From the mHealth Summit 11/8/10

Washington, DC is pretty nice this week given that (a) it was a bit chilly and windy on Sunday but nicer today, and (b) it’s getting dark really early now with the time change (that’s not just Washington’s problem, but since I was here on the day of the time change, I’m blaming them). I like the city, to be honest, even though I loathe the politicians, lobbyists, lawyers, and federal contractors that crawl all over it.

I’m staying in the Grand Hyatt Washington, which hurts a bit less now that I’ve seen it than when I first saw that I would be paying $181 per night out of my pocket. It’s a really nice hotel, two blocks from the White House in Penn Quarter, just down from the main entrance to Chinatown and Verizon Center. It’s also close to lots of funky restaurants, which is a plus. Even the $30 per day self-park fee didn’t seem so bad once I saw what parking cost at the nearby open surface lots. It’s just a couple of blocks from the convention center, an easy walk across a parking lot and up one street.

A friend met me here Sunday, so we took a nice stroll by the White House and down the mall to the Capitol. I took her to Clyde’s of Gallery Place just down the street from the hotel for dinner, which is was what I modestly expected, but with low happy hour prices and a clubby atmosphere that made it quite nice — the $6 empanadas and mussels were good, the $2 PBRs were cold, and the pumpkin bread pudding was pleasantly fall-ish. If you’re looking for someplace cheap and unchallenging near the Convention Center, it’s a safe walk and it feels nicer than the prices would suggest.

About the conference: it’s rather the anti-HIMSS, which I’ll explain as follows. Suppose you really like Las Vegas, with the noise, the glitz, the fakery, the conniving thieves at every turn, and the general sense that lots of people there are expending their pent-up immorality a safe distance from home where nobody knows them. That’s HIMSS.

mHealth Summit has 2,400 attendees (less than a tenth of the HIMSS crowd), most of whom seem to be academics, global health people, federal workers, and people from other countries that are way ahead of us in mHealth (and that’s quite a lot of countries). Vendor presence is minimal. Many of the attendees are young and idealistic, trying to solve big world problems (hunger, infectious disease, etc.) instead of landing their dream job working for a vendor and walking around self-importantly with smart phone in one hand and a mirror in the other. It is, therefore, quite un-HIMSS like – serious people getting serious education mostly working for noble causes underwritten by government money.

Here’s the interesting part: as non-commercial as it is, you might not like it. I felt way out of my comfort zone not seeing the same faces, the neon sprawl of the exhibit hall, and the presenters claiming they had finally reached healthcare Nirvana just by implementing version 26.2 of some vendor’s 1980s clinical system. I recalled that old National Lampoon story about two guys who found an alternate universe version of Las Vegas where the slots paid out freely and the hookers and drunks were absent, but all they could think of was going back to the real, gritty, sleazy Vegas. That’s how I felt today – I kind of missed the debauchery and shallowness.

Logistically, everything was mostly very well done. This was a long day, with the first session starting at 9:30 a.m. and the last one ending at 6:30 p.m. (without those big scheduling blocks that HIMSS leaves open to force you to the exhibit hall – you had to really dig to even tell when the exhibit hall was open). Lunch was scheduled for an hour, but somehow the planners slipped big-time in offering  what was optimistically described as, “Lunch On your Own, concessions stands will be available.” Make that “stand” in the singular: 2,400 attendees were cut loose simultaneously from the one and only keynote, only to find ONE single-line concession stand from which to buy $9 salads and $7 sandwiches. It looked like starving refugees threatening to overwhelm a UN aid truck, to use a global analogy. The line was huge, even at the end of the scheduled hour, and people were still trying to get food well into the next session. The convention center had several signs indicating that food was available elsewhere, but I looked all over the building and there was none. Somebody really goofed. I could have quit my hospital job if I’d had a hot dog cart on the sidewalk just below the window where the line ran.

It was clear from the beginning that this conference was thinking bigger than HIMSS, which fixates on vendors and in-hospital productivity applications to the exclusion of population health. I sketched this on my agenda:

US hospitals < acute care services delivery < US healthcare system < US population health < global population health

HIMSS is mostly in the leftmost category and entirely in the first two (inside the walls of providers almost entirely because that’s the vendors that pay them richly). mHealth Summit is mostly in the rightmost category and entirely in the last two. If you don’t like hearing about charity-funded SMS messaging projects in Kenya and Tanzania presented by volunteers, you should probably stick with HIMSS.

The 2,400 attendees hail from 48 countries. There are 125 exhibitors, a couple of hundred press people, and a ton of poster presentations. The big sessions are in the ballroom, which was nice because it has tables in the round (a place for your laptop, in other words) and free (slow) WiFi.

This site has a lot of information about various mHealth projects. Also mentioned was this site, which will have a cool summer internship program up soon. I jotted down the Web address of this Hopkins-led global health program and this interesting health information project from the Bloomberg School of Public Health at Hopkins.

I liked this quote: “Global is not the opposite of domestic.”

HHS CTO Todd Park was one of the early keynotes. He was pretty good, although he went a little bit too fast for me to be able to follow him. He mentioned that over 100,000 expectant mothers have signed up for the Text4Baby service. He says HHS will be launching similar SMS messaging services for obesity and childhood health. He also said that the HHS-led change in reimbursement will make mHealth a viable business (a feeling not shared by any of the speakers I heard, but I digress).

The next session was a panel, with a couple of speakers standing out. A doc from India said mHealth is important because there’s no way they’ll ever have enough doctors to deliver the care that’s needed. They also don’t have enough broadband penetration, but they do have 675 million cell phones. Allen Hightower from the CDC gave a lot of information, but it sounded to me like they’re doing nothing more than collecting survey information in the field with smart phones. He seemed to bristle a little when the moderator summarized his talk in that way, but that’s what it sounded like to me.

David Gustafson from University of Wisconsin got spontaneous applause a couple of times for saying that mHealth is not ready to scale up because nobody knows what patients and families need and want, the available information is often conflicting and of unverified reliability, and the smart phone form factor has significant limits for many people (small screen and keyboard.) He said research is taking too long and needs to reach the field faster. He expressed his believe that mHealth should be regulated as a medical device (that part didn’t get him any applause – everybody else thinks it’s the Wild West, but will settle down on its own without getting the regulators involved).

Nearly every session addressed the mHealth business model, or rather the lack of one. You get the feeling that maybe it’s not really going to fly given these common speaker opinions that I wrote down:

• Nobody has any idea whether mHealth really affects outcomes because it hasn’t been formally studied.
• There is no business model for mHealth. Companies and programs are almost entirely funded by grant money or by governments that are in the healthcare delivery business.
• Most mHealth applications are interesting and cute, but they don’t fit into the workflow of clinicians or the lifestyle of people. If your app requires going to some dedicated Web site to see or input information, nobody’s going to use it (they didn’t mention PHRs, but all the arguments seemed applicable).
• Doctors either don’t know about mHealth apps or don’t recommend them because they might affect their incomes.
• The only commercially successful mHealth application is Nike Plus, which has two million users who share exercise data via social networking and apparently buy a crapload of Nike stuff.
• One speaker said the conference will be obsolete within three years because broadband will be ubiquitous and SMS messaging apps will be ancient history.

We’ll hear from Bill Gates tomorrow, but one speaker quoted Bill’s take on mHealth, which you might expect to be gung ho since he’s both a technology guy and a world health leader. He’s not fooled into thinking that sending SMS pill reminder messages will change the world, however. “Bathroom scales have been around a long time, but we still have obesity.” In other words, technology doesn’t automatically change behaviors, and it’s behaviors that are often the problem (people don’t take their medicines, don’t stop risky behaviors, and ignore advice). 

I jotted down a couple of interesting items. One researcher said there’s precious little research data on chronic disease management since it takes place in the home. She’s thinking that data sent in via mHealth apps in those homes could be very useful in looking at disease management. Also mentioned was that some countries (not ours, of course) are building a cloud-based PACS image sharing backbone for smart phones to avoid the cost of having each provider buying their own. And a third, which wasn’t surprising: most of the mHealth innovation isn’t happening in the US, but rather in China, India, and Africa (if you’re uncomfortable when anyone suggests that the US is not the world’s admired and envied leader in everything, that’s another reason to not attend this conference – the folks here are a bit more globally objective).

Probably the best speakers were Denis Gilhooly from Digital He@lth Initiative and Joseph Smith of West Wireless Health Institute. They both had short presentations in a panel discussion, but I thought they were objective and authoritative.

I wish the conference used the technology that Inga talked about from MGMA where you texted your questions to the speakers instead of hogging the aisle microphone. The conference allowed long Q&A sessions and as happens every damn time, eager beavers darned near sprinted to the microphones, droning on and on from their written notes, clearly in love with the sound of their voices that were wasting the time of a huge roomful of eye-rolling attendees who wondered if indeed there was a question somewhere in their long monologue (and for a couple, there clearly was not). Starting with the third session, I just started walking out as soon as Q&A was announced, which was for the safety of the microphone droners because I wanted to body-slam them Terry Tate, Office Linebacker-style.

The exhibit hall was low key, mostly non-profits it seemed, with a few vendors. The oddest was a lady in a rather lurid booth selling herbal products, boasting of such medicinal miracles as “Virgin – Again,” herbal Viagra, and “Cleavage Enhancer.” Either she showed up at the wrong event or she has insight into the particular needs of people who attend mHealth events. I can’t quite see strolling up among peers and casually asking for those products, which may have been a shared opinion since people were steering a wide berth around her booth as though there had been a chemo spill. The evening reception was in the exhibit hall, so maybe she’ll get some takers after the drinks have flowed for awhile.

So my takeaway is this: mHealth is not and probably never will be profitable. Insurance companies may pay a little something here and there for some simple apps that might save them a few dollars, but the bottom line is that even if mHealth apps improve health outcomes (which seems debatable), the funding model just isn’t there to turn it into a business. For that reason, it makes sense that the conference attendees are mostly global health people, who I admire (and would admire more if they would do more work in this unhealthy country instead of focusing only on everybody else’s). mHealth, like global health, is a worthy cause that makes a poor business for most of the people in it, who largely self-selected that calling without worrying about cashing in anyway. Kudos to them.

Tomorrow is Ted Turner, Bill Gates, and another long day of sessions. I’m leaving Wednesday morning, so that will be my last report from here.

The ConJoin Group Acquires PHNS for $250 Million

The ConJoin Group, an IT and business services company, acquires HIT services firm PHNS for $250 million. Private equity firm Actis backed the investment.

The new entity will keep the PHNS name.

Monday Morning Update 11/8/10

From Wireless Observer: “Re: Sprint-sponsored article in one of the rags called The Future of Wireless in Healthcare. I find it interesting that it didn’t mention WiFi in hospitals and clinics, but of course the telecom-centric view is that ‘wireless’ only means 3G/4G/broadband. Most wireless data in healthcare is transmitted over WiFi networks. I have been hearing for years (mainly from the telecom side) that WiFi will collapse under its own weight due to capacity limitations, leaving 3G/4G in buildings to step in and save the day. That hasn’t happened and never will, at least if the likes of Cisco has any say. There is no doubt that more data requirements are driven by mobile devices and 3G/4G will be the primary means of transmitting it. But how can you ignore WiFi completely when talking about the future of wireless in healthcare?”

From The PACS Designer: “Re: Microsoft Office 365 Beta. Last month marked the official launch of the beta for Microsoft’s online Office 365 feature set for business enterprises. The Office 365 application is cloud based and focuses on giving users a complete package of business functions to improve office efficiencies for clients through the use of cloud resources.”  

From Chump Change: “Re: Microsoft. CEO Steve Ballmer sold $1.3 billion in stock last week and plans to sell another $700 million in the next few weeks.” I’ll bring that up with Bill Gates when I have lunch with him Tuesday (along with everyone else at the mHealth Summit).

The Missouri HITREC announces its 10 preferred EHR vendors, with Cerner missing the cut. Make that 12 with Cerner among them: the organization reconsiders (probably with encouragement) and adds Cerner and Pulse to the list strictly because they are local vendors. That’s what everybody was worried about with the HITRECs: they can pick whomever they want for whatever reason. Unless those two local companies just happened to be #11 and #12 on their original ranking sheet, that means providers don’t get to hear about higher-scoring systems. I don’t know that being local makes a vendor a better choice. I doubt Neal will drop by on his way to work to make sure everything’s working OK.

News 11/5/10

From Elihu Smails: “Re: Citrix. I believe it’s responsible for many of our industry’s technology issues. Without their stepping in and serving up virtual sessions for EMR systems collapsing under their own client-server weight in the late 90s and early 2000s, the industry would have been forced to move to the Web and to modular platforms. I have nothing against their making lots of money, but for the sake of our industry, I wish they hadn’t saved the butts of the EMR vendors.” I couldn’t agree more. Citrix has customer advantages (security, low end user device requirements, central app management, remote capabilities, low bandwidth) but it did indeed let lazy vendors keep selling apps that were already long in the tooth and technologically overripe. Those systems work, but for dozens or hundreds of millions of dollars, you might expect a little more vendor capital investment. I always say that implementing Citrix is like eating at Denny’s: something nobody intentionally plans to do or is particularly thrilled about.

From DemoChic: “Re: social media policy. Not sure if other vendors have them, but here is NextGen’s, posted as it encourages users to post on Twitter and Facebook from their user group meeting.” The policy seems reasonable, asking that participants identify themselves, refrain from posting proprietary or defamatory information, and not contact other social media users through other means. Companies that don’t have such a policy can get some … ahem … ideas there. The meeting starts Sunday in Orlando.

From HIStalk Evangelist: “Re: my RN friend’s review of your site. She said this, which I found adorable: ‘Thank you for the HIStalk website … it’s very informative in a non-sterile manner.” Both the comment and the evangelism are cool – thanks.

From HIT in the Fog: “Re: Epic project at UCSF. We have had two people leave our 75-person team and the project is on schedule, under budget, and within scope. I’m not sure where the rumor to the contrary comes from, but it’s inaccurate.” Thanks.

It’s amazing how many fun people Inga and I get to meet by various electronic modalities. If you want to connect with us (other than via plan old e-mail, but we like that a lot too), my LinkedIn profile is here (flattering pic, don’t you think?) and Inga’s is here (hot legs!) The HIStalk Fan Club that Dann started is up to 1,177 members, so thanks for that – how many people can tell their moms they have a fan club? As a Round-Number Milestone Fixated American, I also notice that the HIStalk e-mail blast list has hit an even 6,400 verified subscribers. We’re on Facebook, of course, so feel free to Friend us or to Like HIStalk if you want to turn our frowns upside down.

Listening: The Greenhornes, a Cincinnati-based garage band whose members made up much of The Raconteurs. I like the sound. Their new album comes out next week.

The local TV station covers the Epic implementation at New Hanover Regional Medical Center (NC). It says the project will cost $56 million and generate $13.7 million in HITECH money.

A Catholic newspaper talks up the $450 million Epic system in place at the 28-hospital Sisters of Mercy Health System (AR). The corporate web site features MyMercy (their name for it) prominently.

Children’s Boston chooses the MetaVision anesthesia management system from iMDsoft.

CIO salaries: Packard Children’s Hospital at Stanford (CA), $700K. Medstar Health (MD), $642K. Saint Barnabas Health Care (NJ), $538K.

Jobs on the Sponsor Job Page: HIE Team Lead, Director Strategic Marketing Initiatives, Allscripts Consultants. On Healthcare IT Jobs: Cerner FirstNet Analyst, Electronic Clinical Applications Manager, Meditech Advanced Clinicals Consultant.

I doubt anyone cares much about Misys PLC these days (let’s face it, they added no value to the HIT companies they bought and sold), but just in case you do, the IRS rules that its sale of most of its Allscripts shares carries no tax liability. Shareholders will get their billion dollars.

Of all the things Weird News Andy could have observed about this story involving the use of mannequins to train nurses, he zooms in on the fact that the dummy’s hair looks like that of Rod Blagojevich.

Thanks to brand new HIStalk Platinum Sponsor Carefx. You may think of them as offering single sign-on, provisioning, and an enterprise master patient index. They do, but as the informercial guys say, “But wait – there’s more!” The Scottsdale, AZ company offers several products that help close information and workflow gaps among users of existing systems: BI dashboards, an eReferral portal, and the SOA-powered Fusionfx collaboration and patient information aggregation platform (a scalable community portal providing real-time queries to existing systems). You may remember that the company got an exclusive license from Cleveland Clinic this past May to market its dashboards covering core measures, mortality, physician scorecards, throughput, and patient experience. Inga and I thank Carefx for supporting HIStalk.

Steven Nickerson, formerly of Philips and McKesson, joins The Beryl Companies as VP of sales. The company offers a variety of services related to patient engagement and follow-up.

Ottawa Hospital engages the startup of three recent college grads and former game developers to develop physician iPad apps for patient information and lab results.

ONC wants input on consumer use of HIT and electronic health information to manage their health. Comments can be left (and read, surprisingly) on the Health IT Buzz blog entry called Strategy for Empowering Consumers.

Strange: a New York woman, upset over her father’s death due to heart failure, tries to hire a hit man to kill the two doctors and two nurses she says were involved. She is arrested by an undercover FBI agent posing as a would-be murderer after taking her $400 down payment. Not surprisingly, she’s having a psych evaluation.

I’ll be heading off to the mHealth conference in Washington, DC this weekend, weighing whether I’d rather pay $10 a day to use the hotel’s fitness center (Treadmill Timeshare) or turn blue for free while taking a chilly 4-mile jog around the National Mall, but at least getting to see cool sights while my nose hairs freeze. If you’re going, maybe I’ll see you there. If not, I’ll be posting from the conference each day.

E-mail me.

HERtalk by Inga

From Za: “Re: ARRA. Will ARRA be pushed back or repealed because vendors and thus providers will likely be unable to meet the required timelines? My guess Is Horizon Clinicals is a victim of ARRA and I suspect there will be others. The bulk of vendors are struggling with rewrites. ARRA upgrades will need to be implemented and there aren’t enough resources to get everyone up in the timetable.”  I would be shocked if the dates were pushed. Repeal flat out won’t happen. Then again, healthcare always seems to find  millions to spare when it comes to lobbying, so you never know. Based on the ONC-ACTB certification announcements to date, most of the ambulatory vendors seem to have their products ready to go, and in theory, the RECs will shoulder some of the implementation load for primary care providers. I’d say at this point that community hospitals are the ones most at risk of missing ARRA deadlines.

Speaking of community hospitals, KLAS finds that community hospitals with fewer than 150 beds are giving more consideration to the larger vendors than traditional community clinical IS vendors. Meditech remains the most-considered vendor for community hospitals, but providers are also taking more interest in Cerner’s hosted offering and McKesson’s Paragon, and to a lesser extent Epic.  KLAS does not mention this (probably because the report had been in the works for awhile) but I don’t see any of the “traditional” community hospital solutions (CPSI, Healthland, HMS, Keane, and Siemens MedSeries4) on HHS’s list of  ONC-ATCB certified products.

AT&T announces a new practice area called AT&T ForHealth, established to accelerate delivery of wireless and advanced networking services in healthcare. As I understand it, the ForHealth area includes an mHealth group handling HIE connectivity, disease management, and telehealth initiatives; a healthcare mobility team; and, a healthcare marketing group.

The VA awards QuadraMed a five-year, $211 million contract to implement its Quantim Coding, Compliance, and Abstracting solution for ICD-10 coding and compliance. The VA will also add QuadraMed’s Physician Query Tracking and Central Reporting tools, as well as rely on QuadraMed for implementation, technical training, and support services. The VA has been using Quantim since 2005.

Former Allscripts, Misys, and Eclipsys VP Mike Etue joins Ingenix as SVP of provider sales.

Fort Worth, Texas-based HIE SandlotConnect says its exchange contains over 1.5 million patient records and connects more than 1,500 providers.

Boston-based Shareable Ink says it’s relocating to Nashville after securing $4.5 million in Series A funding from Tennessee investors. In case you missed it, T-System CEO Sunny Sunyal talks a bit about his company’s partnership with Shareable Ink in this interview posted yesterday.

Fairview Northland Medical Center and Fairview Lakes Medical Center (MN) go live on Epic.

A former UCSF Medical Center employee is sentenced to a year in prison for using the social security numbers of co-workers to complete online health surveys. Cam Giang received a $100 voucher to Amazon for each of the 382 online surveys he completed. Bet the shopping was good while it lasted.

The Alliance of Chicago picks Ignis Systems’ EMR-Link to provide EMR-to-lab connectivity for its 25-member community health centers.

When its merger with MaineHealth is finalized next month, Pen Bay Healthcare (ME) will receive $3 million and an Epic EMR system.

Medical imaging management provider DICOM Grid secures $7.5 million in Series A financing. The investment will accelerate DICOM’s market expansion and product development.

In case you are still not catching all the hot news featured on HIStalk Practice, here are some of this week’s highlights: (a) workflow analysis, HIT integration, and specialty specific solutions contribute to quality and safety improvements in the outpatient setting; (b) why findings from a recent CompTIA study sound pretty weak; (c) a one-on-one chat with President Obama, who shares his opinions on the significance of IT in healthcare. OK, I made that last one up, but you never know what compelling news you might be missing if you aren’t tuning in.

Sponsor Updates

• NextGen partners with InstaMed to offer providers InstaMed’s merchant processing services, including patient collections and automated posting into the NextGen PM system. NextGen also announces its NextGen Inpatient Clinicals version 2.4  has earned CCHIT 2011 Inpatient EHR premarket certification. Certification under the ONC-ACTB program is pending.
• MidSouth eHealth Alliance (TN) extends its CareAlign system contract with Informatics Corporation of America to include the Middle Tennesse eHealth Connect HIE.
• MEDecision presents its concept for advancing technologies that support patient-centered medical homes in a just published e-book, The Patient-Centered Medical Home: The Cornerstone of Healthcare Transformation. Download here.
• FormFast announces a November 11 webinar featuring Barry Runyon of Gartner entitled World class doctors, world class treatment, broken workflow processes.
• 21st Century Oncology (FL) chooses the Sage Intergy for its 90 radiation therapy centers in 16 states, noting its strengths in handling complex, multi-facility billing.
• The OB department of Good Shepherd Medical Center (OR) selects the Access Universal Document Portal to electronically transfer perinatal documents from GE Centricity into Meditech’s Scanning and Archiving system.
• Picis introduces LYNX I/Point, a new charge capture solution for hospital-owned infusion and oncology treatment centers.
• United Hospital System (WI) activates multiple clinical components of  Sunrise Enterprise solutions from Allscripts, including CPOE, pharmacy, and ED. At both Kenosha Medical Center and St. Catherine’s Medical Center, 100% of ED physicians were entering orders electronically on Day 1.  In its next phase, United will deploy the Allscripts ambulatory EHR for its employed physicians.
• Methodist Children’s Hospital (TX) says it saved $1.5 million in one year after implementing T SystemEV in the ED, which allowed it to speed up discharges and transfers, reduce paper chart management time, and improve infusion documentation for charging.

I noticed that I have almost 1,000 followers on Twitter, which I find a bit amusing and somewhat surreal. Mr. H has a few hundred more followers than me, though I have a few hundred more tweets. Quality tweets over quantity?

E-mail Inga.

HIStalk Interviews Sunny Sanyal, CEO, T-System

Sunny Sanyal is CEO of T-System of Dallas, TX.

Let me ask you the obvious question first. You were president of McKesson Provider Technologies until recently. How do you feel about what you accomplished there?

I was there for a little over six years. I had a great time and accomplished a lot.

I started back in 2004. This was about the time when Horizon Clinicals components were being introduced to the market. I feel like I had a great run. I had introduced a lot of new products, created a successful clinical footprint in the industry, and then it was time to move on.

I’ve always worked in big companies like McKesson. I worked at GE until it was time for me to go out on my own and do something different. I wanted to be in an industry where the company is a market leader, with a strong reputation, with good products, and where there’s market momentum.

That’s why I picked T-System. It’s a good, solid company, perfect products, and the ED is extraordinarily active right now. It made a lot of sense from a market perspective. It’s one of the last green field areas in healthcare IT. I feel really good about this transition and I’m enjoying it.

How different do you think it will be running a company instead of a corporate division?

It is very different in many ways. First and foremost, in a large company, you’re part of a divisional president’s role. There are a number of things that are already in place for you. The infrastructure is there. There’s a much larger portion of your time is spent in communications, communications up and down, horizontally, bringing people along.

In a smaller company, the time from thought to decision to action is extraordinarily short. I come up with an idea, I take a few minutes for us to get a bunch of people together and discuss what we’re going to do, and then immediately actions are taken. I find that extremely exhilarating. That aspect of a small company I’m really enjoying.

T-System is doing well as a company. It has very happy customers, so it makes for a very nice work environment where I can sit back and think and take time to make the right decisions.

Before Meaningful Use, ED wasn’t much of a conversation starter, but now everybody is talking about it. What are your thoughts on how the ED and ED information systems fit with Meaningful Use?

It’s been a rollercoaster ride. Initially, there was no mention of ED as a place of service applying to the Meaningful Use metrics. Then it looked like ED was in all the way. That meant hospitals could on make their Meaningful Use, especially for Stage 1, with just ED alone. At the same time, for those without an EDIS plan, there was no way for them to make their Meaningful Use metrics.

But now we’re stopped a halfway mark, where the patients that are transferred from the ED into inpatient are the ones that count towards the metrics.

Here’s the effect as I see it. Most hospitals were fairly behind in terms of their plans for an ED information system. They had been giving the inpatient automation a much higher priority. But when the second revision of the Meaningful Use criteria came out, it just caught everyone off guard, both from the vendor’s side and from the hospital’s side. Everyone all of a sudden had to scramble to change their plans to create an ED IT strategy pretty quickly.

Now that’s it’s been pulled back at the halfway mark, I think most hospitals that didn’t have a plan are taking a little bit of a breather, taking a sigh of relief. But at the same time, they realize that sooner or later with Stage 2, they’re going to have to deal with this, so they might as well start thinking about how the ED plays a role in their IT strategy.

I think for us, from a market perspective and T-System perspective, we’ve done exactly the right things. We wanted the market to go active, and at the same time we want the CIOs and IT organizations and the hospital executives to think about what they’re doing with the ED — think a little bit about what’s the right way for them to enable collaboration of care across the enterprise and collaboration of information sharing across the enterprise. For me, I believe that for T-System, we had a good positive impact.

Everybody who’s trying to make a case for interoperability always drags out the example of the unconscious patient in the ED, which then implies there’s probably some benefit to tying the ED in with the community-based systems out there for physician practices for allergy information or past medical history. How do you feel that plays out, and what are your strengths and weaknesses as a standalone ED systems vendor?

Meaningful Use was intended to facilitate collaboration of care across the community — all settings of care — and allow the community-based systems to connect with the inpatient and ED-based systems.

The way we see it is, when do you draw the line? If you’re a CIO at a hospital, what constitutes inside your circle for the enterprise system versus an outside? Whether the ED is part of the enterprise system or ED is part of the best of breed. It’s not about just the ED. It’s about the ED, it’s about oncology, it’s about other departments, it’s about the community physicians, and it’s about skilled nursing facilities and the LTACS.

At the end of the day, we know as a best-of-breed vendor that we absolutely have to go overboard and over-deliver on being open and providing interoperability capabilities. That’s the focus of our product road map — to be able to accept information coming from outside, not just problems and allergies and meds, but pretty much the entire medical record. Anything from the medical record that needs to be transferred in, we need to be able to accept that.

At the same time, we need to be able to provide that going back out in multiple formats — in whatever format other institutions want it and codified. So as a best of breed vendor, our focus is squarely on making that happen and making that the priority for us.

T-System had an investment earlier this year from Francisco Partners. It was interesting then that Ingenix bought Picis. What do you think that means overall for the industry in the place of companies like yours, and how does that change Picis as your competitor?

The investment from Francisco Partners essentially allows us to continue on as a best-of-breed vendor. They made an investment because they see a growth opportunity in the ED. They see a company that has a various, large customer base that has a potential to provide more add-on solutions into the base and migrate at the base EDIS solutions. It was a decision based on T-System as a company, based on the market — a number of criteria.

In terms of Picis as a competitor, the acquisition by Ingenix — I can’t comment on that in terms of what led to it or the pros and cons of that. As far as a competitor, they’re still the exact same competitor they were before. I don’t think the Ingenix factor or acquisition has changed much for us from that perspective.

When you look at companies quickly trying to get foothold before the window closes on what everybody thinks will be a bunch of purchases that are fueled by the HITECH act, how do you see companies financing going forward? Do you think there will be more private equity? Do you think companies will merge or will they go public?

I’ll use examples that I’ve seen in the industry over the years. For best-of breed-vendors, there are only two roads. Either you get a tremendous amount of market share and you’re successful as a best-of-breed vendor, or you’re small and your sub-scale and you need to merge with others in order to get scale, and ultimately you end up getting acquired. I’ve seen that happen several times.

We’ve seen that in the radiology space. There were a lot of PACS vendors. While a number of them went out of business, a majority of them ended up consolidating and merging with each other. The best-of-breed vendor ALI, if you remember, got acquired by McKesson and they’re getting a tremendous amount of market share and critical mass.

I feel that’s where we are in the ED space as well. On one hand, you have T-System with over 1,700 hospitals that have a pretty substantial footprint and substantial critical mass. Then there’s a whole bunch of others that are small players. Over time, I believe that small players will continue to merge and either get acquired by the strategics or merge with each other.

Since you came from a background of a larger company that was more interested in making acquisitions than being acquired, will that change the perspective on T-System as far as whether or not you intend to grow by acquisition? Do you see that changing the trajectory that T-System would have taken without you?

If an acquisition makes sense in that it would either allow us to expand our capabilities or accelerate our time to market by acquiring some key technologies, we’d absolutely do that. I’m open to doing that. But a vendor today, it’s still about investing and growing.

We have a very large customer footprint on the T-Sheets. That’s the product that we started with. Our opportunity to grow just by migrating our customer base to an EDIS over the years, and at the same time because given the green field market, there’s still a ton of EDs out there that don’t have an EDI system — I see a significant opportunity for us to continue to grow organically.

Our emphasis right now is in organic growth. We’re going to put together partnerships just like we did with Shareable Ink, our DigitalShare solution. We’ll continue doing that where it makes sense for us to accelerate time to market, but the core focus for us is to continue to invest in our core EDIS solutions and grow our presence in the ED space.

You mentioned Shareable Ink. The T-Sheet documentation system is legendary, and now you’ve got the DigitalShare system. Can you describe, for readers who may not be familiar with it, what the technology does and how it facilitates the ED’s transition from paper?

The T-Sheets have refined and fine-tuned the workflow in the ED. Physicians would use the T-Sheets to document their care. Physicians and nurses use it to chart and create a very complete chart — complete both clinically and operationally. It not only provides full documentation of care, but also makes it incredibly simple from a billing perspective. T-Sheets have been very instrumental in driving efficiency in the ED. 

Shareable Ink gives us the capabilities of a digital pen to be merged with the T-Sheets. When you’re using the digital pen to do exactly what you did previously with a T-Sheet, that process of using the digital pen on the T-Sheet actually captures information from the T-Sheet digitally and creates, immediately, a reviewable, editable, shareable version of that documentation of the T-Sheet that was done on the T-Sheet. It creates an electronic version. All the data elements are then available for either reporting or for transmission to someone else or some other system.

Essentially, we’ve taken the best of two worlds, which is the T-Sheets that were very well regarded. It’s almost an icon of emergency medicine. Physicians these days coming out of their ED residencies have used T-Sheets or know about T-Sheets. It’s a very well-oiled from a workflow perspective — very well put together. Combining that with something that gives you a digital output, we think, is what makes it unique.

It’s interesting as a paradigm. You came from a company that had a CPOE system that had some mixed success, but now you’re with a company that took the other approach of basically saying paper works, and if we can automate the paper, that’s good enough. How do you see those two paradigms playing off each other when people are trying to get doctors to interact with electronic medical records?

I see it quite a bit differently. If you think about physician charting, pen by itself is not bad. But the reason we went down the path of DigitalShare is what’s good about the T-Sheets is the user interface, the ergonomics, the layout, the clinical content, and the decision support that’s baked in there. That makes the physician very efficient. That provides the right information and/or decision support at the point where he needs it.

That simplicity, if you can use a tool like the pen — which has always been the best user interface tool — we have combined a very powerful user interface tool and input device with a very, very solid and very efficient workflow application. That’s what made it strong.

In the ED, you need both charting and ordering capabilities. DigitalShare provides just the charting portion of it. It provides the documentation capabilities. Future versions could very easily migrate into orders, but at this point, the focus is on physician charting in the ED with DigitalShare.

Other vendors probably would have said, “We’ve got this cool thing that works on paper, let’s stick it on an iPad.” You’re taking a slightly different approach. Can you see a point where the limitations of what you’re doing will lead you to what other vendors might have done first, which is going all electronic instead of converting the pen to electronic data?

Very few enterprise vendors have gotten into the physician documentation space as well as a company like T-System has. In the enterprise space, the natural inclination is to first, automate the orders because that’s how everything gets done in the hospital. The doctor places orders, orders get fulfilled, and a patient gets patient care delivered. Automating orders has historically been the highest priority and the first place for enterprise vendors to tackle.

In our case, what goes on in the ED is the T-Sheets and the electronic documentation in the ED is actually what drives the ED workflow. Orders are a by-product of the documentation as the physician is working with a patient and charting and documenting their findings. Orders are a by-product, or the second thing that happens.

From our perspective, we had to begin with where the most deficiencies are going to be. Deficiencies are in what the physician does 90% of the time or 95% of the time in the ED, which is treat the patient, talk to the patient, and document what they’re doing. We decided that we would take the approach of what makes the physician most efficient. Having the most efficient documentation system in the ED is what drives productivity in the ED. We took that and we tackled that problem first.

Where does T-System EV fit in?

The EV is a full-blown ED information system. It’s built on the same paradigm as a T-Sheet. If you’re a T-Sheet user and you’re used to documenting using T-Sheets, you pull up EV — which is Electronic Version of the documentation system — and what you get is the exact same paradigm, same concepts, with traditional capabilities — because in a digital environment, you can do a lot more with the content. At the same time, the simplicity is maintained in the electronic system.  

Think of T-System EV as a full-blown ED information system. It has a tracking board, nursing documentation, physician documentation, ordering capabilities, and CPOE. It has preserved the integrity and the workflow efficiencies of T-Sheets and uses the same paradigms of markings and circles and backslashes.

It also produces a prose version of the report, which in the case of paper T-Sheets, you mark on the sheet and the marking becomes the documentation. In the case of the electronic version, we can use technology not only to preserve the markings, but also transfer the markings into a prose form of the report, which can then be given downstream to other physicians, nurses, and referring physicians.

How do you qualify the extremely large number of T-Sheet users as to whether they would move to DigitalShare or T-System EV?

The customers that have an IT plan that includes the ED in there and they’re planning to go to a full-blown ED information system — they would go directly to an EDIS system. We would migrate them from the T-Sheets to EV.

The ones that either don’t have a plan, or have a plan but it’s still a couple of years out and they want to do something in the interim — they want to capture information and report and get feedback on it or exchange data out of the ED electronically — those are the ones that we would target for DigitalShare.

It’s a step, but at the same time, we also see a scenario where customers could potentially continue to use DigitalShare long-term. They don’t have to go through TEV. They may choose to do their physician documentation with DigitalShare. For nursing and order entry, they may use some other functionality or some other capability.

I’m sure you looked at the company’s strategies and what you would bring to the table before you took the job. What are those strategies?

The company has very deep roots in the clinical domain. T-System became very successful because they really understood the physician and nursing requirements of the ED and how care was delivered.

The strength that I bring to the table is my 23rd year in healthcare IT, healthcare technology. I bring IT background. I bring experience with how to take solutions like TEV and scale them up, grow the business, and at the same time, add the focus for making it more CIO-friendly and enhancing interoperability with other electronic systems.

I saw this as an opportunity to take something that’s clinically very, very rich and very strong and invest in the right technologies and make appropriate adjustments to the product road map to make this a very, very strong, clinically rich IT product.

When you look around the industry, what do you think are the good things and the bad things about it?

On one hand, Meaningful Use has stirred up a pretty significant level of activity in this industry. In the 23 years that I’ve been in this space, I’ve not seen this level of commitment to doing digitization in care delivery. That’s the good news. There’s a lot of activity, its forefront, it’s on everyone’s minds. It has also taken up the mind share of the C-suite, so CEOs and CFOs are involved. It’s something they know they need to do and they’re moving forward with it.

What I’m really concerned about is the quest for stimulus funds might be driving hospitals to make certain decisions that might be more short-term decisions versus longer term. For example, when the initial Meaningful Use criteria came out it did not include the ED, there was very little discussion about putting systems in the ED. Then later, when the Meaningful Use criteria changed to include EDs, I almost saw a stampede of hospitals trying to figure out what their ED strategy needed to be.

They weren’t taking the time to think it through. Instead, they were just blanket going about saying, “Okay, we’ve got an enterprise system, we’ll just stick it in the ED. I don’t care if the docs like it or not.” I see that as a real big problem.

What hospitals really need to do is what’s good for them for the long term in terms of patient care, safety, and efficiency. Those are the right decisions that they need to make. I’m seeing a lot of rush through these decisions and with a short-term perspective in mind.

I think that’s where the industry needs to take a step back and take a little bit of time out and let’s do it the right way. Yes, it’s about Meaningful Use, but Meaningful Use is not about just putting a system in the inpatient setting. It’s about setting up the system so that they will be open, they will be able to interact with the community, and they will be able to exchange information across all the settings of care in the community.

If someone were to ask you to name some predictions that you have that might be surprising to what traditional thinking would have, what would you say?

That’s a tough question. It’s hard to predict what’s going to happen in healthcare and healthcare technology.

Let’s fast forward five-plus years out. In five-plus years out we’re going to see a new breed. Post-Meaningful Use, post-Stage 1, 2, and 3. I think we’re going to see a pullback from people that have done the first generation of digitization and now really want optimal solutions. They may have gone down a path of putting in systems with a vendor that they felt like they had to live with because they didn’t have any other choice and the timeframes weren’t right and they couldn’t rip it out and replace it.

I think five years from now, we’re going to see a full swing of replacement systems being put in in the hospitals. When I walk around the hospitals and I see systems in place that are not doing the job, but yet the hospital has already made a decision and the system’s in place and it’s too late for them to pull it out because then they won’t be able to make the Meaningful Use criteria, it leads me to believe that the replacement cycle for these systems is going to be sooner than later.

I feel five years from now, we’re going to see a host of SaaS-type of applications with newer solutions that are more best of breed-like and that are open and interoperable. The technologies are moving very rapidly in that direction to facilitate that level of interoperability.

Any concluding thoughts?

I think these are absolutely exciting times. These are extraordinary times for healthcare and healthcare technologies. One of the things that we always look at being in the ED space is what’s going to happen to the additional 40 or 50 million patients that are going to get potentially covered under healthcare reform. Where do they go?

There was traditionally the acute care space and an ambulatory space. We’re seeing, potentially, a third place of service, with the ED and urgent cares forming that in-between space and that third space becoming very, very active. It’s very high volumes of patient care being provided by EDs and urgent care clinics.

That’s an exciting thing for us. We’re watching this very closely. We’re watching the trends. That’s an area that, as T-System, is exciting for us because that’s where our strength is. We’re going to watch that play out very carefully.

News 11/3/10

From Biometric Man: “Re: palm vein scan technology. It’s 100 times more accurate as a fingerprint and nearly impossible to hack. The scanner converts the subcutaneous vein pattern into thousands of zeroes and ones, all encrypted and behind the firewall. It’s then encrypted again to AES 128 bit. It’s useless for crime investigation since you can’t leave your vein pattern at a crime scene. Scanning helps prevent medical records overlays and merging, identify theft, lack of ID for unconscious patients, slow registration processes, and having someone overhear the patient’s Social Security Number or other private information when the clerk asks. UW Health has put up a patient guide to the technology, complete with video.”

From NoMoreCoffee: “Re: nancydoll’s rumor of GE Healthcare’s enterprise solution leader. Yes, absolutely true. A few other changes at that level, but no layoffs yet of technical people.”

From Duuude: “Re: Seattle Children’s. This is a good synopsis of what’s going on after the two medication error deaths.” I’ve been through the common post-error reactions of awareness meetings, mandatory training, and process redesign (usually of the quick-and-dirty variety) at my own hospitals. Unfortunately, (a) it happens only after someone dies from a mistake, and (b) going gung-ho after one kind of problem usually means it’s just a different one that harms the next patient. Technology is not usually to blame other than it fails to address the main issue: the lack of information at the place and time it’s needed. I can never figure out why hospitals don’t put up a portal for nurses, aides, and technicians that contains how-to videos, audio instructions, and links to resources. Lots of money is spent on technology to enter and deliver orders, but not much on actually executing those orders correctly. The processes that cause patient harm are usually on the sharp end of the stick: preparing drug doses, marking a surgical site, setting the correct radiation dose, or reacting to the patient monitors. I say this all the time but it’s good for the newbies to understand: HIT’s benefit isn’t how many errors it prevents, but rather how much harm it prevents. There’s a big difference. It’s not much consolation to prevent 90% of errors by number only to find that the incidence of patient harm hasn’t changed much because they stayed in the 10% (see: CPOE). If you implement a lot of technology without changing your outcomes, then you haven’t accomplished much (see: Most Wired).

From Remington: “Re: UCSF. Looks like the GE collapse wasn’t entirely their fault. The Epic team there is already hemorrhaging members due to a combination of inept UCSF employees and absurd out-of-scope demands.” Unverified. Epic usually controls those issues well. 

I got the new iPod Touch, courtesy of Mrs. HIStalk, who knows that the way to this particular man’s heart is through his USB cable. Other than its crappy low-res camera, it’s amazing in every way: impossibly slim and light, FaceTime video calling, HD video recording, the super-fine Retina display, multitasking under the iPhone OS, great WiFi performance, long battery life, tons of apps (SMS messaging, Kindle reader, price comparison by barcode scan, etc.) I was telling Inga all the cool stuff I was doing with it when I realized there was one obvious omission considering that most people think of the iPod as a music player: I had yet to load or play even one MP3 (which is still the case since I’m streaming Pandora from it instead). Not many things can change your life for $219 and no recurring expense, but this is one of them. I’m taking it everywhere, maybe even to bed.

Anvita Health announces its patented application that creates personalized drug regimens using EMR data, comparative effectiveness, and the drug formulary.

If you haven’t made your HIMSS hotel reservations, better get on it. The HIMSS reservation system has good rates, which has been the case for the last 3-4 years (they were definitely not competitive before then). They guarantee the lowest price, which means nothing — you do your own legwork to find out you paid too much, take time to tell them about it, then they get to match the price they didn’t originally offer. I wanted a cheap place not far away and found a hotel I liked, but it was sold out on the HIMSS site. Not on the hotel’s own site, though – in fact, I got a AAA discount that made the price less than what HIMSS was quoting. If you want to be cheap like me (I’m at around $80 per night), you could also Priceline a room and maybe save money. I’ve done that – you can often take a taxi to/from each day and still save money, especially in Orlando where hotels are dirt cheap (and sometimes just plain dirty, so choose at least three stars on Priceline).

Speaking of HIMSS, it will be time to gear up here soon: the HISsies nominations and voting, preparations for our first-ever HIStalk sponsor lunch, and of course details on the big HIStalk bash on Monday night. I think we’ll have some new sponsors coming on board in time to ride that wave if history is a good indication, so thanks to the current sponsors who predated them in supporting Inga and me.

Listening: Horace Pinker, highly melodic, energetic, and smart pop-punk from Chicago. It’s a head-bobber for sure. I heard it on the iPod on HIStalk Radio, the Pandora station that adjusts the playlist as I give tunes thumbs up/down as they play. Others I liked: Metric, Arctic Monkeys, Death Cab for Cutie, and The Strokes.

Fujitsu releases the HOPE/EGMAIN-RX EMR for practices in Japan. It will cost around $25,000.

Michael Donner, former SVP/chief marketing officer of Eclipsys, is named VP of marketing at Tech Data.

Tech firms in India are calling the HIT spending “another Y2K opportunity,” but the Wall Street Journal observes that hospitals aren’t big on sending work offshore, most of the work isn’t the commodity programming work that usually gets sent overseas, and hospitals worry about privacy. It also notes that Indian companies are establishing offices here and offering to do work from either country, with lower prices for choosing offshore. 

Industry longtimer Kerry de Vallette is named sales SVP of revenue cycle vendor SPi Healthcare.

Board members at Regional Medical Center (SC) argue over the $2 million needed to finish its Cerner implementation, with one trustee expressing surprise that the project doesn’t already meet Meaningful Use requirements that would allow the hospital to get $5 million in HITECH money. The CIO explained that the project was started in 2008 before the requirements were defined.

CapSite releases its revenue cycle management study. From the copy they sent me, it appears that hospitals are keeping their core patient accounting systems, but planning to add RCM components from other vendors and are budgeting money accordingly. Most interesting: of the top four strategic priorities for hospitals, two of them involve RCM.

The San Francisco Department of Health chooses eClinicalWorks for its 800 physicians.

Regional Medical Center at Memphis (TN) approves a $20 million capital budget for FY2011, with $6.3 million of that going toward its $21 million EMR project. That’s twice the amount the 418-bed hospital is budgeting for building maintenance. It’s the home of the Elvis Presley Memorial Trauma Center, which sounds strange to me.

Cerner will offer remote hosting in the UK in an agreement with Equinix.

Thomson Reuters launches Pharmacy Xpert, a clinical dashboard that uses real-time clinical surveillance information, patient information, and Micromedex content to help hospital pharmacists manage medication therapy. Pre-built profiles include monitoring of antimicrobials, anticoagulants, and hypoglycemic drugs, as well as IV-to-PO conversion and managing drugs with a narrow therapeutic index.

Cleveland Clinic’s eighth Medical Innovation Summit (to be more precise, it’s run by their Corporate Venturing Arm) started Monday afternoon and runs through Wednesday. Wednesday’s session on HIT includes David Brailer (Health Evolution Partners), Craig Feied (Microsoft), Martin Harris (Cleveland Clinic), Martin-J Sepulveda (IBM), and Vishal Wanchoo (GE Healthcare). If you like reading tweets more than I do, they’re here. 

Several doctors in Australia are disciplined for ordering excessive lab tests, with one ordering 6,000 pathology tests for 771 patients. The director of the Professional Services Review watchdog that found the problem blames computers that make it too easy to order banks of tests without thinking.

The Hartford business paper profiles ProHealth, Connecticut’s largest physician group, and its $14 million technology investment. They see HIT as a key to success under healthcare reform, allowing providers to improve coordination, reduce duplicate work, and use outcome information to develop new programs.

The just-ended TEDMED conference in San Diego had some big-name speakers, among them Sanjay Gupta, David Blaine, Ozzy Osbourne, Tony Robbins, and Deepak Choprah. Among the attendees were Steve Wozniak, Martha Stewart, and Quincy Jones.

E-mail me.

HERtalk by Inga

From Snoopy: “Re: my naivete. I have a confession. As a daily reader, I find it intriguing that your commentary, cadence, and wit are so closely tied to Mr. HIStalk’s. I’ve read Mr. HIStalk say that you are a real person with a custom cartoon-ized representation on these pages. Now for the naivete. How is it that you can circulate around conferences, interview executives, and still remain on the DL? Regardless, it’s a valuable contribution you and Mr. HIStalk (if you’re truly not the same peeps) make to the industry and having the ‘Practice’ part of HIStalk was a great and welcome addition that provides value to all who visit.”  I can assure you that I am real and not a pathetic attempt by Mr. H to be in touch with his feminine side. I take it as a supreme compliment that my wit is comparable to Mr. H’s and appreciate the kind words about HIStalk Practice. Perhaps Mr. H and I have a similar cadence, but he wins the commentary award hands down. As for staying on the DL at conferences, I leave the fun shoes at home.

Eastern Maine Medical Center installs Dialog Medical’s iMedConsent application, which will interface to Millennium.

The Methodist Hospital (TX) and Dell Services launch a program to deploy NextGen EHR and PM at five hospitals in the Methodist system. Dell will provide hosting, training, and software support for the 289 physicians and staff that are part of the Methodist Hospital Physician Organization. Earlier this year, Methodist announced it would subsidized the purchase of NextGen for its affiliated physicians. 

The Nuance Healthcare folks sent over this video that highlights the use of Dragon Medical. Apparently they shared it at a recent sales meeting and the crowd was howling.

Mediware Information Systems reports Q1 results: revenues of $12.5 million and net income of $1.1 million. That’s a 17% increase in revenues and 70% jump in income from last year.

TomoTherapy’s Hi-Art is the top-rated radiosurgery/radiation therapy product in KLAS’s new report on the radiation delivery market. Varian Clinac iX was the highest ranked oncology solution.

Holy Cross Hospital (NM) selects athenaClinicals and athenaCollector for its owned physician group of 40 providers. Holy Cross will also offer athenahealth’s services to affiliated community physicians.

Huron Consulting Group acquires Click Commerce, a provider of software solutions and professional services for academic medical centers and research institutions. Click Commerce president Nick Stier, COO Gary Raetz, and sales and marketing VP Gary Whitney will serve as a Huron managing directors. Terms were not disclosed.

Sponsor Updates

• Culbert Healthcare Solutions is now an Epic-certified consulting firm.
• SRS is listed again on the Inc 5000 List of Fastest Growing Private Companies.
• ACT Medical Group (NC) chooses NextGen’s PM/EHR for its 70 clinicians and 400 locations, including a telehealth service in which clinicians will work offline and sync data later.
• The Medical Society of Delaware signs with RelayHealth as a solution partner. The society will support technologies that connect patients to doctors, including sharing lab results via secure messaging and personal health records.
• NorthBay Healthcare (CA) picks Keane Patcom for its enterprise-wide revenue cycle management solution.

E-mail Inga.

From the eClinicalWorks User Meeting in Orlando
By eCW Superuser

I arrived here on Saturday morning and got registered and checked-in easily. The pre-conference was, to my surprise, packed.

The Saturday evening reception in the exhibit hall was well attended. I was impressed by the size of the hall and the number of vendors exhibiting at the conference.

The keynote hall was massive and full, with 3,000+ attended the keynote (500 walk-ins included). It began with John Halamka discussing Meaningful Use and telling the crowd how to meet MU objectives. He was very complimentary of eCW referred to them as a moral company because, in his own experience, they cared more about their clients.

Girish presented  the company overview and 2010 accomplishments. Sam Bhat ( co-founder) and Girish did an hour-long live product showcase of V9 with EBO 5 (real software, noy PowerPoint). Version 9.0 is not just an incremental step, but a whole new ball game. It incorporates modules for patient communication, interoperability, and mobile and text messaging into the EHR with On-Demand Activation (similar to apps for the iPhone or iPad). There’s a fancy patient portal called 100Millionpatients.com. With eCW P2P, you can send your referrals and charts from eCW to other providers even if they don’t use eCW (similar to NHIN Direct).

The fall festival happy was simply awesome. It was very family-friendly, yet the live band kept everyone hopping . I saw kids at 11 p.m.dancing. The Halloween costumes with face paintings and make-your-own crazy hat booth were fun.

Here are some other highlights:

• Customer Panels (primary care, Speciality care, eRX, Portal, interoperability for community records) were very informative.
• eCW employees are enthusiastic about their success and were very helpful at the conference.
• Sessions were well attended.
• eCW has a very excited customer base.
• Community record technology called eHX is being widely used by hospital clients

Readers Write 11/1/10

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!

A Step Towards the Cloud
By Mark Moffitt

People tend to use the terms SaaS and cloud interchangeably, when in fact, they are two different things.

Software as a Service (SaaS) delivers software as a service over the Internet, eliminating the need to install and run the application on the customer’s own computers and simplifying maintenance and support.

Cloud computing is about using economies of scale and sharing cheap, commoditized computing resources to lower overall costs. To realize these economies of scale large data centers are built and managed to protect and secure customer data at the lowest possible cost. These data centers are huge (see photo below).

Cloud software takes full advantage of the cloud paradigm by being service-oriented with a focus on statelessness, low coupling, modularity, and semantic interoperability. Cloud storage uses shared-nothing, distributed data stores so that low-cost, commodity storage technology can be utilized. Traditional RDBMS don’t fit into these new storage models. The reason is RDBMS need to join data from multiple tables. This requirement is incompatible with the distributed storage configuration found in cloud storage services.

Google’s Dalles, OR data center on the Columbia River

On the banks of the windswept Columbia River, Google is working on a secret weapon in its quest to dominate the next generation of Internet computing. But it is hard to keep a secret when it is a computing center as big as two football fields, with twin cooling plants protruding four stories into the sky. New York Times, June 8, 2006

Few HCIT vendors have architected their system for the cloud. The good news is that healthcare systems don’t have to wait for HCIT vendors. They can take advantage of cloud computing today by storing and archiving clinical results such as lab results, transcribed reports, images, and waveforms in the cloud.

Clinical results are well suited to take advantage of cloud storage for reasons such as:

• Results do not require a schema or other features of a RDBMS to store and access data. Yes, that includes lab results.
• Key-value (object) stores are better suited for storing results than RDBMS.
• Key-value data stores can use cloud storage technologies that are less expensive than the cost of using a vendor’s RDBMS to store and archive data.
• Clinical results often need to be shared beyond the walls of an organization and, therefore, ideally suited to being stored in the cloud.

Amazon’s S3 cloud storage prices run about $18,000 per year for 10 terabytes of data. These prices include storage, archiving, and security. 500 terabytes is priced around $800,000 per year. There are additional fees related to access, but this number gives the reader a ballpark estimate of the price for the service. Other vendors such as Google and Rackspace offer a similar service at about the same price.

Other potential costs include deploying a system to provide local caching of often-used data in the cloud. This is accomplished by deploying a hybrid cloud to include local storage as depicted in the diagram below.

Savings are real and immediate when an organization pursues the cloud storage strategy for clinical results when replacing hardware such as moving from MEDITECH Magic to 6.0 or MEDITECH Magic to Cerner; or upgrading an image archive system. Cloud storage can eliminate the need for hardware and software that would otherwise be needed to store and archive existing and future clinical results.

It seems to me that cloud storage is a better model for an HIE than reposing clinical results into yet another fixed-schema RDBMS. The reasons are:

1. Providers are obligated to maintain a copy of results for legal and reimbursement obligations.
2. Providers save money by storing and archiving clinical results in the cloud.
3. HIE organizations can use clinical results stored in the cloud and focus their efforts on providing services unique to an HIE such as electronic opt-in/opt-out functionality, security, and record locator services for clinical results as a way to offer personalized EHRs to patients.

The transition to cloud computing in HCIT will take years as the business case for the approach becomes financially and operationally attractive as compared to alternatives and customers understand and accept the new paradigm of cloud computing and cloud storage. The transition to cloud computing will not be a waterfall event, but rather a gradual diffusion of the technology into HCIT. Storing, archiving, sharing, and securing clinical results in the cloud may be the first step in moving HCIT to the cloud.

Mark Moffitt, MBA, BSEE, is a former CIO and is working as a consultant while looking for his next opportunity.

Why IT Can Never Be Irrelevant
By Shubho Chatterjee

Over the last few years, journals, trade magazine articles, editorials, and even a textbook (Does IT Matter by Nicholas Carr) have prognosticated the irrelevance and strategic demise of IT. Many thought-provoking articles and blogs have debated the pros and cons of this prognostication.

I am going to add one more and argue that IT can never be irrelevant in organization, strategically or operationally. Here is my argument.

Firstly, IT is a discipline, much like engineering, finance, marketing, and others. Within engineering and finance exist multiple disciplines. As long as the world exists, both disciplines will exist. IT is similarly an assembly of different disciplines providing a very important outcome. Do we come across arguments that engineering or finance is irrelevant? No. Similar rationality will negate the IT “demise” thought leadership.

Secondly, following from the first argument, can we imagine today any organization operating without technology and IT? Take out IT — ERP, EMR, CRM, data networks, Web sites, ad infinitum — from any organization and the entire organization will collapse. Who plans for this, who should strategically plan for this, and who operates these systems? IT. IT is probably the most critical component of a functioning organization.

Thirdly, let’s examine IT functions and how it provides context to this debate. At the lowest level, Tier 1, is the basic infrastructure support, such as, help desk, network management, telecommunications support, and others. These activities are very commoditized and often outsourced, on-shore or off-shore. Outsourcing has also provided a rationality support for the “IT irrelevance” thought camp. But let us examine what happens and who does it.

Even when such functions are outsourced, somebody in IT has to do it, even though it is done by another organization. Often the outsourced employees are absorbed in the outsourcing organization. Therefore, in this case, we cannot say that IT is irrelevant — the function and activity has shifted organizationally and is also managed by IT of the vendor. The outsourced vendor relationship is also managed by the customer IT organization. Similar arguments hold for application development and support activities. For off-shored activities, the job losses are a fact, but it does not make IT irrelevant.

At the middle level (Tier 2) of IT operations, let’s say, at the business analyst, project management, vendor management, or network operations management levels, the IT aspects are critical. For example, the business analysts are key to developing IT product or service development and delivery requirements and pipelines, the IT vendor managers are key to selecting, evaluating, and managing vendor relationships. Can any other disciplines perform these functions? No. Why? Because these activities require domain knowledge and experience. For example, who other than IT can plan how a wireless network will integrate with a wired network to provide a point-of-service usage of EMR for medication management at a patient’s bedside?

Finally, no other function can be responsible for, perform, and meet the strategic technology requirements. Here, IT leadership is key in determining and ensuring the alignment of organization business strategies with technology strategies.

Consider the following example of Miami Jewish Health Systems operating the EMR, HR, Enterprise Content Management, and other applications operating in a cloud (SaaS) environment. The strategic planning and business case for moving to a cloud environment was completed by IT leadership, in collaboration with executive management, as were the tactical and operational aspects.

IT is uniquely positioned to provide results-oriented technology and process leadership to an organization. The future also holds enormous significance for IT, not only in healthcare, but in all industries. Let’s think about the healthcare landscape and the technology leadership requirements. For example, how will Accountable Care Organizations (ACO) function, who will plan and implement the strategic ACO technology requirements, how will cloud computing change service delivery and how will data security be impacted at all levels? These are some of the many very strategic questions that require deep IT involvement.

I believe IT can never be irrelevant. The discussion, while sensational, is moot.

These opinions are mine and do not reflect current or previous employer views.

Shubho Chatterjee, PhD, PE was formerly chief information officer of Miami Jewish Health Systems of Miami, FL.

What Tom Munnecke Is Thinking About Today

I exchanged e-mails with Tom Munnecke after mentioning his VistA-related Congressional testimony. I was fascinated with his 1998 HealthSpace concept paper and asked him if he had updated it or what he was thinking about twelve years later. Here is his reply.

My thinking now largely deals with the deeper implications of time. Here’s a talk I gave at the International Society for the Study of Time and some more in this interview from 2005 for the Pew Internet Visionaries. 

I’ve been also very interested in the physics of anticipation. As this relates to health IT: a deeper understanding of what is sometimes called the placebo effect, but in a broader sense is the self-referential feedback loop between our anticipation of the system and its net effect on us. Also, the need to support the notion of flow or state in our communication systems. 

The Web was built on a stateless protocol, but health information is very stateful, linking things over time. So, I think a "diachronic" model (flow of things over time) is a critical addition to our current "synchronic" (everybody synchronize their transactions, protocols, interfaces, and standards to current).

VistA was designed to be an evolutionary approach from the git-go. We created a "good enough" seed system, and planted it to see it grow. As I’ve learned in my studies of complex adaptive system (Stu Kauffman in particular), the most critical factor shaping evolution is the fitness function, the metric by which "survival of the fittest" is determined. 

In VistA, this fitness function was user acceptance. If people didn’t like or use a module, then it wasn’t fit and fell off the evolutionary path. The finer the granularity of these experiments and the quicker you can get a lot of feedback, the faster you can accomplish the error-making and error-correcting evolutionary process. When you try to do a $100 million centrally-planned change, you lose this graceful process and end up in front of a Senate panel asking what happened when it inevitably crashes.

I think we need to come to grips with the notion of personalization (see my 1999 "personalizing health" paper) beyond just today’s FaceBook craze. While the HHS/ONC focus is weighted to the enterprise-centric (aka the Disease Industrial Complex), turning patients into "consumers," I think we need to turn the healthcare system upside down, putting the patient at the top and the providers as supporting elements. I talked about this a bit in the Opening Chapter (co-authored with Rob Kolodner) in Person-Centered Health Records: Toward HealthePeople. 

What we are seeing now is a heroic battle between rigid, hierarchical top-down control (Blumenthal telling vendors, for example, that it is "imperative" that vendors support less insured populations) and grassroots, peer-to-peer, Net-based activities (FaceBook, Patients Like Me, Cure Together). Looking at the evolutionary fitness functions, I think that the grassroots will eventually win out, but only if the proper constraints can be applied (Tim Berners-Lee constrained the evolution of the web to TCP/IP, for example, a "good fence" that made "good neighbors").

So, I think we need to rethink health IT as a "space" rather than a "system." Perhaps people think that we can keep adding thousands of pages of legislation per year to the 125,000 we already have to end up with a "more perfect" health care system, but sooner or later we are going to have to declare a complexity crisis and admit that our intellectual paraphernalia with dealing with health care is inadequate.

It’s a bit like if Tim Berners-Lee tried to create the Web by going to the UN and asking for the UN High Commission on Innovation to create a Web subcommittee, who would then create global subcommittees and standards for specific applications. The sub-subcommittee of the high commission would meet with all the auction houses to collect all the stakeholders (Christies, Sothebys, etc) to create an integrated approach respectful of all parties and complying with all international regulations, UN regulations, etc. The very thought that Pierre Omidyar would write a simple program to auction off a broken laser pointer and turn it into eBay would be totally beyond belief 🙂

Yes, I’ve been doing a lot of thinking about the future of health and health care IT and dropping notes into my blog. Try the tags for VistA and AHLTA. You can read some of my early thinking at the bottom of this page. And here is some of my early thinking on the personal health record.

Tom Munnecke is a leading expert on healthcare IT, having been involved in the creation of both the VA’s VistA and the DoD’s CHCS and served as VP and chief scientist of SAIC. He is a consultant, entrepreneur, and board member of several health IT startups. He holds frequent workshops, salons, and networking events in a cabana at his home in Encinitas, CA.

Dreaming IT to Reality
By Ron Olsen

For years as a hospital IS manager, I had the tag-line of ‘Dream It To Reality’ in my e-mail signature. I meant that. You dream it and I, the humble IT guy, will do my best to bring it to reality.

Einstein once said, “Innovation is not the product of logical thought, although the result is tied to logical structure.” Thinking about that quote, I realized that to truly innovate, you must not necessarily think illogically, but you must think outside the sandbox you play in every day.

To meet the ever-changing needs of your organization, you have to empower your IS/IT team to approach problems from different angles — every day — and to not be afraid of failing once in a while. The logical structure is all around us, so when looking at processes, give everyone the freedom to question what you’re doing, at all levels.

With the many masters a hospital IT staff serves, what was once good enough for yesterday will never be good enough for tomorrow.

Ron Olsen is a product specialist at Access.

McKesson To Buy US Oncology for $2.16 Billion

McKesson announced this morning that it will buy US Oncology in a deal valued at $2.16 billion, including debt, from its private equity owners. The transaction is expected to close by December 31.

McKesson says the acquisition will have a modestly positive impact on its earnings starting in FY2012.

US Oncology, based in The Woodlands, TX, has annual revenue of around $3.5 billion and has relationships with 1,300 community-based oncologists. Its technology offerings include the iKnowMed oncology EHR, a physician collaboration portal, and clinical trials matching.

McKesson chairman and CEO John Hammergren said this about the acquisition:

McKesson is committed to improving the health and vitality of our customers, with the ultimate goal of improving the health of patients. The combination of US Oncology and McKesson will enhance our ability to achieve these goals in one of the most important segments in healthcare. Community oncology practices need strategic support that offers not only technology and distribution solutions, but also value-added clinical and reimbursement management services that enable them to provide the highest-quality, most efficient care to their patients. With this acquisition, McKesson will offer a compelling suite of services and solutions to community oncologists and other partners in the rapidly evolving specialty business.

US Oncology CEO Bruce Broussard, who will stay on to run the new McKesson unit, was quoted as saying,

With the health-care marketplace moving rapidly toward reimbursement based on quality and cost-effectiveness, our physician customers need access to deep clinical, operational and information technology capabilities to create integrated networks that continually enhance the quality of care in a cost-efficient manner. In joining McKesson, we are building the scale and expertise necessary to empower our customer base to shape the future of health care.

Monday Morning Update 11/1/10

From California Dreaming: “Re: privacy statement on Amazing Charts Web site. Funny stuff!” It is funny. “ … USE COMMON SENSE WHEN USING THIS SITE AND THE AMAZING CHARTS SOFTWARE, AS WE ARE NOT RESPONSIBLE FOR YOUR LIFE AND DECISIONS … USE COMMON SENSE WHEN GETTING INFORMATION FROM THE INTERNET, SOFTWARE, LIBRARY, ENCYCLOPEDIA, DOCTORS, OR ANYBODY ELSE. WEAR SUNSCREEN, USE SEATBELTS & CONDOMS WHEN APPROPRIATE, AND PROTECT YOUR EYES WHEN USING POWER TOOLS.”

From Ex-Concerro!: “Re: layoffs. Concerro laid off all but one of its QA department and demoted the VP of engineering. They have been unable to stabilize the product since 5.0, which was an attempt to turn a shift-bidding product into a scheduling product.” Unverified.

From Personal Problem: “Re: palm biometrics for patient ID. I would refuse to use it since those can be intercepted or hacked. Then what — get a new palm?”

From Nancydoll: “Re: GE Healthcare IT Enterprise Solutions. Laurent Rotival ousted – there on Monday, gone on Tuesday.” Unverified. GE doesn’t comment on personnel issues. His LinkedIn profile is unchanged.

From Aldonza: “Re: PKI security. Have solo practitioners or small groups tried it? Some technologists say its simple to implement, others are skeptical.” Your comments are welcome.

The Dubai government talks up HIMSS Middle East 2010, expecting 300 people at the November 8-10 conference.

A new report by HIT research and advisory firm CapSite covers the HIM market: vendor penetration, mind share, buying plans, etc. based on information gleaned from 500 hospitals. They sent over the full report for me to check out and it was interesting – hospitals are considering lots of new HIM vendors for buying opportunities of an extremely short time frame (less than a year). The table of contents is here (warning: PDF).

The eClinicalWorks user conference started Sunday in Orlando, with over 2,500 attendees.

Weird News Andy rises to the “beer bottle in the colon” challenge, saying, “I raise you some precious gems. I suppose this guy wanted to be the King of Diamonds. what a card!” Police in India arrest an airline passenger on the rumor that he is carrying diamonds. His bags were found to be empty, but he fidgeted suspiciously during questioning, claiming his hemorrhoids were acting up. The hospital X-rayed him and found 42 condoms’ worth of precious stones that he had swallowed. The diamonds were re-mined with the help of laxatives and bananas.

From the last poll, it’s an even split whether “best places to work” companies are really all that great to work for. New poll to your right: will you be participating in the upcoming HIMSS Virtual Conference?

Epic put up a fun Halloween-inspired home page for the weekend, including some bats randomly flying around (since they’re in the Midwest, that made me think of John Candy and Dan Aykroyd in The Great Outdoors, if you’ve seen that scene).

Quality Systems (NextGen) reports Q2 numbers: revenue up 14% to $81.5 million, EPS $0.46 vs. $0.41, with both revenue and earnings falling short of expectations. The Street was looking for $85.7 million and $0.49.

Meditech’s quarterly numbers: revenue up 23%, EPS $0.89 vs. $0.57.

CPSI’s Q3 numbers: revenue up 24%, EPS $0.45 vs. $0.37.

Memorial Healthcare System (FL) signs up for ExactCost’s Cardiovascular Service Line software, allowing it to support activity-based costing.

Chubb Group adds an insurance program for the healthcare IT industry, covering defective software that causes patient harm, liability for data breaches, and the cost of notifying consumers of a data breach.

States don’t have the expertise or money to develop the Health Insurance Exchanges, consumer insurance marketplaces that are mandatory by 2014. HHS announces Early Innovator grants that will be available to up to five states who develop systems that other states can use. HHS announces said that it will announce financial help for all states in February.

A Massachusetts court gives the OK for a private equity firm to take over Caritas Christi, Boston’s Catholic hospital system, for $895 million. Cerberus Capital Management will turn it into a for-profit entity. Closing is expected within a month. The company can cleave ties with the Catholic Church for a $25 million payment.

Microsoft’s HealthVault personal health platform will enter the Chinese market as the company signs an agreement with iSoftStone Information Technology. The announcement says that a total of 150 hospitals are connected to its platform worldwide, which seems pretty skimpy.

St. Joseph’s Hospital (CA) devotes its annual gala to raising money for its EHR, raising $160K from 600 guests who got to play around with iPads and the Microsoft Surface coffee table thingy.

West Penn Allegheny Health System (PA) will lay off 400 employees, most of them from West Penn Hospital, in a restructuring plan.

I really like this idea: a team from Norwood Hospital (MA) and its community health partners use a $200,000 grant to create a LifeBox within their EMR. Hospitalists interview patients about their backgrounds and record the wishes, values, and goals of those patients in their LifeBox so that other caregivers can understand what’s important to them. I think Norwood is one of the Caritas Christi hospitals that will soon be going for-profit.

Sponsor Updates

• Three hospitals in Sweden will implement iMDsoft’s MetaVision for their ICUs, ORs, and PACUs.
• eClinicalWorks announces its Version 9.0 and a new site, 100millionpatients.com, as a patient portal with PHR access.
• RelayHealth’s RelayClinical EHR receives ONC-ATCB certification from Drummond Group.
• Allscripts was a joint presenting sponsor of the Walk to Cure Diabetes held October 30 in Raleigh, NC.

E-mail me.

Article Review
Health information technology: fallacies and sober realities

 

A reader asked me to review this paper, which just appeared in the October issue of JAMIA.

The first thing I noticed is that it was published as a “viewpoint paper.” Rightly so: it’s a lot of footnoted opinion. The problem with opinion papers is that those who agree with their conclusions laud the work as pivotal, long-overdue, and seminal. Those with different points of view say that fancying up personal opinions in a published article, by grant-funded academics, is no more credible than watercooler chatter.

It’s a mildly interesting piece, but the only folks likely to proclaim it as a work of great insight are those who have already convinced themselves that electronic health records, the companies that sell them, and the providers use them successfully are clueless and/or evil (I should mention that the authors use the broad term health information technology, but are writing specifically about clinical information systems from what I can tell).

My red flag went up immediately with this sentence in the abstract: The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. An article that can definitively state the reason that providers don’t use EMRs or that they underperform would indeed be useful, right? Only if the statement is backed by proof, which I don’t see here.

The authors come up with a Letterman-like list of 12 "misguided beliefs about HIT.” Who holds these beliefs is not documented, but the implication is that the authors observed them in some capacity. Maybe they are right and these exact 12 misguided beliefs mean that HIT is in need of a reboot. Or, maybe they worked back from the conclusion that HIT needs a shake-up and selectively chose the ones that made their case.

Here are the 12, reworded to make the opinions of the authors clear:

IT risks are not as minor or easily manageable as IT people think.

The article says that “many designers and policymakers believe that the risks of HIT are minor and easily manageable” (without referencing how they know that). They correctly observe that it’s hard to develop and implement systems as planned, that humans are fallible, and that software problems are hard to prevent and can have widespread impact. Everybody reading that paper or this post probably already knows that.

Being an opinion piece, the authors recommend as a solution: regulation and/or independent, external validation. I agree that some degree of oversight is needed for specific types of HIT. That’s still just an opinion (that of the authors and me). I’d like to have seen citations of articles researching the outcomes of getting the government involved in product regulation.

HIT is a medical device.

This is stated as a fallacy: “the belief that HIT can be created and deployed without the same level of oversight as medical devices.” That’s not really a fallacy since that’s the current state. It’s just another way for the authors to opine that the government should start regulating clinical software.

The article makes a good (but obvious) point: humans can’t be relied on to catch computer mistakes. It doesn’t make another equally good and obvious point: computers catch a lot of human mistakes. Based on the conclusion that HIT can’t be trusted unless it’s regulated, hospitals should immediately stop using bar code scanning, CPOE, clinical decision support, etc. because they might mislead gullible but otherwise error-free clinicians.

The following unreferenced conclusion about lack of FDA oversight would have been struck out of any article not labeled as an opinion piece: “The current approach can no longer be justified.” Says who?

Humans are not the problem when software fails to improve outcomes or efficiency.

This is another obvious point. Outcomes are system-related (people, processes, oversight, etc.) Bad users acting individually aren’t usually the problem. I also don’t know anyone who would say that — is this really a common fallacy that required debunking?

Just because clinicians use a system doesn’t mean it works.

The conclusion seems to be that “meaningful use” is situational, which is absolutely true. Sometimes users don’t get a choice in the decision to use or not use a system. Still, we’re talking about highly educated and licensed professionals who still bear the responsibility to speak up if a system is unsafe.

It’s also true that the same problem happens with paper. Individual providers don’t necessarily get to decide for themselves whether to complete certain kinds of paper documentation, regardless of whether they see value in that activity.

Clinical work is messy and can’t be rationalized into something linear.

It is true that programmers think linearly and logically, so IT systems are designed that way. But it’s also true that software often organizes and standardizes, which is the only hope to improve medical care beyond individual decision-making with whatever information is at hand.

This is the “medicine is an art” argument, which has some merit. But the argument that primitive clinical decision support systems interrupt clinician workflow (true) means we need “new paradigms for effective HIT design” is a leap. I don’t really know what they mean by that. I suspect the authors don’t, either – it’s easy to say that today’s systems don’t always perfectly match the work clinicians do, but hard to say exactly what they should be doing differently. Today’s systems continue to evolve, albeit a lot more slowly than I’d like.

Rightly or wrongly, clinical practice — within the same organization, on the same medical service, and by individual practitioners — is inconsistent, situational, and often illogical. Paper couldn’t fix that problem and neither can technology. I’m all for taking shots at the HIT industry where it’s warranted. However, if the argument is being made that clinical work is admirably illogical, then turning programmers loose to somehow pave that particular cow path doesn’t seem like a great idea.

Front-line users are stuck with poorly designed and inefficient IT systems because people above them incorrectly think they will solve problems.

I’ll buy that. End users often get a few productivity aids, but are stuck with awful features otherwise. Hospital executives make decisions for employees whose work they can’t begin to understand.

I found this statement a bit of a lark even though I agree with it in a pie-in-the-sky kind of way: “Healthcare does not exist to create documentation or generate revenue, it exists to promote good health, prevent illness, and help the sick and injured.” If the authors have figured out a way to improve healthcare by eliminating documentation or working for free, then I’d like to hear it. If not, then they should not blame software for reflecting reality.

Providers drive the design and adoption of HIT by voting with their dollars. If products aren’t meeting their specifications, they presumably wouldn’t be buying them. Software reflects the way things are, not the way we wish they could be. Vendors would go broke fast trying to sell systems that don’t reflect reality.

Software designers assume that their software is perfect and any problems must be due to bad users. Computer consistency is not the same as intelligence.

I’ve worked in the industry for a long time and I’ve never heard this belief expressed. Software designers (among which are often the users themselves) know the limits of what they can envision and deliver. They expect bugs, reworking unforeseen design flaws, and improvement by iteration.

Software is designed to do things that humans are not good at: keeping lists, calculating, and reminding. There’s no doubt that sometimes user interfaces (like the Three Mile Island example cited) are misleading or allow important information to be missed.

The conclusion is that “HIT must support and extend the work of users,” which sounds nice but is hard to define. It also seems to presume that none of today’s HIT systems do that, which I would say is just plain wrong.

HIT systems are designed for a single user working on a single patient doing individual discrete tasks.

That’s often true. Systems don’t always optimally facilitate collaboration, but that doesn’t mean they are worthless. It’s early in the HIT adoption game, so today’s systems are actually yesterday’s systems, designed in the 1980s and 1990s with simple functionality: record, calculate, display. Customers are buying those systems, though, and deriving benefit. You don’t see many hospitals going back to paper.

I agree with this argument. We need better systems that go beyond today’s 1980s paradigms of simply automating repetitive tasks. However, as long as customers keep buying available systems instead of working to demand and design these new ones, this kind of innovation probably won’t happen.

Computerizing paper processes doesn’t help much. Paper will persist.

The article says that paper forms are more than data repositories –  they are artifacts that support situational awareness and coordination. Suggesting that “HIT designers and administrators” are unaware of that fact is insulting.

Hospital executives and HIT vendors may toss around the “paperless” buzzword, but nobody’s paperless and that’s not necessarily bad. I don’t see either providers or vendors who are so enamored with the “paperless” concept that they fully believe that paper is bad and computers are good.

Frankly, I don’t get why this is a “fallacy” and a bad one at that. It seems too obvious to be a fallacy.

Putting clinicians together with programmers won’t necessary create usable systems.

That is undeniably true. Asking users what they want and then turning programmers loose to deliver it is not exactly IT leadership. Users are way too limited in their perceptions and preferences. Their world view is often limited to a single facility, profession, and specialty. That makes it hard to design a one-size-fits-all application that vendors can sell to hospitals of all sizes (which should have been on the fallacy list – that no product meets the needs of all sizes and types of hospitals, no matter who else has implemented it).

The article suggests involving a lot of people who aren’t working in the industry (like the authors). That sounds great on paper, but software designed by committee is usually terrible, a Frankenstein of pet ideas that make the cut only because the most aggressive and outspoken committee members convinced the silent majority to agree.

Conclusions

The authors of this paper are academics. I like their objectivity, but I’m left with the feeling that they are disillusioned about this fact that is distasteful to them: both healthcare and healthcare IT are businesses that, rightly or wrongly, make decisions based on their own self-preservation, not high-minded academic ideals. 

If HIT is as bad as the authors say, why are customers buying it? Nobody’s putting a gun to their heads (although HITECH is a step in that direction).

The authors conclude that the right HIT metric should be not be adoption or usage, but population health. They are correct. I’ve been saying that for years. We’re still in the primitive stage of HIT, automating simple care delivery tasks that may or may not have profound health impact. People are paying millions of dollars for systems that sometimes behave like 1980s database programs: they accept data entry, store it, and regurgitate it in ways that are useful, but hardly revolutionary. I agree that in many cases, providers should be spending the money elsewhere. But it’s their money.

It’s easy to criticize any industry for doing the wrong things or not doing the right things. It’s also mostly irrelevant. MBA 101 tells you that business aren’t good or bad, they simply meet the needs of their customers. Otherwise, they would cease to exist. If you don’t like vendor products, blame the customers who are buying them (and who in many cases, directly influenced their design). As an analogy, it’s too easy to blame the fast food industry for obesity than to fault their customers for creating the demand in the first place.

The track record of vendors who rewrote systems from scratch certainly doesn’t encourage more of the same. The development of Millennium nearly took Cerner down. Soarian turned Siemens into a punch line. A vendor thinking about rewriting a major clinical suite will need to be willing to live without 5-7 years of sales (since prospects don’t want to buy an orphan product) and had better not have impatient shareholders or investors. Not many vendors are strong enough to sit on the sidelines for that time, much less to amass the resources and expertise needed to undertake such a project.

I have less confidence than the authors that adding government oversight and a bunch of non-industry academics to the mix will make things better. That’s how the government does things, and government systems reflect all the bad characteristics the authors decry: they are user-unfriendly, task-oriented, outdated, and massively expensive.

I agree with two major themes from this article: (a) independent oversight of clinical information systems would be a good thing, and (b) the state of healthcare software is as disappointing as the state of healthcare itself. I didn’t need this article to tell me that, though.

NTT Data To Acquire Keane

Japan-based IT provider NTT DATA corporation announced this morning that it will acquire IT services firm Keane, Inc. as part of its plans to expand to the US market. Terms were not disclosed, although sources indicate a price of $1.2 billion.  

The president and CEO of NTT DATA, a quoted subsidiary of Nippon Telegraph and Telephone Corporation, said in the announcement, ““This transaction with Keane will allow us to provide comprehensive IT services including system development and management of mission critical systems in North America. Keane has a superior reputation in the area of application and infrastructure services, as well as deep industry expertise. I believe that this, combined with their unique global delivery model and our global scale, offers more cost-effective and higher value solutions to our customers.”

Keane’s healthcare offerings include IT services, revenue cycle, the Keane Optimum application suite, and the NetSolutions suite for long term care facilities.

Keane was sold three years ago for $854 million to a California outsourcing firm backed by a Citicorp private equity investment. 

Rumor of the acquisition was posted on HIStalk last Friday after a tip from Broadway Joe.

News 10/29/10

From Domestic or Import?: "Re: this NEJM case study. Has Weird News Andy found this yet?” He has not. I’m sure there’s a fascinating story about how a full bottle of beer found its way into this inebriated man’s rectosigmoid colon, but I’m equally sure I’d rather not hear it.

From Man Up, MCK: “Re: most outrageous comment EVER. From the McKesson earnings call transcript, McKesson CFO Jeff Campbell claimed that nearly non-existent revenues for Horizon Enterprise Revenue Management were due to customers who aren’t buying anything except clinicals and are also pushing back their implementations (it’s the customers’ fault, in other words). He also mentions ‘new and latest requirements’ for HERM. What new requirements are causing them to basically stop all installs? The requirement that it work? I think you should ask the customers if it was really their choice to stop the installs. He said it was going to take ‘a number of quarters’ to meet those requirements — is it two, or three, or four? But the most outrageous comment ever is this: ‘… our customers are saying to us, we’re happy running that 20-year-old to 30-year-old software we bought from you 20 or 30 years ago.’ Are you kidding me? Their customers are happy to be on Star and Series, with no embedded contract engines, no professional charge billing capability, bolted-on claims scrubbing, no online bill pay, and no online registration? Customers just called up in the last few weeks to stop installs of a next-gen system that’s been touted for years and said, ‘That’s OK, we’re really happy running this old software, no rush from us?’” I actually do believe that to a certain extent – customers probably aren’t thrilled, but are used to McKesson’s deferred promises and have Meaningful Use to keep them busy short term (which will quite likely bite them long term when reform comes knocking). Also, the CFO’s reality is filtered through layers of corporate underlings like the president of the revenue cycle business they just fired, so maybe he really believed what he was told about how happy the customers are to wait and how impressive HERM will be … someday.

Listening: Atomic Tom, sounding great in the above video playing live on iPhones on the B-train of the New York subway (the video claims their instruments had been stolen, but they now admit that didn’t happen). A cool link sent by a reader, even if it does smack of an intentional viral campaign (multiple camera coverage, carefully mixed audio, and a convenient Apple tie-in).

Microsoft announces Q1 earnings after Thursday’s market close: revenue up 25%, EPS $0.62 vs. $0.40, beating estimates. The Windows, Office, and server software groups put up good numbers, while $527 million in ad revenue from the Bing search engine wasn’t much consolation for its $560 million loss. Still, these are good results and a nice bellwether for a hopefully-recovering economy.

Zynx Health announces a five-site pilot of its software and services solution that prepares hospitals for being involved in accountable care organizations. It will address clinical decision support in improving mortality rates, readmission rates, length of stay, and total costs.

Shore Memorial Hospital NJ) promotes Fred Banner from CIO to vice president, having worked his way up from PC specialist in his 20 years there.

A reader asked me if I knew of any possible candidates for a big health system corporate CIO job that requires CIO experience, but also a strong IT vision for healthcare’s future state (person-centric and involving wellness and not just care delivery). Send me your recommendations if you have any and I’ll pass them along.

University of Michigan Health System and 570 West Michigan doctors form Physicians Organization of Michigan, what they hope will be a statewide network of independent physicians. Benefits mentioned include EMRs and telemedicine.

To-dos for you: (a) drop your e-mail in the spam-proof Subscribe to Updates box to your right to get instant alerts when I post something new, allowing you to feel smug as you sprint down the hall like Paul Revere alerting everyone of some big HIT development, not because you want them to know, but because you want them to know that you knew first; (b) support HIStalk’s sponsors by checking out the ads to your left and clicking those that catch your eye as interesting; (c) Friend Inga and me or Like HIStalk on Facebook so that we can have the illusion of being BFFs; (d) make Inga happy by reading HIStalk Practice and signing up for the e-mail updates there (when Mama ain’t happy, ain’t nobody happy); (e) send me your rumors, news, and guest articles; and (f) tell people you know about HIStalk and the other sites since the ad budget is … well, zero. Thank you for reading.

Cerner just announced $65 million in quarterly profit, but it wants Kansas City to buy the computers for its new $63 million data center without charging it taxes, then lease them back to the company. That would save Cerner at least $3.7 million over 10 years even though it would create no new jobs, just the transfer of 11 existing positions from North Kansas City.

North Carolina public health agencies, free clinics, and community health centers will get broadband services from the initial phase of the NC Telehealth Network, with the $7.2 million cost paid out of a $12.1 million FCC Rural Healthcare pilot program. I couldn’t follow the confusing list of organizations, offices, and grants that were involved, so if you are really interested (I wasn’t), then you should probably read the announcement instead of relying on my impatient summary.

PinnacleHealth System (PA) chooses (warning: PDF) electronic documentation and charge capture solutions from Salar, Inc. I interviewed Todd Johnson, president of Salar, this past February. Sometimes my interviews are lame (usually because the person I’m interviewing is just not interesting or can’t quit pitching their product or themselves, so I rationalize) but this one’s good.

An investigative article from The Center for Public Integrity questions the effectiveness of having a 29-doctor AMA group recommend to CMS how much their profession should be paid for performing individual procedures. CMS accepts more than 94% of those recommendations, leading to “rubber stamp” criticism. Part of the group’s job is to deflate the times specialist groups claim it takes to the procedures they’re paid to perform. A former member of the group says specialists scratch each other’s back in the meetings, but everybody fights with the primary care docs (which the article says nearly always lose to the specialists who successfully get big payments for performing procedures). It was also noted that, even with major technology and efficiency breakthroughs, the group almost never recommends that work units be reduced.

Palomar Pomerado Health (CA) is chosen as a Pyxis development partner by CareFusion.

Sponsor jobs: HIE Team Lead, Clinical Executive Physician, Clinical Executive Nurse. On Healthcare IT Jobs: Clinical Pharmacist, Metadata Administrator, Senior Manager Healthcare Solutions Marketing, Senior Data Specialist.

Curaspan says 354 hospitals and over 2,500 nursing homes use its Web-based discharge planning, referral, ride sharing, and transportation applications.

Ingenix forms an independent physician advisory board to guide its healthcare technology direction. Among them are Joseph Heyman (who was on some Health IT Policy Committee work groups), Salvatore Volpe (president of the New York State chapter of HIMSS), Martin Harris (his ubiquity precedes him), Gregory Reicks (an osteopath who is board president of an HIE), and Alice Loveys (a CMIO).

Charleston Area Medical Center (WV) cuts $40 million from its budget due to low reimbursement, high drug costs, and $16 million worth of software upgrades. They didn’t say which systems were being upgraded, although I seem to remember that they’re a Siemens shop.

The fired CEO of 15-employee, Indianapolis-based EMR vendor iSalus Healthcare sues the company for breach of contract. Mark Day says he was fired after telling the board chair that he was suspicious that employees were stealing software. The board’s termination letter said he was let go for telling a prospect that iSalus was in trouble and warning the customer of some of the company’s untrustworthy executives, also asking the prospect for a job if things went south there (I’ll hazard a guess that they didn’t sign on the line which was dotted). Day says that conversation was misinterpreted.

Boston-based MedNetworks is developing software based on Harvard-licensed technology that maps the social networks of people and clinicians. The startup plans to sell the information to drug companies, insurance companies, hospitals, and the government. It says that the influence of friends and colleagues may be more important than formal experts when it comes to changing healthcare behaviors or getting doctors to prescribe specific drugs. One of the founders is Harvard professor Nicholas Christakis, whose social network book landed him on Time’s 2009 list of the most influential people in the world. I might have to get a copy.

E-mail me.

HERtalk by Inga

From Za: “Re: my McKesson rep. Said that while it has not been verified, Horizon is on life support. Pretty sure this is not news other than I am gloating a bit because when I got to my current hospital, they were looking at McKesson Horizon and I told them there is no way that mess would ever work. I like being right!” Unverified and purely conjecture, we’ll quickly disclaim, but it’s coming from a hospital CIO who’s usually right.

From Trinketeer: “Re: MGMA goodies. I know you like evaluating all the vendor freebies at trade shows. I brought home a bunch of stuff for my kids. My 10-year-old remarked that it was ‘the same old stuff’ and nothing very good.” Kids say the darnedest things. I have to agree with the 10-year old, except for my souvenir photo with the alligator (redacted for anonymity, of course). It supported alligator conservation, but as I said on HIStalk Practice, all I could think of was how nice his skin would look on a pair of pumps.

I  am back from New Orleans and trying to find the bottom of my e-mail inbox. If you care to know what practice administrators are talking about and what vendors and pundits are telling them, we have three days of highlights on HIStalk Practice.

While at MGMA, I had a long conversation with an Allscripts executive. One of the topics discussed was the company’s decision to discontinue upgrades to the Peak Practice EHR. While I can understand how this decision is disturbing for end users, I must admit that Allscripts seems to be trying pretty hard to reduce the pain. A bit of background if you haven’t been following the story:  Peak Practice is an EHR that Allscripts acquired in the Eclipsys purchase, which Eclipsys had acquired from developer Bond Medical. Apparently the Peak product has a number of functionality gaps and only 300 users. Allscripts has applied to have it ONC certified and won’t sunset it per se, but they won’t be releasing enhancements to it, either. They’ll offer Peak users free like-for-like MyWay licenses and perform the data conversion at no charge. Change is difficult, but I can’t fault Allscripts for making what is probably a good business decision and I commend the company for trying to make things as right as possible for the Peak Practice clients. An interesting side note: Bond Medical founder Travis Bond is now a MyWay reseller.

Another MGMA reflection: I asked several of the smaller vendors if they were going to obtain ONC-ACTB certification, and if so, through which certifying body. Those going the CCHIT route said it was easier since they were already CCHIT certified and/or they thought the CCHIT label was more prestigious. No one specifically named InfoGard as their certifying body. Those going with Drummond noted it was less expensive and faster. One vendor, interestingly, said they were “negotiating” with the certifying bodies to find the best price and suggested that more certifying bodies would soon be announced. And, I don’t recall a single EHR vendor saying they would not seek certification of their products.

HIMSS is hosting another virtual conference November 3-4. I “attended” the first one two or three years ago, mostly because I was curious about the virtual format. The conference is free for “qualified” participants and $99 for “non-qualified” HIMSS members. I can’t find anywhere on the HIMSS site that clarifies what it takes to be qualified, but I can say that when I tried to sign up for a conference a year ago, I didn’t have the secret requirements. I am mildly amused because my status must have recently changed, having received two separate invites from HIMSS this week. I should clarify that neither invite was for “Inga,” but for her counterpart in the “real” world. Since not much has changed on my end, I have to assume HIMSS is under pressure to boost attendance, probably to please its 25+ sponsors. If I have time, I’ll probably accept an invite and lurk around a bit.

Rush University Medical Center (IL) awards a five-year, $25 million contract to Siemens Medical Solutions for medical equipment and HIT consulting services. The press release does not provide a breakdown on equipment versus consulting services, but it does specify a whole bunch of hardware for its new facility opening January 2012. The HIT consulting services will focus on providing “a more efficient electronic infrastructure for managing patient information and services.” Rush, by the way,  is in the process of implementing Epic.

GE Healthcare and UPMC announce that their imaging joint venture, Omnyx, is working to digitize the pathology process and eliminate the practice of pathologists using glass slides and microscopes. If glass slides and microscopes disappear, I wonder what schools will teach in seventh grade science class? So far GE and the non-profit UPMC have invested $40 million in the project.

Trustees for New Hanover Regional Medical Center (NC) approve a $56 million move to Epic (that will be another McKesson Horizon de-install). The investment in software, hardware, and implementation is only $15 million more than the $41 million than upgrades to their existing systems were going to cost.

Cerner announces third quarter results, which were up from last year. Revenue was up 13% to $462.7 million and earnings per share were $0.71 vs. $0.57, beating estimates excluding special items.

Northeast Hospital Corporation (MA) will deploy Merge Healthcare’s PACS and ECM systems.

Sponsor updates:

• Advanced Pain Management (MD) selects the SRS Hybrid EMR. Which reminds me: while at MGMA, the SRSsoft folks told me they are working on an app store to be released early next year. It will give users a quick way to add innovative extras to the core application.
• RelayHealth aligns with TransforMED to provide a communication tools that aids primary care providers by establishing patient-centered medical home models of cares.
• EDIMS earns ONC-ATCB certification through CCHIT for its ED EHR product.
• St. Paul Radiology (MN) says its accounts receivable days has decreased 35 to 40 percent since implementing ZirMed RCM tools.
• CareTech Solutions and nine of its healthcare clients are recognized for excellence by the Web Marketing Association.
• SCI Solutions, a provider of access management solutions, completes its fiscal year with 42 new customer contracts representing 86 hospitals.
• Voalte is named a Mobile Health Expo 2010 award winner in the category of outstanding contribution to the growth and success of nursing and mobile health communications.
• Mobile Health Expo also awards PatientKeeper for the best innovation in mobile health technology for patient safety.
• Eastern Connecticut Health Network chooses Access Intelligent Forms Suite to auto-index patient forms in Meditech Scanning and Archiving.

E-mail Inga.

CIO Unplugged 10/28/10

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

Innovation is Leadership

After 30 years of procrastination, I finally did it. I got braces. Yes, the shiny stainless steel that contributes to the bane of fragile teenage egos.

Sadly, the technology related to braces has not changed. Take, for instance, the cosmic gap between my two front teeth. The doc glued the brackets to my teeth and pulled wire through them. He will now tighten them — a slow torture lasting 2-3 years.

After the recent painful, nanometer adjustments, I lamented the fact this technology has experienced little innovation in the past fifty years. While there are magical products to make the appliance less visible, nothing has actually evolved in the clinical efficacy — a gap I liken to the size of the one between my teeth.

Best practices is a regression to the mean. Wouldn’t you agree? Our love affair with the term “best practices” is really another way of embracing the average. We are desperate for improved and enhanced ways of doing things, yet the best most of us can manage is copy someone else — a slide towards shared mediocrity.

Either innovate or perish.

Plenty of scholarly evidence exists to substantiate my critique. You cannot pick up business literature, electronic or otherwise, without reading about the dearth of innovation in our country. And I think healthcare is as fertile a ground for a good outpouring of innovation as any other vertical.

Innovation takes on many forms, from technical to transactional to cultural. Most readers should already be familiar with Christensen’s works, the Innovators Dilemma, and Innovators Solution. More recently, Christensen applied his innovation concepts to healthcare with a landmark piece, The Innovators Prescription. It’s a mandatory read for my leaders.

What can you and I do to spark innovation in healthcare and in our organizations? First, we start with our own lives; and second, our span of control.

Career mimics persona. If you are innovative, it will reflect in everything you do — work, play, relationships, etc. To stay or to become innovative, you must embrace a matching lifestyle. I don’t mean the old pat-on-the-back hug, but an embrace of lovers reunited. Do you select hobbies that wreak creativity and imagination?

One reason I’ve immersed myself in the Argentine Tango is because there are no right or wrong moves. Instead, I can take the 2-4 count patterns learned and arrange them according to the feel of the music or mood. That means I have to think afresh for every song, yet maneuver in a way that allows my partner the space to be equally artistic. Triathlon is credited for its many transformational improvements in cycling, clothing, and accessories that other sports have adopted. The sport itself continues to evolve.

The above hobbies work for me. Clearly, there are thousands of choices that can cater to your personality and ambition. The point is to pick something that stretches you. If I ever grow comfortable, I know I’ve hit stagnation. My career will imitate my life.

At work, you must be boldly intentional. While I do a fair amount of speaking on a variety of leadership-related topics, the most common request I receive is on innovation. After speaking as a keynote at the recent Computerworld’s SNW Fall Conference , the audience enthusiastically embraced the innovation message.

Innovation doesn’t just happen. You have to promote it with sound processes to help those yet uninitiated. You can have innovation portals that showcase processes and how to get involved. Set up reward systems as encouragement. Hold contests where all submissions have to be done via video, which is a creative process in itself. Recruit judges from your C-suite to ensure high visibility.

Host a Tedx event. This is a new program that enables local communities such as schools, businesses, libraries, neighborhoods, or just groups of friends to organize, design, and host their own independent TED-like events. Or pick a technology that you think has potential and invite a wide variety of participants to brainstorm. This mash-up could lead to some amazing outcomes that transform clinical care.

The most pioneering ideas will come from people who are closest to the action and who are given a forum for their voice. The leaders’ function is to act as the catalyst and create an environment suitable for originality.

No single idea will transform your culture into one of innovation. Nevertheless, as you begin to mix in such ideas, processes, and events, you will have an impact, and transformation will begin to take hold. Anticipate resistance — and view it as positive feedback. If you don’t encounter resistance, double your efforts.

Live in such a way that no person could look back at your career or your life and say, “Not much changed.” Kind of like the battle between my teeth and stainless steel.

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

News 10/27/10

From Southern Belle: “Re: Epic. I hear they’re thinking about changing their consultant non-compete agreement from one year to two.” Unverified.

From Blame the Dog: “Re: BlackBerry tablet. Here’s some video up of a demo of the eUnity PACS virtual workstation running quite seamlessly on the BlackBerry PlayBook through their fancy new QNX-based Tablet OS. I’m a big fan of the trend Apple has started with (finally) user friendly tablets, and there’s been a lot of interest in healthcare for the iPad so far because of the cost and usability factors, but I have a feeling there are more than a few healthcare CIOs out there collectively holding their breath for the PlayBook. Apple has some management tools for the iPad and I think they’re starting the realize the potential there, but they’re still nowhere near RIM on the enterprise, information security, and compliance management front. The PlayBook is going to be a BES-compliant device, meaning all those hospitals out there with existing BlackBerry infrastructure don’t have to do much to start putting the PlayBook into lab coat pockets early next year. No matter what, RIM, Google, and Apple are finally giving hospitals and practices simple and cost-effective devices that can integrate more comfortably into existing workflows. No more bulky notebooks posing as tablets, no more clumsy laptop carts, no more silly workstations in every exam room. Finally.”

From BCS Luv: “Re: Epic. Who’s implementing it in Boise?” I’d have to guess St. Luke’s since Saint Alphonsus just went up last week on an unnamed system (Cerner, I assume, since St. Al’s is a Trinity hospital and their Genesis Project runs Cerner, if I remember correctly).

Inga is posting live from MGMA on HIStalk Practice with our patented blend of news, rumors, booth critiques, and observations (she says she got hit in the head by a lady’s tossed beads, which I hope doesn’t mean that she flashed her, French Quarter-style). Check out her posts from today and yesterday.

Core Health Technologies releases its HL7 survey results (warning: PDF). Demand for HL7 expertise will increase, said 85% of CIOs. Respondents predicted that Cloverleaf will lead the integration engine market.

Cardinal Health signs a marketing agreement with Swisslog that will allow Cardinal to offer that company’s drug packaging and distribution technologies.

New York eHealth Collaborative plans to spend $129 million in state and federal money to create a statewide electronic medical records network.

UW Health (WI) is using palm scanning to positively identify patients and to reduce identity theft and insurance fraud. They spent $70,000 for 200 of the scanners.

McKesson announces Q2 numbers: revenue up 1%, EPS $1.25 vs. $1.11, missing on both revenue and earnings excluding a one-time asset sale. Revenue for Technology Solutions was down 3% (with some one-time adjustments), with the press release saying the reduced operating margin “was impacted by continued investment in our clinical and enterprise revenue management solutions.” The company also wrote off $72 million because of Horizon Enterprise Revenue Management, which readers have told us is in big trouble with high development costs and rumored missed deliverables. I looked up their term asset impairment charge and it means (in my non-accountant interpretation, anyway) that an asset’s value has declined even faster than it’s being depreciated and amortized, requiring  one-time adjustment in value.

Disappointing perfomance in McKesson’s Technology Solutions business was surely the cause of Monday’s big McKesson reorg, which I mentioned on Facebook (actually the performance would have been great without the HERM charge). Clinical and revenue cycle groups will be combined to form Health Systems Enterprise Solutions (seems odd). The president of Revenue Cycle Solutions was let go. Several other products (workforce management, surgery, performance, analytics, HR, etc.) are being combined under Health Systems Performance Management. Enterprise Imaging will be made part of Medical Imaging. Sales teams will be integrated with their business lines. They seem to be focusing on differentiating Horizon vs. Paragon prospects.

Healthland promotes sales VP Angie Franks to CEO. Former Interim CEO John Trzeciak of Francisco Partners will keep his board seat.

Surescripts expands (warning: PDF) its e-prescribing network to become a “national backbone” that will allow exchange of clinical messages, expanding on its work with CVS’s MinuteClinic. The company is marketing itself as a trusted network, using messaging tools made possible by its investment in secure messaging vendor Kryptiq. Surescripts says it will follow standards for NHIN, HL7, CCD, CCR, etc. VA CIO Roger Baker was quoted as saying that the Surescripts network would help his organization connect with community providers. John Halamka was also quoted, although in a non-committal way (he doesn’t generally shill products, just ideas). This is a big announcement, both in length and in impact. Implementation dates: Net2Net connect to allow providers and vendors to connect outside their networks (December), Message Stream secure messaging (December), and Clinical Message Portal for providers who don’t have an EHR (January). I had to refresh my memory about who owns Surescripts: the founders, the National Association of Chain Drug Stores, the National Community Pharmacists Association, CVS Caremark, Express Scripts, and Medco.

Even Weird News Andy is speechless at this article (well, almost – he only said “wow”). In England, a quadriplegic home care patient, convinced that he was not receiving good nursing care, puts a bedside camera in his room. It caught an NHS agency nurse panicking after incorrectly adjusting his ventilator’s controls and setting off its alarm. The nurse, who says she was given no training on the ventilator, couldn’t get it restarted and didn’t know how to resuscitate him. It took paramedics 21 minutes to arrive and give him oxygen, but by then he had suffered major brain damage, reducing his mental capacity to that of a child. NHS says it’s sorry.

Panasonic invests in Houston-based CardioNexus, announcing its intention to become a global leader in personalized preventive medicine. CardioNexus, formed last year, is a product of Baylor College of Medicine’s commercialization organization and works with Texas Medical Center, which was already working with Panasonic. The company focuses on early detection of heart disease, which I assume means imaging.

Sage Intergy Meaningful Use Edition is ONC-ATCB certified by Drummond Group. Also earning certification, but from CCHIT: GE Centricity Practice Solution version 9.5.

AirStrip Technologies provided some clarification about its agreement with Sprint that I mentioned recently. Users can choose any mobile device (including Android-powered ones in the next couple of weeks, but 80% of their users are on iPhones so far). Those users generally use AirStrip on their personal smart phones (makes sense – they wouldn’t want to have to carry two). Sprint helps the hospital pay for AirStrip to encourage them to use more Sprint devices, but they help subsidize the cost for all users, not just those who choose Sprint smart phones. AirStrip gets what it says is better 4G performance from Sprint, which will allow it to eventually expanding its offerings to real-time video collaboration, imaging, and extended historical waveform data. Thanks to AirStrip for the clarification. I usually steer clear of proclaiming a company or technology as “hot” since I’m just a cheap seat observer, but I’m pretty sure they are.

Folks I know at Cedars-Sinai tell me that they’re up on Epic’s nurse documentation and care plans. They’ve also shut down CareVue now that they’re live on device integration and doing some physician documentation in the ICUs.

Our Lady of Lourdes (NY) chooses Allscripts EHR for its 16 employed medical groups. They’ll also implement Allscripts Remote, which allows physicians to access the system via the iPhone, iPod Touch, iPad, BlackBerry, Android, and Windows Mobile smart phones.

Martin Memorial Medical Center (FL) borrows $25 million for equipment they say is EMR and HITECH related, including smart pumps and patient monitors.

A prospective sponsor e-mailed me a question I’ve not been asked and couldn’t answer without digging through some stats. How many unique people read HIStalk each month? The answer: just over 19,000. I also noticed the countries they’re from: the US, of course (over 93%), then Canada, Australia, UK, India, Israel, Ukraine, UAE, China, and so on. All I see from this end is a blank screen that I have to fill each day while sitting in my inner sanctum and playing music at excessive volume levels, so it’s fun to occasionally be reminded that real people are on the other end.

Healthcare futurist Jeff Goldsmith says HIT adoption is lagging because there’s no return on investment. He says the payment system is largely at fault for piling tedious documentation requirements on doctors, made worse by new quality measures (I assume those prescribed by Meaningful Use are among them). He says he would have done Meaningful Use differently, offering providers an immediate malpractice shelter for following guidelines instead of a payoff down the road. He also thinks that hospitals buying practices will drive more HIT usage than Meaningful Use since the new owners will want them to communicate with each other (and will want to monitor and control their performance, which Jeff didn’t say but I will). His estimate of consumer influence on EHR adoption by doctors: “nearly zero” since people have stayed away from PHRs in droves and the improved communication that patients really want doesn’t require IT. Jeff’s an investor in some startups, which I’d love to do if I had the money (although I probably therefore wouldn’t have it for long since those rarely pay off).

Francisco Partners takes a majority stake in Quantros, which sells quality and risk applications. The private equity firm is no stranger to HIT, with investments in AdvancedMD, API Healthcare, Healthland, QuadraMed, and T-System. I interviewed Quantros CEO Sanjaya Kumar this past April. Worth a read (or re-read). I have to say that if your vendor is bought by someone, you should hope that it’s Francisco Partners since they appear to be the most patient, most HIT-savvy, least change-demanding acquirer out there. They seem to help the companies they invest in succeed instead of slashing and burning their way to a fast payoff.

A Modern Healthcare article says that the AMA is getting into the EMR business with its Amagine project, which will go live in 2011 after the current pilot in Michigan is finished. It will charge vendors to list their wares on a portal, then take a cut of the action. AMA will actually providing technical support and possibly implementation services. I’m having a rather strong reaction to this, but leave a comment at the bottom of this post and let’s hear what you think first.

Ever wonder how those frequent flier patients get to your ED? By ambulance, of course. One health commissioner said, “The misuse of ambulances speaks to our health system. If we had a place as user-friendly as an emergency room, people would likely use it. The fix is to have more primary care and a better way to get to it.” One New York patient called for a ride to the hospital 313 times in one year. Like the rest of healthcare and the country in general, relying on personal responsibility is a bad idea, especially with a government willing to subsidize stupid decisions by taking money away from those too responsible to make them.

HealthPartners launches virtuwell (annoying all lower case besides being a pun), an online MinuteClinic-type alternative to office visits that offers online nurse practitioners around the clock. Online users (only in Minnesota for now) get a diagnosis, treatment plan, and prescriptions for $40 or less, depending on insurance.

The Wisconsin State Health Information Network is named as the overseer of the statewide HIE, set to launch next year.The group is a non-profit with members Wisconsin Hospital Association, the Wisconsin Health Information Organization, the Wisconsin Collaborative for Health Care Quality and the Wisconsin Medical Society.

Sponsor Updates

• All Children’s Hospital (FL) will use GetWell Town from GetWellNetwork as its interactive bedside TV system offering Internet browsing, games, movies, and behind-the-scenes clinical applications.
• RelayHealth beats the mandatory 2012 date for complying with Version D.0 of the NCPDP pharmacy claim standard. The company’s prescription transaction solutions are compliant now.
• RelayHealth also announces at MGMA its RelayAnalytics Financial Diagnostics, a visibility dashboard into claims and remittance information.
• Revenue cycle vendor ZirMed announces that it has processed 750 million healthcare transactions and is doing 20 million per month. The company says its 39% annual growth rate required adding two executives: former Allscripts sales VP Kevin Weinstein as VP of marketing and Kraig Brown as sales VP.
• MEDSEEK announces its Sprint to Meaningful Use solution, which will help organizations meet the MU goals involving patients and families.

E-mail me.

HIStalk Interviews Michael Rothman, Co-Founder, Rothman Healthcare Corporation

Michael Rothman, PhD is co-founder, chief science officer, and board chair of Rothman Healthcare Corporation of San Francisco, CA.

Tell me about yourself and about Rothman Healthcare.

I have a PhD in chemistry. I’ve been doing data analysis for 30 years. I spent a good chunk of that time working for IBM, including a stint at IBM Watson Research Lab. I then went off and did consulting for a while. 

The reason that I got involved in this whole thing is a personal one. My mother was a patient at Sarasota Memorial Hospital. She went in to have a valve replacement operation. She did well initially, and then started fading. The problem is that no one understood that she was getting sicker until she was very ill. Without going into the whole story, she ended up dying about a week and a half later.

My brother and I spent a long time trying to understand what had gone wrong. What we decided was that, in a way, the system had failed her. It really is almost impossible to look at the electronic medical record and catch a slow deterioration in a patient’s condition, especially with the fact that there are so many different doctors and nurses that take care of a single patient.

We asked the question: why isn’t there a simple measure of a patient’s overall condition that can be plotted versus time to show a doctor or a nurse that someone is getting sicker?

We went in and spoke to the CEO of Sarasota Memorial, who let us come in to the hospital and try out some ideas for several weeks. That led to a real project about four months later. Over the next couple of years, we analyzed about 60,000 patient visits and data extracted from the electronic medical record at four different hospitals. That led to development of software — in fact, a product and a company to deliver that product — to do that very simple thing that we started out to do: provide a measure of a patient’s condition so that a doctor or nurse can see if a patient is getting sicker.

I have to ask the obvious question in terms of how Sarasota came to be involved with your product. Was that related to … you know what I’m getting at. Was this in terms of a lawsuit or something about your mother’s treatment, or was this just their interest in improving what you had seen firsthand?

That’s interesting. No, it was not involved with a lawsuit. We actually considered the idea of suing and rejected it because it’s an empty thing to do. It would not have been of any value to us to get a sum of money. What we wanted to do was try and prevent what happened to our mother from happening to someone else. No, there were no legal negotiations involved.

Did they undertake this with you in the spirit of recognizing that they had room for improvement and that you had something to offer as someone with skin in the game?

They were a pioneer in electronic medical records. My mother died in 2003 and they had already had an EMR, I think, seven or eight years.

Yes, they’re an Eclipsys client.

Yes, yes, and they had been frustrated really, by the lack of insight that they had been able to extract from all this data. They had all this data and it’s difficult to maintain, it’s expensive, and they were waiting for the real demonstration of value.

My brother had worked in data visualization for many years, and as I said, I worked in data analysis. When we came there, it just caught their attention. The CEO was very sympathetic about what had happened in my mother’s case, but there was something else in the background. There was this underlying feeling that something should be done with all this data.

Maybe what we want is people who are coming at it in a very fresh way. We did not have medical backgrounds. In fact, if we had, I don’t think that we really would have been successful, as it turns out.

If this could happen at Sarasota, it could happen anywhere because that’s a highly regarded hospital using a highly regarded clinical system that they’ve used very well for a long time. If you were talking about the experience of Sarasota to this point, what would be their results?

We developed this index, which we named in honor of my mother — the Florence A. Rothman Index. This is a general measure of a patient’s condition. It’s now part of a software product which we deliver and is being used at Sarasota Memorial.

In terms of a measure of success of this endeavor, it really was if we could help one person avoid what had happened to my mother, then that was the sign of success. But I think we’ve helped many people at this point, but I also think we can help many more.

I guess the toughest part is that you don’t really have any way to know whether your product helped. There’s no recordable event that says, “Hey, we just saved this patient because of something we showed a clinician.” Is that going to be a challenge to go into another site to have something more than just anecdotal discussion?

In fact, we did a clinical trial at Sarasota with 1,600 patients over about five months. It was with a randomized, concurrent control group. If a patient was born in an even year, his doctors or nurses would be able to see the graph, and if he or she was born in an odd year, they wouldn’t be able to see the graph.

We then looked at the outcome as measured, in this case by discharge disposition. What we found was that more patients ended up in a healthier condition and so were able to be discharged to home rather than to rehab or skilled nursing facility. We had a seven per cent increase in discharges to home. It turned out to be a number that was statistically significant.

We’re in the process of setting up clinical trials at a number of other hospitals to replicate this and to extend the work, and to show that we have benefit at not just Sarasota, but other hospitals as well.

As I was trying to conceptualize why this works, I thought of the stock market, where you may track five stocks and think you know everything there is until you look at a stock market index and a long-term trend. Then you realize that you got so wrapped up in the trees that you didn’t see the forest. Does it happen often that the data there but clinicians miss the trend?

Yes, that’s part of it. The thing is, there’s plenty of data. We’re not creating any more data. What we’re doing is two things. We take 26 different medical measurements which are available, basically, at all hospitals. We extract the amount of risk which is inherent in the value of each of these measurements and come up with a single score.

Now in a sense, that’s what a doctor or nurse does when they go in. They come up with an overall sense of how the patient is and a good doctor does it well, or a good nurse does it well. But the problem is if a doctor is rushed, a nurse is rushed, how completely can they really evaluate all the data that’s there? Even even more importantly, do they really know how that patient was the day before when maybe this is the first time they’ve ever seen the patient?

Getting that trend is very difficult to do, even if you’re a doctor and you’re sitting down and studying what’s in the medical record. It’s hard to figure out what the trend is, especially if it’s a gradual deterioration.

There’s one other thing, and that is doctors tend to look at three things when they’re doing an evaluation. They look at vital signs, they look at lab tests, and they look at the last doctor’s notes. However, there is a source of information that they tend to overlook, and that is the nurse’s assessments.

The nurses do what is called “the head to toe assessment” of the patient. It’s something that’s taught at nursing school. They evaluate each physiological system and they record it on the computer. Really, doctors don’t look at it.

One of the things that we’ve done is we’ve said, “Hey, this is actually very valuable information about how someone is.” So we used nursing data in the calculation of our score. It gives the doctor access to something that he doesn’t normally look at.

How did you come up with the 26? How do you know those are the most relevant ones? Are you continuing to see how well the correlate with patient status changes, or do you think you’ll be adding more measures?

We started by going to the electronic medical record and saying, “What’s there?” We looked to see what measurements really are available on all patients. Not only are they available on all patients, but they’re available and they are taken on a continuing basis on all patients. That really brings you down to a relatively small number of potential variables.

Then we tested the variables against different measurements and we looked at the independence of variables. We spent a long time working on the model building itself, but in answer to your question, are we continuing to test it and look for opportunities to enhance it? The answer is yes, although we are comfortable with what we have now. I’m sure that there will be opportunities to enhance it in the future.

Do you think there’ll be ways that you can build into the presentation of the information the ability to collect new information that will help you determine if the correlation is better since your system does not accept data entry?

Let me say two things. One is we’re presenting doctors and the nurses with this graph, and basically, every time a piece of data is entered into the electronic medical record, we recalculate the score and we put another point on the graph. That’s the operational side of it.

But what you’re getting at really is something that we thought of right at the outset, and that is when someone is doing medical research, one of the tough things is to have a good measure of an outcome. If you’re looking for mortality as an outcome, generally mortality is very low in procedures or when you’re dealing with one drug or another. So you need large sample sizes to get specifically significant differences between drug A and drug B, or procedure A and procedure B.

At the point at which our index becomes generally accepted as a measure of patient condition, all of a sudden you have another measure of outcome. You can say, “Hey, we have procedure A and the folks who went through procedure A ended up with an average score of 75 after a week, and procedure B, the folks ended up with a score of 65. And just to calibrate you, 100 is the best and 0 is close to the worst.”

You have a way of getting a quick read on the impact of procedure A versus procedure B, or drug A versus drug B, or workflow A versus workflow B. I think there’s a lot of potential in terms of helping in medical research.

Do you see it as being something that’s applied like a pain scale or a blood sugar reading where there’s a standing order that says if the patient’s Rothman Index gets to this, then transfer them to ICU?

We are not prescriptive, nor diagnostic. We’re not telling a doctor or a nurse what’s wrong with the patient or what to do. We’re basically alerting them that something is happening. But what you’re talking about sounds like the rapid response team Initiative. Is that what you’re referring to?

Yes. It seems like one of the key problems is failure to act. There’s something going on, no one notices, there’s no predefined pathways — someone just says, “Wow, this is bad,” and then nothing happens.

Absolutely. There was a talk given by Dr. Edgar Jimenez, who is the president of the World Federation of Societies of Intensive and Critical Care Medicine. He’s also an assistant professor of medicine at the University of Florida, University of Central Florida, and Florida State University, as well as director of medical critical care at Orlando Regional Medical Center. It was a talk given at the 6th International Conference on Rapid Response Systems in May at Pittsburgh. He was talking about some work that he’s done, preliminary work at Orlando Regional Medical Center with regard to rapid response teams.

One of the problems with rapid response teams is it takes the nurse on the floor to activate the system. Some nurses are going to be great at it, some nurses are not going to be great at it, but many times nurses are overwhelmed. As you say, someone can deteriorate and no one notice, so the team doesn’t get called.

They are very excited about the system because of a capability that we have. We produce a graph showing the patient’s condition over time. We can actually produce a single screen with several hundred graphs on it so you can look at the entire hospital on one screen. The graphs are color-coded and it’s really quite easy to see a decline, even though the size of the graphs themselves is small.

One of the clinical trials that we’re going to be doing is on the order of surveillance, where a member of the rapid response team sits in an office and looks at the entire hospital and says, “Hey, there’s a downturn on the sixth floor,” and picks up the phone and calls the nurse on the sixth floor and says, “What’s going on with Mr. Smith?” If the answer is, “I thought he was going home tomorrow, I didn’t know there was anything going on,” then the rapid response team becomes proactive. They activate themselves. They really become a backup for the doctors and nurses to try and prevent people from falling through the cracks.

I would think there’s some potential use even for things like staffing or for nurse acuity; where you have patients whose diagnosis doesn’t really tell you the significance of their care requirements. The number is relative, right? It isn’t just that your number gets worse, but that if your number is lower than some other guy’s number, you’re in worse condition?

It’s an absolute value and it also shows you changes. It’s interesting that you say that because whenever we’ve spoken to, especially a chief nursing officer, she says, “Hey, I can use this as an acuity tool to help me with staffing.” I think there is some dissatisfaction with the tools that are out there because they require nurses to enter data and they can be subjective.

Our system is, in a sense, an absolute measure of the patient’s condition. As I’ve said, we color-code the graph — red being the worst — and so you can say, “Hey, if I have five red patients in one nursing unit, one thing I’m not going to do is assign them all to the same nurse because that’s going to lead to a bad outcome.” It could also be used at a higher level in terms of management of nursing hours, although we’ve not gone down that pathway yet. But it’s been suggested.

I’m a believer in the 80/20 rule –– show me the 20% of patients who are the sickest and if I manage those well, I’ll improve my overall outcomes.

Yes, I think you are right on. We really think that we have a potential of making significant impact in the quality of healthcare and we have people who have had many years’ experience in hospitals who feel the same way. It’s very exciting for us.

I know that you worked with Helios, or ObjectsPlus as it used to be called, when you started connecting to Eclipsys at Sarasota. What kind of interfacing would be required for a non-Eclipsys user and how difficult is it to manage those interfaces?

We’ve spoken to a couple of the other EMR vendors. We are prepared to interface with any of the systems.

Really, we are self-contained. We touch the world in two ways. On the one hand, we go up to the hospital’s database and we extract data periodically, but we do it in a way which has no impact on response time. Hospitals are very sensitive to anything that may degrade their response time for doctors and nurses, so we have a way of not doing that. Basically, it’s not a real-time query, so we wait for real-time queries to finish.

The other place is when a nurse goes to a nursing station and she goes to her computer and she wants to see the graph. All we need to do is know who the current patient is that you’re looking at and we can be either loosely integrated or tightly integrated with the system. With Eclipsys, we’re tightly integrated, so that there’s actually a tab on the main screen that says Rothman Index. A Sunrise Clinical Manager user wouldn’t know that they’re not using Eclipsys-native software.

But if it’s a looser integration, it might be an icon on the desktop. You click on that icon and you’re already logged on to our system through a single sign-on software system which is controlling their screen. We would know which patient you’re pointing at. We just need to know which patient it is and our server has the data and has the values of the Index, and would then be able to display a graph.

Does it alert or is it just display? Does somebody have to notice that the number’s bad or can it automatically page and escalate?

We produce a graph, but we also produce a number. That number can be used in a rule that is created by the hospital to generate an alert.

What parts of the system do you consider the proprietary and how do you envision this turning into a business?

The algorithm is proprietary, although we’re submitting an article for publication which will give the general outlines of what we’re doing. Doctors don’t like the idea of a black box. I guess that’s the proprietary element of it — the algorithm.

We’ve submitted several patent applications on the work. But we’ve spent years now validating this and so, in a sense, the protection that we have is the fact that we’ve done all this work. If someone wanted to do the same thing, it’s going to take them quite a bit of time.

Are you going to try to sell this directly to hospitals or partner with vendors? How do you see this getting out in the field?

We’re starting out by selling it to individual hospitals. We’re starting clinical trials at a number of them. The basic idea is an annual license fee, which is based on the size of the hospital. But we can see going into the future that we might partner with one or another or maybe all of the EMR companies to make it available to their customers.

Is it satisfying to see this turn into a business when the original point of it was a very personal circumstance that you knew you could improve for others?

I think that in order to deliver this and really have the largest impact, we needed to make it into a business. If it were simply a study or a paper, I don’t think that it would have reached a lot of people.

The fact that we were willing to go the extra distance to make it into a product that hospitals would be able to use easily and it will reach a lot of people, that really is a way to achieve our original goal. We just didn’t want this to happen to someone else’s mother. I think we’re going to end up accomplishing that goal.

Monday Morning Update 10/25/10

From Polemic: “Re: Epic-certified resources. Only Epic knows and they’re not sharing. That leaves everyone else to make sense of what it means when someone claims to be Epic-certified (what module, what release, etc.) Tightly controlled certification keeps qualified people in high demand, but doesn’t seem to take into account the rate at which they are signing new accounts. One has to wonder whether the ‘we’re Epic, you’ll do it our way’ approach won’t perhaps come back to bite them someday.”

From Celling Yourself: “Re: AirStrip’s Sprint announcement. I don’t get this. AirStrip’s target customer carries an iPhone, which doesn’t work on Sprint.” It is interesting since the deal offers hospitals Sprint’s help creating an in-building Sprint infrastructure for running AirStrip’s apps on 4G smart phones, but AirStrip says it’s staying carrier agnostic. I can’t imagine docs giving up their iPhones (and thus AT&T now and possibly Verizon soon) or carrying a second Sprint-capable device only for on-property access. It sounds like little more than a targeted Sprint promo for its infrastructure business.

From Former McKessoner: “Re: long overdue. I’m one of the many departures from the McKesson senior sales ranks since the June 1 beginning of the fiscal year. It took over 10 years, but the Horizon undoing is coming fast. No new business, customers grudgingly upgrading.” Unverified. All I’ve seen is the recent KLAS report, which says Horizon lost more clients than it gained in 2009 (along with the other faders you might expect — QuadraMed, GE, and Eclipsys). The company has announced nothing pertaining to its Horizon strategy as far as I know, so unless a customer verifies they were told something officially (and those I’ve asked haven’t responded), I’d say it’s business as usual.

From Introspect: “Re: Houston hacker. Here’s an update with the hospital’s side of the story. I wish you had withheld judgment until at least hearing both sides of the story.” I agree, although I assumed the newspaper’s account was accurate and complete and I did hedge my bets by referencing the hospital’s “apparent” security incompetence. The original article said the hospital had to hire outside help to fix the problems the kid claimed he told them about. The CIO’s story is different, although he didn’t mention the problems the kid says he discovered. He says the 21-year-old had installed “back door” code on the hospital’s server that would have let him bypass security to log on at any time, which he accomplished by using a doctor’s password instead of actually penetrating the hospital’s security (I’m surprised he was able to do that with a doctor’s security privileges, which I assume means any doctor could do the same, but that’s not my area of expertise). As the CIO says, “He didn’t discover a breach, he was the breach.” The outside help was engaged to make sure the kid didn’t do anything else, the CIO told the newspaper.

At least most readers think their employer’s economic conditions are no worse than they were six months ago, although more say they’re unchanged than better New poll to your right: what’s your experience working for an employer that has won a “best place to work” award?

It’s easy to confuse patients about healthcare benefits. A non-profit clinic in California sends out ID cards to all its recent patients that include the patient’s name, medical record number, and doctor name. They wanted to speed up registration by giving staff information needed to look up patients in their new EMR. Puzzled patients seen at the clinic but not its regular patients are calling their providers and insurance companies demanding to know why they’ve been turfed off to a new clinic and doctor.

RemCare, fresh off $2.7 million in new financing, renames itself (warning: PDF) after its product, Care Team Connect. The Illinois company’s product helps hospital care managers by creating evidence-based discharge care plans and coordinating care, reducing readmissions.

Vanguard Communications, which offers the MedMarketLink marketing service for specialty practices, signs a partnership deal with Intuit Health to market its portal.

HP announces its Slate 500 would-be iPad competitor, which it will market to businesses (note the medical apps featured in the above promo). It’s more expensive (starting at $799) and runs Windows 7, meaning that unlike the iPad, it supports Flash. It comes with 2 GB of memory (which is needs since it’s running Windows), has a shorter battery life (Windows again), and does not support 3G (WiFi only). I’m guessing all of those facts led to the decision to steer a wide berth around the consumer market created and owned by Apple in the hopes that businesses are so pro-Windows they’ll pay more to get less. This will be problematic: all those users with iPhones, iPods, and iPads at home are not likely to be thrilled by their employer’s offering. Apple doesn’t make mistakes too often, but failure to reach detente over Flash is a big one since that’s one of few chinks in its armor and it involves all of its products as its competitors will tell you constantly.

Mobile Health Expo announces its 2010 award winners. HIStalk sponsors winning were PatientKeeper (best patient safety innovation) and Voalte (outstanding contribution to nurse communications).

Greenway acquires Visual MED’s PACS technology, which will power its PrimeIMAGE solution for its PrimeSUITE 2011 EHR.

The radiologist who founded teleradiology services vendor Virtual Radiologic launches an early stage venture fund that will invest in consumer, healthcare, and technology companies. Sean Casey was kicked out of the company, which he started and took public, with $68 million worth of stock. It was the subject of a private equity buyout for $294 million this past May.

HHS CTO Todd Park is added to the speaker lineup of the mHealth Summit next month, run by the NIH, its foundation, and the mHealth Alliance. Also speaking: Bill Gates, Ted Turner, and US CTO Aneesh Chopra. I’ll be filing daily reports from there as will HIStalk Mobile editor Dr. Travis Good.

The Austrian man who was the first person to use a mind-controlled robotic arm for driving dies in a single-car crash that may or may not have been related to the technology.

I can’t decide if HIMSS is clueless or evil with this announcement: attendees at the Orlando annual conference in February will be tracked by RFID for the benefit of exhibitors, who can “… derive a more accurate score of a visitor’s buying potential.” RSNA has been doing this, apparently, triggering specific booth ads to play based on who’s around (Philips is a happy customer cited in the above promo video). An RFID tag will be attached to conference badges that will let vendors track attendees by job and employer (and name if the conference allows it), ending the days of anonymous and obligation-free booth cruising. The technology will log booth visits and duration by product being viewed and will alert vendors in real-time when a “key prospect” is in the area (CIO alert! Ignore everyone else!) The conference keeps getting more similar to a cattle butchering operation: you’re herded into a holding pen (the exhibit hall) since the token educational offerings (getting less useful every year) intentionally go dark during major booth hours, you’re fed and watered in the exhibit hall with vendor snacks until it’s your turn with the the high-paying exhibitors, and now you’ll be tracked like livestock throughout the process. Let me just say that, as a paying attendee and member, I resent the hell out of this (I’m sure I can get info on how to cripple the RFID tag and I’ll run it here if so). I can imagine what was going through the minds of the HIMSS dim bulbs who approved this: hey, we can charge vendors even more by selling them the personal information of attendees, vendors can pounce like snakes when attendees identified by job title as a decision-maker enter their air space, companies can monitor whether competitors are encroaching into their proprietary neighborhood, and HIMSS can justify its exorbitant exhibiting costs by showing who dropped by. People seemed to be resigned to letting HIMSS do whatever it wants in the name of picking the pockets of its vendor members. I say it’s time for provider members to push back and make the conference theirs again. Being tracked as nothing more than a roving sales prospect is just insulting. HIMSS apparently doesn’t extend its claimed interest in patient privacy to its own paying customers in the Ladies Drink Free model in which it pimps access to low-paying providers to high-paying vendors.

AHRQ spends $26.5 million of its ARRA money to hire a high-powered PR agency. Ogilvy Washington will “market and promote” the findings of Patient-Centered Outcomes Research in a newly created Publicity Center. I didn’t volunteer to have my taxes used for wasteful economic stimulus projects, but if I had, I’m pretty sure dozens of millions for a HHS PR wouldn’t have been on my list even though the general idea of comparative effectiveness research is a good one (but hugely expensive – $1.1 billion in stimulus money).

Four NICU babies in a hospital in Canada are given insulin instead of heparin in their TPNs, killing one of them.

Shares in athenahealth jumped by 23% on Friday after good Q3 numbers that beat estimates.

E-mail me.

From BeKind: “Re: the Senate Committee on Veterans’ Affairs testimony about MUMPS. This dialog occurred at 75:26 in the video.”

Senator Richard Burr: If you maintain MUMPS can the private sector have full access into the VA system, into the MUMPS system, for the exchange of electronic information?

Roger W. Baker, Assistant Secretary for Information and Technology, Department of Veterans Affairs: I would answer it this way, I believe just as much as if we implemented it in any other language because at the bottom it’s the data that’s important.

Senator Burr: Let me turn to Mr. Tullman if I can just simply because he’s out there. Now, let’s see what the limitation is.

Glen Tullman, Allscripts CEO: What I would say is again that you can extract data from any system. What we’re really talking about, and I don’t want to get too technical, is the native exchange of information. So you can pull information out of a mainframe system and put it into a PC if you want two people to talk to each other. The question is why would you do that when you could have two PCs that were talking with each other? So again we think MUMPS was the right decision to make when it was made. We think there’s a reason to carry it forward. We’re just saying as we go forward into the future we need to broaden the understanding of what systems to use, what architectures to use, and what the general reason we need these systems for and that is for communication and I think that’s this idea of this community is important and no one’s using MUMPS to build systems that communicate and exchange data efficiently today in anywhere else but the US government.

Wow, there’s a lot of interesting stuff in this video of the committee meeting, which runs two hours (meaning I didn’t listen to every word yet). The chair, bless his heart, leads off by reminding everybody that the VA and its contractors flopped big-time with CoreFLS and the projects it had to kill because they weren’t being managed well. Ed Meagher talks about the VistA Modernization Committee’s recommendation to put VistA on a stabilization program while developing its replacement. Glen criticizes MUMPS-based systems (meaning not just VistA, but his company’s competitors Epic, MEDITECH, QuadraMed, etc.) and saying the military’s evolution requires new EMR requirements for data sharing. He also says its replacement should be either Microsoft-based or open source (technically, VistA sort of open source, so I assume he means non-MUMPS open source). He says its time for the government to learn from the private sector.

Tom Munnecke, a former VA guy who helped build VistA, testifies at around the 61 minute mark. He credits the original VistA developers, all of whom were clinicians turned developers, for its success, starting it with “good enough” and then refining it from field experience instead of sitting around writing specs. He said MUMPS criticism isn’t new, going back to the beginning, but it works and has been stable. He likes the open source idea for a VistA replacement but cautions against throwing out the lessons learned from VistA. He also advocates additional forms of communication other than the EMR, saying that 25% of VistA’s use was the Mailman app used to simply communicate among professionals (comparing that to today’s social networking). He talks up personalization that can be delivered by cheap, easily implemented tools.

The chairman also asks VA CIO Roger Baker directly what assurances he can give that they won’t screw up again like they did with their replacement scheduling system. He cites the VA’s cancelled or retooled projects as proof that they’ll kill projects with minimal chance for success (the “fail fast” approach of identifying and killing the dog projects fast before they cost too much). Munnecke agrees, but says users need to scale back expectations and allow the software to develop instead of going for the gold-plated Cadillac upfront.  

Munnecke: “Mr. Tullman’s comments have a number of technical issues that I think we need to talk about over coffee some time, but I probably largely agree with his conclusion. I don’t want to be characterized as pro-MUMPS. I do want to be characterized as having a very successful legacy system that has accomplished a lot and just going with the standards of the information technology industry and thinking we’re going to take the shiny new technologies and word on PowerPoint presentations and develop a successful system is not going to work.” When interrupted by Sen. Burr’s comment that he’s never heard anybody comment that DoD actually has working EMR software and wondering why it’s so hard to send DoD medical records to the VA, to which Munnecke replies, “I think you’d have to look at DoD actually throttling back CHCS and crippling the features that were design into it for communication in order to protect their bureaucratic stovepipes.”

Sen. Burr’s summation (in which he repeatedly refers to VistA as “the MUMS system”): “It is absolutely essential, in my estimation, that private sector companies buy in to what technology decisions you make at VA because of exactly what Mr. Tullman references, and that’s that this is no longer our population of people that we’re taking care of. They’re bouncing back and forth … if we want to reach the efficiencies long-term of private healthcare, as most have realized, then we’ve got to have this interoperability solved … if a company like Allscripts, a leader, is questioning whether they’ll be able to exchange through your system, I think we ought to pause for a minute and talk to those companies and find out what is your concern …”

Then came the comments BeKind mentioned above. Sen. Burr mentions that three people in the room have iPads, yet soldiers returning from the military hospital at Landstuhl have paper medical records taped to their chests, saying that the VA should collaborate with the private sector.

News 10/22/10

From Wee Man: “Re: [vendor name omitted]. The rumor you recently ran about halted implementations and delayed upgrades for [product name omitted] is true, I’m 95% certain. Also, the same company’s flagship clinical product line [product name omitted] is going to maintenance-only.” I’m chickening out in naming the company since this is big news if it’s true and I’d hate to get in trouble just in case it’s not. I’ll say just this: the non-anonymous source is a good one, this rumor fits with some earlier stories and customer survey results that I’ve run, and some mighty big hospital systems are going to be super PO’ed if it’s true. If you have confirming evidence, send it my way.

From FormuLarry: “Re: Micromedex. They’ve released free versions of their drug information application for the iPhone and iPod. It’s not as slick as Epocrates, but the price is right.”

From Stifler’s Mom: “Re: Epic certifications. Can anyone share the exact numbers of certified people out there for products like Prelude, Bridges, Beacon, Cadence and the year/version? Also whether they have clinical backgrounds?” I’m pretty sure there’s only one source for that information so I wouldn’t get my hopes up, but if anyone knows, send it over and I’ll forward to Stifler’s Mom (I gave this non-anonymous HIStalk pal that name years ago and she adores it, not to mention it makes me cackle every time because I have a puerile sense of humor).

From Broadway Joe: “Re: Keane. Being purchased by NTT Data for $1.2 billion.” Rumor is that the Japanese company (part of Nippon Telegraph & Telephone Corp.) is in advanced talks to buy Keane, which is half owned by Citigroup. The deal is imminent, Tokyo newspapers are saying. Keane offers application, BPO, and infrastructure services, not to mention its healthcare presence (Keane Healthcare Information Systems), which markets the Keane Optimum system and other products.

From Oops, Here: “Re: glitches. We are not aware that any of these patients were injured after death.” Errors in loading UK driver’s license organ donor information to the NHS databases cause the wrong organs to be removed from 25 donors. Nobody noticed until prospective donors (the ones not already dead, in other words) complained that their information was wrong.

From Matt Mucha: “Re: my blood pressure chart. I’m a Web developer from Krakow, Poland who also happens to have hypertension. I created a tool to let people keep records online and share them with a doctor. I know you’ve written healthcare apps in the past, so I hope you can relate :). Check out the video and forums. I’m not profiting from the site in any way.” It’s a pretty slick with a clean design. Nice job. Take a look. 

From Greed Earns Justice, Eventually: “Re: McKesson/HBOC scandal. Sales SVP Dominick DeRosa pleaded guilty in 2000 to one count of aiding and abetting securities fraud by hiding side agreements to manipulate revenue recognition. This past April, the judge overrode the prosecution’s request for probation and sentenced him to a year in federal prison. While waiting 10 years for his sentence, he appears to have built quite a resume, serving as CEO of OneWeb Systems, VP of sales at Transcend Services, and executive VP of sales at CareMedic. Rumor is that he was at MedAssets before getting the bad news about jail. Mastermind and former president Al Bergonzi is apparently doing his 41 months in Atlanta after being given more time than the prosecution requested. He’ll get out Christmas Eve this year. He’s been doing consulting work for former friends and one of the many HBOC acquisitions he coordinated. CEO Charlie McCall, who almost got off, is due to be release in 2019. Controller Timothy Heyerdahl was released in 2008 and CFO Jay Gilbertson was released earlier this year. I wouldn’t be surprised if he’s still in HIT somewhere.” He didn’t even mention Jay Lapine, one of few corporate counsels to ever be indicted for securities fraud (he got off on criminal charges a year ago and then settled the civil case against him, barred by the SEC from involvement with publicly traded companies for five years). McKesson’s executives, desperate back in 1998 to prove they could run something sexier than drug warehouses, paid Charlie $14.5 billion for a company everybody knew was a house of cards ready to collapse if he couldn’t fast-talk some rubes into taking it off his hands in a hurry. He did, with the announcement of the accounting scandal just a few months later evaporating $9 billion in McKesson shareholder value in a single day (the stock went from around 90 to less than 20 and still hasn’t hit that level since). Not to mention that a lot of HBOC software was as crappy as their corporate books, also widely known by nearly everybody. It’s always ugly for the foot soldiers when greed meets stupidity. Sorry for the rant, but what those guys did to McKesson’s employees (many of them unfortunate conscripts due to HBOC acquisitions), their hospital customers, patients, and to the industry really ticks me off even after a decade. 

Hosted pharmacy applications vendor MedKeeper announces its acquisition of DoseResponse from Keystone Therapeutics, a competitor in outpatient anticoagulation management software.

I mentioned the 21-year-old Georgia computer tech who was arrested for accessing a hospital’s computer system. I’m beginning to think he got a raw deal. He was working on a physician group’s hospital connectivity problems and documented seven problems with the hospital’s server, hoping to impress the hospital enough to land him a job. The hospital CIO and security person met with him, asked him for a copy of his resume and a list of the problems he found, and then came back in with police officers to arrest him. The kid’s been in jail since last week, with the hospital claiming he’s a danger to them since they can’t fix the problems he cited without outside help. Maybe the hospital should swallow its pride, admit its apparent security incompetence, and hire the kid cheap.

Acuitec announced its iCare mobile anesthesia apps for the iPhone, iPad, and iTouch at the American Society of Anesthesiologists conference in San Diego this week. Jessica sent me a press release that I can’t find online anywhere to link to, so you’ll have to take my word for it. The above is a shot of its Vigilance remote presence monitoring system running on an iPad, which I found while looking unsuccessfully for the press release. The Birmingham-based company is a joint venture with Vanderbilt University.

HIStalk pal Justen Deal sent over a position listing for “geek interns” at his Vieu Health startup that was a fun read (he’s a really good writer in a Joel On Software kind of way). I was hooked enough to read the whole thing. If you’re a techie and want to be underpaid (so Justen says), but live and ski free at a resort, get a MacBook Pro and a BlackBerry Torch, and work with “misfits, rebels, square pegs, and troublemakers,” you might want to connect with Justen. I have no idea what Vieu Health is building since they haven’t said yet, but it’s something to do with electronic health records and networks. Maybe I should follow his lead and get some interns myself since I always seem to be buried.

Former NaviNet SVP Tim Mills is named VP of sales and marketing of revenue cycle management company Avisena.

The Toronto newspaper profiles the involvement of Telus in Canada’s move toward digital healthcare. It mentions that Telus provided the software and technology behind The Ottawa Hospital’s plan to buy 3,000 iPads to run on the Telus-provided wireless network to access an aggregated database. That hospital’s CIO says the information needed by key staff members that is available electronically has gone from 30% in 2008 to 100% now. It also mentions the Oacis product, mentioned several times here previously. The healthcare division of Telus is bringing in $400 million a year. It’s a well-done article. Somehow Telus Health seems to come in under the radar in the US, but it’s an impressive operation run by a a large telecommunications company.

Cardinal Health Foundation will award $1 million in medication and OR safety grants in 2011 for the fourth consecutive year. Applications are due by December 3, 2010.

The Chicago Sun-Times covers the local healthcare use of iPads: University of Chicago Medical Center will give iPads to all of its internal medicine residents, a plastic surgeon uses her to explain reconstructive surgery to breast cancer patients, and one hospital says at least half of its ED docs bought their own iPads once they found that they could use the EMR on them.

Jobs on the HIStalk Sponsor Job Page: Clinical Executive Physician, Clinical Executive Nurse, Healthcare Consulting Lead. Platinum sponsors get free listings there. On Healthcare IT Jobs: Epic BSA Ambulatory EMR, Clinical Product Specialist, Epic Consultants.

In Germany, CompuGroup Medical AG says it will invest $180 million in its software over the next five years, most of that to further develop its Software Assisted Medicine medical knowledge system.

Ontario’s health administration is slammed by an auditor’s report that found the same expensive practices previously found in eHealth Ontario scandal last year: single-source contracts, overpaid consultants, and excessive expense reimbursement. One temporary executive who was making $275K per year billed the hospital an extra $150K for helpers, $14K for bonuses, a Christmas lunch, and world-wide travel, including $500 in telephone charges in one hotel stay.

Q3 numbers for UnitedHealth Group, parent of Ingenix: revenue up 9% to $23.7 billion, with net earnings of $2.15 billion in earnings from operations, easily beating expectations on revenue and earnings. The company gave guidance of $94 billion in revenue for the fiscal year. Ingenix revenue was $592 million, up 23%, with $70 million in earnings from operations. The announcement also gave the cost of the Q3 acquisitions by Ingenix (Axolotl, Picis, and A-Life Medical, I assume) at $1.9 billion in cash. UnitedHealth market cap is $41 billion.

Odd lawsuit: a couple says a waiter at the local Steak ‘n Shake gave their child a bottle of Blair’s Mega Death hot sauce for his chili, causing him to break out in hives (assuming the child wasn’t hitting the restaurant on his own, maybe the parents should have intervened). They’re suing for $10,000 in compensation and $50,000 in punitive damages.

E-mail me.

HERtalk by Inga

CMS incentive payments are taxable. That’s the opinion of Steven Waldren, director of AAFP’s Center for Health IT. I’d never really thought about it, but that hardly seems fair. Definitely not nice.

Cerner Ambulatory tops the list of a recent Ovum report entitled Selecting an Ambulatory EHR Vendor in the Healthcare Market. I mentioned this on HIStalk Practice yesterday, but it perplexes me so much that I’m also asking HIStalk readers to share their impressions. I don’t know much about Ovum (which is a division of DataMonitor) so I asked them to provide me more background on their research methodology. No response as of yet. Cerner, along with eClinicalWorks and GE Healthcare, make their short list of top vendors based on strong brand names “in the ambulatory market” and for demonstrating “market-leading positions.” The report also says Cerner is the “most versatile and multi-faceted” of all the vendors reviewed (which included Allscripts, Sage, NextGen, athenahealth, and Amazing Charts.) To be fair, I know Cerner ambulatory by reputation only, so for all I know Ovum is spot on. The Cerner folks have graciously offered to dispel my skepticism and asked me to stop by for a demonstration at MGMA next week.

Follow-up: back in March I mentioned the former MedAssets employee who was arrested after using a fake identity to get her job and stealing financial information on more than 1,200 patients. Katina Candrick was sentenced to 10 years and ordered to pay more than $163,000 in restitution. As I was looking for a photo of Candrick, I noticed that in 2008 she had been charged with fraud, falsifying identity, and fraudulent possession of a controlled substance after posing as a medical clinic employee and attempting to pick up prescription drugs at a CVS pharmacy.

HealthGrades says that overall hospitals are improving, but the gap between the best- and worst-performing hospitals is substantial. A typical patient would have a 72% lower risk of dying in a 5-star rated hospital compared to a 1-star rated hospital, and a 53% lower risk of dying by going to 5-star rated hospital compared to the US hospital average.

Baptist Health System (AL) contracts with Passport Health Communications for Passport’s IntelliSource software for revenue cycle management.

Virtual Radiologic is named the top-rated vendor in the KLAS Teleradiology Study 2010. KLAS notes that teleradiology contracts had historically been held by local radiology groups, but now hospitals and clinics have 40% of the contracts. Look for teleradiology volumes to rise in the next few years.

athenahealth posts a 33% in increase in third-quarter revenues ($63.1 million vs. $47.4 million). Excluding one-time items, the company’s net income doubled from last year, coming in at  $6.4 million or 18 cents per share. Analysts were looking for a 27% increase in revenue and 13 cents share. Basically, a darn good performance. The always entertaining Jonathan Bush will provide more details at 8:45 a.m. Friday on CNN.

AirStrip Technologies collaborates with Sprint to offer a bundled solution that includes Sprint’s clinical grade in-building coverage and AirStrip services for hospitals agreeing to expand or extend an enterprise commitment to the Sprint network for more of their employees.

Thomson Reuters releases a new version of Clinical Xpert Navigator mobile for iPhone, iPod Touch, and iPad devices.

Lots of good stuff on HIStalk Practice this week: in addition to the usual posts, we feature several HIT Vendor Executives who shared their opinions on what attendees will be discussing next week at MGMA 2010 in New Orleans. We also published a handy vendor guide summarizing what each of our exhibiting sponsors will be highlighting at MGMA (you can download a PDF to print and take along). Do us a favor: stop by their booths, ask for a tour of their offerings, beg for a trinket, and tell them thanks for powering HIStalk and HIStalk Practice.

Sponsor Updates

• Greenway introduces PrimeSPEECH, an integrated direct-to-EHR speech technology and PrimeIMAGE PACS solution. Both solutions are fully integrated with Greenway’s PrimeSUITE EHR and physician workflows.
• MED3OOO acquires health benefits consulting firm Insurance Solutions Group.
• Voalte partners with Meru Networks to extend its capacity in hospitals running the Voalte application. The company also announces a trial at Parkview General Hospital (IN).
• For the third year, Vitalize Consulting Solutions earns a spot on the Philly 100 List, coming in as the 57th fastest growing privately held company in the greater Philadelphia area.
• Bronx-Lebanon Hospital Center selects the Allscripts Care Management solution, which will integrate with the hospital’s existing Sunrise Clinical Manager system. Bronx-Lebanon also recently deployed Allscripts solutions in its ED and 40-physician multi-specialty practice.
• SRSsoft is named to Deloitte’s Technology Fast 500, which lists the 500 fastest growing (by revenue increase) high-tech companies.
• MedPlus parent company Quest Diagnostics releases its Q3 financials: revenues of $1.9 billion, down 1.7% from last year; net income rose to $198 million ($1.13/share) compared to $192.2 million ($1.02/share).
• McKesson signs an exclusive agreement with MedVentive to offer that company’s SaaS-based Analytics Advisor analytics solution to the payor market, where it connects payors and providers transparently around clinical and financial performance metrics.

I’ll be traveling to New Orleans this weekend to attend the MGMA conference. I’ll be on the lookout for cool HIT stuff, collecting giveaways, and hopefully learning a few new things. Look for updates and photos.

E-mail Inga.

HIStalk Interviews Kevin Maher, VP, McKesson Health Solutions

Kevin Maher, MHA is VP of product and outcomes management at McKesson Health Solutions.

Give me the elevator pitch on Personal Health Advisor.

I think about Personal Health Advisor as a multi-channel consumer engagement platform at its highest level. It’s really aimed at helping consumers to help them utilize online health tools and, in general, to provide consumers with both inbound and outbound health advice, recommendations, and services.

Who is the targeted user or customer?

The targeted users are health plan members and the target clients are typically health plans, which I would describe as any organization that holds some degree of financial risk for a population. That could translate into at least three segments. Certainly the payer segment, which is where we are focused today. Second, the employer in the self-insured employer market. Third would be the kind I like to describe as the fledgling ACO market.

There’s always a survey claiming consumers want to use tools like secure e-mail, personal health records, and assessment tools. So why don’t they?

I think our point of view on that would be that a lot of the lack of use goes to a few things. One is not enough skin in the game overall today. I agree that consumers are still largely shielded from the financial cost and burden of delivering healthcare.

I think a second issue we’re dealing with is who’s the trusted source for information — the payer or the provider? Our position is that the provider is a much, much better trusted source than the payer, so anything sponsored by the payer — or potentially, by the employer — in and of itself will create some barrier to use.

I think some of those barriers can be removed if the design of the benefit structure encourages the use of online, member-focused tools, which is what we are beginning to see with the clients that we’re working with on this solution.

So you’re saying an insurance company might say, “Sign up for our personal health record and get a gift certificate or get a discount on your premium”?

Correct, and it has to be meaningful. I think what the research has shown, and what we seem to see, is at the individual level, you’re talking somewhere around $500-$600 a year. You’d need to see that level of impact — the consumer would need to see that, and at the family level, at least double that to $1,200 or so — to really move the dial on engagement.

So to your point, without the right level of incentive, we’re seeing use rates in the single-digit range. When we see that level of benefit impact, whether or not it’s discounts or reductions in premium or gift certificates, we can see engagement rates upwards of 50%. That seems to be the big dial that the payer has ability to control and throttle.

When they provide these incentives or whatever encouragement that form takes, how do they do that beyond “you have to complete a questionnaire”? Are there targets that encourage actual outcomes that are wellness related and not just looking at a screen?

I would say that there are probably a few health plans that have moved to outcomes. Or, I wouldn’t even say health plans. I would say more employers, that have moved toward more outcomes-based rewards model, vis-à-vis the Safeways of the world.

I think most of the market is still on “perform an activity and we will reward you.” I think that transition from activity to outcome is likely to be a 3-5-year transition, but we’re certainly beginning to see clients thinking about using more biometric results to ultimately get that, or give that reward. So, whether or not it’s some kind of annual biometrics that’s evaluating blood pressure, LDL panels, BMI — that’s certainly the early, preventive information that consumers need to know about.

More employers and providers also talk about the use of Bluetooth wireless devices that are providing more immediate or more continuous feedback on some of those key metrics versus a 12-month look at it. But I would say again, most of the market today continues to be focused on — and I say this because it’s the reality and it’s relatively still a new concept — but most of the market is paying for activities today. That activity could be, to your point, completing a HRA, participating in a program, getting the biometrics done, seeing their physicians for preventive care testing, etc.

McKesson operates a 24-hour-a-day nurse hotline. In terms of a key differentiator, what resources does that require on McKesson’s end and what infrastructure do you have in place?

We’re the company that was formerly known as AccessHealth, which was actually the first company that offered a nurse hotline to the payer market. We, today, have about 30 million lives under management that we’re providing nurse line services to.

Approximately 600 nurses is a major differentiator. I mean, it provides that human channel, and I think a number of things that we are doing to tie the offline world and online world are, for example, nurses or nutritionists or pharmacists we have available. So we think about our line as a clinical hotline, not just providing nurse recommendations for acute health problems.

The nurses reinforce getting the preventive testing. They’re able to use that information to reinforce the availability of incentives that the sponsor is offering if a member performs a certain function. A clinical staff has the ability to push content after a call to a secure message center as a reminder — could be content, could be videos.

The ability to take information from provider, member, and health plan data and make that information exposed to the nurse, and make that nurse or that clinician smarter about the member’s health. Remember when we get that data, we’re able to push content from the call center or from a telephonic interaction into an a member care plan and tie those two again, those two different worlds come together through the integration of data.

I’m interested in the data sources that the Personal Health Advisor can collect and put together for the subscriber to review.

We have core data sources as follows. It’s basic member eligibility information. It is provider linkage information of provider files, again, from the payer. Medical claim information, pharmacy claim information, HRA health risk assessment information; and biometric information. And the biometric information at this point is contained to blood pressure, BMI, validated smoking cessation smoking status, and the lipid profile.

One of the things that interested me after the e-Patient Dave fiasco at Beth Israel Deaconess was information that may be correct or meaningful for billing purposes that may not be something that a consumer should be turned loose to interpret. Is there any level of oversight or preparation to ensure that what lay people see on the site is something they won’t misinterpret?

The medical claims, I think, is where it gets dicey. What we’re doing there is all of that information is being coded. It’s being coded using the SNOMED standard terminology codes. When members see that information in their personal health record, all they need to do is basically hover over whatever detail is on the page.

Say one of the line items was diabetes. You hover over that, click on it, and it presents a consumer definition of whether or not is was a diagnosis or a procedure code. It provides a consumer again, some sort of definition associated with each of the pieces of information that are being generated by claims data.

Underlying that is that we have mapped all of our clinical reference system content, and you may be familiar with that content. That content, historically, was sold into the provider market, continues to be a strong leader in the provider market. Providers historically printed these kinds of one- to two-pagers out for their members when their members would leave the office, explaining what their upcoming procedure was or their condition is that they’ve been recently diagnosed with.

That’s how we’re handling that pure medical information.

Who do you compete with in reaching the consumer and how is your offering different?

There are two or three big competitors that we see. I think, first and foremost, is WebMD. I think what’s different about our solution than WebMD probably revolves around the point that you made earlier — the telephonic channel, in addition to just the online channel. That’s number one.

I think, secondly, I’m not sure I’ve seen a whole lot of momentum or press release around extending the channel to a mobile channel. We’ve added three capabilities to our mobile channel for PHA. One includes taking the PHR and making that available through the mobile device. Second, is a pharmacy adherence tool. Third is a messaging tool that leverages our clinical staff.

I think it’s the telephonic channel and the mobile channels that we believe are our key differentiators from a WebMD. And then we’ve got our classical health management payer/employer competitors such as OptumHealth, Health Dialog, or Healthways. But we also see ourselves competing with other services that would be competitors of A.D.A.M. I mean, those are potential partners, longer-term.

Do your offerings leverage RelayHealth’s tools?

We looked at that. We do not leverage the RelayHealth tool today, but certainly know that long term, we’re going to need to figure out — along with the rest of the industry — how do you tether this PHR closer to the doctor? I think that’s a downfall in any PHR that is not somehow associated with, tethered to, or connected to that provider’s EMR. We know that’s a challenge we’re going to have to solve in order to make that PHR ultimately more valuable to both the member and the provider.

Quite frankly, the reason we did not reevaluate that when we were first building that, and the big drawback that we could not solve with Relay, was the belief that in the markets that we were selling to, that we needed to be able to pre-populate these personal health records with some type of information in particular, given that we were focused on the payer market.

We felt that we needed to be able to pre-populate this information with claims, and I think we all are aware that there’s significant … it goes back to one of your questions about ‘why aren’t these tools used as often as they are?’ At the time, clearly one of the big feedbacks that consumers were giving around PHRs is too much time to populate that information. We wanted to remove that barrier by pre-populating, and unfortunately, Relay did not have that capability.

What tools are needed to make a difference in either improved outcomes or reduced costs?

I think we think several things. We need to continue to evolve this solution to provide tools that focus on members that are driving the spend, which typically are members with chronic disease. I believe we’re going to need to add a number of features, both through the mobile channel as well as the online channel, that focuses on members with chronic disease.

I think number two is something that we’re working on right now that would tie together the concepts of multi-source data, number one.

Number two is using this data, and then be providing very clear information as it relates to this data — where they can go to take part in programs that utilize this information and where they’re sitting on this data. So are you in range or out of range on your blood pressure or whatever? Letting the member know what the incentive opportunity is and then making it clear in a single view. What are the activities, or what are the metrics you need to get to in order to collect that measure?

This is something that we’re working on right now. We’re calling it a Health Report Card, but it’s literally, you can think of it as a stoplight report — a red, yellow, green report that is a single view, that again, pulls together all of the major sources from claims data, self-reported data, biometric data – that presents whether or not incentives and opportunity, and if an incentive is an opportunity — if the member has to do these three activities, all in a single view — I think we view that as a critical aspect as well.

Pulling together the pieces from the various tools into a single actionable view for the member, and I think ultimately, this data — because of the conversation we had — needs to be able to be accessed to the provider as well. So much of this comes down to — is the provider also focused on making sure that the member’s getting the preventative testing that they need and helping support the messages that the payer is trying to deliver to that consumer, in terms of behavior change?