudge and/or desire to sell information for money. Carelessness is also a major problem when people are working with large data sets or spreadsheets as part of their job and leaving it on laptops or sending it in unencrypted files via e-mail. 

The use of workarounds to data security initiatives. The tighter the security lockdown, the greater the impingement on ordinary work and productivity, especially in comparison what people are used to doing in other realms of life. Rather than helping with data security, the workarounds just seem to make matters a whole lot worse because then people exchange info surreptitiously by cell phone images, Gmail, and the like. 

Since I’m not in management, my top priority is making sure that I keep the data of my own patients secure. Another goal is to educate residents and medical students about the importance of patient privacy. I also advocate for more enlightened approaches at a local and national level for protecting confidential information and for giving patients more say in the way their sensitive information is stored and shared with others.

Where to start? My biggest concern is not knowing what I don’t know. Our customers are doing all kinds of things that I can’t control. I’m sure that data is leaking like crazy and we’re doing all we can to contain it. I am hopeful that in the next 60 days we will have a much better understanding of what is occurring and that we will have better control. Our biggest HIPAA priorities are data loss protection and then preparing for the inevitable audits.

With the increasing use of clinical and other data (read PHI), our concerns are growing around mobility and continued violations of our use policies. We are moving to our second mobile security platform/tool, but are not convinced that even after best efforts that we are "safe." There will always be threats and we have to continuously evaluate what those threats are and how to prioritize the work to protect our data.

Our organization has finally realized we are not impervious to breaches or attacks and is supporting new efforts to ensure we are doing what is appropriate to secure the environment. In addition, we are trying to play more "hard ball" with violators of policy on data use and access. I am afraid a few examples will have to occur before the majority of our users realize we are serious about this as an organization.

The biggest HIPAA issue would be a breach > 500 which triggers a multitude of bad events  We do take the approach of "when" not "if" so we are prepared, but we are implementing technology and procedures to reduce the risk of occurrence. The biggest risk is related to PHI leaving the organization. That can happen in many ways (e.g. mobile devices, mobile media, viruses and e-mail). We have implemented encryption in these areas to reduce this risk. We also have virus protection and a SEIM tool to monitor network attacks.

Our next effort is implementation of a data loss protection (DLP) tool. This tool maps the location of all PHI in your domain. Strict rules can then be applied to govern the movement of that PHI. Besides encryption, my feeling is that DLP will have the biggest impact in protecting an organization from a breach.

We had two significant reportable breaks last year, but neither were related to the electronic medical record or other electronic systems here. The first was a physician who e-mailed an Excel spreadsheet which contained PHI to an external unsecured e-mail server. The other was a resident who took home paper copies of patient records for the purposes of a lawsuit they were gathering potential evidence for. In neither case was the patient information actually exposed, but they were reportable breaches nonetheless.

We are in the process of implementing a new clinical platform, so my focus is creating one balancing the new robust functionality with the safeguards that are needed to protect the information. Not an easy task.

Laptops. No matter what we do or what we say, folks will still copy and past information and manage to store PHI on their laptops. We lock down the laptop as much as possible, train, and continuously educate and inform, but the laptop is still our weakest link in the chain.

New phones. With new phones and applications for them, I believe there is more opportunity to access PHI. If you can clone someone’s phone by walking by them and picking up their information, what happens if someone is sending them e-mails, updates, or questions via e-mail, etc.?  I am not very informed in this area, but very concerned.

Top concerns: access controls within older non-core EHR systems, such as radiology, lab, and custom systems that we have developed. Providing appropriate levels of adolescent confidentiality. Opening access to psychiatric care visit information as much as legally possible. 

Top priorities: dealing with the above. Getting lawyers and others to understand that data-sharing across legal entities for ongoing and potential future care is the same as "treatment" and therefore allowed by HIPAA. Physicians who are members of different legal entities who practice together (e.g., in an ACO) often need to use the same EMR database and that having two or more separate records in a system for a single patient (which is their idea how to do this) is just dangerous.

Vulnerabilities that are rooted in human behavior or misbehavior concern me the most: apathy, naiveté, curiosity, theft, and vengeance. Continual education and empowering employees and physicians with scenario techniques on how to appropriately deal with common situations is helpful. Not intending to scare or intimidate people into compliance, we share media stories of fines and prosecutions of healthcare systems who have had incidents of security or privacy breaches.

The proliferation of personal devices where clinical information can be accessed (smartphones, tablets). We’re working on how to best encourage provider access / patient engagement while still ensuring appropriate security and privacy. 

Many vendors, including our eClinicalWorks vendor, are increasingly utilizing cloud technology. We’re working to be able to make best use of the new products while managing security.

The people. Information technology systems are relatively easy to secure, but people have this aggravating habit of not doing what you tell them or expect them to do. I’m functionally the assistant security officer, although my title doesn’t reflect it.  I did about half of the facility education in 2003 for the Privacy Rule implementation and it still amazes me how many people don’t make basic information security and patient privacy a part of their day-to-day existence in healthcare.

In 2003, there were three groups of people: those who lived privacy, those who had heard of privacy but for whom it was an add-on to their daily life, and those who had never heard of privacy or the Privacy Rule. In 10 years, we’ve pretty much stamped out the "never heard of it" problem, but there are a lot of people who still treat patient privacy as something to think about when everything else is done. A text message to a friend here, a social media message to a friend there (even a private one) and you have opened yourself up to serious problems. Somehow we still have to convert those folks over to people whose lives include patient privacy. I’m still working on how.

Not misspelling HIPAA :) 

The use of HIPAA as a way to make life harder for physicians, such as CIOs and lawyers creating inane password policies or medical record clerks denying access to results of study I ordered without a written consent "because of HIPAA.”

Stupid mistakes (e.g. having patient info on an unprotected medium which gets stolen). Interestingly, while this may result in embarrassment and financial penalties, it rarely actually compromises a patient’s medical information.

The reality is that HIPAA is simply a mandate of common sense (i.e. only share patient info with someone who should be able to see it for obvious clinical, operations, or payment reasons), and yet ironically it actually winds up making people lose their common sense in how to deal with data and potentially hurts the quality of care by denying access to data needed by caregivers.

Downloading PHI to personal laptops or other mobile storage devices that are not encrypted and not secured with a strong password. All of our corporate laptops and portable storage devices (e.g., thumb drives) are encrypted and password protected, but that’s not the case with personal laptops which inevitably are used by employees for work-related tasks. I’m also constantly concerned about insiders and trusted agents who engage in for-profit identity theft.

In our organization, a chief privacy officer has virtually shut down all research in the name of HIPAA and patient privacy. She has even begun to question the utility of quality improvement efforts and their need to review patient records.

Our health system is most vulnerable with the new culture of real-time information, which means that caregivers are texting, e-mailing, taking photos, etc. as part of the normal practice of patient care. Our EMS and cardiology service line had a great process in place to get information to cardiologist on the patient prior to arrival by using a smartphone to take a picture of the EKG and text it to the physician. Great idea, but not vetted for patient privacy and security.

It is up to us to stay in front of this new culture and put the appropriate privacy and security measures into place. Our health system is developing its updated security program now and I’m concerned that some of these things are going on without our knowledge or preparation.

Readers Write: Healthcare’s Crystal Ball – Predictions for 2013

Healthcare’s Crystal Ball – Predictions for 2013
By Terry Edwards

As many have noted, there’s been more innovation in the past five years than in the last 50. But it’s onward and upward, and I spent quite a bit of time over the holidays thinking about what 2013 will look like. With Obamacare here to stay, healthcare executives certainly have more clarity into what their future will look like than they did for most of 2012. Investments in IT and communications are going to continue at a steady pace and likely even increase. But here a few of the biggest shifts that will take hold in the year ahead:

EMRs will be upstaged/usurped by population health management tools. In 2012, the industry finally came to a consensus that EMRs are simply data repositories, and also remembered that they were originally created so that hospitals could capture information to send a bill – and really nothing more. As we move toward business models based on maintaining the health of populations, EMRs will become an afterthought, while population health management, predictive analytics, and actuarial capabilities take center stage. Health systems are going to be focused on putting the technologies, people, and processes in place around the EMR that will enable true population management by 2014.

Clinical integration will take hold. Call me an optimist, but 2013 is going to be (finally!) the year of the integration. Hospitals will continue to reduce the number of systems they manage by making sure the ones they do keep can easily share data. Mobility is going to be key to pushing vendors to collaborate, because it’s going to be more and more critical that clinicians receive patient data on smartphones and other mobile devices, both within and outside the walls of the hospital.

Population health will push healthcare into the cloud. I see a huge opportunity in new applications moving to the cloud – specifically those that facilitate the freer flow of information that’s going to be required under a population health model. An ideal example: there’s a device or application that allows me to manage my weight, and I’m a patient with a chronic condition. I weigh myself every day or take my blood sugar, and that information goes from my smartphone to a database in the cloud, then accessed by my care manager. Or maybe there’s an alert that goes off if there’s a change of a certain percent over a set period of time. That’s an ideal cloud-based healthcare application, and we’ll see more of those move to the cloud in 2013.

Patients will be financially incented and will vote with their pocketbooks. To be blunt, patient accountability is an area where Obamacare really whiffed. Under the ACA, everybody is responsible except for the patient. But in the year ahead, the market will introduce more ways to incent and motivate patients, with financial pressures and rewards related to their health. We’ve already started to see new health plan designs where smokers pay more, putting a price tag on making better lifestyle choices. For those who are already more involved in their care, we’ll see them opt out of private or government-run insurance programs and gravitate toward concierge-type services. They’re also going to drive demand for better access to care, as they pay for faster, easier access to “retail” health care in CVS MinuteClinics, etc. – especially as primary care physicians continue to be spread thin.

Health systems crack the (scarily complex) code on clinician-to-clinician communication. I’m always fascinated by the different methods hospitals and health systems have in place to get information from one clinician to another. I’ve seen everything from NASA-level flow charts to third-party call centers to systems that seem like a step away from carrier pigeons. Effective clinician-to-clinician communication is essential to nearly every initiative a hospital has on its plate these days – meeting new regulations, driving new quality initiatives, moving to new models of care, etc. – but it has often been an afterthought, or as I’ve seen all too often, completely overlooked.

In the year ahead, hospitals will begin to gain an understanding of the complex processes between clinicians both inside and outside the walls of the hospital, and also start to see that there’s no technology solution that will improve efficiency. It’s not about smartphones or text messaging or pager replacement software, but about the process of who needs to talk with whom and when – and what changes need to be made in the current workflow to make that happen in a reliable way. With all the competing priorities hospitals are facing today, many don’t even understand their current workflows – and certainly don’t know what it should or could be. But sticking technology into a flawed workflow will only lead to an automated, flawed workflow. Hospitals need to identify the current state and the needs and concerns of clinicians, make improvements to processes as necessary, and then apply technology to the new and improved workflow. Only with an understanding of the process will hospitals be ready to start thinking about and implementing a successful clinical communications strategy.

Now that my tarot cards are on the table, what are you healthcare predictions for 2013?

Terry Edwards is president and CEO of PerfectServe of Knoxville, TN.

Readers Write: The Transition TO Paper Record Keeping

The Transition TO Paper Record Keeping, Featuring the "King of Desks"
By Sam Bierstock, MD, BSEE

With the digital age has come the rejection and vilification of paper. The entire healthcare industry has been on a writhing, agonal path to the adoption of electronic health records for more than a decade.

Have you ever wondered, though, about the transition to paper record keeping?

In a previous historical perspective, I paid tribute to Joseph Lister and his Herculean efforts to convince physicians and hospitals about the need for asepsis – the champion of champions of physician adoption. Compared to today’s challenges with physician adoption of technology, it took Lister almost 20 years to move past ridicule and 30 years to see his arguments fully appreciated and his recommendations put into practice.

In the world of paper record keeping, another, less well-known 19th century figure deserves recognition – William S. Wooton.

We have been documenting on paper for centuries. It is fascinating to walk through Jerusalem’s Israel Museum and browse through the ancient, centuries-old handwritten documents dealing with issues that persist to this day – contracts of sale, employment, marriage, divorce, debt, inheritance, and all other matters of transaction, discord, and agreement. Record keeping of the day involved rolling documents and wrapping ties of various sorts around the resultant paper cylinder for storage in jugs or other designated compartments. Copies were reproduced by hand. Larger and longer documents were recorded on scrolls that piled up in corners and on tables.

Paper record keeping progressed slowly, the most major advance in printing of course coming as a result of the invention of the paper press by Gutenberg in the mid-15th century. Still, business transactions were maintained in ledgers and entered by hand. Essentially no written records were kept by physicians, even well into the 19th century. Past history and treatments administered were simply left to the physicians’ memory and the strength of physician-patient relationships over time.

In today’s world, we recognize the need for record keeping to maximize our ability to deliver the best possible care, overcome our limited memories, and ever increasingly, to protect ourselves as caregivers from medico-legal vulnerability.

In ancient civilizations, shamans with consistently poor therapeutic results were often dealt with simply and quickly by being killed. Evidently, iatrogenic patterns have been recognized for a very long period of time. Greece, Rome, and later Europe during the Middle Ages were much more forgiving, often having laws in place to provide immunity for misjudgments of doctors. During the Great Plague in the 14th century, almost one-third of England’s population perished, and people began to wonder if it was possible that physicians of the day didn’t actually know what the hell they were doing. But the idea of medical record keeping still did not occupy the concerns of physician for centuries after the Plague.

It is not clear as to when physicians began to understand the need for complete record keeping. I am old enough to remember my own family doctor maintaining my entire record on a set of index cards, and it’s not that long ago that I saw practices where physicians kept the records of an entire family in single file. It is my personal belief that medical note-taking probably became much more prevalent with the availability of the fountain pen, which made the act of writing much less arduous and certainly more portable. Beginning in the middle of the 20th century, we must reluctantly tip our hats to malpractice attorneys who made it painfully obvious to us that we needed to defend our decisions and actions.

The first recorded malpractice case was probably that heard before the court of John Cavendish of the Court of King’s Bench in 1375. A highly regarded surgeon by the name of John Swanlond had treated the crushed and mangled hand of one Agnes of Stratton. The condition of her hand had not improved after a few weeks and the patient consulted a second surgeon, who informed her that Dr. Swanlond’s treatment was deficient. When her hand became severely deformed, she sued Swanlond. Although the suit was voided because of a technical error made by the patient’s lawyer, the judge made the following note in his written opinion: "If a smith undertakes to cure my horse, and the horse is harmed by his negligence or failure to cure in a reasonable time, it is just that he should be liable." This case set the precedent upon which has rested all subsequent Western malpractice litigation.

The first recorded malpractice case in the United States (Cross v. Guthery) was heard in Connecticut shortly before the American Revolution. “When Mrs. Cross complained that there was something wrong with her breast, her husband sent for a doctor named Guthery. The doctor examined Mrs. Cross, diagnosed her ailment as scrofula, and amputated her breast. Shortly after the surgery, Mrs. Cross hemorrhaged to death. Dr. Guthery expressed his regrets to her husband and then sent him a bill for 15 pounds. Cross hired a lawyer, who persuaded a jury to dismiss Dr. Guthery’s bill and award Cross 40 pounds as compensation for the loss of his wife’s companionship."

In the United States, the years following the Civil War began an age of remarkable industrialization and business growth. Until then, most businesses were run by one or two principals, often in the same family. Services were provided directly and most material products were constructed on site. Paperwork requirements were therefore low. Customer interactions were recorded by hand in ledgers, and payment for employment services was generally in coin or via bank draft. After the war ended, enormous growth of commerce combined with technical advances allowed for massive growth of business. White collar workers were needed and their numbers increased at a very rapid rate. At the same time, the first fountain pens and typewriters appeared, as did carbon paper and the first rudimentary copying machines.

Within the space of one or two decades, businesses had a new problem – a lot of paper and a need to keep it filed in an orderly fashion and readily accessible.

William Wooton was born in 1835. He was employed during the 1860s as a furniture maker in Illinois. The idea struck him that if he could build school desk and chairs in a single unit that folded up and could be moved, a classroom could serve multiple purposes, including such activities as both teaching and gymnastics. After obtaining a patent on his design for a foldable school desk and chair assembly, he opened his own furniture-making company in Indianapolis in 1870 and achieved rapid success selling school and church furniture.

As his business grew, he observed his own employees taking and fulfilling orders, and struggling with paperwork strewn about. Wooton then realized that businessmen needed an efficient way to file and keep their ever-growing accumulations of paper organized. From this realization, came his design which ultimately earned him the title "King of Desks" – the Wooton Patent Desk.

Produced between 1874 and 1885 to 1889 (it is unclear when the actual last desk was produced – some may have been produced into the 1890s), the Wooton Desks were (and are) magnificent pieces of furniture, with 110 compartments for storing documents. Two large swinging doors open to reveal a folded-up desk top, which when lowered, exposes more storage bins. A slot is usually present on the left front of the desk for a built-in mailbox. A horizontal hidden cabinet is present above the desktop for even more paper storage. Wooton also patented and produced a flat desk with pedestals containing rotating sections which contained filing bins and shelves.

The upright Wooton Desk came in four styles: Regular, Standard, Extra and Superior. Although production peaked at one point at 150 desks per month, it is estimated that as few as 12 Superior-grade Wooton desks were produced. Ownership of one of these desks was considered a status symbol and a privilege of the wealthy. They ranged in price from $75 to $750, equivalent of $1,531 to $12,765 in 21st-century dollars. Four US presidents are known to have been Wooton desk owners: Grant, Garfield, Harrison, and McKinley, as well as John D. Rockefeller, Joseph Pulitzer, and railroad magnate and speculator Jay Gould. Queen Victoria also commissioned a Wooton desk. Three are in the possession of the Smithsonian Institute, one being President Grant’s. One of the desks purchased new by the Smithsonian in 1876 has now been in continuous use for 137 years.

William S. Wooton conceived of, designed, patented, and produced the both the Wooton Patent Desk and the Wooton Pedestal “Rotary” Desk between 1872 and 1885. In 1884, he abruptly left his successful company to become a Quaker preacher, leaving the company management to others. Business reversals followed as the company could not keep up with demand, leading to slowed production after 1885 and closure around 1889. Wooton died in 1907 at the age of 72.

I saw my first Wooton Desk in the office of a realtor when I was setting up my practice in 1977 and was instantly smitten. I immediately offered to buy it, but didn’t have the money. Today, I am a proud owner of a Standard style Wooton desk, and find an ultimate irony in placing my laptop on the desk surface. Having spent my professional career advocating the adoption of electronic health record systems and the elimination of paper, beginning almost exactly 100 years after Wooton dedicated his life to maximizing the efficiency of working on paper, the irony seems exceptional. To use a computer on a Wooton desk seems to bring together two completely contradictory forces of history – one representing the ultimate and revolutionary means of its day for controlling paper record keeping, and the other a tool designed as the ultimate solution to the elimination of as much paper as possible.

Original “Standard” style Wooton Desk

“Standard” style Wooton desk with doors open and desktop down

An “Extra” style Wooton desk

A pedestal-style Rotary Wooton Desk

Rare single-pedestal roll-top Wooton Desk

The Ultimate Irony

If anyone is interested in learning more about Wooton desks, please feel free to contact me at samb@championsinhealthcare.com.

Sam Bierstock, MD, BSEE is the founder of Champions in Healthcare, www.championsinhealthcare.com, a widely published author, and popular featured speaker on issues at the forefront of the healthcare industry.

Morning Headlines 1/30/13

Medecision Completes Acquisition of Cerecons

Medecision announces the acquisition of California-based Cerecons, a software provider specializing in population management and quality outcomes tools. The acquisition will result in a care management entity that supports more than 90 healthcare organizations nationally.

University of Virginia Health System Selects MModal’s Speech Understanding Solutions

The University of Virginia (UVA) Health System will implement MModal’s speech recognition and natural language processing solutions to speech-enable its EHR across UVA’s 604-bed hospital, level I trauma center, cancer and heart centers, and primary and specialty clinics throughout Central Virginia.

HealthTech Names Tom Mitchell Vice President of Marketing

HealthTech Holdings, parent company of Healthcare Management Systems (HMS), MEDHOST and PatientLogic, hires Tom Mitchell (MModal) as vice president of marketing.

HL7 Names Two New Advisory Council Members

HL7’s Board of Directors names Joyce Sensmeier, RN-BC, Vice President of Informatics for HIMSS, and Walter Suarez, M.D., PhD, Director of Health IT Strategy of Kaiser Permanente, to serve a two-year term on HL7’s Advisory Council.

6 ways AHRQ will explore EHRs and workflow redesign

AHRQ will interview focus groups with clinical, non-clinical, and management staff about their experiences with electronic health records, stemming from a groundswell of complaints that EHRs create more work, new work, excessive system demands, and inefficient workflow.

News 1/30/13

Top News

Medecision, which just announced plans to lay off 83 employees, acquires Cerecons, a provider of care coordination, population management, and quality outcomes and reporting applications for ACOs.

Reader Comments

From Greenway Rep: “Re: iPractice Group. During the last few days, we did learn that iPractice Group, one of Greenway’s resellers, ceased operations effective last Friday, January 25. This reseller represents a very small percentage of our provider base. We look forward to continue working with these sites, which will have the option to either transition to another Greenway partner or choose to work directly with us for implementation and/or support services.” Greenway confirmed that iPractice Group has ceased operations, as reported by reader Nasty Parts this past weekend. The company claimed to have almost 1,000 provider clients, so the impact to Greenway remains to be seen. The CEO of the three-year-old iPractice blamed its closure on poor Q4 sales. The company moved into a new headquarters building in October 2012 that was more than triple the size of its former location, increased headcount by 800 percent to 70 employees since 2011, and acquired a competitor in 2011. Greg Bolan, who runs the healthcare equity research arm of brokerage firm Stern Agee, credited HIStalk with the initial rumor in an investor flash note, also expressing concern about the impact on Greenway’s sales. Greenway was among the ten biggest percentage decliners on the NYSE Tuesday, with shares dropping 7.7 percent.

From Tom: “Re: [inpatient vendor name omitted]. Is laying off 75 percent of its staff. All IT staff gone, most implementation and some development staff gone.” Unverified, so I’ve left the vendor’s name off for now. Usually someone leaves a comment saying, “Yep, that’s my company and it’s true,” so we’ll see.

From Mrs. Te’o: “Re:  Joe Schmitt, previous CIO of Steward Health Care. Will be named new CIO of Brigham and Women’s.” Unverified, but the forwarded second-hand e-mail insists that’s the case.

From CIO Tracker: “Re: Barry Blumenfeld, MD, MS. Leaving as SVP/CIO of MaineHealth less than 60 days after bringing Epic live at the main hospital. The planned rollout to seven member hospitals is being pushed back while the main hospital consumes all resources. The CIO is a casualty of exceptionally wide scope without commensurate resources.” CIO Tracker provided a genuine-looking memo purporting to be Barry’s notice to staff that he’s leaving as of January 30, but I’ve heard that he actually left early. They’re looking for an interim CIO, rumors say.

From The Amish Avenger: “Re: GE/IDX. I want to pare back its use for scheduling and registration and use the EMR instead. I keep hearing that GE/IDX isn’t selling well and has had job cutbacks. What can I expect to see? Fewer code updates? Less support?” I’ll step aside and let readers chime in.

From Danbury Whaler: “Re: Norwalk Hospital. Getting swallowed up by Western Connecticut Health System. Rumored layoffs of 200+.” Norwalk signed the affiliation agreement last week. Layoffs weren’t mentioned, but are certainly likely.

HIStalk Announcements and Requests

The window for expressing interest in attending HIStalkapalooza is closing. Sign up now if you’re interested in a March 4 evening of food, drink, HISsies, bowling, and Zydeco music.

Welcome to new HIStalk Platinum Sponsor Dearborn Advisors, LLC. The Chicago-area professional services firm, founded in 2001, is a trusted advisor to clients who need help with clinical systems strategy, adoption, and deployment. Its services fall into three groups: strategy and value, clinical, and engagement and project management. All of those help clients maximize the return on investment of their clinical systems. The company’s consultants are experts in Allscripts, Cerner, Epic, GE, McKesson, Meditech, and NextGen, while the company maintains a close working relationship with Epic and Meditech. I’m impressed by the quality of their blog posts, such as this one on medication management. You surely know some of their executive team members if you’ve been around the industry for a while: Rick Mager, Jay Toole, Sally Akers, Bruce Bowers, John Brill, and quite a few more highly experienced people, with a significant number of them clinicians. Thanks to Dearborn Advisors for supporting HIStalk.

Acquisitions, Funding, Business, and Stock

Intuitive Health, which offers a platform that connects providers with at-home patients and their personal health devices, raises $3.8 million.

Informatica’s Q4 results: revenues up three percent; non-GAAP EPS of $0.41, down from $0.47 last year. The consensus EPS estimate was $0.37.

Roper Industries announces Q4 results: revenue up 10 percent, EPS $1.44 vs. $1.23, beating expectations on earnings while falling short on revenue. Chairman, President, and CEO Brian Jellison said the integration of Sunquest, which the company acquired this past summer, is on track, with Sunquest being a strong performer with high single-digit growth. The company’s CFO did note in explaining a tax rate adjustment, “Sunquest as a US-based company generates most of their earnings in the United States, which is the highest tax rate in the world.”

Lexmark announces Q4 results: revenue down nine percent, EPS $0.10 vs. $0.94. Its Perceptive Software unit was the bright spot, reporting revenue that increased by 40 percent over 2011.

Startup Ringadoc, which offers after-hours triaging of physician calls for $50 per month with no contract, raises $1.2 million in seed funding. I believe that’s a reflector thingy in its logo.

Philips announces that it will exit the consumer audio and video business to focus on home appliances and healthcare.

Margo Hendrickson, athenahealth VP of human resources, responded to our query about the company’s announced plans to lay off 36 employees of its Birmingham, AL office on March 6. That office is the site of the former care coordination platform vendor Proxsys that athenahealth acquired in July 2011:

“As a high growth company, we are always looking to apply efficiencies to the way we work. While it is incredibly difficult to let people go from what otherwise is a growing employee base, our intent and commitment to shareholders is to align investment with business growth opportunities. This focused set of employee restructuring will allow us to achieve several critical business scaling and financial objectives that otherwise we would struggle to meet. At athenahealth, we are committed to ongoing team growth; in the past year alone the Company has grown its US employee base 28 percent, adding a total of 473 new employees to its US total of 2,140.”

Sales

Sidra Medical and Research Center in Qatar selects Amcom’s emergency notification and call center solution and Omnicell’s G4 automated medication management system.

Scripps Health (CA) will implement Wolters Kluwer Health’s ProVation Order Sets software as its electronic order set solution.

Pioneer Medical Group (CA) signs an agreement with McKesson’s MED3OOO division to jointly own and operate an advanced management services joint venture.

Holyoke Medical Center (MA) expands its relationship with eClinicalWorks to include the eCW Care Coordination Medical Record for advancing ACO and PCMH objectives.

University of Virginia Health System will deploy MModal Fluency Direct and MModal Catalyst for Quality to speech enable its EHR systems.

People

HealthTech Holdings hires Tom Mitchell (MModal) as VP of marketing for its HMS, MEDHOST, and PatientLogic companies.

HIMSS recognizes James L. Holly, MD (UT Health Science Center) with its 2012 Physician IT Leadership Award and Robin S. Raiford (The Advisory Board Company) with its 2012 Nursing Informatics Leadership Award.

MedAssets appoints Keith L. Thurgood (US Army Reserve) president of its Spend and Clinical Resource management segment.

Streamline Health adds  Richard D. Nelli (OptumInsight) as SVP/CTO and Herb Larsen (Edifecs) as SVP of client services. Streamline also announces the resignation of SVP/COO Gary Winzenread.

HL7 appoints Joyce Sensmeier (HIMSS) and Walter Suarez, MD (Kaiser Permanente) to its advisory council.

Randy Gaboriault, VP/CIO of Christiana Care Health System (DE), is named by Computerworld as a 2013 Premier 100 IT Leader.

Former Barnabas Health (NJ) SVP/CIO Joseph Sullivan is named “client in residence” by management print services vendor Auxilio.

Announcements and Implementations

CPSI announces the formation of TruBridge, LLC, a wholly-owned subsidiary that will provide business services, consulting services, and managed IT services to rural and community healthcare organizations.

Intelligence InSites announces integration of its real-time intelligence platform with ScheduleAnywhere, an online employee scheduling software from Atlas Business Solutions.

Gottlieb Memorial Hospital (IL), part of Loyola University Health System, goes live with Epic.

TriZetto announces that BCBS of Tennessee is using its benefits solution to offer value-based insurance benefits to members.

Government and Politics

ONC publishes research to help providers putting HIEs in place, including findings on query-based exchange, HIE-driven notifications and subscription services, provider directory solutions, master data management, and consumer engagement and consumer-mediated exchange.

The operator of the leading cord blood bank settles FTC charges that it lacked policies and procedures to protect patient information in a 2010 breach involving unencrypted computer equipment stolen from an employee’s car containing the information of 298,000 patients. The company avoided a financial penalties by agreeing to improve IT security and to conduct a security audit every other year.

Technology

State auditors cite University of Iowa Hospitals and Clinics for not encrypting laptops. The hospital responded by saying it encrypts “where technically possible,” but the state official refused to back down, saying, “If it’s not technically possible, then they need to tweak the system a bit so that it is technically possible.”

Other

This patent troll story doesn’t involve healthcare, but it provides a good lesson. A fake company set up by a lawyer who bought some old patents and created a business based entirely on suing big companies for infringing on its claimed patent on online shopping carts finally gets its butt kicked, courtesy of online retailer Newegg. The company had shaken down big online retailers, demanding a percentage of annual revenues. Victoria’s Secret and Avon had already been ordered to pay $18 million and one percent of their annual online revenue, while Amazon had paid the patent troll an amazing $40 million. Newegg, which has vowed that it will never settle with a patent troll, successfully had the company’s patents invalidated on appeal. You have to admire Lee Cheng, Newegg’s chief legal officer (above):

”We basically took a look at this situation and said, ‘This is bullshit.’ We saw that if we paid off this patent holder, we’d have to pay off every patent holder this same amount. This is the first case we took all the way to trial. And now, nobody has to pay Soverain jack squat for these patents … Just think about the dynamic if you’re a juror … Everyone wants to go home. It’s not their money. Defense oriented jurors are more likely to compromise and say, ‘Maybe we’ll just split the baby. Maybe we’ll just give them $2.5 million and call it a day.’ … We’re competing with other economies that are not burdened with this type of litigation. China doesn’t have this, South Korea doesn’t have this, Europe doesn’t have this. Just in our experience, we’ve been hit by companies that claim to own the drop-down menu, or a search box, or Web navigation. In fact, I think there’s at least four that claim to ‘own’ some part of a search box … Then they pop up and say, ‘Hello, surprise! Give us your money or we will shut you down!’ Screw them. Seriously, screw them. You can quote me on that.”

Guam Memorial Hospital says a software bug introduced by its vendor NTT Data caused it to underbill drugs by $1.9 million since May 2012. It found the problem as part of a financial improvement initiative and says NTT Data has confirmed and fixed the bug.

Zoll Medical says it’s the first defibrillator vendor to promise that it will share patient data from its devices, providing tools that allow other vendors to share the information it collects for patient care, such as in emergency medicine.

A small town in Australia loses its Internet connectivity for the third or fourth time in a month, with some of the previous outages having lasted days. Merchants can’t charge credit cards, but the medical clinic brings up more pressing problems: “We receive all our pathology results, specialist letters and discharge summaries through the Internet. If a patient comes to us needing treatment after they have just been discharged from hospital and we don’t know what they need or what they’ve had done, that’s a real problem.”

HIT incubator Rock Health rolls out a single online employment and internship form for applying to work at any of its 49 portfolio companies.

Weird News Andy finds this story amazing: researchers at Texas Heart Institute are building replacement human hearts from pig hearts, saying animal organs “reanimated” with human stem cells can be used in emergencies. The lead scientist also predicts being able to reverse aging at some point, storing stem cells from patients while they’re healthy as replacements for when they aren’t. She says she’s regularly called Dr. Frankenstein.

Sponsor Updates

• Intellect Resources offers tips for job seekers hoping to get the attention of online recruiters.
• Infor Healthcare and NTT DATA host a February 13 webinar to discuss Lawson Financials and the effective interaction between legacy and new technology systems.
• CommVault announces details of its fifth annual WTG Customer Seminar March 13 in Boston.
• Truven Health Analytics hosts a January 31 Webinar highlighting coverage challenges under the ACA.
• First Databank releases the FDB State and Federal Controlled Substances Module, which facilitates the e-prescribing, dispensing, tracking, reporting, and claims processing of controlled substances.
• Vitera Healthcare Solutions will give practices using its Vitera Stat PM/EHR product access to DiagnosisOne’s CDS content and patient education materials at the point of care.

Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis.

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 1/29/13

Computer Programs and Systems, Inc. Announces Formation of TruBridge, LLC

CPSI announces the formation of TruBridge, LLC, a wholly owned subsidiary which will provide business services, consulting services, and contracted IT services.

Siemens Healthcare’s Q1 profits jump 38%

Siemens posted quarterly profits of $1.62 billion, or $1.89 per share, on sales of $24.15 billion.

Request for Information on Hospital and Vendor Readiness for Electronic Health Records Hospital Inpatient Quality Data Reporting

CHIME comments on CMS’s request for information on EHR-based quality reporting readiness, raising concerns over how discrete data should be extracted from narrative physician notes for reporting.

5 findings in ONC HIE research

ONC publishes new research highlighting the types of high-impact services that can sustain HIE organizations.

Health chief wants big telemedicine network across Georgia

Brenda Fitzgerald, MD, public health commissioner for Georgia, reports that every public health center across the state will be able to put patients in front of top specialists via telemedicine within three years, citing grant applications as the primary means of paying for the program.

Readers Write: In Defense of Copy-Forward

In Defense of Copy-Forward
By Lyle Berkowitz, MD

I’m part of the Association of Medical Directors of Clinical Information Systems (AMDIS), a group of 2,000+ physicians who are the experts in implementing and using EMRs. We have a pretty lively listserv discussion board, and I enjoy seeing what my colleagues are thinking, as well as posting my own thoughts. I especially enjoy posting when I feel like certain studies or comments by non-clinical researchers, administrators, or politicians make us start to question common sense.

One of my favorite topics recently came up — the fear and horror associated with actually reusing some of a previous note. This usually falls into the concept of "Copy-Forward" (when you copy forward the whole note and then edit for today’s visit), or "Copy-Paste" (when you select certain parts of a past note and just copy that part of it. I posted my reply and thought I’d share and expand a bit.

So as not to bury the lead, I think Copy-Forward of a note is a great tool and supports both efficiency and quality, when used appropriately. Turning it off is a classic throwing the baby out with the bathwater analogy. To clarify my biases, my thoughts and ideas are mainly from the perspective of an outpatient physician using Copy-Forward over the past decade, but much of this certainly can be applied to the inpatient world in various ways.

Also, the use of Copy-Paste has some similarities to Copy-Forward, but I agree Copy-Paste is not nearly as efficient and poses more quality issues since it does not have the automatic updating features you might see with Copy-Forward. Here are the points I would suggest we consider.

First, I am sick of these reports which say that things like, "We used plagiarism software to show that 60-80 percent of a doctor’s note is the same as their last one." Um, of course! Since when did progress notes become creative writing endeavors about coming up with different ways to document diabetes, hypertension, and obesity in the same patient visit after visit?

The creative parts of doctoring should involve being "House": figuring out the diagnosis, figuring out the best treatment plan, and artfully explaining it all to the patient. It should not be writing Edgar Allen Poe-like short stories to amuse our auditors or confuse our colleagues. Although, it could be fun, hmmm… what if I described a diabetic’s problems with hypoglycemia in Poe’s style: "Arousing from the most profound of slumbers (due to a glucose of 45), the patient states he feels as if he was in a gossamer web of some dream. Yet in a second afterward, so frail may that web have been, he claims to not remember that which he was dreaming."

Second, there are obvious efficiency benefits to Copy-Forward, but there are very real quality benefits as well. The most obvious is that this type of workflow makes it less likely that important diagnoses will be missed or forgotten over time. Additionally, many systems update certain pieces of data during the Copy-Forward process, so that you can see the most recent results (discussed more below). Obviously incorrect information can be duplicated, especially when a note is being authored by multiple providers over time, but this is where good training and leadership are needed to ensure every provider feels fully responsible for everything in their notes.

Third, getting rid of Copy-Forward or even Copy-Paste is certainly overkill, but we do need to use some common sense in designing technology, workflows, and processes that make it easy to do the right thing when documenting. In the ideal system, much of the critical data would either be updated automatically (e.g. the most recent lab would appear when a note is copied forward), or the system would date entries so it is clear what was done in the past versus today. To clarify, let me break down how an ideal progress note might look like when Copy-Forward is used:

Allergies, Meds, Problems

These update automatically, which is great, and means the note has the most recent data. I would hope all EMRs have this functionality already.

Past Histories (Social, Surgical, Family)

These copy forward and allow for easy editing in the note. Ideally, they could be managed in a widget external to the note and have them update from those profiles as well.

Physical Exam

Want to ideally be able to view old physical exams, and even reuse them when desired (except for vitals). In my current system, the full exam (sans vitals) does copy forward. So I usually just delete it and drop in a new macro and edit that. However, some patients have findings I want to compare from last time (e.g. size of a rash), or consistent findings (e.g. murmur) which I want to be reminded about

Labs/Studies

For labs (e.g. CBC, chem, chol profile) and certain studies (e.g. mammogram results, last ECG), we use macros which "auto-updatem" so when a note is copied forward, they update automatically to the most recent dates and values.

HPI/Impression/Plan

As some have heard me detail before, I use a form of "problem-oriented charting" in which I type out the history, impression, and plan for a diagnosis (e.g. diabetes) or system/problem area (e.g. "GI issues") all on one line. I also use a macro which includes the date of the entry and my initials.

• Example for a diabetic patient. "01/19/13(LLB): Stable on Metformin 500bid, CS 100-120s before meals, no med side effects or other complaints. Impr: Stable DM, PLAN: CPM, labs, rtc 4 mos". No flourish is needed. The result is that when copied forward I can see the last time I addressed the DM and if I made any changes. In the same "area" for the problem, I would also have a list of relevant meds, labs, and testing results (e.g. ECGs and ECHOs for hypertension). This way I can see everything I need about a problem all in once place – which means I can make quicker and more accurate decisions.
• Summarizing old entries over time. I will either retain the old entry, or can summarize over time (e.g. I might take four entries from 2012 and summarize into one line such as, "2012: Dx with DM 4/12, added Metformin 500qd, 6/12 incr to 500 bid and did well").
• Multiple issues. Since I often address multiple issues in a given visit, I created a line which reads, "Problems below not addressed this visit" so that I can clearly demarcate what I did and did not address on a certain day. I think this method is extremely efficient and higher quality than the method of trying to document all the HPI about multiple issues at the top of a note, and then separating out the Impr/Plan at the bottom.
• What is a SOAP note? Larry Weed, MD devised the concept of problem-oriented charting 50 years ago, but I think it’s fair to say we have over-complicated it over time. The SOAP note is supposed to be based around a problem. In other words, each problem should have a documentation area for Subjective, Objective, Assessment and Plan. Instead, we create one large SOAP note where we break away all the Subjectives into their own paragraph ("HPI"), thereby distancing your thinking about the complaint and what we are going to do about it. I hope we will soon see more EMRs going "back to the future" by embracing the true problem oriented charting philosophy.

Fourth, the outpatient world is different from inpatient, but there are similarities. I understand that inpatient notes can be more difficult to manage due to quickly changing problems, and especially multiple authors. Personally, I hope we put some more thought into the concept of an "Inpatient Wiki," a single type of inpatient note that can automatically pull in the relevant information for each specialty (e.g. different for medicine, OB, and various types of surgery). Then each author could see what they need to see – it would pull in the labs, tests, consult suggestions, or a nursing note – why make the doctor repeat this themselves every time?

The care provider would then be prompted to write what they are supposed to add, and the note would be a living document which flexes to the individual, but can be time-stamped for medico-legal purposes as well. It could have clear sections (similar to above), as well as an organ or system based areas (e.g. Cardiology issues, GI Issues, Neuro Issues, F/E/N issues) for documenting the SOAP note .

In summary, I would go as far as to say that we need to change our paradigm to "The Note is the Chart." The chart should no longer be a collection of distinct and incomplete notes, but rather the last note can really be the complete chart which contains everything a provider needs. If we do this, then we can reframe our expected workflow from, "You need to read every note ever written to understand the full patient" to, "You just need to read the last note".

The result: when a patient goes to the ER or sees another doc, those providers will find that the most recent note in the system will have all the info they need, so they won’t need to try and dig through 48 notes over 10 years (and let’s face it, they never do that anyway). Granted, the paper record allowed for a much easier way to flip thru past notes, but sooner or later we have to acknowledge that computerized systems have different attributes than paper. We can either keep trying to force the computer to act like paper, which never works out well, or we can start embracing the differences and truly take advantage of them.

Lyle Berkowitz, MD, FACP, FHIMSS is associate chief medical officer of innovation for Northwestern Memorial Hospital; medical director of IT and innovation for Northwestern Memorial Physicians Group; and co-founder and chairman of healthfinch.

Readers Write: New HIPAA Rule Overview

New HIPAA Rule Overview
By Brian Ahier

Four years ago, the HITECH Act introduced major revisions to HIPAA. Now everyone is all atwitter since the Office for Civil Rights (OCR) of the Department of Health and Human Services (HHS) has published the omnibus final rule modifying the HIPAA Privacy, Security, Breach and Enforcement Rules as well as additional changes required under the Genetic Information Nondiscrimination Act of 2008 (GINA).

"Much has changed in healthcare since HIPAA was enacted over 15 years ago," HHS Secretary Kathleen Sebelius said in a statement. "The new rule will help protect patient privacy and safeguard patients’ health information in an ever expanding digital age." This rule also creates a lot of work for healthcare organizations.

First off, organizations will need to amend notices of privacy practices and make sure the revised notices are properly posted and distributed. This means creating new forms and posters as well as allocating resources for legal review. There will likely be other forms, such as requests for access, that should also be updated or created. There will also be a need for workforce training to promote more ongoing awareness among staff. This is a good opportunity to take advantage of the safe harbor provision by encrypting PHI according to HHS guidance.

The rule has significantly expanded the scope and impact of the Privacy and Security Rules on business associates. Anyone providing services to a health plan or healthcare providers who receives or generates PHI may be subject to these expanded provisions. Previously, most business associates were subject to the Privacy and Security Rules only through a business associate agreement with the covered entity. Now, even if there is no BAA, if you are simply acting as a business associate, you are liable under HIPAA. The rule specifically identifies as business associates subcontractors, patient safety organizations, health information organizations (and similar organizations), e-prescribing gateways, and vendors of personal health records that provide services on behalf of a covered entity.

Another interesting development is that the rule revises the definition of a “breach,” which will serve to make breach notification much more likely. The HITECH Act requires covered entities and business associates to provide notification following discovery of a breach of unsecured PHI. Breach means the acquisition, access, use, or disclosure of PHI in a manner not permitted under the HIPAA privacy rule that “compromises the security or privacy” of the PHI unless an exception applies.

The rule amends the definition of breach to clarify that the impermissible acquisition, access, use, or disclosure of PHI is presumed to be a breach and breach notification is necessary unless a covered entity or business associate can demonstrate, through a documented risk assessment, that there is a low probability that the PHI has been compromised.

Previously under the interim final breach notification rule, the privacy or security of PHI was deemed to be compromised if there was a significant risk of financial, harm to reputation, or some other harm to the individual as a result of the impermissible use or disclosure of PHI (commonly referred to as the “harm standard”). In other words, if you could demonstrate no significant risk of harm, then the incident did not rise to a reportable breach.

The new rule replaces this "harm standard" with what HHS calls a more objective process for assessing whether PHI has been compromised. The new standard, however, still appears to leave covered entities and business associates with a lot of questions. The rule has deleted the definition of “compromises the privacy or security” of PHI (which was the harm threshold), and declined to adopt a clear standard requiring notification of all impermissible uses and disclosures without any assessment of risk.

The rule expands what uses and disclosures of PHI are considered marketing thus requiring an individual’s authorization; however, the new marketing restrictions do not impact a covered entity’s face-to-face communications with individuals. For example, prior to this new rule, an authorization would not be required for a hospital to send a brochure to its patients about a new imaging device being used by the hospital, even if the communication was paid for by the manufacturer of the imaging device.

Now the hospital would no longer be permitted to send communications about its new imaging device if the manufacturer of the device pays the hospital for the communications unless the hospital first gets authorizations from its patients. The rule provides an exception for communications about drugs that are currently is prescribed to an individual as long as any payment is reasonably related to the covered entity’s cost of making the communications. For example a drug manufacturer would be able to subsidize a physician’s cost for sending out refill reminders.

The rule has also implemented a new tiered penalty structure. Depending on the degree of knowledge that the covered entity had or should have had regarding the violation, penalties for each violation range between $100 (did not know or have reason to know) and $50,000 (willful neglect without correction), with a maximum penalty for a given year of $1,500,000 for any violations of the same requirement or prohibition. It will be very interesting to see how aggressive enforcement is over the next few years.

One of the significant changes in the rule is the expanded rights for patient access to electronically-stored PHI. The rule extends beyond those promulgated under Meaningful Use and provides the right to obtain an electronic copy of PHI stored electronically in a designated record set (e.g., medical records, billing records, and other records relied upon to make decisions about the individual) rather than simply and electronic health record.

If the covered entity can’t readily produce the form and format requested, then it must offer other electronic formats that it can provide. If the patient doesn’t agree to any alternate electronic formats offered by the covered entity, then the covered entity must provide a hard copy as an option to fulfill the access request. Also, if an individual requests that a copy of his or her PHI be sent via unencrypted email, then after advising the individual of the risks a covered entity is permitted to do so.

Another notable requirement is that  covered entities now have 30 days to fulfill a request with the possibility for a singular 30-day extension allowed. Electronic and hard copy PHI, no matter where the data are located, must be provided within the timeframe.

The rule also clarifies the fees that may be charged. For example rule adopts the proposed amendment at § 164.524(c)(4)(i) to identify separately the labor for copying protected health information, whether in paper or electronic form, as one factor that may be included in a reasonable cost-based fee. However fees associated with maintaining systems and recouping capital for data access, storage and infrastructure are not considered reasonable, cost-based fees, and are not permissible to include. The rule also  rule we clarifies that a covered entity may not charge a retrieval fee (whether it be a standard retrieval fee or one based on actual retrieval costs).

Even with some of the protections in the Affordable Care Act, the rule still provides that a covered entity must comply with an individual’s request to restrict disclosure to a health plan (or the plan’s business associate) of PHI that pertains solely to a health care item or service for which the health care provider has been paid out-of-pocket and in full. This right extends to situations where a family member or other person, including another health plan, pays for the service on behalf of the individual.

Last week I joined Deven McGraw and David Harlow for a Google Hangout where we discussed the new HIPAA rules. It was a lively discussion and is well worth taking the time to see, so grab some popcorn and watch the video for some great insights.

Brian Ahier is health IT evangelist at Mid-Columbia Medical Center of The Dalles, Oregon and president of Gorge Health Connect, Inc.

Curbside Consult with Dr. Jayne 1/28/13

I spent most of my week trying to help colleagues retool budgets, which is never a pleasant task. Everyone is being asked to do more with less. In healthcare, sometimes that’s extremely tricky.

I’m lucky in that my medical informatics group is a department of one. I don’t have to worry about our current hiring freeze or the potential of laying anyone off unless they decide they don’t need a CMIO any more. With the current climate in MU, that’s unlikely. We already had our travel and conference budgets slashed last year, so there are no surprises there. We’ve already figured out how to receive education and training for free — no surprises there either.

From an IT perspective, we’re cutting budgets for hardware and extending refresh cycles. No one can expect to see new devices on the scene any time soon. I’m glad lots of vendors are designing for the tablets and Apple platforms, but our teams won’t be able to take advantage of any of those new features. As much as feel like I’ll be missing out, I can live with it. We’ve been using the same hardware platforms for years and we’re used to them. I don’t think continuing to use a wheeled cart as my workstation is going to kill me. (on the other, hand it might – keep reading.)

The hospital where I work is fully committed to its brand spanking new Accountable Care Organization. It has announced that it’s putting all hands on deck to make sure we’re investing in care management, patient engagement, and marketing. We’re going to spend tens of thousands of dollars making sure patients don’t want to leave our organization so that we can achieve shared savings. We’re going to make sure that we’re their hospital of choice.

As a part of that effort, I’ve been asked to prepare a handwritten thank you note and deliver it personally to each patient I discharge from the emergency department. I’m also supposed to recite a fairly canned statement about how much I appreciate the patient choosing my hospital and thank them for the opportunity to deliver excellent customer service.

When I saw the memo this week, I was just speechless. As a physician who has to care for patients, I’m horrified by sinking so much effort into marketing and frivolity when we’re making cuts to the bone in frontline clinical service areas. What about delivering excellent care? Where did that go? Here are some chilling examples:

• After 5 p.m., we only have one housekeeper on duty for the entire ED and two floors of the hospital. Nursing staff and patient care techs are expected to clean all the emergency department rooms after patient discharge. Most of the time we don’t have a tech, so an RN (or sometimes the physician) is cleaning rooms. I know this is not a new phenomenon, but it’s still not right. This also means that if we have a situation where we need a “terminal clean” of an exam room (highly contagious disease, etc.) we have to shut down the room, often for hours, while we wait for housekeeping.
• Lack of housekeeping also means trash is overflowing in the exam rooms. But there’s more. To cut down on costs, staff has been asked to conserve on the use of trash can liners. I didn’t believe it until someone showed me the memo. This means that rather than pull up the plastic bag around the trash, seal it, and carry it to a larger waste receptacle, they are expected to wheel a larger receptacle into the exam room, heft the trash can into the air, and dump the trash into the larger can. Inevitably things wind up on the floor, not to mention the potential for infectious material to be flung into the air. This is also done with biohazard cans, although I haven’t seen a specific memo that says that the can liner recommendation applies to “red bags.” Leaving the liner in leaves the bacteria in. Whoever came up with that policy should be gifted with a trash can containing a used diaper.
• We no longer follow isolation protocols in the “low acuity” portion of the ED because our patients are “low risk.” Last time I checked vancomycin-resistant enterococcus didn’t play favorites.
• Exam rooms are often “turned” so quickly that registration brings new patients back before the room has been adequately cleaned.
• Non-clinical areas do not get cleaned at all. The floor of our work area in the ED is so dirty that staff places towels or drapes on the floor before depositing their tote bags (no, we don’t have lockers).
• IT hardware is no longer cleaned. That picture above is the keyboard I was greeted with last week. It is not fit for use by anyone. The worst part is that there was visible food on it, meaning someone touched it while also touching food.

It is in this circumstance that I am expected to write thank you notes. This is in between trying to see patients, providing decent quality care, getting all my documentation competed (including the mandatory sepsis screen we just added for all ED patients regardless of presenting problem), educating patients on not coming to the ED inappropriately, serving as my own social work staff, figuring out how to get patients to afford their $4 generic prescriptions, and convincing patients that plugging their iPhones in to the outlet above the bulging biohazard trash can so that the cord dangles into it is a bad idea.

You’re probably thinking right about now that I work in some third-world hospital. Not so much. We’re urban and safety net, but we’re decidedly first-world with an academic presence. We have the endowment to prove it.

You may also think I’m just complaining, but seriously, I love my job. I love the people I work with. I love my patients, even the ones who are handcuffed to the gurneys for the duration of their stays.

I apologize for the wait. I apologize for delays. I apologize that the police used a Taser on you and I ask you politely to stop spitting at us. I apologize to the other patients for having to witness your behavior. I thank patients for coming and wish them well even when they scream at me or when I have to call armed guards to help discharge them. But if the administrators want thank you notes, they’re going to have to hire Emily Post. Maybe she’ll bring a feather duster (or a blowtorch) to clean the computers.

Good luck with making our facility the destination of choice. Congrats to the marketing team that dreamed up the thank you note scheme. Maybe we should start with basic sanitation if we want patients to come back. It’s hard to understand how we’re going to be meaningful users of EHR technology when we can’t be meaningful users of sponges and mops.

Have a story of administrative ridiculousness? Can your gross pictures top mine? E-mail me.

E-mail Dr. Jayne.

Morning Headlines 1/28/13

Athenahealth to lay off 36 in Birmingham area

A spokesperson with the Alabama Department of Economic and Community Affair reports that athenahealth has filed notice to announce the layoffs of 36 Birmingham-based employees, effective March 6.

Compuware turns down Elliott offer, Covisint unit IPO still on

Compuware turns down hedge fund Elliot Management Corp’s proposal for a $2.3 billion buyout.

2 Chesco companies report combined 168 layoffs

MEDecision will lay off 83 workers effective February 1, representing more than 25 percent of its total workforce.

Hospital’s electronic records system goes off line after AT&T outage

New Hanover Regional Medical Center went to paper downtime procedures when a regional AT&T outage cut access to its Epic system.

Why Do Patients Derogate Physicians Who Use a Computer-Based Diagnostic Support System?

A survey focusing on why patients have a negative perception of physicians who use clinical decision support concludes that it may not be related to seeking the physician external advice, but rather that the physician is turning to a computer rather than a colleague.