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.

News 9/7/12

Top News

Merge Healthcare’s board hires an investment bank to seek strategic alternatives for the company that could include a merger or outright sale. Merge, which has lost money for six straight quarters, has seen its share price drop 40% on the year, although shares were up 10% Thursday on the announcement. Above is the one-year share price compared to the S&P 500 (green) and Cerner (red).

Reader Comments

From Acorn: “Re: emergency power off switch. An engineer fell onto ours today.” Been there. We had just moved into a new data center at my previous employer and the entire data center was going dark a couple of times per day. We couldn’t figure it out, but suspected a construction mistake. The UPS wasn’t kicking on and the standby generator wasn’t coming up, so all systems were going down hard, creating a nightmare of system outage and recovery downtime (we’re talking every server, connection, telephone system, etc. spanning several hospitals). We eventually figured out the problem: the big, red emergency power-off switch was right beside the exit door where the old data center’s “press here to open door” button was located. Employees were smacking it by habit as they exited, and then sheepishly running for the hills without telling anybody when the data center suddenly went dark and quiet. We put a $1 plastic cover over the switch and that was the end of the problem.

From Sadie: “Re: Merge Healthcare. Three weeks after an RIF in France and one week after a 56-person RIF in the US, Merge announces plans to sell the company. I hate to say that I called this months ago.”

From MindYourOwnBusiness: “Re: UPMC. They’re in the hospital (and EMR) business, not the law enforcement business.” A patient who says she contracted hepatitis C from syringes infected by a drug-using radiology tech at UPMC sues the hospital and two of its staffing agencies. The lawsuit says UPMC caught the tech in the act of stealing fentanyl from the OR and told his contract employer to stop sending him to work there, but didn’t notify anyone else. The tech then worked at eight more hospitals, spreading hepatitis C to at least 30 cardiac cath patients and possibly hundreds or thousands. I’ve negotiated the “resignations” of a couple of hospital employees for known or strongly suspected drug theft over the years, and as irresponsible as it sounds, begrudgingly let them walk away without a resume blemish. The reason: the hospital’s legal counsel said that unless we had an airtight case against them (which is almost impossible to obtain) and ran them through a couple of cycles of optional drug rehab at our expense, they would probably sue us immediately for even insinuating to a potential employer that their records were anything but impeccable. In this case, the tech wasn’t even a UPMC employee. Nobody is bothering to sue the actual criminal, of course, given his unattractively shallow pockets.

From Curious: “Re: Dell. Heard they’ve cut a large number of experienced senior people from their outsourcing group.” Unverified.

HIStalk Announcements and Requests

HIStalk Practice highlights from the last week include: MGMA urges CMS to remove duplicate e-prescribing requirements in the MU and PQRS programs. Physicians express concerns about the impact of the ICD-10 transition on finances and practice operation. GenX physicians want a life outside of work, rely heavily on EMRs and smartphone apps, and like sharing the load with other doctors. Dr. Gregg has a geeky moment about Scanadu. The HIStalk Practice Physician Advisory Panel provides insights on patient volumes and the impact of EMRs and other technologies and the anticipated impact of the Affordable Care Act, with the possibly surprising finding that many of them won’t increase their patient volumes or workload even if it means higher incomes. Thanks for reading.

On the Jobs Board: Cerner and Epic Resources, Inside Sales Manager, Services Implementation Consultant.

Travis’s post on HIStalk Mobile, What I Learned about Health IT in Medical School, seems to be popular based on who’s linking to it or tweeting it (including some high-profile folks). Sign up for his updates and you’ll get the viewpoints of somebody who’s both a doc and an mHealth expert.

If Inga, Dr. Jayne, and I were running for office, we would kiss babies, try to appear humble by wearing carefully casual costumes to our scripted photo ops, and make a lot of promises we know we can’t keep. We aren’t, so the only vote we seek is one of approval, which you may cast by (a) connecting with us on the usual social not-working sites (and thus enlarge your own network significantly); (b) signing up for spam-free e-mail updates; (c) sending us news, anonymous rumors, and anything else that might amuse us; (d) enjoying the company as we do of our much-appreciated sponsors, whose click-worthy electronic greetings you see entirely coincidentally on this page (they look a bit like ads); (e) peering into the Resource Center, which contains more detailed sponsor information; and (f) telling others that you are shocked by the irresponsible and objectionable material you see here since nothing draws Internet page views like bad behavior. We thank you for reading, and if you were in the room with us, there’s a good chance Inga and Dr. Jayne would plant a kiss on each of your cheeks simultaneously.

Acquisitions, Funding, Business, and Stock

Registerpatient.com, which offers a Web-based patient registration and scheduling system for $50 per provider per month, raises $1.1 million towards a $4.1 million target.

Pamlico Capital acquires home health technology provider HEALTHCAREfirst from fellow PE firm The Riverside Company.

Vocera Communications announces a public offering of 4.5 million shares of common stock.

MobileHelp, a provider of mobile emergency response technology for personal use, acquires Halo Monitoring, a developer of home monitoring products.

Harris Corp. is investigating potential violations of US anti-bribery laws by its Carefx China division, whose employees were found to have provided gifts and payments to prospects and customers. Healthcare executives in government-run healthcare facilities in Europe and Asia are considered foreign government officials by the Justice Department and SEC.

Physician networking site Doximity secures $17 million in series B financing led by Morgenthaler Ventures, bringing its total funding to $27 million.

Sales

Intermountain Healthcare (UT) chooses Accelarad’s medical imaging solution for its 22 hospitals and 185 clinics.

Medical Center of the Rockies (CO) selects ProVation from Wolters Kluwer for GI documentation and coding.

People

Healthcare Quality Catalyst names Todd Cozzens (Optum) to its board. Todd got in touch to say that the company is building data warehouses and Subject Area Marts on top of Epic and incorporating quality and workflow principles developed at Intermountain into more of an industry quality engineering type capability. He’s been around healthcare for a long time and has a nice viewpoint from his work at Sequoia Capital, so when he says it’s the next big thing, it just may be. I interviewed Steve Barlow, CIO and co-founder, a year ago.

Intelligent InSites appoints Margaret Laub (Policy Studies, Inc.) president, CEO, and board member. Interim Doug Burgum will become executive chairman of the board.

Ivo Nelson (Encore Health Resources) is announced as a financial partner of Health Care DataWorks, where he has served as a board member.

Announcements and Implementations

HIMSS Analytics recognizes the University of Iowa Hospitals and Clinics with its Stage 7 award for EMR adoption.

Caverna Memorial Hospital (KY) and Palestine Regional Medical Center (TX) go live on their HMS information systems.

OB-GYN PM/EMR vendor digiChart will integrate Dialog Health’s text message patient reminder system into its product.

Oregon Community Health Information Network will provide Epic to 10 public health centers in King County for $500K per year.

Government and Politics

CMS reports that through the end of July, 128,000 EPs and 3,624 hospitals have collected almost $6.6 billion in MU incentives from Medicare and Medicaid.

A BMJ editorial by two professors says that, based on their fields of behavioral economics and social psychology, pay-for-performance probably won’t deliver the expected results. Their reasons: (a) risk adjustment methods are inconsistent; (b) the system can be gamed by upcoding; (c) process-based indicators are poor proxies for quality of care; (d) social characteristics of patients can make good doctors look bad; (e) overly detailed criteria may encourage just checking off the boxes instead of really taking care of the patient; and (f) doctors may stop exhibiting empathy and pride in their work since nobody’s paying them for those qualities.

A new report from the Institute of Medicine says that the US healthcare system wastes 30% of its cost, or $750 billion, on unneeded care, administrative overhead, and fraud. It says that if other industries worked like healthcare, an ATM transaction would take a full day, laborers building a house would each use different plans without talking to each other, stores wouldn’t post prices, car warranties would not be offered, and airline pilots would make up their own pre-flight check list if they felt like following one at all. Many of their potential solutions for creating a continuously learning healthcare system involve technology.

Other

Surescripts will connect Epic’s Care Everywhere interoperability framework to its network, allowing Epic users to exchange patient-specific information with other providers regardless of their technology platform.

Forbes puts Cerner in good company as one of the 10 most innovative companies in America, citing it as #8 because “its servers handle 150 million healthcare transactions a day.”

Florida’s HIE adds Broward Health, Health First, Martin Health System, Mt. Sinai Medical Center, and Tampa Bay Regional HIE to its clinical exchange network.

Bill Clinton was such a good president (especially when graded on the 25-year curve) that the man formerly known as Slick Willie has completed his ascent to Elder Statesman/Rock Star, capped by his ad-libbing convention speech this week (how many people were like me and thought, “Why can’t we vote for him?”) and the announcement that he will deliver the Wednesday afternoon keynote at the HIMSS conference in New Orleans in March. HIMSS didn’t mention Hillarycare or his Monica Lewinski-driven impeachment, which I find myself being OK with since his relatively benign scumbaggery was eclipsed by his results in office. He could easily be elected president again, I expect, were it not for the anti-FDR 22nd Amendment that limits him to the two terms he already served. I don’t know what HIMSS is paying for his hour or so at the podium, but his rumored rate is in the $400K neighborhood. Also announced on the post-election, politics-heavy HIMSS keynote schedule: James Carville and Karl Rove, which I would find more interesting as a boxing match.

An ACO formed by Blue Shield of California and Dignity Health (the former Catholic Healthcare West) saved $37 million in projected costs over two years for the CalPERS state retirement program, with most of the improvement due to shorter hospital says and fewer readmissions.

Temple Community Hospital (CA) notifies 600 patients that their information was contained on a computer that was stolen from a locked office in the radiology department. The hospital says it will upgrade its security, presumably meaning it is belatedly considering encryption.

Lucile Packard Children’s Hospital (CA) announces a 150-bed, $1.2 billion expansion ($8 million per bed, $2,300 per square foot).

The San Franciso Jewish newspaper profiles David Jacobs, who started kidney paired donor-matching software company Silverstone Solutions within a month after his own kidney transplant in 2004. He expects to add several large hospital groups as customers in the next few weeks.

The feel-good Weird News Andy, temporarily changing his e-mail signature to Wonderful News Andy, likes stories about surgeons who help others (“a cut above,” he calls them). Two Salt Lake City surgeons win awards for their combined 100+ foreign medical trips, taken at their own expense to treat individual patients and educate physicians. WNA’s carriage turns back into a pumpkin with what he calls, “Doctors – The Flip Side,” as he reads the story of a patient undergoing surgery in a Swedish hospital whose anesthesiologist decides to knock off for lunch at the stroke of noon even though he’s the only anesthesiologist working. The patient crashes an hour later, employees can’t reach the anesthesiologist, and in the confusion someone turns off the respirator of the patient, who dies weeks later of brain damage.

Ministry Health Care (WI) tentatively agrees to join Ascension Health. Ministry’s stats: $2.2 billion annual revenue, 12,000 employees, 15 hospitals, and 46 clinics.

Self-proclaimed “EMR geek” Rob Lamberts, MD lists 10 ways EMRs could be made better. Ones I particularly liked: (a) require all visits to have a simple summary entered; (b) since the patient is often the “interface” between EMRs anyway, allow them to pull up their own records and show them to their new doctor; (c) maintain one comprehensive patient calendar that can be shared among providers; (d) let the patient manage the information they provide, such as family history, meds list, and social history; and (e) make patient records searchable.

Sponsor Updates

• A letter to the editor of SIIM by Brad Levin of Visage Imaging offers suggestions on how the organization can decrease radiology technology commoditization by offering crowdsourced innovation theaters, product showdowns, and demonstration of extreme use cases.
• Trustwave introduces security education services to help organizations protect against security risks and compliance missteps.
• Jay Deady, president and CEO of Awarepoint, discusses RTLS technology in an interview.
• MED3OOO announces that its customer PriMed (CT) will participate as an ACO in the CMS Shared Savings Program.
• SimplifyMD will offer Capario’s EDI platform to its customers.
• 21st Century Health selects Sandlot Solutions as a profiled business.
• MedHOK’s 360ACO solution is NCQA certified for P4P, HEDIS, and disease-management performance measures.
• NextGate begins operations at a new corporate office in Monrovia, CA.
• Divurgent hosts The After Party September 12 after Epic’s UGM.
• Wellsoft demonstrates its EDIS at next week’s 2012 ENA Scientific Assembly in San Diego.
• T-System issues a call for presentations for its April linkED emergency care conference.

EPtalk by Dr. Jayne

I’ve spent a lot of time the last several weeks digesting everything there is to read about Stage 2 Meaningful Use. My eyes are glazed over and my brain has become addled. To help providers make sense of it all, CMS has released some tables comparing Stage 1 and Stage 2 Objectives and Measures. I’ve found them helpful, although I wish their page breaks made a bit more sense and didn’t chop a single row into multiple pages.

Mr. H wrote Monday of the Epic vs. McKesson patent appeal. For those readers who enjoy shoes as much as Inga and I do, here’s a bit of patent news. The 2nd US Circuit Court of Appeals reversed a lower court decision, with the outcome that Christian Louboutin was entitled to trademark protection of its well-recognized red soles, but only on contrasting shoes. Competitor Yves Saint Laurent is still allowed to make red soles, provided they are attached to red shoes.

A Medscape article reveals results from a survey on physician EHR preferences. Although nearly two-thirds of users were happy, that means there are a lot of unhappy users out there. Other interesting (but not surprising) tidbits: many physicians are unaware of whether their systems are hosted vs. locally installed, the magnitude of maintenance or installation costs, or what happens in the back office.

CMIO magazine has renamed itself Clinical Innovation + Technology, citing a recognition of “the ever-growing convergence of the IT and technology management teams within the provider setting.” I’m pretty sure that at most places the IT and technology management teams were already intermingled. I think it would have made more sense to say that the IT and clinical management teams were converging. For those hospitals that are still in denial about the need for a CMIO in the first place, it’s probably validating.

A recent study demonstrated that men who consumed chocolate reduced their likelihood of stroke by 17%. It’s not entirely proven how chocolate provides health benefits, but dark chocolate in particular is thought to have anti-inflammatory properties. Maybe I should try some medicinal cocoa instead of ibuprofen after my next workout.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Interviews Larissa Lucas MD, Senior Deputy Editor, DynaMed

Larissa Lucas MD is senior deputy editor of DynaMed of Ipswich, MA.

Tell me about yourself and the company.

I’m a general internist. I trained at Cambridge City Hospital. I practiced there in primary care after my training. 

I joined DynaMed and EBSCO Publishing about five years ago. DynaMed is a point-of-care reference tool to help clinicians answer questions in an evidence-based way while they’re with their patients. EBSCO Publishing is a larger publishing company that provides information through databases and eBooks and other technology to libraries around the world.

You called DynaMed a point-of-care reference company, which I assume is a somewhat different model than the company had when you started with them. How important is it to push the information out where it can be used?

It’s very important. Physicians are challenged today with so many changes in the healthcare system — needing to use electronic health records, communicating to patients through e-mail, and the volume of evidence that is published. It’s nearly impossible to keep up with all that information. It’s critical for physicians to have that information at their fingertips where and when they need it.

If you were to pull 1,000 patient charts and compare that to the evidence that you have on record in your product, how much compliance do you think you’d find?

What a great question. That would be an interesting study to do. For my colleagues, they’re probably pretty good. I think physicians in general do the best they can to stay current with the evidence and follow practice guidelines. Using electronic health records and  clinical decision support tools certainly has made that easier. I would say a chart review in the last five years would probably reveal a lot more compliance than a chart review 10 or 20 years ago.

Physicians presumably don’t know what they don’t know rather than ignore solid medical evidence. Do you find them to be receptive to being presented with the evidence and then changing their practice?

I think they’re receptive. It’s a matter of time balance. There’s a lot to cover in that 15 minutes. Clearly we want to spend as much time of that 15-minute visit addressing what the patient needs. A lot of the documentation and investigation of the questions that come up needs to happen usually at the end of day, before the day begins, and during lunch.  

The problem we’re trying to solve is to integrate that back into patient care, the face-to-face, point-of-care decision point. That’s where you should have the information.

The issue of information needs at the point of care has been studied by a few folks, such as our friends over at InfoPOEMs, Allen Shaughnessy’s group. Many physicians finish their clinical day with five to 10 unanswered questions. That could be disturbing from a consumer point of view, but it can also be disheartening for the physician who probably feels like they just can’t get to all of it in the same day. Creating tools that make that easier is really what we’re trying to do.

Academic medical centers have rounding teams, which you would assume probe the evidence more thoroughly than in the ambulatory setting, where it may be seen as undesirable to leave the patient to look something up. Where do you think the evidence is most heavily used and most lightly used in terms of practice setting?

The scenarios are quite different. Even in an academic setting, you have the team that’s rounding that is really also the education unit. It’s got students and residents in it and hopefully a teaching faculty that’s at the bedside engaging those residents, teaching them what questions to even ask.

There’s a lot more richer learning there, but there’s been a change in the way patients are treated in a hospital now. They’re not in the hospital for very long. A lot of those problems either get solved quickly by an intervention or they’re discharged from the hospital and those problems have to then be resolved outside the hospital.

Even that academic, rigorous learning experience has changed dramatically in the last 10 years so. You don’t necessarily have the opportunity to do the rich investigation at that time.

Studies have attempted to prove that physicians deviate further from the evidence the longer they’ve been out of medical school, which then roughly correlates a patient’s mortality risk to the age of their physician. I notice that DynaMed was recently voted by Harvard Medical School students as one of their top five favorite apps, so I was thinking that maybe having residents fresh out of school using apps like yours would influence the attending more than if that same doctor was out on their own in a non-academic setting.

Oh, absolutely. I agree with that. It’s very important to have the students and residents around. They’re asking those key questions and they challenge us to answer the “why.” Products like DynaMed also challenge the users. 

People define evidence-based medicine in different ways. I like to see it as understanding why we make our medical decisions, not just which medical decisions we should make. Many guidelines, many decision support tools, will put a patient on a protocol that doesn’t actually require a lot of thought. Sometimes that’s more efficient, sometimes not. 

From an academic standpoint, I prefer we as educators, life-long learners, and physicians think about, “Why are we doing it this way?” instead of, “What should I be doing next?” Investigating the evidence and synthesizing it around that clinical question helps answer the “why.” Certainly students and medical students and residents challenge us to do that.

Do you think having reference material available on an iPhone or an iPad has changed the willingness of physicians to use information at the point of care than when it existed only as a book they had to go find?

Definitely. Having it at the fingertips makes it a lot easier. Even as a busy clinician, you can integrate it more easily into your workflow, because now it actually seems realistic that you could achieve that steady state of having some tool that you can constantly look things up on and stay current. Before, it was such a daunting exercise that I would think it was overwhelming to physicians to think, “How could I ever look everything up that I don’t know?“ Now it’s much easier to do that.

The ideal point of inflection would be the EMR, where you have patient-specific information available on the same platform from which the treatment decision will be created. What’s the level of integration of your product within applications from vendors like Epic, Cerner, and Meditech?

DynaMed integrates very well with electronic health records. Our structure is very templated and volatized. You can see the answer to your question very quickly and you can launch different sections depending on whether you’re interested in diagnosis or treatment.

In Epic, it can integrate all the way down into the problem list. It seems to be more of a limitation on the EMR side than on our side. One of the challenges of the EMR is that each one is so different it’s hard for all of that technology to talk to each other. But we integrate very well, and with order sets, too.

We collaborate with Zynx order sets to support some of their evidence.  Users can link right to DynaMed or the Zynx evidence. That’s really where we need to be, because that’s now where physicians are interacting with their patient, and they’re interacting with their own question and intellectual curiosity.

Obviously DynaMed will continue to research the literature, but is it a different mission to work with these vendors to turn your information into more useful forms? You have more incentive than they do to accomplish that.

Yes. I think that’s on the technology side, not so much for us editorially. Editorially, our prime objective and vision stays the same. We certainly have enhanced our interface quite a bit in the last year, but more in response to our user feedback and also a need in the market for a tool that both sends out alerts and is a searching tool. We added that alerting feature as well. That doesn’t interact with the EMRs, but we are modifying the way that we’re producing the content a little bit to answer some of those demands from the market.

Do you have examples of how customers are using the information at the point of care?

We have people using it on iPads and iPhones, obviously, and we have quite a few customers using it integrated within Epic and within Meditech. I’ve seen it in Epic, either in just the InfoButton, the information drop-down menu at the top where an institution may have links to multiple resources that they subscribe to, all the way to an InfoButton right next to the problem list so that you could click on the diabetes in the patient’s problem list and launch the topic in DynaMed that would about diabetes.

Is the InfoButton the least common denominator, or is the look-up function even more standard?

All EMRs have the look-up function, usually in their top menu where institutions can put links to external web sites that have information. That’s the most basic integration that anybody can do.

The InfoButton is still somewhat unusual for a vendor to enable?

Yes. It just takes a little bit more technology.

Do you have significant usage by nurses or other clinical users who aren’t physicians?

Absolutely. DynaMed is part of a suite of point-of-care medical products that use the same evidence-based methodology and literature. We have one for nursing — that’s Nursing Reference Center. We have Rehabilitation Reference Center for physical therapists, Patient Education Reference Center for patients. 

If a hospital subscribes to all those products, they’re fully integrated within one search engine. We also provide full-text data bases to Cochrane reviews and other journals in Medline. Subscribing to the whole suite of medical products gives you information across different disciplines. We have quite a few users that go between products, so nurses will look something up in Nursing Reference Center, but then they also jump over to DynaMed and use that as well.

How is DynaMed differentiated from its competitors?

We’re all very different. DynaMed is based on the critical appraisal of the literature. Then the rest of the content is built around that, but it’s synthesized around the evidence in presenting the limitations and the strengths of the research that support our decision-making.

The other products in the market – UpToDate, ACP PIER, BMJ Point-of-Care — many are published still in a traditional textbook publishing model. The whole chapter is written by the author and then updated and kept current with the literature. It’s just a very different model. They’re all very good. I think we’re all very good at what we do.

How we’re set aside from the competition is that we are very focused on the critical appraisal piece of the evidence and providing the information to support the medical decisions so that physicians are more informed about why they’re deciding to go down a certain pathway.

You have folks on the front line that are contributing their expertise as well, right?

Yes, all over the world.

Is that hard to coordinate?

It’s very challenging.  We have sought experts from around the world. Sometimes time differences are challenging to deal with, but we try to be global.

We have a team of very experienced medical writers from varied scientific backgrounds. They’re very good at what they do, objectively evaluating the evidence. The collaboration with clinicians happens very smoothly and very naturally to make sure that relevance piece is part of what we do. With validity, anybody can follow a protocol in how to critically appraise and assess the validity of a trial, but the relevance needs to happen from the physician level. We’re always engaging with other physicians to get that input.

Do you know how your products are being used and being received by frontline physicians?

Every page has a “send comment to editor” button. That e-mail goes to myself, the editor-in-chief, and our support team. We get a lot of feedback from customers who are using it right at the point of care. That’s very helpful. It helps us drive our editorial priorities as well when we hear directly from customers.

We also work closely with many residency programs and get their ongoing feedback for how it’s used in their practices, in their education, and in their workflows. Our peer reviewers are also always giving us feedback. We definitely solicit feedback and we get it passively from our users. We love it. We’re dynamic. That’s why we have that name.

I once suggested to one of your competitors that it would be interesting to analyze the lookups of a reference product to infer information about prevalence of disease or outbreaks, like people who are always trying to use Twitter or Google searches to spot epidemics early.

That would be interesting. I’ve seen some of that research. Certainly our influenza topics had huge usage when we had the outbreak of H1N1, but typically our usage logs are consistent with what is seen in most general practices. Our top-hit topics are asthma, diabetes, pneumonia, sepsis, heart attacks, and urinary tract infections. 

It’s interesting to me, because you’d think some of the more common diseases that we see in practice, we wouldn’t have to look up answers to questions because you see it so often. You should be comfortable with it. But I like seeing that data, because it tells me my colleagues are constantly striving to see if there’s anything new. I’ve treated 50 UTIs this month, but is there anything new I can learn? In that sense, it’s very rewarding to see those usage logs are hitting some of the major topics.

Any final thoughts?

The challenges facing physicians are so complex. I really enjoy being part of this tool that’s hopefully going to make practicing medicine easier for physicians and make physicians feel more comfortable as they have to make quick decisions in their patient care. It’s definitely going to improve quality. It’s definitely going to improve patient outcomes. Those studies are yet to be determined, but I’m hopeful that all of this technology is going to to make it easier to practice medicine.

News 9/5/12

Top News

HL7 will make its standards and other intellectual property available to all healthcare stakeholders at no charge by the first quarter of 2013. The company says it hopes to increase private and governmental use by eliminating licensing fees, thereby improving care and reducing costs.

Reader Comments

From Mandrake: “Re: NuPhysicia. I’m looking for information from healthcare systems that have worked with them, but I’m not having any success and I see they haven’t been mentioned on HIStalk even though they’ve been around for several years.” I couldn’t find anything either, but I snooped around and found that the company – which has offices in Houston, Brazil, and Malaysia – shares its Houston address with medical staffing company eCareGroup and is apparently the same operation even though they never actually say so (NuPhysicia also offers telemedicine services under the name InPlace Medical Solutions). NuPhysicia is selling a commercialized version of telemedicine software developed at UTMB, best known for its use in prisons, but also used in retail clinics and on oil drilling rigs.

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor Vonlay. Given their location in the epicenter of Madison, WI, you might cleverly guess that Vonlay is an Epic consulting firm and a successful one at that, with 30 clients in more than 20 states. It deploys some of the industry’s best EHR consultants individually or on teams, working at your site when you need them there or via Vonlay’s Remote Services program, which offers big savings to its customers. If your Epic go-live is impending or completed, Vonlay’s remote experts can help work down your open tickets, pitch in on applying upgrades and SUs, and help you phase out more expensive on-site consulting services. The company also provides application mentorship and management-level strategy consulting on how to design, build, and roll out EHR projects, including technical assistance with system builds, Cache programming, interfaces, Web services, and portals. You’ll be in their neighborhood if you’re going to next week’s Epic UGM, so keep an eye out for their folks. Thanks to Vonlay for supporting HIStalk.

Here’s a fun Vonlay video I found, Attack of the Issues List.

Acquisitions, Funding, Business, and Stock

Net Health Systems, which offers an EHR for wound care, acquires competitor Wound Care Strategies.

Data analytics startup Predilytics raises $6 million in its first round of VC funding.

Sales

Geisinger Health System (PA) selects TeleTracking’s RTLS technology to track mobile medical equipment at two of its six hospitals.

Saint Vincent Health System (PA) contracts with onFocus Healthcare for its enterprise performance management software.

St. Vincent Hospital (WI) will implement Merge Healthcare’s complete cardiology solution across its enterprise.

Rex Healthcare (NC) will use Passport’s eCare NEXT solution for eligibility checking, demographic verification, precertification, and estimation of patient payment.

People

Virtual Radiologic names John Way (UnitedHealth Group) CFO.

John Gomez of JGo Labs is interviewed at Apple’s WWDC.

Announcements and Implementations

South Lyon Medical Center (NV) will complete transition to CPSI’s clinical applications by the end of the year. 

Government and Politics

The VA says that over one million patients have registered to download their health information via Blue Button.

The FDA issues a warning letter to Merge Healthcare, saying the company isn’t manufacturing its blood pressure monitoring kiosks within FDA’s guidelines.

Other

Picis, Epic, and GE own the largest share of the anesthesia information system market, according to KLAS. The survey found that customer satisfaction is highest when AIMS purchasing decisions are handled cooperatively between the hospital and OR/anesthesia department rather than either entity making the decision alone.

ZirMed will undertake a $5.1 million expansion project that is expected to create 85 jobs over the next two years at its Louisville, KY headquarters. The state is offering $2 million in incentives for up to 10 years.

Apple announces a September 12 event that is likely to include its announcement of the iPhone 5 (note the shadow in the picture. )

Scotland-based Craneware says demand for its hospital revenue products has returned to high levels after a slow first half caused by US hospitals focusing on EHRs.

The government of China will invest $63 billion in its healthcare system over the next seven years, with part of the money going toward creation of an electronic health information network.

Technology investor and Sun Microsystems co-founder Vinod Khosla says computers will eventually replace 80% of doctors because computers are cheaper, more accurate, and objective, while healthcare is “witchcraft … based on tradition.” He also says that it will take outsiders to fix healthcare rather than those working within it. He has a knack for throwing out outrageous sound bites that earn him exposure, such as saying that hybrid cars offer no environmental advantage – they just make their owners feel better about themselves.

Highly regarded UCSF physician Bob Wachter, MD (chief of medicine, invented the term “hospitalist,” author) says UCSF’s new Epic system generates an impressive-looking progress note from fragments of manually entered information, but the “monkeys and typewriters” approach not only violates the legendary teachings of SOAP note inventor Larry Weed MD (in the 1971 video above that everybody who designs physician documentation systems should study regularly), it’s not as useful as the old fashioned written note. However, he also offers a solution: ditch the use of Epic’s Smart Text and offer a “Big Picture” field where physicians are encouraged to tell the patient’s story as of that moment (although he wonders whether natural language processing will make that unnecessary at some point). Wachter describes the current state as:

Why did Epic and our UCSF IT gurus structure things this way? The primary virtue is that this charting-by-problem approach allows the patient to be followed longitudinally, since one can track problems such as “hypertension” or “ovarian cancer” over years, seeing how they have been managed and observing the response to therapy. It isn’t a bad conceit, and it probably makes tons of sense when described in a fishbone diagram on an informatics seminar whiteboard. But the effect I witnessed on patient care and education was less positive. When I was on clinical service in July and read the notes written by our interns and residents, I often had no idea whether the patient was getting better or worse, whether our plan was or was not working, whether we need to rethink our whole approach or stay the course. In other words, I couldn’t figure out what was going on with the patient.

Small software vendor QueueVision says the Tampa VA hospital is refusing to pay for its medication tracking software despite using it since 2006. The company says the purchase was approved by the hospital’s pharmacy administration, but the VA won’t cough up the $214K it owes. Says a partner in the company, “We were suckers. They took us. I figured the veterans were so happy, the staff was so happy, everybody loved it. So we thought they would pay. We never fathomed that they would lie to us.”

In England, small blood-tracking systems vendor MSoft eSolutions is expanding after winning eight of eight RFPs last year. Its Bloodhound system provides positive ID of employees and patients throughout the blood transfusion process.

I liked this Facebook article by disgraced investor / interesting author Henry Blodget, in which he says publicly traded companies destroy their own value by trying to appease impatient investors and venture capitalists. He explains why nobody should be surprised at the fall in Facebook’s share price (May IPO price $38, Tuesday’s closing price $17.73) given the clear message that CEO Mark Zuckerberg has sent all along that he’s focusing on the customer experience and long-term value as Amazon has always done rather than next quarter’s share price. A snip of Blodget’s paraphrasing of a section of Zuckerberg’s pre-IPO shareholder letter:

Let me remind you that I own 57% of the voting stock of Facebook, which means I have complete control over it. I organized the company this way many years ago, with the very deliberate intention of maintaining complete control over it. I did this so I wouldn’t get overruled and canned by venture capitalists, a fate that unfortunately befalls many entrepreneurs. I also did it so in the event that we ever had to go public—which we unfortunately have to do now—I would never have to pay attention to whiny short-term public shareholders. Those whiny short-term public shareholders have destroyed many great companies by making management obsess about absurd near-term financial targets … Maximizing near-term profits" often means under-investing in future innovation, customers, and employees. And although it sometimes temporarily boosts stock prices, it often guts companies and clobbers their value over the long haul.

The Florida teenager accused of impersonating a PA and practicing medicine without a license is found guilty by a Florida jury and could go to prison for up to 10 years.

Sponsor Updates

• Aetna will offer eviti’s oncology decision support tool on its Medicity iNexx platform.
• The Surgical Information Systems anesthesia information management system earns the highest client satisfaction scores in KLAS’s anesthesia specialty report.
• MED3OOO CMO Paul McLeod, MD discusses the challenges of controlling ER visits in a blog post.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 9/3/12

This weekend on HIStalk Practice, Dr. Gregg wrote about the possibility that the “infamous tricorder from Star Trek” is about to become reality. A company called Scanadu has a prototype handheld diagnostic device that (at least according to their website) will debut in a little over a week. Although I agree with Dr. Gregg that it has huge potential to empower consumers with auto-diagnosis tools, I really have to wonder about the entire premise.

Their trailer video is quite engaging. They walk through a parent diagnosing their child’s rash, a mom receiving a warning about a whooping cough outbreak and the fact that her daughter needs an additional immunization, and parents diagnosing their sick child with a potential urinary tract infection and being sent to an urgent care facility. The voiceover states, “We’re building a way for people to check their bodies as often as they check their e-mail.”

Like so much today, some technology is surrounded by a lot of hype. While I don’t doubt that this is going to be a very cool and potentially powerful technology, I have some concerns with it. It feeds into the idea that we just have to embrace technology and we will live happier, more fulfilled lives.

I’m betting most Americans will hope that at the end of the diagnostic algorithm, it suggests a single pill that can fix everything. Just a few seconds of scanning a day will convince us that everything is OK.

Guess what? It’s not OK. Americans are fatter and more unhealthy than ever. We don’t need any miracle technology to tell us this. There are simple things we can do every day for our health that we are simply unwilling to do because they’re not sexy or high tech. They’re hard work and involve difficult choices and possibly sweat.

Physicians and other health providers have been preaching these things for years, yet people do not follow these recommendations. Will it make a difference if the recommendation comes from an impersonal device? I doubt it. I’m willing to keep an open mind, though, if there is even a small chance it will make a difference.

I’d like to live in an age where people are as obsessed about their body mass index as they are about finding out what Snooki named her baby. An age where people sit around the pub comparing their best fitness data instead of the statistics of their fantasy football teams. An age where I never have to diagnose another child with diabetes.

The folks at Scanadu have a great tagline: We are the last generation to know so little about our health. I really don’t think that’s true. I think we know a lot about our health. We’re just unwilling to do anything about it.

I look at my thousands of co-workers at Big Hospital. We all have to check our biometrics every year in order to get the best discount on our health insurance premiums. But looking at our population as a whole, having this information hasn’t led to a tremendous cost savings or healthier employees. People know their numbers, but they simply don’t care. They don’t want to give up habits or behaviors they find pleasurable. They haven’t come to grips with the fact that in the end, it’s a zero-sum game. Unless you’ve won the genetic lottery, each of us has to pay for our dietary and exercise indiscretions.

Being a physician doesn’t make me any better than the next guy. I have weak spots for chocolate and martinis. Those who know me really well know that I also have a thing for Buffalo chicken wings and all things fried. I love to watch bad TV and once became nearly vegetative watching a marathon of Deadliest Catch.

At the opposite end of the spectrum, I work with residency faculty members whose most indulgent meal is a baked potato with some olive oil and spices. They may get by on that, but I know that ultimately I am going to make less than perfect food choices and I’m going to have to balance it out with healthier meals at other times and also with daily exercise. I don’t take my health for granted – none of us should.

Technology can be a great motivator to help people track their health. I love reading HIStalk Mobile and seeing all the cool trackers and apps that Dr. Travis finds. I’ve even tried some of them. Recently a community group I’m part of decided to take part in the Presidential Active Lifestyle Award challenge. We created a group where we could log our activity and track some group goals as a motivator. As a community group that mentors youth, the adults have a vested interest in making healthier lifestyle choices so we can serve as role models.

After two months on the challenge, we have exactly four people who are willing to go online and log their activity, and only two of them are actually active. It’s a sad commentary. (I have to think we’d have better participation if The President’s Challenge had a mobile app, but alas, they do not.) Today I can’t even log in. We can put a man on the moon, but we can’t handle our exceptions, apparently.

I’m looking forward to seeing what Scanadu has in store for us. Having served on the sidelines for youth sports teams, I’d love a hand-held scanner that can help me determine the prognosis for a concussion or whether that student with mononucleosis really has an enlarged speen and needs to sit on the bench. As someone who cares for children, I’d love something that can reassure a parent when their toddlers slip in the tub and hit their heads. I’d be thrilled with any handheld device that can actually get people excited about their health and convince them of the need to eat less junk and move their bodies regularly. Unfortunately, I’m just a little bit skeptical at the moment.

E-mail Dr. Jayne.

Readers Write 9/3/12

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.

Routine Killer
By Bill Rieger

I was at a conference recently. Before I left, I was looking forward to getting away and enjoying the sights, sounds, and energy of Chicago. The first few days were awesome, filled with several miles on foot experiencing the Magnificent Mile, Navy Pier, Lake Michigan waterfront, and several good restaurants. 

By the third day, I started to feel “it.” I wasn’t sure what "it" was, but I knew it was uncomfortable and it was starting to impact my trip. By Friday, I was drop-dead ready to return home. You know that feeling. Tired, "problems" because of way too much restaurant food (OK, maybe that’s too much information, but it’s true), and sorely missing my wife and kids. 

The weekend was great and very busy. The weekend before the first day back to school is always crazy, but compound that with the fact that I had been gone all week and still hadn’t resolved what "it" was, I could have been a better husband and father.  

I got up Monday at 5:00, hit the shower, made the coffee, read for 30 minutes, prayed, got the kids up, made breakfast, got dressed, and walked out the door headed to my drive (which always includes a podcast of something educational or uplifting). It hit me. I figured out what "it" was. My routine had got way out of whack.  

As I started to consider this more, books I have read that speak to the significance of routine started running through my squirrel cage.  Podcasts I listened to and personal conversations I have had that reinforced purposefully creating a schedule started reverberating through my head.

One of the best books I have ever read relating to personal growth and development is The Compound Effect by Darren Hardy. He reveals a formula that I have adopted as a way to manage my own growth: 

Choice + Behavior + Habit + Compounded (over time) = Goals

The funny thing about this formula is that if you remove one of the addends, the sum could be reduced dramatically. The lack of routine in my trip, I believe, decreased my effectiveness on the trip. As a result, I didn’t get as much out of it or pour as much into it as I could have.  

As I continued to reflect on this, I started looking around me at who I influence: my wife, my kids, my co-workers, my team. The trip I took, at least to some degree or another, impacted their ability to achieve those goals that I’m helping them with. I am not saying here that the world revolves around me (or any one of us specifically), but we do have an impact on those around us. Even if you cancel the weekly meeting ahead of time, the routine is broken when you aren’t there. According to the formula, there is an impact.

This reflection has been a good one for me. The next time I travel, I will develop a schedule and routine for the trip. The next time I have to cancel a standing meeting with a staff member, I will try to think about how that is impacting the routine that is built into that relationship.

Routines and habits make up who you are. Our lives are defined by how we spend out time, talents, and treasures, I want to be as responsible and accountable as possible for all of these areas of life.

The takeaway: Routines have impact.  If you do not have habits or routines, take the time to make up daily routines and you will experience growth. The people around you will benefit immensely. I have a schedule I use as a template that I would be glad to share. E-mail me at bieger@gmail.com.

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

It Doesn’t Matter if Allscripts is “Open” – Their API is a Game-Changer
By Jonathan Baran

More and more vendors are thinking about going "open" — turning their EMR into a platform for third-party application developers. Allscripts is the first major EMR vendor to the party. Because of it, they are taking criticism for whether they are truly "open."

I’m here to say that it doesn’t matter if you call Allscripts open or not. Their API will create an ecosystem of innovation that will both solve provider needs and increase vendor revenue.

My company has first-hand experience with their API. This is what we’ve learned:

The Allscripts API removes the burden of integration away from the health system IT staff

For an EMR app to be truly useful, it will require data. In a pre-API world, you can use HL7 or a Web client to get some data, but what does it cost? It seems like regardless of how simple the project is, it will take three months of IT time. When tacked onto a list that is already 12 months long, there is a lot of waiting for an innovation to reach the light of day.

Compare this with an Allscripts world. Want to get an application integrated? Call your Allscripts sales rep and the app will be integrated that afternoon. The integration has been completed once with Allscripts API, which means it can scale to all their users on that single product. This simple elimination of IT time could have a profound impact on the pace of new technology adoption.

By using an API, applications can work in the background, minimizing the training and go-live time

Now that you have gotten the application integrated, it’s time to train the users. But of course that will not be easy, because HL7/Web client are a good source of clinical data, but demand a disjointed experience for the user. This requires awkward steps like seeing websites “embedded” in the EMR, having to click a button to transfer data, requiring users to copy and paste text, or needing to have a completely separate application. Even the simplest process becomes difficult when you’re asking users to take these pseudo-integration steps. I know this because we did it. Ugly.

Compare that with Allscripts. Everything can be done in the background. Want to pull tasks out of a task list and read the patient’s medication list? Want to have everything happen automatically in the background with no clicks? Done. It is easy to see how this could impact training and go-live. In the first example, every staff member in the organization needs to be trained on the "new system.” In the second, they don’t even need to know it is happening.

API level access means that your product can fit within the end users existing workflows

Workflow change is hard – really hard. The only easy way to change a workflow is to get rid of it. Eliminate steps. Remove clicks. How can you do this when by definition you are adding something? The answer is "addition by subtraction.” By getting deeper levels of integration, workflows can actually be made better.

This is only a small sample of the benefits that come to mind. Others include piloting (“Dr. CMIO, would you like to try the solution out this afternoon?”) and the App Store (find new apps in a single marketplace).

Jonathan Baran is co-founder and CEO of Healthfinch of Madison, WI.

EHR Donation and Accountable Care
By Jed Batchelder

I’m working with a healthcare system that is in the process of developing an EHR subsidy for the independent affiliated physicians in their community. They’ve just made a large IT investment, including EHR and HIE, and have started building a platform to help deliver accountable care.

Right now the challenge is how to structure the subsidy so it is attractive enough to entice physician adoption while remaining fiscally responsible for the sponsoring entity.

Much of industry is still living in the fee-for-service world, which is perfectly understandable given that’s how we get paid today. But we need to imagine and prepare for how that is all going to change in the coming years and make the right decisions now to prepare for it. We have the unenviable task of having to live and pay the bills in the fee-for-service world while investing in an infrastructure for the next value-based world.

Imagine you own a large retail store in the year 1997 and are trying to decide how much money to spend on web sites, computers, e-commerce solutions, and Internet connectivity. You can already hear the disagreement in the budget meetings and smell the fear in the room. You can’t yet see how the web is going to transform how you conduct your business, how sales transactions will occur, and how you’ll get paid.  

All of your revenue comes from customers who walk in the door of your stores, but you keep hearing about this thing called the World Wide Web and e-commerce that is supposed to be the next big thing. You could take a wait and see approach, possibly allowing a disruptive innovator like Amazon or Zappos to take your market share. Or you could pause and notice the ways that the world is already changing. (Best Buy just reported a 90% drop in earnings last quarter.) In a bricks and mortar retail model, large IT investments can initially look reckless, but once that new world arrives, you’re relieved that you took the risk.

When viewed solely from the view of the numbers, the EHR subsidy doesn’t make a ton of sense in the fee-for-service model. In fact, it looks more like a charity. But what happens when you look at it through a value-based ACO model, where providers will be compensated based on how well they jointly take care of patients, how well they coordinate the care, and how healthy their patients are? Just as it was difficult to predict the extent that the Internet would transform commerce, it is difficult to imagine what care will look like in a post fee-for-service world.

These points support both the idea that the hospital should take on more of the cost and the idea that independent docs should put more skin in the game, lessening the financial burden on the sponsoring hospital system. How far should we move the slider? How much skin should both sides put in? Who is more at risk by not having the connectivity and common platform? Who stands to gain the most and lose the most? These are perhaps the most pressing questions.

Jed Batchelder is an independent healthcare IT consultant.

Monday Morning Update 9/3/12

From HITEsq: “Re: McKesson. Won its appeal against Epic for patent infringement. The Federal Circuit, en banc (i.e., before all the court of appeals judges), overturned existing law to find in favor of McKesson. The case is remanded to the lower court to decide if Epic really does infringe.” It’s a complex issue, and since I covered it when McKesson lost the original appeal in April 2011, I’ll recap from there. McKesson said Epic’s MyChart violates a McKesson patent for a method of placing visit-specific patient information on a Web page so that patients can schedule appointments and request prescription refills. The original  “joint infringement” decision (about which the three-judge panel argued a lot) was that Epic wasn’t liable since it doesn’t directly offer those capabilities, but rather allows individual patients to request MyChart access subject to the approval of their physician. Since no single party violated McKesson’s patent, the original court said Epic wasn’t liable. Legal experts are troubled with this latest decision, which appears to make “inducing infringement” actionable even if no infringement has been proven. All of this is way over the heads of mere non-lawyer mortals like myself who can’t resist snickering while repeating phrases from the document like “joint tort feasor” in humorous voices because it’s just so weird and funny, so if any legal beagles wish to expound pro bono, here is your electronic lectern.

Patent on personally controlled health record with notation of source/ authority (filed 3 yrs ago) HT @craigjoseph patft.uspto.gov/netacgi/nph-Pa…”

— Farzad Mostashari (@Farzad_ONC) August 31, 2012

From Lex Luther  Van Dam: “Re: Epic’s patent for a patient-controlled, patient-generated health record. This is bizarre. Much of this was already on the market when the patent was filed, so either Epic didn’t know or forged ahead anyway, and either is not good. Epic has seemed indifferent to patients controlling their own information, to the point that they don’t even talk about Lucy, their own PHR solution, and they certainly don’t cooperate with anyone else offering a PHR solution.” My guess is that this patent either covered Lucy when it was first being developed or was simply a legal stake in the ground to prevent further legal incidents like the McKesson one above. I also don’t know that Epic’s customers, being turf-protecting and somewhat patient-paternalistic academic medical centers, have a heartfelt interest in empowering their patients via PHRs from Epic or anyone else. Or for that matter, avoiding the “walled gardens” between proprietary EMRs that Farzad was railing against given that Epic-to-Epic direct data exchange has displaced the interest in a vendor-neutral exchange in some areas where most of the major players run Epic.

From MU Nick: “Re: worksheet. Has anyone created a worksheet for MU2 for the EP and EH requirements (as opposed to a PDF?)” If you’ve put something together and are willing to share, let me know.

From DanburyWhaler: “Re: Western Connecticut Health Network. Hired Steve Laskarzewski, Waterbury’s former CIO, as clinical applications director. Looks like they’re grooming him for the top spot when Kathy DeMatteo steps down later this year.” Steve’s LinkedIn profile says he started in June. He’s one of the 2,716 members of the HIStalk Fan Club that reader Dann started years ago, so he gets a shout out.

From Douglas: “Re: Mr. HIStalk. Why do you use that name?” I needed an e-mail address when I started HIStalk back in 2003, and being in a minimally creative mood at that moment, the best I could come up with was mr_histalk (the name HIStalk itself was equally lame, with the HIS standing for Hospital Information System, which was in vogue at the time). I had zero readers and minimal expectation of gaining any, so I didn’t give it much thought. I don’t recall having actually called myself that at any point, but readers did over time, and then Inga at some point shortened it to Mr. H. It feels odd since I have never even once referred to myself as Mr. Anything in real life since I’m not too impressed with titles in general. My latest pet peeve: family members of dead doctors who stick “Dr.” in the title of their obituary listing instead of just their name like everybody else does, apparently hoping that like Egyptian boy kings, their most valued earthly possession will carry over into the afterlife. Putting “MD” after your name is perfectly fine on your office door, as is “Doctor” in front of your name is for professional encounters. A doctor who is so deficient in self-esteem as to demand the use of those titles in social situations when nobody else is calling themselves Mr. or Ms. is, in my opinion and experience, an arrogant ass. Lots of people earn doctorates, many of them requiring more education than a medical degree, and yet it’s most often an MD (or, in the case of male MDs, their wife) who insists on cramming their title down everybody’s throat at the auto repair place or at school meetings (my theory: that’s why hospital administrators enjoy putting physicians in their place). So, to complete my circular logic, the Mr. HIStalk thing is not indicative of a superiority complex since if anything, my tendency is the opposite.

It’s Labor Day, so I am appropriately laboring (in the non-obstetrical sense). I hope your holiday is – or was, depending on when you’re reading – delightful.

We are collectively fatigued with the endless Meaningful Use palavering, apparently, as 46% of respondents say they are indifferent to release of the Stage 2 rules. Of those who cared, reaction was split between positive and negative. New poll to your right: if the presidential election were being held today, who would you vote for? An online issues quiz says that I’m exactly evenly split between the two major candidates with a 63% alignment with my beliefs for each, but both are far dwarfed by my 91% match with Libertarian candidate Gary Johnson, who I’d never heard of until I took the quiz. That leaves the same options I had in the last presidential election: vote for either of two candidates that I would dread seeing take office or vote for one I’d like to see win who doesn’t have a chance.

Surescripts acquires Kryptiq, of which it previously owned a 21% share. Surescripts uses Kryptiq’s secure messaging technology for its network. Other healthcare IT vendors are also among its customers (GE Healthcare and Vitera), and its other offerings include clinical messaging, a patient portal, and electronic prescribing. Kryptiq announced earlier this year that its revenue grew 60% and its user count exceeded 40,000.

Cambridge Health Alliance chooses EDCO’s Solcom electronic document management system for managing historical paper records and paper documents originating outside of CHA. It will integrate that information with its Meditech and Epic systems to eliminate the file room and hybrid record environment.

Joint Township District Memorial Hospital (OH) chooses the Optimum general accounting suite from NTT Data. The company also announces that its NetSolutions Point-of-Care clinical and billing system for long-term care facilities will now send care data toAssured Proactive Analytics to optimize payment.

A Wells Fargo Securities report sent over by a couple of readers says that hospital users of Meditech, Cerner, and CPSI lead the pack in total number of Meaningful Use attestations through June 30. On the ambulatory EHR side, it’s Epic, Allscripts, and eClinical Works, although Epic would drop to third if it didn’t have 10,000 Kaiser doctors of its 15,000 attestations. Of new attestations, it’s Cerner and CPSI leading for hospitals (those same two vendors also led in the overall percentage of client base attesting) and athenahealth and Practice Fusion for EPs. A reader, however, notes that the numbers suggest that Epic has 650 hospital customers, which seems awfully high, so there’s always the question of what’s behind the data.

CoCentrix hires Clayton Ramsey (Elsevier) as SVP of delivery.

I chose this graphic in mentioning the new KLAS evaluation of Meaningful Use consulting firms a few days ago and regretted it the next day when I had more time to ruminate on it. I’m unhappy with how KLAS presented the graphic since they committed the cardinal sin of not setting the Y-axis of the graph to zero. That’s usually a red flag indicating that someone is trying to make an overly dramatic point that their data points don’t support. In this case, the actual range of consulting firm “money’s worth” scores was 7.1 to 8.8, which are pretty good numbers within a fairly narrow spread. The KLAS graph only shows the range of 7.0 to 9.0, making it appear that huge gaps separate the firms, which is absolutely not the case. This doesn’t give me a lot of confidence that the behind-the-scenes work at KLAS is statistically rigorous, a often-made but never-answered charge. I would also question whether this graphic means anything at all considering that the Y-axis is customer-reported value, while the X-axis is “relative cost per resource,” whatever that means. Should we infer that a company with a high per-resource cost can’t be worth it no matter how satisfied their customers are? My main gripes with KLAS (and the Most Wired surveys and HIMSS Analytics and so on ) is their tendency to take a modest amount of data and over-extend it to lofty conclusions using a black box that nobody’s allowed to peer into. I like what they do, but as we healthcare types say, “In God we trust – everybody else bring data.”

Among the speakers at this past weekend’s health IT conference in Hyderabad, India were Lee Shapiro (Allscripts president) and Marc Probst (Intermountain Healthcare CIO).

TeraRecon launches its iNtuition Review, iNtuition Enterprise Medical Viewer, and iNtuition SHARE at the AOCR/RANZCR radiology conference in Sydney, Australia. The products provide multi-modality review and the capability to distribute images throughout the enterprise via a browser-based viewer.

Cancer Care Group (IN) announces that medical information of 55,000 patients and the organization’s own employees was exposed when server backups were stolen from an employee’s locked car. The announcement leads off with, “Patient confidentiality is a top priority,” which is apparently now a bit closer to the truth since they’re suddenly considering encrypting backups and mobile devices. It’s an immutable rule that nobody encrypts anything until they are publicly embarrassed for not having done so, and then they can’t jump on board fast enough.

Novant Health (NC) rolls out a screensaver featuring former UNC star Michael Jordan to remind employees of its zero-tolerance handwashing program, launched in 2005 after three premature babies died in one of its hospitals from MRSA infection. The source was tracked back to staff who hadn’t washed their hands, which Novant found was common with a compliance rate of only 49%. They’re at 98% now.

In Australia, a hospital CEO sues a nurse who he says disparaged him in her Facebook comments that were brought on by a labor dispute. One of her comments: “We don’t take kindly to misinformation by well-paid fat cats who only visit the hospital wards for photo opportunities.”

Surgeon and best-selling author Atul Gawande, one of the most visible and respected people in healthcare, apparently is sold on the use of analytics but  isn’t a fan of using technology in his own practice. Some snips from a recent interview:

• I do use the iPad here and there, but it’s not readily part of the way I can manage the clinic. I would have to put in a lot of effort for me to make it actually useful in my clinic. For example, I need to be able to switch between radiology scans and past records … I haven’t found a better way than paper, honestly. I can flip between screens on my iPad, but it’s too slow and distracting, and it doesn’t let me talk to the patient.
• I think that information technology is a tool in that, but fundamentally you’re talking about making teams that can go from being disconnected cowboys in care to pit crews that actually work together toward solving a problem.
• I worry the most about a disconnect between the people who have to use the information and technology and tools, and the people who make them. We see this in the consumer world. Fundamentally, there is not a single [health] application that is remotely like my iPod, which is instantly usable … In many of the companies that have some of the dominant systems out there, I don’t see signs that that’s necessarily going to get any better.
• The reason [data analytics] works well for the police is not just because you have a bunch of data geeks who are poking at the data and finding interesting things. It’s because they’re paired with people who are responsible for responding to crime, and above all, reducing crime … That’s what’s been missing in health care. We have not married the people who have the data with people who feel responsible for achieving better results at lower costs.
• Timeliness, I think, is one of the under-recognized but fundamentally powerful aspects because we sometimes over prioritize the comprehensiveness of data and then it’s a year old, which doesn’t make it all that useful. Having data that tells you something that happened this week, that’s transformative.

More on Keane’s HIS-tory this week from Vince.

E-mail Mr. H.

Time Capsule: The Incentive Misalignment Between IT Leaders and IT Projects: Why CIOs Set Unreasonable Expectations

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.

The Incentive Misalignment Between IT Leaders and IT Projects: Why CIOs Set Unreasonable Expectations
By Mr. HIStalk



Spoiler: because projects would never get done otherwise.

A recent Canadian report provides a good overview of the how clinical information systems are (or more precisely, aren’t) improving patient safety. As simple as it sounds, one recommendation struck me as being profound: “Expectations for EHRs and patient safety must be realistic.”

Why that’s interesting: big clinical system projects would never get done unless the CIO takes an internal salesperson role, not much different than the salesperson who sold the hospital on the (unrealistic) system benefits in the first place. In other words, CIOs have to set false hopes to get projects going. If users knew what was coming, they’d opt out.

Users (played by Tom Cruise): “I want the truth.”

CIO (played by Jack Nicholson): “You can’t handle the truth!”

Maybe that’s why system users become disillusioned, vendors feel customer heat, and CIOs get fired. Everybody has an incentive to overstate the likely benefits, right down to the point where those benefits don’t materialize. Then, let the finger-pointing begin.

Systems have gaps of various sizes between what customers expect and what they actually get in the form of real, working software that they’ll use optimally. How big the gap is depends on two things: (a) the product, and (b) the customer. The money’s been spent, though, and the higher powers want to see the results that everyone agreed to in that innocent, long-ago moment of pre-purchase euphoria.

The result: disappointments and delays must be glossed over. IT types huddle behind closed doors with the same fervor as vendor marketing departments, carefully crafting the message, singling out project friends and enemies, and enlisting shills to vouch for inevitable wonderfulness of it all. The IT department knows the ugly underbelly of what’s ahead, but a grin-frozen face must be presented so users won’t panic. IT and its users have become uneasy enemies.

Beyond even that irrational exuberance, CIOs are sometimes create further damage. They push automation as a great way to implement organizational change because that’s what IT cheerleaders are supposed to do. They override popular voting for which system to buy. They overestimate the capabilities of their own stretched department to implement and support new applications. And worst of all, they sometimes unwisely let themselves be cast as project champion or owner.

You don’t want to own something you can’t control. You’ll be constantly begging everybody else to donate their resources to what has suddenly become your project. Executive supporters suddenly can’t spare their own folks to get it done. Before you know it, it’s CIO Giant Sucking Sound 2.0.

Hospital operational executives can’t control clinicians day to day. It’s CIO hubris to think that a tiny, stretched IT department can lead organizational change from the cheap seats. That’s never happened and it never will.

The project champion must be an operational leader who’s responsible for most of the affected areas and who can deliver the expected results. That person, along with a team of stakeholders, should define the need for automation, lead the selection process, oversee implementation, and set and measure benefits and outcomes. They should also weigh the inevitable (and often justified) objections of clinicians worried about patient safety.

It’s a shame that the only way to convince users and departments to change is to paint a falsely rosy picture of the likely result. If organizations had more willpower and focus, the need to deceive them to get projects done would be greatly reduced.

News 8/31/12

Top News

SAIC announces Q2 results: revenue up 8%, EPS $0.32 vs. $0.32, beating expectations on revenue and meeting on earnings. The company announced plans to split itself into two independent, publicly traded companies, one offering technical services and the other delivering solutions. Healthcare will be part of the solutions business. Shares are up 10% in after hours trading. SAIC acquired Vitalize Consulting Solutions in August 2011 and maxIT Healthcare in August 2012.

Reader Comments

From Klinger: “Re: Epic support. I always heard it was second to none, but what I’m getting is lacking. Have other people noticed, or is it just the TSs that I have?”

From Palmetto Jack: “Re: Palmetto Health. Not an affiliate of USC.” Thanks for the correction. Wikipedia says Palmetto Health Richland is affiliated with University of South Carolina and Palmetto Health’s graduate medical education page says the USC School of Medicine is a “partner and close affiliate,” so it’s one kind of affiliate but not another. I don’t really claim to know the difference.

From Honey Badger: “Re: Cerner. Heard a rumor that they will switch to Greenway’s ambulatory clinic EHR product.” Unverified.

HIStalk Announcements and Requests

This week’s top picks from HIStalk Practice: Consumer Reports publishes ratings on over 500 Minnesota practices. Practice administrators at large groups see a rise in median compensation, while their small practice peers experience a decline. AMA urges CMS to delay the move to ICD-10 by at least two years. Is HealthTap’s model viable in the long term? Physicians give high scores to Amazing Charts, Epic, and the VA’s ambulatory EMR. Practice Wise CEO Julie McGovern advises practices to avoid tackling other projects in the midst of an EMR implementation. We don’t have a Like button for our posts, so the next best thing is to sign up for the e-mail updates on HIStalk Practice. Thanks for reading.

Listening: new from Dispatch, their first new material since disbanding in 2002. The indie band hoped to draw 10,000 people to its free final concert in its home town of Boston in 2004, but instead became record-holders as the largest independent music concert in history when 166,000 fans came to say goodbye. The band’s mostly Northeastern tour starts in three weeks.

Welcome to new HIStalk Platinum Sponsor Health IT Quality Solutions, a certification program offered by Quest Diagnostics to vendors of ambulatory EHR products that support Quest’s DEX lab orders and results network. The program’s goal is to maximize lab data quality and enhance interoperability for the 500,000 patients per day that use Quest’s testing services. Three certification tiers are available based on solution capabilities, implementation processes, and participation in mutually beneficial activities. The entire program is free for vendors who qualify, with benefits that include customer satisfaction, solution visibility, faster interface approval, and priority access to Quest’s IT staff. Download a brochure and take a look at the several vendors that have already earned certification. Thanks to Quest Diagnostics and Health IT Quality Solutions for supporting HIStalk.

Acquisitions, Funding, Business, and Stock

Greenway announces Q4 results: revenue up 24%, EPS $0.07 vs. –$1.09, missing on earnings expectations. The company also projected lower than expected earnings for FY2013. Shares fell 7.1% on the announcement, making GWAY the biggest percentage loser of the day on the New York Stock Exchange. Shares priced at $10 in its February IPO are at $15.27.

Sales

The 300-provider Cornerstone Health Care (NC) selects MedAptus Pro Charge Capture solution for coding and billing.

People

HealthTech Holdings hires Stan Gilbreath (Allscripts) as VP of client services for its HMS and Medhost divisions and Eric Anderton (Jackson Key Practice Solutions) as VP of new account sales for HMS.

Joe Miccio (maxIT Healthcare) joins Divurgent as client services VP.

In Canada, Nancy Martin-Ronson RN, who joined Peterborough Regional Health Centre three months ago as CIO, will also take on the role of chief nursing officer.

Arkansas Governor Mike Beebe names Ancil Lea, executive director of HITArkansas, as coordinator for the Arkansas Office of Health Information Technology.

Announcements and Implementations

The Karmanos Cancer Institute (MI) implements Versus Advantages RTLS in once of its clinics to monitor patient location, track throughput, and manage workflow.

McKesson will offer NovoPath’s anatomic pathology solution to its LIS customers.

Craneware earns CMS’s Electronic Submission of Medical Documentation certification, allowing it to offer customers the ability to electronically submit medical records to review contractors.

Government and Politics

ONC names CCHIT, the Drummond Group, ICSA Labs, InfoGard Laboratories, and Orion Register as certification bodies under the Stage 2 certification program.

Farzad Mostashari says that ONC will not allow EHR vendors to drag their feet in supporting data exchange with competing EHRs.

Other

KLAS names its top-rated Meaningful Use consulting firms in three categories: Impact Advisors (enterprise implementation leadership and advisory); Cumberland Consulting (team implementation leadership and advisory); and Navin, Haffty, & Associates (team implementation leadership and staffing). Of the 51 firms identified, more than half achieved satisfaction scores of 89 or above out of 100.

SCI Solutions announces record growth for the first six months of 2012, with 82 hospitals choosing its solutions for care coordination, referral management, and scheduling.

Queens Health Network (NY) honors Congressman Joe Crowley for supporting ARRA, which will pay the hospitals and clinics of New York City Health and Hospitals Corporation up to $200 million.

Madison Memorial Hospital (ID) unblocks access to Facebook from its wireless network after patient complaints. One employee said it was “stupid” that as a patient, she couldn’t post photos of her newborn baby on Facebook. A newspaper reader was more rational: “What an inconvenience when we have to go to a hospital and we can’t get on Facebook. I guess most of us in this day and age feel entitled to more than that what we get.”

Real estate sources say that Meditech is finalizing a deal to acquire 200,000 square feet of office space in Foxborough, MA. The company abandoned plans for a Freetown, MA campus earlier this year after running into a mountain of red tape triggered by the discovery of native American artifacts on the property.

Epic not only submitted MU Stage 2 comments to ONC, it even helpfully distributed them to their customers so they could submit the same comments under their own names. David Clunie noticed this and lists the hospitals who sent in the boilerplate, including University of Miami, which submitted the same comments five times without noticing the “Remove Before Submitting” headline that prefaced Epic’s explanation of why its customers should share its opinions with Uncle Sam.

In Kenya, the country’s hospital insurance fund won’t issue insurance to a man who claims to be 128 years old because its computer system can’t handle birth years before 1890. His family says they don’t appreciate the implication that he should be dead, and until the issue is sorted out, he’s relying on the insurance of his youthful wife of 89.

Odd: a 29-year-old man sues the maker of the sexual enhancement supplement VirilisPro, claiming that the ensuing sex with his partner in a Scottish Inn damaged his manhood to the point that blood was squirting out onto the walls. A physician expert says the man’s story is “the most absurd thing I have heard of in my life,” explaining that men often arrive embarrassed in the ED with damaged sex organs and make up elaborate stories to explain their predicament. He says, “The most common one told is they walked into an ironing board.”

Sponsor Updates

• Billian offers its fellow HIStalk sponsors discounts on first-time purchases of its programs for vendors, including the HealthDATA database and prospecting portal and Porter Research market analysis.
• NextGen will integrate the TRUEresult blood glucose monitoring system from Nipro Diagnostics into NextGen Ambulatory EHR.
• Velocity Data Centers hosts an open house at its Ann Arbor, MI facility on October 25.
• T-System offers two September 5t webinars on attesting to MU with T SystemEV.
• HealthStream expands its suite of products with the addition of NurseCompetency’s exams and skills checklists.
• Cumberland Consulting Group promotes Christopher Miller to principal and Jennifer Vesole to executive consultant.
• Emdeon expands its Clinical Exchange solution to include e-prescription routing, lab orders and results exchange, care alerts, medication history, and clinical messaging.
• Worldwide Clinical Trials selects Merge Healthcare’s eClinical OS solution for data capture, processing, and reporting on clinical trials.
• ICSA Labs hosts two September webinars to help EHR technology developers understand the 2014 Edition certification criteria and testing requirements.
• A CareTech Solutions white paper offers customer insights on achieving Meaningful Use Stage 1 for the 82% of hospitals that haven’t completed it yet.
• Kareo updates its website and branding to reflect its commitment to small practices and billing services.
• TeleTracking invites hospitals to visit its new Enteprise Solution Center in Raleigh, NC to try its capacity management solutions hands on without the time challenges of a site visit.
• An informatica blog post covers Hadoop and big data.

EPtalk by Dr. Jayne

I often wonder how Mr. HIStalk does it all, balancing his day job with his HIStalk duties. He’s done an amazing job for just short of a decade, so when I run across a bit of writer’s block, I know I have no reason to complain.

The last few days have been bereft of ideas. Maybe it’s the weather (I hope all of you in storm-tossed areas are safe) or maybe it’s just the end-of-summer doldrums. I was particularly pleased, though, when an idea squeezed its way into my mind this morning (pun intended, keep reading).

Why All the IT in the World Will Not Fix Health Care

Like many women, I go every year for a certain radiologic screening test. This year’s adventure was a prime example of why technology is not necessarily the answer. There was a fair amount of hassle in my attempts to complete this testing, and it largely revolved around people failing to look at the monitors right in front of them.

First, I had to schedule. As in previous years, I scheduled over the phone. I have my films done at an independent imaging facility, which is funny being the CMIO of a pretty good-sized hospital. Frankly, despite all the HIPAA training, I don’t trust the hospital staff to not discuss employees who are patients. The imaging center also charges half the amount the hospital does, which makes sense with my insurance coverage limits. Plus, I don’t want to have to disrobe for people who I might have to later “counsel” about their bad EHR habits.

The first annoyance was when I was asked (after the staffer pulled up my account) whether I’d been there before. I chalked it up to someone just following a script without thinking about what they were asking. Knowing the billing and scheduling system they use, she should have been able to see the date of my last visit on the patient information screen.

Due to family history, I’m being screened at an age much younger than the standard recommendation. Because of this, I know exactly what my insurer will and will not cover. Luckily, I have a “pseudo health savings account” type of coverage which allows me a lump sum (no pun intended) for preventive services. I can use it as I see fit — exams, labs, tests, etc. — as long as they’re preventive in nature.

The staffer proceeded to argue with me about needing a physician order for the screening test, citing, “Your insurance won’t cover it without an order.” Being a doc (and a savvy patient), I know what they cover and how they cover it. I reminded the scheduler that I’ve never needed an order in the past (especially since my state allows women to have screening mammograms without an order).

She was insistent, so off I went to call a physician. I was tempted to just write my own order, but that would have been too sassy even for me. I just shook my head at the barriers to care that were being placed in front of a paying patient with a valid medical need.

Even though I regularly drink martinis and hang out with my personal physician, I didn’t want to abuse our friendship with something so clearly silly, so I called the office. They unfortunately are pretty early in their EHR transformation and do not yet have a patient portal (which would have been ideal for something like this – e-mail the request, get the order electronically, and be done with it). I survived phone tree hell and reached a nurse (they didn’t have a choice for “Press 3 if you need an order that you don’t really need, but it’s totally not urgent, requires no clinical skill, and you’re embarrassed to even have to ask for it.”) Luckily it was a nurse I know, who laughed with me and agreed to mail the order.

It was with my order in hand that I dutifully arrived 15 minutes early this morning. No one asked for it. After a few minutes of deliberation (while filling out the same information on a paper clipboard that I fill out every year), I decided to proffer the order. The receptionist handed it back to me kindly, telling me they already have my physician’s information on file and don’t need orders for screening tests.

For the actual testing, the imaging center has an excellent facility, caring staff, and “on demand” results, which is another key reason I go there. Who wants to wait to get results in the mail (or even from a patient portal) if you can get them directly from the radiologist while you wait? Especially for cancer-related screenings. If it’s not normal, I want to know right away, so I value the service they provide.

The technician didn’t bother to look at my record, instead asking me if this was my first screening, and if not, how many films have I had and where were they done. At this point, I was ready for a mint julep or perhaps some smelling salts.

Fortunately, the radiologist did take the time to look at the previous films and determine there was no change (which was good, because sometimes I have to have additional views and was spared that particular fun) and came in to chat. He knows I work for Big Hospital and usually has something funny to say about my not using their radiology department. I in turn tease him about the candy-colored kiosks from Merge Healthcare that I tried to get them to purchase a few years ago to spice up their lobby.

I decided to gently broach the details of my experience and my concerns about barriers introduced that might have been important to less-savvy patients. He’s an owner of the facility, so he has a significant interest in the amount of money spent on technology. He seemed genuinely frustrated that employees are using old paper-based processes rather than new ones supported by the technology at hand.

He pulled up my record and showed me that I am clearly flagged as high risk, an existing patient, and as a VIP (although apparently my VIP status is funny to his partners since I’m an exec at the competitor — it seems I’m not the only one.) He plans to address the workflow at the weekly staff meeting, which I appreciate.

Still, as a physician, patient, and payer (aren’t we all payers these days?) I find it striking how difficult it is to achieve ideal healthcare. In my dream world, patients are only asked information once (unless they’re asked to validate their existing information) and the staff uses the information at their fingertips to provide high-quality, expedited care. Even in a facility with a very favorable payer mix, well-paid staff who don’t appear overworked, engaged owners and managers, and a huge IT budget, they’re still part of the healthcare problem, and technology just isn’t going to fix it. Until we start addressing process, procedure, and performance, we’re just throwing money and technology at the problem.

On a lighter (but still feminine) note, an old friend of mine made my week by sending an article about the new Bic pens “for Her.” Of course, I had to go to the actual Amazon UK website and read the reviews for myself. In the words of one of yesterday’s reviewers, “If they made Bic for Her keyboards, I could write this so much easier! Darn my silly lady hands …”

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Interviews Joe Frassica, MD, CMIO, Philips Healthcare

Joseph Frassica, MD is VP and chief medical informatics officer of Philips Healthcare and a senior consultant at Massachusetts General Hospital.

Tell me about yourself and the company.

I am a physician and I serve as chief medical informatics Officer for Philips Healthcare’s Patient Care and Clinical Informatics Business Group. Patient Care and Clinical Informatics is one of three major divisions within Philips Healthcare: radiology imaging systems; home health, devices, and services around the care of patients in the home; and everything else we do, which includes clinical informatics, decision support, monitoring, therapeutic devices, defibrillators, ventilators, and a special division that’s very close to our hearts called Maternal and Child Care, a business unit that focuses on the care of infants, children, and mothers.

How does that all roll up into an approach that’s different from software-only vendors?

From my perspective, Philips is in a bit of a better position. Sort of like Apple, in that we make hardware and software. Our hardware is a large part of the business, which includes our monitoring devices and therapeutic devices. From the insight we gain from creating the hardware, we have become experts in the part of informatics that’s related to the hardware, how clinicians use it, and how it fits into the workflow and the data that’s derived from it.

Software vendors are really antsy about crossing over into the FDA-approved side of the business. They probably won’t encroach much on your turf, but you may encroach on theirs. What’s the grand plan for Philips and informatics?

That’s a tough question to answer because there are so many facets to it.  I can tell you that we feel our core competence is in the use of near patient information – the high resolution, near patient information — incorporating that with information from the rest of the informatics universe within the healthcare system to create knowledge for clinicians at the point of care. It is definitely our sweet spot.

Clinical content such as evidence-based guidelines, data warehouses and analytics, and the constant stream of real-time information from biomedical devices have suddenly drawn a lot of interest and challenged what the universe of the electronic medical record looks like. Do you as a physician see that changing how medicine is practiced?

I think there’s great potential to utilize that information to effect outcomes for patients. In the past, this high-resolution information that streams from our devices and streams from the patient reflecting their physiology … we used to throw it on the floor and then throw it out. We would take little snippets of it. We would take an hourly blood pressure, let’s say, and commit it to the record. The rest of the information that was hidden deep within the signals we would dispose of. We didn’t really have any way to process or use it within the EMR environment. Or within the paper environment, for that matter.

Now with the advent of cheaper storage and better interoperability for the kind of information that we deliver from patients, we believe that that information can be harnessed to improve care in ways that we haven’t anticipated when we started to collect information in transactional systems like the EMR.

I read an article about patient condition warning systems and Philips IntelliVue Guardian showed clear benefit in the ICU in the Melbourne study. Not coincidentally, hospitals have gotten in trouble for failing to act on patient device alarms. Can technology help filter out the nuisance alarms and send to clinicians only those patient alerts that are useful?

Absolutely. IntelliVue Guardian is a solution that we designed to work in the lower-acuity setting. We know that when you apply an ICU monitoring solution to the lower-acuity setting, users face a number of challenges.

One of the challenges that they face is that the monitoring that’s designed for the ICU is often tuned for patients who have a high likelihood of a problem developing. Patients in the sub-acute setting are different. They don’t have a high likelihood of deteriorating, but they do have a possibility of deteriorating. You need a different kind of approach to monitoring those patients so that you don’t create a lot of false positives,  but you create a safety net. If they start to fall, if they start to deteriorate, you catch them before the crisis happens or before they need significant resuscitation and more expensive and more serious care.

I think having solutions that are designed for different patient population makes sense. It will help improve the landscape of noise and advisories that are happening within the hospital and help make them more relevant for particular patients.

The nurse has discretion about alarms, and when you’ve heard the same alarm 100 times, confirmation bias makes it hard to catch that hundredth time where it’s critical. Are hospitals seeing benefits and getting to the point of being able to prove the benefits of smarter alarms?

Absolutely. I am part of the Healthcare Technology Safety Institute’s alarms group. It’s a group of folks from academia, from the industry, from the research community, and from agencies that have an interest in regulation of medical devices. We’re trying to come up with the appropriate research imperative to help us improve the alarm landscape, as well as what can be done immediately to help improve it.

On the public front, we’re actively involved in the effort of the Association for the Advancement of Medical Instrumentation to improve the alarm landscape. In addition, we have a large number of folks who sit on standards committees which actually help to create the rules around the delivery of these vigilance alarms. Internally within Philips, we have a very large group that I lead of researchers, clinicians, research and development folks from around the world, as well as marketing and consultancy teams, that are working internally to help us make our alarms as smart as we can make them.

There are tools that we already have built into our products that can help to improve the current landscape that you see talked about in the newspaper. We can help healthcare organizations improve based on our current tools, but we’re also looking to the future to make alarms smarter and more likely to signal clinically significant events than standard, single-parameter alarms are today.

That’s similar to the path followed by clinical decision support, where it first didn’t do much of anything, and then it did everything to the point that physicians got lost in the noise. Now investments are being made to make it smarter with fewer alerts. Is the alarm paradigm that you should eliminate the ones that aren’t useful, but also escalate when appropriate?

Yes. There are significant rules around how you deliver alarms and what we are required to do. Generally, I look at it like just exactly as you described CDS. We’ve created very sensitive tools that have created an environment where sometimes the noise is more than the signal.

In the CDS world, I remember when we implemented our EMR in my last organization and we turned on the drug-drug interactions, we looked back and we saw that 98% of drug interactions — even the significant ones — the clinicians just ignored. Completely ignored. That’s consistent with what everyone else has found as well.

The reason was, I think, that drug-drug interaction information didn’t present information that the clinician thought was consistently helpful. It didn’t present information that the clinician felt would help them make the right decision, rather than telling them that they were making the wrong decision.

There are two sides to it. You have to not only help the clinician know when they’re going to make the wrong decision, but guide them to the correct decision as well. Drug-drug interaction information, that kind of basic clinical decision support, was always presented at the wrong time. When the clinician is most pressured, it’s pushed in front of the clinician when they wanted to finish the order. They typically would just blow through it.

We think of alarms as potentially decision support as well. They need to be tuned so that they provide significant information to the clinician — actionable information — and they need to be tuned to the workflow of the clinician. When you said should they be escalated, for sure there should be paradigms where alarms can escalate. That’s outside of the part of the regulated space where we deliver vigilance alarms today, but there’s no question that escalating alarms that are unanswered can be helpful to be sure that no alarm that significant goes unanswered.

The trick, though, is if you escalate every alarm that’s unanswered, then you create more alarms. It’s a challenge not to take a situation that’s difficult and make it worse by creating alarms that now ring on everybody’s pager.

Philips is active in home monitoring. Is that more of a challenge because there’s nobody paid to sit around to stare at incoming data signals for all these folks that are being wired up with all kinds of sensors at home?

Alarms around home monitoring are regulated differently. We have different latitude to deal with them. You wouldn’t want to create a lot of false positives in the home, and patients in the home are less likely to have events. If you monitor them in a traditional fashion like you would a patient in the ICU, you’ll get a huge number of false positives.

There has to be a different paradigm in the home, like there has to be a different paradigm in the sub-acute setting, where we monitor for subtle changes and trends that then alert the clinicians to go and care for the patients before they deteriorate significantly. In the ICU, if the heart rate changes above a certain limit, the alarm goes off. In the home or in the sub-acute setting, the heart rate is one factor in determining whether the patient needs an intervention. Combining these things into something like the early warning score like we do with Guardian helps the clinicians focus their care on the patients that need it most at the right time.

The eICU concept is one of those Gartner Hype Cycle things that got everybody excited, then it went quiet, and now it’s almost a given that it’s out there and working. What are hospitals doing with eICU and what success have they seen?

The eICU is a solution that fits a lot of healthcare organizations’ needs. Over the past couple of years, there have been proof points that have been published. One in particular showed a 20% decrease in mortality among the patients in ICUs that were cared for within the eICU setting. Savings in length of stay and adherence to guidelines are also part of that publication and others that have come out recently. We know that an eICU that’s highly functional and that’s really well implemented can affect outcomes in a very positive way.

I just read a fascinating article that talked about the people side of sticking a camera in an ICU with an expert peering over the shoulder of ICU clinicians. You would think that an eICU is just an intensivist who happens to be sitting off site, but in reality there is a lot of human dynamics in making sure the on-site clinicians feel part of the care team and not like they’re being Big Brothered.

Exactly. One of the secrets to success is building a collaboration between the remote clinicians and the bedside caregivers. The most successful telemedicine ICUs or eICUs have a tight linkage between the bedside and the remote clinician. They come to depend on each other’s judgment and on each other’s expertise by sharing respect and by sharing their insights over time. 

The other side of it is collaboration between the ICU physicians and the intensivists or other physicians that care for patients in person in the ICU. Both sides need collaboration.

One of the keys to VISICU’s success and for the continued success within Philips has been that they provide the clinical transformation services, the consulting that’s necessary to implement the service. It’s not just technology. A lot of it is people, as you said, and the people part is sometimes the most complex and needs that support that VISICU provides.

Interoperability is everybody’s buzzword at the moment. Tell me what IntelliBridge does and what people are doing with it.

IntelliBridge Bedside connects the data from multi-vendor point-of-care devices to the Philips monitoring solution. Then we have the next level up, which is IntelliBridge System, which connects up, again, multi-vendor devices from Philips and other vendors as well to our IntelliSpace clinical, critical care, and anesthesia solution, as well as with EMRs. The third level is Enterprise, which is between all of Philips’ products using one pipe to all of the enterprise systems — your hospital information system, your EMR, your CPOE, your lab, your ADT, or anything else, like a research database.

Our goal with IntelliBridge Enterprise is for healthcare organizations to be able to simplify their architecture, if they work with Philips, to create one point of contact with Philips systems through IntelliBridge Enterprise so that they create one ADT interface, one lab interface, one pharmacy interface, etc. We handle on the back end communication from IBE to our systems. That would simplify that spider diagram that we all have in the healthcare IT world of our IT architecture.

I know at my last organization, we had a diagram that had 85 individual point-to-point interfaces from our EMR. When we purchased an EMR, the purpose was to have a single data source. But when you looked at the architecture, it really in fact was 80 interfaces, and one of the data sources was the EMR. 

We know that that’s the reality. We as an organization want to not contribute to the complexity of the healthcare IT environment. We’d like to help simplify it. Creating one point for an interface to Philips systems is the goal of IntelliBridge Enterprise. When we update our systems, we take care of the back end. We take responsibility for what we do with our systems and there’s one interface to the hospital IT system.

Any final thoughts?

I appreciate the time to talk with you, and to let you know that what we feel is the next thing that needs to be done in the healthcare IT world is to bring near patient information into the architecture so that clinicians can make better decisions at the point of care. In addition, to free the information up that is stored within our hospital IT systems, including ours, to free it so that clinicians can utilize it to make good decisions for individual patients and for populations.

That’s our goal. We think that’s within our reach. We’d like to contribute to the advancement of those goals.

News 8/29/12

Top News

Johns Hopkins will use a newly received $8.9 million grant to improve coordination in the ICU. Peter Pronovost MD, PhD, who leads the Johns Hopkins Armstrong Institute for Patient Safety and Quality, says he’ll be looking for ways to integrate new technologies into ICUs that he says “look the same as they did 30 years ago.” Part of that effort will be to develop software that allows medical devices to communicate with each other and with the EMR. The money comes from the Gordon and Betty Moore Foundation as part of a 10-year, $500 million Patient Care Program that was announced this week. Gordon Moore is the 83-year-old founder of Intel who in 1965 postulated Moore’s Law, which says that the power of computing circuitry doubles every two years.

Reader Comments

From Marketing Gal: “Re: HIMSS. Would you suggest participating in the Exhibitor Spotlight for a product launch?” Vendor readers, feel free to weigh in on whether the Exhibitor Spotlight would be a good way to make a big splash amidst a sea of 1,000 vendors trying to make big splashes. It costs $950 for corporate members.

From Lost in the Woods” “Re: Patient portals. Do you have any idea how and what vendors charge, especially those for practices?” I think it would make sense to just ask them, but readers, please leave a comment if you can help.

From Former MCK Employee: “Re: Practice Partner Seattle office. Developers and QA are leaving as MCK shifts its focus to the new SaaS application.” Unverified.

From Crook County Doctor: “Re: U Chicago Medical Center. Several days of Citrix logon misidentification troubles affecting all physicians. The help desk recording warns doctors to beware when logging on to Epic.” Unverified.

From The PACS Designer: “Re: ONC. Wimps out on image sharing. TPD is disappointed and angry that ONC has allowed vendors to intimidate the comment group when it comes to image sharing among practitioners. The overall comments were positive about the subject, but the powerful had the upper hand and made sure that image sharing was excluded from the next phase of Meaningful Use. David Clunie, a highly respected blogger on DICOM, did some sleuthing and points the finger at the Good Enuff participants. I can see why they wouldn’t want the image sharing, as it would reduce the need for more imaging at the next treatment facility and lower their chances to sell more imaging equipment.”

HIStalk Announcements and Requests

Here’s the latest musical production of The American College of Medical Informatimusicology, “Gimme My DaM Data,” featuring HIT notables Ross Martin MD (founder and HIStalkapalooza Elvis tribute artist), Harry Greenspun MD, e-Patient Dave, Todd Park, and “a cast of dozens.”

HIStalk sponsors with executives on Modern Healthcare’s 2012 100 Most Influential People in Healthcare list include Aetna (Mark Bertolini), McKesson (John Hammergren), and MedAssets (John Bardis).

This isn’t a pitch, just a recap. A relative saddled me with selling her 16 GB AT&T iPhone 4 after she upgraded, and it became obvious that messing around with Craigslist and eBay scammers and fools was going to be a big waste of my time. I ran across TriPhonia. Their online form took a few seconds to complete and I got an instant e-mail offer of $175 for my stated condition of “excellent.” They shipped a prepaid Fedex mailer and e-mailed a couple of days later saying it had a few scratches and wasn’t quite “excellent,” but said they’d still offer $158. I accepted, and within about two minutes I had the balance in my Amazon account. Maybe I could have held out for a few extra dollars elsewhere, but it was well worth it to just sell it and move on, plus they guarantee they’ll wipe the phone clean before reselling it. Do your own due diligence (almost all of the similar services have terrible reviews), but it might be worth a look.

Acquisitions, Funding, Business, and Stock

WellPoint Chairman and CEO Angela Braly resigns over criticism that the company is underperforming. Above is the five-year stock price chart for WellPoint, which was voted by hospital executives last week as the worst insurance company in the country.

Dell signs a deal to provide computer kiosks for SoloHealth, whose interactive healthcare kiosks provide free health screenings from retail locations. CoinStar (aka Redbox) and WellPoint are investors.

Sales

Lexington Medical Center (SC) selects Patient Access and Payment Certainty solutions from Passport Health Communications to integrate with Epic.

Erie County Medical Center (NY) contracts for Omnicell’s G4 automated medical management system.

OCHIN will deploy Caradigm’s Amalga solution.

People

TeleTracking Technologies promotes Mike Gallup from VP/COO to president/COO.

Business intelligence vendor Agilum Healthcare hires Winnie Fritz (Carondelet St. Mary’s Hospital)  to lead its healthcare performance improvement consulting service.

Caradigm names Rich Berner (Cerner) SVP of client services and support.

Announcements and Implementations

Memorial Health Systems (FL) nears completion of its two-year, $150 million Cerner implementation.

HealthHIE Nevada goes live on eHealth Image Exchange, allowing HIE participants to share diagnostic quality images.

The Pennsylvania eHealth Collaborative awards grants of $1.5 million each to four organizations to promote regional and statewide electronic information exchange.

Implementation draws to a close at two Missoula, MT, hospitals: St. Patrick Hospital (above) will go live in January on Epic, while Community Medical Center is on target for a November live with Cerner. Each hospital’s ambulatory clinics have begun their migrations (St. Patrick to Epic and Community to NextGen).

St. Mark’s Medical Center (TX) replaces Meditech with McKesson Paragon.

Virtua (NJ) initiates CPOE across four hospitals using Siemens Soarian.

PerfectServe launches a new version of its clinical communications app for iPhone and Android.

OnShift announces new acuity-based staffing capabilities for its long-term care scheduling and shift management software.

Government and Politics

HHS launches a competition for developers to create apps for reducing cancer among women of color. The top three developers will split $100,000 in prize money.

Here’s a Meaningful Use Stage 2 overview by Justin Barnes of Greenway.

Innovation and Research

IBM expects to market its Watson computer beyond healthcare to consumer uses, with plans to turn it into a Siri-like voice-activated analytics tool. IBM says the next version will work on tablets and smart phones, but they’re still working to add functionality such as speech recognition and the ability to understand images. Apparently IBM’s vision of its value for patients doesn’t necessarily include the participation of physicians – according to its VP of innovation, it will eventually so good at answering patient questions and making diagnoses that “you don’t need any intermediary.”

Other

Most healthcare providers still can’t justify the expense of infection control systems, though new incentive programs may spur adoption, according to a KLAS report. The market is dominated by best-of-breed solutions, with CareFusion taking top scores in product training and ease of use. Hospira led in interface capabilities and mandated reporting.

Allstate Insurance Company sues a Florida rehab hospital that it claims falsified medical records to bill it for $7.6 million in unnecessary medical services. Allstate says the hospital markets heavily in Michigan, which does not cap no-fault auto insurance payouts. The state is also investigating the hospital for alleged patient abuse.

A man reviewing the contents of a storage unit he bought at auction finds human brains, hearts, and lungs preserved in soda cups and plastic food containers. The unit was once used by a former Florida medical examiner who had been fired in 2003 for not completing autopsy reports.

Sponsor Updates

• AT&T CMIO Geeta Nayyar discusses early successes and high participant engagement rates in AT&T’s DiabetesManager pilot.
• SimplifyMD adds billing software provider Healthpac as a reseller for its EHR.
• Greenway will offer Isabel Healthcare’s medical diagnosis tool with its PrimeSUITE EHR.
• ICA’s chief marketing officer John Tempesco speaks at this week’s AlliedHIE-sponsored workshop on Direct healthcare communication.
• The Pittsburgh Technology Council includes TeleTracking Technologies as a finalist for its Tech 50 Awards in the tech titan category.
• iSirona is named the 82nd fastest growing company in America in the Inc. 500.
• The Achievers names Impact Advisors to its list of 50 Most Engaged Workplaces.
• AirStrip Technologies incorporates a real-time Meaningful Use tracker in its mHealth platform.
• Imprivata customers share best practices in workflow, securing patient data, and enhancing patient care during this week’s VMworld 2012.
• UpToDate by Wolters Kluwer Health adds psychiatry as its 20th specialty. The company also announces a partnership with the Altos Group to develop a sepsis mortality reduction program.
• IDC MarketScape ranks Medicity as a leader of packaged HIE solutions.  
• Billians adds 7,400 hospital social media links to its Portal healthcare sales and marketing database.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 8/27/12

One of my personal heroes passed away on August 25. Neil Armstrong’s death was marked in a way that matched the way he lived – quietly and with little fanfare. By commanding the Apollo 11 mission and being the first person to walk on the moon, he had earned the right to be celebrated.

The amazing part of his story, however, is what happened after July 20, 1969. He didn’t dance in the end zone or become tabloid fodder. He went back to work and back to his roots. I’m touched by a quote from an article marking his passing. In an interview in February 2000, he said:

I am, and ever will be, a white socks, pocket protector, nerdy engineer. And I take a substantial amount of pride in the accomplishments of my profession.

We should all take a substantial amount of pride in the accomplishments of his profession. Not to take anything away from the astronauts, but I’m talking about the engineers. NASA’s steely eyed missile men sent people to the moon using chalk boards and slide rules. They didn’t have anywhere near the technology that most of us carry in our pockets today, but they changed the world.

Those of us working in healthcare IT today are up to our eyeballs in technology. It feels like things are moving so fast we will never catch up. As hospital leaders, we are challenged to deploy the latest “thing” regardless of quality or outcomes.

I have many friends in the medical software industry, ranging from developers to CEOs. The aggregate of their skills and creativity could propel us into a new era of patient care. Instead we seem mired between the twin terrors of governmental compliance and simply improving yesterday’s products. I want to see the software equivalent of the space race, where vendors are competing for the best designers and engineers and working to deliver a superior product.

Rather than the challenge of getting a man to the moon and returning him safely, the goal should be to deliver patients safely through the health care experience while we collect all the telemetry data needed to make the next trip with even better safety and quality. Another challenge – it’s easy to forget that as broken as our health care delivery system is, it is still better than what is available in some parts of the world. Let’s figure out how to make those leaps for all mankind.

E-mail Dr. Jayne.

A 2012 Campaign Primer 8/28/12

Campaign 2012 arrives at a formal down select today with supplier presentations in Tampa and Charlotte over the next two weeks. Like most selections, people involved are bemoaning the available options and questioning who designed the process in the first place.

The current preference gap is razor thin. The Real Clear Politics number, a blended average of major nonpartisan polls, has President Obama at 47% and former Massachusetts Governor Romney at 45.5%. It remains — for all the Fear, Uncertainty, and Doubt of the last several months — well within the margin of error.

Of course, as we were reminded in Campaign 2000, the popular vote doesn’t determine the President. The Electoral College does. And despite all the noise this summer, it too is a largely unchanged landscape since June.

The dirty Election 2012 secret is that 40 or so states are largely irrelevant, residing squarely in one camp or the other. Only about nine states, as of now, are being heavily contested: Florida, North Carolina, Virginia, New Hampshire, Ohio, Iowa, Colorado, Nevada, and now Wisconsin. And if you live in one of these states, you are being bombarded with micro-targeted messaging almost to the point of affliction. “Hello 9-1-1. It’s me again.”

The expansion of what the pros call the “map within the map” to include Wisconsin is a function of native son Paul Ryan joining the GOP ticket earlier this month. At 42, Congressman Ryan is the third youngest vice presidential nominee in the post-WW II period. He is, both sides agree, a serious policy thinker. He also brings a detailed plan, Path to Prosperity, to the national conversation.

The healthcare provisions within the Ryan policy sketch have of late been a focal point of the nightly shouting matches on cable news. Brookings Institute’s Henry Aaron and Robert Resischauer may have originated the term “premium support.”* Senator Ron Wyden (D-OR) may have embraced it last December. But Romney and Ryan now own it as the campaigns fight for seniors in Florida, Iowa, and rust belt states like Ohio.

The aggressiveness of the debate is a reminder that the modern presidential campaign sadly does not lend itself to deep educative efforts, particularly in the last 90 days. As the former DNC Chair Howard Dean said last Sunday, “I have always told people that campaigns are not for educating” and much of the last several weeks validates that near term view.

Romney and Ryan, of course, know how the game is played. And thus as we start the Republican National Convention this morning, the U.S. economy will be front and center. Q2 GDP (advanced) was middling at just 1.5%. Median household income has had its worst 10-year stretch since the Great Depression. U-3 unemployment remains above 8%. It is a tough narrative for any incumbent, even for the personally well-liked Barack Obama.

These Hurricane Isaac-quality headwinds, in turn, all but ensure a close race through November 6. For believers in Surowiecki’s Wisdom of Crowds, the online betting market Intrade currently favors Obama to win by 57.3% to 42%. That collective sentiment feels qualitatively right, with the caveat that even a week can be an eternity in modern politics.

Beyond the electoral outcome, it also is worth asking the larger question: what realistically can be accomplished in the coming Congress? The down ballot House and Senate terrain looks poised to deliver two closely divided chambers, including a U.S. Senate where Joe Biden or Paul Ryan may well cast the tie-breaking vote. Absent a fiscal crisis, and in the wake of an ugly campaign, it may make the current Congress look comparatively productive.

It will be a tough environment for either man. Selection is, of course, always easier than the change management required to make something work. And while some surely will bemoan the process, the blame in a democracy actually has to begin with us.

*Premium support, in simple terms, would provide Medicare recipients with an annual payment from the federal government to enroll in the health plan of their choice. It is a serious policy idea that has champions and critics alike. A primer can be found here. Beyond that, we will leave the debate around approach to the myriad sites focused on health policy and politics.

Donald Trigg, along with his long history in healthcare IT, spent a decade in the public policy space, including his work on the 2000 Bush for President campaign in Austin, Texas.

Monday Morning Update 8/27/12

From Siemens Surfer Dude: “Re: Mark Zielazinski, CIO of Alameda County Medical Center. An e-mail was distributed to ACMC staff last week saying he’s leaving with no details. They’re in the middle of an Invision to Soarian implementation scheduled for go-live on CPOE this fall.” Verified. Mark says he’s moving on to Marin General Hospital to rejoin his old El Camino Hospital boss Lee Domanico, who is now CEO at MGH. They’re building a replacement hospital and Mark will have some related additional responsibilities beyond IT, telecomm, HIM, and biomed. As far as ACMC goes, Mark says the Siemens / NextGen rollout is going fine and ACMC is getting its ARRA money. Both organizations will make announcements about his new job sometime this week.

We would expect that an EHR technology developer could satisfy § 170.523(k)(1)(iii) by disclosing: 1) the type(s) of additional cost; and 2) to what the cost is attributed. In reference to the first example above, an EHR technology might state that “an additional ongoing fee may apply to implement XYZ online patient service.” In situations where the same types of cost apply to different services, listing each as part of one sentence would be acceptable, such as “a one-time fee is required to establish interfaces for reporting to immunization registries, cancer registries, and public health agencies.

From Frank Poggio: “Re: MU Stage 2 zinger. Buried back on Page 405 is a real ditty, Price Transparency. Looks like in spite of all the flaming comments ONC received from vendors on the draft of this idea, they are moving ahead with it. ONC backed off requiring vendors to publish a specific price list, but now mandates that they list out all component, install, training, interface, third party and other costs. At this rate, I predict in Stage 3 they will ask for the numbers. Also, in the new certification rules, ONC estimates that it will cost vendors $195 million. If you take the 816 vendors certified under Stage 1 and then reduce the $195 million by ONC’s $60 million annual budget, that means each vendor will spend $165,000 to revise and certify their software for Stage 2. Who will eventually pay, and would that money be better spent elsewhere?”

From Sagacity: “Re: MU Stage 2. For the pleasure of your readers, the bookmarked and cross-linked versions of the Stage 2 and Certification Criteria rules. Save to the same folder with the original names and the cross-linking will work.” Thanks for that.

From Luminosity: “Re: authors. You should get more people to write instead of just giving space to a few guest authors.” Everybody is welcome to submit Readers Write articles as long as they meet my requirements for length, quality, and non-promotional topics. Being invited as an ongoing contributor to HIStalk is another matter – I’m not desperate for content, so I would expect folks to be way better than average. Regulars like Ed Marx, Dr. Rick, and others have an interesting and credible perspective, state it well, are entertaining as well as informative, and are diligent enough to keep it up month after month. Writing is like teaching – everybody thinks they could do it perfectly because really talented folks make it look easy. Anyone who thinks they have the right stuff and can send me a sample article along with ideas for their ongoing series and we’ll see where it goes. That’s the limiting factor on whose articles you’ll see here, not my unwillingness to give someone else a platform.

Welcome to new HIStalk Platinum Sponsor Sandlot Solutions. The Fort Worth, TX company, which is uniquely jointly owned by Santa Rosa Consulting and North Texas Specialty Physicians (NTSP), offers a platform that turns data into information. NTSP is a pioneer ACO (one of only 32, also named one of eight ACOs to watch including its use of Sandlot Solutions by Information Week) with 2.5 million patients. They know how to connect providers with critical information. Sandlot Solutions offers a next generation HIE and analytics system that uses low-cost cloud computing to connect physicians across all care settings and practice locations to improve care and reduce costs. The underlying products include Connect (HIE and master patient index); Dimensions (data warehouse); Metrix (analytics); and Care Manager (caregiver workflow driven by near real-time clinical and claims data). If you’re in the market for HIE software, check their no-nonsense evaluation checklist. The company’s leadership team has some familiar names, including that of our own “From the Investor’s Chair” Ben Rooks as an advisor. Thanks to Sandlot Solutions for supporting my work.

Now that I’ve talked about Sandlot Solutions, let’s have a short demo (which I found by cruising YouTube).

Allscripts says its systems are open, but 70% of poll respondents say really aren’t, at least by their definition of the term (the thoughtful comments are worth reading). New poll to your right: is your reaction to the announcement of the Meaningful Use Stage 2 rules positive, negative, or indifferent? Once you’ve voted, click on the Comments link in the survey box (or click here) and explain your opinion.

From that last poll, a comment by Limber Lob was particularly thoughtful given his obvious knowledge of several vendor EMR products:

Whether Allscripts is "open" centers on the definition of the term "open." "Open" conjures up notions of "open source" or at least multiple read/write APIs for a system, but it also reminds us of the important related concept of "extensible systems." An extensible software system is one that can be "extended" by someone other than the original developer AND in the programming language in which the system was written. It isn’t widely realized that three of the four successful long-lived integrated EHRs (with single patient database) are extensible by this definition. The VA VistA’s programming Standards & Conventions (SACs) allowed the extension of VistA over the years by VA sites nationwide, with — for example — the Puget Sound VA developing VistA’s Provider Order Entry (POE) system, and the Topeka VA writing VistA’s Bar Code Medication Administration (BCMA) module. VistA’s extensibility under the VA’s Decentralized Hospital Computer Program (DHCP) of the 1980s and 1990s is a principal reason why VistA now has more than 100 major sub-systems and an estimated 125,000 function points. Cerner’s EHR can be extended using Cerner Command Language (CCL), which is a proprietary "scripting language" in which as much as a quarter of the Cerner EHR’s logic is written. Many Cerner sites employ multiple CCL programmers, and books on CCL are available from Amazon. And perhaps surprising to many, Epic’s EHR is also extensible by Epic customers, as Epic makes source code and documentation available so that customer organizations can develop name-spaced code and data structures that extend Epic’s functionality in a manner similar to Epic’s customizations of their system for their clients. Epic encourages customers to use the other mechanisms for enhancing the functionality of the Epic EHR, but they also support what they term "free range programmers" in their customers’ organizations. Meditech, the fourth of the long-lived integrated EHR systems, has a closed code base. Finally, Allscripts’ supports extension of their Sunrise environment using a package called ObjectsPlus that has a reputation for being hard to use, and requires highly skilled and expensive programmers — which makes it an impractical proposition for many Sunrise customers.

I must have received half a dozen breathless “Breaking News” e-mails at work Friday screaming that HHS had delayed ICD-10 implementation until 2014. I’m not sure why this news was earth-shattering given that HHS itself proposed the extension in early April. Were the rags expecting some other outcome, or did they just forget that this is old news?

Here’s a new book on healthcare business intelligence. The folks involved sent me a Kindle copy, but I haven’t had time for more than a quick skim so far. Amazon has the Look Inside! feature turned on, so you can peruse the table of contents and quite a few sample pages. The author is Laura B. Madsen, who works for BI vendor Lancet Software.

In England, Lewisham Healthcare NHS Trust chooses Cerner Millennium for electronic patient records, its first UK win since it jointly bid to Royal Berkshire along with UPMC in 2009. InterSystems and Cambio were the other finalists and iSoft is the incumbent.

Also in England, Buckinghamshire Healthcare NHS Trust  admits that a software problem prevented the parents of some children from receiving their follow-up vaccination notices. The trust took over the vaccination program a year ago, but some parents were sent multiple reminder letters while others received none. A trust spokesperson said other customers of the unnamed software may also have been affected.

In another item from England, the county of Herefordshire, trying to determine why only 3% of its residents received an invitation to be checked for serious disease vs. the 20% target set by the government, find that a software problem may be responsible. A doctor tells them that the screening software only works with the Google Chrome browser, while the county-side medical system is not compatible with Chrome, forcing doctors to print out their entries and then re-enter them manually on two dedicated computers.

The Meaningful Use Stage 2 Webinar offered by NeHC and ONC on Friday filled up quickly. They’ve added sessions for Tuesday and Thursday at 12 noon Eastern, or you can view Friday’s recorded session or download the slides.

Researchers working with data from hospitalized HIV patient create a predictive model to estimate the chances of readmission within 30 days and death, using only EMR information from the first two days of their admission.

Keynote speakers at New York eHealth Collaborative’s October 15-16 conference at Pier Sixty in New York City: David Brailer, chairman of Health Evolution Partners, and Stephen Dubner, author of Freakonomics. Several dozen other speakers will grace the lectern. Receiving career achievement awards in health IT at the event’s gala will be Jeff Immelt of GE and Sam Palmisano of IBM. General registration is $395, licensed healthcare professionals and government employees get a $195 rate, and students get in for $100. The gala runs an extra $750. Rooms at the Hilton New York Fashion District are $319. HIStalk sponsors who are sponsoring this event include Optum, Emdeon, NextGen, and Nuance.

Tom Carson, founder and former president CEO of MD-IT until January of this year, is named CEO of Axion Health, which sells employee and occupational health software.

ZirMed names Kenneth Willman (WellPoint) as VP of payer solutions and strategy.

The University of Toledo Medical Center announced last week that it had temporarily suspended its live donor program and suspended two nurses after unspecified human error forced surgeons to abort a planned transplant while both patients (a male donor and his sister, who was the intended recipient) were in the OR. The university provided more information Saturday: the human error was that a nurse put the donor’s kidney in the trash, ruining it.

Doctors in Ontario complain in a town hall meeting about changes in their fee codes, intended to reduce costs by $340 million but making it impossible for physicians to bill for certain services. An interventional cardiologist says doctors are now paid only $2.50 for reviewing an ECG, with the rationale being that computers are doing all the work, leading her to say, “I’d like to think I’m better than a computer. I feel disrespected and disillusioned.”

Vince takes a short HIS-tory break to memorialize industry long-timer Dick Schopp, who died earlier this month.

E-mail Mr. H.

HIStalk Interviews Tom Ferry, CEO, Curaspan Health Group

Thomas R. Ferry is president and CEO of Curaspan Health Group of Newton, MA.

Tell me about yourself and the company.

You’ve probably heard this before, but I think we’re a very unique company and do something that no one else does. At a high level, we try to solve problems and not sell solutions. We look for really simple problems that can provide some value to our clients and build on that incrementally. 

We’ve been connecting providers to share information electronically since 1999. We do it across a platform that we call Synchronized Patient Management that has multiple uses across many related organizations. Since 1999, we’ve grown to about 4,400 providers in 41 states and continue to see good growth throughout the year and good adoption of our technology.

Since you didn’t dwell on your own biography, I’ll throw something out there. You went to Harvard Business School. What did that teach you that you use every day?

I think the interactions that we get in a classroom and talking to people from a variety of different backgrounds really gives you a broad and good perspective on different approaches to solving gnarly problems. I think you can put that in your toolset to be able to address different situations as they arise.

I’m sure you spend a fair amount of time there analyzing business processes and figuring out where the bottlenecks are. Curaspan is heavily involved with the discharge process, which seems so simple to people outside of healthcare, but those of us on the inside know what a disaster it is. What’s wrong with the discharge process and what’s changing with new expectations as far as how discharges work?

I’m glad you asked that question. That was favorite course and probably the most useful out of HBS. I really enjoyed looking at bottlenecks and driving efficiency.

When you look at the discharge process, the tools that are utilized are paper, phone, and fax when there’s technology readily available. It really detracts from those valuable resources to clinicians that are supposed to provide counseling and support the patient in their choices and direct them to the right resources. When they’re consumed with redundant administrative tasks in pushing paper around, they can’t spend that time in that more value-added situation.

We’ve identified workflow automation tools and a communication platform to eliminate those redundancies and put more time in the hands of the clinicians so they can do what they were trained to do, which is providing that clinical information and that direction to the patient and family.

What will organizations look for now the discharges and readmissions are becoming more important?

I think everyone is looking for more information to make better decisions. When you provide tools to your organization in order to share clinical information and to see the interactions between the different parties that are communicating over a patient, where they should be treated, and seeing how that interaction and relationship works, that data can help drive best practices. That data can be utilized to make better decisions in the moment. 

We continue to aggregate that information and provide it in a useful manner so that people can make better decisions at the time of intervention, at the moments of working with that patient and making those critical decisions on what treatment should take place and ultimately where that patient should end up.

A free market requires free information. Both sides win on a referral from a hospital to a skilled nursing facility. Hospitals need to move the patient out, skilled nursing needs to move the patient in. It sounds like what you’re doing is just making the information available so that they can connect with each other.

That’s exactly right.  That’s the underlying premise to our organization as a whole. We look for those interactions, those transactions between disparate parties and where they need to share information for a better outcome. When you find that there’s not efficiency  — there’s paper, phone ,and fax around that interaction — by driving the efficiency, by driving utility to those users, you’re going to provide the data that allows them to behave in a better relationship.

Historically, the hospitals didn’t trust their post-acute care provider partners and the post-acute care providers didn’t trust the hospitals because of the absence of the information on how that interaction worked. By providing the data on the types of referrals that are being sent out, the types of patients that are available, and then ultimately understanding the outcomes of when that patient gets placed and ultimately where they end up – hopefully not in the readmission – that begins to built trust among those two disparate organizations and allows them to behave in a more equitable manner. That’s what we try and do.

We’ve expanded that capability, driven predominantly by our customers, into the case management department. Now we’re driving a better communication and interaction between hospitals and the insurance companies. In particular, we have a pilot going on with Amerigroup and some of our hospitals.

When you look at the function of concurrent review, it has very similar characteristics to the discharge planning function. Again, paper, phone,and fax; a lot of clinical information; and inherent mistrust between the hospital or acute care setting and the payer setting. By allowing them to communicate electronically in more real time, you’re driving efficiency within the hospital setting and you’re getting better response time and intervention from the payer, because they’re getting information — time of admission, the necessary clinical information, discharge summary — all in real time. They want to have a better relationship with that organization. They have more of a willingness to interact in a more equitable manner.

There are companies that offer products to help schedule schedule available community-based practice appointments for ED patients. The underlying message seems to be that the healthcare system has more capacity than it seems, it’s just not visible and therefore not used. The key for both examples is building a network to connect those parties. Do you see yourself as being in that network-building business?

Absolutely. You have 20-30% of patients that are high-risk patients, and so those community case management tools that can address that patient population is something that we’re looking to build upon. We are exploring opportunities because there are some interesting companies out there that have some interesting tools that can allow you to address that issue without pouring in too much human resources and using and leveraging technology to a certain extent. We look at that as an extension upon the foundation that we’ve started to build.

What’s your sense of how diligent hospitals are about evaluating skilled nursing facilities that could accept their referrals for on such criteria as, “Are we going to get that patient back as a readmission?” or “Are we going to transfer someone to a place where they’re going to be very unhappy and it’s going reflect back on us negatively?”

In the absence of technology and the data on how your community providers are behaving, if you don’t have the technology in place and you can’t quickly review whether they’re contributing to your higher readmission rate, then it’s hard to make good decisions and assess whether they’re good community partners.

Our clients have used that information. They run monthly scorecards on the performance of their post-acute care community and run quarterly meetings to share that information with them and set certain expectations, goals, and guidelines. It only enhances that relationship, and ultimately it leads to better clinical outcomes. They can highlight those outliers that are not participating at appropriate level. To your earlier comment about free-market society, those that don’t perform at a certain level ultimately won’t be in business, and probably shouldn’t be in business.

Other than hospitals doing it inefficiently and manually, do you see yourself as having competition?

You’re always worried about when you have a good idea and success that people are going to come into the marketplace We’re always diligently looking at potential competition.

Our current and biggest competition is complacency and doing nothing. There’s always the challenge that CIOs and the decision-makers are looking for the big ideas to boil the ocean and  solve every problem because it’s new and sexy. Unfortunately, those tend to take away a lot of resources from the executable ideas.

We’re out there trying to continue to convince people. Start incrementally. Go for the low-hanging fruit. Solve some problems. Get credibility. Drive some good, positive financial outcomes. Then incrementally build off that platform. That’s our biggest competition.

Even for those hospitals that haven’t figured out how important transfers out are, it’s been called out specifically for them in various forms. Are you getting a lot more calls now that readmissions are what everybody is looking at?

Definitely. It’s moved up the rank of priorities. When you think about building an accountable care organization or if you’re going to participate in a bundled payment pilot, you have to understand the outcomes in the post-acute care community. The patients that you’re trying to manage are going to be placed out into those community resources. You need the insight and transparency into what’s taking place within that organization and what the outcomes are going to be.

Unless you’re connected and have the access to that information, you really can’t participate in either one of those models. We provide that platform access and information to better manage one of those types of new potential models.

Hospitals used to get paid for readmissions, so the people in the hospital who cared about them were worried only about overall bed capacity. Now there’s a direct financial hit for readmissions. That should have got other hospital departments interested.

I would agree with that, but it’s also interesting in that in some markets you have over-capacity on the acute care side. They’d rather take a reduced reimbursement just to fill up the bed…

Wow. That’s your Harvard Business School again, looking at marginal revenue versus marginal cost and figuring that readmissions can be profitable even if there’s a penalty involved. Like yield management on Southwest Airlines, where filling a seat with a low fare is better than flying with an empty seat.

You got it. I hate to say it, but unfortunately the way our healthcare exists today, it still supports it. Those models are not good for the long term, but there are still organizations that think that way.

Give me a couple of examples of how customers are using DischargeCentral and what benefits they’ve seen.

The most obvious, and the one that you initially focused on, was from a throughput standpoint. If you start to hit your geometric length of stay, ultimately you add more capacity to the hospital. In many cases, we’ve seen up to 30% of additional capacity. If you’ve got the patient flow, that’s going to be increased revenue.

From a readmissions standpoint, our hospitals can identify the pain points in readmission, whether it’s internally the staff doing incorrect assessments and sending them to the wrong level of care, or community providers that are unable to handle certain types of patients. By zeroing in on those root causes, they’re able to help solve those problems and reduce their readmissions rather significantly.

We also have found that organizations are starting to leverage downstream assets and acquire skilled nursing facilities, LTACs, rehabs, home care agencies. Outcomes tend to be better when a patient stays within a particular care setting because of the better handoff of information and physicians can follow that patient through the system. Our hospitals have been able to use the technology to, while offering choice, keep patients within their own networks.

And then of course there’s still a nursing shortage. Hospitals are continuing to look for clinicians. If we’re able to give their staff more time to do what they were trained to do and less time doing the administrative tasks, they can reallocate staff into more productive and fulfilling areas.

You’re doing what a lot of companies have done, starting as somewhat of a niche offering and then rounding that out with content and other services, in your case such as providing a patient transport applications. What will your emphasis be over the next five years?

As I mentioned earlier, we’ve expanded in bringing payers online to communicate with our acute care hospitals. Our payer organizations have expressed strong interest in starting to communicate with our post-acute care providers as well, so providing a connected platform. We’ll leverage the information that we’re able to collect on the patient to be able to share through various conduits with their primary care physician as well.

We’ll also look to expand in the areas that you were talking about, from not only a community case management standpoint, but also from a consumer – I wouldn’t say consumer is the right word, but maybe the overall caregiver – and provide the tools and resources and content that we’ve developed for the professional organizations. We would make those resources available for the caregiver as well.

Any final thoughts?

As we talk to various professionals in the industry, they don’t necessarily look for best in breed. They don’t necessarily look for simple, executable solutions. They tend to look for the much broader ideas — the EMRs, the HIEs – that will solve every problem. It’s refreshing to hear someone ask more penetrating questions and more detailed questions about solutions that can be executed upon and then create a platform that you can continue to grow and expand and deliver value. I appreciate that.