News 9/21/12

Top News

 

The Forbes 400 list of richest Americans includes Epic’s Judy Faulkner (#285 with a net worth of $1.7 billion) and Cerner’s Neal Patterson (#391 at $1.12 billion).

Reader Comments

From HIStalk Fan: “Re: EHR experience reporting. The IOM recommendations could improve outcomes and safety. It remains puzzling that ONC is against robust vetting for safety and efficacy.” ONC asked the IOM to suggest ways to collect and report EHR user experiences, particularly those involving problems with patient safety. IOM’s just-published paper lays out ways that could be done. Possibilities include (a) testing vendor products against use cases; (b) placing a “report a problem here” button on EHR screens to allow users to quickly report problems; (c) have EHRs collect information such as number of clicks or the number of screen views and mine that data to look for problems; (d) conduct user surveys; and (e) develop a formal reporting program. The article recommends posting the collected information on a website that would rate individual functions vendor by vendor using a star-type rating system.

From Misys_Ex: “Re: QuadraMed. Not all to be sold, only the HIM/Quantim line. Sale to close in a week. Spending and hiring freeze in effect. MModal is the rumored buyer.” Unverified. An all-company call has been scheduled for October 1, rumor has it, which would logically place the announcement on the first day of the AHIMA conference.

From Dale Sanders: "Re: odd iPad requirement. The Colorado Department of Health Care Policy and Financing is re-competing its Medicare and Medicaid Information System contract. The draft RFP requires each vendor to submit their response on seven iPads, one for each member of the selection committee.” The rationale is that the iPad saves printing and shipping cost, although you could do a lot of printing for the $3,500 or so. The state says vendors like the idea and the iPads are more secure than paper, ensuring that documents don’t fall into the hands of competitors and thereby force an expensive re-bid and/or legal challenge for the $100 million project. None of that would seem to preclude returning the iPads given that the state plans to erase and reuse them anyway.

From Laura: “Re: Practice Fusion. Another cloud downtime.” Only for a few minutes, apparently, but judging from the comments, I bet that Like button didn’t get much action while the users killed time waiting to get back on.

From Writing My Resume: “Re: McKesson’s Better Health 2020. Will go down as the largest mistake in the history of HIT. Customers like Providence, Southwest Washington, Ohiohealth, John Muir, Valley Health, WellStar, HealthEast, and Resurrection are moving from Horizon to Epic. The new Paragon customers are small community hospitals and it will take 10-15 of them to replace one Horizon customer. Rumors of another layoff coming.” Unverified. I interviewed MPT President Dave Souerwine when the program was announced in December 2011. Better Health 2020 was a series of commitments to (a) invest $1 billion in R&D over the following two years, a good bit of that in enhancing Paragon over a 30-month development cycle; (b) sunset no products, but shift resources away from Horizon clinical applications to Paragon; (c) stop the development of Horizon Enterprise Revenue Management and lay off 174 employees immediately; and (d) continue to support Horizon customers through Meaningful Use and ICD-10.

HIStalk Announcements and Requests

Are you current on all the latest ambulatory HIT news? Here are some highlights from HIStalk Practice over the last week: RAC auditing of physicians begins in 15 states, focusing on higher-level E/M codes. The state of Colorado reports that Medicaid medical homes are reducing hospital inpatient stays and ER visits. EHR adoption at community health center grows to 74 percent, thanks to HITECH funding. eClinicalWorks predicts a 23 percent increase in revenues for 2012. Implementation costs and low patient adoption are big barriers for practices wanting to add patient portals. A physician weighs in on the impact of the ACA, incentives, and EHR. Nuesoft Technologies’ Blake LeGate offers tips for preparing for ICD-10. Dr. Gregg thinks (a lot) about going back to paper. Some days, especially those when Mr. H is especially busy at his day job, the only way I know I am appreciated is to see that someone new has subscribed to HIStalk Practice. When you check out these stories, show me the love and sign up for the e-mail updates. Thanks for reading.

Working anonymously is good in some ways, bad in others. On the “bad” side, Inga, Dr. Jayne, and I labor in our otherwise empty rooms with no human contact, meaning our little HIStalk world will evaporate the moment we quit or get hit by that proverbial bus. It’s up to you to write our electronic epitaph in advance, as follows: (a) connect with us and Like us (note to Mark Z — a Love button would be better) on the usual ego-feeding social not-working sites; (b) sign up for our spam-free electronic updates; (c) show your appreciation for the companies that keep our caustic keyboards clacking by reviewing the gallery-quality ads to your left and impulsively clicking those that pique your interest; (d) inspect the more detailed sponsor information housed in the Resource Center and consider using the Consulting RFI Blaster to effortlessly contact several consulting firms at once about your needs; (e) send us news, rumors, photos, ideas, or anything else that interests you and therefore would probably interest the rest of the HIStalk universe; and (f) look into the nearest reflective surface and give yourself a jaunty thumbs-up on our behalf for being discerning enough to recognize that despite its amateurish presentation, occasionally inappropriate content, and intentionally ironic pipe-smoking logo character, HIStalk does a mostly OK job in keeping you informed as well as a guy with a full-time hospital job can do.

My inbox is bulging and I have a lot of catching up to do this weekend. That’s the best I can do, unfortunately. Re-sending your e-mail doesn’t really help solve my problem of needing to sleep five hours or so, which is about all the time I have left at the end of the day. I promise I have not forgotten you.

Welcome to new HIStalk Platinum Sponsor TeraRecon of Foster City, CA. The company is a global leader in enterprise image management solutions, especially with regard to advanced imaging procedures. Its zero-footprint iNtuition EMV (Enterprise Medical Viewer) can deliver interactive images to any Web browser for even the largest and most complex CT exam, even interactive 3D. Instead of a peering at static JPGs in the EMR or a generic 2D viewer short on useful tools, physicians get a rich viewer with contextual tools and viewing configurations that are automatically set based on image type. Specialists in particular get real value from 3D images. The flagship iNtuition solution integrates with any vendor-neutral archive, so it works with a wide variety of systems including PACS from any vendor. TeraRecon created the concept of advanced visualization and iNtuition is the leader in enterprise-wide, thin-client server-based visualization with over 4,500 installations all over the world. Thanks to TeraRecon for supporting HIStalk.

I admit that imaging solutions aren’t my strong suit, so hopefully this TeraRecon overview video that I found on YouTube will make up for any deficiencies that I shamelessly exposed in my introduction above.

Acquisitions, Funding, Business, and Stock

Skylight Healthcare Systems, a provider of interactive patient systems, raises $5 million in Series D financing.

Sales

The New York eHealth Collaborative selects MedAllies to operate its Direct Solution on the Statewide HIN of NY.

CMS awards HP a $43 million task order to continue providing IT services for the EHR incentive program and for maintaining the CMS Integrated Data Repository database.

Loma Linda University Medical Center (CA) selects Nuvon to provide medical device connectivity and interoperability as it migrates its OR, ICU, and dialysis center to Epic.

The VA awards Systems Made Simple (SMS) a $27 million renewal contract to support the Veterans Service Network program and Benefits Gateway System development project.

People

Bill Conroy joins Kareo’s board, a position he also holds for Prognosis Health Information Systems and Phreesia.

Ben-Tzion Karsh, a University of Wisconsin-Madison professor of engineering and one of the authors of the IOM article on EHR experience reporting that I mentioned above, died last month at 40.

Announcements and Implementations

INTEGRIS Health (OK) implements PatientSecure by HT Systems for biometric palm scanning.

Intelligent Medical Objects announces a search engine appliance to deliver just-in-time secure terminology services at the point of care.

Elsevier releases a version of its ClinicalKey reference system aimed at individual clinicians, which features information from 900 textbooks and 500 medical journals covering 41 specialties.

In Canada, three-employee Clinisys launches its first product, a cloud-based EMR.

New in the AMA’s CPT 2013 data file: consumer-friendly descriptors of each CPT code for patients and caregivers.

Santa Fe-based Seamless Medical Systems launches an iPad app for physician waiting rooms that allows patients to complete their forms online, review educational material, take notes during the visit and e-mail them to themselves, and play games.

Government and Politics

Sen. John Kerry (D-MA) introduces MITECH, a bill that expands the MU program to include safety net clinics that don’t necessarily qualify under the Medicaid incentive program. Kerry’s legislation would allow providers to qualify for incentives if at least 30 percent of their patient volume comes from lower-income patients.

ONC posts the vendors who signed up for the Blue Button Pledge (Alere Wellogic, Allscripts, athenahealth, AZZLY, Cerner, eClinicalWorks, Greenway, Intellicure, NextGen, and SOAPware) and invites other vendors to tweet their #VDTnow pledge to be added. Above is Farzad Mostashari’s welcome to the Consumer Health IT Summit where the companies were announced.

The US Army tests real-time medical communication software that uses mobile devices and 4G networks to support battlefield medics treating severely wounded solders. Portable physiologic monitors are used to to send streaming video, voice, and photos, along with treatment records, to surgeons that in real-life situations would be located in remote hospitals.

Innovation and Research

Mobile health apps that help manage medications and blood glucose are linked to improved diabetes management in socially disadvantaged populations.

Other

The board of directors of the Kansas HIE votes to transfer its duties to the Kansas Department of Health and Environment by October, 2013, which will save $350,000 a year.

The Joint Commission designates 620 hospitals as top performers on 45 evidence-based care processes closely linked to positive outcomes.

Joe Goedert of Health Data Management wrote a rebuttal to the Soumerai and Koppel editorial that ran in The Wall Street Journal this week called A Major Glitch for Digitized Health-Care Records. Joe mentioned some of the same points I did in my criticism of the editorial and the studies it selectively cited, but added quite a few more in Bad Research Shouldn’t Affect Good Policy. I respect the opinions of the authors and I’m as cynical as the next guy, but the editorial had just enough citations to possibly fool someone into thinking that it was new research (or that the old research mentioned was actually well done, which it wasn’t.) My criteria for assessing the objectivity of articles on almost any contentious topic (religion, politics, sports, or healthcare IT) is this: if the authors never give credibility to anything that doesn’t match their own beliefs, then I simply don’t bother reading because I already know what they’re going to say. I should note, though, that Ross Koppel was one of the authors of the IOM report on EHR problem reporting that I mentioned above and that’s a nice credit.

Job postings for healthcare professionals with EHR skills have jumped 31 percent over the last year.

Georgia Tech is offering a free, online Health Informatics in the Cloud class taught by Mark Braunstein MD, who has more relevant experience than anyone I can think of. Students don’t need a technical background – just five to seven hours per week for 10 weeks. The class is offered via Coursera, an online education startup that has already enrolled 1.5 million students in its “massive open online courses.” Its partners include Brown, Columbia, Stanford, Penn, and other topnotch schools that aren’t ordinarily interested in giving away their courses for free. This looks really good, especially for folks who don’t have a lot of formal healthcare IT education on their resume.

The family of a man who died in the ED of Beebe Medical Center (DE) files suit against the hospital and the ED staffing company it uses. The patient was discharged from the ED after being seen for chest pain, but he made it no further than a chair in the lobby before dying of a heart attack while waiting for a ride. Nobody noticed until hours later.

People who have eaten in Epic’s cafeteria will enjoy this profile of Executive Chef Eric Rupert (not celebrity French chef Eric Ripert, although I’m sure Epic could afford him if they wanted). The chef says Judy is a serious foodie — the only non-chef he’ll talk to about food — and she insists that Epic’s employees and visitors be fed well. He leads a staff of 78 Epic employees and describes the company environment: “There really is very little hierarchy here. You’re either a team member or a team leader, and the team leaders do everything that team members do, and then they also manage people. It’s not considered a promotion to go from a team member to a team leader; it’s just additional responsibilities.” He says Epic is different from its Silicon Valley counterparts in that employees pay the cost of ingredients for their meals instead of getting them for free, and everything is made in-house, even the baked goods. But like Google and other high-tech companies, Epic uses their food as a recruiting tool and has a diverse group of employees to feed, representing 55 countries.

Inga masquerades as Weird News Andy in finding this story. A Colorado man sues several food companies for “popcorn lung,” claiming that he ate microwave popcorn for years and the artificial butter fumes damaged his lungs. The jury, who apparently didn’t find his years of exposure to carpet-cleaning chemicals to be contributory, awards him $7 million. Inga adds that she hopes he gets his money in a Jiffy.

Epic UGM Report
By David Miller

Dave Miller, vice chancellor and CIO of University of Arkansas for Medical Sciences, e-mailed me privately about Epic’s UGM. I asked him if I could run his comments on HIStalk since non-Epic customers are always mystified by the company’s cult-like following. If you were one of the 8,000 UGM customer attendees and would care to share your thoughts about why it’s different than other user group meetings you’ve attended, I’d like to hear from you.

I have been to a number of UGMs at Epic, though it has been about three years since my last one. I am always amazed at the creativity of the Epic staff and the almost flawless way in which they execute the logistics to handle almost 8,000 users.

It continues to be primarily a user-driven event, from the advisory councils to the UGM sessions and even to the entertainment. The sessions themselves demonstrate the excitement that their users feel with what they have been able to do with one of the top healthcare IT products.

At the end of the day, it really comes down to Epic’s ability to instill their culture in each and every employee. Their simple focus on customer service was demonstrated by every employee I encountered. They had people stationed everywhere on campus to give directions, to drive golf carts to your destination, or just about anything else you needed.

I actually did not see a lot of Judy, but when she was present, she cheerfully took pictures with about anyone who would ask. Pretty amazing for a CEO of that stature. In my experience, most individuals in her position are self-absorbed and would never mingle like she does. I’ve also known Carl Dvorak for about 15 years, and he is about the most down-to-earth individual you would ever want to meet.

Judy creates an atmosphere for her employees that encourages and enables them to be at their creative best. The end result is a really good set of tools to manage the complexity of issues that healthcare organizations deal with every single day. Yes, there are imperfections, but they are so outweighed by the positives that they become irrelevant.

They used to say that no CFO ever got fired for hiring a Big 8 firm. Short of having someone completely inept in that role, I think I would say the same thing about a CIO.

Sponsor Updates

• ChartWise Medical Systems profiles Jennie Stuart Medical Center (KY) and its use of ChartWise:CDI to improve documentation an reporting.
• SuccessEHS reports that more than 10 percent of its EHR and PM client are now using its RCM services.
• Health Care DataWorks offers a September 25 webinar on CMS’s Value-Based Purchasing program.
• DrFirst offers Meaningful Use webinars over the next three weeks covering avoiding penalties, data exchange, the EHR as a clinical tool, and clinical quality measures.
• Orion Health’s portal solution for Alberta Netcare reaches 100 million views since its 2006 implementation.
• Versus features Northwest Michigan Surgery Center in its October 17 Webinar on maximizing patient flow with RTLS.
• TELUS Health Solutions and Sun Life Financial launch an eClaims solution for extended care providers across Canada.
• The Web Marketing Association recognizes CareTech Solutions as Outstanding Website Developer for winning nine WebAwards in 2012.
• CommVault joins The Association of Certified E-Discovery Specialists as an affiliate member.
• Awarepoint integrates its awareED module with Rauland Responder’s nurse call system.
• CDN Channel Elite recognizes NexJ Systems with gold awards for best cloud computing and best mobile solutions.
• MEDSEEK hosts roundtable discussions on marketing’s role in MU at this week’s Society for Healthcare Strategy and Market Development conference.
• Greenway hosts a Webinar series addressing the trends of electronification, consumerism, and improving population health.  
• Lifepoint Informatics will sponsor the Pathology Informatics 2012 conference in Chicago October 9-12.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Interviews Matt Sappern, CEO, PeriGen

Matthew Sappern is CEO of PeriGen of Princeton, NJ.

Tell me about yourself and the company.

I joined PeriGen in January of this year. I came over from Allscripts and Eclipsys, where I had been for about eight years in various capacities. I headed up a big chunk of our development organization at one time, ran our remote hosting business, ran our services business for awhile, and then after the merger, ran all of our client sales for a year-plus. I joined PeriGen in January and now getting my arms around labor and delivery.

What’s the size and scope of the company?

We’re about 100 folks. We’ve got offices in Tel Aviv, Princeton, and Montreal. We are the combination of two firms that merged in 2009. We’ve got more than 150 customers right now, including Banner, MedStar, Maimonides, and Albert Einstein. It’s a good cross-section of teaching hospitals as well as community hospitals. Our solution flexes pretty well across the entire gamut of hospitals.

How have fetal surveillance systems changed the way that obstetricians had practiced over the years?

The interesting part about fetal surveillance systems is that they really haven’t changed much at all for a number of years. That’s what attracted me to PeriGen. It was the first time that I saw that any vendor was applying some new technology and starting to innovate.

Surveillance systems, archiving, and annotation on the strip have been around a long time. Everybody does it, right? Philips, OBIX, GE, WatchChild, and PeriGen … we all do it pretty well, to be honest with you. PeriGen takes a different approach in applying evidence-based medicine to detect when there’s risk in labor. I’m hoping that we’re ushering in a whole new age of applying systems to healthcare. That’s really what drove me here.

That must be a different driver than at Allscripts, where you had to convince doctors to use CPOE or EMRs because someone else wanted them to even though the benefit might not necessarily accrue to them personally. I assume obstetricians want or demand PeriGen’s products.

When I was at Allscripts, Meaningful Use happened and hospitals were getting behind EMRs. It is a great feeling when we show our product. Clinicians’ eyes really light up, because it is just a bit different from everything else that’s out there.

It does everything that what I term “commodity systems” need to do, but our ability to apply technology to what has been a subjective part of labor and delivery is important. Probably 80% of medical malpractice comes back to bad interpretation of the fetal monitoring strip. We’ve figured out a way to apply technology to help interpret that strip.

Docs and nurses … their eyes tend to light up when they see this stuff. I think as with every new disruptive technology, it takes a little bit of time for people to understand why it’s so much better than what’s out there, particularly as budgets are tight.

What malpractice benefits have obstetricians seen from using the product?

There’s a bunch. Banner Health Systems has seen a precipitous drop, on the order of millions, in their malpractice expense.

Not only are we a great hedge on the downside of malpractice, but it’s my contention that we actually can help hospitals categorize when there are complications with labor, and potentially get greater reimbursement for that work. Even Medicaid provides higher reimbursement for vaginal delivery with complications as opposed to vaginal delivery without, but a lot of times that goes unchecked because there’s no simple system to categorically and systematically define or determine whether there have been complications in labor.

Most of the physician documentation begins with the moment of birth. Our ability to show that there were complications in the labor portion, we think, is going to allow hospitals to correctly charge and code their DRGs and establish some top-line revenue growth as well.

As unfortunate as it is when there’s any kind of patient harm that could have been avoided, everybody is very sensitive to anything involving newborns or peds. When you look at those malpractice-driven events, are they usually because of lack of following procedures or failure to detect complications?

Those go hand in hand sometimes. A lot of times there’s a subjective interpretation around whether the fetal monitoring strip is showing complications or not. What we’ve tried to do is firmly establish a tool that helps us determine that case. In fact, the NIH has licensed our tool to go back and take a retrospective view of thousands of strips from problematic births to determine if there’s any way to change the protocol.

Many companies are trying to develop software to analyze incoming data streams from patient monitoring systems. What have you learned as an early adopter in applying evidence to physiologic monitoring data?

You’re only as good as the evidence. We’ve put an awful lot of research into the 19 patents that we have. We have about 6,500 OB-specific protocols that we use. We’re continuously vetting that.

We’ve got some great clients. They work very closely with us in helping to shape our product as we go forward. Sometimes they say, “This protocol might be a little bit outdated,” or, “We had a case in here that your system really doesn’t contend with, and here’s how we think the workflow ought to go” and they help write new protocols. I think vigilance is part of that.

You’re applying accepted knowledge, but it sounds as though you’re also using the information you collect to develop what may become the next standard.

Yes. Standards evolve. Part of evidence-based medicine is when you get the evidence of something evolving, you got to take advantage of it. We’re constantly working with our clients to evolve our solution set. It’s really worked out well for us and for them.

Everybody’s spending a lot of their time and money working to implement electronic medical records, but the solutions market seems solid for high-acuity specialty areas like surgery, labor and delivery, and the ICU. Is it hard to earn a place at the table when those hospitals have made their big investments and you’re offering them a system they may not have thought about?

I think the rush towards Meaningful Use and deploying EMRs in as fast a manner as possible definitely eats up resources on the hospital side that they would otherwise deploy against programs like ours. But I think you’re absolutely right that there are specific areas in the hospital and labor and delivery, perinatal is probably the highest-risk service line in most hospitals. There is just so much nuance that I don’t think any of the larger EMRs can develop. I’d like to think that most of the clinicians understand the need for a specialty solution like ours.

You mentioned that your competitors do a good job. How do you differentiate PeriGen from them?

We’re the only ones who have gone well beyond that commodity solution set of surveillance, annotation, and archiving. To us, that’s great, but it’s an old application of technology. We are truly the only ones who are certainly doing that, but also applying our systems to deliver clinical decision support, to essentially say, “Hey, doc or hey, nurse — you’ve got a problem here. You need to look at this” and allowing that clinician to intervene.

None of the other systems do that.  In a way, I don’t feel like we have any competition because no other systems are doing that. Everybody is doing the commodity stuff. Nobody is doing what we do.

Where do you take it from here? Companies usually branch out into something unrelated or add functionality to what they have.

There’s a number of different directions. If you look at the number of obstetricians that are going through school, you see a downward trend in terms of available obstetrical talent. Careers are running a little bit shorter. It’s hard work being an OB, getting up in the middle of the night all the time. 

Our solution set lends itself to a service line around the remote OB hospitalist, an intriguing direction that we’re looking at. There are a number of areas that our technology is well suited for because it is so visual and it’s doing a lot of the heavy lifting for the clinician. I think we’re far more suited for that kind of a solution set than anyone else in the space.

At the heart of it, though, we also have an engine that can be abstracted away from labor and delivery content and populated with content from other departments as well. The concept of applying clinical decision support engines at the bedside in real or near-real time is one that can grow pretty significantly into other service lines.

I hadn’t heard of remote OB hospitalists. How is your product used remotely compared to products like AirStrip?

We’re published via Citrix. There’s a number of physicians using mobile applications now without using AirStrip. The last time I was at Banner, I was speaking to a doctor and he was sitting there on his iPad looking at tracings and actually entering some orders. Mobility is something that we feel pretty confident that there’s a solution set around for us and that a lot of our clients are already employing our solution in a mobile fashion.

The remote OB is a different concept. If you are in a hospital somewhere where you’re having trouble getting access to OBs, like any number of community hospitals around the country, perhaps there is a service that provides a consulting physician or that uses our system as an alerting system, like an ADP in home security.

None of these are productized now, but your question was where our application goes. Our application allows immediate visual recognition of a problem, so therefore lends itself to a number of services that don’t exist today.

In a small town, obstetricians spend a lot of time waiting on labor to progress. Is it easier for hospitals to attract and use those obstetricians efficiently when they’ve got a tool like yours?

Yes. There is no doubt that both nurses and docs have a more efficient workflow when they’re using our tools. Nurses can come in, check on patterns, and see it right away over a two-hour trend line whether there are problematic decelerations or not in the labor. It’s a lot more relevant clinical information, and a lot quicker than having to stare at the strip or unroll the strip out on the bed and see what’s going on.

How do you think obstetric services and obstetricians will fare under the Affordable Care Act?

I’m more worried about the number of obstetricians, frankly. I think they’re going to be fine. As you look at where hospitals are going with accountable care organizations, I think tools like ours are going to become more and more important.

If there’s a baby that’s born with a birth defect – heaven forbid, but we all know it happens — that child is in that system for, in many cases, the perpetuity of its life. Any tool like ours that employs systems to manage risk is going to be quite important in accountable care organizations going forward. 

Ultimately, I think that the practice of obstetrics is changing. We’re going to continue to see a higher demand, as there’s less OBs delivering babies. Systems like ours can help make those OBs and the nurses on staff a bit more productive, which is what we see a lot of excitement around.

From your time at Allscripts, what lessons did you learn that you will and won’t apply at PeriGen?

There’s a lot of things that we can do, being a much smaller organization than Allscripts and having a much tighter focus. We’ve got the freedom, agility, and speed to do things that they maybe can’t do quite as well. There are organizational tenets that I am taking a slightly different approach than we ever did at Allscripts relative to how I’m organizing our development and product teams. Stuff that the size and scope of Allscripts just wouldn’t allow.

Any concluding thoughts?

When I saw this application at work, I had been up for the job and I wasn’t sure if I was going to take it. I wanted to go see the application at work in one of our client hospitals. There was a woman having some complications and decelerations in labor, which are a bad thing. I’m not a doc, so that’s about as medical as I’m going to get. 

Our system helped detect what was going on. They were able to do an emergency C-section. Everything came out great. At that point, i saw more than ever in my career how technology can change the course of healthcare on a patient-by-patient basis.  

I feel like we’re bringing innovation where there has been little to date. We’re applying technology to one of the most problematic and subjective areas, which is interpreting the fetal monitoring strip. It’s a great proving ground for clinical decision support overall.

HIStalk Advisory Panel: Patient-Facing Technologies

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

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

This month’s question: What patient-facing technologies (portals, PHRs, kiosks, patient education, etc.) have you implemented that have had the most positive impact on patient satisfaction?

Patient Portal

• We’re in the early stages of a portal deployment. Too early to tell what kind of impact it will have on patients, although our CEO sees it as a Kaiser killer. I’m not so certain.  
• We are in transition with our Epic implementation. We have an existing patient portal and also a failed attempt to use kiosks. With Epic, we have already signed up 20,000 new users to MyChart and the reviews have been very positive. In addition, we will most likely move away from kiosks as they just don’t seem to generate much interest in spite of widespread adoption in banking (ATMs) and airlines.
• Patient access to their health records has had the most positive impact on patient satisfaction so they can access their own information or schedule on their own time.
• None, and "therein lies the rub!” Some doctors in my group have tried Phytel, but not with a lot of enthusiasm, and I did not hear that they had an earth-shattering experience. I chose instead to test drive on my patient population the actual need and demand for such tools before I invested time and staff effort into a technology that may as well go nowhere because my older patients are simply not ready for it. All of that while the company as a whole was looking for a more integrated solution/EMR that would offer a patient portal along with practice management and other tools all in one as opposed to having a piecemeal approach.We did find one after a long and arduous process and I hope that it will prove to be worth the wait. However the patient’s response and demand for such technology remains to be seen as many of them are not computer savvy, nor do they even have a computer.
• Nothing yet. We are still trying to get the Stage 1 criteria met for Meaningful Use, but I’m very much looking forward to the patient portal. We’re among the last facilities in our state to allow our employees to look at their own records within our hospital information system. I want to get them moved over to the portal as soon as we can so we can close that loophole!
• Undoubtedly it is the patient portal that has had the most impact on satisfaction. People who want to take individual control of their health appreciate and utilize the opportunities to review their test results, communicate with their caregivers, and make their own appointments, among other things. Promotion of this kind of ownership over one’s health is also a key to improving health outcomes for patients and a critical component of realizing the kinds of outcomes that will help determine our payments in the near future.
• Many of our physicians indicate that access to a patient portal has been the most significant change in terms of patient satisfaction that they have seen in a dozen-plus years of medical practice. A physician example: for the first six months, about a third of the messages I received were just to say, "Thanks for this new system – it’s awesome." Now I have good stories to tell — the case of an elderly heart failure patient that we have interacted with regularly (via daughter and home care) using the patient portal. She was in the hospital or ED every 2-6 weeks for the year prior to the portal and (knock wood) has not been admitted in >6 months since our more frequent touch points and monitoring.
• I have yet to work at an organization where we’ve implemented any of these with a verifiable increase in patient satisfaction. Not saying that the technologies aren’t useful, just that there was not a reliable way to verify the impact. As a side note, the implementations with the greatest impact are those where patients wait less and answer questions the fewest number of times. Implementing portals and kiosks can help support this experience, but only if the organization changes workflows to support activities such as pre-registration.
• Most successful patient-facing tool has been Epic’s MyChart, especially on the primary care side. They have been very diligent about getting patients signed up while they are in the office using cheap netbooks. Adoption has been very strong and feedback has been very positive. The key was to go live with a fairly robust set of features enabled on day one rather than trying to ramp up over time.
• We’re still working on implementing the patient-facing technologies. Previously as a patient, I was thrilled about patient portal. One of the cool things we’re working with our EHR vendor on is a tool that will help us proactively reach out to patients to remind them of wellness activities specific to them.
• The area of patient portals has been a problem area for me. I struggle with how a patient should engage with a community hospital directly as opposed to a primary care physician. The fact that MU is driving both hospitals and physicians to have portals is going to create a larger issue in my opinion. This opinion is shared by patients in a recent focus group we did. Two patients in the group had recently connected to their PCPs athena portal. Their question for me and my hospital colleagues was, "What would I go to you if I have this with my PCP?" Because of MU S2, we will be implementing a patient portal and spending close to $400k to do so. This to me is another example of how MU is gone awry. A Patient Portal in an IDN make sense. In a community setting with an independent hospital and small independent providers, a portal aggregation strategy makes more sense – a single sign-on to the hospital, PCP, and specialists in a community but three separate systems. I wish such a solution existed, but we have not found one (but still looking).
• Patient Portal. We are a large group which has over 60 percent of our patients signed up, giving patients what they want and need – actionable transactions (e.g. messaging the office or doctor, refill requests, appointment requests), not fluffy marketing material or even PHR info. We will add in more PHR info over time, but we have seen the demand for actionable items be what drives their use of the system. They LOVE it, and most of our docs now love it also, as it is an easy way to communicate in a non-synchronous manner, which allows for better explanations and web links, as well as better documentation for the chart.
• Portals work very well. We use MyChart and have hundreds of thousands of patients using it for lab result lookup, appointment scheduling, bill review and payment, after visit summaries, etc. Public PHRs have gotten no traction. Kiosks we haven’t deployed due to ADA concerns.

Kiosks

• Patient check-in kiosks associated with patient portals, allowing the patient or caregiver to fill out visit information in advance of office visit and/or in waiting area of office.
• Kiosks. If done well, can facilitate the registration process, which starts the whole care process on a positive note.

Interactive Patient Systems

• GREAT question.. Not sure any of them have really “delighted” our patients. If I had to pick one technology that seems to be pleasing SOME of our patients, I would suggest the kiosk, in the ambulatory environment, seems to be perceived as a good thing. We also recently developed an application that runs on our interactive television system. It allows a patient (or a family member) to view photos of all members of their care team. In a large academic medical center, this can be important. A member of the clinical team is added to the system if they order something or view something in the patient’s record. When they interact with the system, their photo, their name, and their title are added to the patient’s profile. The patient can then view the entire care team. A photo and name stay active on the profile for four days and drop off if no interaction. It’s very new, but patients seem to like it.

WiFi Access

• The single patient satisfier most raved about by our patients was WiFi in the waiting rooms. It took many patients asking for it and some persuading of the clinical and admin folks. We had to assure them that this would not affect any of our patient care systems. We did have to add a disclaimer page that there was no support and that folks should not be going to certain sites — all of the legal jargon that admin wanted. From a technical side, we carved out some bandwidth that always uses a lessor priority and will reduce itself to almost nothing if the bandwidth is needed for patient care. We impressed on our patients that once called to an exam room, all electronics were to be powered down and turned off. We have about the same acceptance rate as the airlines or your local movie theater. Some of our more technical folks (like me) make use of any spare time to keep up on emails and issues. We got a lot of positive feedback.

Social Media

• I think the jury is still out on our patient-facing technologies and their impact on patient satisfaction. However, it is well worth noting that our endeavors with social media (Twitter and Facebook, particularly), even though our efforts are in their infancies and perhaps relatively minor when compared to others, have yielded great increase in patient and community engagement and affinity for our health system.

Patient Messaging

• Delivering engaging communications via text messaging (confirming appointments, medication refills, etc). They like this proactive approach versus the passive communications on the portal. My internal medicine physician practices in a fairly large group affiliated with an academic medical center. Getting anyone on the phone is a miracle. It is like they are in the Get Smart cone of silence. However, they have finally implemented a secure messaging system (they use an old flavor of Allscripts) and I recently had a positive experience using it to have a prescription refilled. Worked nicely. They do not, however, have online scheduling and I don’t think I could actually "talk" to my physician
  on line.

Printed Patient Documentation

• In general, we are not there yet. Still getting physicians implemented on EMRs. However, we have had some very positive comments from patients who receive their clinical visit summaries at the end of their office visit. They love having their visit information printed out for them so they can share with families. This coming year, we will be implementing Patient Portal and integrating Healthwise Patient Education with eClinicalWorks.
• So far Thomson Reuters CareNotes for patient education has had an huge impact on our patient satisfaction. The patients really appreciate have clear documentation they can take home. However, we are in the process of implementing a patient portal that I think will really increase our patient satisfaction scores.

News 9/19/12

Top News

Massachusetts Eye and Ear Infirmary and its physician group will pay HHS $1.5 million to settle potential HIPAA violations following the theft of an unencrypted laptop containing electronic PHI of patients and research subjects.

Reader Comments

From Honky Cat: “Re: Waiting in line at Apple. Don’t wait in line for your iPhone upgrade. Go to this link and pre-order your phone. They will ship it to you in two to three weeks. Surely you can wait that long for it.” I considered setting my alarm to be one of the first people to go online last Friday and place an order. Instead, I slept in and waited until 6:00 am to get online. By that time Apple had stopped taking orders to reserve the iPhone 5s for pick up at the local Apple store, so I’ll wait for mine to be delivered in a couple of weeks. Apple, by the way, sold two million iPhone 5s in the first 24 hours of pre-orders, more than double the previous record set in 2011.

From The PACS Designer: “Re: mobile image viewing. TPD congratulates Aycan Medical Systems for being one of the first to gain FDA approval for its Aycan Mobile for the iPad. Now that the FDA is involved with mobile solutions, we’ll see more teleradiology mobile solution approvals for other vendors.“

From Steve: “Re: QuadraMed. To be sold in the next 7-10 days.” Unverified.

From Pointer: “Re: EHRs. A vendor-agnostic viewpoint on how they don’t change the cost curve.” It may be vendor-agnostic, but this particular article is a clearly labeled opinion piece written by authors who have been historically negative toward EMRs, EMR vendors, and government. They are entitled to their opinions, but recognize them as such despite the bait-and-switch newspaper headline trumpeting “A Major Glitch.” Their editorial conclusion is accurate, though – most studies have failed to prove that EMRs save money (I haven’t seen any studies that convinced me that paper records save money or improve outcomes either, of course.) That’s not to say they don’t, only that it’s tough to prove since nothing in healthcare stays unchanged long enough to get a baseline. It’s also true that expecting technology alone to create savings without changing incentives is unreasonable. I agree with the authors that blowing taxpayer billions to get providers to buy software they weren’t willing to spend their own money on was illogical, but no amount of Monday morning quarterbacking will bring that cash back or cause providers to toss their EMRs out the nearest window. It’s time to move on, realize that healthcare IT is here to stay, and constructively make it better instead of hand-wringing. Like everything else, the industry has 10% cheerleaders, 10% naysayers, and 80% rational people who don’t need the self-proclaimed experts on either end of the spectrum to tell them what to think or do. If you’re a provider, choose EMR or paper as you desire, do something innovative with it that improves outcomes and reduces costs, and then write your own article. That’s the one I’d rather read.

From Looking Deeper: “Re: patient portals and self-scheduling. I install patient portals for a living, including scheduling. There really aren’t technical challenges any more. Providing convenient, immediate online scheduling is a solved problem even in healthcare, especially in primary care. The problem is in people’s heads. Whenever online scheduling comes up, physicians and clinic staff will tell you that their patients can’t possibly handle it – they’ll schedule the wrong kind of visit (office visit vs. physical) or create some other vague problem. I dutifully inform them that online scheduling is working fine in clinics and practices across the nation. ‘Other clinics find that their patients can handle this,’ I always say. They usually say, ‘Not our patients.’ Interestingly, clinics serving less-affluent areas and the indigent tend to be more in favor of such patient-centric services. ‘Our patients are an especially incompetent group’ is a pretty negative view to hold of the people you’re trying to care for. If we could just get past this attitude, pretty much all primary care visits could be scheduled online. In the rare case where something needs to change, the clinic can call or e-mail the patient and reschedule, but that’s less than 5 percent of appointments scheduled online. Specialty and procedure visits are a different beast and need some careful analysis before they are opened up to online scheduling, but online scheduling for primary care is a solved problem.”

HIStalk Announcements and Requests

I have newfound respect for anyone working with insurance companies to secure payments. I had mentioned a few months ago that I had a minor medical procedure that resulted in some complications, lots of doctor office visits, and about 20 different medical claims. I was lucky enough to have both primary and secondary coverage in place since the claims were in the thousands. I also thought I was lucky because both policies were from the same very big insurance company. Unfortunately, the insurance company has spent the last four months trying to decide internally which policy should be primary, and so far no claims coordination has occurred. After several weeks of hour-long phone calls, yesterday I finally turned “not nice” and demanded to speak to a supervisor. I explained that I didn’t give a (expletive) which policy was primary or secondary, it was all one insurance company, and the (expletive) claims needed to be paid. I actually believe the claims will finally be processed correctly. The moral of this story is that if you work in a hospital or practice, take a moment to say thanks to your billing and collection staff. And bring them chocolate on a regular basis.

I don’t know about you, but I’ve been busy turning off all my Facebook and Twitter connections to folks who keep preaching politics. Has anybody ever convinced someone to change their political beliefs by proudly posting a Facebook link to the latest nut-job partisan article? Actually, they sometimes almost convince me to vote the other way out of annoyance.

Thanks to Healthcare Quality Catalyst supporting HIStalk as a Platinum Sponsor. The Salt Lake City company offers a practical clinical data warehouse solution that combine technology and clinical improvement methodologies to improve care. The information needed to answer a clinical improvement question is scattered in most hospitals (satisfaction surveys, Epic Clarity transactions, and lab and prescription information, for example) and HQC puts it together in its Adaptive Data Warehouse and subject-specific data marts (such as women and newborns) to support continuous, evidence-based care improvements. HQC offers more than just the tools, supplying clinical improvement methodologies such as role definitions and process templates to create effective improvement teams. If you’ve been around the industry for some time, you surely know some of their folks: Todd Cozzens, Larry Grandia, Dale Sanders, Bruce Turkstra, and David Burton, MD were some of those I immediately recognized. I interviewed co-founder and CIO Steve Barlow a year ago and got a good background on the company. Thanks to Healthcare Quality Catalyst for supporting HIStalk.

I naturally cruised over to YouTube and found this video that introduces Healthcare Quality Catalyst better than I did.

Acquisitions, Funding, Business, and Stock

PE firm ABRY Partners makes a “significant” investment in SourceMedical Solutions, a provider of software and services for ASCs and rehab centers.

In England, a company that commercializes university research invests in an Oxford spinoff whose software that can monitor pulse, respiration, and oxygen saturation using only a webcam.

Also in England, eHealth Insider reports that CSC will stop selling iSoft GP systems to NHS markets, in which it has 582 practice customers. CSC denies the report.

Vipaar, which sells surgery proctoring software based on technology developed at the University of Alabama at Birmingham medical school, raises half of its $1.2 million funding goal.

Sales

Community Medical Center (NE) selects BridgeHead Software’s Healthcare Data Management Solution for backup and archiving.

CommUnity Care (TX) will deploy NextGen RCM Services throughout its 22 clinics.

Pemiscot Memorial Health Systems will expand its deployment of Prognosis Health Information System by implementing its financial system and its laboratory information system powered by Orchard.

Community Hospital Grand Junction (CO) chooses the perioperative system of Surgical Information Systems.

People

Zotec Partners hires Kristy Floyd (American Society of Anesthesiologists) as director of anesthesia business development.

The Medical College of Wisconsin appoints David C. Hotchkiss (University of Texas Health Science Center) VP/CIO.

Healthland names Patrick Spangler (Epocrates) CFO.

Douglas Billian, founder of Billian Publishing, died September 15 at 84.

Announcements and Implementations

HIMSS Analytics recognizes Fort HealthCare (WI) with its Stage 7 Award for EMR adoption.

Providence Medford Medical Center and Asante Rogue Regional Medical Center (OR) will complete their hospital and clinic implementations of Epic in April.

Nuance will purchase Ditech Networks, a provider of voice technologies and voice-to-text services, for $22.5 million.

AMA releases the 2013 CPT code set, which goes into effect for claims filed as of January 1, 2013.

Certify Data Systems announces the general availability of its HealthLogix HIE platform, which it says is the first to deliver an aggregated patient view from all community health encounters regardless of EHR.

Cincinnati Children’s Hospital Medical Center (OH) implements Passport Health’s PatientSimple and Smart Statement online billing solutions.

eClinicalWorks launches its $10 million open, secure collaboration platform that works with any EHR or even paper-based practices. The NHIN Direct-compatible network allows members to transmit electronic referrals and patient records with attachments.

Government and Politics

ONC posts the second wave of draft test procedures for the 2014 Edition EHR certification criteria.

I don’t think Farzad ever followed through on his promise to name the EMR vendors who took his #VDTnow pledge to allow patients to view, download, and transmit their medical information. Claudia Williams of ONC tweeted her list, which I assume is complete: Allscripts, NextGen, AlereWellogic, Intellicure, eClinicalWorks, Greenway, SOAPware, athenahealth, Azzly, and Cerner. Conspicuously but not surprisingly missing is Epic, which doesn’t even have a Twitter account as far as I know. Maybe they already offer the capability as some have suggested, but if so, all they had to do was tweet out their already-met pledge. Judy’s on ONC’s Health IT Policy Committee, after all.

Innovation and Research

The National Library of Medicine awards The Ohio State University College of Medicine’s Department of Biomedical Informatics $1.3 million to develop a system that uses EHRs to identify potential patients for clinical trials.

Other

Wider use of EHRs over the last decade may be contributing to a growing up-coding trend that has added $11 billion to healthcare costs. Physicians argue the higher codes are justified because care of seniors has become more complex and technology allows them to code more accurately. Critics say the findings suggest billing abuse and fraud. I I were still selling EMRs, I’d be handing this study to doctors and touting it as proof that technology is helping physicians bill and be paid for the actual care provided. Meanwhile, naysayers like Mr. H will probably dig deeper and suggest objections to such hasty conclusions.

Hell hath no fury: a Washington dermatologist wins a $600,000 settlement and a rare apology from state health officials who had investigated him for drug abuse and medical fraud. An anonymous tipster had reported that the doctor was falsifying drug records, using cocaine, and running in-office orgies among his staff, patients, and prostitutes. In a separate lawsuit, the doctor was award more than $100,000 from his former wife, who turned out to be the anonymous tipster who had filed the complaint late in the couple’s bitter divorce proceedings.

The folks from Arizona Associated Surgeons sent over their video for the Western Users Group meeting at ACE (the Allscripts user meeting) last month.

Want to rub elbows with sexy celebrities on your hospital employer’s dime? CHIME’s Fall CIO Forum will feature Olympic beach volleyball gold medalists Misty May-Treanor and Kerri Walsh Jennings, mostly known for leaping around nearly naked in prime time reminiscent of the much-beloved “Girls on Trampolines” segment of The Man Show except with smaller bikinis. Misty and Kerri (or was that Misti and Kerry?) will discuss Meaningful Use Stage 2 and … no, wait, they’ll pose with star-struck CIOs, sign autographs, and collect a big non-amateur payday courtesy of patients who pay $5 for an aspirin.

A group of 30+ physicians labeling themselves as “Doccupy” complain to Contra Costa, CA county supervisors about the $45 million implementation of Epic at its hospitals. They said 10 percent of ED patients are leaving without seeing a doctor, a number that increased after the hospital’s July 1 go-live as the average time in the ED increased from three hours to four. Patient loads were cut in half to prepare for the implementation, but the doctors claim that several of their peers still quit because of stress, saying, “We were not ready for Epic and Epic was not ready for us.” An ED physician going off shift said she still had documentation to complete for 16 patients, adding, “It’s going to implode.” Some doctors spoke up about the advantages of Epic, and all agreed that it’s important to have an integrated electronic record. Detention facility nurses had complained about Epic to the supervisors last month.

The Cure JM Foundation (juvenile myositis) is in the running for a $250K research grant that will go to the charity with the highest number of Facebook votes. Information and voting links are here. Several HIT folks I’ve heard from have children with JM and I’m sure they would appreciate your vote.

Patients storm Charlton Memorial Hospital (GA) after a contracted collection company incorrectly manipulates the hospital-provided data file, sending patients collection notices for bills they don’t owe.

Of the seven highest-earning non-profit CEOs in the country, four run hospitals, according to the Chronicle of Philanthropy. I think they’ve missed a few since I’ve seen several hospital tax forms with CEO salaries above these figures.

Bloomberg Businessweek profiles Terry Ragon, founder of the Boston-based InterSystems, which sells the Cache’ database that runs Epic, Meditech, and quite a few other MUMPS-based healthcare systems. The article calls Ragon a “Hidden Software Billionaire,” estimating the value of the company he directly owns at $2 billion.

Here’s a fun coincidence. Dave Miller, vice chancellor and CIO of the University of Arkansas for Medical Sciences, sent over the above video of him doing a nice cover of “Mustang Sally” at Epic’s UGM (his wife had the camera 90 degrees off kilter for a few seconds, but his singing was fine). The day they got back home, he impulsively bought some raffle tickets from a charity fundraiser. He won the prize, which was made in 1967, the same year Wilson Pickett released “Mustang Sally” on an album – a classic Ford Mustang.

Sponsor Updates

• SuccessEHR grows its RCM services business 92 percent over the last year.
• First Databank hosts its 2012 FDB Customer Seminar this week in San Diego.
• T-System offers Webinars this week on  improving ED throughput.
• Melanie Pita JD, EVP of product management at Prognosis Health Information Systems, presented a session on EHRs and Meaningful Use at the Georgia Rural Health Association conference this week at Callaway Gardens.
• TeraRecon is exhibiting its advanced visualization solutions for medical imaging this week at CIRSE 2012 in Lisbon, Portugal.
• Michigan Health Connect HIE and Greenway Medical will provide data exchange between Greenway’s PrimeSUITE customers and hospitals on the Michigan Health Connect platform.   
• MedPlus offers a three-part Webinar series hosted by Steven Waldren, MD, director of the AAFP’s Center for Health IT.
• White Plume releases a white paper discussing practical considerations to minimize losses while migrating to ICD-10.
• ChartWise Medical Systems unveils its ChartWise:CDI software at this month’s AHIMA convention in Chicago.
• Orion Health opens an office in Singapore for development and technical support employees.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

EHR Design Talk with Dr. Rick 9/17/12

A Single-Screen EHR Design for the Patient Encounter

The benchmark . . . for all navigation techniques should be the saccadic [rapid] eye movement. This allows us to acquire a new set of informative visual objects in 100-200 [milliseconds]. Moreover, information acquired in this way will be integrated readily with other information that we have recently acquired from the same space. Thus, the ideal visualization is one in which all the information for visualization is available on a single high-resolution screen. – Colin Ware, Information Visualization: Perception for Design

I would like to bring together some of the user interface designs we have been considering and propose for discussion a single-screen EHR design for a patient encounter. Before presenting the design itself, it is useful to recall the design concepts covered in previous posts:

• The human visual system is very good at organizing data spatially (Why T-Sheets Work; Pane Management – Part 2).
• We excel at grasping patterns and seeing relationships among data elements when they are presented in a single view, but have limited capacity to remember these elements when they are distributed across multiple screens (Humans Have Limited Working Memory).
• The most efficient way to navigate visual space is by using rapid (saccadic) eye movements (Fitts’ Law).
• Using a large, high-resolution screen supports navigation by saccadic eye movement (Pane Management – Part 1).
• When we do need to navigate using a mouse or other input device, we can reduce the cognitive costs by making the targets large and reasonably close (Fitts’ Law).
• It is often easier to grasp patterns visually than mathematically or verbally (Computer-Centered versus User-Centered Design).
• It’s easier to find patterns and solve problems with data presented compactly and grouped visually – using columns, rows, and formatting – than with data presented as free text (Pane Management – Part 1).
• Using vertical and horizontal scrollbars to navigate small panes requires cognitive effort and doesn’t solve the working memory problem (The Problem with Scrolling). It is preferable to display an overview of the data and use mouse hovers or clicks to display details as needed (Overview with Details on Demand).

The Design

A large single screen with high resolution, for instance 1920 x 1080 pixels (full HD), is used to display all the categories of data for a patient encounter on a particular date. Each category of data is assigned to a pane of fixed size and location on the screen:

Because humans are able retain about nine spatial locations in visual working memory (although we can only remember simple visual objects or patterns contained in about three to five of them), a set of nine panes arranged in a 3×3 grid was chosen for the high-level design.

The figure below shows this same screen design populated with data from a patient encounter:

Click on the thumbnail below to see the design at higher (but not full) resolution:

The figure below shows the Problem List pane:

A marker (for instance, an asterisk) indicates that more detail is available for a data field. Detail can be displayed by hovering or clicking, as shown below for Diabetes Mellitus:

and for transient ischemic attack (TIA):

The same high-level design is used for all panes, as in the Exam pane below (size slightly reduced):

Again, hovering over or clicking on a line with an asterisk brings up more detail for that data field:

The design allows default or normal findings to be summarized:

while still making the full default text available on demand:

Expanded Panes:

As an alternative to expanding individual data fields, all the data fields within a pane can be simultaneously expanded by hovering or clicking on the pane’s title bar, as shown below for the Problem List:

An expanded pane will necessarily obscure adjacent panes, as below:

Even in this case, context is at least partially preserved because of the large high-resolution screen.

Design Considerations

Expanded data fields:

• In order to maintain as much context as possible, data fields within an individual pane expand only to the minimum size required.
• More than one data field within a pane can be expanded at the same time, provided that the expanded fields don’t overlap.

Expanded panes:

• In order to maintain as much context as possible, panes expand only to the minimum size required.
• More than one pane can be expanded at the same time, provided that the expanded panes don’t overlap.
• The same single-screen design is used both for data entry and subsequent data review. Any pane can expand for data entry and then contract to its original size.

I would propose that this kind of single-screen design for a patient encounter, with all its interactive capability both within panes and among panes, should be thought of as the chart note. In this design, there is no separate text-based or PDF "completed note," except as needed for use outside the EHR.

The design above is a sketch – a design being considered, reformulated, and reworked. I tried to design it based on an understanding of how the human brain best takes in, processes, and organizes information. Its purpose is to generate discussion and debate. I look forward to your comments and suggestions.

Finally, there is a major caveat that comes along with the single-screen design presented here. A patient’s electronic health record is a longitudinal record, while the design above represents a snapshot in time. More on this in coming posts.

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

Curbside Consult with Dr. Jayne 9/17/12

There’s been a lot of talk lately about the perils of cloned documentation. I had several readers forward me the recent notification from Medicare administrative contractor National Government Services that states that it will deny payments for encounters whose documentation appears cloned.

Let’s face it. Many of us have been creating what could be construed as cloned documentation since our residency days. Back when the average length of stay was a little longer (especially on a teaching service), we were encouraged to completely recap the contents of the previous day’s note, which often led to copying.

With 15 or 20 patients on our rosters, it was often impossible to remember subtleties about each patient, so you just copied what you had from the previous day, updated the lab values, any new complaints, etc. It was a lot like using copy forward / update technology in EHRs today, except a pen with a drug company logo and some truly horrific penmanship was involved.

When dictating discharge summaries, the vast majority of patients had strikingly similar exams since patients had to have largely normalized to go home: Heart regular rate and rhythm; no murmurs, rubs or gallops; lungs clear to auscultation bilaterally; and so on. When confronted with a stack of discharge summaries to dictate (which lazy attending physicians had kindly “flipped” our way) on patients we had maybe seen once, they all started to sound remarkably alike in other ways as well.

I remember being on service at a pediatric hospital, where in a single call night I personally admitted 17 patients for asthma exacerbation. The other interns on the team had at least five or 10 asthma patients each as well. Since there were three interns on a team, the senior resident was covering nearly 50 patients – and more than 30 of them had similar chief complaints and presentations. We had strict criteria for who was admitted (thanks to evidence-based medicine), so their presentations were actually very similar, and all had failed identical interventions in the emergency department before admission. You can bet those senior resident notes didn’t have any new or different information than what was presented in ours.

Ditto on Labor and Delivery during residency, where I trained at one of the highest volume birthing hospitals in the region. Since a normal uncomplicated childbirth really isn’t an illness, the documentation was routine and nearly identical. It would have been difficult to find truly unique information to write about some of the patients. I supposed we could have put in frivolous information like, “This blonde Caucasian mother of the adorable blue-eyed infant has no complaints,” but we were tasked with rounding, not writing beautiful, flowing prose.

My problem with the entire issue of cloned notes is that no one really has defined what they consider cloned, making this just another arbitrary way for payers to deny reimbursement. One contractor defines it as, “Documentation that repeats language from previous entries on that patient or from other patients with similar conditions.” I dare anyone to find a note written in the last two decades that doesn’t repeat language in some way, shape, or form.

Prior to EHR, I used a homegrown paper template documentation system that created remarkably uniform notes. On the positive side, it also created remarkably high-quality visits. Clinical decision support was baked into the documentation forms for various chief complaints. We often took materials provided by various professional organizations (AAFP, AAP, ACOG, CDC, etc.) and customized it to meet local and payer guidelines. For uncomplicated illness (strep throat, sinusitis, urinary tract infection, etc.) the notes would be strikingly similar from patient to patient.

Why is it bad thing for the physician to document exactly the appropriate information to substantiate level of care and quality? Should extraneous information be required for payment so that the note appears individualized just for the sake of being individualized?

I can easily avoid the appearance of cloned documentation across patients by including nuance information in the history of present illness. I have no problems doing so if it is relevant to the patient’s story and his or her care.

Another issue entirely is that of cloned documentation within a single patient chart. Regulators and anti-EHR voices are after those of us who like to “drag and drop” previous visits into today’s note, then update it. Note that I said “update.” I didn’t say drag, drop, and depart. Who among us who actually cares for patients does not have at least a few dozen “Groundhog Day” patients, those where every single visit is the same? I’m talking about patients like the noncompliant hypertensive diabetic who refuses to follow the instructions from the previous visit. Every single assessment and plan looks something like this:

1) Diabetes: Reviewed blood sugar log. Counseled patient to take medications as directed and continue 1,800-calorie ADA diet. Patient to exercise 30 minutes daily and check blood sugars daily, bringing meter to next visit for download.

2) Hypertension: Counseled again regarding sodium intake and packaged foods. Exercise as above, continue medications.

3) Obesity: Discussed diet and exercise as above. Refer to nutritionist. Discussed consequences of continued noncompliance including worsening of chronic health conditions, heart disease, and potentially premature death.

Really, what else do I need to say here? Maybe I should start adding incremental data like, “Counseled patient for the 15th time” to make it more individualized. Or I could document specific details of the data in the blood sugar log, but that would be redundant and also introduce a potential source of error as I manually key numbers into my note.

The bottom line is this. Why should I not be able to pull this data forward, then update or add to it? It’s clear, it’s complete, and it accurately documents what I stated in the visit. I shouldn’t have to add extraneous information just to satisfy an auditor.

A friend of mine has a collection of hilarious patient visit notes (of course, with any patient identifiers carefully redacted with a broad-tip Sharpie) from both the paper and EHR realms. One of my favorite pages in his scrapbook is the ultimate healthcare haiku, written before the days of E&M Coding:

Boil-Lanced.

And that, dear readers, is a thing of beauty.

Have a great example of patient documentation to share? E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 9/17/12

From Another View: “Re: your Time Capsule editorial. You have missed a competitor to Epic … Sunrise/Eclipsys. Ring any bells? Long Island Jewish has it installed as well as others and it is well received. Is the price tag of Epic is going to bankrupt medicine? I really think Sunrise could very well be the Apple product that beat the giant Microsoft. Any thoughts?” Read more closely: I specifically mentioned (twice, in fact) Cerner, Eclipsys, and McKesson as Epic’s big-hospital competitors. That was true when I wrote the article in 2007, but I would expect that Allscripts/Eclipsys and McKesson have faded since then in terms of big-hospital customer count. Epic’s huge number of wins since 2007 were replacements, meaning their gain was somebody else’s loss. No, I don’t think that Allscripts (or any other vendor, at the moment) can compete with Epic in the large-hospital inpatient clinical systems market. Reasons: (a) incomplete integration; (b) narrower product line; (c) lower customer satisfaction; (d) lack of momentum; (e) hospital consolidations favoring existing Epic customers; and (f) trying to disrupt the status quo with one hand firmly planted in Wall Street’s lap. It’s not the end of the world for Allscripts – 80% hospitals aren’t candidates for Epic but need a lower-priced, pre-packaged, hosted product, meaning the biggest companies to beat are Meditech, McKesson, Cerner, and Siemens. Struggling to compete against Epic in big-hospital accounts hasn’t hurt Cerner, which doesn’t bag a lot of fresh Millennium wins over Epic but still has turned its assets into a $12 billion company. If you want to score Epic vs. Allscripts without emotion or subjectivity, it’s easy – just watch the number of new sales, the total number of beds and EPs covered, and KLAS scores.

From Music Lover: “Re: Epic UGM. You missed it, Mr. H! Some cool end users rocked the house Monday night. Anyone have pics or YouTube?” I only found the video of the opening session above, which is a clever riff on a horrible Journey song (was that redundant?) that reminds of me when Mrs. HIStalk dragged me to grit my teeth through the traveling Broadway version of “Rock of Ages” (who would have guessed that disco would be more fondly remembered than 80s hair bands?) By user group standards, though, it is darned cool. From the end of the video, it appears next year’s theme will be, predictably, Deep Space (the new 14,300-seat Deep Space auditorium pictured above will be open then.)

Listening: new from The Avett Brothers from Concord, NC, who have matured from frantic newgrass revivalists into something like an indie, rootsy Beatles with banjos. Long-term fans will have to decide whether the de-emphasis on hillbilly picking and grinning is inevitable maturity or perhaps overly slick production by hit-maker Rick Rubin. The new album is more accessible and probably less embarrassing to crank up in a vehicle that isn’t a pickup truck.

I was making an appointment for my annual PCP visit last week. After navigating through the annoying phone tree, waiting on hold, and negotiating with the scheduler for a convenient appointment time, the phone connection dropped on their end. My call-back went right to the “we’re too busy to talk to you now” message, so I figured I’d just try another day. The next day, I got an e-mail confirmation for a date/time I had declined, so it must have gone through as we were changing it. I noticed an unobtrusive link in the e-mail to “click here to cancel or reschedule” and darned if it didn’t work – I clicked, it gave me available days/times on the screen, I clicked on a convenient date/time, and I was all set. It actually felt like 2001 instead of 1980 in using Expedia to book a flight instead of wasting everybody’s time by calling a travel agent for an inefficient and entirely unnecessary telephone conversation. It’s not exactly cutting edge, but very few businesses let you schedule appointments online (restaurants being one exception, and that’s only because of OpenTable). Scheduling an appointment is a lot different than buying a product online, so the usual snarky Amazon references don’t apply.

Forbes chose the wrong company as the most innovative in healthcare, according to readers who said it’s actually Epic (had Forbes included non-publicly traded companies, of course). Cerner wasn’t too far off the mark, though. New poll to your right: have you ever requested and reviewed your electronic medical information from your PCP? The poll accepts comments if you’d care to elaborate on your experience. I didn’t even bother asking about hospital records since I know what a nightmare that can be.

Allow me to introduce new HIStalk Platinum Sponsor ChartWise Medical Systems. The Rhode Island-based company describes ChartWise:CDI as a Computer-Assisted Clinical Documentation Improvement solution that improves the accuracy and speed of documentation. it guides physicians to high-quality and complete documentation, using its built-in intelligence to analyze labs, meds, and procedures to suggest diagnoses and complications that may not have been correctly coded. Easily retrievable, auditable, and AHIMA-compliant query templates ensure compliance and consistency for internal QA and external auditors, with physician communication automatically initiated and documented by e-mail. Customers can reduce staff and physician training, ensure continuity when key team members leave, and get real-time metrics for their CDI programs. It’s offered by a subscription-based license, online training is free, and ICD-10 is built in and carries no upgrade fee. Customers can use it their way, regardless of whether documentation is on paper or EMR and with or without the participation of physicians. Half of Medicare paybacks are due to erroneous or incomplete documentation and you know the RAC auditors are out there digging since they’re paid a percentage of recovered dollars. The company was founded by Jon Elion MD, who also developed the Heartlab imaging software that was acquired by Agfa in 2005. Thanks to ChartWise for supporting HIStalk.

CapSite releases its new HIE report. It shows a big jump in hospital HIE participation in the past year (from 30% to 50%), with 71% of respondents planning to invest in new HIE technologies in the next two years. Surprisingly, two-thirds of respondents chose their primary HIE vendor because the company was an extension of their core hospital system (Epic was the most-named HIE vendor, so that gives you an idea). That probably reflects the uptick in private HIEs.

A hospital in England uses Skype for video teleconsultations with ADHD and Asperger syndrome  patients.

The flagship product of Detroit-based startup SchedFull manages an online waiting list for physician practices that allows them to fill appointments opened up when patients cancel, alerting the standby patient by e-mail or SMS if an opening matches their expressed preferences. The product is in beta.

Twenty-three employers participated in a jobs fair that was held last week in the new Sheik Zayed Tower at The Johns Hopkins Hospital, hoping to hire healthcare IT and informatics graduates from Johns Hopkins University, George Washington University, and University of Maryland University College (surely the strangest and most multiply-redundant college name ever, which they cheerfully admit and explain here). The event was held in the Chevy Chase Conference Center, which I assume is named after the nearby municipality rather than the embarrassingly unfunny comedian who did in fact have a Hollywood theater named after him for six weeks in 1993, which is all it took for his horrible late night TV show to flatline.

The Dallas-Fort Worth TV station covers the technology used in a new Texas Health Alliance hospital.

The local paper covers the use of shared medical appointments by Reliant Medical Group (MA), in which 90-minute visits are scheduled with groups of patients suffering from the same chronic health issues. Patients have the option to request one-on-one doctor time during the visit if they feel the need, but three-quarters of them like the group appointments. That’s an interesting approach to maximizing the use of resources while providing peer support for patients, which is probably far more effective than the usual online groups. All that’s missing is a financial incentive for consuming fewer resources, which is of course a healthcare problem not limited to how patients schedule their visits.

Raul Recarey is named executive director of the Illinois HIE in his third HIE leadership role in less than three years, having been named COO of the West Virginia Health Information Network in November 2009 and CEO of Missouri Health Connection in March 2011.

Indian River Medical Center (FL) will implement centralized appointment scheduling using McKesson’s Paragon Resource Scheduling, which issues printable appointment itineraries and procedure instructions. After the May go-live, the hospital will implement patient self-scheduling.

A hospital in Scotland is found by NHS to be cancelling 12% of its outpatient appointments due to problems with its new computer system. The hospital cancelled 105,000 outpatient appointments and 7,500 inpatient appoints in a 15-month period.

The author of an upcoming book says that children’s hospitals are banking huge cash surpluses and paying eye-popping executive salaries despite their non-profit status and ongoing solicitation for donations, which he says threatens their non-profit status, government subsidies, and community reputations.

California’s attorney general sends out subpoenas to several big health systems (Scripps, Sharp, Sutter, and others) in launching an antitrust investigation to determine whether consolidation among hospitals and physician groups is increasing healthcare costs through increased pricing power over payers.

A nurse working for an Atlanta-area anesthesia service is released to rehab after being charged with driving the wrong way on a highway and causing several vehicles to crash, injuring six people. She is alleged to have stolen propofol from Gwinnett Medical Center and starting an IV on herself to administer it in her car right before the accidents.

Vince tells the story of Compucare and QuadraMed this week, going right to the source in somehow connecting with Dynamic Control co-founder David Pomerance, who then introduced him to Ron Aprahamian, whose fascinating story is that he bought all of Compucare’s stock for $50,000 as a 29-year-old, struck a deal with Meditech, took Compucare public for $40 million, took leadership roles at Superior and First Consulting Group as those companies were acquired … well, just check Vince’s slides because it’s too amazing for me to summarize. I’m glad Vince shared Ron’s story because even though I knew his name, I had no idea how much influence he had on so many major industry players. We would never have heard these stories if it weren’t for Vince, who seems to be the only person willing to work hard to preserve our industry’s history. If you can help him with stories, photos, or connections to folks he should talk to, give him a shout.

E-mail Mr. H.

Time Capsule: Two Economic Theories That Explain Why Epic’s Competitors Had Better Improve Fast

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in November 2007.

Two Economic Theories That Explain Why Epic’s Competitors Had Better Improve Fast
By Mr. HIStalk

Let’s say you own a hot sports team. Your tickets are more expensive than those of any other team in the league. Your venue sells out for every game with no group discounts, $8 concession stand beer, and an indifference to customer requests to change the uniforms, get better-looking cheerleaders, and add more women’s restrooms. You as the team owner know what’s best, and if the fans don’t like it, there are thousands more eagerly willing to take their seats.

Welcome to Team Epic Systems.

Arch-competitor Cerner embarrassed itself last week by complaining that a big provider in its back yard, University of Kansas Hospital, chose Epic over lower bidder Cerner in a $50 million deal. According to a spokesperson, the Epic choice was “a disappointment to Kansas City.” Cerner, she said, would have spent a ton of research money at KU, but will have to look elsewhere because KU’s doctors vastly preferred Epic’s product (the unpatriotic nitpickers).

Make no mistake, Epic has changed the industry, at least when it comes to high-end academic medical centers. Back in the late 1990s, economists might have characterized the healthcare systems market as an oligopoly. That’s when four or fewer sellers own at least 40 percent of the market. SMS, HBOC, Cerner, Meditech … yep, sounds like one to me.

Epic’s remarkable record of big-provider wins moves the high-end HIT market closer to a monopoly, a market with no substitute goods or economic competition.

Epic is quirky. They don’t negotiate pricing. They share the “we know better than our customers” business model as Meditech, but from the opposite end of the pricing spectrum. Complain and it’s the Soup Nazi – no system for you. They’ve got all the customers they need, so they aren’t about to put up with foolishness.

Some of the Epic craze is surely due to the bandwagon effect (buying what everyone else like you or better buys), but most of the credit goes to its only real competitors in the high-end market – Cerner, Eclipsys and McKesson. What does it say about the products and services of those companies when customers like KU buy from high bidder Epic even though it costs far more and VIP coddling is highly improbable?

Perhaps the next market phase will follow a far more obscure economic theory called Hotelling’s Law. It postulates that sellers will make their products as similar as possible to maximize overall demand, even though customers would benefit from product differentiation (examples: drugstores and gas stations operate across the street from each other, airlines copy each other’s flight schedules and prices, both of which benefit the businesses at the expense of customer convenience in having a choice).

In other words, if I’m a vendor and Epic is beating me like a drum, maybe I’d better just copy what they do. For businesses, the best role model is the one making the most money.

Epic needs more competition than Cerner, Eclipsys, and McKesson are giving it. For those companies, Epic’s product is seen by prospects as so vastly superior (including in KLAS rankings) that they’re willing to pay more for it, quirks and all.

It would be good for the entire industry if those or other vendors could mount a credible challenge to the big dog. Unfortunately, operating in a publicly traded, quarter-by-quarter mindset, nothing suggests that such an invasion of Epic Stadium is imminent.

News 9/14/12

Top News

Mediware will be acquired by PE firm Thoma Bravo LLC for $195 million, the company announced Wednesday. The $22 per share cash offer represents a 40% premium over Tuesday’s closing price.

Reader Comments

From Shades of Green: “Re: RECs and EPs. You point out that only 17,144 EPs have demonstrated Meaningful Use through the REC program. I did a little digging and found that total grants for RECs to date (which does include some funding for rural hospitals) is $706 million. That comes to $41,181 for each of the 17,144 EPs demonstrating Meaningful Use.”

From N2InformaticsRN: “Re: MappyHealth. You mentioned a few weeks back our entry into the HHS NowTrending 2012 Challenge. I have an update – we won! Not bad for two nurse informaticists and a computer science student.” Social Health Insights LLC’s free application mines real-time tweets via Twitter’s open APIs to serve as an surveillance system for emerging health issues. The challenge, which drew 33 entries, was created by HHS after it observed that social media trends can be correlated to disease outbreak. The team is Brian Norris, Charles Boicey, and Mark Silverberg. I’m sure they are keeping their fingers crossed that their app doesn’t get hosed as Twitter continues to reduce the functionality and terms of service of its APIs in hopes of monetizing tweets instead of allowing others to build applications around them. Several small companies whose only products were Twitter add-ons have already gone belly up when their data hose went dry.

From The PACS Designer: “Re: iPhone 5. Faster, thinner, 4” display, and iOS 6. Apple is prepared to meet Q4 demand by preparing suppliers to ship as many as 50 million of them in the quarter.” The only Apple products I own are an iPad and a Nano, but I still watch blow-by-blow live-blogging of every Apple announcement, which is an indication of how dramatic Apple makes their unveilings (not to mention how well they keep those huge, world-impacting announcements a secret, which is truly amazing to me). I can’t think of any reason I should care given that I’m not in the market for new Apple products, but I still do. I’m not convinced that the iPhone 5 is better than some of the Samsung or other Android phones (many of the new iPhone features have been on Android for a long time, leading some analysts to openly ridicule Apple for under-delivering), but I can safely predict that the fanboys will be camping out at the Apple store next Thursday night (what recession?) I read the other day that Apple’s iPhone sales volume alone is bigger than all of Microsoft.

From Arnold: “Re: KLAS report on Epic consulting firms. They just posted an update saying one firm has been removed because KLAS mistakenly gave them credit for another company’s survey. How shoddy, and it isn’t the first time we’ve seen this kind of mistake.” I blurred the company’s name on the KLAS announcement since it’s a good news/bad news thing – in removing some other company’s negative survey, this company’s score went up, but then it didn’t have enough surveys, so KLAS removed it completely from the updated report.

From Blue Dog: “Re: Allscripts Enterprise EHR. Heard CHS in Oklahoma City had a great implementation and they are re-looking at using it in other markets. They had a huge contractor downsizing and had postponed or shifted to athenaclinicals in many markets.” Unverified.  

HIStalk Announcements and Requests

This week’s HIStalk Practice highlights include an example of “EMR garbage.” Opinions on why specialists may seek MU incentives less often than primary care providers. Healthcare expenditures fall when patients have more access to office-based care after hours. An internal medicine physician grades his EHR. More feedback from the HIStalk Practice Advisory Panel on the ACA’s potential impact on patient volumes. Culbert Healthcare Solutions VP Jeff Wasserman offers strategies to help independent practices enjoy the financial benefits of quality-based care. Thanks for reading.

Despite the inconvenience of the new adapter, I am ready to take advantage of the $199 option to upgrade my iPhone 4 to the 5. The fast-draining battery has always been my biggest gripe with the iPhone, so longer battery life is the most appealing new feature. A bigger display will also be nice and I am envisioning all the cool panoramic photos I’ll be able to take at the upcoming MGMA meeting. I’ll be one of the geeks standing in line at the Apple store on September 21.

I was waiting for the elevator at work today with the “going up” button lit. As I stood patiently, some guy charged around me and gave the already-lit button several quick jabs. Do you suppose he thinks there’s an algorithm built in that gives preference to the number of times the button is pushed, does he harbor suspicions that elevator lights are rigged, or is he just an impatient jerk who assumes I’m not capable of pushing the button correctly?

Acquisitions, Funding, Business, and Stock

Streamline Health reports Q2 results: revenue up 22%, EPS –$0.04 vs. $0.00.

MRO Corp. acquires the assets of Florida Medical Records Services, a provider of release of information services.

Athenahealth signs a definitive agreement to acquire Healthcare Data Services, a provider of healthcare data analysis and population health management solutions for payers and providers.

Nightingale Informatix secures $2.75 million in Series B funding.

In England, mental health EHR vendor Strand Technology is acquired by Advanced Computer Software Group for $3 million.

Sales

Community Hospital Anderson will use Summit Healthcare’s Express Connect and Provider Exchange technology  for internal and bi-directional integration with its Meditech system.

Cherry County Hospital (NE) chooses Access Intelligent Forms Suite for electronic forms management as it migrates to Meditech 6.0.

The Federal Economic Development Agency will use the Connected Wellness Platform of NexJ Systems for its Connected Health and Wellness Project.

Fort Drum Regional Health Planning Organization (NY) selects Wellcentive to provide disease registry, case management, and predictive analytics.

Anne Arundel Medical Center (MD) chooses Medseek’s ecoSmart Patient Precisioning CRM solution for patient engagement and education.

Key-Whitman Eye Center (TX) selects Versus Advantages RTLS to track patient progression and staff workflows.

HealthEast Care System (MN) chooses Humedica for its ACO and PCMH initiatives.

People

Lance Fusacchia (Webmedx) joins Shareable Ink as CFO.

CHIME awards its State Advocacy Award to Texas Health Resources SVP/CIO Ed Marx.

Tom Penno (Indiana HIE) joins NoMoreClipboard as VP of channel management.

SuccessEHS promotes Lori Junkins and Elizabeth Featheringill Pharo to VP and Elizabeth Pitman to general counsel.

Jim Speros, who led the VA’s innovation prize contests and promoted its use of Blue Button, died September 3 at 59.

John Cox, former CIO at the Hospital for Special Surgery (NY), died September 12.

Announcements and Implementations

HIMSS names Hawai’i Pacific Health the winner of the 2012 Enterprise HIMSS Davies Award of Excellence.

In the UK, Moorfields Eye Hospital NHS Foundation Trust adds three modules to OpenEyes, its self-developed, open source patient management system. The new modules include surgical notes, discharge letters, and prescriptions.

Government and Politics

HHS announces $983,100 in grants to support improved healthcare access and coordination for veterans living in rural areas using telehealth and health information exchanges.

HHS Secretary Kathleen Sebelius admits to violating the Hatch Act, a federal law that restricts the political activity by government employees. Sebelius called for the re-election of President Obama at a February speech to a gay rights group. Sebelius has apologized and the Democratic National Committee has reimbursed the government for the cost of her trip.

ONC’s blog urges nurses to request a copy of their own electronic health record, verify the accuracy of its contents, and sign an online pledge. I suspect few of us in healthcare IT have requested electronic copies of our information, so I will post this as a challenge of my own to all readers. Request a copy of your EHR information and let me know how the process went – how convoluted the request process was, how long it took, and how accurate and complete your information was. I’ll run anything you send me. Somehow I think that, like almost everything related to healthcare, it doesn’t work nearly as well as patients have a right to expect. It’s not exactly Golden Rule territory.

ONC releases its educational security training game for medical practices. I played it and it’s pretty cool.

Medicare says it won’t pay providers based on copied-and-pasted patient notes.

Other

Beth Israel Deaconess Medical Center is named the #1 company in the InformationWeek 500 list of the most innovative users of business technology. Other healthcare organizations in the top 50 include Quintiles (#6), Sparrow Health System (#16), Premier Inc. (#30), Miami Children’s Hospital (#31), RadNet (#32), McKesson (#34), Intermountain Healthcare (#48), Kindred Healthcare (#48), and Sharp HealthCare (#50).

CareCloud will establish a Massachusetts office to take advantage of the region’s technical talent.

I said in January when US CTO Aneesh Chopra resigned that I expected him to run for lieutenant governor of Virginia, but instead he went back his previous employer, The Advisory Board Company. I should have paid more attention to the election calendar: the election is in 2013 and he has announced as a Democratic candidate for that office.

A Financial Times article called “Healthcare: Cyber wards” covers Silicon Valley companies trying to break into healthcare. It doesn’t contain anything all that interesting, but it does quote an entrepreneur who says VCs are still wary of investing in companies because of long healthcare sales cycles and their previous experience with products that were never perfected.

University of Minnesota Medical Center, Fairview violated patient protection and EMTALA laws by its aggressive collections tactics overseen by Accretive Health, a federal investigation finds. Fairview says they “continue to learn from this experience.” Shares in Accretive were down 11% Thursday on the news, by far the biggest percentage loser on the NYSE. The company had already paid a $2.5 million fine and agreed to cease operations in Minnesota. Shares owned by founder and CEO Mary Tolan  are still worth $108 million.

Weird News Andy is convinced that being real smart doesn’t preclude being real stupid. Richard Keller MD, a pediatric endocrinologist and Harvard Medical School instructor (WNA summarizes as “a vile human being,” at least assuming he’s found guilty), is arrested when a package containing 50 DVDs of child pornography is delivered to his attention at Phillips Academy, where he was medical director until last year. He might be one of few people whose life goes directly into the toilet because he forgot to update his shipping address or perhaps had the misfortune of back-ordered porn.

Markle Foundation puts out a video promoting the consumer use of Blue Button.

The computer hacker / brain tumor patient in Italy who cracked the proprietary formats of his electronic medical records so he could post them publicly to seek help has updated his site with the ideas he has received so far. It’s getting interesting – he’s about to publish a tutorial explaining the quirks he found with DICOM images and he’s putting out some rather eloquent ideas about health and technology:

The definition of "diseases" is "reserved" to doctors. Often using words which we don’t understand and, most important of all, touching only a part of the human condition, which is made from body, but also of spirit and sociality. The DICOM format is open, yes, but in a very "peculiar" condition of openness: it is like the openness of the words which they use to tell you about your health condition, and with which they describe and actuate their version of the "cure": you can’t understand it, you can’t reuse it, you can’t combine it with other possibilities. It is thought for "experts" and "professionals" (of one single type), leaving little space for other possibilities for expression and socialization … Maybe we could start to think about an "open" world in this sense, too, not dedicated to "professionals" and "procedures", but also to human beings.

Sponsor Updates

• Vonlay created a Web page featuring live tweets and photos from the Epic UGM this week.
• PDR Network announces that its flagship service meets Meaningful Use Stage 2 requirements in delivering real-time FDA drug safety alerts and product program information at the point of prescribing.
• More than 50 employees from the Burlington, VT office of Allscripts will take part in a Habitat for Humanity build this week.
• Amerinet makes McKesson’s pharmacy automation solutions available to its 3,000 hospital members.
• Intelligent InSites integrates its RTLS with Haldor’s ORLocate surgical instrument tagging to offer a surgical instrument management and tracking solution.
• Lifepoint Informatics announces its Silver Level sponsorship of next month’s Pathology Informatics 2012 conference in Chicago.
• LDM will provide consumer medication information from Polyglot Systems in its point-of-care messaging solutions.
• HIStalk sponsors Allscripts, NTT Data (formerly Keane Inc.), and World Wide Technology earn spots on the annual InformationWeek 500 list of innovative business technology users .
• Forbes cites Greenway as being “ahead of the pack” in delivering information exchange and interoperability between its PrimeSUITE and the EHRs of other vendors.
• Orion Health will incorporate images from Agfa’s clinical imaging platform into its clinical portal.
• DrFirst and Meditech will demonstrate their combined solutions during a series of Webinars in September and October.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 9/12/12

Elevation (Part 2)
As Slope Rises, Leadership Must Rise

Last month, I posted on elevation using a mountain climb metaphor and honed in on the privilege of leadership. The unwritten covenant of leading people:

To be the leader I aspire to be, I must elevate to match the slope before me. Anyone can lead when the terrain is flat or even at a moderate incline. But there comes a time when the journey leads to a peak. It’s on this trail where leadership is tested, validated, and honed.

A few months back, I spoke on elevation. Someone asked, “How do I know I and/or my team need to elevate?” That’s a great question.

How do you know you need to elevate? Self-awareness. Take a good look in the mirror.

• Comfort. If you feel everything is comfortable, you’ve probably reached a state of stagnation. Comfort is cozy, but retards growth.
• Perfection. When you believe everything is fine, or you’ve reached the top.
• Reality. When you are unable to discriminate the top 10% of your staff from the pack because they are all “best in class.”
• Self-evaluation. When you do your annual review, you think you are a perfect performer.
• Invincibility. You talk more about past accomplishments than the work ahead.

How do you get your team to realize they need to elevate?

First, admit your own need to elevate, and then make necessary changes. Second, provide clarity around expectations and hold others accountable. Finally, share behavioral examples of what it means to elevate. The gaps should become self-evident. Sharing what it means to elevate helps even the most defensive person begin to see a need for change.

Here are a few behavioral examples to begin with. Feel free to add others in the comments.

Elevation is:

• Manic attention to detail. Mistakes happen. I make them and we all make them. I get it. That said, when I make mistakes because of lack of attention, it makes me look sloppy and takes away hard-fought wins. When I’m late, turn in inaccurate numbers, neglect spell check, screw up e-mail, storage, etc., it hits my credibility. If I lose credibility, I lose our ability to lead.
• Loving my people by disciplining them when warranted. Just as I lavish praise and recognition for incredible performances, I must balance with discipline. Discipline should always be private.
• Leading my customers. Customers are not always right. Steve Jobs recognized this. He knew the concepts customers wanted and designed from there and led. Old IT simply responds to customers – order takers. That worked in the past, but will not work for the future as the slope of competition rises. I must be unafraid to lead my customers, even when the customer does not want to be led.
• "My team is never my enemy." We are a team. We don’t have cycles and emotions to waste fighting one another. I address team conflicts within the context of organizational values and inside our own house. Don’t go outside of this boundary. Don’t go complain to the customer. They have their own issues and don’t want to hear about ours.
• Not allowing variation from good practice. Or, better said, mavericks will kill you. We’ve all experienced the negative impact of mavericks. Leaders must root out mavericks for the higher good. I am not talking about someone who does things differently and brings unique perspective. I am talking about those who willfully do things they know they should not because they think they know better.
• Assertiveness. I tire of hearing lame excuses about why things are delayed, i.e. waiting on so-and-so to call or e-mail me, or “The reason we have poor performers is because of HR.” No, I don’t buy that. I pick up the phone or go to their office. Make it happen. The ball is in my court.
• I can be counted on to do the job expertly and without complaint and without silliness. Reminds me of Garcia. This is required reading.
• Messaging commander’s intent throughout your organization. If the captain says take the north hill, we take the north hill. If I allow the message to be reinterpreted, I’ll find staff taking the south hill. If there’s a major disconnect between what’s commanded and what people do, it’s a leadership issue.
• Evaluating employees honestly. If the majority were top performers, we’d have a perfect organization, which we don’t. If I’m friendly to a fault with some of my subordinates, this might blind me, so I must constantly acquire external opinions. If a staff member loses their position, am I concerned more about their impact on our mission or the impact on their lifestyle? My primary concern should be the organization.
• Knowing I need to elevate. Most do not perceive a need for elevation. Leaders elevate constantly. Period.
• Being a non-conformist. (Not to be confused with maverick.) Don’t “get” just to get along. Don’t comply simply to fit into the culture. Push against grain where warranted. Change culture if necessary. Never for self; always for the organization.
• Knowing the mind gives out before the body. Train myself to be strong in mind and my body will follow. Healthy mind, healthy body.
• Ownership. Own problems. Don’t play ticket tennis. Never give up. Don’t point fingers. Take responsibility and practice accountability.
• Busting silos. If someone is bleeding, should I wait for a medic since I’m not the medic? No. I go stop the bleeding. Don’t let artificial walls keep you from action.
• Continuous self-improvement. Don’t wait for a required book study or a class to come along. Ask: How am I better than last year? How have I transformed?
• Line of sight. Knowing how my efforts lead to the fulfillment of organizational objectives. I must know my individual staff’s mission and staff should know mine. Collectively, they should inspire all of us.
• Faithfully lifting up and living out the values of the organization.
• Raising my hand to say, “I found a risk, and we need to address it.”
• Competency. Doing my job, and doing it well. No shortcuts or cheating the system.
• Cross-organizational teamwork.
• Spending more time with users than with my office mates.
• Embracing correction.
• Getting eye to eye with those I’ve been entrusted to serve (lead). Never, ever deliver difficult messages via any other means except eye to eye. Never.
• Pouring myself into those I’m entrusted to serve.

Leadership is tough, especially when the slope rises. You may reach a point along the journey where you hit your limit. That’s okay. Recognize it, and deal with it.

Not everyone reaches the summit. Most mountain expeditions have less than a 50% success rate. Smart climbers know their limits, and they stop and turn around to avoid disaster. Sometimes you need to head back down and regroup before you start back up. Other times, it’s best to let someone else lead.

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.

Tweets and Photos from Epic UGM 9/12/12

They have the best swag! #epic #ugm2012 #newbie

— Michael Lamb (@lambatwork) September 10, 2012

Barry Bershow from Cedars-Sinai (Lake Wobegon West) where all the men, women, children, and Epic progress notes are good looking. #UGM2012

— Jorge Scheirer (@infomedoc) September 10, 2012

I’d like to thank google maps for the ability to see in real time that traffic at Epic Lane is already backed up to exit 77 #ugm2012

— K Wroblewski (@kdwroble4) September 11, 2012

#UGM2012 stats: 7900 customer attendees, 3400 gallons of coffee

— borborygmi (@nickgenes) September 11, 2012

Epic CEO Judy Faulkner on rock theme for #UGM2012: says “hey Jude” has particular meaning for #healthIT “take a sad song and make it better”

— borborygmi (@nickgenes) September 11, 2012

Only 1.2% of US hospitals are at top HIMSS stage for #EHR integration — and 3/4 of those hospitals are at Epic’s #UGM2012

— borborygmi (@nickgenes) September 11, 2012

CEO Judy Faulkner says Epic is installed in over half of US academic medical centers #UGM2012

— borborygmi (@nickgenes) September 11, 2012

47% of Epic expenses are R&D. Moving into long term care, home care. Faulkner wants her programmers to have individual offices #UGM2012

— borborygmi (@nickgenes) September 11, 2012

Epic CEO Judy Faulkner: too few physicians on meaningful use committees, and their input is lost on way from ONC to CMS #UGM2012

— borborygmi (@nickgenes) September 11, 2012

Next big things for Epic seem to revolve around mobile apps on your phones and tablets. #UGM2012

— Sarah Nelson (@Sarah_at_Vonlay) September 11, 2012

#UGM2012 physician slicer dicer: from evidence based practice to practice based evidence. Cool!

— Arjen Noordzij (@dokter_no) September 11, 2012

Especially excited about Epic planned release of patient centered product for pts in hospital. Very cool for pt engagement#UGM2012

— Luis Saldana (@lsaldanamd) September 11, 2012

Great riff on ICD-9 and ICD-10 in relation to Spinal Tap and going to 11. "It’s one version higher. So it has to be better." #UGM2012

— Sarah Nelson (@Sarah_at_Vonlay) September 11, 2012

RT @gruntdoc: #EPIC #EPICUGM 14K here, about 7.4K are clients, rest Epic staff; 10 countries rep’s. #UGM2012

— Luis Saldana (@lsaldanamd) September 11, 2012

#UGM2012 Wouldn’t it be great: the UGM2013 app with your schedule notifying when to go and showing how to get there?

— Arjen Noordzij (@dokter_no) September 11, 2012

After day 1 at #ugm2012 I am exhausted, but #Epic has been fantastic, need to take notes on guest services!

— Autumn (@rhodes_aut) September 12, 2012

In upcoming Epic release, patients will be able to log into myChart and download their records to a PDF #UGM2012

— Robert S. Miller, MD (@rsm2800) September 12, 2012

#ugm2012 300/500 of the Epic hospitals are using barcode med administration. Very good for patient safety!

— GruntDoc (@gruntdoc) September 12, 2012

Good job Epic – lots of cool new features. Loving the emphasis on analytics! @epicugm #UGM2012

— Krishna Ramachandran (@krishna_gr) September 12, 2012

#ugm2012 good news, Epic is going to have an opt-in for benchmarking across Epic hospital systems. Terrific!

— GruntDoc (@gruntdoc) September 12, 2012

Beacon oncology updates: therapeutic substitutions 4 antiemetics 4 drug shortages; breast ca survivorship plans; better analytics #UGM2012

— Robert S. Miller, MD (@rsm2800) September 12, 2012

Epic will use protocols from #DirectProject to push information to outside EHRs #UGM2012

— Robert S. Miller, MD (@rsm2800) September 12, 2012

Mobile payments to be built into Epic myChart. Can also sign up via mobile for paperless statements #UGM2012

— Robert S. Miller, MD (@rsm2800) September 12, 2012

#ugm2012 Need this Cogito data model! It is a data warehouse that compiles Epic and non epic data in one place to help reporting.

— GruntDoc (@gruntdoc) September 12, 2012

#UGM2012 #Carl Dvorak did it! His childhood dream came true: live on stage with a guitar.

— Arjen Noordzij (@dokter_no) September 12, 2012

#ugm2012 surreal seeing software planned for release in 2 years, that we won’t get for at least three. Like hearing about the cool1/2

— GruntDoc (@gruntdoc) September 12, 2012

Fun idea to improve clinical note quality: ‘Like’ button on peer’s progress notes! #UGM2012

— K Wroblewski (@kdwroble4) September 12, 2012

Was intently watching #UGM2012 tweets and Apple anncmt live blogging. Neither affects me, but I felt temporarily cool.

— histalk (@histalk) September 12, 2012

News 9/12/12

Top News

ONC publishes a Health IT Dashboard that includes six views and 250 custom dashboards for states, ONC programs, and grantees. It includes charts, maps, and downloadable tables pertaining to EHR adoption, REC programs, and HIT workforce training. An interesting statistic: of the 143,890 EPs enrolled in RECs, only 17,144 (12%) have demonstrated MU. Also surprising: only 39% of acute care hospitals were using even a basic EHR by the end of 2011.

Reader Comments

From David: “Re: Dr. Jayne’s comment on ‘educational session’ put on for members of Congress. As someone who used to put these on, these are simply a forum for making a lobbying pitch to lawmakers and Congressional staff under the guise of education. The ‘education’ is to get lawmakers to vote in the interests of the event’s corporate sponsors.” Sponsors listed include HIMSS, Ingenix, Allscripts, BCBSA, and a bunch of other companies, government contractors, and member organizations. It was the Washington schmoozing and complete surrender to its Diamond members that largely turned me against HIMSS as an organization that represents me as a non-profit hospital employee and dues-paying member instead of a piece of meat offered up for ogling by its conference exhibitors. I would rather see HIMSS split into two groups, one for providers only (like it almost was before the current regime got dollar signs in their eyes) and the other being the vendor trade association that HIMSS denies being despite ample similarities.

From Dell-lightful: “Re: Dell Services layoff. It’s true. I’ve spoken to two senior salespeople in the healthcare vertical who were laid off in recent weeks. One of them said the action was called Operation Savings Storm. He e-mailed me a picture of him shaking hands and smiling with Michael Dell. I suppose that only Michael is smiling now since his labor cost just went down, good for his quarterly report.”

From Eileen Dover: “Re: Lahey Clinic. Scrapping their Allscripts implementation and going big with Epic. You probably already knew that.” I ran reader rumors to that effect in June, but got no response from the CIO when I asked about the “unified architecture” the rumor said they were pursuing (which means they’re planning to buy Epic nine times out of ten). Their original strategy involved using Orion Health to serve up scanned PDFs of inpatient records and using Allscripts on the outpatient side, which doesn’t sound like much of a strategy at all given Meaningful Use requirements and changing care models. I’ll leave this as Unverified since I’m missing the standard confirmation: the posting of a ton of Epic jobs on their site.

From SubDude: “Re: athenahealth. Saw this poster on the green line of the Boston T.”

From Empty Handed: “Re: Encore Health Resources. In talks to be acquired by Dell.” I asked the Encore folks a few weeks back and they said this rumor isn’t true. I believe them, but I also noted from experience with other companies being acquired that you always get that same answer even when it really is true, with an apology later for being less than truthful out of necessity. All I can say is that I’ve heard the rumor from anonymous readers twice now, the company denies it, and I have nothing to back it up.

From Debunker: “Re: the EMR cost study you mentioned. There are also significant issues with how the HIMSS Analytics data collection is performed when you look under the covers at the raw data.” That’s a good point. Everybody trying to do these lazy database-matching “studies” assumes that those databases have perfect information, which I’m sure they do not.

From Neal: “Re: Glen Tullman compensation by Allscripts. Thanks for keeping an eye on the mega-earnings of the vendor CEOs. However, it’s fair to note their value is not reflected solely by share price. Tullman grew Allscripts from a niche ambulatory vendor to a near-competitor with Cerner if not yet Epic across virtually every segment of the market. It’s too early to tell if he’ll be successful, but they will be a serious competitor if they can integrate their myriad solutions. He has one year, two tops, to deliver or face the boot from his new board.” Glen did a masterful job of wresting control of the company from Misys and then buying Eclipsys. The mistakes he’s made from my cheap seats view: (a) paying too much for Eclipsys, which nobody else seemed to want; (b) declaring mission accomplished with Sunrise integration almost immediately after the acquisition, backing up that statement with questionable comments that having two unrelated systems both running on Microsoft-powered servers meant they could just start happily interoperating once the ink dried on the sales collateral; (c) trying to pass off Allscripts as a serious competitor to Epic; and (d) escaping an ugly board power struggle and then caving in to a proxy fight that gave a dissident shareholder board seats. You are right that Wall Street encourages actions that boost share price for all the wrong reasons, often at the cost of long-term possibilities, like when Cerner stock took a beating in the late 1990s as they dared spend research dollars to build Millennium instead of booking big earnings per share. Allscripts needs to deliver technically before the competition (both inpatient and ambulatory) pushes it permanently into the mid-majors. If you’re a customer, you’re better off with Glen in charge than selling off to private equity investors, who would have a field day retiring products, selling off divisions piecemeal, and milking services revenue to juice the bottom line to enable a quick flip. We’re already down to basically three vendors for big hospitals (Epic, Cerner, and Allscripts plus a bit of Meditech in the mix). I don’t see Allscripts gaining much inpatient ground given its few announced sales to mostly small hospitals, which is the same problem Eclipsys had despite an arguably superior product, but I hope they keep it competitive. I should have also mentioned that despite seemingly generous compensation, this particular bonus plan announcement actually represented a pay cut for Glen.

HIStalk Announcements and Requests

Say hello to LDM Group, supporting HIStalk as a Platinum Sponsor. The St. Louis-based company offers behavior-changing prescription management programs. Specifically, its patented process improves patient compliance and outcomes by connecting patients with their prescribers and pharmacists. The company’s electronically targeted ScriptGuide messaging (print, e-mail, SMS) helps build tighter provider-patient relationships and helps meet Meaningful Use and ACO requirements for customized patient education and engagement. LDM Group’s network of providers, EMR/EHR vendors, and sponsors of educational material (pharma, payers, health plans, and PBMs) help patients become better educated about their healthcare via personalized messaging from their trusted providers right at the point of service. The company’s case studies show that medication adherence increases up to 16% for specific disease categories, potentially avoiding expensive interventions due to non-compliance. Thanks to LDM Group for supporting HIStalk.

Epic’s UGM is underway. Your report, photos, etc. are welcome since we are not in attendance. So many conferences, so little time.

Acquisitions, Funding, Business, and Stock

Mediware completes its acquisition of the assets of Strategic Healthcare Group, a provider of blood management consulting, education, and informatics solutions. Mediware also reports Q4 results: revenue up 4%, EPS $0.29 vs. $0.25.

Elsevier acquires ExitCare, LLC, an enterprise-wide solution for patient education and discharge instructions.

Sales

Rush University Medical Center (IL) selects MethodCare’s Charge Recovery Solution to optimize charge capture.

The University of Colorado Hospital will implement Infor Lawson Healthcare’s financial, supply chain management, and human capital applications.

Coordinated Health (PA/NJ) selects Allscripts Sunrise Clinical Manager. Their hospitals are Coordinated Health Allentown Hospital (22 beds) and Coordinated Health Bethlehem Hospital (20 beds).

Cancer Treatment Centers of America chooses QlikView to replace its existing business intelligence software, using its analytic capabilities to find opportunities for improvement and planning its future use to predict which therapy options will work best for a given patient.

People

Clarity Health names Bill Bunker (Vertafore Agency Markets) as CEO, taking over for founding CEO and newly appointed executive chairman Peter Gelpi.

The GAO appoints Christopher Boone, director of outpatient quality and HIT for the American Heart Association, to fill a vacant patient advocate seat on the HIT Policy Committee

Announcements and Implementations

West Virginia University Healthcare installs the Patient Safety Net incident reporting system from Datix and UHC.

HIMSS Analytics recognizes Hennepin County Medical Center (MN) and Truman Medical Center (MO) with its Stage 7 award for EMR adoption.

Franciscan Alliance goes live with iSirona’s device connectivity solution at multiple facilities.

In Southeast Texas, CHRISTUS Health, Texas Children’s Hospital, UTMB Galveston, and Legacy Community Health Services sign up with Greater Houston Healthconnect to exchange patient information.

Medecision’s care management solution is added to the Availity network to support post-discharge planning and coordination.

Government and Politics

ONC posts draft test procedures and test data files for the 2014 Edition EHR certification criteria.

HHS Secretary Kathleen Sebelius announces that the public can vote for their favorite innovation among finalists in the HHSinnovates Program, which is designed to recognize innovative projects developed by HHS employees to solve healthcare challenges. Public voting is open until September 14.

Allscripts CEO Glen Tullman pens a Forbes opinion piece extolling the accomplishments of his friend President Barack Obama, also saying great things about his stimulus bill, particularly the HITECH part that benefited Allscripts immeasurably. He concludes, “Now what he needs is one more term to finish the job.

Technology

AirStrip Technologies is awarded a patent for its technology and process for delivering physiologic monitoring data to smartphones, tablets, and other devices.

A 17-year-old invents an inexpensive and portable EKG that collects heart rhythm data via Bluetooth and sends it to a remote physician.

An orthopedic surgeon uses an iPod Touch in knee replacement surgeries, saying it allows more precise placement of the artificial knee and thus reduces complications and provides a greater range of motion.

Weight loss company Diet Doc offers its customers weight loss consultations with physicians at its 30 locations via Skype. The (female) CEO cites the “growing possibilities that telehealth has” in decided to replace its telephone-based consultations with video in managing its human chorionic gonadotropin diet plans. They’re probably the only telehealth-using provider featuring a Star magazine cover of Kim Kardashian with the CEO’s unsolicited opinion that “comfort foods added a few pounds to her frame” but that she has thankfully “slimmed down to snag a man.” The FDA doesn’t have anything good to say about HCG diets and has banned non-prescription sales. It requires prescription HCG products to be labeled with a warning that there’s no proof that they work.

Other

Two University of Miami Hospital employees are accused of selling the information of thousands of patients they obtained from registration face sheets over 22 months. The university’s medical school reported the theft of a pathologist’s briefcase earlier this year that contained an unencrypted flash drive with six years’ worth of patient medical record data.

A computer hacker in Italy with brain cancer, desperate for second opinions, cracks the proprietary format of his electronic medical records, converts them to an open format, and shares them on his Web site. Two doctors responded in the first 24 hours to what the patient is calling “My Open Source Cure.” He invites doctors, hackers, musicians, or anyone who can help to review his information and e-mail him their “cure,” which he will post on his site. If you’d like to help out, you will need someone who can read Italian to translate the scanned records.

The former hospital equipment designer who in 1982 designed the first laptop computer, the GRiD Compass, has died. Bill Moggridge was 69.

In the UK, Fujitsu is reportedly blacklisted from being awarded any government services contracts after previous failures, notably its work on the failed NPfIT project.

A Chicago-area health department says EMR implementation temporarily reduced the walk-in patient capacity of its clinics by half right after go-live last week. At a two-physician clinic whose appointments are booked out for months, one patient said the line that snaked around the corner looked like “a Depression-era soup line.”

Weird News Andy says an interdiction might be placed on the future work of this surgeon, who is being sued by a patient whose lawsuit claims his cancerous penis was amputated without his consent.

Sponsor Updates

• HTMS, an Emdeon company, and Managed Care Executive Group launch the fourth annual Industry Pulse Survey to identify issues and concerns important to healthcare payers.
• Pivot Point and NextGate collaborate to offer identity management, credentialing, and RCM enhancement solutions to HIEs, ACOs, and health systems.
• Orion Health posts the agenda for its October Healthcare Collaborative in Colorado.
• Imprivata demonstrates its secure no-click access at Epic’s annual UG meeting and offers a white paper on optimizing Epic clinical workflow.
• Awarepoint adds VT Group as a VAR for its aware360 RTLS suite.
• MED3OOO announces the keynote speakers and agenda for its October National Healthcare Leadership Conference in St. Thomas, USVI.
• Greenway recognizes Pediatric Associates (WA), Premier Family Physicians (TX), and Medical Park Orthopaedic and Sports Medicine Clinic (AR) for their innovative use of Greenway solutions to improve care delivery.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Readers Write 9/10/12

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!

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

I Am the BOSS!
By Bill Rieger

There is no question who the boss is around here. I earned the office with two — count ’em, two — windows.  My paycheck is at the top of the pile and serves as a paperweight for the rest of them. The CEO and I swap stories about how great we are. I am the one in front of the board every month reviewing IT strategy and direction. Make no mistake about it, I am the man!

Ever work for anyone like this? Maybe you still do, although it may not be this obvious. Or, are you yourself like this?  

WAKE UP! The time for career oppression is over.

Change is happening faster than ever. We no longer have the luxury of centuries, decades, months, weeks, days, or even hours to adapt. While back in the day it took just about 2,000 years to invent the stethoscope after discovering that heartbeats do actually have clinical meaning, today a discovery can reach millions of scientists around the globe in seconds.

Have you seen some of the "Did you know" videos that illustrate the rapid pace of change today? Certainly not all of them are validated, but it makes you think, doesn’t it? One of the statistics I like is about text messages. The first commercial text message was sent in December 1992. Today the number of text messages sent and received every day exceeds the total population of the planet. 

The point? As stated before, change is here and it is coming faster every day. If you think you can manage the change of this generation alone, you will cut short yourself, your organization, your community, and all of those you influence.

At our hospital, a member of the IS leadership team had previously been exposed to the Clifton Strength Finders book. Their idea was to purchase it for all IS staff members to help them find their strengths. This led to a whole mindset shift of the IS leadership team, including me. Instead of focusing on what we don’t have, let’s determine what we do have and capitalize on it.  

What a difference it has made. All staff members who participated have proudly tacked their list of strengths to their cubicle or office. The entire IS leadership team from supervisors on up have gone on to read Go Put Your Strengths To Work to help align staff member roles with their strengths.

From here, it is a work in progress. I am fully confident that many more ideas will come from this and we will continue to focus on and better use the strengths of the team. What if I would have said, "Great, Chris, now go back to your office and get me the budget report?" or something else insignificant in comparison? Where would the department be? Where would the organization be, as this concept is certainly leaking out of the IS department?  

Healthcare is in the beginning of great change and healthcare IT is in the middle of frantic change. As the stethoscope example indicated, healthcare changes slowly. After all, change in healthcare is risky. My response to that is that indeed change can be risky. In order to mitigate that risk, you cannot — I cannot — be the big shot in the corner office. 

You have to — I have to — seek out who can best help manage the seemingly unmanageable change that is coming. The talent exists. It is up to leadership to draw out those strengths that will be needed.  Leadership should be seen as a springboard, not as a ceiling.

When Abraham Lincoln worked hard to free the slaves, his original idea was to "free" them from their oppressors and then send them to Jamaica or Cuba where they could be "free." When some of the slaves were freed, they asked to be able to fight for and with the Union. That was great, and in response, they were given shovels and uniforms. When they asked for weapons, they were originally told that they could not have them. It literally took an act of Congress to get weapons in the hands of the newly freed slaves. The fear was that they would turn on their oppressors. What actually happened is that they fought with honor and courage and played a vital role in the final defeat of the Confederate army.

That is exactly what I believe some leaders are like: afraid to empower their teams, afraid they will turn on them when they lose control of them. If you want to see an empowered employee, bring them to the CEO’s office, the next board meeting, or the next department meeting and give them credit for a great idea. Watch their world change as they grow in front of your eyes.  

How many more ideas will be born of that one? How many light bulbs and stethoscopes will be created from simply giving credit where it is due? As a result of our Strength Finders journey, the IS org chart changed. The CIO and the directors are at the bottom, supporting those who are above. The ceilings are gone. Fly, people, fly! 

Bill Rieger is CIO of Flagler Hospital of St. Augustine, FL.

Moving from Care Following Technology to Technology Following Care
By John Haughton MD, MS

How is it the feds have paid out $5.7 billion for Meaningful Use Stage 1 incentives and we are still missing community-wide patient views and shared care plans accessible across EHRs and mobile devices for acute providers or across providers and payers working to enhance coordination of care or across acute and post-acute providers engaged in streamlining health delivery effectiveness?

The answer is threefold, but simple. Standards-based interoperability using discrete data is hard. Available EMRs, at their core, were designed with an encounter and billing perspective rather than a discrete patient level portable data and shared care focus due to business and legal needs. Technology in the standalone, client-server / web screen-sharing world is not designed for moving data across systems.

Integration and processing of discrete data across populations requires dynamic community views of information coming from multiple sources to realize the true value of shared care – better coordination, pre-crisis intervention, and decreased redundant care delivery. To date, incentives and needs haven’t requested the collaborative care technology infrastructure. That’s changing.

Enter the cloud and native Internet applications integrated with secure cloud information brokers, cloud consumers, and cloud providers. Cloud coordination is front and center in general federal IT acquisition activities. These systems are designed for collaboration and to share information across organizations, systems, and technologies from different vendors in different formats.

True and complete interoperability requires standards that are useful and usable, which are still hard to come by in general and certainly in healthcare. Heck, even a simple one – Medications and RxNorm didn’t allow for the prescription of birth control pills (two in one box) or prenatal vitamins (more than three ingredients in one) until recently. Fortunately, there are ways to use modern security, data, and analytic processes to move information now. Methods that are proven from other industries to work in environments without perfect standards are available to healthcare.

MU 1.0 was a good first step: $2 million or more for hospitals and $18K to start for providers. Money flowed into the system to purchase IT. Even so, the electronic health records purchased by and large don’t talk to each other yet. Even the Beacon Communities are into their third year without real interoperable clinical data from various EMRs (fingers crossed — we should see data movement starting this fall. Lots of folks have been working hard to make it happen.)

Now with MU 2.0 out, the money for change won’t come so much from the same ONC carrot. The majority of incentive dollars will have been earned during MU 1.0. Instead, there’s a new carrot — shared savings rewards in ACOs and other value purchasing — and now a stick in penalties for fee-for-service Medicare payments for a lack of reporting and performing on various quality of care metrics. Additionally, rewards and penalties from commercial insurers are creating narrow networks with less revenue and access for providers at the lower end of the cost-quality matrix.

What is the right design for EHR and community care systems in the evolving world? At a minimum, systems must make sure the data collected is secure, accessible, portable, and interoperable. To make this happen, EHR systems must include the perspective of being part of a network — part of a data fabric — at their core.

Newly emphasized functions from MU 2 for collaborative care include: data formatting; content normalization; patient-level information aggregation – in discrete, standardized elements – attributable to sources; population analytics for opportunity identification and effectiveness measurement; workflow that includes access to information at a place where it can be used; and collaborative communication across teams. Expanded decision support rules are useful for clinical care, financial management, and measurement and reporting for payment based on value.

As we move forward, the biggest change will be a change in design mindset for electronic health records, from one of monolithic, vendor-specific islands of technology to a connected ecosystem of secure data collection, portability, display, aggregation, and access across the community, across payers and providers, across patients and their caregivers , across healthcare and the general community.

Change is unstoppable as we move to networked healthcare. That’s good, but it’s tiring. In the new world, providers will no longer be dependent on singular big IT infrastructure as secure, clean, portable data and identity coupled with lighter-weight modules, interoperable widgets and applets solve real problems. Vendors will open communication channels as a strategic asset rather than “wall the garden.” Monolithic HIE umbrellas will fade as government initiatives — such as Direct for the patient and Query Health for the population — continue to gain traction as front and center techniques for simplifying interoperability and shared care tasks.

What will be needed? Outside of healthcare, the federal government has a framework. It’s moving into the cloud – a framework that includes cloud suppliers and cloud brokers – to ensure a secure, reliable interoperability experience. In fact, it is the cornerstone of the federal strategic plan for technology and information management: increasing usability and access to information while decreasing the complexity and cost of information technology. Why should healthcare be any different?

John Haughton MD, MS is CMIO of Covisint of Detroit, MI.

Patient Engagement
By Kim South, RN

With the new Stage 2 Meaningful Use rules finalized and released, patient engagement is becoming a major focus. Can providers control that their patients are logging in online to view their medical information? Can providers control their patients to the point of sending secure messages? Everywhere I turn, these are the questions I am hearing. 

The short, quick answer is, “Of course we can’t control them.” That’s also the answer the people who are asking the questions are searching for. 

On the surface, it’s an accurate answer. We can’t control our patients. We can’t make them engage in their care. We can’t make them be interested in losing weight or quitting smoking. But we do have the potential to influence their behaviors and encourage them to be our partners in their health.

As an oncology nurse, I spent hours every day talking with my patients and their family members about what was discussed in the recent office visit. It’s so much foreign information to take in, remember, and explain to others. Online access to this information has the potential to seriously reduce office time spent in this role, which translates directly into the nurse’s ability to focus on other tasks. 

I’m no longer a practicing oncology nurse, but it’s where my heart lives. Being on the vendor side now, my patients are always in the back of mind: what would benefit them, what would make their burden less, what would make them feel more in control of this disease process? Patients with chronic diseases are hungry for information. What better information to supply them with than their own? It makes perfect sense to me. 

I’m sure I’m in the minority, but I actually see this transparency with medical records as a benefit to both the patients and the medical personnel who care for them. Fewer phone calls about what was said, secure messaging to answer questions that would be a phone call interrupting a clinic, the ability for patients to visually see their health. It’s very powerful stuff and why I stay in the healthcare field — to make a difference for the patients.

Can we control patients? No, but we sure can influence them. I could sell online access to my cancer patients in a heartbeat. Online access to their office visit information, online access to their lab results, online access to send me a question as they think of it regardless of the time. 

The 5% threshold to meet these measures is very attainable. Having the right tool to enable your patients to participate in their health is core, but those tools already exist. As a medical community we need to embrace patient engagement and give our patients the tools to be intelligent about their health.

Kim South, RN is product manager of Jardogs, LLC of Springfield, IL.

Curbside Consult with Dr. Jayne 9/10/12

Today is the start of National Health IT Week, which was created to “raise awareness about the power of health IT to improve the quality, safety, and cost effectiveness of health care.”

One of the events being held in conjunction with the festivities is a Blog Carnival. HIMSS invited bloggers to submit posts answering the question, “How will health IT make a difference a year from now at the next National Health IT Week?” Posts had to be submitted during the last month, and selected contributors will have their pieces appearing this week. I wasn’t confident that HIMSS would select anonymous bloggers for their showcase, so I didn’t bother to try. Plus I’m not much for deadlines these days since I’m getting pounded with work at my day job.

Another event will take place on the 13t, the Capitol Hill Health Information Technology Showcase. It is sponsored by the Congressional Steering Committee on Telehealth and Healthcare Informatics and will offer Members of Congress and staff “first-hand demonstrations of health IT and interoperable communications capabilities.” I was surprised to learn that this Steering Committee was founded in 1993. You would think if you had a bunch of lawmakers advocating for telehealth for nearly two decades, they would have figured out a way for providers to be reimbursed for providing it. If they haven’t been doing that, what have they been up to?

I surfed the Internet a bit and couldn’t find that they do much beyond organizing “widely attended educational sessions and healthcare information technology demonstrations” for Congress, legislative staffers, agency officials, industry, and the public. A different search revealed that the Committee is part of the Institute for e-Health Policy, which is part of the HIMSS Foundation. The Institute also sponsors a Congressional Luncheon Seminar Series funded by a vast array of IT vendors, insurers, hospitals, and government contractors. There was a smattering of quasi-nonprofit organizations on the list, but they may be there just for show.

In that frame of mind, I’d like to try to answer the question originally posed. Putting on my academic hat, it’s really a terribly worded question. It may have been more interesting if they added some qualifiers – such as how will health IT make a difference in a specific area? Or to patients? I’m admittedly in a cynical mood, but I’m going to have to say that I don’t think health IT is going to make any more of a difference next September than it does today.

Flash forward to September 2013. Vendors will be shipping out their “MU Stage 2 Compliant” releases to get customers ready to start attesting come January 2014. That means they will have spent the better part of the preceding year “teaching to the test,” or rather focusing their efforts on coding to the specs and achieving certification. Any innovation they had planned will likely be sidelined as they are forced to shift pre-defined blocks of resources to coding for MU goals rather than being revolutionary.

Customers will be readying last-minute upgrade plans and running full tilt towards the dual threats of Meaningful Use and ICD-10 mandates. Rather than focusing on clinical transformation and physician adoption, they will also be “teaching to the test” and training clinicians to make sure every nonsensical “i” is dotted and “t” is crossed. Providers will receive monthly (or worse, weekly) reports from practice and health system administrators that do nothing more than measure their performance on checking boxes.

Patient care will be largely unchanged. Rather than focusing on specific diseases or quality improvement projects, they will be scrambling to make sure they don’t lose revenue or get dinged in audits. Hundreds of millions of dollars will be spent, but clinical metrics will not be appreciably better.

Maybe it’s better that I didn’t submit for the blog carnival. I bet the chosen bloggers will paint a dramatically different picture. I can’t wait to see what they come up with.

E-mail Dr. Jayne.

Monday Morning Update 9/10/12

From Lickety: “Re: percentage of EPs/EHs achieving MU Stage 1. Does anyone know the percentage of all EPs/EHs to get a feel for where the country is in total?”

From Candy Albicans: “Re: Allscripts. Considering selling its profitable MyWay division to SYNNex, a reseller that has purchased 1 million licenses.” Unverified.

From Eric the Well-Read: “Re: your posts. I’m pretty sure I see another site that you’re writing for under a different name. True?” False. I barely have enough hours in the day to write HIStalk. I suppose I could attempt to pimp myself out in several ways (writing elsewhere being one) and use the proceeds to quit my hospital job, but I like things the way they are, which is they way they’ve been for the past nine years. That represents either high satisfaction or low ambition (probably the latter).

From Mrs. Beasley: “Re: EMR implementations led by hospital business units. This seems to be more common, especially with Epic. I’m curious to hear whether anyone else thinks the role of the CIO is changing because of this. I’m in the middle of one and wondering whether after the install, it will be business as usual for IT.” I’ll expand your original thought a bit for the benefit of the many CIOs whose hospitals are implementing Epic: if your hospital has been live on Epic for more than a year, how did your IT budget, staffing, priorities, consulting budget, staff training costs, and personal responsibilities change? I bet I’m not the only one curious about what happens in the Epic afterlife.

President Obama would win a close race if the election were held today and my poll respondents were the only voters. New poll to your right: which of the five listed inpatient clinical systems vendors offer the most innovative products? I’m asking since Cerner was just named by Forbes as one of the top 10 innovative companies overall, but I’m skeptical about how the magazine arrived at that conclusion since they didn’t actually say. And note that there’s no “none of the above option” since it’s unnecessary based on the question being asked.

Thanks to the following sponsors, new and renewing, that supported HIStalk, HIStalk Practice, and HIStalk Mobile in August (click a logo for more information):

Listening: new from Katatonia, brooding Swedish progressive metal that is admirably devoid of the characteristics of suckier bands that drive many potential fans away: grunting, screaming, excessive tempo, and a wall of impenetrable noise. Good vocals, minor key melodies, and fine musicianship.

Hey, EHR vendors! tweet a pledge to do View/ Download/Transmit in 2012. Will shout out on Monday. #ONCPledge #VDTnow #HealthIT4U

— Farzad Mostashari (@Farzad_ONC) September 7, 2012

I’m impressed with how openly Farzad Mostashari uses Twitter. Granted the bar was set low by his deadpan predecessors, who probably would have been happy to turn the ONC Twitter account over to a federally contracted, chirpy, 23-year-old marketing ghostwriter with a blissfully empty head, but he’s out there tweeting away with original thoughts at all hours. Here’s a brilliant throw-down he posted Friday afternoon: which vendors are willing to publicly promise that they will roll out View / Download / Transmit capability for patients by the end of 2012? He says he’ll post the names Monday, with takers so far being eClinicalWorks, athenahealth, SOAPware, and Greenway. What say you Epic, Practice Fusion, NextGen, Cerner, McKesson, SRS, Allscripts, and GE? Farzad wants to know whether you own cattle or just big hats.

Speaking of ONC, they decide not to proceed with their intended regulation of NHIN’s “conditions for trusted exchange.” Reason: regulation might slow things down, which is just about the last thing that HIEs need.

The board of Allscripts approves a $1.9 million 2012 incentive for CEO Glen Tullman. His total compensation in 2011 was $7.2 million. Above is the two-year MDRX share price (blue) compared to Cerner (green), athenahealth (red), and the Nasdaq (brown). Had you invested $10,000 in each two years ago, the value of your holdings today would be worth $6,257, $22,854, $32,844, and $14,025, respectively.

Orchestrate Healthcare names former Dean Health Systems IT VP Jerry Roberts as VP of its Epic practice.

Olympic Medical Center (WA) will spend $7.6 million to get Providence Health and Services to implement Epic for its hospital and clinics over the next year. They expect to get $7 million in HITECH money in return. Annual support fees will run around $750K. The CEO says they’re getting a tremendous deal, especially given that Epic will replace five systems. “I think our current systems really don’t help us take care of our patients the way they should. I think Epic is the best system available.”

Nuance announces its 2012 Understanding Healthcare Challenge, offering prizes to the top three developers to describe how they would integrate Nuance’s clinical language software into their products. Entries are due October 5.

Crain’s Chicago Business found 10 Illinois physicians who are making at least $1 million per year from Medicaid, with four of them being pathologists (as with most businesses, those higher on the supervisory food chain did better than those doing the actual work). Leading the pack: the head of pathology at safety net hospital Sinai Health System (also their CMO), who pocketed $5.9 million in a three-year period. The second-highest was a urologist who raked in $5 million while being investigated for questionable billing. The third was the medical director of Planned Parenthood of Illinois, who just agreed to a $367K settlement for overbilling. She made $3.9 million in just over one year of the study period before being cut off because of the billing investigation.

Vince finishes up his HIS-tory of Keane with the stories of First Coast Systems and Source Data Systems. As always, he welcomes your contributions about vendors of yesteryear.

A reader sent over an article from the HIMSS cheerleader rag, knowing I wouldn’t have seen it since I don’t read free healthcare IT magazines (they’re mostly just re-worded press releases). The article proclaims, “It’s confirmed. Electronic medical records can indeed yield marked savings for hospitals.” Just to be a contrarian, I dug up the original article to see what they were gushing about (other than everything that’s pro-vendor).

As I expected to find, this is another example of the pitfalls of outsourcing your conclusions to non-experts armed with the dual motivations of (a) not biting the hand that feeds them, and (b) drawing in readers with sexy headlines that the article doesn’t support. I think the work of the study authors was OK, but hardly conclusive or even convincing.

What the paper actually says is that EMRs have provided “mixed performance,” i.e. the paper isn’t suggesting predictive value. The authors tried to prove (unsuccessfully, in my opinion) that the driver of whether hospitals save money as a by-product if implementing an EMR is the availability of local technical expertise, which just doesn’t make a bit of sense given that (a) technical resource availability doesn’t have much impact on cost since it’s a tiny portion of overall hospital cost, and (b) hospitals use remote and/or contracted technical resources all the time, making geographic location only marginally relevant.  

My reactions:

• The study is just a paper, so it hasn’t gone through peer review or acceptance. I would hardly say it “confirms” anything.
• This was yet another drawing room study where someone just mashed up conveniently available but questionably relevant data, in this case the HIMSS Analytics database, the Medicare Cost Report, and the AHA Hospital Survey.
• The databases were current only through 2008, so this is four-year-old information that predates almost every significant EHR event.
• The study’s main finding is that the average hospital that implemented an EMR during the 12-year period saw no improvement in efficiency, and in fact, saw their costs go up after adoption (“quite high,” the article says). I notice that didn’t make the magazine’s headline.
• Hospitals located in areas with a lot of IT talent saw costs go down 4% from previous IT cost (those adopting basic EMRs) and no change (those adopting advanced EMRs).
• Hospitals in low-talent areas increased their costs 2-3% with EMR adoption.
• I didn’t really understand how they considered hospital ownership, which is a good predictor of both IT utilization and overall cost structure. Or for that matter, separating hospitals that outsource IT functions from those that don’t.
• I don’t think most hospitals buying an EMR in the early 2000s expected or even wanted to reduce costs, so I don’t really see the value of finding out whether they did.
• The idea that the likelihood of a given hospital reducing its costs by implementing an EMR is based solely on how many programmers live in its area does not pass any sniff test I can envision.
• The article’s abstract contains the real conclusion: “Adoption of EMR is generally associated with a slight increase in costs. We argue that this average masks important differences over time, across locations, and across hospitals.”
• The thrust of the article can be inferred from its title, “The Trillion Dollar Conundrum: Complementarities and Health Information Technology.” It is actually, to a certain extent, debunking the questionable conclusions of CMS and the Cerner-funded RAND study in proclaiming that EMR adoption will reduce healthcare spending. The article says EMR cost savings will be “mixed” until technical resources are more widely available. That doesn’t really sound like the upbeat conclusion the magazine trumpeted.
• As always, even if you buy the study’s methodology, it at best identifies a slight correlation rather than causation. I would not attempt to predict the impact of a $200 million Epic install in a large academic medical center to generalized, old information of mostly small hospitals (which as a percentage, is most of them).
• Implementing an EMR to save money is an iffy proposition at best, not to mention that maybe patient outcomes should be the stronger consideration.

My conclusion is that it’s not a bad study, just not all that conclusive and certainly not worth detailed coverage in an industry magazine. I lost interest in further analysis at this point since it was time to have a beer and watch some college football. If you didn’t, feel free to elaborate further.

E-mail Mr. H.

Time Capsule: Actual vs. IT-Measured Quality: Giving Data the Benefit of the Doubt When Money’s On the Line

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in October 2007.

Actual vs. IT-Measured Quality: Giving Data the Benefit of the Doubt When Money’s On the Line
By Mr. HIStalk

It’s inevitable that hospitals and providers will someday get paid more or less based on how they perform on quality measures. Smart people will create a list of clinical actions that supposedly measure quality, or at least serve as a proxy for it. Follow those standards and you’ll get a bonus (or, for you fellow pessimists, avoid a penalty).

Coming up with standards is hard. Medicine keeps reminding us that it’s an art and not a science. Patient outcomes don’t always bow down obediently to even a well-designed medical cookbook (if they did, all doctors would already be treating patients the same). And if you start paying hospitals to give aspirin for heart attacks, you’d better make sure it adds value.

Still, at least for common chronic diseases, the standards are starting to become clearer and more defensible. Widespread use will prove or disprove their value. They can always be changed to reflect new knowledge.

Once the standards are in place, what’s left sounds easy: just sift through reams of electronic information to see how well providers have followed them. Then, write those checks. However, an editorial in the current issue of JAMA reminds us that data standards are poorly defined.

I don’t think providers will cheat, but I think they will err on the side of getting paid when the information is murky. For example, heart attack patients who smoke are supposed to get advice on stopping. Somewhere in the digital soup lives a data bit. It gets turned on when a nurse checks off a “smoking cessation education offered” item.

But, what does that check mean? (or as the geeks say, what is the metadata?) Does the nurse check the box only when she’s done a bang-up job of patient education, including having the patient demonstrate their understanding? Or, does a “smoking cessation” item pop up from an order set, which creates a task, which creates a “click here to make this item go away” entry on the flowsheet?

Reminder: you get paid for checking the box, not doing a wonderful job.

Hospitals are supposed to give clot-buster therapy to new heart attack patients with 30 minutes of their coming through the door. That means you need a super-accurate recording of the time they came in, plus the actual time the drug started coursing through their veins (not when the order was entered or when a nurse pulled the med from the Pyxis machine).

Reminder: conveniently retrievable data isn’t necessarily the same as clinically relevant data, even though it fits the loose definition of what’s being sought. It’s easier to rationalize that what you have is good enough than to go after something new.

Payers might want doctors to encourage patients to get flu shots. Do they pay them for actually giving it, or just for recommending it? Is it for all patients, or just those who happened to have an appointment at the time of year the flu shot inventory is available?

Reminder: physician payments may be based on a denominator of all patients under their care, not just those who have had an office visit.

I’ve looked at a lot of hospital data, particular that involving medications and treatments, and I wouldn’t trust it in many cases. There’s a lot of variability behind what looks deceivingly black and white to a programmer.

We IT people like the idea of pay-for-performance because we are logical and data-driven. It also provides the comforting illusion that providers who follow checklists will keep us from dying. Where we may get uncomfortable, however, is when we realize that our information systems will be taken as gospel by the check-writers. Deep down, I don’t think we really believe that our information is quite ready for that level of scrutiny.

Now’s the time to review your data and metadata. Most quality measures involve just a few data points: when something happened, what drugs were given or what tests were performed, and what was done when the patient was discharged. If you can comfortably produce that data without crossing your fingers behind your back as to its reliability, then you are ready for data-driven quality measurement.

HIStalk Interviews Greg Dorn MD, President, First DataBank

Gregory H. Dorn, MD, MPH is president of First DataBank of South San Francisco, CA.

Tell me about yourself and the company.

I’m a physician. I went to medical school, undergraduate, and medical school at Columbia. I trained in surgery at UCLA and then did a Masters in Health Services Management at UCLA.

During my residency, I became very interested in the process of care and how to improve the clinical process of care. That stemmed from my undergraduate work in operations research, or really industrial engineering. This became a nice marriage of the two.

Throughout my clinical training and subsequent to that, I saw a lot of opportunities where there were clinical practices that weren’t always well substantiated as being best practices. Also, in the hecticness of clinical practice, you would see a lot of errors that would occur, particularly with complex medications in the ICU — I’ve spent a lot of time there.

That passion grew in me. That’s where I helped start a company called Zynx Health. It has grown to become, I think, a standard bearer within the field of evidence-based medicine. Subsequent to that, I moved over to First Databank to take what I’d learned at Zynx, and also prior to that , to bring it to bear within the clinical drug decision support environment. To try to optimize what I think is a really significant opportunity to inform clinical practice at the point of care around drugs. That’s one of the most heavily integrated into the workflow decision support domain today, as opposed to perhaps referential content or medical or nursing or traditional clinical information.

First Databank has been around for about three decades, focused exclusively on integrated drug knowledge. I emphasize the “integrated” piece because there’s a lot of drug knowledge out there, reference and integrated. But from its very inception, FDB has been heavily focused on integrated. That means embedded into the software application used by the clinician, whether she or he be a nurse, a pharmacist, a physician, a nurse practitioner, a physician assistant, and any myriad of care extenders that may come to bear here as the healthcare economy expands tied to the Affordable Care Act. 

We’re focused on delivering that clinical content to the point of care. We’re not focused on being a supermarket of information, or being all things to all people and assembling every different type of clinical content you might want, but rather to be true experts at the point-of-care decision-making process such that clinicians get the most value out of that alert, that ordering sentence, or any other type of dosing information or a range of other clinical decision support in the drug domain.

Both First Databank and Zynx have strong brands, to the point that I’m not sure everybody knows that both owned by Hearst. What are the commonalities between the two companies?

Hearst is a very broad, diversified media company. They own the San Francisco Chronicle, Cosmopolitan, parts of ESPN, A&E, and Lifetime. They’re all organized into major operating clusters that are thematic. We’re in Hearst Business Media, which is focused on business-to-business, workflow-embedded content — decision support.

First DataBank, Zynx, and Map of Medicine in the UK are all focused on the medical-clinical side or healthcare side of things. The relationship specifically between Zynx and FDB is that Zynx takes a broad view of clinical decision support and says, “What are all the sources of information I can derive a best practice from? How can I then package that information in a useful clinical format — an order set, a care plan, an intelligent clinical alert?” There’s also a significant amount of forecasters and calculators. Taking a broader approach to distilling best practices.

FDB goes one layer deeper. Zynx can run on the infrastructure of nomenclature data, alerting, drug structured information that FDB provides.  We go that layer deeper, where we’re optimizing the exact order sentence. If you have a Zynx order set that’s evidence based that’s going to drive reductions in mortality and you select to execute that order sentence, the next series of steps to make that orderable sentence truly specific to the patient’s context and very intuitive to the clinician but also that it translates into a dispensable that can be handed out by the pharmacy –we have specific data sets that allow that translation to occur seamlessly.

If you think about ordering that medication in the setting of a particular diagnosis or co-morbidity or the setting of another medication or the setting of a particular lab result, our alerts are optimized to make sure that that alert is meaningful to the clinician. That’s where the interplay between Zynx and FDB comes in. Those that use both see significant benefits.

You could argue that most of the value of CPOE and other clinical systems, beyond standardizing what’s available for ordering, is the third-party content such as that offered by Zynx and FDB. Are you actively looking for other areas where critically reviewed literature might come into play to enhance existing clinical systems?

Yes. We think of the clinical decision support environment as a cycle. If you can think of the patient making a transition from healthy to sick and then having to interact … this could be in a chronic sense. I don’t have a chronic disease, I now have a chronic disease. I don’t have an acute condition, I now have an acute condition. At that point, there are three phases where an individual interacts with the healthcare economy with regards to clinical decision support.

There’s something we call a pre-encounter phase, which is before I have an encounter with the healthcare system. There are whole hosts of activities that occur – eligibility, necessity, formularies.

Then there’s the encounter stage, which is when I’m actually in front of the physician. There’s that intimate moment with the nurse, the physician, the pharmacist when the decision is being made. That’s what we’d call the encounter phase of the clinical decision support cycle. 

Then there’s the post-encounter phase, all of the activities that relate to what happens after the patient has had an encounter with a health system that are related to clinical decision support. There you’ve got a measurement around data and dashboards and you’ve got clinical billing and just a whole host of activity – claims paying and so on.

We look at the universe with that framework. Today we’re very focused on the encounter phase. As you can see, Zynx and FDB really dominate that encounter phase. When you’re at that moment of receiving care, we can influence the decisions that are being made and reduce mortality and morbidity. We are very interested in looking at types of content that fit the other two domains, whether that be post-encounter and pre-encounter and beyond. Without getting in too many specifics, just know that those are very interesting to us right now.

You recently announced AlertSpace. What are its advantages?

In this encounter phase,  there’s this problem of alerts being highly sensitive but not specific. You get lots of alerts, but you don’t know which one is really germane to your patient’s care, so you ignore a lot of them. What we’ve seen in our research is that by clicking through alerts, unfortunately, there’ll be a click-through of the one alert that really mattered. The patient can have an adverse outcome by oversight of that valuable dosing alert, valuable drug –disease interaction, or whatever it may be.

In AlertSpace, we’re allowing institutions to customize their alerts — turn off the alerts that are not as meaningful clinically to them and promote or retain the alerts that are highly clinically meaningful to them. This is done through a web-based tool, a SaaS approach, so it’s pervasive. It’s available to any subscribing institution. 

They actually customize their data directly before they get their data load. They’re able to see those alert customizations the next time they publish their FDB data,  which can be weekly, monthly, or even daily.

AlertSpace helps reduce the noise factor and highlight the alerts that are truly clinically meaningful, thereby reducing the risk that meaningful alerts are overlooked and patients have adverse outcomes. Right now we have a whole of host of institutions that are using the tool. It’s been our most successful new product launch in the history of FDB.

AlertSpace is a tool, a solution to helping with alert fatigue. But there are also other approaches that we’re taking around the editorial choices we make about which alerts and serve upstream and trying to understand the validity of the content before it has to be adjusted by AlertSpace. There are myriad of approaches we’re taking to optimizing alerts. It’s not just that we’ll keep publishing the same content and give you tool to fix it. It’s more that we’re going to really improve the alert relationships and give you a tool.

That’s an interesting approach. Instead of relying on EMR vendors to repackage your data with the inherent delays, you’re letting customers pre-customize their own. What was the thought process there?

We wanted to close the cycle time gap between new technology reaching the end user. We obviously work with all of our vendor partners because they have to support these customizations, but what I experienced at Zynx, where we have a web-based authoring environment that allows for content to be customized and then published within a myriad of target systems … that paradigm is one we brought over to FDB. We thought FDB had the capabilities to deliver an end user application. We thought that would be very valuable to our brand and to the value we bring the clinicians.

It’s a little bit of what we learned in Zynx. It’s a little bit of trying to close the cycle time between innovation and the end user’s access to that innovation without having to enter into, as you can imagine, a long product cycle or revision cycle. How can we get this alert customization technology into the hand of end users as fast as possible? Through our client base, we know about the mistakes that occur out there around drug CDS. I know personally of hospitals that have had errors that are related to alerts. We’re mission driven about that now.

The rebranding of the company’s image appears to signal that FDB wants end user visibility, not just to the IT folks or people who apply your updates. Are you looking for a brand identity with the end user? 

Absolutely. That’s been one of my focuses since I’ve been here.  We’ve talked a lot about it, the idea that we are so pervasive throughout all of these different systems — not just with hospitals and medical groups, but  PBMs and insurance companies – but yet if you were to go to AMDIS or HIMSS or a whole range of different meetings and ask CMOs or CMIOs, “Have you heard of FDB? Do you know of FDB?” Even the end user clinician, chances are they’re going to say, “No, I haven’t heard of it.” 

Based on the impact we’re having and the impact we can have on clinical workflow, we really wanted to have that be more effectively recognized by the marketplace. End user tools that don’t interfere with our relationships with the large system vendors are a very significant strategy going forward for us. I think the reception’s been pretty good. We had a lot of large systems who we’ve met with and they like the approach so far. So I think you are right on there. We’d like to raise that profile.

We’d like to do more around end user tools; help customize the content. The thing I observed when I came in was that pharmacy clinical information was one size fits all. This is across the industry. People just publish a file, the system takes it, puts it in, and you deal with the result. That’s maybe 1.0, or even 0.5 – the first phase of the industry.

Drug CDS 2.0 is going to be about customization and personalization. That’s where we’re headed. Tools and the highly specific content that gets right down to the individual nuances, whether it be their renal function, liver function, physiology, a whole range of things. Eventually and in the not-too-distant future, their genotype and how that’s expressed as a phenotype and how they then metabolize drugs will be a very important area for us.

How do you prepare to start using genomic information?

You have to be vigilant, first and foremost, about the body of evidence — what the body of evidence is telling you about where you can adjust dosages. We’re tracking that. That’s first and foremost. As that grows, we’re compiling it.

The second piece you really need is physicians, nurses, pharmacists, and healthcare institutions to become much broader users of genetic testing. Then using those results to close the loop for a metabolic adjustment with regards to a drug. We can capture the data and develop a dosing tables that say, “If you’re a cytochrome P450 metabolizer, this is your warfarin dose” or whatever it may be in a chemotherapeutic regimen. We can do that. We have people tracking that today.

What we need is the input side, which is doctors becoming reimbursed so that it becomes more common to order a genetic test. That result can be pinged off our data and a more specific dosing parameter can be returned. Our goal is to try to help move that along. Obviously we don’t control all the pieces, but we’re very excited about how that might unfold over the next five years.

You joined the company after average wholesale price lawsuits had come up. What was the impact on the company, and how do you think the industry has changed now that average wholesale price not used to calculate provider drug payments?

That’s a great question. I joined right as we were heading into this cessation of publication, so it was a little bit after my tenure. I spent about six months re-analyzing that challenge. Hearst asked me to do that. 

What we realized is that we couldn’t continue to publish AWP, which if you really look into it, is a relatively arbitrary measure. Ceasing publication of AWP had very little impact on the company. We were able to go to our customers and provide them with alternatives, whether it be wholesale acquisition cost or other measures, that they could use to meet their needs. We very successful in being able to provide alternatives that were anchored more directly to data submitted by manufacturers.

What we moved on to is that we are in partnership with the State of New York, doing a survey of average acquisition cost. New York is collecting acquisition costs from pharmacies. We’re averaging those in partnership with Ernst & Young. That’s potentially generating a new benchmark for the State of New York. 

You also probably know that Alabama and Oregon both have acquisition price types. California, which we’re very close to, is close to moving forward with an acquisition price type. The federal government has launched an acquisition price type initiative. We’re doing our utmost to push towards this acquisition metric in the hopes of adding transparency around pricing, but still not saying it’s the only measure, but saying there is now a range of price types that can be used. We’ll definitely do our utmost to be first and foremost with the acquisition price type.

I think it’s very exciting. If we can get  better transparency on drug reimbursement, it’s better for the patient, it’s better for the healthcare economy, it’s better for employers. There’s a whole host of benefits. I think part of being innovative in that space is what’s been interesting for me.

Any concluding thoughts?

I want to make sure that your audience understands that we’re not just a US-based drug clinical decision support company. We have a division in the United Kingdom — FDB UK — and they have a very, very large position in the UK with drug clinical decision support. We have a significant presence in Asia. We also have a very nicely growing footprint in the Middle East.

We operate as a global drug clinical decision support company. If you look at all the different drug clinical decision support companies, we may be one of the few that do that successfully.That’s an important characteristic of who FDB is. As the healthcare IT market grows globally, we’ll be ready to address the needs that come, wherever they may come from.