News 9/29/10

From Waterkeeper: “Re: CPOE reality. Another example.” A study finds that electronically preventing entry of CPOE orders for concomitant use of warfarin and sulfa drugs did great at preventing the potential drug interaction, but also delayed treatment in patients for which the simultaneous use was appropriate, causing Penn researchers to stop the study early as being unethical. Says the lead author: “[It] worked extremely well, but putting it in place actually hurt people … it’s naive to think that CPOE 1.0 is going to be perfect. This is a clarion call for continual evaluation of whatever we’re doing in terms of electronic interventions.” You’ve read it here in various interviews, but it’s worth reiterating: CPOE isn’t done just because it’s live and doctors are using it. That’s where the scientific work should begin, but unfortunately usually doesn’t as everybody declares mission accomplished and moves on to some other fire du jour that requires extinguishing.

From EMR Salvage Here, Can’t Bill There: “Re: downtime in Pittsburgh.” Included was an August e-mail to providers purportedly from Medical Service Associates, apologizing for problems in which a network failure led to the discovery that backups couldn’t be restored from either their own two backup systems or the two of their vendor. At the time of the late August e-mail, they still hadn’t restored anything from before the downtime. All unverified and most likely not the final word on the situation there, but my takeaway from experience is the same as always: backups don’t work at least half the time.

Inga e-mailed our sponsor contacts today about a little get-together we’re having for them in Orlando at HIMSS, separate from our Monday night HIStalk reception (nothing too fancy since it’s on a blogger’s budget, but sincere nonetheless since we really appreciate our sponsors). Response has been brisk, so if you’re the boss and haven’t heard about it, check with your internal person before we run out of space. If your company is on the fence about sponsoring HIStalk, we can probably make room if you sign up soon. Plans for the Monday night reception are progressing nicely as well. Expect a big evening that will go a bit beyond our usual food, drinks, and HISsies (running until late, so pace yourself). Stay tuned.

New readers sometimes get confused about who writes what on HIStalk, e-mailing the wrong one of us about something the other wrote. Here’s the deal: Inga writes the part starting with “HERtalk by Inga.” I write all the rest. I do most of the interviews, but I should mention that Inga did the most recent one with Doug Ardoin. And it’s all Inga on HIStalk Practice. Clear as mud, right? She and I are kindred spirits anyway, so we’ll figure it out.

Medical office patient check-in vendor Phreesia completes a $20 million Series D equity financing round. Jumping in is Ascension Health Ventures, the $325 million strategic healthcare venture fund of Ascension Health. 

Strange: a hospital trauma nurse gets a 2 a.m. call on her cell phone from the California Donor Network, with which she’s familiar because of her job. They tell her that her brother has died and they need her permission to harvest his organs. Agitated, she goes to her other brother’s house and they call their sister-in-law to console her, only to hear the sleepy voice of her I’m-not-dead brother asking what they want. The hospital had given the donor group the wrong contact information, that of a patient with the same name but spelled differently. The hospital can’t explain the mistake except to say that the information was wrong when they switched computer systems in 2005. The coroner’s office claims they would have caught the mistake before taking the organs of decedent with the wrong family’s permission.

HHS’s open source CONNECT program wins the 2010 Wall Street Journal Technology Innovation Award for health IT. Runners up are diagnostic image sharing platform vendor lifeIMAGE (I interviewed CEO Hamid Tabatabaie a couple of weeks ago) and Disease Precursor Identification from Ingenix, which identifies people at risk for chronic diseases. 

Munroe Regional Medical Center (FL) says it dropped ED-door-to-balloon time for heart attack patients to 48 minutes, below the national average of 62, by using incident command management software from LiveProcess to manage the Code Blue calls.  

A Weird News Andy find: NewYork-Presbyterian/Columbia University Medical Center admits that someone accidentally opened up a server containing ICU patient information to the Internet. A patient’s family ran across the information via a search engine and told the hospital. I can’t decide which is more annoying about the hospital’s name: that it’s absurdly long with dashes and slashes or that they insist on conjoining New York into a single word for no apparent reason. 

RIM previews its BlackBerry PlayBook tablet device. Like the Torch, I doubt it will generate much consumer interest, especially since it may work only on WiFi, not 3G/4G. That’s speculation since it’s not coming out until next year, making the video a bit premature in its lost cause of convincing iPad prospects to hold off. Businesses will probably like it, though.

The National Quality Forum endorses performance measures and preferred practices for care coordination. Among the latter is electronic medical records.

Ed Marx has updated his Tool Time post with responses to your comments.

Here’s another bad HIT press release, replete with enough odd phrasing, incorrect punctuation, and bizarrely missing information (like the names of the company’s president and the customer who are both quoted) to make it seem highly unlikely that the writer speaks English as a first language. Not that there’s anything wrong with that, but the company is in Minneapolis, where English is pretty common (albeit with a cute accent, like in this horrible, sappy movie that I just played from Netflix for Mrs. HIStalk while I pretended to watch while daydreaming).

The Canadian government will spend $500 million on EMRs in the next fiscal year, with $380 million of that going toward implementation.

ClearPractice announces GA of Nimble, which it says is the first comprehensive EHR for the iPad. It connects to the company’s cloud-based system by WiFi or 3G. Or maybe it’s not the first after all: an updated press release omits the “first” reference and fixes other unspecified errors in verbiage. The release came from a PR company, but it’s never encouraging (in a “Quality Is Job 1.1” kind of way) for a software company to let obvious mistakes get out the door. And in another tactical error, there’s a beautifully made demo video on their site (where I grabbed the screen shot above) that you’d be watching right now if they were smart enough to make it embeddable like everybody else does who wants widespread exposure for free (it’s called YouTube, people). Now I’ve lost interest.

Deborah Peel, MD of Patient Privacy Rights comments on an Information Week article about healthcare data breaches.

I don’t need a cell phone, but I’m thinking about getting the new model of the iPod Touch for running apps, checking e-mail where there’s a WiFi connection, and playing music and video. Good idea or not? I thought it was perfect until I read that Apple had to downsize the camera resolution from 5 megapixels to one to fit into the slim case. Still, it seems like a good deal for $299 for the 16 GB model.

Mohit Kaushal, MD joins West Wireless Health Institute of EVP of business development and chief strategy officer. He was a key player in developing the healthcare portion of the FCC’s national broadband plan, which includes mobile health, when he worked for that organization.

Bob Mitchell, former editor of the dearly departed ADVANCE for HIE, interviews John Glaser about his new job as Siemens Healthcare CEO.

Deaconess chooses Omnicell for medication management.

The Greater Dayton Area Hospital Association (OH) signs up with the HealthBridge HIE.

It’s funny today how many car problems are fixed with a software update. The same is true for implantable defibrillators, for which a new upgrade checks for electronic problems that indicate wire integrity problems that could cause patients to be shocked inappropriately.

Costs of Care, a Boston-based non-profit whose goal is to reduce healthcare costs by giving providers pricing information as they make medical decisions, announces a national essay contest. The best anecdotes from doctors, nurses, and patients illustrating healthcare cost awareness will earn $1,000 prizes. The judges are former HHS secretary Mike Leavitt, Atul Gawande, Tim Johnson of ABC News, the dean of the Harvard Medical School, and Mike Dukakis. Entries are due by November 1. The group, founded in 2009 by medical resident Neel Shah MD, plans to create smart phone and Web apps to provide pricing transparency.

A nurse at Seattle Children’s Hospital kills an ICU baby by mistakenly administering a tenfold overdose of calcium chloride. A 15-year-old died from a narcotic overdose at the same hospital last year.

InterSystems announces Cache’ 10, which adds database mirroring and a high performance solution for Java applications.

I’m totally behind, so be patient if you’ve e-mailed me. I’ll be vacating soon, which will dig the hole I’m in a week deeper, and then attending the mHealth conference to make the backlog worse, but my lack of timely response doesn’t mean I love you any less (that’s my go-to excuse when Mrs. HIStalk catches me paying insufficient attention to her or her movies).

E-mail me.

HERtalk by Inga

From Jellico Jerry: “Re: reality check. Loved your point today about Cerner and Epic, and which deals Cerner won vs. Epic. Cerner won sites with no $$ (UHS, Tenet). Although they are still significant wins, they are very different client bases.” In case you aren’t up to speed, KLAS recently reported that nearly 70% of 2009 hospital EHR purchases were for Cerner and Epic. A reader then noted that if one were just reading HIStalk, you’d think Epic had “cleaned everyone’s clock.” We countered saying Epic got the bigger, more lucrative deals that really count. Anyone who’s dealt with either or both companies knows that Cerner will darn near give the software away to avoid losing a deal, while Epic won’t discount a penny.

The Ohio Health Information Partnership (OHIP) names its five preferred EHRs from the 40 that were considered: Allscripts Professional; eClinicalWorks Unified EMR/PM Solution version 8; e-MDs Solution Series 6.3.0; NextGen Healthcare EHR; and Sage Intergy suite 6.0. Interestingly, OHIP requires that the selected vendors conduct all technical support within the United States.

Quality Systems, NextGen’s parent company, strikes a deal with Pricedoc.com to incorporate PriceDoc’s online search marketing tool into the NextGen Practice Management system. Pricedoc.com is basically a medical version of the travel site Priceline.com, giving patients the chance to name the cash price they are willing to pay for particular procedures or services. Sounds like the deal gives Pricedoc.com access to NextGen’s PM client base and Quality Systems gets a spiff when physicians and patients connect.

T-System releases DigitalShare, a new solution made possible through a strategic partnership with Shareable Ink. DigitalShare allows clinicians to document patient encounters on T-Sheets using Shareable Ink’s digital pen to capture the data. I first saw the technology at MGMA a year ago and made the Mr. H-esque observation/prediction that it would be great technology for the ER.

Lehigh Valley Health Network selects QuadraMed’s Quantim computer-assisted coding solution to help prepare for its ICD-10 transition.

Confer Health Solutions acquires MediHealth Outsourcing, an HIM and clinical revenue cycle company.

Providence Health & Services hires Summit Healthcare to provide dictionary management and data migration services as it moves to Meditech 6.0. Providence also purchases Summit InSync and Summit Scripting Toolkit technology.

GE was the overall leader in the US ultrasound market last year, according to Millennium Research Group. GE increased its lead over Philips and Siemens and now holds about 27% of the $1.2 billion US market.

Former Cerner Eastern US general manager Greg White is promoted to VP and managing director of the company’s Middle East, Africa, and India region. He replaces Rich Berner, who returns to KC as VP of client development.

Axolotl introduces Elysium Discover, a suite of reporting and analytic tools for HIEs.

Northwestern Medical Center (VT) goes live this week on its first phase of Meditech.

ChartWise Medical Systems signs a strategic agreement with 3M Health Information Systems to integrate 3M’s Grouper Plus Software the clinical documentation tool ChartWise:CDI.

Frederick Jelinek, one of the pioneers in the field of voice recognition, died earlier this month. I had never heard of him before reading this article, but he’s credited with enabling computers to understand English. While that accomplishment is significant in and of itself, Jelinek’s challenging background makes his work even more laudable. He was born in what is now the Czech Republic and his dentist/physician father died in a Nazi concentration camp. After his death, Jelinek’s mother moved her family to the US. He graduated from high school and took a job working in a factory to help support his family Jelinek later enrolled in night classes, studied engineering, and eventually earned a doctorate from MIT. He spent his career with IBM and Johns Hopkins University, creating the bones for today’s voice recognition systems. Isn’t that a great story?

Friday marks the first day of the hospital payment year for implementing certified EHRs and using them meaningfully. Guess it would help to have some certified EHRs out there.

Sponsor Updates

• eHealthAlign selects ICA as a strategic partner to technology and infrastructure for its multi-state HIE.
• maxIT Healthcare earns a spot on Modern Healthcare magazine’s list of Best Places to Work in Healthcare.
• Voalte VP Trey Lauderdale will participate in a panel discussion at next week’s CTIA Everywhere Healthcare event in San Francisco.
• MEDecision announces that its Nextalign iEXCHANGE 8.0 solution is now generally available.
• BridgeHead Software wins a contract with The Rotherham NHS Foundation Trust for healthcare data and storage management.
• Picis and The Sullivan Group (TSG) will integrate TSG Clinical Rules risk management solution with Picis ED PulseCheck.
• HealthEast Care System (MN) implements Ingenix Web.Strat medical coding technology, integrated with its McKesson HealthQuest billing system.
• EDIMS announces that its ED EMR clients can access the admission review service of Proven Healthcare Solutions, which offers a 30-minute guarantee.

E-mail Inga.

HIStalk Interviews Doug Ardoin MD, Physician-in-Chief, Memorial Hermann Healthcare System

Charles Douglas Ardoin Jr, MD is physician-in-chief of Memorial Hermann Healthcare System and president of Memorial Hermann Medical Group of Houston, TX.

What are your responsibilities at Memorial Hermann?

I’m involved with physician integration, physician strategy, business development, physician employment, that kind of thing.

Is Memorial Hermann considering creating an Accountable Care Organization?

Absolutely. Our goal at a company level is to continue to follow what changes, or what additions get addressed through those statements throughout the law that said, “The secretary shall.” We’re waiting to see what kinds of things may occur between now and January 1, 2012, but our goal is to definitely be prepared.

Here’s what’s interesting about this whole ACO thing. There are bundle payment demonstration projects going on around CV surgery. There are some of these ACO pilots that are occurring right now.

What I think is really interesting about this whole concept of Accountable Care Organizations is where in the law they describe what kinds of entities will be able to participate in some of these ACO demonstration projects, or will be able to call themselves Accountable Care Organizations.

What hasn’t come out yet, and I’m sure is going to have to come out from the federal government — almost like a Joint Commission certification or the NCQA designation for Patient-Centered Medical Home — that includes a real set of criteria that says, “OK, we’ve told you from a structure standpoint what’s necessary and what we’re going to allow.” But there’s got to be certain benchmarks that you have to hit so that when you apply to one of our ACO demonstration projects, we can say, “Yes, you meet our certification designation or whatever they’re going to call it to be an ACO and to participate in our ACO demonstration project.”

The thing is, none of that’s really been finalized. In the mean time, we’re keeping our ear to the ground saying, “What is that going to look like down the road?” But in the mean time, we know that we’ve got a very large hospital system in Houston, Texas with a very nice geographic footprint. We have acute care, post-acute care, emergency care, trauma care. We’ve got so much of the aspects of care covered. We have relationships for long-term acute care, and skilled nursing home help — all that stuff covered.

We have a relationship with our academic partner, the University of Texas, which has a large clinical practice group. We have our own employed physician organization. We have a very large IPA with over 3,000 physicians that is part of the Memorial Hermann system. We think we have all of the pieces of the puzzle, if ACO was a puzzle and you had to have all the pieces. We think we have it all to be able to connect it together.

I think we’re still waiting for the federal government to come out and say, “Here’s how you connect it. Here’s how you fill out the application so that you can get in the game.” I think we have minimal stuff we’ve got to go build or buy, so to speak. I think we’ve got just about all the pieces that are going to be necessary to put it together. That’s not to say that in some ways we’re not already engaged in or doing things that fit within the model of an Accountable Care Organization.

Like our family practice residency program. The Memorial Hermann Family Practice Residency Program was the first family practice residency program in the country to receive NCQA designation for Patient-Centered Medical Home. The things like that that we’ve done have been fortuitous. Things we’ve been working on over the last few years that we think, “Wow, OK, this positions us very well for this.”

Another good example is our independent physician organization, which is called the Memorial Hermann Physician Network. We’ve been, for the last four years, developing and engaged in our clinical integration model. So, much like the Advocate Physician Group in Chicago that’s probably been at it for over 10 years now, we’ve been at it for about four years. But, we’ve consistently followed all of the FTC guidelines and recommendations on developing our program.

We do have one clinical integration contract now and we’re looking at developing others. Our independent physician organization — the whole basis of clinical integration — is about high-quality, cost-effective healthcare where you get otherwise independent physicians to come together and agree to develop a quality platform amongst the physicians that’s both specialty-specific and for the organization as a whole. It buys a higher-quality care that we think creates a real differentiation in the marketplace.

In the ACO model that Memorial Hermann is considering, what would the governance structure be?

Right now, the law is not very specific, other than that they say that it has to be a shared governance model. Our intent would be to create a shared governance model so that you have — I don’t want to say ‘equal’ — but the correct representation of physicians and hospitals, and maybe the academic medical center and all of the right components.

We like the concept of the shared governance model. We strongly believe that it’s going to need strong physician leadership in that governance model.

As you’ve looked at what’s being proposed and the goals of the ACO model, what would you say are some of the bigger implications for both hospitals and individual physicians?

For years, hospitals and physicians have wanted to figure out ways to better align incentives around patient care, managing costs, and driving good revenues and things like that. I think physicians and hospitals have looked for some kind of a model that really pulls it all together. I think the ACO can potentially do that because the ACO, at the end of the day, is very much focused on the patient, where it’s really about how do you give the most highly coordinated, highest quality care you can give. Quality from the standpoint of process and outcomes.

How do you really give that high-quality care in a model that’s most cost-effective that can be efficient? I think it’s a way for hospitals and physicians to be fully aligned in that regard, because I wholeheartedly believe if you focus on the patient, you do the right thing by patients, then you shouldn’t have to worry about the money.

If you’re doing the right thing for patients, you’re giving them high-quality care. You’re not over-utilizing. You’re not wasting. You’re not ordering tests that they don’t need. You’re not leaving them in a hospital longer than they need to be where they can get an injury or an infection or something of that nature. You’re truly doing the right things for the patients. If you do that, I think the finances will follow suit.

But I think there are some issues here. I think there’s some upside and downside for patients. The upside for patients is the fact that patients will be able to get a sense that their providers are better connected, a better flow of information. That the continuum of care should be more seamless and patients should feel comforted by the fact that the federal government is not going to relax its quality standards. As a matter of fact, it will only enhance their quality standards over the years, so the ACOs will still have to give high-quality care.

I think the issue, though, is that there may be some impact on provider choice for patients. Because what may end up happening down the road — whether it’s through CMS or private insurance plans that decide to follow the same model — is that you’re going to see, in order to achieve the level of connectivity, information flow, quality, and cost savings, these networks are going to have to be rather exclusive to some degree. I think patients are going to have to be willing to accept the fact that, whereas there will be choice within the network, going outside of the ACO, outside of the network, is going to be detrimental to the whole purpose. I think there will be some impact on provider choice to patients.

I think some of the issues that the federal government needs to work through is this whole concept of continuing to pay fee-for-service for some kind of a bonus for cost savings because I don’t think that’s going to work. I see the government having to migrate quickly to fixed payment for certain procedures, like a bundled payment, and some other type of a fixed, bundled payment for populations of patients — almost like a capitation model — in order to really control costs.

I still think within both of those, there can be rewards for achieving certain quality benchmarks and cost savings as well. But the fee-for-service model, I don’t think it’s going to lend itself to the level of cost saving that the federal government is looking for.

Could the fee-for-service model, in time, go away?

I don’t know if it will go away or become significantly modified. Look, if doctors and hospitals continue to get paid on a per-click basis, then what’s going to prevent them from adding up clicks?

So that’s my concern about rolling this out and continuing to have it in a fee-for-service model. I don’t know that it’s going to drive the level of efficiency and cost savings that could be achieved without suffering the quality.

As healthcare moves more to the ACO or Medical Home models of care, what will hospitals and health systems need to do in terms of physician alignment?

I think what you’ll see are increasing models of integration. In other words, you may see more physician employment. You may see more PHO development — Physician Hospital Organization development — where physicians are still independent, but either through a PHO or an IPA model, they declare their loyalty to a hospital or hospital system. I don’t think that ACOs will necessitate employment of physicians, but I think it is going to necessitate a unique level of loyalty or exclusivity for private, practicing physicians who want to engage with a specific ACO.

What are some things that Memorial has done, or things you think need to be done, to effect change in physician behavior when implementing new models of care or even new technology?

Two completely different kinds of questions there. The technology issue really has to do with how disruptive the technology is. At the end of the day, you’ve got a certain generation of physicians who maybe aren’t as IT adept. Therefore, sometimes they have a hard time adjusting to new technologies. I think a lot of the physicians coming out of residency and fellowship today, because they grew up in the Internet age, are much more accepting of new technologies. Therefore, I don’t think that’s as big of an issue, but technology’s one thing.

Models of care .. I think what you have to do there is really work on the alignment of incentives. I think that when you start talking about creating a new model of care, it can’t be a zero-sum game, obviously, to the physician or to the hospitals. There’s got to be a consensus that drives a win-win so that both the hospitals and the doctors can benefit from a new model of care and the incentives can be aligned.

That means just as what’s been described in the ACO. Developing ways that cost savings can be shared back with the providers, both the physicians and the hospitals, is important. Or, rewards for reaching levels of excellence and quality. I think that’s important, too, where you can reward and align incentives around reaching certain quality benchmarks.

What are your thoughts on incorporating decision support tools into the care process?

Let me just say this. I’m a big proponent of always learning how to work smarter and not harder. In other words, why does a physician, every time they admit a patient to the hospital, have to sit down with pen and paper and go through the ADCVAANDIML of writing admission orders?

If you believe a patient has pneumonia, then why don’t you use a common pneumonia order set to admit the patient, or a pneumonia pathway that has flexibility within it to adjust it for the uniqueness of the patient? All of the basic things that happen every time are there. They get covered. You know they’re going to happen, therefore they don’t get forgotten.

I’m a big believer in using admission order sets or care pathways, these kinds of things. I think they’re smart. I think they work. There’s evidence in the literature that patients do very well when they’re placed on these things.

Regarding clinical decision support, I think their only issue there is that you have to worry about alert fatigue. I think you can overdo clinical decision support where physicians will be able to ignore the suggestions. I think that there’s a fine balance there as to how you offer that in the electronic medical record setting without creating alert fatigue, but I think it’s smart stuff.

I think any time you’re about to prescribe a medication that’s going to interact with the patient’s blood thinner and you hadn’t thought about it, you get a nice alert that says, “Whoa, didn’t you know they were on Coumadin?” or whatever. I think that’s perfectly fine. You’ve just got to be careful how often those things trigger and at what levels.

Does Memorial have much in place in terms of clinical pathways?

Yes. Not all of our hospitals are on computerized physician order entry. We have a few that are, and they use order sets and there’s clinical decision support tools and things like that that are being rolled out.

Shifting gears a bit, how will recent healthcare reform affect Memorial? Are there changes being considered or that are being put in place to control cost and improve efficiencies?

I would say Memorial Hermann is always engaged in continuous improvement around being more efficient, controlling costs better, etc. I don’t necessarily know that the healthcare reform law has changed what we’ve always done around here. We’re a not-for-profit, community-owned healthcare system. We always practice good stewardship of our resources, so there’s always that opportunity to look at how we’re doing things.

I think it’s going to impact us, though, just like it’s going to impact everyone else. You’ve got up to the 26-year-olds that you have to be able to offer insurance for under a family plan. The issues of the no-lifetime max, when that kicks in; issues of the no pre-existings, all these kinds of things.

Our health plan is self-funded and I don’t think we’ve ever, for employees or dependents, turned anyone down for pre-existing illness, but we’re going to have the same kind of pressures. We are a healthcare provider and healthcare system, so I think we will always do our best to provide a benefit for our employees.

But unlike us, I think there are going to be, maybe not so much in healthcare, but certainly other industries, where large employers and even small employers are going to have to weigh the option of — do I provide a benefit or do I pay the fine? Which is less expensive for me? Then let the employees get out there and get insurance on their own.

The other thing we worry about is really how strong will the individual mandates be? What are the chances that instead of more people having insurance, actually less people have insurance? You know, there’s always that chance that actually, individuals, if they’re not being provided insurance through their employer, may say, “Well then, I’m not going to go buy it on the open market until I absolutely need it.” So what are the chances that actually the uninsured will go up?

There’s just so much uncertainty and potential unintended consequences that the best I can say is we’ll just kind of hunker down and try to do our best to be prepared.

How is the health system positioned for qualifying for Meaningful Use?

I’m not the expert on that, but I can tell you according to our chief informatics officer, we are extremely well-positioned for Meaningful Use. I think we’ve hit all but one of the last remaining checkmarks. We’ve been named one of the most wired companies in America and all that kind of stuff.

Trust me, we’ve got an ISD team that’s second to none. We’ve got a leader there who is really, just a rock star, and he’s been with us for several years. Very well respected. We’ve done a lot of work in that area and I can assure you, we’re there. We’ve done a lot of work on that one.

What are your priorities for the next five years?

I can tell you that my boss, the president and CEO, Dan Wolterman, said that my number one priority is learning everything I can about Accountable Care Organizations and preparing all aspects of our physician organization to be prepared to move in that direction. That really is the number one thing.

A lot of it is working with our IPA and our clinical integration model to use that as a tactical platform to get us toward an ACO strategy. Also, to integrate with our employed physician enterprise to basically do the same. It’s about helping the physician organization develop all of those aspects of high-quality, cost-effective care in partnership with the healthcare system.

Healthcare IT from the Investor’s Chair 9/28/10

Capitalizing a New Venture: So Many Choices…

I appreciate everyone who reads, especially those who leave comments. A comment on my previous post asked, “Isn’t it ALL about the patient?” 

As I pointed out in my response, for better or worse, healthcare in America is all about entrepreneurship — from medical spas to physician-owned hospitals and imaging centers to million-dollar salaries for hospital execs (I agree wholeheartedly with Mr. H on that topic, btw) to software entrepreneurs like Neal Patterson (Cerner), Judy Faulkner (Epic), or Randy Lipps (who realized that supply storage could be improved while his child was in the hospital and so founded Omnicell).

Anyone in the healthcare system, from physicians to business people to lab managers, who realizes that the current system they are using or experiencing just isn’t working as well as it could or should can decide to take the risk and form a company, develop a product, and go to market. Even before ARRA, HCIT attracted more than its fair share of entrepreneurs. That’s what makes this sector my favorite playground.

That said, I think it’s more like the playground of my youth. Before safety was the law and springy floors and safety teeter-totters came into being, it has historically been an area where start-ups thrive, but a disproportionate amount of investment dollars have been lost. Never a dull moment.

Hopefully someone reading this has started or is thinking of starting a new venture. Let’s explore their options along the continuum to finance it.

Friends and Family

Just what it sounds like. It’s going to Mom and Dad, Rich Aunt Joan, Crazy Cousin Bill, your stoner college roommate who was employee #55 at Google, and all the other friends you ask to put money into your new venture.

This is clearly a mixed bag. While their terms will likely be the most generous and they’ll likely value your new venture at the level you think is fair, these shareholders can be demanding in a psychic way. Family gatherings could turn into business updates. You’ll get calls on nights and weekends.

There’s the risk of that feeling in the pit of your stomach that if it goes wrong, you’ll have to face these people for the rest of your life. Hmm, sounds like a more expensive form of capital then I originally thought.

Angels

“Angel” typically refers to high net worth individuals who invest in private companies for themselves, as opposed to within a fund.

Angel investing has been on an upswing over the past few years for several reasons. First, with the stock market’s mixed performance over the past five years, this class of investor is looking to enhance their returns with some non-traditional investments. More importantly, angels are filling a gap that has resulted from the decreased popularity of traditional venture capital (discussed below).

Angels are typically much closer to the friends and family investor. They also have some of the same pros and cons.

On the positive side, they’re typically easier on valuation and they’ve often been entrepreneurs themselves. On the other hand, they’re not professional investors and so might lack some of the dispassionate views that a VC can bring. While they might have run companies, they might not know healthcare or software at all and might insist that their great success running a plumbing supply business obviously translates to your venture.

Their lack of a traditional venture fund (and its limited partners) cuts both ways as well. Where a VC might care only about an ultimate sale (or IPO), an angel might care more about receiving cash distributions. If you want to invest for growth, that could be a source of conflict.

If you have a choice of angel investors, as the knight in Indiana Jones and the Last Crusade said, “Choose wisely”. Do they bring experience and industry knowledge and contacts, or are they just a source of funds? Whichever it is, would they answer that question the same way that you would? How active do they want or plan to be? Will they want a board seat? Even if not, what will they require for ongoing communication as well as general care and feeding?

The importance of clarity and alignment of goals, vision, and timing here simply can’t be overstated. More than ever before, angels are starting to organize around their activities. Many top-tier business schools and tech associations have formed quasi-official angel groups.

Venture Capitalists

Traditional venture capitalists (VCs) are professionals at investing in private companies. Typically structured as a partnership, the investors (limited partners) tend to be foundations, pension funds, endowments and often high net worth individuals.

Research (and my observation) shows that VCs can bring much more than capital to their portfolio companies. They typically have strong networks in the sector and a great ability for pattern recognition, often having seen similar companies grapple with similar issues.

One of the most successful HCIT entrepreneurs I know once told me that, after herself, she attributed her company’s success most to the VC involved. This clearly suggests that valuation (and even terms) shouldn’t necessarily be the key factor in selecting one’s financial partner.

Beyond that, however, I’ve observed a huge continuum of both personalities and skills. I’ve seen VCs add tremendous value and insight. I’ve also seen VCs where I’d suggest the entrepreneur sell a kidney on eBay before taking their money.

Another factor to consider is that different funds tend to invest at different stages of a company’s life cycle. Loosely defined, these stages range from: (a) a good idea and founder (Seed Stage); (b) great team and product (Series A); (c) proven product and critical mass of customers (Series B); and business seems to be working, but needs growth capital (Series C and beyond).

While topnotch venture capital funds are continuing to fund early stage companies (and HCIT is no exception), for multiple reasons (to be discussed in a future post), fundraising has become more of a challenge to earlier stage companies than ever before. Hence the significant growth in angel investors to fill the gap.

None of the Above

What other options might exist for funding early stage ventures? I’ve seen companies of all stages think creatively to help bridge funding gaps. Government grants (especially lately) are a source of capital. Sourcing expertise from academia can help reduce the burn (many business schools and engineering schools have programs for students to consult).

One of my favorites is customer or partner financing. Perhaps a distribution partner or a few customers will pre-purchase software licenses, allowing you to combine a revenue and capital event. This win-win scenario serves to both build a customer reference and development partner and help your balance sheet.

Many hospital systems now have internal venture funds as well. These range in terms of stage of company they invest in (some are more risk-averse than others), but can also provide an appealing imprimatur to the marketplace of both customers and ultimate investors.

As I said, even though I don’t guard the Grail, my best advice here is to choose wisely. From my research days to now, when I’m looking at a company, one of the first things I do is see how they’re capitalized and who their investors are. Whether it’s shallowness or just a lesson learned, I find that it can tell me a great deal about a company. Is this a fund with a reputation for thoughtful investing and management, or an investor that typically throws companies to the public before they’re ready to maximize their own returns? Are there angels involved with experience and reputations for success?

While perhaps not the best way, assessing the backers is sometimes an efficient way of coming up with preliminary judgments about companies and their management teams.

Thanks for reading, but I’m afraid I’ve run out of space before even getting to Private and Growth Equity investors (who are sometimes also known as leveraged buy-out investors). While I touched on this in my Take Private post, it probably warrants its own, so let me know if there’s interest.

In the mean time, I’ll be attending the Health 2.0 Conference in San Francisco. That will be the topic of next month’s Investing Chair post. If you’ll be there and would like to chat, drop me a note.

Ben Rooks spent ten years as a sell-side equity analyst covering HCIT and related sectors before spending six years as an investment banker where he closed transactions ranging from $40 to 365 million. Seeking to make an honest living, he then founded ST Advisors, LLC where he works with healthcare companies and their sponsors, most often on issues around strategy, financing, and outcomes/exit planning. After all this time, he still can’t wait for HIMSS!

Monday Morning Update 9/27/10

From Sara Dippedy: “Re: crass KLAS. Our company suffered for years under KLAS ‘extortion.’ If we didn’t pay to belong, we were relegated to an asterisked account, insinuating that we were hiding something. All it took was one ticked off IT underling to nail you with an anecdotal crack, even though they were often happy as a bird 24 hours later. Opinions vary due to overambitious vendor guarantees and unrealistic customer expectations. We need an independent, not-for-profit testing authority, like Consumer Reports.”

From EHR Geek: “Re: proctologist. Did I beat Weird News Andy to the punch?” You did. A New York proctologist is arrested at his oceanfront condo for submitting $3.5 million in false Medicare charges, including charging for 85 hemorrhoidectomies performed on the same patient and procedures adding up to more than 24 hours in a single day. My mind immediately offered several witty comments, but I’m sure yours has already done the same.

From Me So Corny: “Re: eHealth Align. The Kansas City HIE’s board approved signing with ICA’s CareAlign as its HIE solution on Friday. It will be announced this week.” Verified, apparently, since it’s on ICA’s Twitter feed.

From The PACS Designer: “Re: ResolutionMD Mobile. The reading of image files on the iPhone is getting easier with ResolutionMD Mobile. The app is free from the iTunes Store. One of the key features is the DICOM processing, and storage stays on the server with window and level manipulation residing on the iPhone.”

Listening: a 1995 CD from obsolete harmonic Canadian power poppers Zumpano. Sounds great.

The California Academy of Family Physicians will use (warning: PDF) a $145K grant from The Physicians Foundation to create an online EMR resource for physicians, including a readiness assessment and tools for EMR selection. “We liken it to changing the tires on a moving car. Our physicians struggle every day to keep the doors open and keep patients healthy. Look, the office doors are open, patients are coming in, it’s flu season — and at the same time you have to adopt an EMR?”

I ran across a cool open source laptop security app called Prey Project. You install its invisible client on your laptop or mobile phone. If the device is stolen, the app phones home via the Internet or text message, sends you its location determined from geolocation services, takes the thief’s picture via webcam, grabs a screenshot of whatever the thief is doing, and locks down the PC. It will look for any open WiFi hotspot if the device isn’t connected to the Internet. If you’re feeling vengeful, you can annoy the thief by remotely triggering an alarm or an onscreen warning.

Doctors in Australia are warned by the New South Wales medical board not to make “flippant and derogatory” comments about patients after a patient complains. Related: the Australian Medical Association questions whether it’s a good idea for doctors to accept the Facebook friend requests of their patients, saying it’s inappropriate for them to blur the professional-social line.

This week’s company-wide e-mail from Kaiser chairman and CEO George Halvorson makes the point that by collecting ethnicity information in HealthConnect, Kaiser can uncover important ethnicity-specific health risks. He makes an interesting point: since every Kaiser patient has the same coverage, treatment, and providers, the only variable is often ethnicity.

Lisa Busby, CIO of Inter-Lakes Health, is named interim CEO after Kevin Haughney quits.

A couple of readers offered software alternatives for mind mapping. Luke O’Scyte recommends for the iPad and iPhone Headspace ($3.99) and iThoughtsHD ($9.99). For the desktop, he’s trying the open source Freemind, which Les also recommends. Ben suggests the free XMind. 

The Health 2.0 conference will be held October 7-8 at the Hilton San Francisco. Companies sending speakers include O’Reilly Media, Microsoft, HHS, Executive Office of the President, Wired Magazine, The New York Times, Cerner, Google, Kaiser Permanente, and WebMD. Other events during Health Innovation Week include a developer’s challenge at the Googleplex, a REC/HIE summit, and HealthCampSFBay. Early bird registration ends Thursday. You can save an extra $100 by using code “HIStalk” when you sign up. I have no financial interest – I’m just being nice in mentioning it.

Epic UGM photos from Wisailer.

Hyland Software, the OnBase document management company, acquires Computer Systems Company of Cleveland, OH. CSC offers document imaging, revenue cycle, and OB/GYN workflow and EHR tools.

Northern Ireland electronic document management vendor Kainos wins its third NHS contract in the last few months.

The Government Accountability Office appoints 19 members to its Patient-Centered Outcomes Research Institute, which was authorized under the Patient Protection and Affordable Care Act. It’s a big deal: this group will get $500 million per year of the $1.1 billion in ARRA money set aside for comparative effectiveness research, including setting research priorities and overseeing clinical trials. CMS can use its results for what sounds like setting co-pays that will encourage more effective treatments. The dean of UCLA’s medical school will head the group.

A patient sues Medical City Dallas (TX) for mishandling her electronic medical records after being called by collectors claiming she owed money for psychiatric treatment. The hospital had mistakenly chosen her medical record for that of an uncooperative psych patient with the same name, then merged the two accounts. Afterward, the hospital sent her a letter saying they would fix the problem, she got more collector calls, and she found the same patient had been admitted again and the same mistake had been made.

Greenway announces the start of its two-day, regionally-offered Meaningful Use training sessions for customers.

It would be fascinating to know why (heavy vendor response?) 75% of readers wouldn’t use a free, ad-supported EMR. New poll to your right: are the product ratings offered by KLAS representative of product performance in a way that’s useful to providers?

An ISMP survey finds that providers are exasperated with never-ending drug shortages. For those unfamiliar, let me explain why that’s a big deal for hospitals. Sometimes there’s only one source of a given drug, meaning doctors are forced to order alternatives they don’t know much about, often drugs that are less effective or more dangerous. Nurse are suddenly looking at unfamiliar drug packages, increasing the chance of medication error. From an IT standpoint, systems have to be changed: automated dispensing cabinets have to be set up for the new item, CPOE and pharmacy systems may require modification, and any systems that read drug bar codes must be re-programmed. Imagine being a high-acuity patient and finding out that your anesthesiologist or surgeon can’t have his or her critical drug, which they know inside and out from years of predictable use, and instead will be rolling the dice on some alternative they’ve already judged inferior, all because a drug company is mysteriously out of the A-team product. Nobody seems to know why shortages happen, but speculation usually runs to the cynical in my hospital: scumbag pharma tactics, wholesaler market fixing, and hoarding by other facilities who hear shortage rumors (that hoarding is often by us, I should add, since we’re just as unhappy about running out of drugs as anyone else and we don’t hesitate to use our clout to jump the line).

The FCC opens up “super WiFi”, the white space airwaves formerly taken up by analog TV signals, a boon for wireless device and service vendors (including those selling hospital technology). An early adopter is rumored to be Microsoft, which supposedly needed only two towers instead of thousands of routers to cover 500 acres on its Redmond campus. Strange: country singer Dolly Parton filed a complaint – she’s worried about the effect on wireless microphones.

This should fuel the usual HIT takeover rumors: Oracle’s Larry Ellison says the company’s string of acquisitions will selectively continue with semiconductor companies and vendors of industry-specific software.

This is scary, especially since it’s probably true here: the #1 organization that graduating college students in Canada would most like to work for is the federal government.

E-mail me.

HIStalk Interviews Paul Brient, President and CEO, PatientKeeper

Paul Brient is president and CEO of PatientKeeper of Newton, MA.

 

Describe what PatientKeeper does.

PatientKeeper focuses very much around automating the day in the life of a physician. We started out about 11 years ago with the observation that physicians weren’t using technology, in hospitals in particular. Some physician practices invested more and more in automating their core workflows, but physicians were largely left out. The general response was to blame the physicians.

We’ve taken a bit of a different tack and said maybe if we blame the technology or looked at the technology differently, we could get physicians to voluntarily adopt technology. Eleven years ago, we weren’t sure that was going to work. Today, we’re pretty excited that we’ve got about 23,000 doctors that have voluntarily adopted our product.

When you look at the Meaningful Use requirements, do you think they put the proper on emphasis on physician utilization?

Certainly the brilliance in Meaningful Use is that it focuses on at least one of the two third-rail workflows in hospitals, that being CPOE. Without it, I know that our organization wouldn’t be spending as much time on CPOE as we are now. I’m certain that our clients would not be spending as much time on CPOE as they are now. That’s one of the last pieces of physician workflow — the other piece being physician documentation — that has really not been adopted in any meaningful way.

If the goal is to get physicians to fully automate their workflow, having focus on it is a good thing. I think, obviously, it’s a very difficult task to come up with the right way to structure those incentives and structure that motivation. I don’t envy anyone in Washington that had to go through that.

In your mind, was it good news or bad news when they throttled back the CPOE target percentage?

It’s certainly a very odd metric for the inpatient hospitals to focus on one medication — I think it’s now ‘per year’ is the interpretation — that needs to be entered electronically. It’s more of a, ‘Hey, this is important — let’s get started.” Here’s a hurdle which I think that it would be pretty unnatural to try to even achieve that particular hurdle because that’s a bit of awkward workflow for doctors. Again, I think it’s a very difficult thing for them to do. I think the key thing is it’s a stake in the ground that says CPOE is important.

Stage 2, hopefully, will be much more significant in terms of really requiring meaningful adoption of CPOE. I think that if that isn’t, then there may be some organizations that don’t really go full-bore. I mean the goal here is to get most of the doctors in a hospital using CPOE. It’s the ultimate goal. One hundred percent is unrealistic given most community hospitals, but 80% and 90% is pretty realistic. How you get there is a little baby step. Hopefully the next step is a bit bigger.

What would you advise hospitals to do now to be ready for the next stage or to accomplish more than just the minimum requirement now?

The timeframes are getting compressed and we spent a long time getting ready. I think it’s a year and a half from the ARRA legislation to the final ruling of Meaningful Use in an overall six-year timeframe, so we spent a lot of time starting. I think that if an organization said, “Hey, I’m just going to try to do the letter of the law here,” there are lots of crazy ways that people have conjectured that an organization could get to the letter of the law in Phase 1.

I think they’re missing the gift of this. The gift is, “Hey, we’re going to give you some more time to get a proper rollout in place. We’re also going to give you some money, because if the first round is relatively easy to comply with, you get the money from that so you can invest in your ongoing rollout.”

I think if you just said, “We’re going to try to maliciously comply,” or “comply to the letter of the law” and don’t have your eye on the prize, you’re then going to get caught in the same squeeze everyone was complaining about when it was a hard hurdle early on.

So unless you’re intending just to say, “We’re going to do Stage 1 and not do Stage 2 and 3,” which I guess would be a strategy, I think that you really need to be focused on how are you going to get to real adoption of CPOE in the provider community, which is still not an easy task just because you have a little more time to get it done.

Will it be different for community-based hospitals whose physicians practice at their discretion versus hospitals that have employed physicians?

I think very much so. We think of the world as three kinds of facilities. As the academic facilities with a large resident population where CPOE has been most successful — where you have the most control, obviously. Then there’s the more employed model hospital in the community setting, although they overlap. And then there’s this, we’ll call it the “classic community hospital,” where you’ve got physicians that are non-employed and in many cases practice at multiple institutions that are your competitors.

That’s obviously the most difficult environment in which to implement these advanced kinds of workflows and get physician adoption. It’s also the environment where we spend a lot of our time because physician adoption of IT has been particularly problematic in those areas. That’s not all of our customer base, but it’s certainly where we can solve some pretty big problems for our customers.

How are hospitals using technology to attract physician business?

It’s interesting. If you put yourself in the seat of a CEO of a community hospital and you’re not employing physicians, you’re trying to get physicians to refer to your facility. There aren’t very many levers that you can pull to make it more attractive for physicians. Most of the levers, really, are around making the physicians more productive and more efficient. Everything from, “Here’s some nice food or doctor’s lunch, they don’t have to go out and get food” to “Here’s some OR block time” and things like that.

We’re seeing a lot of organizations rely on technology and say, “Look, we can put technology in place. It’s going to save you time when you practice here and reduce hassle.” That’s a big win for doctors because essentially, what they do is they sell their time. So if you make them 10% more efficient by coming here versus going there, that translates pretty directly into more patients, more revenue, a more effective physician. We work with a lot of organizations that really have physicians-facing technology as part of their competitive differentiation in the marketplace.

People aren’t paying much attention to is the fact that the majority of community-based physicians practice in multiple facilities. Are there going to be concerns or push-back from doctors that they’re expected to learn more than one system for more than one hospital?

Very much so, and unfortunately, not just more than one from more than one hospital.

We’ve done some studies of community physicians. When you start adding up all the different systems they have to use, even in a hospital, and then you replicate that at two or maybe three hospitals, it’s just chaos. Early in the day when PDAs first started coming, a lot of them had PDAs just for their usernames and passwords. Of course now they’re on their iPhones and Android phones, but it’s a real problem.

If you think about something as critical as order entry, you have to learn two different user interfaces with potentially two different order sets. Since we talk a lot about evidence-based medicine — which is great, except that 70% or so of the orders in the order set aren’t evidence-driven — two hospitals in the community might have very different-looking order sets.

That’s a real challenge and something that I think people … I know our customers in those situations fully appreciate the challenge, but it didn’t really resonate as much, I think, in the Meaningful Use dollar.

You mentioned evidence-based order sets. It’s interesting that in most hospitals, all they’ve done is to take the market basket of every possible order already being used, dump it in an order set, and say, “OK, we’ve accomplished something.” How do you see that progressing to get to where it is more evidence-based and not just reflecting current practice?

It’s really interesting and very challenging. Especially if you start with a notion, which I think is pretty well-documented, that the majority of the orders in an order set aren’t evidence-driven. You end up with these crazy order sets, which is here are all the personal preference items for all the physicians in one order set, so it’s like nine pages long. Clearly that’s not useful really to anyone other than you can check a box and say, “Yes, I have an order set here.”

I think where things are going, and why people are trying to push this, is the core evidence around conditions are reasonably non-controversial, not necessarily practiced by everybody, but at least when you present it to someone, you don’t get a lot of push-back. There’s starting to be organizations like Zynx and Provation and others that have evidence-based order sets you can purchase and you can say, “Here’s the evidence piece.”

The trick is what to do about the rest of the orders. I think that’s where you can end up with the simplest, from a technology perspective. It’s, “Let’s go with doctors together and we’ll agree here, in this medical staff, on all the non-evidence-based orders and which ones we’re going to put in and make it more reasonable.”

Again, that works great in an academic setting where you’re trying to teach everyone to practice medicine, so it’s good. In a community setting, especially one with splitters and voluntary physician staff, it’s almost impossible to get the bandwidth to do that.

I think you’ll see organizations really want to try to say, how do we take evidence and then allow the physician convenience items to be managed separately from the evidence so that we still have a nice evidence-based, consistent practice of medicine here, but if I want the nurse to call me when a temperature is 102 or their hematocrit hasn’t gone up by more than 10% every hour or whatever the triggers I like to use. They’re different with another doctor. I don’t necessarily think that we try to homogenize that across all the surgeons in the community.

Is it reasonable to expect, given the status of the technology today and how people are likely to deploy it, that we’ll see an immediate improvement in healthcare delivery with an increased utilization of technology?

That is the $20 billion question. Clearly with Stage 1 Meaningful Use, we’re not going to see a significant impact on the cost or quality of healthcare delivery. The requirements aren’t such that that’s going to make a difference. It’s a process, and I think that the people that put together Meaningful Use really recognized that process.

I think that in order to really get a big impact, we have to change behavior, and that isn’t just a technology problem. You can put all the standard order sets in the world in front of physicians, but unless they do something different as a result and you’re able to change the way they practice or the way they interact with information or the way they operate with the care teams, then this isn’t going to make a difference at all. Except for perhaps to save some time with ward clerks and save some paper and things like that.

I believe that technology’s a really critical tool. With a fully electronic environment, you can see in real time what’s being ordered. You’ve got computer systems that can generate alerts and understand things. Used properly, it can make a huge difference, but it’s got to be used properly. I don’t think we’re going to see those impacts until the late stages of Meaningful Use, and probably thereafter.

I’m sure you’re familiar with the studies that show in some cases, increases in mortality as a result of putting in CPOE systems. Obviously, that’s using things improperly, but it is not a given and it’s not just a, “Check the box, it’s automated. Look, wow, it’s better!” It’s not like factory automation. It is really something that’s going to become part of the process, part of the culture, but you have to have it in place in order to do that.

If I were to read intent into the Meaningful Use approach, I really think that’s what’s going on here. I think that it’s an investment that will pay off, but it’s not immediate. My fear is that the world at large is looking for an immediate kind of increase and improvement. Just like, frankly, many other automation tasks in other industries, the improvements aren’t that immediate, but they’re there.

Do you think this is the carrot and there’s a stick yet to come?

I don’t know. Certainly, the stick is an important part of the legislation. The stick isn’t that big, frankly. You can take away the Medicare increases for organizations, but of course people remind us that Medicare’s been going down recently. I think it’s going to be difficult, politically, for the government to impose much of a stick. That’s just my conjecture.

I think the stick will come, probably more from peer pressure, if that’s the right term — competition of industries — but these hospitals are geographically separate. But I think if we can get 60-70% of the hospitals in the country to whatever Stage 3 Meaningful Use is, then it becomes a, “Look, you have to do this to keep the doors open.”

Hospitals have adopted all sorts of things. We don’t give them credit for basically going filmless in the imaging side. Most nursing workflow automation, pharmacy automation, lab automation — all these things have happened. Bar code meds administration — all these things have happened without Meaningful use, so I think there will still be pressures in the industry.

I think what this has done is brought these applications that probably would have been very low on the list of priorities to the forefront. I think if there can be a real effort to get most of these hospitals going, the rest will fall in line without a stick.

How big a game-changer is mobile access going to be?

We think it’s fundamentally important for so much of physician adoption. Not so much because it’s the only way, or even the primary way someone would put data in or look at data. But just like your e-mail and your BlackBerry are so fundamentally important to the way knowledge workers work today, without my BlackBerry, my e-mail’s a very different thing.

Likewise with physicians, when we give them desktop access and mobile access, it gives them the ability to work in ways that fit so well the way physicians work, especially these physicians that have multiple, different hospitals. Great, we’ve got lots of computers at our hospital. You go to the next hospital, in some cases they’re a huge pain to get at. Sometimes you can’t get into your other hospital system –  you’re not comfortable on the floor pulling up some of the hospital’s stuff. You get a call — you can’t get access to information in your car, so it really is a really important, critical part of the physician workflow.

If you go into the CPOE world in particular, you see a lot of adoption challenges with CPOE around the simple orders, the bedside order, where you walk in and the nurse says, “I want to give the patient a medication for nausea.” Today, that’s a simple thing. I’ll just note in the chart because I’ve got it here in my hand. It takes 5-10 seconds to write down the order. In the CPOE world, now I’ve got to go get a computer, I’ve got to get logged in, I’ve got to get the order in. Maybe that’s only a minute and a half, but I do that times 20 and now I’ve wasted a half hour of my day being annoyed.

Whereas on my iPhone or my Android, three taps and the person’s got the medicine. That’s even easier than the chart and I know that it’s checked so I don’t have to think about what meds they’re on already. So in cases of contraindication, it comes right away so I can be confident in that. I think it’s a game-changer in CPOE. I think it eliminates some of the real issues that we’ve heard from physicians, even in organizations that have been successful in the CPOE world.

Any final thoughts?

Well, it certainly is an exciting time to be in healthcare IT. I know you’ve been in this industry for quite a long time. I have been my entire career. Up until about two years ago, I showed up at a cocktail party and told people I was in healthcare IT and people kind of looked at me funny and we’d talk about something else. Now, everyone’s excited about it. They’re like, “Wow, this is going to really make an impact,” and I think that’s both a blessing and a curse.

I’m hopeful that, as an industry, we’re able to deliver the impact, the ultimate impact. Bending the cost-curve, improving quality, and frankly, helping make it less painful for patients and doctors. But ultimately, for patients to access the healthcare system. I think technology holds a lot of promise for that.

We didn’t talk a lot about HIE, but I think that’s another area of opportunity for the industry, where it could really become a really important game-changer around patient engagemen,t a reduction in patient frustration that I think can also save a lot of costs.

News 9/24/10

From Clinical Wisdom: “Re: KLAS. A friend told me that Eclipsys paid KLAS $300K per year. Can KLAS accept mega-bucks from vendors they evaluate without being influenced by their cash? Imagine Consumer Reports taking money from car companies. I think they owe those who buy their reports a full accounting of what they earn from vendors and what those vendors are promised.” We’ve been around and around the KLAS business model over the years. Providers don’t usually pay KLAS for the reports; they get them free in return for providing data, so they would not be surprised to find that vendors pay big bucks (i.e., it’s the HIMSS “ladies drink free” model). I asked Adam Gale in my 2007 interview if the company would be willing to have its survey and ranking process audited by an outside expert. He said yes, but that hasn’t gone anywhere as far as I know. He offered this comment when I asked if being paid by vendors is a conflict of interest:

I would say we have one of the world’s strangest business models, where internally, if you ask anyone at KLAS who our customer is, they’d tell you it’s the provider. That sometimes irks the vendors because they pay a reasonable amount of money to have access to the subscriber data. One vendor, as a mistake, sent us an e-mail intended to be internal that said, “Doesn’t KLAS understand who the customer is based on how much money we spend?” We hold that up and cheer. The vendor is not our key customer. The provider is. We frame every vendor question in terms of, “Will it help providers make a better decision?”

From Spell Czech: “Re: CareFusion Pyxis. Are they really struggling against Omnicell? I hadn’t heard that. Love the blog — been reading for a couple years now!” I’m sure Pyxis still holds most of the market, but it wasn’t long ago that they never lost customers. Both my current and previous hospital employers reconsidered whether Pyxis was worth keeping (clunky software, arrogance, bad support). In one case, we begrudgingly stuck with them because McKesson’s product wasn’t fully baked and Omnicell was struggling. In the other, we dumped Pyxis and never looked back. My conclusion is that, finally, Pyxis has some real competition from both of those now-acceptable alternatives and the market is reacting at least somewhat to that, even though those competitors share some of the same flaws (too many engineers making design decisions and worrying about moving parts instead of nurse-friendly software). I haven’t heard anything about Cerner’s entry into that business. Competition is good for everyone, especially the customer and patient.

From Mighty: “Re: ED denominator for Meaningful Use. CMS has finalized it, though I don’t see it mentioned in many places.” The CMS clarification says that only ED patients who are admitted as inpatients or who are treated as observation patients count toward the CPOE requirement and other parts of MU.  

From Computer Giant: “Re: UPMC. Can the EMRs not solve this problem?” That was tongue in cheek, in case you couldn’t tell. UPMC howls when a state report finds that flagship UPMC Presbyterian-Shadyside has a higher-than-expected mortality rate for CHF, septicemia, respiratory failure, and stroke. Their excuse is the standard: “our patients are sicker,” but when the state responded that everything was severity-adjusted, UPMC then commented that their younger patients throw off the stats. I’ve yet to see a hospital that took the news constructively that it’s underperforming. Be comforted: in their own minds, every hospital is above average.

From Peggy: “Re: Epic co-op. I love your site. I read it religiously! Our hospital is evaluating vendors to replace our clinical core and Epic is (of course) one of them. I’m interested in the consulting co-up you mentioned. Would you mind sharing more information?” I don’t have details, but I’m sure they will emerge publicly at some point.

From Slidell Computer: “Re: executive director of Physician Hospitals of America. She’s leaving. Rumors are circulating that changes will force physician-owned hospitals to sell out or close. Maybe she sees the writing on the wall.”

From Not Quite: “Re: GOP’s Pledge to America. It returns the country to the 2008 budget, ARRA stimulus money for EHR systems will end, and according to polls, the GOP will take over Congress. Shouldn’t all EHR purchases stop now since they won’t get their incentives?” I’ll stay out of the political debate since I distrust all politicians equally (except maybe Chuck Grassley and Ron Paul), but I would say that anyone buying an EHR solely because of Uncle Sam’s promised largesse should think twice even without the Pledge to America. CMS is like a devious cat owner waving a laser pointer around: they love to see providers jump around in reaction to ever-changing and mind-bendingly complex policies that address what initially seemed like simple, good ideas to make sure no payouts actually occur.

Wisailer, a reader attending Epic’s UGM, shared some of the interesting aspects from the meeting so far (his or her words, not mine):

• According to Judy, one of Epic’s goals is "to improve health care for the world," based on their estimate that 30% of the US population is covered by an Epic EMR.
• She says “do what Epic says" and your implementation will succeed.
• Epic has spent 66,000 hours on Meaningful Use, which Carl Dvorak seemed to imply has slowed down their transition to Web-based applications.
• The customer base is 224, up from 190 last year, and many of the sessions were oriented to new installations.
• 200,000 physicians use Epic.
• Vendor ally — boring. Lots of suites and pretty smiles. More consultants, fewer device and service providers.
• Swag consisted of pre-washed, BPA-free water bottles with special refill funnels at water coolers.
• The Haiku iPhone app will be extended to the Droid soon.
• Canto, a new Epic iPad application, will be released in the near future. LOTS of buzz about this product.
• Horse-drawn carriages are giving tours of the campus and bikes are available directly across from Epic Farms, thought by many to be the production source of Epic Kool-Aid.

The pic above of some of the Epic festivities, which looks like a more affluent, less crowded, and much colder (highs in the 60s this weekend) version of Woodstock, is from Dave Yost’s blog.

As Inga told me, we’ve been outed by Google. I set up HIStalkTV a few months back on a slow Sunday afternoon just to play around with posting HIT-related videos that I found amusing or useful. The site is suddenly popping up on search engines for some reason and readers are e-mailing us about it. It’s definitely beta and I haven’t really decided what to do with it if anything, but feel free to send me your thoughts. We even had one of our favorite PR people ask about sponsorship opportunities, which I appreciate even though I’ve given that zero thought.

I was motivated by Ed’s CIO Unplugged post about his use of MindManager for mind mapping, list making, etc. (maybe because he featured HIStalk prominently in the picture). I tried some of those programs years ago and lost interest, but figured I would look again since I really like the concept for creativity. I lost interest in MindManager again when I saw that it has become Visio-ized (tons of overly complex functionality added for corporations and priced accordingly — $349), so I found a simpler alternative that seems to work great: MindVisualizer ($79). I’m running the free trial and will probably buy it because it’s pretty darned slick. I used it today to make a few plans for the HIStalk reception at HIMSS and the tool didn’t get in the way of my thought process, which is the most important criterion.

This seems remarkably open minded considering the source: on the HIMSS blog, the senior director of federal affairs (Tom Leary) asks for comments on the federal government’s role in ensuring the safety of HIT products. Supposedly the only reason the FDA doesn’t regulate HIT today is because of some fancy, long-ago behind-the-scenes political footwork by various groups and vendors, so maybe HIMSS is considering taking an official position. Why not chime in?

A fun Medgadget post: the National Space Biomedical Research Institute has developed an astronaut EMR that combines a mobile monitoring device with software. The EMR is iRevive from 10Blade, which was designed for EMS users (you mean astronauts don’t enjoy the benefits of a certified EHR?)

Continuing my rant on badly written press releases, this HIE one speaks for itself. For the love of God, doctor and press release writer, take a breath! In addition to the hopelessly dense text, it starts off with (1) a mini-editorial; (2) a snooze-inducing history lesson; (3) a ton of quotes, apparently all so equally significant that none could be omitted to make it readable; and (4) in the VERY LAST paragraph, one long sentence that contains the only real news in all that fluff. There is a reason that companies pay experts to craft their communication instead of doing it themselves.

Precyse Solutions will unveil its new Automated Clinical Documentation software and Computer Assisted Coding software engine at AHIMA in Orlando next week.

Weird News Andy entitles this as “Half a woman is better than none.” Doctors in Canada take a drastic step to save a 31-year-old woman with untreatable bone cancer: they cut her body in half by removing her leg, lower spine, and part of her pelvis, then do a “pogo stick rebuild” in fusing her remaining leg back to her body. I wish I had her positive outlook: “I have no problem getting around. If I need to, I’ll crawl (up stairs) or scooch like a kid.” The most bizarre aspect of the story in my mind, however, was how the doctors described the size of the tumor: they said it was the size of a calzone.

Welcome and thanks to brand new HIStalk Platinum Sponsor T-System of Dallas, TX, which created and sells what is surely one of the most effective, well-accepted, and ingenious paper documentation solutions ever devised: the famous T-Sheets, on which over 30 million ED visits are documented each year. The company offers other versions for ED nurses, order sets, urgent care, and primary care, but I’m sure they would also want you to know about T SystemEV, the company’s emergency department information system (with modules for patient tracking, status board, nurses, physicians, and CPOE) that’s used by 240 hospitals. It offers comprehensive physician and nurse documentation, clinical content, a short learning curve (often just one shift, they say), status board, prescription writing, discharge instructions, CPOE, lab integration, real-time coding capture, and patient satisfaction and reporting tools. All are important for Meaningful Use, of course. Former McKesson MPT President Sunny Sunyal recently joined T-System as CEO, so I’d say he did his due diligence and liked the company’s performance and potential. Thanks to T-System for supporting HIStalk — Inga and I appreciate it.

All adult hospitals in Milwaukee County, WI will use My Health Direct for ED referrals to community health centers, courtesy of an agreement signed with the Wisconsin HIE. I interviewed Jay Mason, the chairman and CEO of My Health Direct, in June.

I was checking up to see what’s happening with long-time HIStalk bestie Scott Shreeve MD, formerly of Medsphere and now building Crossover Health, a member-based medical practice that will provide individualized urgent, primary care, and online health services from clinics in California (Newport Beach, Foothill Ranch, and Aliso Viejo). I didn’t think I’d be interested in the construction video above, but it’s pretty fascinating to see how that company and others are taking a very different approach to healthcare delivery for those who can pay for it themselves.

Some unusually juicy jobs on the HIStalk Sponsor Job Page: Sales Director, VP of Solutions Marketing, McKesson Consultants, Head of Quality Systems, Sales Director. On Healthcare IT Jobs, Senior Account Executive for VA, Sales Professional – North Carolina, Clinical Systems Analyst III, Epic Project Managers, Eclipsys Documentation Consultant.

Home care mobile solutions provider CellTrak Technologies announces the latest version of its smart phone system, which includes Android capability. It’s also sold in Canada by TELUS Health.

The US Army awards a research grant to InterSystems to look at its HealthShare platform to exchange data between Madigan Healthcare System (WA) and South Sound HIE.

Medical College of Wisconsin spinoff Imaging Biometrics gets an $800K NIH grant to develop its software that helps clinicians distinguish tumors from healthy tissue.

Odd: a woman’s iPhone is stolen while she is hospitalized and in labor.

E-mail me.

HERtalk by Inga

From Hamlet: “Re: KLAS, Epic, etc. KLAS found that nearly 70% of new 2009 hospital EMR purchases were for an Epic or Cerner integrated solution. Reading HIStalk, you would think Epic cleaned everyone’s clock.” They cleaned a lot of the clocks that counted, i.e. the big, influential hospitals with lots of beds and big dollar volume.

From A-Rod: “Re: on the move. Long-time healthcare CIO Bob Kaplan has been appointed EVP and CIO of Audax Health Solutions in Washington, DC. Bob has been CIO of WebMD, NCQA, IFMC, National Preferred Provider Network, and PHP Healthcare Corp.”  According to the Audax Web site, the company is an early-stage startup developing products that “change how patients and providers interact.”

From Sunshiney: “Eclipsys wins. Mercy Memorial Hospital System in Michigan is replacing McKesson with Eclipsys and Sidra Medical and Research Center in Qatar picks Eclipsys’ inpatient EHR.” Both verified.

Capario promotes sales and marketing VP Jim Riley to president. He replaces Andrew Lawson, who will be moving to another company within Martin Equity Partners, the entity that owns Capario. Riley was previously VP of sales and marketing for Payerpath, where he also worked under Jim Brady, Capario’s executive chairman.

Saint Barnabas Health Care System (NJ) picks EDIMS and its EDIS software for its six-hospital system.

Scribe Healthcare Technologies introduces Scribe Mobile, a new dictation app for the iPhone, iTouch, and iPad.

Yet another entity announces its ICD-10 conversion strategy. Global IT service provider HCL Technologies will use Health Language’s Language Engine solution as part of its end-to-end ICD-10 conversion solution.

Central Jersey HIE Project selects Advanced Data Systems, Greenway Medical, and MDTablet as its recommended EHR vendors. Well, at least that is what I think was said in the HIE’s very rambling press release.

Holy Redeemer Health System (PA) will implement MobileMD and its 4D HIE technology to provide connectivity among the hospital, community physicians, and other area care providers.

This week on HIStalk Practice: InfoGard provides an update on when they’ll begin EHR certification and testing. A medical office janitor lands in jail after selling patient charts to a recycling company for $40. Theories on why medical office hiring is up despite declining revenues. A new study reveals the top EHR/PM companies in the ambulatory world.

A sign of the times: San Juan College (NM) says it will shut down its medical transcription program at the end of the school year. School administrators admit that computers are increasingly taking the place of traditional medical transcription, so the school will instead focus on modernizing its coding and HIT degrees.

The local press highlights Rapid City Regional Hospital and its migration to Meditech. The hospital has implemented bedside medication verification and is now moving to physician documentation. The transition is not without its opponents, including one neurologist who is apparently not a big fan of EHRs:

They are good for insurance companies and good for controlling data, but it’s not necessarily good for patient care. The travesty is, so far the systems are bad. You’re not talking to the patients. You’re talking to the computers. If the doctor has to type, they’re not going to add very much information. Either you input data or you take care of patients, but you can’t do both well.

KLAS finds that the oncology market has been mostly ignored by enterprise software vendors, with best-of-breed vendors dominating the market. Enterprise vendors are more focused on the medical, rather than radiation oncology market, and often vendors are less interested in functionality and more focused on integration with other systems. Epic is named the closest enterprise system to delivering an oncology solution. Cerner, Eclipsys, GE, Meditech, and Siemens offer varying functionality as well.

E-mail Inga.

CIO Unplugged 9/22/10

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

Tool Time

This is a picture of my home workbench. I think you can tell from it that I’m not a productive handyman. I learned some time ago that power tools were not my thing. I leave that work to those who have a passion and talent for it.

What does stoke my fire is leveraging IT to enable improved clinical and business outcomes. Thus, I have a much greater interest in my career “workbench.”

What follows is what works for me. Perhaps it will inspire some new ideas for you. Either way, share what works for you in the Comments section.

A common thread throughout my life is the principle of simplicity. Hardware, software, or systems that are robust, yet easy to use,are my tools of choice.

Software

Texas Health is a Microsoft strategic partner and my applications largely reflect this. I use the Office suite exclusively, including OneNote. Everything is integrated and I can easily move in and out of these apps without any format or compatibility challenges.

I use Office Communication Server (video, voice, IM) as my communications tool for all of the aforementioned reasons. It is very simple and easy to have all of my primary business applications on the same platform.

Two exceptions include Yammer and Mindjet Manager Pro. Yammer is our internal collaboration software, often referred to as “Twitter for Business.” The use of Yammer has helped our enterprise in some incredible ways, including responding to emergencies (H1N1, power disruptions) and leveraging the wisdom of the crowds.

Mindjet is a tool to help me organize my thoughts for presentations, meetings, and yes, my blogs.

Hardware

Texas Health is also a HP strategic partner and my device is my office, so I currently have a ProBook 5310. I love that my video and communications devices are all built in. No air cards, phones, or cameras to mess with. It’s all included and very lightweight for travel. Because I like to mess with people’s minds, I have an Apple logo affixed to the black casing, which causes people to scratch their heads.

Mobile

I’ve had a BlackBerry for years and do not plan to change anytime soon (sorry, partners). I upgrade each year and currently have the Storm2. On more than one occasion, I have gone without my ProBook and just leveraged my BlackBerry. I am trending this direction as a permanent solution, albeit I think we are a couple of years out.

What I absolutely will not carry around is a laptop and a mobile and something akin to an iPad. This is way too many devices. I know people who function like this and in some cases, add a pager and/or office phone to boot. That’s just plain silly and gives IT a bad vibe. If you use more than two devices, your life is unnecessarily complicated.

Manbag

Since I operate within a virtual office, another key tool is my leather briefcase. People make fun of my soft-sided manbag because it is worn and weathered. Well, there’s good reason for its scuffed look — I’m always on the go, visiting my team and my customers. It is practical and durable.

Systems

The least tangible but most important of all the tools is what I call “systems.” A system is a well-established routine that you no longer have to think about that enables your highest level of productivity. You can have the greatest tools in the world, but you hamper your effectiveness by not automating manual and routine processes. Sound familiar? Think EHR/CPOE.

One of my “systems” is to have everything I need for the next day’s adventure ready and updated the evening before. When I wake up, I am out the door and driving to the gym in five minutes. Manbag included.

What about you? What’s on your workbench? What tools work best for you?

Update 9/27/10

Thank you for your comments and input on tools that work for you. There is no single perfect tool for everyone, but it is critical that you find one that works best for you.

There were some great suggestions on HIStalk for mind mapping-like software. You should certainly give one of these a try and see if it helps you organize your thoughts and work.

As for “where’s the beef?” as one reader asked, I have posted on more technical subjects like cloud computing, mobility, and virtualization, but I tend to focus more on leadership oriented topics. In my journey, I have found plenty of great technical expertise in our industry, but believe what is lacking to make us more strategic is fundamental leadership.

My focus is on leadership, service, partnerships, and strategy. I will sprinkle in a few thoughts on the more technical side, so stay tuned and keep letting me know what you would like to see.

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.”

UnitedHealth Group To Acquire A-Life Medical

UnitedHealth Group announced after the market close Tuesday that it will acquire computer-assisted coding vendor A-Life Medical of San Diego, CA. Terms were not disclosed.

UnitedHealth Group will add A-Life Medical to its Ingenix Health Care Delivery business, extending a strategic alliance formed between the companies last year to develop advanced coding solutions.

A-Life Medical’s products include the LifeCode natural language processing solution, which analyzes clinical documentation to identify diagnoses and procedures and recommend ICD-9 and CPT-4 codes to coders. Its Actus computer-assisted coding product will allow Ingenix to market services to providers transitioning to ICD-10 by the mandatory October 1, 2013 date.

The acquisition is UnitedHealth’s fourth technology-related buy so far this year, having previously absorbed Picis (high acuity systems), Executive Health Resources (medical necessity and compliance), and Axolotol (health information exchange systems).

News 9/22/10

From Medicament: “Re: Epic UGM. Announced attendance is 5,500 vs. 3,800 last year. Surreal. This panorama is from the auditorium just after Judy’s keynote.” If you are there, send me a report of any newsworthy developments. Sorry the pic is small, but that’s the point: the meeting isn’t.

From Neils Bohr: “Re: Accenture. I heard they got the HHS contract for use case for the Standards and Interoperability Framework last Friday.”

From Epic CoOp: “Re: Epic consultants. Given the huge demand, 20 of them are forming a consulting co-op to keep the cut that temp agencies take.”

From Blue Danube: “Re: video. Even though it’s an ad for Centricity, it paints a pretty accurate picture of primary care and the need for EMRs.”

Listening: new (released just today) from John Legend and The Roots, a collaboration between the modern R&B/hip hop singer (John Legend) and the Philly funk band (The Roots), updating socially conscious soul songs from the 60s and 70s. I can’t describe just how awesome this album is, sounding as fresh and uncomplicated as Motown circa 1968. If you don’t like soul or hip hop music because it’s over-produced, non-melodic, and fixated with trite subjects like lust or fame, let this rekindle your hope for the genre. I usually condition my recommendations knowing they aren’t for everyone, but this one’s for everyone.

UnitedHealth Group makes another buy, announcing plans to acquire coding vendor A-Life Medical. I covered it in a news blast here. UnitedHealth Groups is obviously on an HIT tear, bagging four companies so far this year. That’s a good reminder to sign up for updates using the Subscribe to Updates box on the upper-right of this page and/or to Friend/Like us on Facebook since I usually post new stuff there too.

The San Diego office of the FBI announces that El Centro Regional Medical Center (CA) will pay $2.2 million plus interest to settle Medicare fraud allegations brought forward in a former employee’s whistleblower lawsuit.

Rothman Healthcare hires Richard Sommer as CEO. I hadn’t heard of the company, so I checked it out. It markets products based on The Rothman Index, an automated system that collects 26 observations and results for each patient every hour and graphs the score so caregivers can quickly see who’s crashing. The trial was at Sarasota Memorial (FL). The Rothman brothers found the company after their mother died after post-surgical complications that were subtle and therefore undetected in the hospital. According to the company’s site, nurses at its first hospital site identified a patient going bad within five minutes of bringing the system up in test mode, reacting to a patient whose pulse-ox had dropped from 98% to 85% over two days without alarming anyone.

Jewish General Hospital of Montreal, Quebec will use education and clinical image sharing tools from Aurora Interactive to create an online pathology education network.

McKesson, HP, and Intel launch a site that mixes HITECH resources with preconfigured EHR hardware/software packages.

Transcend Services announces BeyondAlerts, which extracts clinical data from transcribed narrative to trigger provider alerts.

Panasonic will offer data encryption from Mobile Armor in its Toughbook notebooks and mobile clinical assistants. That includes self-encrypting Seagate drives, centralized management, pre-boot authentication, and auditing. Smart.

I made fun of a Brainware sales announcement a few weeks back because it didn’t name the customer (for contractual reasons, no doubt, but I still questioned the newsworthiness of an anonymous customer sale). They sent me their latest announcement this week, joking that this one names names, that being Gundersen Lutheran Health System (WI). Brainware and Ascend Software are providing the Brainware Distiller intelligent data capture tool along with business process automation for the health system’s Lawson accounts payable system. Brainware’s tools pull data out of unstructured sources such as invoices without templates or indexing. For AP, that means speeding up processing and providing a near real-time view into liabilities. It uses fuzzy search to assign GL codes and vendor numbers to non-PO invoices. Its Gateway product is a portal for vendors to check the status of their invoices online.

Since I shamed Brainware, let’s move on to the next poster child for bad press releases. Does this headline roll off your tongue? The Institute for Transfusion Medicine(SM) (ITxM)(SM) Deploying BIO-key(R) Fingerprint Search and Identification Solution for Donors and Patients. Marketing people can’t even introduce themselves without holding up little trademark and service mark signs. I guarantee that nobody could read this even 2-3 times and have the slightest clue what it’s about with all the unnecessary, lawyer-paranoid clutter.

Covisint, the portal vendor owned by Compuware, acquires DocSite of Raleigh, NC, which offers PQRI, registry, decision support, e-prescribing, progress notes, and integration tools. Roger Sterling tipped us off in the 9/1 HIStalk, although Inga couldn’t get Covisint to confirm.

Children’s Boston will use Allocade’s On-Cue Operations Management software in radiology. It pulls data from existing systems to create a rule-optimized patient itinerary and provides caregiver collaboration tools and business intelligence.

New Jersey’s HITREC contracts for physician practice consulting services from Nit Health. Being a hospital guy, I couldn’t help but think of small combs and Kwell shampoo.

Maimonides Medical Center (NY) goes live with InterSystems Ensemble for rapid integration and development, using it to develop new interfaces to/from Sunrise Clinical Manager.  

An interesting debate at the VA: should tech-savvy doctors be allowed to store limited patient information using cloud-based Web tools if they appear to be secure and if the VA’s systems can’t meet their needs otherwise?

A study finds that a heart attack risk calculator used by consumer health sites is not very accurate, misclassifying 15% of patients as needing medications when they really don’t (check out the screen shot I took above from the American Heart Association’s version of the calculator to see why that’s not too shocking). Epocrates is mentioned as offering physician treatment applications based on the flawed formula.

E-mail me.

HERtalk by Inga

From Heresay: “Re: certification pricing. I’ve heard CCHIT is charging $40-$60,000 for EHR certification compared to Drummond’s $20K.” If anyone thinks they have a solid handle on the pricing from the three ONC-ACTBs, please step forward. InfoGard has yet to publish any details, but here is how I am interpreting the pricing from CCHIT and Drummond:

• Complete EHR Ambulatory: CCHIT $34,300; Drummond $19,500.
• Compete EHR Inpatient: CCHIT $32,550; Drummond $19,500.
• If you don’t need testing for the full EHR and just need individual modules tested, CCHIT has assigned a per-module fee for testing that ranges from $650 to $2,000, depending on the module’s complexity, plus a $7,000 base fee that includes the mandatory security criteria.
• Drummond charges $11,500 for up to 19 modules, include the mandatory measures, or, $16,000 for 20 or more modules, including the mandatory items.

To summarize: Drummond is less expensive if you need complete EHR certification and testing. If you need module testing only, CCHIT could be less expensive. The CCHIT folks would probably add that their fee includes a comprehensive testing and certification toolkit for vendors, which they will sell to non-applicants for $1,000. Also, vendors with CCHIT 2011-certified products will not need to pay additional fees for the ONC-ATCB certification through CCHIT, though additional testing is required.

I happened upon this blog post by an Epic User Group Meeting attendee. He shares details of Sunday night’s round-the-campfire wienie roast, complete with s’mores, dogs, and employee-provided entertainment. Very cool. Epic is expecting over 5,300 customers to hit Verona this week for this year’s theme, “UGM: The Musical.” In addition to 300 educational sessions, the meeting will  feature Epic staff singing Broadway tunes, Les Feud game show, and a tug-of-war tournament.

KLAS finds that nearly 70% of new 2009 hospital EMR purchases were for an Epic or Cerner integrated solution. Overall EMR sales nearly doubled last year in the 200+ bed hospital market. Meditech and Siemens saw limited growth and McKesson’s Paragon product outsold McKesson’s Horizon solution.

RCM company NHPN appoints David Garber SVP of managed care. Garber has held leadership positions in a number of managed care organizations, including CompServices and Coventry Health Care.

A third of office-based providers are now e-prescribing, according to Surescripts. However, only 12% of all prescriptions were written electronically last year. The number of providers using electronic prescribing grew significantly from 2008 to 2009, from 74,000 to 200,000, while the total number of e-prescriptions jumped from 68 million to 190 million. Massachusetts had the highest e-prescribing rate at 57%, followed by Rhode Island and Delaware.

Corey Hall joins REACH Call as EVP of medical informatics, coming over from the College of American Pathologists.

Sponsor Updates

• iMDsoft and Medical Web Technologies (MWT) partner to integrate their technologies. iMDsoft will offer MWT’s One Medical Passport pre-op workflow solution as part of its MetaVision AIMS product.
• Greenway Medical Technologies introduces its Allergy Module for PrimeSuite EHR, which includes injection record tracking, allergen testing, serum development, and lot administration and reporting.
• API Healthcare says that 35 provider and contingent staffing clients have gone live with its workforce management solutions this year.
• NextGen Healthcare provides VHA members special pricing on its clinical and financial software.
• Vanguard Health Systems deploys Medicity’s Novo Grid HIE technology to 850 physicians across four states.
• Parkview Medical Center (CO) selects RelayHealth’s RevRunner to improve its revenue cycle performance.

E-mail Inga.

HIStalk Interviews Jessica Berg, Professor, Case Western Reserve University

Jessica Wilen Berg, JD is a professor of law and bioethics at Case Western Reserve University of Cleveland, OH, with joint appointments in the Schools of Law and Medicine. She conducts research and publishes in the areas of informed consent, human research, reproductive law and ethics, confidentiality, mental health law, professional self-regulation, and e-medicine.

 

Hospitals have transitioned from the charitable care model to a purely business model, some of them with hundreds of millions of dollars in annual profits and paying multi-million dollar executive salaries. How has that changed healthcare for better and for worse?

On the plus side, I think we’ve seen a lot of innovation. I think that’s commonly what you see in a business model, or hope to see in a business model, which is a lot of different attempts to try things in different ways — take on a new technology, try different models of providing services, and in theory, be fairly responsive to the market. Ideally, a business model is set up entirely to be very responsive to the market.

The downside … I don’t think we’ve ever really reconciled ourselves as a society to the notion that healthcare, of all things, is a business. It comes along with all the things that come with the business model. And that is profit motive: there’s a bottom line, you want to stay in business, you want to do better than others, you want to make as much profit as possible.

For people that can’t pay, a business model doesn’t incorporate into it, naturally, anything that affords you a mechanism to offer services for free.

There is no other business model that expects the people who are able to pay to subsidize those who can’t. How are hospitals effectively, or not effectively, meeting that need?

I don’t want to say there’s no other business model that doesn’t assume different sliding scales, because on an international market level, for example — although this, again, is a healthcare example — pharmaceutical companies do somewhat assume that they will make more money in some countries, like this country, to subsidize less money they can make in other countries.

I’m not familiar enough with lots of other business models to say that there aren’t other ones that do that. That being said, it is not typical that a business model always incorporates the fact that there are sliding scales. That some people are going to pay more, and that subsidizes the people who pay less.

Is the hospital industry effectively meeting that need as an efficient arbiter that says, “We can efficiently transfer money from those who can pay into those who can’t and it will all work out?”

It’s not, because it’s not a whole system. I think if it was a system, you might be able to do that, but the people who can pay are not always located in the same areas, either geographic areas or with the same problems, as the people who can’t pay. Within a system, you might be able to do that as long as you cover a large enough area that you’re getting both sides of it.

That’s a fundamental flaw of the way healthcare delivery is organized in the country overall, which is we’ve known for a long time — and this is true of any insurance market, for example — that what you ideally want is a wide mix of problems, and from that perspective here on the payment, you want wide mix of ability to pay in order to get an adequate subsidization.

You’re not going to get that, necessarily, in one inner-city hospital. It could be that your hospital in the high-income suburb has the ability to pull in people who have health insurance, or even out-of-pocket ability to pay for some things that they’re doing, and your inner-city hospital doesn’t have that at all.

The term has been to create hospital systems, so more and more you see hospitals merge together. You may have the satellite units in the suburbs and you may have the one inner-city unit. Usually, your inner-city hospitals are just going to lose money, and a lot of money. They’re dealing with a generally poor population. They’re dealing with significant health problems, a lot of chronic conditions.

Just, as a general rule — this is not always true — they’re going to lose a lot of money. Not to mention, of course, emergency rooms are huge cost losers, basically. Emergency rooms do not even break even. They cost institutions enormous amounts of money.

A hospital network I used to work for had a motto of, “We serve all, but market to few.” Does marketing and competing for paying patients raise costs?

It can drive up costs, and I think there are more fundamental flaws in the system that are really driving the costs than just concern about marketing or the few that can pay. There are lots of debates about what’s driving the increase in cost. The vast increases in new technologies, the fact that very rarely do we get rid of an old technology and add in a new.

Say when you come in, maybe it used to be that all we could do was a direct physician exam. Then, maybe we could do an exam and an x-ray. Now, maybe we could do an exam and x-ray and an MRI because now, if it’s not a bone, maybe it’s a soft tissue injury. Maybe beyond that you could then do a PET scan. I mean, we add technology. We very rarely replace it or get rid of some of the earlier ones.

The technologies, as a whole, do not tend to be things that drive the cost down considerably. Unlike in other fields where you’re saying, “Well, we used to have this way of doing it and it cost this much money and this much time. We found a new, very quick way to do it now, and it’s much less expensive.” That’s rarely what occurs in the healthcare field. Usually the new technology is very, very expensive and doesn’t drive the cost down at all. It drives it up.

Every now and then someone gets the idea of claiming that hospitals are gaming the numbers on the charity care they provide and urge taking away the non-profit status hospitals. What would be the effect if that were to happen?

I want to take a little issue with the idea of gaming. There is a game that goes on, although who set the rules of the game and put it in place in the first time,  it’s not necessarily the hospital. You do have a strange set-up going on where you incentivize the organizations to play a game a certain way, including making sure that their charity numbers become very high.

There’s a lot of debate about what would happen if you get rid of non-profit status. Some of it has to do with, what does it mean when you say you’ve gotten rid of non-profit status? The really quick answer is that non-profit status goes along with some other things, like the ability to get charitable donations from other groups and organizations; and those people, then, to tax-deduct those donations. For people who give money to a hospital, they may not be able to be deduct it if they lose their non-profit status.

I also should say this as a little aside, technically, as a legal matter, non-profit and tax-exempt are slightly different determinations. As a practical matter for whatever we’re doing, you don’t really need to worry about that. But it’s two, slightly different things that are going on here.

The other thing that you might worry about is grants. There are many grant organizations that will not provide grants except to a non-profit. There are some other kinds of things that go along with that. And then, the big part of course is if you take away their tax-exempt status, they’re going to have to pay a significant amount of money out in taxes.

It seems like in hospitals you’ve got these two, polar opposites — big IDNs that make enormous amounts of money and then these tiny community hospitals that struggle to not close up shop because they’re losing money every year. Do you think the larger groups will absorb the smaller ones and would that be good or bad?

I don’t know if it’s good or bad if it happens. Part of it’s going to depend on how we see the evolution of the provision of care, including charity care, over these next few years. But the question of this absorbing the other ones, that’s what’s already happening now if you look at many cities and many hospital environments.

It used to be you had many little hospitals, and by and far, the vast majorities have been absorbed into major systems. Most places have now, two, sometimes three hospital systems rather than many individual hospitals.

On the plus side, as I mentioned before, that does give you some ability to spread across the institutions between some of your hospitals that have the ability to make more money versus some of them that don’t have that ability. On the downside, you do have then, fewer choices of smaller community hospitals. You might get less in the way of unique ways of doing things.

It’s not clear what the overall effect will be of that, but I think we’ve seen the consolidation of hospitals now going on for quite a bit of time.

It’s interesting too, the recent case that came up where the hospital in Marin County is suing Sutter, claiming that Sutter basically pillaged the hospital for $120 million before they walked away and turned it back over. Is that going to be a concern when you’ve got hospital systems that, overall, have a fairly equal balance of income to services provided, but yet maybe not geographically equal?

It’s always a problem and it’s always going to be a hard thing to think about. If you look into the idea behind this, it’s that if you’re a business and you have a manufacturing plant that’s just constantly losing money, or an arm of your business is losing money, as a business, you’re inclination is to say, “Well, we no longer want to have that particular arm. That’s where we’re losing all our money. That’s what we have to do, we have to close that.”

And hospitals, even internally, have started to think that way when they say, “Look, we’re losing all our money on our prenatal care, “ or, “We’re losing all our money on our emergency rooms.” These are areas that don’t tend to be moneymakers. They’re pretty much just not. They’re areas where you lose a lot of money, and so the tendency’s to say, “Well, that’s where we’re losing money, that’s what we close.” The difficulty and the tension, I think, continues between this idea — even as I said in the beginning — that it’s a business model.

In a healthcare model, we’d say, “Well, that’s ridiculous. You’re open because you need those services. That’s the whole point. We need an emergency room. We need those things. You have to stay open.” Even though what we’re saying to you is, “You have to do that, although we know you’re losing money.” That’s the same thing that happens, just on a larger scale when you look at a hospital system that looks around and says, “Well, this hospital’s losing all the money.”

But one response to that might be, “Well that’s how it’s how it’s going to be. The system is that you have to have that there, we need this service. As a community, we need this service.” So then the question is, have we done something wrong in setting up our delivery system that creates this tension?

We told them that they’re a business, even a non-profit business, and then said, “Oh, but we expect that you’re going to provide these services we need for the community,” and created this very uneasy feeling where companies come in, or hospitals systems come in, and they have to say, “We’re going to accept that we’re losing enormous amounts of money on this institution or on this service,” as opposed to really thinking how we’re supposed to fund this in such a way that they don’t feel that degree of pressure. That either we don’t survive at all as a hospital system unless we get rid of this and there’s some other way to maintain the things that the community thinks that it needs.

It hasn’t been too many decades ago when hospitals were mostly run by nuns or by people who were trained in healthcare administration or by doctors. Now they’re mostly run by people who have mainline MBA-type training. Could it be that people trained to think in terms of cost centers and widgets and market share don’t see healthcare as all that different from other businesses?

I don’t know. I mean, some of the people who work and have the degrees have health sciences backgrounds or health administration backgrounds. It’s not like they’re completely foreign to the notion of delivery of health systems versus the business of health, versus the business of anything else. I don’t think you see a ton of transplants across fields, for example. You know, someone who ran Ford and General Motors suddenly running a hospital system. It is a fairly unique and specialized area that people get in to.

It could be different, although there are some great studies that show how horrible physicians are as business people. There’s the same with lawyers, so I can’t say much on my field either. There are studies that show it’s a skill. Management’s a skill, administration is a skill. You might need some more specialized information, and there are degrees in those. There are business degrees in health administration.

But maybe you should have people running an organization whose degree is in running organizations, not in caring for patients. That’s not to say you don’t need some level of communication. You need some way to bridge the gap and we’ve seen that problem. We’ve seen it at its worst in institutions where you have no communication and you really feel like people are making business decisions without thinking about the patient decisions.

It could be that the best model here is some combination of people who have some understanding about how to run and administer a healthcare organization, and people who have understanding about direct patient care.

Hospitals are spending all these millions to implement electronic medical records, subsidized by the government stimulus money. How do you see that changing the hospital business?

Ideally, it reduces cost. The wonder of the electronic medical record is supposed to be that it has all these benefits in terms of actual care to patients, as well as reducing costs, reducing medication errors. Maybe even the ability to engage in some kind of comparative effectiveness research on broad scales if you gather enormous amounts of patient data.

The problem is that it can take many years before it’s actually implemented. In the mean time, you have compatibility issues, you have learning curve issues. You have enormous cost outlays if you do this.

I think, in the end, it’s still the best place to be heading, but it’s hard to say in the short term whether we’re just not going to see a lot of growing pains.

You would think that the for-profits, especially the investor-owned chains, would be the most aggressive in their adoption of information technology like any other industry. And yet in healthcare, they’re probably among the most backward outside of tiny, standalone hospitals. Is that surprising to you?

Not necessarily, because it’s a long-term investment issue and it can be very difficult to do long-term investments. You’re balancing bottom lines at different points. You’ve got to somehow be able to deal with the fact that you have a certain amount of money outlay that you’ve got to do to put in place an electronic medical record system, and the cost estimates are enormous. Somehow you have to then — when you balance your books that year when you’re showing your profits and losses, that’s going to cut into your bottom line significantly — you have to be in a position where you can look long term. And to a certain extent, non-profits have a slightly better situation in doing that.

They’re not quite as focused on the bottom line. They’re not going to have some of the same pressures, or shareholders looking at things going, “Wait a second. What happened here? Why did you authorize this giant outlay that we’re not going to see the effects of for 5-10 years down the road?” They also have possibly the ability to take advantage of, as I said earlier, some grant organizations will give grants to anything but non-profits. The non-profits have the ability to take advantage of some of the grants and such that are out there to encourage the adoption of some of these records.

To the extent that some of them are government institutions — not all non-profits are government institutions, but the ones that are government institutions can have an additional impetus that are getting pushed on from the government itself saying, “You need to go ahead and implement records.” The Veterans Administration hospitals are far ahead of the game in the electronic medical records world, and much of it is because basically, word came from above: “This is what you’re going to implement and what you’re going to do,” and they didn’t have anybody going, “Well, we’re worried about the bottom line in the end.”

I was interested in your research with e-medicine and its impact on the healing aspects of physician-patient relationships. What were your conclusions?

That there are some excellent, excellent tools out there in e-medicine if you use them appropriately and carefully; and there are some that can cause significant problems if you’re not careful. But like anything else, it can be used very well.

Any concluding thoughts?

I do think we’re going to see some movement around this. There’s certainly a lot of interest in it, and at various times we get a lot of political interest and concern about non-profit hospitals and charity care and tax-exempt basis. I think we’ll see something, and we’ve seen some states start to put in place, creative mechanisms to deal with it. I’m not sure if we’ll see something on a federal level, but I do think that we’ll see additional state movement. We’ve already seen localities, as you have already noted, remove tax-exempt status from hospitals where they say, "You know what? You’re not really fitting the model of what we thought we should be using for tax-exemption."

Monday Morning Update 9/20/10

From Tobias Funke: “Re: interesting billboard. This is from Avera Health in Sioux Falls, SD.” That’s pretty cool – the billboard has a smoke machine behind it to extend the smoke into the sky. It drew lots of attention, both from passers-by who checked out the site afterward and the local fire department, who shut it down.

From The PACS Designer: “Re: Windows 1E9 beta. Just like Mr. H, TPD loves Firefox and avoids Internet Explorer. Well, now we have the Windows IE9 beta release, but you won’t be able to use it for Windows XP! It looks like a move by Microsoft to push more of us XP users to upgrade to Windows 7.” I’m still holding Vista against them. The decades-old Windows pattern is obvious: one really OS good release alternating with a bad one that causes endless frustration. My preferred browsers, in order, are Chrome, Firefox, Opera, and then IE (I don’t use Safari, so I don’t know where it would fit). Windows 7 is a winner, though, which is still not great consolation given that I paid for Vista instead of jumping right from XP to the next good version. I don’t think anyone would complain about moving up to Windows 7 if it didn’t require starting over for XP users — you have to have wasted your money on Vista to do a simple upgrade, or at least that’s what I recall when I last considered it. I suspect I’m like the typical XP holdout — not cheap, just not finding a good reason to risk problems knowing that Microsoft offers no help (in other words, have lots of time and a second computer to Google your problem just in case the first one is trashed because you’re on your own).

Former McKesson Provider Technology CFO Craig Niemiec is named EVP/CFO of US Preventive Medicine. I checked out that company’s prevention program and it sounds pretty cool: you pay $229 for the first year, complete an online health risk questionnaire, and then go to a local lab to have a panel of blood tests. The company sends your lab results to a PHR, you and your doctor get a custom prevention plan, you gain access to online dashboards and action programs, and a nurse advocate is available to help with health maintenance. Since it’s not tied to insurance or employment, nobody sees the information without your approval.

Job candidates with a CPHIMS credential would impress one out of five HIStalk readers if they were hiring. New poll to your right: would you use an free, ad-supported EMR?

Sonney Sapra is promoted to CIO of Tuality Healthcare (OR).

iOptimal announces the beta of iPad Hospital Toolkit, which it says requires no iOS programming and connects to standard databases to convert legacy apps to run on the iPad.

A third organization is approved by HHS to certify EHRs as an ONC-Authorized Testing and Certification Body: InfoGard Laboratories of San Luis Obispo, CA. They have many certifications and list extensive internal expertise (cryptography, security, systems architecture, etc.) that makes CCHIT’s credentials look a little anemic in comparison.

St. Edward Mercy Medical Center (AR) will go live on Epic September 26. The local paper’s article says Sisters of Mercy Health System, of which St. Edward is part, spent $450 million on Epic.

Siemens will make its IT Solutions and Services unit a separate company on October 1, having previously announced plans to cut 4,200 jobs there to set up a spinoff. That business covers a bunch of industries including healthcare, but I wasn’t familiar with the healthcare parts: content management, PACS data storage, identity management, and RFID. I assume this has nothing to do with Siemens Healthcare.

Cardinal Health sells its remaining shares in its CareFusion spinoff for $706 million. Some of the CareFusion medical device and technology brands include Pyxis, Alaris, AVEA, Jaeger, SensorMedics, V. Mueller, and MedMined.

England’s Connecting for Health wants NHS trusts to report their inventories of Microsoft licenses by October 1. Since CFH didn’t renew its Enterprise Agreement and their license count is fixed, that means trusts are own their own to budget and pay for their Microsoft licenses.

I’m not sure how this qualifies as defense funding, but Assistant Senate Majority Leader Dick Durbin brings home the Illinois bacon in getting $3.6 million in funding through the Senate Appropriations Committee for Children’s Memorial Hospital of Chicago to study regenerative genes. It’s great for wounded soldiers, so I guess you could squint a little at the tumescent federal budget and make it so. The Senate has to approve, but I think they are battle-weary themselves from approving endless federal handouts that, if you continue squinting, only slightly resemble a robust economy.

An interesting and cheap idea for practices interesting in reducing missed appointments: sign up for a Web-based virtual phone service and use it to send SMS reminders to patients.

Vecna Technologies signs a marketing deal with Cycom Canada to sell its QC PathFinder real-time hospital infection monitoring system to hospitals in Canada. The company, whose offices are in the DC area and Cambridge, MA, also offers a Web portal and patient self-service kiosks. Also, the medication delivery robot above. Their stuff looks pretty cool.

Former treasury secretary Paul O’Neill questions David Blumenthal after the latter’s EHR-love keynote speech at a patient safety meeting, asking him (I’m paraphrasing): if the government is so hot to spend billions on EMRs, then why not design a prototype and then refine it, creating a national standard? Blumenthal’s answer, also paraphrased: there’s a debate about whether the ideal approach is like the Internet, where competition took the basic structure of the Internet and turned it into something amazing, or should someone just set detailed standards centrally? He also touted certification. An interesting quote from the excellent Mass Device article, from Atul Gawande at an August meeting talking about reducing medical errors: “Ignorance remains, but we have a new kind of human failure that has emerged as important and that is what the philosophers call ‘ineptitude,’ meaning that the knowledge is there, but the individual or group of individuals fail to apply that knowledge correctly.”

A former Medco pharmacist nears the 80th day of his hunger strike protesting the mail order pharmacy’s requirement that pharmacists fill at least 50 prescriptions per hour, saying it causes medication errors.

The VA and DoD launch a fourth records-sharing pilot, this one involving the Spokane VA, Fairchild AFB, and Inland Northwest Health Services. The first three are in San Diego, Norfolk, and Indianapolis.

California Attorney General Jerry Brown wants to review the salaries of hospital executives, among several public positions that he thinks are overpaid. The healthcare example he gave was the CEO of Washington Hospital, who makes $847K. The hospital gave the stock answer about having to pay market salaries for the best hires, which always sounds lame to me. First, some of healthcare’s hires are clearly not the best people. Second, by that logic, you’d be paying teachers and ministers huge dollars if only they were lucky enough to have higher-paying alternatives. And third, I like the idea of offering less than market salary and seeing who really wants to help patients vs. themselves. If you can’t stand the idea of running a non-profit hospital for a paltry $500K, then don’t let the door hit you on your way out.

E-mail me.

Sponsor Updates

• T-System announces the six winners of its 2010 Client Excellence Awards.
• Medicity announces that Carolinas HealthCare has selected the company as its partner to build a multi-state HIE.
• Nuance will be at AHIMA next week.
• Baltimore-based clinical documentation vendor Salar is recruiting for a number of positions to support its growth: software engineer, RVP of sales, implementation specialist, marketing specialist, and others. I like these guys – their crew was having a blast at the HIStalk reception at HIMSS in Atlanta.
• A good Facebook to follow – NPC Creative Services. I read a lot of Facebook posts and theirs is always on point about HIT.
• HIS vendor IntraNexus will be at HISpro’s seminar for buyers in Dallas on October 13-14. That’s Vince Ciotti, who keeps the registration fees and hotel costs way down ($295 to register).
• I don’t remember if I’ve mentioned this: Quest Diagnostics and Surescripts will work together to create a service that will make lab and prescription information readily available to physicians. Quest is the parent company of HIStalk sponsor MedPlus, which offers the Centergy data exchange, ChartMaxx document-based EHR, and Web-based Care360 EHR that is used in more than 70,000 practices.
• Holon is offering downloable overviews of its offerings: central order entry pharmacy, results notification, workflow scheduling, pharmacy solutions, and others. The company offers the Holon Framework that includes solutions for data exchange, workflow, interoperability, and document management, all designed to enhance rather than replace existing systems.
• International informatics and medical terminology vendor Apelon will be at AHIMA, where Kathy Giannangelo will present on the state of standardized terminologies. The company’s expertise is in terminology asset management, data interoperability and integration, and data warehouse content and consulting.
• If you’re going to the Virginia MGMA fall conference in Virginia Beach next week, check out DIVURGENT’s presentation on tactical approaches to HITECH, delivered by partner Colin Konschak and client services VP Shane Danaher. The healthcare consulting firm will also be at the CHIME Fall Forum and VAHIMSS in October.
• Stockell Healthcare Systems offers several success stories about its InsightCS solution for patient registration, ADT, and revenue cycle management.
• Precyse Solutions will oversee transcription, medical records processing, coding, and storage for Benefits Health System (MT), taking over its 60 employees.
• Rechargeable workstations from Enovate are highlighted on the Web page of Children’s Hospitals and Clinics of Minnesota, which shows the amenities and benefits of its patient rooms. Cool idea: each room has a caregiver window so that nurses can check on the patient and perform documentation from the hallway without barging in.
• UC Irvine Medical Center gives credit to Surgical Information Systems for its best practices in patient handoff and communication that led to a successful Joint Commission survey.
• Order Optimizer has added a very well laid out Web page on Meaningful Use. It says its SaaS-based CPOE can be live in nine weeks with no capital investment and no impact on legacy systems, making it feasible to meet Stage 1 incentives within 90 days.
• MED3OOO offers free electronic newsletter subscriptions covering coding and compliance, clinical tools, and developing healthcare news.
• SRSsoft publishes its online EMR Straight Talk, with the latest entry being EMR Purchase – Caveat Emptor.
• Cumberland Consulting Group is growing and therefore looking for candidates at these levels: consultant, managing consultant, and executive consultant.
• Regulatory compliance consulting firm The Anson Group will present at the 2010 RAPS Annual Conference in San Jose next month. The company also offers technology commercialization services that can include licensing, sale, and partnerships, particularly with regard to products involving FDA approval and the resulting regulatory risk.
• I like the people at electronic forms management experts Access, being among the very few sponsor folks I’ve actually hung out with non-anonymously here and there. I’m still trying to get them to bring their award-winning Texas barbeque team to HIMSS in Orlando for your benefit as an attendee, since that part of the world struggles by with pathetic chain barbequed chicken of no particular regional specialty and therefore is generally unaware of the glories of Texas brisket and sausage (although I do like that of Cecil’s Barbeque on Orange Avenue even if they smoke it over hickory instead of post oak and/or mesquite). Anyway, Access has a blog here, which coincidentally gives HIStalk a shout-out in the latest entry.
• Informatics Corporation of America is offering an October 21 Webinar entitled Sustaining HIEs Through Leveraged Infrastructure – A Multi-Community Approach.
• Sunquest is at the pathology informatics conference in Boston this week and will head on over to CAP ‘10 in Chicago immediately after. Stop by and tell them you saw it on HIStalk.
• API Healthcare launches its Client Connections site, providing easy access to support materials, manuals, and training materials. It also offers clients the ability to network with each other and with API’s experts on workforce management technology. Clients can search the support database, review and enter support tickets, and receive e-mail updates when the status of their ticket changes.
• Enterprise workflow vendor FormFast offers a Webcast library covering EMR maturity and adoption, RAC audits, workflow applications, prescription printing, and others.
• The Sentinel RCM application 340b drug pricing application from Sentry Data Systems will be integrated with Omnicell’s WorkflowRX 7.0 software.
• EDIS vendor EDIMS will be at ACEP 2010 in Las Vegas next week. I’m sure they would appreciate a howdy from HIStalk readers also at the Mandalay Bay.
• Culbert Healthcare Solutions just won a “fast growing” award, so it stands to reason that they might want to talk to you if you’re an ace consultant (Allscripts, Epic, GE, integration, revenue cycle, PM, etc.) Info here.
• Interesting in outsourcing revenue collections? AdvancedBiller, a service of AdvancedMD, will match you with up to three AdvancedBiller partners, who will provide needs analysis and price quotes. Register here.
• TELUS Health offers an online demo of Telus health space, its HealthVault-powered consumer platform for Canadians that is the first to achieve Canada Health Infoway pre-implementation certification.
• SCI Solutions is making customer reviews of its access management services freely available online via Customer Lobby, including KLAS-like commentary and star ratings. I believe you can infer that they have little to hide about their ordering, patient scheduling, and revenue cycle applications. SCI was one of the first HIStalk sponsors and doesn’t really advertise much, so thanks to John Holton, Cindy Dullea, and Hans Morefield, some of the folks there that keep in touch regularly.
• Wellsoft announces that CCHIT has certified its EDIS v11 emergency department EHR, making it one of the first.
• EHR consulting experts Enterprise Software Deployment (Allscripts, Cerner, Epic, McKesson, Meditech, Siemens) brings on David Tucker as national sales VP. The company is growing like weeds and is on the lookout for both salaried and contract consultants – check out their job board.
• Software Testing Solutions has posted fun photos from their creative booth activities at SUG 2010. You can sign up for a variety of demos and classes for their application testing solutions for Sunquest, Eclipsys/Allscripts, and Epic.

News 9/17/10

From Bama Birdie: “Re: HealthSouth. Trinity Medical Center will relocate to its unfinished hospital on US 280.” This was the endlessly touted digital hospital that was to serve as the flagship for the HealthSouth rehab chain, to have been built by HealthSouth and Oracle. It was called the “hospital of the future” when construction began in 2001, which turned out to be apropos since Richard Scrushy’s $2.7 billion fraud scandal left it permanently unfinished. It was vaporware anyway, said HealthSouth’s CEO last year: “It was a pipe dream and a figment of the imagination. It never had a chance.” You would have believed otherwise given the gushy coverage by the bootlicking healthcare rags back in the day, which were apparently unaware that Oracle had pretty much nothing to offer hospitals despite periodic, uninspired healthcare waters toe-dipping.

From RegularReader: “Re: Broadlane. MedAssets buys competing GPO/services company Broadlane for $850M Tuesday and the Street doesn’t exactly love it. Stock is down approximately 10% since the deal was announced. Only time will tell how many jobs the expected $20M in 2011 expense-based synergies represents.” MedAssets shares closed Thursday at $18.54, down from Tuesday’s peak of $21.50.

From Willie Maquitt: “Re: Adreima. Where do companies come up with these names? How do you pronounce it?” Advocacy for Reimbursement Matters, like George “T-Bone” Costanza in Seinfeld, decides to give itself a contrived nickname, Adreima, maybe to celebrate its acquisition this week of eligibility vendor Hospital Inpatient Services. I’d say it “addREEmah”, but I hate it when companies make up a name of their own free will, then insist on shortening it. Why not just pick a short one to start with?

From Human Error, Here: “Re: Pittsburgh. The executive, who spent $10 million of taxpayer money on an emergency dispatch system upgrade (downgrade) when the county and city can barely afford to patch potholes blames human error for care delays.” The new system was missing addresses and landmarks, so dispatchers got confused when multiple surrounding towns share the same street address. A dispatcher who sent police to a cell phone tower instead of a house to check out a break-in was suspended indefinitely. I’m not sure if that’s better or worse than in Detroit, where ambulances don’t have computers or GPSs, ambulance response times are long, and firefighters and police officers aren’t allowed to help a victim until the ambulance gets there.

From TexLAHawk: “Re: JPS Health Network, Texas. Word is that Jamey Pennington has resigned as CIO. So basically a county facility that has historically had terrible management and clinical outcomes now is set to buy the most expensive, resource-intensive EMR possible without a CIO at the helm. Glad to see our tax dollars are hard at work!” I’ll guess the CIO part is true since JPS IT director Joe Venturelli sent a Rumor Report to mention that the book he wrote, The Informed Patient, is available on iTunes (or at least it claimed to be him) and mentioned his role as interim CIO. They couldn’t force the CIO to stay if he wanted to leave, of course, and I’m sure that he’s as replaceable as any of us.

Inga and I get occasional personal invitations to attend conferences of various kinds. Even though we rarely do so because that means arranging vacation days from work and all that, we do appreciate the offers. Thanks for thinking of us.

Capsule announces Mobile Vitals Plus, part of its Enterprise Device Connectivity solution. It’s a single, touch screen-powered, nurse-friendly device that captures vital signs and sends them to the patient’s electronic record. A video demo is here. Seems cool, but I’ll defer to the nurses (I’ll bet you rarely hear that from an IT person).

HIMSS 2010 Davies Awards winners, just announced: Sentara and Nemours, organizational; The Diabetes Center (MS) and Miramont Family Medicine (CO), ambulatory; Open Door Family Medical Center (NY), community health; and Wisconsin Division of Public Health’s Wisconsin Immunization Registry, public health.

Jobs: Clinical Systems Analyst III, EMR Implementation Specialist, Eclipsys Documentation Consultant, Allscripts Consultant.

I mentioned the Davies winners even though HIT awards are a waste of time if you ask me, so I might as well mention the hospitals just named to the InformationWeek 500: Banner Health (90), Caritas Christi (44), Children’s Omaha (184), Children’s Dallas (187), Cincinnati Children’s (13), CoxHealth (144), Geisinger (243), HCA (213), Heartland Health (118), Lifespan (74), Norton (157), OhioHealth (238), Parkland (143), Poudre Valley (224), Sparrow (22), University of Pennsylvania Health System (54), UPMC (5), and Wuesthoff (172).

The College of American Pathologists contributes to the first DICOM medical imaging exchange standard for pathology slides, a step along the way to full integration of imaging information with LIS information. 

At a meeting of the Health IT Policy Committee, Epic CEO Judy Faulkner says she is worried that the “government is going to get into the electronic health record design business,” apparently concerned that its future Meaningful Use requirements may be overly prescriptive. Members are also debating how HHS can give the industry a heads-up on the second-stage MU requirements given that they won’t have had time to understand how providers are faring with the first-stage ones by the due date.

LTC Patricia Ten Haaf, commander of the Army’s 452nd Combat Support Hospital in Afghanistan, leads a Lean Six Sigma project to upgrade its MC4 battlefield EMR. ED charting was cut in half when electronic notes replaced paper and nurses created 22 templates that reduced paper forms from nine per patient to two and shaved more than 10% of an admission duration. In the US Army photo above: SGT John Michel, SSG Brooke Stauner.

Free EMR vendor PracticeFusion had two revenue streams in its early business models: pushing ads and selling de-identified patient data. Above is how the first option looks — an ad running at the bottom of a PracticeFusion screen, courtesy of its announcement this week that it has hooked up with an ad company.

Munroe Regional Medical Center (FL) budgets $2 million to upgrade its McKesson Horizon Expert Orders system.

GE Healthcare announces that it’s working with Bassett Medical Center in a Smart Patient Room pilot to develop real-time monitoring of safety protocols such as hand-washing and falls.

Sentara chooses Omnicell for medication dispensing. I assume that means Pyxis was displaced, which is happening pretty often these days.

Teleradiology service provider Musculoskeletal Imaging Consultants introduces Virtual Viewbox, which presents multiple patient PACS records in a single display and allows side-by-side consultations (the company calls that “HITECH Teleradiology”). It runs on an iPad and is free, with a catch: the docs have to ask their imaging centers to use MSKIC for reading.

In England, the Morecambe Bay NHS Trust creates an ambitious improvement plan for its just-implemented iSoft Lorenzo system: “transact a day’s work in one working day.” There’s also a problem in that the system informs users that a patient is dead when in fact they are not.

E-mail me.

HERtalk by Inga

A Boston Medical Center insider confirms that the organization’s recent layoffs included a few IT staffers. However, they added that BMC sees its IT strategy as an integral component of the organization’s overall financial recovery. BMC is on track to implement a new GE revenue cycle system and is working towards qualifying for Meaningful Use incentives in 2011.

Wanted: 13 senior healthcare executives to work for free on CCHIT’s Board of Trustees and Board of Commissioners. Commission chair Karen Bell says CCHIT says participants will help in the development of new business strategies and programs. Application deadline is October 15th.

National Surgical Hospitals contracts  with Summit Healthcare to provide data normalization and clean up following its migration to the Meditech 6.0 platform.

This week on HIStalk Practice: Dell plans to integrate its Android-based Streak mobile device into its EMR technology bundle; providers may one day need EMRs to prove clinical competence when renewing their medical licenses; female physicians are slightly higher performing and producing better outcomes than their male counterparts; and, doctors are more likely to adopt EMR if their physician friends (and not just peers) do.

There’s now an iPhone app for real-time drug safety surveillance. MedWatcher tracks the latest drug safety updates based on FDA alerts, media, and other sources. The bi-directional app also allow users to report possible side effects.

Google unveils an upgraded version of Google Health that includes a cleaner interface and more focus on wellness. I took a five-minute spin, which was enough time for me to conclude that 1) there were lots of new options, nice graphics, and a handy dashboard, and 2) the iPhone app I have been using for tracking calories, exercise, and weight (My Fitness Pal) has more much built-in functionality and requires fewer keystrokes for data entry. Plus, it runs on my iPhone. Overall, Google Health is a more comprehensive tool and would be great for someone wanting to track chronic health conditions, but, I didn’t see enough there to make it worth my time.

Spalding Surgical Center of Beverly Hills installs the web-based MMRPro professional solution, allowing the center to digitize and upload medical records from treating physicians.

Claims clearinghouse vendor InstaMed raises $6 million in a new round of funding that includes both debit and equity capital. Investors have contributed $22 million to date.

Sponsor Updates

• MEDSEEK secures an 18-month engagement to develop and deploy a new consumer Web site for ProMedica Health (OH).
• Keane earns a #70 ranking on the InformationWeek 500 list of top technology innovators in the country.
• CareTech Solutions makes available the recorded Webinars from its eHealth Innovation Series.
• FormFast will demo its HIM workflow and document management tools at AHIMA in Orlando next week.
• VHA, Inc. will offer PrimeSuite, Greenway’s EHR/PM solution, to its affiliated physician practices.
• KronosWorks 2010, the Kronos user conference, will be held November 7-10 in Las Vegas, with former labor secretary Robert Reich as the keynote speaker. The $100 early registration discount ends October 1.
• I see Wellsoft EDIS is heading to the ENA conference in San Antonio Sept. 23rd, as well as the ACEP Scientific Assembly Sept. 28th.
• Voalté brings on five employees to support the success of its Voalté One smart phone system. The company has doubled its headcount so far this year.

E-mail Inga.

Readers Write 9/15/10

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!

Document Management is Good for Business
By Shubho Chatterjee, PhD, PE

Enterprise content management (ECM), also referred to as document management, is a capability with significant potential to centralize content and document storage, streamline and automate processes, and integrate smoothly with other enterprise systems. The business benefits are improved operational efficiency, reduced manual labor, reduced paper consumption, and improved process quality.

ECM consists of a central content or document repository, with indexing and searching capabilities, integrated with automated workflow allowing documents to be routed to appropriate processes and processors. The usage of the system is controlled by access policies at individual and group levels. Examples of use of this system include, but are not limited to, patient admissions, medical records management, invoice and payment processing, finance and accounts management, contract management.

A rigorous vendor selection process is critical to selecting the appropriate vendor. This should include an initial evaluation of functions and workflows where ECM is deemed to impact the most. Additional selection parameters include, but are not limited to, the total future cost of ownership for the proposed system, the projected process improvements and labor reductions, current material consumption, and current storage costs, product functionality, deployment options, and scalability. These parameters should be used to construct ROI scenarios for different options. Both objective and subjective factors should be integrated into the decision making.

Deployment options can be in-house (client server) or SaaS. While the in-house option provides for greater control, it also requires dedicated resources to manage, maintain, and upgrade the environment. SaaS deployment enables access to the system on a subscription basis with the vendor managing and operating the system and associated infrastructure in its data center.

The SaaS option frees IT staff to focus on more strategic tasks that add value to the organization while avoiding the expense of adding more IT infrastructure and resources to manage the system. Key factors to consider here are Internet connectivity and bandwidth and information security. Implementation is also quicker as the vendor completes the system build, configuration, and installation at their data center.

Collaborating to build a solution requires a thorough examination of the current processes across the organization with supporting process turnaround time data collection. This forms a baseline from which process improvements can be tracked in the future. To maximize the impact of the solution, this in-depth, step-by-step process analysis should be used to re-engineer and automate processes using ECM.

Creating efficiencies with this solution is feasible in many areas. After implementing ECM in the admissions department, Miami Jewish Health Systems has a central repository for patient documents. Seamless integration with the EMR application allows authorized users from any location to instantly access the associated patient’s documents from their workstation, eliminating time-consuming manual searches.

Routing documents electronically to employee’s workflow queues allows for faster processing and greater security. Eliminating the need to search for documents or make paper copies frees the admissions staff from tedious tasks and focus on patient care. Medical Records Management workflow has also improved with easy, instant, and effective collaboration across the organization. Medical personnel receive automated alerts for completing charts and associated notes and deficiencies. Previously, this required a visit to the medical records office.

Back-office departments, such as accounting and finance, have a high volume of paper flow and manual process being susceptible to lost invoices, missed bills, overpayment, or underpayment.

ECM deployment at MJHS is automating invoice processing. Invoices are now indexed to payments made and are searchable easily. With this technology, invoice approval is also automated and does not require manual inter-office mailing and completion. Payments are also completed in a timely manner.

As with any technology solution implementation, ECM must be well planned with a cross-functional team. Integration aspects with other enterprise applications must be well thought out. Baseline process documentation and re-engineered processes are also critical for success and before-after comparisons.

Shubho Chatterjee is chief information officer of Miami Jewish Health Systems of Miami, FL.

Regaining Control of Disaster Recovery
By Tony Cotterill

While working with our clients in hospital IT departments, we come across a variety of data backup scenarios. Some hospitals do full backups nightly, while others rely on an incremental/full backup strategy. Some sites exclude specific applications from their nightly backup simply because the volume is too great to complete in a 24-hour period.

Although there’s no ‘typical’ approach to backup and disaster recovery, a hospital’s data is a vital asset that must be protected. Before deciding how to protect it, however, first you must understand it.

The data landscape in the healthcare industry is more complex than in many other sectors, primarily because of the varied data types – namely, structured, unstructured and semi-structured — that are generated by both clinical and administrative systems. The type of data being secured and protected is inextricably linked to how that data needs to be recovered.

Structured data comes from database-driven applications, such as the hospital information system, radiology information system, electronic health record, and accounting systems. These applications typically generate hundreds of GBs, possibly a few TBs in larger facilities.

Unstructured data comes from applications that produce discrete files that are not associated with a database. Examples include word processing and spreadsheet files, which are routinely created by administrative staff and then stored on file servers. Many TBs of unstructured file data can be a challenge to backup and recovery.

Semi-structured data is produced most commonly by picture archiving and communication systems and document management and imaging systems. Both maintain a database of information (structured data) that references large quantities of discrete files (unstructured data). A PACS database may run on Oracle or SQL, and its size may be relatively small in relation to the many TB of DICOM images that database references.

Once you understand the three categories of hospital data, you can determine how much is dynamic vs. static. The dynamic data, which typically comprises 20-30 percent of overall healthcare information, is accessed regularly, and therefore changes constantly. This is the data you should be replicating every day.

Static data, which probably makes up the other 70-80 percent of your storage, should be treated differently. This unstructured and semi-structured data never changes and much of it will never be recalled again. Nevertheless, regulations and/or institutional policies compel hospitals to store it for five years, ten years, perhaps even the life of the patient.

So here’s the good news: once you’ve identified your static data, you can replicate it and move it to a self-protecting archive. Then there’s no need to include it in your backups.

This combination of backup and archiving provides an optimal strategy for treating each data type with the right method. By understanding the nature of the data in the critical clinical systems, the IT team can deliver both realistic and acceptable data recovery objectives to the business. In the event of a disaster, the organization can rest assured that the data can be recovered in a reasonable timeframe, minimizing the disruption to patient care.

Tony Cotterill is president and CEO of BridgeHead Software of Ashtead, Surrey, UK.

RTLS and Temperature Monitoring Mania
By Fed Up with the Fever

Would someone please tell me what real-time locating systems in healthcare have to do with environmental monitoring? I keep seeing all these temperature monitoring requirements pop up in RFPs and press releases. It concerns me that the healthcare CIO (or whoever is making these decisions) doesn’t realize that temperature monitoring of refrigerators has nothing to do with real-time locating, and even worse, is willing to saddle their wifi  system with this function risking QOS-sensitive systems such as POE and VoIP.

Sure, real-time alerts of out-of-range or variable temperatures are important, but unless you’re subject to that old Bart Simpson joke where he calls up the bar and says, “Is your refrigerator running?” followed by Moe’s inevitable “Yes” and Bart’s “Well, then you better go catch it!” — well, your refrigerator is not mobile! There’s no need to locate it, and certainly not in real-time.

The real-time alerts and reports that healthcare needs related to temperatures of refrigeration units can be easily achieved with over-the-counter probes. Then, just as it would with any other DCC-based system (i.e., “dry contact closure” such as security cameras, alarms, doors, or nurse call lights), the RTLS would respond to certain pre-established conditions (i.e., temperature out of range). These other systems do not rely on real-time location except to “trigger” an event condition. That is, if you want a security camera to come on if a certain tagged piece of equipment enters the egress zone, you need the RTLS as it relates to the real-time location of the tagged piece of equipment.

Temperature monitoring requires no such “trigger.” It requires only that you “push” an alert to an individual (or group) when a particular event is recognized within the event software. No location changes are recognized or recorded. If healthcare organizations could recognize this, they would save a tremendous amount of money and not be subject to the heartache of a low-grade RTLS that does only one thing (wholly unrelated to real-time locating) well.

So I ask what RTLS has to do with temperature monitoring even as I understand why temperature monitoring is so prominent in the RTLS space. It’s an easy way for vendors to make money. So long as the company can write some basic rules, they can provide an alert when temperatures are out of range. They can also record temperatures at regularly scheduled intervals without staff ever having to physically approach the unit.

There’s no doubt it’s an important time and money saver for the hospital. And it’s a money maker for the RTLS vendor. They get to solve a problem for the customer and appear wholly competent on this level, so that when it comes to delivering their RTLS with any level of accuracy, there will be a certain level of trust pre-instilled.

Unfortunately, too many hospitals fall prey to the belief that environmental monitoring is a function of RTLS, so if the vendor can do that well, surely they can locate assets and automate patient flow, right? Sorry, folks, but it’s just not so.

News 9/15/10

From Across the Pond: “Re: Alert Online Healthcare, Portugal. Delays all over the place in their first Netherlands implementation of their flagship hospital. It seems they couldn’t deliver the Dutch-specific adjustments in their software on time. Testing was delayed, causing the testing squad of physicians, nurses, and administrative staff to be sent home. Needless to say, the atmosphere is less than sparkling and vibrant right now.” Unverified.

From Nasty Parts: “Re: Sage Healthcare. A new sales approach.” Sage seeks 40 to 50 more solution providers to sell Intergy and Medical Manager, adding to its direct-only channel because it doesn’t have the resources to meet demand.

From Peony: “Re: WellStar. The former cardiology practice of fired CEO Dr. Simone was recently purchased by WellStar for a lot of money. I wonder if this had anything to do with him being fired?” Unverified. I assume that practice is WellStar Cardiovascular Medicine, the 30-doc group he founded. Showing him the door will cost the hospital group $1.8 million, though, since his contract guarantees a paycheck for two years if he’s canned. Ditto for the also-fired general counsel, who will get an $856K parting gift. What the hell are boards thinking when they sign these contracts?

From Cable Cutter, Here: “Re: Verizon. Verizon workers severed a fiber optic cable near Pittsburgh Monday afternoon, affecting businesses and hospitals from Pittsburgh to Steubenville, Ohio and cutting all IT and phone service to thousands. Several call centers were out and emergency calls from hospitals went unanswered.” Unverified. Frontier in Illinois, which took over the old Verizon lines, had the same problem, with hospitals forced to use cell phones for several hours. 

From Situation: “Re: MyChart. Now available on iTunes.” Here’s the link.

Related: Dean Clinic (WI) says it became the first hospital to offer Epic on the iPhone Tuesday. The lady in the pink top really chews the scenery with enthusiastic overacting.

From Cmon Man: “Re: FDA regulation of smart phone apps. Patient safety and innovation are intertwined. Usability and efficacy would be escalated by FDA regulation, contrary to the protests of the industry.” FDA is watching app stores for imaging-related smart phone software, saying that anything that sends images to a medical facility requires FDA approval. They also supposedly called out iStethoscope and Instant Heart Rate as apps that might pique their interest. They say they’ll be issuing guidance.

Cmon Man also weighs in on HHS’s spending taxpayer money to design a trademarked phrase and logo for Connecting America for Better Health, saying it’s cutesy, presumptuous, and expensive. He also finds it uncanny that “better health” is part of the name, making it reminiscent of the UK’s Connecting for Health flatlining boondoggle, or the “HIT Devolution” as he calls it. I guess I don’t agree about the cost since the pallets of stimulus cash being shoved out of the HHS plane make this a non-issue, although I agree with the assessment that government-run HIT projects that cost billions are almost always colossal failures. And if you’re going to spend all that money, you might as well give the project an identity.

From Pretty Kitty: “Re: CPHIMS. Tupelo Honey was right. I have come to believe the same and it’s apparent that even HIMSS isn’t investing much effort or support in it. Although I knew I had passed walking out of the testing center, it took two months to receive notification from HIMSS and a year to get notification to my company. Other than a hearty congratulations, the certification has meant nothing. I will not be renewing.” I think HIMSS does OK with CPHIMS, but the bottom line is that generalist certifications aren’t worth much to employers. You can be pretty dense and still pass if you’ve been around awhile and do well on multiple choice tests. But, feel free to weigh in on that survey to your right asking about the value of CPHIMS. It’s still more relevant than CHIME’s Certified Healthcare CIO program, which makes no sense at all (other than the “cents” the related revenue stream brings to CHIME and the anemic ego boost it gives CIOs sporting unimpressive educational backgrounds). If you can show me even one hospital CEO who will state in writing that they hired a CIO because the candidate waved a CHCIO paper in his or her face, I’ll say so publicly (and that would be a terrible reflection on that CEO). In fact, what’s next, a certified CEO?

Listening: new from Stone Sour, the Des Moines band with some Slipknot personnel overlap. And as an intermezzo sorbet, speed punk from Lazy Cowgirls.

Paging Dr. Pronovost: a survey-based study finds that about half of healthcare workers think it’s a good idea for patients to remind their caregivers to wash their hands, yet a third of those respondents say they would not personally appreciate such a reminder. A third also said they would refuse to wear a badge inviting patients to question their handwashing.

The New York Times agrees with my assessment of Hewlett-Packard’s board for firing CEO Mark Hurd on shaky grounds, then suing Oracle for snapping him up. Its conclusion: “The HP board can now lay claim, officially, to the title of Most Inept Board in America … The whole world will know Mr. Hurd walked away with $40 million of HP shareholders’ money, and joined a multibillion-dollar competitor with HP in its sights — and there wasn’t a thing HP could do to stop him. Confidence-inspiring, this ain’t.” It points out that California courts don’t buy the validity of non-compete agreements, which is what HP is suing Hurd over. McKesson CEO John Hammergren, formerly viewed as ept, is one of HP’s board members.

CapSite sent me a copy of their 2010 US Remote Radiology Study. The big players are Nighthawk and Virtual Radiologic, but their share is not very large. It’s still mostly a preliminary reads business, but remote radiology is chosen for other interesting reasons (cost savings, mostly, but also turnaround time). CapSite provides reports and services that help healthcare organizations make informed capital expenditure decisions.

Outpatient imaging center operator RadNet acquires Image Medical Corporation, which owns PACS vendor eRAD of Greenville, SC, for $10.75 million in cash and notes. The publicly traded RadNet, which has $500 million a year in revenue, is forming a software development team for its newly created radiology information technology division. They say they’ll save up to $20 million over ten years by owning their vendor, plus eRAD is bringing in $5 million a year in revenue.

Weird News Andy notes that the last person a surgeon would want to leave a sponge in would be a lawyer. Or a judge, as in this case in Florida, where a surgical sponge and its metal ID tag were repeatedly misidentified over five months as it became infected in the judge’s abdomen, measuring a foot long by a foot wide when doctors finally took it out. Neither the hospital or its owner, Tenet, responded to his questions about how they would prevent the same problem in the future. The judge settled with the hospital, but he’s suing the radiologists and surgeons.

Stuff you can do right here: (a) stick your e-mail address in that Subscribe to Updates box to your right so you’ll be the second to know hot news (after me, of course, since I have to write it); (b) use the Search All HIStalk sites to … well, search all HIStalk sites; (c) Like us on Facebook with that widget to your right or search us out (Tim Histalk and Inga Histalk) and Friend us to support our pathetic illusion of popularity and acceptance; (d) send me a scandalous rumor via the garishly green but soothingly secure Rumor Report box; (e) add your two cents’ worth by leaving a comment or writing a guest article. And indulge me as I profusely thank the companies that sponsor HIStalk, which I think you’ll agree even though you may complain about the number of ads, do perform a service in bravely supporting an anonymous, abrasive, and hard-working blogger who toils by night after sometimes crappy days in the hospital (not usually, fortunately) to bring you news and opinion you wouldn’t hear otherwise (at least until tomorrow when the next rag or blog passes it off as their own creation). Mostly, thank you for reading.

eHealth Ontario signs a $46 million contract with Canada-based CGI Group to develop and manage a diabetes management portal.

Modern Physician names Amazing Charts CEO Jonathan Bertman, MD as its Physician Entrepreneur of the Year. He says he got into the EMR business because of the money, buying Visual Basic for Dummies in 2001 to create a simple, easy-to-use EMR that costs $995 upfront and $500 a year for maintenance (he says, “I like having a car and a house, but I don’t think you need to extort money from colleagues just because you can.”) I’m not sure I’d want him as either a doctor or a vendor given his admission that “In between patients, I would literally run back to my office to write code”, but I assume he’s got people to do that now since the company is up to 30 employees and 3,500 customers and has won some awards. I like his marketing pitch: “Is Amazing Charts crap? Um. No. But don’t take it from us. Try it yourself. As we’ve repeated ad nauseam, you can try it now without any payment or even giving us your name.” In a sideline business, he’ll also sell you a Male Genitalia Guide for $12, which he notes makes a great stocking stuffer (the guide, not the genitalia). Bet you can’t get that from Allscripts or Epic.

Dubai is having an mHealth Conference and Expo this week. Not to be confused with the mHealth Summit in Washington, DC in late October, or the mHealth Ecosystem in Chicago in December, or the mHealth Summit in Washington, DC in early November. The last one is most notable in my opinion because (a) Bill Gates is speaking; (b) the Foundation for NIH is involved; and (c) I’ll be attending and reporting (anonymously and at my own expense and taking time off from work, just in case my mentioning of it is suspect). It’s got a global health emphasis, of which I’m a fan.

The New York State Department of Health funds $109 million worth of HIT grants for 11 organizations, hoping to build an IT infrastructure to support the patient-centered medical home model of care.

A Mayo bioinformatics researcher gets a $3.1 million NIH grant to develop an EMR that will tie drug response to genomic information.

Odd: a hospital in India buys an MRI machine, but shuts it down a month later when it fires the only doctor who knows how to use it. He was on contract from a private lab and was accused of sending patients there instead of doing the work at the hospital. The hospital can’t get radiologists for the “meagre salary” it offers.

E-mail me.

HERtalk by Inga

Kadlec Regional Medical Center (WA) will deploy Wolter Kluwer Health’s Medi-Span for its Epic EMR.

Also integrating with Epic: Mediware and its HCLL blood transfusion management software.

HIE vendor Availity extends a multi-year contract with Prematics for e-prescribing services and the Prematics Care Communication messaging service.

3M Health Information Systems says its ICD-10 Code Translation Tool is now fully integrated with its medical vocabulary server, the 3M Healthcare Data Dictionary.

Benefis Health System (MT) outsources its HIT functions to Precyse. Sixty Benefis employees, including those in IT, transcription, coding, and medical records, will be offered jobs with Precyse.

Corepoint Health and IPeople partner to offer a bi-directional interfacing solution for Meditech hospitals.

Boston Medical Center will lay off 119 people, including 44 nurses and 30 managers. The hospital is attempting to reverse its projected loss of $175 million for the year. Dartmouth-Hitchcock (NH) will eliminate 300 jobs to stave off its $50 million deficit, but hopes to avoid layoffs.

I see Praxis EMR  is applying for HITECH certification through the Drummond Group. I can’t help but wonder if CCHIT is second-guessing its decision to wait until September 20th to announce its final certification and testing plans.

HIT purists: move to the next item while I share healthcare fashion news with our more couture-conscious readers. I do wish HIT involved more fashion-related stories, but this is about as close as it gets. Cleveland Clinic premieres a new Diane von Furstenberg-designed hospital gown that features an elastic waistband (which I don’t think is particularly fashionable, though better than the Johnny gown), wrap-around closure, and a wide V-neck. There’s also a “signature” von Furstenberg element: a bold, graphic print that incorporates the clinic’s logo. Some male patients think it’s too girly-looking, but I bet the Voalte guys would wear it.

AHIMA comments on HHS’s proposed rule-making for HIPAA privacy, security, and enforcement. Key concerns/questions: allowing individuals to restrict the release of certain health information to health plans compromises data integrity and could affect reimbursement; it’s unclear how best to cover costs for the release of information within the context of privacy and security regulations; should consumers have the right to decide if their health information should be transferred to a new entity when the ownership of a health organization changes; and, further clarification is need regarding the definition of “agents” as it relates to covered entities and who should be covered.

The Reading Hospital and Medical Center selects TeleHealth Services and its TIGR interactive patient education and entertainment system.

Mr. H isn’t too big on surveys that include lots of percentages that are suppose to indicate certain things, probably because his analytical mind finds too many flaws in their methodologies. However, my simple mind spent years calculating things like my percent over quota or what my commission percentage would be when I closed the next big deal, so I have an affinity for percentages. That’s a long way of saying I liked reading that 62% of CHIME member respondents are optimistic they’ll qualify for Stage 1 HITECH stimulus funds. However, a bit of Mr. H has rubbed off on me because I question what that figure really tells us about anything. CHIME says 152 of its 1,400 members took part in the survey. Heck, if I knew I was nowhere close to qualifying, I would have ignored the survey too — that’s like salespeople not turning in their forecast when they know they won’t make their numbers. Also, CHIME members as a whole tend to be some of healthcare’s top-tier CIOs, so you would expect this bunch to be ahead of the curve compared to the rest of the industry. So my take on these results is that perhaps the survey provides insight into how CHIME members are positioned, but I don’t think you can extrapolate the results.

Sponsor Updates:

• Hayes Management Consulting announces a new EMR Conversion and Migration Management service.
• Sunquest Information Systems releases its Diagnostic Intelligence BI solution, which provides lab managers a dashboard view of their financial, clinical, and operational performance.
• MEDecision makes the list of the 100 Best Places to Work in Healthcare by Modern Healthcare magazine.
• Cass County Memorial Hospital (IA) begins implementing the e-MDs EHR/PM solutions across its 11-provider practice. e-MDs says an endorsement by Iowa’s HITREC helped seal the deal.
• RelayHealth expands its portfolio of HIE options with the introduction of its Connected Orders solution. St. Luke’s Health System (MO) is live on the program, which allows physicians with or without EMRs to electronically order tests, meds, patient care, and referrals. 
• Picis says it implemented its LYNX revenue management solution at 29 US healthcare facilities in the second quarter.
• Orange Regional Medical Center (NY) hires Orchestrate Healthcare to provide implementation and migration services for its Epic EMR rollout.
• EMR vendor SRS will offer its customers an integrated PACS solution from Medstrat, which specializes in orthopedic PACS.

Odd: Skyridge Medical Center (CO) briefly closes its ER after a patient knowingly brings in a radioactive rock. A hazardous materials team later it was determined the rock’s radioactivity was relatively low and posed no danger. No word on why the patient was carrying around a radioactive rock.

For some reason, images of dogs and fire hydrants came to mind when I read this story. A gynecologist uses a cauterizing tool to brand the patient’s name on her removed uterus. He says he “felt comfortable putting her name on the uterus” since the patient was a  “good friend.” The patient says she never met the doctor until the first consult and she’s suing. Her lawyer called the branding “inexcusably bizarre behavior.”

E-mail Inga.

HIStalk Interviews Hamid Tabatabaie, President and CEO, lifeIMAGE

Hamid Tabatabaie is president and CEO of lifeIMAGE of Newton, MA.

Tell me about lifeIMAGE.

lifeIMAGE is a company that got started a few years ago with Amy Vreeland, my co-founder. The two of us had finished a successful career at Amicas. After we decided that the market was on its way to adopting PACS entirely, we decided there was a gap between what happens inside the facility with their PACS and what the needs are outside the facility to have access to that data.

We spent some time and came up with a product design and a marketing approach to make it practical to essentially create a network on which anyone can exchange information with anyone with relative ease. We are in the market primarily offering services that let people deal with outside images. We allow hospitals to receive outside images electronically. If they receive them on CD, we have a workflow that addresses the complexities that exist today with the CDs.

Over time, we will add services to enable people to deal with consumers when necessary, to deal with community physicians whenever possible, and generally bridge the gap that exists today, all the way to having access to anyone’s images at the right time and the right place. Specifically, having a smart network.

I hope that’s who lifeIMAGE ends up being. We’re doing everything we can to get it there.

What’s the general state of interoperability and data sharing with diagnostic imaging systems?

It’s really not good. It’s spotty at best. There is an underground world of image sharing that goes on today that no one really has the right applications for, no one is responsible for. People have CDs and thumb drives and still film, primarily, as the way they exchange imaging information.

It used to be that the useful life of an image ended when the report was done. Now that images are much more pervasive, especially among whom we call image intensivists. The real useful life of an image starts when the report ends. People receive the report to know what they need to know, and they use images for where they need to go anatomically and otherwise.

There’s a huge need, unfortunately, today that is being satisfied with various manual routines and workflow, and/or at best, a Home Depot-style of putting parts and pieces together to accomplish specific use cases.

When you look at the financial and clinical impact of that lack of access or that substandard way of accessing images, what is the impact of having these workarounds?

The financial impact, to start with, is tremendous. In that, everyone agrees. Various different research shows that somewhere between 10-20% of all exams are duplicate exams. Arguably, a larger percentage may be unnecessary exams, but physician support capabilities will hopefully affect the unnecessary exams. The duplicate exams we can stop by having a reliable network. If you believe those numbers, the financial impact starts somewhere around $10-20 billion to our healthcare system.

Then there are financial impacts outside the system. Every time Liberty Mutual is in the middle of a case for workman’s comp, they spend a lot of money getting images from the patient, and to their experts, and to their lawyers, and to the surgeons that afterwards see the lawyers. Those costs are ultimately passed on to the consumers via more expensive insurance bills. We can avoid those costs and hopefully even have an impact in that arena.

Self-insured companies that have a direct relationship with their healthcare expense assume that self-insured companies simply has a rule that says if you ever imaged one of my employees, you have to give me back the images and report somehow that I can avoid the next doctor who would want to otherwise order the duplicate exam. You can imagine that you can extend that to the Medicare and Medicaid patients, to the Blue Cross and Aetna patients.

All together, the cost really starts at $20 billion when you want to look at it from a macro point of view.

At the micro level, the duplicate exams used to be a revenue point for radiology departments, but the new financial arrangements between radiology departments and payers even erode that value.

I would assume there’s patient impact because of lack of timely treatment or over-radiation with retakes.

That’s absolutely a side effect. The financial impact of that alone is all the mistakes that can be made, all the delays it can cause, additional costs and complications. Simply avoiding the duplicate exam is a great deal of value, never mind the negative side effects of it.

You’re selling your offering as service. Who pays for the service and how is it priced?

That is, I think, a compelling point to get people to want to initiate connection to these potential exchanges. We charge the hospitals and imaging service providers, but they have a cost themselves, whether it is for the ingestion of the CD or for delivery of results to the patient or community physicians. We simply replace those costs with better services and less expensive approaches, much more effective at the same time.

Our business model is very much on a per-month basis. You effectively become a subscriber to whichever one of our services. You can almost think of us as a cable box that you choose to have various channels on, and for each channel you pay a monthly fee. Sometimes it’s dependent on the number of exams, sometimes it’s dependent on the size of facility you are. But invariably it’s always less expensive than the current costs.

You just signed Moffitt and Memorial Sloan-Kettering. How do you market to hospitals like that to get such prestigious clients?

We have them on our mind when we design products, when we design services, and when we design our pricing.

We are very mindful of the fact that specialists and sub-specialists are the ones who want to have access to these images more than anyone else, so we target those with the most intensive specialty population. Cancer centers, as you can imagine, are not only a great focus of a lot of specialists and sub-specialists, but also their patient population migrates in and out back to their local communities. That itself is a primary need for imaging exchange between the centers for specialty, like the cancer centers, and the patient and the community physicians.

Tell me a little bit about the size of the company.

We are a relatively young company. We started officially two years ago almost. Unofficially, three of us founders have been doing this for another three years designing things. Today, we are just under 40 people, full-time employees, and perhaps another 20 people in various contract positions.

A lot of the management team came from Amicas. What lessons did you learn working there that you’re using at lifeIMAGE?

I think Amicas, without question, was one of the early innovators of using Web technology for imaging access. We’ve continued the culture of innovation at lifeIMAGE. Our focus is on doing the right thing, and in the process, creating yet another disruptive technology. This time around, you learn both operationally how to run a much more efficient company and you learn how to more effectively market.

At Amicas, we learned a lot about radiology and radiologists. What we’re doing in lifeIMAGE is to focus on the specialists and the sub-specialists in their relationship with the radiologists. I can compare Amicas and PACS companies to the ‘local call’ equivalent of an imaging system, and lifeIMAGE is the ‘long-distance call’. You need to think about the outside world, and the need of the outside world, in order to design a system.

The lesson we’ve learned is how to focus on one constituent for one reason and other constituents for other reasons.

When you look at some of the other imaging companies like Amicas and Merge and Emageon, how do you hope the business evolves for lifeIMAGE?

They will continue to have their great place in the industry. PACS systems have been very much adopted universally and there’s almost nowhere that PACS doesn’t exist. These are complex systems that over time need to be revamped, rewritten, and bells and whistles added and so forth, so they have plenty of backlog to satisfy their markets.

We are an innovative company outside of the market. We start our life with the long-distance aspect instead of the local aspect. I think there’s a tendency to have a cooperative relationship between the ‘local call’ and the ‘long-distance call’ and similarly, our relationship with the PACS companies will be that way. Invariably, the lifeIMAGE environment can be used by smaller settings as the Salesforce.com model for some of the imaging functions that one can assume companies will offer in the future.

Your Web site uses common internet metaphors such as ‘inbox’ and ‘dropbox’. How important is it that your system be easy to use?

I believe after security and reliability, usability is by far the most important aspect of the system. Every time you try to change the current habits of busy people like doctors — or anyone, for that matter, who’s terribly busy — you have a challenge of introducing yet one more thing they’ve got to get used to. The easier you make that experience, the more likely it is to have adoption. Obviously, the choices of our naming conventions are not an accident. I invite you to take a look at some of our products to see that the design and the usability criteria for our systems follow that design.

I was interested in the company’s vision statement that is built around the concept that there will be health record aggregators that will be the equivalent of banks for consumers; and also, that there will be some sort of incentives offered like there is for Meaningful Use for providers to share images. Can you explain how that all fits together?

I think if we fast-forward some years — I don’t know how many years that exactly will be, but it won’t be too long and it won’t be very quick — we will be at a place where a patient walks into a facility and their medical record will be available to their new care providers just as easily as the current and local records.

In order to satisfy that, you have to envision a lot of social economics, political, regulatory functions will get a hold of something like this and bend and twist it to the satisfaction of how you can practically use environments like that. As a result, it’s very much likely that these will have regional flavors. I can see various networks have the capability of reaching across one another’s network so an AT&T subscriber can make a call to a Verizon subscriber — that sort of analogy. But yet among the Verizon users and among the AT&T users, they may enjoy a certain kind of behavior that is unique to them. That will satisfy some of the pressures that will come from various constituents I named and alluded to earlier.

Ultimately, I think the insurance companies and the payers stand to benefit from the exchange and the networks that enable these sorts of exchanges. But ultimately, I think we will have a way for them to either entirely or partially subsidize the costs of these kinds of networks.

I can see a relationship very much like the banking system between the Federal Reserve and the private banks. There will be some overwhelming and overarching missions for the new networks that will be governed by some hopefully good practices. But yet there will be some private providers like lifeIMAGE which will satisfy either regional or national requirements.

Any final thoughts?

From what I’ve read on your blog, you know the market well enough to put this in the right context. But really, somebody needs to kick-start the ultimate goal of healthcare information exchange. Those of us who’ve been around healthcare IT like you know that the concept of boiling the ocean never works. You have to have very, very clever, deliberate places and then you market the technologies in order to achieve some end goal. Imaging tends to be a very good, sticky one. 

The question that I would have wanted to answer if you had asked was, why start with imaging?

The answer may be obvious to you, and that is it already enjoys a great deal of standards. It is a very expensive component of our healthcare expense, and probably just second to pharmaceuticals. It is a growing expense even if we control the expense and utilization.

We are at the infancy of the benefits imaging bring to medicine. We better learn how to take advantage of this, while on one side, not bringing the costs up; or on the other side, choking innovation because it is an incredibly important component of diagnosis. Imaging to me: is a good place to start because there are a lot of good standards and it is very much universal — it exists in almost all sub-specialties.

Patients are already used to touching their CDs and being the courier from one point to the other. Finally, it can act as a catalyst for some of the rest. For instance, we allow attachments to be sent with images. So not only are you looking at somebody’s echocardiogram, but you’re also looking at their EKGs and their medication history.

That’s what’s really needed to have meaningful information at the other end. Hopefully there will be CCR- and CCD-type of standards that govern how to ingest those documents as well. But in the mean time, let’s satisfy the clinical needs.

Monday Morning Update 9/13/10

From Slinky Nighty: “Re: JPS in Fort Worth. They have definitely chosen Epic. They attended the Epic Texas Collaborative meeting this past quarter and are moving forward and looking for assistance.” Thanks for both the info and the name imagery.

From Old IS Person: “Re: Siemens. They’ve started a second help desk for radiology and PACS products, so those of us with multiple products are supposed to use two different systems just to report problems.” Don’t get me started on vendor help desks. Like the one from one of our key vendors who brags on how fast we’ll hear from an analyst, but it takes days to weeks to get anything other than the automated e-mail response that says “I have your case and I’ll get to it when I get to it” (I’m paraphrasing slightly). Not that it really matters since 90% of the time, the answer is, “Oh, we know about that problem and it’s on development’s list,” which paraphrases into, “It’s kind of a pain for us to fix that, so we’ll just add it to an Excel worksheet that nobody ever looks at.” Do some of the issues vendors ignore in this way endanger patients? No question. I bet if they were forced to go public with their open issues list they’d be a lot more responsive.

From Tupelo Honey: “Re: CPHIMS. I got an e-mail from HIMSS asking them to send me a glowing letter about all that having CPHIMS has done for me, which is mostly nothing. I am guessing that not so many people are signing up or renewing.”

From The PACS Designer: “Re: OpenMRS. TPD has posted about the third world medical record system called OpenMRS and how it was being used in Uganda, where Brigid O’Gorman is presently trying to educate their countrymen. Now they have improved their Web site and expect to release a new version OpenMRS 1.7 soon.” I noticed they’re having their Implementers Group Meeting in Cape Town, South Africa this weekend (group pic above).

From EHR Geek: “Re: HISsies. PLEASE do those again! The ones you posted today are still relevant and hilarious! ROTFL!” Thanks. I’ll try to crank out some cynically funny stuff again since I miss doing that, although someone always complains if I write anything that isn’t just a bullet list of facts addressing only those precise news stories that interest them personally. Meanwhile, you can check out the 2006 HISsies recap or one of my phony news items, of which here are a couple for old times’ sake.

HIMSS Announces 2008 Conference to Be Held in Baghdad
(CHICAGO, IL) HIMSS has announced that its 2008 Annual Conference & Exhibition will be held in Baghdad, Iraq, following a successful 2007 stop in New Orleans. Steve Lieber, CEO of HIMSS says that HIMSS has learned that it can benefit disaster-stricken cities by flying in planeloads of attendees with large expense accounts, a concept first tested by bringing conventioneers to New Orleans shortly after it was virtually destroyed by Hurricane Katrina. "We’ve proven that we can all have a great time at a site mostly known for death, civil disorder, and senseless violence. We’re going to have a blast in Iraq, no pun intended," said Lieber. HIMSS sources indicate that the surprise speakers for the "View from the Top" session may be Saddam Hussein, Donald Rumsfeld, and Neal Patterson.

Hospital Trainer Collapses During Class
(DAYTONA BEACH, FL) Todd Cleaver, a 41-year-old computer trainer at Halifax Hospital, was stricken this morning with an apparent heart attack while leading a computer class for nurses. He is reported in stable condition and is expected to recover. Debbie Dallas, a registered nurse attending Cleaver’s electronic clinical documentation course, said he was working with her one-on-one when he collapsed. “He was starting to tell me how to make a flowsheet entry and I just reached over and did it correctly. Then, he was going into switching between Windows tasks and minimizing windows, and I showed him I could that, too. That’s when he went down.” Cynthia Roda-Tiller, education manager for Halifax, says she believes that Cleaver suffered a strong physiologic reaction upon seeing a nurse use a computer intuitively. “Usually they just stare at the screen like it landed from Mars or they start clicking everything in sight like it was Whack-A-Mole. You’re thinking, ‘they let you use medical equipment?’ I’d like to think I could have handled it myself, but it’s making me shake even now. I’m not sure I even believe she’s really a nurse, at least not one I’d want working my bedpan.”

Somebody must have gotten to the Forbes writer who wrote a generally negative article called Bribing Doctors To Go Electronic. Its implications: North Shore-LIJ and Allscripts are struggling with their $400 million to implement EHRs for 9,000 doctors, it’s taking doctors longer to get their work done, they’re pawns of the government, EHRs are a tough sell culturally, and community docs don’t like hospital-hosted EMRs because they don’t trust hospitals. Careful readers may have noted that he talked to a grand total of two docs (both recently implemented) in writing the lengthy piece. Now he’s backing off in a mea culpa that says he wasn’t trying to write a definitive article on the value of EMRs and that those complaining early adopters recognize their value because they volunteered. I guess the two pieces cancel each other out, other than the time it took to read both.

As New York, Nashville, and Cleveland race to book tenants for their medical trade center buildings, the Nashville group says it’s not worried despite not signing anyone except HIMSS for its 1.5 million square feet of space scheduled to open in 2013. Reason: it says HIMSS will bring 85 to 125 companies to lease space in their building, with a handful taking up to 15,000 square feet.

Hey, it’s only $20 million, which is a HITECH rounding error, but ONC throws more money at RECs, this time as a little extra to help critical access and rural hospitals.

Stanford’s Lucile Packard Children’s Hospital appeals the $250K fine levied by the state’s health department when the hospital waited 11 days before reporting a stolen PHI-containing laptop. They fired the employee who took it home against policy.

Ivo Nelson, chair of Encore Health Resources, joins the board of Health Care DataWorks. That’s the Ohio State spinoff whose CEO is former OSUMC CIO Herb Smaltz.

The Bethesda Hospitals’ Emergency Preparedness Partnership (Hopkins Suburban Hospital, National Naval Medical Center, and NIH) chooses Versus Advantages RTLS for patient tracking in emergency care areas during mass casualties. The Versus product met its requirement for 95% accuracy down to the room level and also links patient information to location for emergency responders.

Not many folks think that the average EMR will give providers enough information to manage population-based risk. New poll to your right: if you were filling a position, what impact would a candidate’s CPHIMS credential have on your decision? Tupelo Honey wants to know.

Ken Rardin, former CEO of Merge Healthcare, IMNET Systems, and a couple of non-healthcare companies is named CEO of telemedicine provider REACH Call of Augusta, GA.

This could make a an interesting novel: the former CFO of Danbury Hospital pleads not guilty to scamming the hospital by approving phony invoices for contract management software from a software company he ran from his house. He adds witness tampering and harassment to his list of charges after e-mailing the hospital president begging him to make the charges go away despite a hospital-requested court order to keep him away for fear he would go postal. He closed his plea with, “I got no place else to go (quote from An Officer and a Gentleman)” The judge nearly put him back in jail for that, but the man’s attorney made a convincing argument: “He would have to be a total idiot to do this again.” Ever the CFO, he showed up in court with a sports coat over his jail coveralls.

One of two winners of IBM’s SmartCamps start-up competition: CareCloud, a Miami company offering physician practices a $499 per-doc-per-month practice management system with social networking thrown in and revenue cycle services optional. I’ve mentioned the company a few times previously when they won an award and were pitching at the Health IT Venture Fair at HIMSS. Points off for their latest blog entry extolling the virtues of Twitter, which they summarize in a grammatically incorrect manner as, “… us enlightened folk know that the conversations on Twitter are insightful and illuminating.” They must be living in an alternate Twitterverse than the one I’ve seen, which combines the worst aspects of text messaging and Facebook but at least allows only 140 characters of time-wasting, stream-of-consciousness preening (if they would ration the number of tweets like they do the number of characters, they’d be on to something). Do we really need to hang on the every un-profound word of vapid celebrities, self-appointed pundits, and a guy having a heart attack?

Here’s another example that healthcare is different when you have money: a new startup called ExpertConsensus will take your tough medical problem to a group of big-name doctors who will teleconference and make their collective recommendations. The company’s minimum charge: $20,000. I hated that concept until I thought about it: they’re offering convenience for those willing and able to pay, but patients on a non-$20K shoestring could find these docs on their own and pay just a consultation fee to get the same opinions (or pay Cleveland Clinic a few hundred dollars for an electronic second opinion, which I can’t believe isn’t more popular than it seems to be). ExpertConsensus offers other services seemingly unrelated except for their common denominator of buck-making opportunity: research reports, care management, on-site clinic setup, physician referrals, wellness, and personal health records.

Louisiana doctors will have to pay back $17 million in Medicaid overpayments because the state’s Department of Health and Hospitals just now got their computers programmed to handle budget cuts that went into effect 13 months ago. Said one doc who says the cut will put him out of businesses, “We’ll gut it out and when it’s obvious that we aren’t making ends meet, we’ll all retire.” I need to give docs some PR advice for those situations where they’re complaining about making less money: don’t say “retire,” but instead say “find another line of work.” People hearing “retire” assume that means you’ve milked your medical practice to the point of not needing to work any more, which doesn’t exactly bolster the “we’re poor” argument.

Interesting: doctors at McGill University in Montreal administer anesthesia electronically for a surgery being done in Italy, a pilot project for “teleanesthesia”. They managed the patient using video cameras and remote dosing computers that make up what they call “an anesthesia cockpit.”

I’ve written before about the UK’s hospital radio stations, charities run by volunteers and featuring patients and family requests. London’s Radio Marsden, which runs 24 hours a day for patients in two cancer hospitals, will move its service to the Internet this month to allow patients, friends, and families to listen together. I’m listening to Bowie’s China Girl on it right now, followed by the Talking Heads doing Burning Down the House and an announcers’s suggestion that patients ask for hospital pens and paper to write letters home. Hot on their playlist based on patient requests and favorites: Lady GaGa, 30 Seconds to Mars, Alicia Keys, Kinks, Billy Ocean, The Clash, and The Saturdays, among others. It’s kind of addictive.

Former Sun CEO Jonathan Schwartz, who replaced Scott McNealy for a short time before selling the company to Oracle, gets involved with a healthcare-related startup, Picture of Health. He’s not saying what the company will do. 

A hospital ED patient is arrested for assaulting another patient and then pulling a knife on an ED nurse. The man’s occupation: minister.

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A Mr. H Book Review
Safe Patients, Smart Hospitals
By Peter Pronovost, MD, PhD and Eric Vohr

A reader asked me to review this book, so I bought a copy. I interviewed Peter a couple of years ago, before he won the Genius Grant. It’s still one of my favorite interviews, with this as my favorite quote from it:

That’s the tension that we have. How much evidence do I need to give up my autonomy? We’re still uncertain about that. As an industry, healthcare is grossly understandarized. Compare that to pilots who have to use checklists or they won’t be flying. Healthcare is still very much like the Wild West or like Chuck Yeager in The Right Stuff, where we have this cowboy mentality and we’re just beginning to accept that standardization is a key principal to making care safe.

That frames up the book nicely.

My first thought when seeing the book (published just this year) was, “Hey, I get it, providers need to make lists … why do I need to buy the book since I already know the ending?” There’s a lot more to it than just making lists, however. The book is really about translational medicine, rigorous measurement of healthcare quality, and the patient harm caused by the toxic culture of hospitals and physicians. Here are the takeaway points.

• Doctors and hospitals harm patients because of poor communication, not following rules that are indisputably beneficial to patients, and not using proven research in their treatments.
• Culture dictates that doctors and hospitals pretend that they don’t mistakes and to avoid admitting them when they do.
• There is no wisdom of crowds in hospitals. Doctors are trained to be sole decision-makers and to lash out if anyone questions their decisions. Not to mention that Peter’s background is in academic medical centers, where the problem is tiny compared to community hospitals with their non-employed doctors who are always complaining to administration and trying to get employees fired for looking after the best interests of patients.
• In terms of communications, even on his own rounding team, only 5% of residents and nurses could articulate the care goals for a patient who had just been the topic of a 15-minute team discussion. You wonder what they would have concluded without the team discussion and armed only with a paper or electronic medical record, given that academic medical centers are a small percentage of hospitals and others don’t do that kind of rounding at all.
• Overworked doctors will break rules for a single patient if they think the greater good is served. Every doctor knows to wash their hands before and after seeing each patient, but only 30% actually do it because they’re busy or supplies aren’t available.
• Communication in the OR is especially bad, where the nurses know everybody’s name but the surgeons see just a sea of scrubs and have no interest in names and roles. The pecking order is inviolable.
• Some tasks or procedures can be summarized into a checklist of no more than 5-7 evidence-based items, no different than a pre-flight checklist. The list can be developed locally to encourage ownership.
• Even though Peter’s work has saved thousands of lives and hundreds of millions of dollars, most of that came from just one checklist (central line placement) out of thousands upon thousands of medical procedures and tasks. That’s either a wide-open field or a depressing commentary on modern medicine, depending on your perspective.
• Non-clinicians, like administrators and probably IT executives, aren’t usually comfortable getting out on the floors but can play a big role on offering a fresh perspective for problem-solving and in understanding how projects are financed, staffed, and run.
• Doctors practice as they were originally taught in school using the “see one, do one, teach one” model that tells them to ignore everybody else’s opinion and go with their own. Good teamwork means a nurse doing what the doctor says. Doctors are not taught to communicate or to manage stress. They do not have time to keep up with the literature. There is no standardization, even within one organization. Residents make mistakes because they don’t want to look stupid by asking questions.
• Checklists worked in aviation because the industry admitted that pilots make mistakes and took the attitude that every crash is preventable. That hasn’t happened in medicine, where hospitals and doctors refuse to admit that they are not infallible. Even Hopkins (arguably the best hospital in the country) defended its catheter infection rates (among the worst in the country), using the “our patients are sicker” argument. After using Peter’s methods, their infection rate dropped from 19% to near zero, saving an estimated eight lives and $2 million.
• Quality requires central analysis of data. You don’t know what’s working without data. No other industry would tolerate healthcare’s sloppy data practices.
• Making the list is easy. The hardest and most important parts, which hospitals always want to skip, are evaluating the culture, making sure every patient is treated using the list, and measuring the results.
• State-wide projects don’t always work. They took shortcuts, made data reporting voluntary, and let turf wars (infection control docs vs. intensivists) compromise the plan. But in Michigan, their infection rate dropped from 2.7% to zero when they swallowed their pride and followed the plan.
• Medical research gets all the funding, while patient safety research hasn’t. Part of healthcare reform is creation of the Office for Patient Safety Research.
• The only profit to be made in patient safety is for insurance companies.

I extrapolated his thoughts into IT:

• Peter said in my interview that errors will go up when CPOE is introduced because it’s a change, nothing is standardized, and CPOE is set up to look like the paper it’s replacing.
• Decision support is the real value of CPOE, but it’s not usually added until afterward.
• Every hospital has to develop its own clinical decision support rules, which is like each airport having to build its own air traffic control system.
• IT systems can support enforcing the lists and reminding providers about them.
• Use shared decision support rules to begin standardization and using best practices.
• Look at data collection, reporting, and transparency. Peter found that virtually no hospitals have the right information in their databases to be able to know their infection rates.
• Use these methods for IT project rollouts and maintenance to reduce mistakes and to remove vendor and IT pressure to do something harmful.
• Find ways to get research into practice. Why is research a science, but the practice of medicine is an art?
• For vendors, build support for lists and reminders into applications, where they can be cued by workflow.

It’s a bit disconcerting to see just how inconsistent healthcare delivery is. It’s based on science, but often is a long way from being delivered in a scientific way. The major point of the book is that nobody’s head is big enough to hold all the information about medicine and research findings, so practitioners often are endangering patients by what they don’t know or don’t practice.

Few would doubt that the book outlines incredible opportunity for improvement in every kind of patient care setting. We’re talking saved lives, not just saved dollars. The good news is that’s exactly what computers are good at. Giving providers access to lists, providing immediately usable reference material (how-to videos, audio instructions, etc.), linking to the evidence, and offering collaboration platforms could all be key elements in implementing the quality measures called for in the book.

This is an excellent book, although it will make providers question their core beliefs about the healthcare system they work in. It’s pretty screwed up, as we know, and getting worse. The goal isn’t perfection, it’s improvement, and that won’t be easy (if it were, everybody would already be doing it). Are there enough providers who can look beyond the knee-jerk reaction of just making a Pronovost list and claiming mission accomplished to actually improve healthcare quality? Maybe or maybe not, but if enough at least try to tackle their problems in a rigorous way, they’ll probably avoid killing a few patients.

News 9/10/10

From A. Nonnie Mouse: “Re: Kadlec Regional Medical Center (WA). Turfing McKesson inpatient and GE Centricity and moving to – surprise! – Epic. The number of Epic customers in Washington and Oregon make Epic CareEveryWhere something of a de facto HIE.” Unverified, but the hospital is running Epic recruitment ads, so your information may well be correct.

From FortWorthFan: “Re: JPS Health in Fort Worth, TX. I noticed they are hiring Epic Revenue Cycle analysts, but I don’t recall ever reading that they selected Epic as their replacement clinical system.” I’ll guess they’re going Epic since this position listing seeks Epic clinical analysts. From this job opening, it appears they are seeking a CIO as well.

From Tina LaBoeuf: “Re: HISsies. I miss your hilarious write-ups of the awards announcements that went away when you started the awards party :(” Tina’s comment sent me to the search function to find and relive those moments. I did find them amusing, especially since I mixed in actual winner quotes with my phony recap. You can read it here if you enjoy these snips from 2007, featuring as host my alter-ego, former HIT sales jock Billy “Biff” Jutjaw:

Imagination at Work? Must be talking about their Carecast guys porn-surfing at their desks! Zow! Rimshot! BA-DUM-PAH. GE guys … hey Jeff … we need one of your lightbulbs over here … yeah, a replacement for that faulty one that went off over your head when you bought IDX! Owwww! But I kid. What a great evening! What a constellation of industry stars! What a rack on that broad at Table 3! … Say, Chuck, let’s see who’s here. Hey, are we in the Ying or the Yang side of the house? Judy must have been having a Woodstock flashback when she laid this place out. Where did she get compost-powered PCs, anyway? That Kool-Aid they drink here must have been from Ken Kesey’s original recipe! … Yeah, it’s like a CHIME meeting – you can’t swing a golf club without hitting two CIOs and four sales VPs clinging to their underbellies like remoras on a shark. … Come on up here, Howard Messing. Nice suit! Must be nice to keep getting awards for doing nothing! But I kid, old friend. MEDITECH was an established company when some CEOs were still backdating options in Monopoly! Booyah! Boston community swimming pools always hate it when MEDITECH starts hiring because they take all their lifeguards! Kapow! You know the first thing a MEDITECH employee says after getting home from work? "Mom, is dinner ready?" BAD-DUM-PAH. I’m like butter, baby, I’m on a roll!

Listening: new from singer-songwriter Sara Bareilles, thoughtful pop-tinged heartbreak music if you’re in the mood for that sort of thing. Watching on Netflix streaming: Studio 60 on the Sunset Strip, a stupendous 2006 dramedy series about a Saturday Night Live-type program (think 30 Rock played mostly straight with an amazing cast).

An expert tells South Shore Hospital (MA) that 800,000 patient records that were on lost backup tapes of their Meditech system can’t be easily accessed, so they decide against sending out breach notices to individual patients. They’re just going to run newspaper ads, which given the state of American intellect and newspaper circulation these days, means about a hundred people will see them, especially if they ads don’t appear in the sports or entertainment sections. This is the incident where the hospital paid Iron Mountain to destroy the tapes, only to find out afterward that the company subbed the work out to another company and lost the tapes in shipping.

In England, the dismantling of NPfIT appears to be underway, as the government cuts its total cost by $2 billion to $17.5 billion and decentralizing the project. Said the co-director of the Royal College of Physicians Health Informatics Unit, “One of the dirty secrets of the NHS is the regrettable state of medical record keeping. Earlier reports have shown that this compromises patient safety and clinical care. If IT in the health service is going to regain the confidence of the medical profession, then more emphasis has to be placed by the Department of Health on making sure that the new systems accurately capture the dialogue between doctor and patient. Everything else flows from getting that right.”

Speaking of NPfIT, an NHS Foundation Trust invites bids for a new patient care and e-prescribing system, opting out of NPfIT’s iSoft Lorenzo option because of concerns it’s not ready for prime time.

The latest ISMP Medication Safety Alert (from Institute for Safe Medication Practices) has a fascinating article about why the CMS rule requiring hospitals to administer drugs within 30 minutes of their scheduled times endangers patients. ISMP only posts excerpts online, but it was truly revealing as real-life nurses (thousands of them, in fact) describe why it’s unreasonable to meet that goal. The IT-related gist: we’ve put in eMAR and bar-coding systems and written cool “overdue” functions for clinical documentation systems, but hospitals have done nothing to address the challenges of nurses trying to meet a staggering variety of patient needs without turning into medication-pushing robots. This is one of those areas where non-clinical IT people would struggle with the idea that it’s not just calculating a “med overdue” time and dinging the nurse on a report. Everybody in involved in any capacity with clinical systems should read the full text of this article – it is a tremendous eye-opener for folks who’ve never trodden the uncarpeted areas of the hospital where the real work gets done.

Athenahealth CEO Jonathan Bush tends to be a “love him or hate him” kind of guy, but he’s still eminently quotable either way. He was definitely wound up for The New York Times. On why the company was in the birthing center business in the early days: “You know, Bush family noblesse oblige. I wanted to take advantage of all this education and support I’ve had and do well by doing good, and health care seemed like a place that no one else in my family had been much. A new approach to health care seemed to me to be the oil fields of 1997.” On the company’s competitors: “We are the only cloud-based service in an industry segment full of sclerotic, enormous, personality-free corporations that have been in business making 90 percent margins doing nothing for decades and decades.” On the cost of healthcare reform: “Oh, it’s going to go through the roof! It’s widely accepted that this is not a cost-reform bill — it’s an access bill … Eventually, consumers will need to eat a big part of their health care cost, because health care will fundamentally consume the entire G.D.P. in the not-too-distant future.”

It’s interesting that WellStar Health (GA) apparently fired its CEO after it was fined for excessive Medicaid billing, but it named the CFO as the interim president. Wouldn’t the CFO be the person most accountable for billing mistakes? Mostly unnoticed: they fired their general counsel as well. And from an IT standpoint, the CEO blamed their billing system (McKesson Star, I think). Does it get the axe, too?

We like Encore Health Resources a lot since they threw one heck of an HIStalk bash in Atlanta this year (as many of you told Inga and me afterward and we saw first-hand ourselves – that’s Ross Martin in the pic). Dana and Ivo are fun at work too, apparently — the company is named as one of Modern Healthcare’s Best Places to work in Healthcare 2010. That’s pretty cool for a new, small consulting firm.

Jobs on the sponsor job page: Project Manager – Healthcare Implementation, Eclipsys Activation Consultants, Technology Account Executive. On Healthcare IT Jobs: Metadata Administrator, McKesson Horizon Consultants, IT Applications – VP. That reminds me to mention that I made a Google Gadget that you’ll see to your right that has tabs for the Events Calendar, Healthcare IT Jobs, news headlines, and posts from HIStalk Mobile. I did that for two reasons: first because the WordPress events widget wasn’t displaying the calendar entries correctly, and second because I was looking for an excuse to build something.

I always like to highlight badly written press releases, so it’s imperative that I recognize this gem from a home monitoring technology company, which leads off with: “Cytta Corp’s CEO Stephen Spalding is pleased to announce that, after a series of well received presentations and demonstrations, Cytta has been invited to provide its first major proposal to a major healthcare payor/provider to develop an individualized monitoring system.” It’s a penny stock, but the price would need to go up fivefold to actually reach a penny, closing today at $0.0018 for a market cap of $1.83 million, doubling in price since April.

The North Carolina sheriff’s association proposes that the state give its members access to its doctor shopper database of known drug seekers, saying they “can better go after those who are abusing the system.” Privacy advocates are less enthused by the idea.

iMedicor launches its National Healthcare Communications Network, which offers practices secure messaging, peer collaboration, referrals, and CME. The company changed its name from Vemics last year, which seems like a good idea since that sounds like worm medicine. According to the site, it costs $24.95 per provider per month. It looks pretty cool to me. I can think of several business models that would work if they get enough subscribers.

Jim Bradley, former CEO of RXHub and Abaton.com, is named chairman of the board of e-health connectivity vendor VisionShare.

Let’s hope they aren’t big cloud computing or ASP users. Local hospitals (along with everybody else in four Tennessee counties) lose their Internet, cable TV, and telephone access for two days when some goober takes a shot at a bird sitting on the only cable line connecting that area to the rest of the world.

E-mail me.

HERtalk by Inga

Streamline Health Solutions releases its Q2 numbers: revenue of $4.7 million (15% better than last year) and a net loss of $76,000 (versus an $18,000 loss last year). The company attributes the higher loss to increased investments in marketing and hosting operations and the reinstatement of bonuses. Streamline also announced the promotion of Gary Winzenread from SVP of product development to COO.

CIO C. Martin Harris, MD of the Cleveland Clinic and former FTC commissioner Deborah Taylor Tate join HealthStream’s board of directors.

Hard to believe, but registration for HIMSS11 is now open. If you are a HIMSS member and pay before December 7th, registration is only $695. Mr. H and I are already strategizing about all the fun HIStalk-related things we’ll be doing. If you have ideas, let us know.

HHS unveils CuidadodeSalud.gov, a Spanish-language website to provide consumers with public and private health coverage options.

Mediware doubles its fiscal year profits to $3.24 million. Revenue for the year grew 17% to $47.6 million.

KLAS adds five new members to its advisory board, including HIStalk’s own Edward Marx, CIO at Texas Health Resources. Other new members include Alastair MacGregor, MD from Methodist Le Bonheur Healthcare, Kara Marx of Methodist Hospital of Southern California, Dan Morgan from Bay Medical Center, and HCA’s Noel Williams.

Forbes magazine profiles North Shore-Long Island Jewish Health System and its $400 million effort to help 9,000 employed and affiliated physicians move to Allscripts EHR. Though North Shore is taking advantage of relaxed Stark laws to subsidize up to 85% of system costs, so far only 175 of the system’s 7,500 community physicians have signed up. The health system’s chief executive admits there’s been resistance around “cultural stuff,” including concerns about North Shore’s hosting of the EMR data and discomfort with having to make work flow changes.

Wayne State University Physician Group (MI) chooses Orion Health Rhapsody Integration Engine to help create patient data exchange between their offices and other providers and facilities.

McLeod Health (SC) contracts with Merge Healthcare to integrate Merge’s cardiology workflow solutions with McLeod’s existing radiology product.

Perioperative employees at Southwestern Vermont Medical Center explain to the local press how their Picis system works, noting it “soothes some of that anxiety” felt by family members while loved ones are in the operating room.

Stamford Health System (NY) says its MedAssets Charge Capture Audit tool helped recapture $1.9 million in lost charges last year. It will also use group purchasing contracts, consulting services, and BI tools from MedAssets.

St. John’s Hospital (IL) selects Amelior Tracker from Patient Care Technology Systems for automated medical equipment tracking.

HHS awards a $980,000 grant to the University of Kansas Medical Center, University of Missouri, and University of Oklahoma to create the Heartland Telehealth Resource Center. The center will help physicians treat rural patients using telehealth technology. Almost 90% of the counties in those three states are considered rural with limited access to healthcare.

Sponsor Update:

• The Massachusetts eHealth Institute (MeHI) REC releases a list of certified EHR vendors and Implementation and Optimization Organizations. EHR vendors include Allscripts, eClinicalWorks, eMDs, Greenway, MedPlus, NextGen, and Sage. Implementation organizations include Culbert Healthcare Solutions, eClinicalWorks, eMDs, and MedPlus.
• San Juan Regional Medical Center (NM) will use the Universal Document Portal from Access to share information between its MetaVision ICU system and Meditech CIS. San Juan also uses the Access Portal to interface perinatal documents from its GE Centricity system into Meditech’s scanning and archiving product.
• Bridgehead Software and Dell introduce an enterprise medical archiving solution that combines Dell hardware with Bridgehead’s healthcare data management software.
• Nuance Communications introduces Dragon Medical Enterprise Network Edition for  large practices and hospitals. The new release includes a centralized management console and enhanced support for Citrix-based EHRs.

Medical office employees in Colorado smell a strong odor and discover the source is a dead animal stuffed into a filing cabinet. The clinic owner believes the incident was the result of a break-in, likely by a former employee. He does not indicate whether or not he suspects the prank was some sort of statement about the clinic’s need to move to an electronic filing system.

E-mail Inga.