Monday Morning Update 1/14/13

From The PACS Designer: “Re: TPD’s list. The latest update of my iPhone apps lists is online. In addition to many new apps is a new section highlighting the apps of HIStalk sponsors.” TPD’s list is here. He’s always up for additions to it.

From Frank Poggio: “Re: Meaningful Use Stage 4.  At the January 8 HIT Policy Committee meeting, Farzard Mostashari, ONC director, waxed eloquently about MU Stage 4. Hey, wait a minute — the original playbill said this was to be a three-act play! Does he think we can stay in this claustrophobic theatre all day and night? How many more acts will there be? One thing for certain — the bonus money will run out long before the last act, but you can be sure the ‘penalty’ clauses will not. This MU theatre of the absurd must be in the Hotel California… you can check in, but you can never check out.”

From Green Space: “Re: Judy Faulkner’s new company to generate electricity for Epic. Search the Wisconsin Department of Financial Institutions for Galactic Wind. Here’s a photo of the wind farm, about 15 miles north of Epic’s main campus.”

From Dragovitz: “Re: Peake Healthcare Innovations. The image sharing joint venture between Johns Hopkins Medicine and Harris Computer appears to be defunct. Rumor has it they found it hard to differentiate themselves from PACS vendors and underestimated the risk of trying to use MINT, a protocol that would have displaced DICOM.” Unverified. The JV was created on March 2011 and their “new approach to medical image management” was rolled out at HIMSS last year.

Sixty percent of us have used a patient portal offered by our PCP. New poll to your right: was the 2005 RAND study naïve, biased, decent but not useful for justifying EMR subsidies, or possibly accurate once more time goes by? Pick the best answer since you get only one.

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

A new report commissioned by the National Research Council and the Institute of Medicine finds that despite the largest per-capita healthcare spending of all countries, the US ranks dead last among 17 developed nations in health. Most surprisingly, it’s not our also legendary number of poor and uninsured residents who are dragging our average down – our unhealthiness is equal opportunity by income and education. If you want your child to live to 50, move to another of those 16 other countries because they’re a target here for being murdered, dying in a car wreck, and not even living long enough to attend pre-school (we’re #1 in all those categories). We’re lucky that one other country beat us in the percentage of people dropping dead of heart problems and lung disease. We’re dead last in the percentage of doctors in primary care, and the graphic above shows IT as one of the “worse than average” items (the others being coordination of care, medical errors, patient dissatisfaction, and miscommunication). No single cause was identified, but it says a lot of the problem starts with being fat, overusing legal and illegal drugs, shooting each other, and wrecking cars, not to mention a healthcare non-system that’s superb at Rambo-style interventions but really bad at almost everything else. The authors found no silver bullet other than spending a lot of taxpayer money, which is another not-so-great #1 they didn’t bring up (the largest national debt at $16 trillion with the lead widening by the minute). Being rugged and self-determinant individualists, we’re not real big on public health programs in the US, so it’s ironic that excellent schools crank out thousands of public health stars who immediately head off to Africa or South America to find work despite a target-rich environment here.

ONC announces that Authorized Certification Bodies are now authorized to test and certify EHRs using the 2014 Edition Standards and Certification Criteria.

My guilty pleasure is reading John Halamka’s “Building Unity Farm” posts on his Life as a Healthcare CIO blog. I skim his other IT-related posts on occasion, but I never miss an episode about how he uses his engineering and IT background to approach building a gentleman’s farm, like Oliver Douglas on Green Acres except he knows what he’s doing. I find myself fascinated by what kind of guinea fowl he favors, his hardwood management plan, and what was on his vegan Christmas menu.

The Illinois Department of Financial and Professional Regulation, the state’s overseer of physicians, will lay off 18 of its 26 medical unit employees next week because of a $9.6 million budget shortfall.

An interesting Alabama Supreme Court ruling allows patients who claim injury from a generic drug to sue the manufacturer of the brand name drug they didn’t take. The court ruled that generic drug makers are required to use the approved labeling of the patented drug, so a lack of warnings isn’t their fault. Alabama high-end real estate values will probably benefit as out-of-state trial lawyers shop second homes there.

Academic Ranking of World Universities, assembled by researchers at a university in China, ranks the world’s best clinical medicine and pharmacy universities, with US schools taking all but four spots in the Top 20, counting ties. In order, Harvard, UCSF, University of Washington, Johns Hopkins, Columbia, UT Southwestern, UCLA, Stanford, University of Pittsburgh, University of Michigan, University of Minnesota, Mayo Medical School, University of North Carolina at Chapel Hill, MD Anderson, Yale, and Vanderbilt.

BCBS’s Blue Health Intelligence acquires Tampa, FL-based Intelimedix, which offers employer and payor analytics from its medical claims database covering 110 million patients.

Miami Children’s Hospital receives a hospital association’s marketing award for sending urgent care wait times via text messages. The hospital uses a service from ER Texting.

RAND Corporation’s admission in a Health Affairs article that its own 2005 study predicting vast savings from EHRs was dead wrong gets major space in The New York Times, even scoring a quote from original National Coordinator David Brailer, MD, PhD, who now says HITECH was a “colossal strategic error” that encouraged providers to earn government checks by buying EHRs quickly and worrying later about actually using them for anyone’s benefit. The new analysis says the original vendor-funded report was “enthusiastically embraced,” but that now “critics of the RAND team’s analysis can claim a measure of vindication.” Some quotes from the new article:

• Lack of interoperability means systems function “less as ATM cards, allowing a patient or provider to access needed health information anywhere at any time, than as frequent flier cards intended to enforce brand loyalty to a particular health care system,“ with the huge amount of information stored by Kaiser and the VA “essentially useless if the patient seeks out-of-network care.”
• EHR adoption is still arond 40 percent instead of the 90 percent threshold RAND said was needed despite billions of HITECH payouts, which it described as, “Most of the action is concentrated among facilities that were already planning to implement or upgrade their health IT systems. Federal incentives have not yet closed the health IT gap between small, rural, and nonteaching hospitals and larger, urban, and academic ones.”
• Patients share the blame, with few of them even signing up to view their electronic records and most of those never actually looking at them.
• “Considering the theoretical benefits of health IT, it is remarkable how few fans it has among health care professionals.” The article says market forces aren’t working to demand more usable systems since comparative system information is not readily available and HITECH encourages just buying whatever’s out there anyway.
• The “do more, bill more”healthcare payment system provides no incentives to use IT to reduce costs or improve outcomes.
• The article concludes, “The optimistic predictions of Hillestad and colleagues in their 2005 analysis of the potential benefits of health IT have not yet come to pass. This is not because of shortcomings in their analysis but rather because of shortcomings in the design, implementation, and use of health IT in the United States. When the preconditions these authors posited are finally realized, the benefits they predicted will be realized as well.”

I bet most readers saw this coming when the exuberant 2005 study started putting stars in the eyes of vendors and the federal government. People who put their hopes in a tool rather than tool users are usually wrong, and it’s almost always true that those tool users will do whatever it is that they’re paid to do, like cranking out procedures, stealing each other’s profitable patients and doctors, and buying EHRs quickly without a lot of thought or commitment.

My take is that the original article was more naïve than biased. The new article, however, puts a lot of the blame on HITECH — which wasn’t implemented until four years after the original article — and not enough blame on a screwed up healthcare system whose technology reflects that unfortunate reality. A vendor could easily develop a usable, interoperable, patient-centered EHR if they didn’t have to deal with mountains of billing rules (most of them coming from the same federal government that’s complaining about complex systems), insurance companies, regulators, and market-force competitiveness, following the specifications of users dedicated to a framework of standardized and repeatable processes. They would, however, have no customers. That’s why only the VA has done it, and they developed their own VistA system having the luxury of a vacuum to work within.

The worst thing about the original RAND study is that it was quickly co-opted by special interests as validation for spending billions of taxpayer dollars to subsidize fast-tracked sales of systems to providers who had already declined to buy them with their own money. We have good providers, good electronic systems, and good patients — we just can’t seem to put the policies in place to move the needle on the marginal ones.

Vince has a great look-back this week, getting some first-hand history of Sphere Healthcare Information Systems as it eventually became NextGen’s financial system.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: The First Lesson I Learned Working for a Vendor: Products Don’t Need to Be Great, Just Good Enough

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.

The First Lesson I Learned Working for a Vendor: Products Don’t Need to Be Great, Just Good Enough
By Mr. HIStalk

I took my first vendor job many years ago, moving over to the dark side after a short career in hospitals. It was a common vocational change then and still is today: learn an application as a hospital user, then hire on with the vendor who sells it. Ca-ching!

I was anxious to use my hard-won experience to address the application’s many shortcomings. I figured it would be a slam dunk since none of the vendor’s people seemed all that sharp. My dazzling insight, I reasoned, would not only make the vendor’s application the best on the market, it would sweep me to my inevitable destiny as a software genius.

In other words, I was delusional enough to think that the only thing standing between the vendor and greatness was bringing me on board to share my vast frontline knowledge. I expected awe-struck respect, endless gratitude, and … OK, I’ll say it … maybe an outpouring of publicly proclaimed vendor love from my new best friends that I’d have to smilingly shrug off in amused embarrassment.

Stop your snickering. I admit it – I was naïve (I lost most of that naiveté when the vendor eliminated my job just a few months later with no visible sign of reluctance or regret. I was, as it turned out, highly expendable).

Instead of teaching the vendor some lessons, I had learned a few myself.

Vendors don’t necessarily want their applications to be the best; they only want them to be good enough. In the secret vendor playbook, some applications are simply placeholders to keep them from losing profitable package deals. Anything more is a waste of resources better spent on something more strategic.

Knowing how hospitals work is useful to a vendor, but not essential. In my company, decisions were made by humorless corporate wannabes who were short on brilliance and hospital experience, but long on ambition and political skills. It was like high school, where jocks and bullies ran roughshod over the smart and sensitive kids, except that these particular jocks had MBAs didn’t mind lying to the faces of employees and customers alike and were constantly plotting their upward mobility and the people whose backs they’d happily climb to get it.

Vendors enhance software applications to make new sales, not necessarily to keep current users happy. Leverage drops enormously once a hospital progresses from prospect to signed customer.

It’s not a shortage of good ideas that makes a product mediocre, it’s the decisions executives make about allocating resources to it. Execution is the rate-limiting step, not brilliant planning and design.

Perhaps the most eye-opening lesson for me was to appreciate how disillusionment breeds contempt among product insiders nearly everywhere. They’re like hot dog factory workers – they’ve seen the unsavory manufacturing process and wouldn’t eat one on a dare. “Held together by spit and baling wire,” they’ll snort, “old code cobbled together to form a house of cards on a shaky foundation. It’s junk and needs to be rewritten.”

As a new hire fresh off the hospital front lines, I was uncomfortable hearing my beloved application sneered at by those who developed and supported it. Surely they realized how well it really worked.

Most companies don’t have a place for product lovers. There’s too much compromise and indifference required to work for vendors who sell a broad range of applications. A software application is the end result of years of compromise and mediocrity-seeking, the perfect tension between intentional underinvestment and outright customer revolt.

It’s no wonder that few customers really love their software applications. They were designed to be tolerated, not adored.

Morning Headlines 1/11/13

VA Launches Challenge.gov Contest for Scheduling Appointments

A challenge.gov Medical Appointment Scheduling System contest sponsored by the VA will award $3M to as many as three winners for the creation of a scheduling system to replace the 25-year-old scheduling software in its VistA system.

After evaluating GE’s future EMR strategies, Intermountain will look elsewhere

Intermountain, the Salt Lake City-based 22-hospital health system, sends an internal e-mail notifying staff that it will part ways with GE Healthcare after the organization’s unfinished EMR system that it had been building with GE failed to produce enough functionality to meet MU requirements.

More Doctors, Hospitals Partner to Coordinate Care for People With Medicare

HHS announces the formation of 106 new ACOs, bringing the total to more than 250.

HL7 Announces a CCD to Blue Button Transform Tool and Early Adopters

HL7 releases an interface to allow organizations to send patient information stored in CCD format to the Blue Button Network.

News 1/11/13

Top News

The VA launches a Medical Appointment Scheduling System challenge to replace its VistA scheduling module. Up to three entrants will win up to $3 million each.

Reader Comments

From TV’s Frank: “Re: Intermountain Healthcare. Finally dumping GE Healthcare.” An e-mail from Intermountain CIO Marc Probst to IT employees says the still-incomplete system it’s been building with GE is deficient in clinical documentation, CPOE, and integration with coding and billing. As a result, Intermountain has evaluated GE’s future EMR strategies and decided not to renew their contract, instead considering three options: (a) keep building their homegrown EMR without GE’s involvement; (b) buy Epic, Cerner, or Siemens; or (c) buy best-of-breed and try to integrate. I’ve panned the GE-Intermountain deal since it was announced in 2005, skeptical that dumping a few hundred million dollars and GE’s questionable expertise was going to ever yield anything tangible, which apparently is exactly the case seven-plus years into the 10-year deal. Or as I described it in 2011, “GE-Intermountain screwing around that never seems to provide any real, marketable products (are those Intermountain-led Carecast enhancements just about done?)”

From Jerry Aldini: “Re: Geisinger Health System (PA). I contacted you a while back with the rumor that they were developing a commercial solution for accountable care enablement. It was announced at JPMorgan last week. Announcement attached.” I haven’t seen announcement hit the wires, but it says that Geisinger is launching xG Health Solutions, a for-profit spinoff that will commercialize its intellectual property. On the list: consulting services, population health analytics, care management, healthcare IT optimization, and third-party administration services. Geisinger EVP Earl Steinberg, MD, MPP (above) is named CEO and former Alere Chief Innovation Officer Gordon Norman, MD will be chief medical officer.

From PolishingMyResume: “Re: Allscripts. Preparing for relocations and layoffs in the software development organization for development people who work remotely or outside the seven core offices of Boston, Bangalore, Burlington, Chicago, Raleigh, Pune, and Vancouver.” Unverified. Seems like a smart strategy to me. The problem with indiscriminate acquisitions is that you have people strung out all over the place who understandably don’t want to move, limiting your opportunity for the synergy or culture management that Allscripts could use quite a bit of right about now (not to mention expense reduction, ditto). One of quite a few bad decisions by Eclipsys before Allscripts overpaid to buy the company was hiring CEOs who refused to relocate and instead occasionally jetted a few time zones over when the troops needed demoralizing, so I assume that lesson was learned and Paul Black will work out of the Chicago office.

From Joan Hovhanesian: “Re: Howard University Hospital. Went live on Soarian clinical documentation on January 7.” Congratulations to the folks there. That’s a gutsy move going live immediately after the holidays. I still think of Joan as being with FCG and later VP/CIO of Shands Healthcare, so I’m out of touch – she’s with Program Advisors now.

HIStalk Announcements and Requests

HIStalk Practice highlights from the last week include: only 16 percent of providers met PQRS requirements in 2010. Primary care physicians are more likely to demonstrate improvement on measures of care when they have had sustained and extensive technical assistance. A billing service and four pathology groups agree to pay $140,000 to settle allegations that they improperly disposed of thousands of medical records found in a public dump. Job opportunities for physicians will continue to rise in 2013. The AMA and other professional medical organizations urge CMS to stop the implementation of the ICD-10 code set for outpatient diagnosis coding. Galen Healthcare releases a plug-in for Allscripts Enterprise EHR that sends providers EHR task updates to their PC or smartphone. It’s a new year and I hope your 2013 resolutions include not only a commitment to good health, but also a vow to expand your HIT ambulatory knowledge by faithfully perusing HIStalk Practice. Thanks for reading.

On the Job Board: Marketing Manager, Senior Applications Engineer – EMR.

Welcome to new HIStalk Gold Sponsor HTTS (Health Technology Training Solutions). For you vendors out there, this is my theory: customers often slam your product on KLAS surveys when their problem is really inadequate user training, not your software. The last thing you want customers to experience before go-live is a hastily thrown together set of PowerPoints and talking head demos put together by someone who knows the application but has no knowledge of instructional design and adult learning theory. You’ll hear an earful afterward, but not just on your training evaluation forms – users will under-use your systems, overload your help desk, and badmouth your product on reference calls. The HTTS team of healthcare IT and instructional design experts can help eliminate those problems by reviewing your training strategy, conducting a training needs analysis for new products or releases, and developing your training content using state-of-the-art learning techniques. Check out the testimonials of vendors who have engaged HTTS to optimize their training experience. If you’ve experienced professionally designed software training (both online and instructor-led), it’s easy to distinguish it from the more typical variety assembled by well-meaning amateurs. Now’s a good time to arrange a HIMSS conference connection to learn more. Thanks to HTTS for supporting HIStalk.

Acquisitions, Funding, Business, and Stock

7 Medical Systems closes on its acquisition of HealthLink Minnesota Management Group, a provider of administrative and IT services to clinics.

ManTech International completes its acquisition of CMS contractor ALTA Systems.

EBSCO Publishing expands its evidence-based pediatric content with the acquisition of PEMSoft, a pediatric point-of-care clinical information library and multimedia decision support system.

Sales

Saint Luke’s Health System (MO/KS) expands its use of Perceptive Software solutions to include integration with Epic.

CalHIPSO contracts with ClearDATA Network to offer cloud hosting, offsite backup, and disaster recovery services to CalHIPSO provider members.

Emergency Medicine Physicians selects athenaCollector and athenaCommunicator for its 800-physician group. athenahealth also announces that Prospira PainCare with deploy athenaClinicals, athenaCollector, and athenaCommunicator.

Children’s Mercy Hospitals & Clinics (MO) selects GE Healthcare’s Centricity Business as its enterprise-wide RCM solution.

Straith Hospital for Special Surgery (MI) chooses the ONE EHR from RazorInsights.

Flagler Hospital (FL) contracts with Surgical Information Systems for Sunrise Surgery.

Doylestown Hospital (PA/NJ) subscribes to the CapSite Database to assist with the capital planning and purchasing processes.

Lincoln Orthopaedic Center (NE) selects SRS EHR for its 14 providers.

Vanderbilt University Medical Center will use event-driven software from Tibco to support its clinical decision support capabilities.

Rainbow Babies & Children’s Hospital (OH) will encourage non-emergent ED patients to instead use HealthSpot telemedicine kiosks staffed by medical assistants and equipped with monitoring instruments. Also announced: telehealth provider Teladoc will offer HealthSpot’s kiosks.

People

MedSys Group names Steven Heck (First Consulting Group) president and Luther Nussbaum (First Consulting Group) chairman of the board.

URAC President and CEO Alan P. Spielman announces his resignation.

Announcements and Implementations

Sentara Healthcare (VA) begins implementation of Morrisey Associate’s Concurrent Care Manager software across its 10 hospitals and 100 medical facilities.

The dbMotion-powered ClinicalConnect HIE (PA) expands its reach to 1.3 million patients.

South West Medical (KS) and Rems Murr Kliniken in Germany go live on iMDsoft’s MetaVision platform.

Hospital messaging services vendor Critical Alert Systems partners with Mobile Heartbeat, which provides hand-held messaging and alarms, to create an enhanced nurse call solution.

3M Health Information Systems opens an innovation center in Silver Spring, MD that will showcase its offerings.

Meta Healthcare IT Solutions announces customized versions of its clinical documentation, CPOE, pharmacy, and medication administration software that meet the requirements of Canada-based customers.

Government and Politics

The FCC announces it will make available up to $400 million in annual funding to healthcare providers to spur development of broadband networks for telemedicine.

HHS Secretary Kathleen Sebelius announces the formation of 106 new Medicare ACOs.

Former CMS administrator Don Berwick, MD says he is strongly considering running for Massachusetts governor in 2014. He says healthcare experience gives him sensitivity to issues, adding, “I get more and more excited about the idea of Massachusetts as a model.”

Technology

Panasonic announces an expanded line of Toughpad enterprise-grade tablets that include a 10-inch model running Windows 8 Pro ($2,899) and 7-inch ($1,199) and 10-inch ($1,299) Android versions.

HL7 releases a CCD to Blue Button Transform Tool that allows organizations using the CCD format to allow patients to download information as ASCII text.

Other

A heavily recruited professor couple at University of Minnesota’s School of Public Health, one of them director of the ONC-funded University Partnership for Health Informatics (UP-HI), quit amidst charges they were double-dipping by simultaneously being paid by another university employer. The State of Georgia handed down felony indictments against Julie Jacko in 2011 after finding that she and Francois Sainfort were collecting full-time paychecks from both UM and Georgia Tech, but dropped charges in return for a plea agreement, restitution payments, and probation by Sainfort. Jacko ran the UP-HI project, funded by a $5.1 million ONC grant.

A California judge refuses to grant Kaiser Permanente access to the PCs and e-mail accounts of a couple whose small document storage business it hired to manage paper patient records. The state health department found last month that Kaiser put medical records at risk by turning them over to the small company without a signed contract. Kaiser claims it picked up the paper records, but the couple didn’t return everything.

Vermont’s Department of Financial Regulation scolds Porter Hospital for overrunning the $4.3 million budget of its Meditech-MedHost EMR project by 63 percent. The hospital undertook the project to earn HITECH money and to participate in Vermont Blueprint for Health. The hospital’s VP of public relations said, “The Meditech folks would hand you a box and say, ‘Good luck, do you have any questions?’” The hospital admits that during the physician practice rollout, all of its practices stopped accepting new patients for an unstated period, with the article ironically concluding, “Porter found that the productivity of doctors took a big hit each time the software was rolled out at a new practice … Officials said it has not been unusual for a doctor who normally saw 20 patients an hour to be able to see only 10 or 12 once the productivity-enhancing software was introduced.”

Weird News Andy finds this story a HIPAA stretch. Police confiscate the cell phone of a man filming an arrest on a public street, with a deputy telling him, “If I end up on YouTube, I’m gonna be upset.” The man was charged with obstruction and disorderly conduct, with the deputy claiming it was a HIPAA violation. A Stanford law expert opines the obvious: “There’s nothing in HIPAA that prevents someone who’s not subject to HIPAA from taking photographs on the public streets. HIPAA has absolutely nothing to say about that.”

It’s not an April 1 gag: the iPad-ready children’s iPotty debuts at CES. My only surprise is that the adult model wasn’t rolled out first.

Sponsor Updates

• Jim Stilley, director of clinical workflow consulting for Versus, will discuss the use of RTLS to improve patient flow and efficiency at the 2013 Patient Flow Management Congress January 28-29 in Las Vegas.
• The Advisory Board Company offers a February 14 Web conference on the inpatient value-based purchasing program.
• MedHOK earns full 2013 NCQA HEDIS software certification for its 360Measures v2.56.
• Bill Bithoney, MD of Truven Health Solutions discusses innovative and targeted approaches for reducing costs by improving care quality for better patient outcomes in a blog posting.
• Medicity publishes a white paper discussing how to build patient centeredness into the ACO model.
• iMDsoft highlights some of its 2012 milestones, including successful implementations in Canada and the Czech Republic, 60 critical care and anesthesia projects, and go-lives of MetaVision in 17 countries.
• Prognosis HIS doubles its client base for the second consecutive year and announces that all of its eligible clients exceeded baseline requirements to complete Stage 1 MU attestation using ChartAccess EHR.
• Beacon Partners defines population health management and its relation to ACOs in a January 18 Webinar.

EPtalk with Dr. Jayne

CMS is seeking comments from hospitals, EHR vendors, and “other interested parties” on its electronic quality reporting. Starting in 2014, the Hospital Inpatient Quality Reporting (IQR) program requires use of the Quality Reporting Document Architecture (QRDA) standard. According to the e-mail, “CMS wants to increase efficiency and reduce the burden for providers…” If that’s true, I have some other suggestions for them as well. The comment period closes January 22, so sharpen those pencils and fire up those keyboards.

Speaking of CMS, don’t forget that if you completed your 2012 reporting period on time, you only have until February 28 to attest for Medicare. Those attesting with Medicaid should check for their specific state deadlines.

One more CMS deadline-related item and then I’ll quit, I promise. The comment period for ONC’s Health IT Patient Safety Action & Surveillance Plan is open until February 4. Goals of the plan include making it easier for clinicians to report patient safety events, engaging vendors to “embrace their shared responsibility for patient safety,” and incorporating health IT safety in post-market surveillance of certified EHRs. It’s only 40 pages, considerably shorter than most ONC reads.

From Follow Up Fred: “Re: sticky workplace problems. Good topics for discussion! One solution I’ve successfully employed for years is this. If I need a prompt response to a question or request communicated by voicemail or e-mail, I always end the message by asking for a response by a certain date and time. Typically, “Hey Jane, I’d appreciate it if you’d get back to me by close of business Thursday, January 10.” I then flag the e-mail or voicemail follow-up date on phone in the event the requested deadline is missed. I’ve found it very effective for myself but also the recipient, who in turn can prioritize the return response.” An excellent point, especially in a workplace where people won’t do anything until they’re absolutely up against a deadline.

The AMA continues to play Chicken Little with their ongoing pleas for CMS to halt implementation of ICD-10. Citing the cost and administrative burden, they ask that it not simply be delayed again, but to call on “appropriate stakeholders to assess an appropriate replacement for ICD-9.” There has already been significant expense to prepare for implementation and I know many people will be aggravated at the lost time, money, and effort if they’re successful. Do I sense an HIStalk poll in the making?

Inga and I are hard at work designing the beauty queen sashes for HIStalkapalooza. Thanks to some virtual BFF shoe shopping (via camera phone and text message), I’m ready for HIMSS. Do you have your shoes picked out and your accessories coordinated? E-mail me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 1/10/13

Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication

Analysis from this month’s issue of Heath Affairs concludes that the anticipated primary care physician shortage could be resolved by moving to a team-oriented care model and expanding the use of non-physicians. The study was conducted jointly by Columbia and Wharton Business Schools and included no clinicians on the research team.

Benefits Consulting Firms Form Acclaim Health Analytics, LLC

Consulting firms Peel & Holland, Silberstein Insurance Group, and Virtus Benefits create a jointly owned data analytics company called Acclaim Health Analytics, which aims to aggregate health data to identify actionable health risks.

LifeBridge Health Names Tressa Springmann Chief Information Officer

LifeBridge Health, a Baltimore-based three-hospital health system, names Tressa Springmann as CIO.

Hottest IT jobs are in health care

Healthcare ranked as the fastest growing segment of the IT jobs market in 2012 and looks to repeat in 2013. Insurance and finance also outperformed the overall IT jobs market.

 At CES, staying healthy the high-tech way

The Boston Globe covers the growth of health IT startups representing the industry at this week’s CES tradeshow.

Readers Write 1/9/13

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

The views and opinions expressed are those of the authors personally and are not necessarily representative of their current or former employers.

Why Medical Practices Must Manage A/R Better … Now
By Tom Furr

“I didn’t go to med school to be an accountant.” How many times have we heard those words being muttered from a physician’s mouth?

Until now, that’s been an acceptable sentiment for any doctor. Today such thinking is financially dangerous if not downright disastrous. Even doctors in practice for as little as 10 years kept their focus on the insurance company, the source of 85 to 95 percent of their income. That almost predictable cash flow made reviewing accounts receivable reports — universally known as A/R — barely necessary.

Today, looking at A/R is an absolute requirement because of four letters that are having a huge impact on medical practices of all sizes and types – HDHP, which stands for High Deductible Health Plans.

These insurance plans have sent a loud and clear message to doctors across the United States: the game has changed. Simply stated, those practices that adjust quickly and wisely will be better able to survive. Those that don’t will be at risk of needing to sell out to hospitals or suffer serious issues with cash flow that could threaten the survival of their practices.

According to the annual report of America’s Health Plans, the number of U.S. residents using HDHPs rose nearly 20 percent in the past year. In 2013, 70 percent of larger employers will offer HDHPs, noted a Tower and the National Business Group of Health study. While the growth rate of this type of plan varies from region to region, no practice can think it won’t affect them soon.

The new reality is deductibles as a percent of contracted rates are about 50 percent. The days of the $25 co-pay are gone. Now practices are tasked with securing half the service bill’s balance from the patient. Unfortunately, physicians today don’t know the amount due until weeks after service, making it a priority to get the patient bill out as soon as the claim is adjudicated by the insurance company. That’s especially the case at the start of a calendar or plan year.

No one is suggesting doctors turn in their white coats and stethoscopes for green eye shades and a handful of sharpened pencils. However, they must become more attuned to the state of their practices’ financial condition. If a system is not embedded in their practice management software to manage patient bills and balances as well as produce insightful A/R reports, the doctor and his/her office manager should identify one and put it into place. Even if a new practice management system has just been deployed, that doesn’t mean you don’t need to ask the questions immediately of how to capture patient balances and post them automatically.

In the HDHP environment, everyone in the practice has a role to play, from front desk personnel to physicians. Each member of a practice should be educated on the new reality of HDHPs and how patients understand this new reality. However, it is also the responsibility of the practice to provide patients a simpler way to meet their financial obligations to the practice and continue to keep their healthcare relationships sound. If patients understand and have easy ways to remit payments, the physician keeps a sharp focus on the practice of medicine, secure in the fact that the A/R is being managed.

However, make no mistake, there is a limit on how much delegation a doctor or his/her office manager can allow. The tough calls need to be made by those individuals leading the practice. Decisions of the sort that most medical professionals could never have conceived of during their internships, like “firing” a patient.

Think about it:  with HDHPs, the shift from patient to deadbeat can occur in a matter of weeks if close attention is not paid to A/R.

Tom Furr  is CEO of PatientPay of Durham, NC.

NLP and Physician Workflow: An End to Physician Resistance?
By Chris Tackaberry, MB, ChB

“I hate all the EMRs out there, including the one our practice just bought. Notes that come from an EMR have so much extra stuffing in them that it takes me forever to figure out what you guys really had to say about the patient I referred to you. I have to wade through lines and lines of empty verbiage to finally find a meaningful sentence or two that tells me what I need to know.”

While the promise of the EHR/EMR remains as great as ever for healthcare providers, so too does the issue of physician resistance, as evidenced by this doctor’s comment, part of a conversation highlighted in a MedPageToday online article. Since EHRs came on the scene decades ago, physicians have remained slow to adopt the technology, even with the promise of improved workflow automation, enhanced care quality, rapid data exchange, and increased efficiencies. While the issue of physician resistance is certainly not new, it becomes an ever-more important concern as many hospitals continue to struggle to achieve Meaningful Use requirements.

There may be several reasons why physicians remain slow to come on board, but the most obvious is simply that doctors want to spend their time caring for patients, not struggling to use technology that introduces foreign, cumbersome tasks into their workflow. The truth is, even with today’s best systems, EHR data remains, on the whole, insufficiently descriptive or lacking in clinical context. Complete patient details often reside within historical notes embedded deep inside the EHR, and manually reviewing them for each and every patient, if a physician can access them, is incredibly time consuming and cumbersome.

Even with the technological advancements EHRs have seen over the years, physicians still have to spend tremendous amounts of time describing patient problems, medications, allergies, etc., in cumbersome forms or templates. As my colleague Tielman Van Vleck, PhD, Clinithink’s director of language processing, recently stated: “There is an intrinsic inefficiency in this process because so much of this information must be documented in the clinical notes repeatedly. As a result, there has been significant physician pushback against EHRs, despite their potential to improve both the quality and efficiency of physician-delivered care.”

NLP effectively embedded into an EHR has shown remarkable promise when it comes to minimizing the negative impact EHRs have on physician workflow. Rather than burdening physicians, NLP delivers more efficient and intuitive documentation of patient information in a manner already natural to the traditional physician workflow.

This is an important concern for providers dealing with Meaningful Use requirements, particularly Stage 2 and ICD-10, where capturing patient problem lists with unfamiliar coding terminology is another big deterrent to physicians. The good news is that NLP within an EHR can automatically tag all the problems referenced in a patient note, which in addition to facilitating analytics and clinical decision support not previously possible, can also support the capture of medications and allergies, saving physicians time associated with filling and maintaining these lists.

Physician resistance to EHRs won’t end tomorrow. But with the advent of Natural Language Processing and the manner in which this technology compliments physician workflow and will ultimately improve care quality, the light at the end of the tunnel may be considerably closer. Dr. Van Vleck recently noted, “NLP isn’t just a bigger hammer to build better widgets. If we do this right, we can improve medicine, helping people lead healthier, longer lives; we can simplify healthcare delivery and involve patients more; we can even help researchers make medical discoveries or respond to new diseases. There are a million ways that NLP can be leveraged in healthcare.”

It would seem tough to find a physician who could resist that scenario.

Chris Tackaberry, MB, ChB is CEO of Clinithink of London, England.

Vendor Resolutions for 2013
By Vince Ciotti

I tried to go to the gym today, but couldn’t get in. Too many people making New Year’s resolutions to exercise! So I went back to the office early and wrote this piece on New Year’s resolutions for our top 13 vendors, listed in order of their annual revenue.

1. McKesson. So big (over $3B in annual revenue) that they made two: (a) find jobs for the 200+ well-paid Horizon veterans they laid off last year, all with 15+ years experience in healthcare, programming, etc., and (b) hire 200+ new employees for the expanded Paragon line, following the Epic model of young, inexperienced, and cheap.
2. Cerner. Kick Paul Black’s butt.
3. Siemens. Use the excellent marketing materials and RFP responses for Soarian financials to start the design and programming soon.
4. Allscripts. Make Neal Patterson sorry he ever let Paul get away.
5. Epic. Find a NYC bank with a high interest rate on CDs.
6. GE. Sell something to somebody, somewhere, sometime, somehow …
7. Meditech. Start the design work on Release 7.
8. NextGen. Integrate the brochures, proposals, and PowerPoints for Opus, Sphere, and IntraNexus.
9. CPSI. Sell a large hospital (over 25 beds).
10. QuadraMed. Take a Quantim leap backwards.
11. NTT/Keane. Optimize their disparate product lines.
12. HMS. Get ready for Primus time.
13. Healthland. Rearrange their various products in Concentriq circles.

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

Morning Headlines 1/9/13

More Changes in Health Care Needed to Fulfill Promise of Health Information Technology

RAND releases a study that recognizes that the cost savings expected from EMR implementations have not been realized. The study points the finger at the cumbersome design of healthcare IT systems and the lack of integration across the systems.

NARMC Becomes First of Many Hospitals to Launch SHARE

North Arkansas Regional Medical Center (NARMC) announces that it is the first hospital to launch SHARE (State Health Alliance for Records Exchange), Arkansas’ fledgling health information exchange.

Guidelines Released for $10 Million Qualcomm Tricorder X PRIZE Reveal Health Condition Sets for Winning Solution

Qualcomm announces contest guidelines for a $10 million prize which will be awarded to the team that can produce a Star Trek Tricorder-inspired home medical device that can wirelessly monitor vital signs and accurately diagnose any five of the following conditions: anemia, UTI, type 2 diabetes, atrial fibrillation, stroke, obstructive sleep apnea, tuberculosis, COPD, pneumonia, otitis, leukocytosis, and Hepatitis A.

Why Athena Bought Epocrates

Travis Good of HIStalk Connect outlines the most viable ROI strategies that Athena will target after the Epocrates acquisition is finalized.

Health Catalyst Closes $33M Series B Investment From Norwest Venture Partners, Sequoia Capital and Sorenson Capital

Health Catalyst, a leader in healthcare data warehousing, announces it has closed $33 million in Series B funding. Norwest Venture Partners, which led the investing, will add managing partner Promod Haque to the Health Catalyst board as part of the deal.

News 1/9/13

Top News

A RAND study finds that the cost-saving promise of healthcare IT it predicted in a vendor-subsidized 2005 study has not been reached because deployed systems are not connected and not easy to use. The study’s authors blame shortcomings in the design of IT systems and recommend improving interoperability between systems, providing better access to records for patients, and designing more intuitive systems. The original RAND study published in Health Affairs (above), partly paid for by Cerner, claimed that electronic medical records would save at least $81 billion per year, which the Congressional Budget Office said at the time was a ridiculously inflated number. Still, the study was cited repeatedly to justify government spending on EHR-related programs. Another RAND study predicted that HIEs would generate hundreds of billions of dollars per year in healthcare savings.

Reader Comments

From Homecare: “Re: interesting misstep. From a VC-backed home care tech vendor.” Family Care Medical Services (WI) files suit against medical equipment and home health billing service vendor Brightree, claiming that the billing company Brightree acquired made inadequate efforts to collect money owed to the business. Brightree, an investment of Battery Ventures, acquired home health and hospice software vendor CareAnywhere late last week.

From Big O: “Re: HL7. Announced in September they were going to open up their standards for free in Q1. Anyone know the specific data?” I inquired via HL7’s contact page. They didn’t respond. I found a bunch of free downloads on their site, but I don’t know what else they’ll be releasing.

From Mickie: “Re: CenTrak RTLS lawsuit. Attached.” AeroScout, owned by Stanley Black & Decker, claims Centrak violated its patent for a WLAN-based RFID asset tag and locating system.

From Brandywine: “Re: Octo Barnett, MD at Massachusetts General Hospital. He’s officially retired and is not giving interviews any more.” I’m sorry to hear that since I really wanted to interview him. He should write his biography since he’s one of the pioneers of healthcare IT, along with the recently deceased Homer Warner and a few other key players. Octo developed the MUMPS programming language in the 1960s with Meditech Chairman Neil Pappalardo, which more than 40 years later still runs the systems used to care for probably 90 percent of hospitalized patients in the US.

HIStalk Announcements and Requests

Mr. H and I have been talking HIStalkapalooza the last few days. I’m not sure he is quite ready to leak all the details, but here’s what I can share. The party, which will likely be the most fun event of HIMSS 2013, will be bigger than ever and include exotic shoes, excellent food and drink, entertaining music, a few contests, and even a bit of dancing. And of course the annual HISsies awards. You will want to keep your calendar open for the evening of Monday, March 4.

Acquisitions, Funding, Business, and Stock

Health Catalyst, known until recently as Healthcare Quality Catalyst, raises $33 million in Series B funding from Norwest Venture Partners, Sequoia Capital, and Sorenson Capital Partners. I interviewed co-founder Steve Barlow in 2011 and SVP Dale Sanders this past October.

Point-of-care technology vendor PatientSafe Solutions closes a $20 million Series C round led by the Merck Global Health Innovation Fund.

Private equity firm Riverside Partners invests in Stinger Medical, a provider of mobile clinical workstations and medical technologies.

Care Thread, a provider of secure mobile messaging and a recently named “App of the Month” by Nuance Healthcare, secures $250,000 in seed funding from Slater Technology Fund.

Lightbank, the venture fund launched by Groupon’s founders, leads a $1.4 million investment in fertility app vendor Ovuline. The startup’s next product is a pregnancy monitoring app.

Data analytics company Blue Health Intelligence acquires Intelimedix, a healthcare analytics firm specializing in employer group and payer reporting solutions.

Passport Health Communications acquires California-based Data Systems Group, a provider of revenue cycle software solutions.

Travis analyzes possible reasons that athenahealth acquired Epocrates on HIStalk Connect.

Sales

ICON selects Cerner’s Discovere Late Phase platform to support its pharma and device studies.

The Health Information Trust Alliance designates Booz Allen Hamilton a Common Security Framework Assessor, tasked with conducting information security audits of healthcare organizations.

The Liverpool Heart and Chest Hospital NHS Foundation Trust augments its Allscripts electronic patient record with Hyland Software’s OnBase solution for enterprise content management.

St. Anthony’s Medical Center (MO) selects Capsule Tech’s device connectivity technology for use in multiple areas to automate the flow of patient data into Epic.

Stellaris Health Network (NY) signs a multi-year agreement with MedAssets for strategic sourcing, BI, and process improvement consulting.

Delaware Health Information Network approves the AlliedHIE Company as a Direct messaging provider for the HIE’s enrolled practices, with messaging and interoperability technology provided by ICA’s CareAlign Direct Messaging and Exchange solutions.

People

CHIME and HIMSS name University of Utah Health Care CIO James Turnbull its John E. Gall, Jr. CIO of the Year.

LifeBridge Health names Tressa Springmann (Greater Baltimore Medical Center) as CIO.

Blackford Middleton, MD, MPh, MSc (Partners HealthCare) will join Vanderbilt University as assistant vice chancellor, chief informatics officer, and professor of biomedical informatics.

O’Neil Britton, MD is appointed chief health information officer of Partners HealthCare, replacing David Blumenthal MD, who left earlier this year to head The Commonwealth Fund.

The South Florida REC promotes Amy Rosa from assistant director to interim director.

Vocera Communications names M. Bridget Duffy, MD (ExperiaHealth) CMO.

QuantiaMD names Daniel Malloy (IMS Health) SVP, promotes President Mike Coyne to CEO, and appoints CEO Eric Schultz to executive chairman.

Home monitoring systems vendor Healthsense names A.R. Weiler (Emdeon) as CEO.

Announcements and Implementations

North Arkansas Regional Medical Center becomes the first facility to implement the State Health Alliance for Records Exchange (SHARE), the statewide HIE for Arkansas.

CareCloud and the online physician platform QuantiaMD partner to survey QuantiaMD members on key practice trends.

Philips Healthcare introduces Lifeline GoSafe, a mobile personal emergency response system that includes fall detection capabilities, locating services, and two-way cellular voice communications.

Coding software vendor Trucode announces a cloud-based product that allows vendors to incorporate coder functionality into their systems. Customers include ChartWise, BayScribe, Dolbey, MModal, Precyse, and PlatoCode.

Florida Hospital Wesley Chapel (FL) completes the first phase of its nurse response system, which includes a Rauland-Borg nurse call system, Cisco wireless handsets, and Extension middleware.

Innovation and Research

The X PRIZE Foundation announces ambitious competition guidelines for the $10 million Qualcomm Tricorder X PRIZE, for which 255 teams have already registered. Along with monitoring vital signs and specific conditions, devices will need to address a core set of 12 conditions that include diabetes, atrial fibrillation, stroke, TB, and COPD.

Other

Hunting and fishing supplies retailer Cabela’s apologizes for a New Year’s Day computer glitch that added the Affordable Care Act’s 2.3 percent medical device tax to every purchase. The company says it has no idea how that happened.

In the UK, an NHS surgery practice blames human error on its creation of over 4,000 summary patient records without giving patients the chance to opt out.

Xerox files a protest with the West Virginia Department of Health and Human Services after the state awards a $248 million Medicaid claims processing system contract to Molina Medicaid Solutions. Xerox claims the state’s 2011 contract with Incumbent vendor Molina to upgrade the state’s existing system gave that company an unfair advantage.

An article on patent trolling identifies a maze of closely held companies that are sending out threatening letters to businesses, demanding license payments of $900 to $1,200 per employee for their patent that covers e-mailing scanned documents. The article says a study of startups found that 22 percent of them ignore patent trolling letters, 35 percent fight back at average court cost of $870,000, and 18 percent go out of business.

VistA guru Tom Munnecke observes that Secretary of Defense nominee Chuck Hagel was intimately involved with the MUMPS-based VistA system in its skunkworks early days as a VA deputy director, praising him for supporting the “Underground Railroad” despite the objections of VA brass who wanted to run a huge, centralized hospital information system instead.

Weird News Andy is stuffed with good news: the guy who invented the Segway is working on a gadget that will let people gorge themselves on food, then pump their own stomachs through a surgically installed abdominal valve. WNA says Dean Kamen obviously “has his finger on America’s thready pulse” since his inventions discourage walking and encourage gluttony.

Sponsor Updates

• The PriMed (CT) provider group and MED3OOO distributed coats, sleeping bags, and gift bags to the needy through the Bridgeport Rescue Mission’s Sleeping Bag Give-Away event right before Christmas.
• The local paper profiles Don Catino,who co-founded New Hampshire-based Digital Prospectors in 1999.
• McKesson Paragon is named Best in KLAS Community Hospital Information System for the seventh straight year.
• API Healthcare participates in the ACNL 2013 Annual Conference in San Diego February 10-13.
• AdvancedMD hosts a January 23 Webinar  that provides a crash course on qualifying for Meaningful Use.
• T-System offers complimentary benchmark information that considers the timeliness and quality of ED care.
• Nuance Healthcare’s Jonathon Dreyer, director of mobile solutions, predicts that 2013 will be the “year of the mHealth user” with more widespread availability and adoption of mobile health technology.
• CSI Healthcare IT earns satisfaction scores 2.2 times higher than the industry average for staffing firms in an independent satisfaction survey, also earning a74 percent “would recommend’ score.
• Vocera releases updates to its software platform that enhance nurse workflow and provide improved analytics and reporting. 
• Medseek looks at patient engagement, MU, and meeting patient expectations with technology in a January 16 Webinar. 
• Billian’s HealthDATA releases a white paper that focuses on the top innovations in HIT.
• Imprivata names Johns Hopkins Medicine the winner of its 2012 Healthcare Innovator of the Year Award for an exceptional implementation of OneSign.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 1/8/13

Athenahealth to Acquire Mobile Health Leader Epocrates

Athenahealth agrees to terms on a deal to acquire Epocrates for $11.75 per share, in cash, for a total of approximately $293 million. The purchase price represents a 22 percent premium over the closing price per share of Epocrates on NASDAQ on Friday.

James Turnbull Named CHIME-HIMSS 2012 John E. Gall, Jr. CIO of the Year

CHIME names James Turnbull of the University of Utah Health Care System as CIO of the Year for 2012.

NextGen Healthcare and Medline Partner to Expand Integrated Solutions

NextGen has entered into an agreement with Medline Industries, the nation’s largest privately held manufacturer and distributor of medical devices. The agreement provides sales support to NextGen from Medline’s 1,100 sales representatives along with marketing access to Medline’s more than 100,000 customers.

Vast cache of Kaiser patient details was kept in private home

Kaiser Permanente is under federal investigation for violation of patient privacy in connection with a document storage firm it hired that was discovered to be storing more than 300,000 patient medical records in the private home of its husband and wife owners.

EHR Design Talk with Dr. Rick 1/7/13

The Overview-by-Category Design

We have been considering two alternative high-level EHR designs for organizing a patient’s data over time – the Snapshot-in-Time design and the Overview-by-Category design.

In a recent post, I made the argument that the Snapshot-in-Time design supports our mental model of how a dynamic system, such as a patient’s state of health, changes over time.

In my last post, I proposed that the user interface (UI) that results from the Snapshot-in-Time design supports how the human visual system takes in and processes information.

While the Snapshot-in-Time design is at the core of much paper-based medical charting (see Why T-Sheets Work), for a number of reasons — only some of them due to technical limitations — it has not been widely adopted as a high-level EHR design. Instead, most EHRs employ an Overview-by-Category design.

The Overview-by-Category design places emphasis on the patient’s present state of health. A single summary screen displays multiple categories of EHR data (History of Present Illness, Assessment and Plan, Medications, etc.) each as a separate pane or table containing time-stamped data from both present and past encounters.

In my opinion, the Overview-by-Category design has several fundamental limitations:

• The patient’s story does not unfold as a narrative.
• Significant cognitive and mouse / keystroke effort is required to make sense of how entries in the different categories fit together.
• The overview screen tries to convey too much information. To see details, the user either has to scroll within the tables (see The Problem with Scrolling), to scroll the overview screen itself, or to navigate to entirely different screens (see Humans Have Limited Working Memory).

To help compare the two designs, I have constructed mockups below based on the Overview-by-Category design, using exactly the same patient database that I used for the Snapshot-in-Time mockups in my last post.

The Overview-by-Category mockups below are based on a widely-used EHR. While these illustrations are for an ambulatory patient, similar designs are common in hospital-based EHR systems.

In order to see the mockups and read the accompanying text, enlarge them to full screen size by clicking on the ‘full screen’ button

in the lower right corner of the SlideShare frame below.

Rick Weinhaus MD practices clinical ophthalmology in the Boston area. He trained at Harvard Medical School, The Massachusetts Eye and Ear Infirmary, and the Neuroscience Unit of the Schepens Eye Research Institute. He writes on how to design simple, powerful, elegant user interfaces for electronic health records (EHRs) by applying our understanding of human perception and cognition. He welcomes your comments and thoughts on this post and on EHR usability issues. E-mail Dr. Rick.

Curbside Consult with Dr. Jayne 1/7/13

I lucked out this year by having the privilege of being on IT backup call for both Christmas Eve and New Year’s Eve. Since health IT is by definition part of the 24 x 7 world of health care, a lot of us were working. Although our clinical departments never take a day off, our administrative organization is trying something new this year and actually allowing a full day off for Christmas Eve and New Year’s Eve rather than the traditional half days. I always thought the half days off were kind of silly, since any work that was actually attempted was half-hearted at best.

With the long weekend over New Year’s and the short work week to follow, I hoped our team would take advantage and spend time with family and friends or otherwise recharge their energy for the coming year. The team knows better than to expect responses from me on e-mail when we’re officially not working. However, I forgot to sign time cards, so I found myself online on New Year’s Eve. I found dozens of e-mails waiting. Several of them wanted answers or decisions.

Apparently in addition to signing time cards, I also forgot that we have a couple of staffers working on our team who are on loan from another part of the organization. From the looks of my inbox, a couple of them decided to spend their long weekend working, and I could tell that at least one of them was still online. I instant messaged him and reminded him it was a holiday and that he really needed to take a break. We went back and forth a bit and he eventually figured out that I wasn’t kidding, that I wanted him offline and doing something other than work.

When we returned to the office on Wednesday, I approached him to talk about the weekend / holiday work situation. He admitted that in his “home” department, they are expected to check e-mail several times a day, even on weekends, “in case someone needs something.” Like a lot of people, he had a hard time just “checking” e-mail and would get sucked in to answering e-mails and working on projects and had difficulty letting things sit. I reminded him that in our department we have on-call coverage for that eventuality – someone is always reachable via the help desk. Should the on-call person not respond, the help desk has permission to contact the managers or directors (or even me) to make sure our clinicians have what they need.

In his department, there seems to be a lack of trust that the help desk group knows how to appropriately escalate issues to the on-call team or that the on-call person will be able to solve the problem. The team doesn’t necessarily trust each other and they don’t feel that there is adequate cross training to allow for rapid problem solving. It leads to a cycle of continuous frustration and feeling like they can’t get anything done and that they always need to be watching over their shoulders.

It was a good conversation and really got me thinking about our team culture of time management and what makes teams effective versus what makes teams struggle. I thought about some of the most productive teams I’ve been a part of and some of the worst team experiences I’ve had. With that bit of reflection, I’d like to share my thoughts on what I think works.

Have an E-mail Policy

I personally like a “three day” policy. This means that people have three business days from the time the e-mail is sent before a response is due. This also means that if you need an answer sooner than three days, you need to either call the person or speak to them personally – no texting. This also applies to meetings, since invitations come via e-mail. If you need to schedule something with less than three days’ notice, you have to reach out to people by phone or in person.

Our policy discourages people from working e-mail at night unless there are unusual circumstances or employees are working flex time. Staff who aren’t routinely at their desks are encouraged to block time on their calendars to handle e-mail. They quickly learn that calendars fill if they’re left open, so it’s to their advantage to set up regular times to focus on e-mail. They’re also encouraged to not check e-mail during meetings, which can be incredibly disruptive. Some individuals even need to avoid trying to check e-mail between meetings if they’re not disciplined at knowing what they can answer quickly and what will be a time suck. In addition, appropriate use of “out of office” replies is required.

Have a Voice Mail Policy

If you’re a field employee, indicate on your outgoing greeting how often you check your voice mail and if you prefer an alternative method of contact. Some of our field employees (such as trainers and desktop support liaisons) don’t even have voice mail, because they’re never at their desks to check it. My voice mail greeting specifically says to not leave a message as it will not be returned. You’d be surprised at how many people leave messages anyway. That gives me a general idea about those folks and their listening skills, especially when they do it more than once.

Have a Text Message / Instant Message Policy

The text message policy is easy at our organization. The hospital doesn’t pay for texting service, so people don’t use it except for personal messages. Although instant messenger is in use (and integrated into our e-mail suite), I don’t encourage my team to use it and actively discourage some staff from using message notifier popups. The constant distractions on the screen are lethal to those who have difficulty paying attention. (This goes for e-mail notifiers also.) Instant message is also challenging because it often doesn’t leave an easily followed trail. Saving chat logs isn’t as efficient as using e-mail reply tracking when you have to prove who you told, what you told them, and when the message was delivered.

Have a Meeting Policy

Meetings should have agendas which should be distributed at least one full business day in advance. I used to have a team member who routinely sent the agenda for an 8 a.m. meeting the night before at 8 p.m. Note the use of the past tense. Sending agendas in a timely manner allows people to actually read them and speak to you if there is a problem with the agenda or if they’re not prepared to discuss an item. Agendas should be adhered to. If the leader isn’t a good time manager, he or she needs to appoint a time keeper to stay on track.

The most successful teams I’ve ever been a part of have meetings that only last 45 minutes. The trick to squeezing an hour meeting into that block is to start on time and end on time. This prevents productivity loss at the beginning due to late arrivals and at the end due to those scooting out to attend the next meeting. This allows 15 minutes between meetings for people to check e-mail, walk to the next meeting, return to their desks to dial into conference calls, or take care of other needs.

Another trick – do not recap for late arrivals. Nothing is worse than being on time for a conference call and having the leader recap the roll call and activities for late arrivals. A word on conference calls – if you have access to web meeting software, require its use and require people to sign in so you can see who is on the call, avoiding the whole roll call issue altogether. Many packages even allow you to sign in from your cell phone, removing that as an excuse for not signing in.

My last meeting pointer is to always end on time. Adherence to the agenda is paramount. If a topic is taking too long, that means it likely needs its own meeting. A key element of my team culture is ending early whenever possible. People who try to cram new agenda items into three free minutes are quickly neutralized by their self-policing teammates.

For many of you, these are common sense items, and hopefully most of you follow similar rules in the office. I know from experience though that there are a large number of workplaces that have no clue about these (or many other) time management and team management dynamics. If you’re on the leadership team and you don’t have these policies in place, consider implementing them as part of your resolutions for the new year. You might find yourself with stronger teams, happier workers, and greater output.

Have a solution for sticky workplace problems? E-mail me.

E-mail Dr. Jayne.

Athenahealth To Acquire Epocrates for $293 Million

Athenahealth announced this morning that it has signed a definitive agreement to acquire mobile application and clinical reference data vendor Epocrates for $11.75 per share, representing a 22 percent premium over Friday’s closing share price. The all-cash transaction is valued at $293 million.

Jonathan Bush, president, chairman, and CEO of athenahealth, said of the acquisition, “I have been an admirer of Epocrates since it first emerged and have watched the company grow consistently, one app download at a time, as it has cemented itself into the consciousness of America’s physicians. No other company has been able to replicate the brand awareness, familiarity, and trust that Epocrates has across the clinical mobile user base. We are confident that we can provide Epocrates with the stewardship and resources it needs to grow and develop within health care, and that Epocrates’ capabilities are going to mesh exceptionally well with athenahealth’s cloud-based physician and patient services. Together, we’re excited by the opportunity to redefine the mobile toolset for care givers.”

Epocrates held its IPO in February 2011. Shares rose quickly from the $13-15 opening range to over $26, but have traded mostly below $10 for the past 16 months. The two-year share price chart above shows Epocrates (blue) and athenahealth (red).

Morning Headlines 1/7/13

CMS Announces 90-Day Period of Enforcement Discretion for Compliance with Eligibility and Claim Status Operating Rules

CMS announces a 90-day reprieve for healthcare facilities not yet in compliance with ACA’s insurance eligibility and claim status checking mandate.

Wolters Kluwer Health Completes Acquisition of Health Language, Inc.

Health Language, a leader in the medical terminology management market, is acquired by Wolters Kluwer.

Copying common in electronic medical records

Reuters reviews the electronic progress notes of 135 patients, generated from an ICU in a Cleveland hospital, and finds that progress notes contained copied material about 75 percent of the time. Mr. H analyzes the report, its flaws, and its findings in greater detail below.

UNC cancer center computers hacked

Hackers have gained access to the personal information of more than 3,500 employees, visitors, and contractors of UNC Lineberger Comprehensive Cancer Center. No patient information was exposed.

Monday Morning Update 1/7/13

From Willy Mays Hayes: “Re: Cerner. Our remote-hosted Cerner system just experienced a six-hour downtime that they are attributing to hardware failure in Kansas City. We’re wondering how many other clients were effected.” Unverified, but speak up if your system went down.

From Zorba P: “Re: non-compete agreements. A Wired essay says enlightened companies realize that non-competes hurt the economy.” The article didn’t convince me that companies shouldn’t require employees to sign non-competes, only that allowing employees to freely take their proprietary knowledge to a competitor might increase competition and thus economic output. Maybe it all works out where companies poach each other’s people like a Cold War spy exchange, but the odds of that intellectual property flow being equally balanced among all competitors seem slim and some companies are going to lose. The article tries unconvincingly to make the point that Boston’s Route 128 startup environment lost out to Silicon Valley because California law essentially voids all non-compete agreements, leaving the Massachusetts companies with no-choice lifer employees who stagnated their employers. I might agree with the conclusion that employees should be free to immediately leave and start their own companies since the economy would benefit from having more entrepreneurs and fewer unmotivated corporate clock-punchers, but I’m just not comfortable with the idea that any company with big pockets should be able to steal competitive secrets by simply hiring away insiders.

From The PACS Designer: “Re: Pebble e-paper Smart Watch. Our Travis Good posted in The Year of the Health Gadget about Pebble e-paper Smart Watch, so TPD thought it would be a good addition to the upcoming update of TPD’s List of iPhone Apps. Also found a YouTube preview explaining its use in transferring apps from mobile devices to the wrist watch.” I inadvertently burst out laughing at 0:20 when the company’s “Dream Team” (i.e., stereotypical startup nerds) make a reluctant and un-photogenic appearance, displaying palpable discomfort at being exposed to actual sunlight and fresh air. If your life won’t be complete without a rather ugly but smartphone-connected watch whose least-interesting capability is telling time, you’ll pay around $150 if it ever reaches the market (pre-orders started in May and the company isn’t providing updates), you’ll be buying from a company that failed previously before renaming itself and raising $10 million on Kickstarter, and you’ll be waiting until they find Asian companies willing to build their product cheaply. Not to mention that depending on hard-to-predict fashion acceptance, you’ll either look like the coolest kid around or a clueless idiot flashing a geeky Dick Tracy calculator watch.

As healthcare IT professionals, we’re even more skeptical than laypeople that providers can keep our medical information secure, with 84 percent of poll respondents saying they lack that confidence. New poll to your right: have you used a patient portal offered by your PCP? I have, and I like it — it’s convenient for making appointments, checking lab results, and pre-paying for a visit and printing a barcoded page that lets me check in at a kiosk instead of waiting in line.

Welcome to HealthITJobs, sponsoring both HIStalk and HIStalk Connect at the Platinum level. I like the clean look of their site, which has some pretty cool jobs listed. Employers typically need to fill positions in a hurry, and with HealthITJobs.com, positions you post go online immediately. Job hunters can manage the process from their smartphones: checking for openings, receiving real-time alerts when new jobs go up, and even applying for jobs from anywhere. As an employer, I’ve posted hospital IT jobs on some of the big job boards and it’s usually been a disaster, with 95 percent of the applicants having no healthcare experience, no US work credentials, or clearly insufficient capabilities. HealthITJobs focuses on health IT professionals, so you won’t be have Bolivian bricklayers bugging you about your CMIO position. The biggest regret I have about the crappy jobs I’ve held as an employee (thankfully not recently) was that I let inertia keep me from getting serious about moving on. It would have been so easy then and even easier now to find a new gig: register, download the iPhone app, and see what’s out there (hint: it’s a booming industry, so there’s a lot). For employers and recruiters, unfilled positions cost a lot of energy and money, so HealthITJobs is a painless way to post your listings and find that one right person who’s apparently not perusing your listings posted elsewhere. Thanks to HealthITJobs for supporting HIStalk and HIStalk Connect.

Hackers hit the servers of UNC Lineberger Comprehensive Cancer Center (NC), exposing the information of 3,500 employees and contractors. No patient information was involved. The breach occurred in May, but those affected weren’t notified until after Christmas. University IT employees say their servers are hit with attempted hacks thousands of times every hour.

CMS announces a 90-day extension for meeting Affordable Care Act transaction standards for eligibility and claim status. The reason given: nobody was going to be ready.

Wolters Kluwer Health completes its acquisition of Health Language, Inc., announced in October.

The fired former president of University of North Texas Health Science Center says he was let go for a variety of not-so-good reasons. One of them was his analysis of an all-campus shared services business center, which he says upset the university’s chancellor because it found that the health science center was paying twice as much as before with reduced quality, including a two-day EMR downtime that affected patients.

Home medical billing software vendor Brightree LLC acquires CareAnyware of Raleigh, NC, which sells home health and hospice software.

Reuters covers the recent Critical Care Medicine article in which researchers used plagiarism detection software to determine that most physician progress notes contained at least 20 percent material copied and pasted from elsewhere in the electronic record. I pulled up the original article (thanks to my academic medical center employer for providing remote access to our online journal library) and offer these observations:

• It was a one-hospital study (MetroHealth Medical Center, Cleveland) of 135 patients admitted to a 14-bed ICU for at least three consecutive days.
• The EMR system was Epic, which offers built-in functions for copy-paste and copy into a new note.
• Residents copied more often, but attendings copied more actual text.
• The threshold for identifying copying was phrases of at least four words and 20 or more total characters that contained at least a 20 percent match.
• The authors did not interview any of the physicians found to have copied material, did not postulate why they did so, did not ask those involved in care of the identified patients whether the copied material negatively impacted patient care, and drew no conclusions about the potential or actual impact of copying progress note text on patient outcomes.

My conclusion: like many studies that raise a red flag and then run, this one seems to have been thrown together and executed quickly, resulting in a slightly interesting article that has no meaningful conclusion other than that someone with more resources should do a better study. Doctors may well copy progress note material, but that’s not necessarily a bad thing given that EMRs don’t typically offer easy ways to tag highly relevant material from the routine junk that hospital administrators, regulators, and malpractice lawyers require. It should be assumed that bringing material forward has an at least an equal likelihood of being positive for the patient since it might be missed otherwise. And intentional copying is a lot less bothersome than template-generated babble that looks good but says nothing useful.

Everybody wants to armchair quarterback how doctors document. How would you like having a roomful of stern third parties examining every e-mail you write for relevance, insightfulness, originality, and style, looking for opportunities to reduce your pay or sue you? If doctors aren’t complaining about the body of progress notes they work with in caring for their patients (including attendings reviewing the work of residents), then the armchair quarterbacks aren’t likely to find a smoking gun of vast conspiracy or widespread negligence.

If you’re a hospital, set standards on how documentation should be done. Demand that your EMR vendor develop ways to separate the useful from the worthless, and to add logic that considers the age of a documentation element and its graded value from individual providers in predicting its relevance. If you want elegant and thoughtfully composed prose, expect to pay for it in reduced physician productivity. And if you can prove that particular methods or styles of progress notes directly impact patient care, let’s see your data.

I think we can agree that electronic documentation works better in theory than in practice due to poor design and unguided use and therefore could be improved. To that end, I’ll close with a pithy quote from contributor Robert Lafsky, MD: “I’d sure like to see that visiting expert professor try to unravel a difficult case using nothing but the printed output from a typical EMR.”

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: EMR Vendor Starts Secretive, Lucrative Business: Pimping the Patient Data of its Provider Customers

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 March 2008.

EMR Vendor Starts Secretive, Lucrative Business: Pimping the Patient Data of its Provider Customers
By Mr. HIStalk

Genetic medicine company Perlegen Sciences probably never saw the controversy coming. Its March 18 press release innocently and proudly announced an exclusive collaboration agreement with an unnamed EMR vendor to mine that vendor’s database, which is said to hold medical information on four million patients. To egghead scientists who don’t get out much, that sounds like a victorious achievement for medical research.

Perlegen will sift through mountains of data to select patients who meet its research criteria. The company will then contact the providers of those patients, asking them to contact the patient on the company’s behalf and offering them cash for providing a DNA sample. (Everbody’s watched enough CSI to know about the Q-Tip cheek swab thing, of course).

Perlegen’s intentions sound noble, at least when they’re the ones reciting them. The company is hoping to find genetic markers that can predict the individual response of patients to specific drugs. That correlation could improve patient safety and drug efficacy. And boost drug company profits, of course, which is the real point (some of its investors are drug companies).

The fastidiously unnamed EMR vendor is being paid to provide massive amounts of supposedly de-identified patient data (that methodology wasn’t specified). They get a cut of the take. Perlegen gets an ownership stake in the EMR vendor. Everybody’s happy.

Except perhaps those patients whose information is being probed by a company they’ve never heard of. Generously provided by another company they’ve also never heard of. Do they really want a genetic research firm peeking into their medical records, obtained in an open-air bazaar?

You’ll be hearing more about this story. It opens up a number of legal and ethical questions that are sure to tickle the fancy of journalists, privacy advocates, and software vendors.

The document trail will be interesting. Did the providers’ Notice of Privacy Practices indicate to patients that their data would be marketed since this goes well beyond the usual treatment, payment, and operations? Did the EMR vendor’s contracts with its customers reserve the right to not just store their data, but to sell it?

Perlegen drops the words “HIPAA” and “IRB” to make everything sound on the up-and-up. They’re HIPAA-immune, however (they’re not providers) and it’s not clear whose IRB will oversee the project. In other words, it’s not illegal, but it sounds a bit loophole-ish. So much for HIPAA offering broad privacy protection.

The biggest villain here appears to be the EMR vendor. It has no contractual agreement with patients as far as we know, so what is it doing selling their information?

Don’t blame Perlegen – they should have been told ‘no’. Blame lax privacy protections, the unnamed EMR vendor, and poor IT market conditions for leading to such a desperate cash grab. When that vendor is named – and it will be – we’ll know how it worked out such a sneaky deal, how it’s de-identifying the data of its customers, and how it justifies being partially owned by drug company interests.

HIStalk Interviews Dan Schiller, CEO, Salar

Dan Schiller is CEO of Salar of Baltimore, MD.

Salar has been through a couple of acquisitions. Explain what happened and how the company will operate going forward and the changes Constellation Software will make.

To say it’s been an interesting ride is an understatement. In the last 15 months, Salar has been purchased three times.

Initially we were bought by Transcend Services, a transcription company, in August 2011. Our hope was to create a budget-neutral documentation transition solution for existing Transcend customers by moving them off transcription and on to TeamNotes, Salar’s electronic physician documentation platform. Before we were able to formalize and launch this strategy, Nuance purchased Transcend to expand Nuance’s share of the transcription services market. This was early 2012, and we became a small blip on the larger corporate radar.

While we may not have been given the visibility we wanted, we used this time to focus on our internal processes, customers, and R&D. I think it was time well used. We’ve emerged with a new Web-based platform that we’ve deployed over the last few months to a new customer.

That brings us to our acquisition in early December by Constellation Software, Inc. We think Constellation is an ideal partner for us. They’re focused on growing vertical market software businesses that provide mission-critical solutions. They have a solid track record of purchasing and nurturing software companies in many industries. Most importantly, they believe in us – the strength of our solutions and our team.

So no immediate changes. They’re going to let us do our thing. I believe we already have the best electronic clinical documentation and billing workflow solution on the market, and with Constellation’s support, I believe we will be even stronger on the other side of 2013.

You’re a programmer moving into an executive leadership role, which rarely happens since the business world often ends up being like Dilbert and the pointy-haired boss. What are your priorities for the company and what parts of the job are you looking forward to?

I might feel out of place if this were a clothespin factory, but I know how to build software pretty well. Technical innovation has always been key to Salar’s identity, so it’s natural that a software engineer has always been at the helm. Hey, if you call in the middle of the night, you might still catch me on Tier 3 support. I hope to keep up my spot in the rotation for as long as I can.

My main priority is keeping us innovative, agile and relevant in front of all the change this industry will see in the next few years. We have always felt that, at their core, initiatives like Meaningful Use, ICD-10, and quality-driven payment reform are documentation problems, which are right in our wheelhouse.

The bottom line is that I’m eager to leave behind the mess of the last 15 months and lead this company into a very exciting future. I am fortunate to have a smart group of people who are passionate about solving real problems. With their support, this is going to be fun.

Salar’s selling point in documentation with TeamNotes has been a form-type metaphor that users could customize to look like familiar paper forms. How are users responding to that, and what kinds of devices are they using it on?

We all know that there are still large facilities using paper documentation, so that metaphor still translates to some degree. But TeamNotes has evolved far beyond just mimicking paper notes, and that’s been driven largely by the evolution we’ve witnessed in how comfortable physicians have become with technology. They want it to work for them, not against them.

For example, they want the ability to interface clinical data within their notes, jointly author notes with the entire care team, and capture structured data. Our newest version of TeamNotes enables physicians to do all these things, and do them on their preferred desktop, laptop, or mobile device. As our template content has become richer with each implementation, all of our users benefit.

Where do your documentation products fit with a hospital that’s already running a major EMR?

All of our customers already have major EMRs in place. In each case, the EMR was not able to fill their inpatient documentation needs functionally or achieve acceptable physician adoption rates. In most cases, the documentation tools are not intuitive and too rigid to fit varying clinical workflows. With Salar, each hospital has developed notes that are intuitive, reportable, and effective in their unique workflows. In our opinion this is how you achieve physician adoption of electronic clinical documentation.

There have been a lot of great strides within the industry to develop CLU and CAC tools to accommodate notes coming out of the EMR because they were never structured well in the first place. To get any sort of specificity out of a flat unstructured note, you’re required to use some expensive tools or employ smart people to deduce what happened at the point of care. This specificity needs to occur at that point of care, in the physician’s hands, and the outcome must be represented in a structured, discrete way.

These CAC tools are tremendously capable, but are employed in the wrong place in the process. By embedding CAC capabilities into the documentation workflow, Salar helps hospitals realize the full potential of their EMR investment.

How do you see your market and products changing as healthcare reform continues over the next several years?

For the short term, the customizability of our documentation platform makes us ready for everything we’re going to see in the next year or so. For ICD-10, we’re incorporating NLP tools from HLI and other vendors to accomplish meaningful front-end CDI at the point of documentation. For Meaningful Use or any other report-heavy regulations, the ability to add specific fields overnight is going to allow customers to handle these changes without any additional overhead.

Looking out a little further, we will be focusing on the front-end CDI loop in TeamNotes. By incorporating more computer-assisted tools to physicians, as well as providing for more complicated workflows with CDI staff, we believe we can truly maximize the value of these tools for both hospital and physician.

We’re very interested in how Physician/CDI/Billing workflows develop and how we can facilitate a more efficient process. We’re also very interested in the ACO model and what needs to be provided from both a reporting and a documentation perspective. We think we’re in a good position to accommodate multiple reimbursement models because of our customizable templates.

In the longer term, we’re looking at how other workflows within hospitals – and workflows between hospitals and other care organizations – are starting to blend. There are many processes that have been overlooked and underserved from a technology perspective, and for the good of the patient population, should be optimized. We can’t wait to solve these problems.

Morning Headlines 1/4/13

Lexmark Acquires Acuo Technologies

Acuo Technologies, archive and clinical content manager vendor, is acquired by Lexmark’s Perceptive Software unit for $45 million

Welsh, Carson, Anderson & Stowe Completes Acquisition Of GetWellNetwork

GetWellNetwork is acquired by PE firm Welsh, Carson, Anderson & Stowe. GetWellNetwork just signed a deal with the VA last month to provide in-room patient engagement solutions across 21 facilities.

Patient Portals: Providers Choose Path of Least Resistance

A new KLAS report on patient portals shows that most physicians are going with whatever product their EHR vendor is offering. “The existing EMR vendor relationship appears to be more important than any other factor when choosing a patient portal,” said report author Mark Allphin. “While functionality and ease of use are important to providers, they take a back seat compared to providers’ desire to manage fewer vendors and interfaces.”

SRS Receives Substantial Investment from Thoma Bravo

Thoma Bravo, a PE firm which holds equity in Hyland Software and Mediware, invests an undisclosed sum in SRS Software.

TriZetto Acquires Claims Workflow Automation Company To Further Enhance Efficiency of Healthcare Payers And Providers

TriZetto acquires Healthcare Productivity Automation, a Franklin, TN-based vendor of an automated claims administration solution.