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.

Time Capsule: Where Good Products Go to Die: The Elephant’s Graveyard of Conglomerate-Acquired Products

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.

Where Good Products Go to Die: The Elephant’s Graveyard of Conglomerate-Acquired Products
By Mr. HIStalk

Some people were surprised by last week’s announcement that GE Healthcare had acquired Dynamic Imaging, a well-regarded vendor of Web-based radiology and PACS systems. If you’ve ever been a customer of the clunky Centricity PACS product as I have, you might not be quite so shocked.

What happens next (at least if the past is a reasonable predictor of the future) is that Dynamic Imaging as a product and vendor will be quickly assimilated into GE. That’s a nice way of saying that the innovation and non-bureaucratic sales and support that attracted customers in the first place is about to be sucked out of it, much like an Army recruit who’s given a humbling crew cut to strip away his individuality.

The problem is more widespread than this example, even though GE has a disproportionate share of the elephant’s graveyard of formerly well-regarded products. The “first to worst in KLAS” phenomenon has struck before, nearly always at the hand of large conglomerates. The least-positive news you can get as the happy user of a focused, niche software application (short of company bankruptcy, anyway) is that its vendor has been bought out by some multi-national corporate behemoth.

Conspiracy theorists might blame the big company for executing a strategy of buying and burying its more nimble competitors. More often, though, I think it’s the big boys overestimating their capabilities. If they were that good, how did a little company beat them in the first place?

Another argument is that, if you have the money, you can let someone else blaze the trails, then just buy whomever’s left standing. Wall Street apparently loves the cheap nameplating of software instead of the R&D intensive building of it, although searing a once-proud application with the corporate branding iron often has the same effect as splashing holy water on a vampire.

If you’re a prospective customer of a recently acquired product, remember that KLAS is a lagging indicator. The damage won’t be obvious for years. What, then, are the danger signs?

• The product’s name is quickly changed in a Soviet-like revisionism to provide the illusion of integration.
• The new owner decides to keep selling overlapping products despite certain market confusion and cannibalization.
• Full and synergistic integration is quickly proclaimed after a superficial bolting-on to other applications the vendor sells (at least enough to keep salespeople from giggling out loud when they talk about an integrated suite).
• The people brought over from the old company leave, surprised to find that even a big paycheck isn’t enough to put up with endless corporate nonsense. They’re replaced by well-traveled and interchangeable corporate managers who thrive in such an environment, i.e. people that provider-siders are guaranteed to dislike and distrust intensely.
• Development timelines are extended, functionality promises are increasingly vague, and technical innovation takes a back burner. The idea of having bought for the future seems hopelessly naïve.
• Longstanding customers are bewildered when attending the first post-acquisition user conference and realizing that the main objective has changed to “keep them minimally happy so we don’t threaten the maintenance revenue stream until we can sell them something else.”

Companies with a “buy” instead of “build” strategy should succeed, at least on paper. Their financial and organizational strength should theoretically take a promising upstart and turn it into an industry leader. That sometimes happens with well-run technical companies like Microsoft, Cisco, and Google.

Unfortunately, that’s the exception rather than the rule in healthcare IT. The hot little company’s spirit is usually wrung out in the smothering embrace of the massive corporate bosom. Nobody’s left smiling except the founders who took the money and ran.

News 8/24/12

Top News

#meaningfuluse Can’t guarantee perfection, some hard choices made. But I promise- no arbitrary decisions, no unconsidered comments.

— Farzad Mostashari (@Farzad_ONC) August 23, 2012

Meaningful Use Stage 2 regulations are approved.

National eHealth Collaborative will present a free Webinar Friday afternoon, August 24, from 1:00 to 2:30 p.m. Eastern time called How to Play by the (Final) Rules: An Overview of Meaningful Use State 2 and the Standards and Certification Criteria Final Rules. CMS and ONC presenters will go over the rule and answer questions.

Reader Comments

From Limber Lob: “Re: Massachusetts healthcare law. Note the quote by Governor Dev Patrick.” In summarizing the bill that he says will save the state $200 billion over 15 years, Patrick said, “We are ushering in the end of the fee-for-service care system in Massachusetts in favor of better care at lower cost.”

From Concerned in Texas: “Re: Epic. I work for a Epic hospital and haven’t signed any kind of agreement. I’ve heard from two sources that if my hospital wants to block another hospital from hiring me, my hospital can call Epic and they’ll tell the other hospital not to hire me. Is that true?” Recent discussion on that topic here brought out lots of folks with firsthand experience, so I’ll defer to them.

From Kara: “Re: managing population health and overall analytics. I would love to know who is having tangible, positive ROI-type success in this area. Not a vendor white paper, but real-world experience measuring financial impact done by someone who would be willing to talk about it.” I told Kara that the payment model isn’t very far along to have allowed anybody to demonstrate ROI on managing population health, but that’s probably a hospital-centric answer that doesn’t include other kinds of programs. She would really appreciate your comment if you can help.

HIStalk Announcements and Requests

Do the dog days of summer leave you wishing for cool reading material? If so, here are a few HIStalk Practice highlights from the last week: physicians are more likely to suffer job burnout than other professionals. Happtique introduces prescribe-able apps. Epocrates offers its Essentials reference product free to medical students. The number of retail clinic visits increased fourfold between 2007 and 2009. Student loan repayment is the top source of stress for physicians. Attorney Jessica Shenfield offers advice for physicians to stay HIPAA compliant in the age of mobile devices. Dr. Gregg shares the “gray lining” of the cloud. While you’re catching up on your HIStalk Practice news, click on a few sponsor ads and see if there are any ambulatory HIT goods or services that might make your life more complete. Thanks for reading.

I don’t like being scooped, so I was pleased to put a reader’s rumor that Inga forwarded to me on Twitter early Thursday morning saying that Meaningful Use Stage 2 would hit the Federal Register Thursday afternoon (which it obviously did). I tweet only stuff I think is important, so you won’t get bombarded following @histalk, but you might share my scoopage on occasion.  While you’re in that interoperating mood, you might as well follow Inga too, and follow that with a LinkedIn and Facebook chaser of connecting with any or all of our various personas since we are free with our Internet love. We don’t really solicit sponsors or hold their hands if they’re considering it, so marvel at how many of them have exhibited the resourcefulness to become one anyway and perhaps click on their ads to your left in a primitive form of the Like button. You can dig around in more detail in the Resource Center, and if you want to summon offers of consulting help while sitting regally on your throne and beaming benevolently at your hushed minions, simply fill out the Consulting RFI in maybe 60 seconds and dispatch it to several willing providers with one click of your royal scepter and wait for your e-mail to light up. You have surely noted that HIStalk is a contact sport – we minimize the usual pontificating and self-indulgent journalism and give readers the floor whenever they’ll take it – so feel free if not morally obligated to send us your news, rumors, and anything we would find interesting. It’s delightful having you as a reader.

On the Jobs Board: Services Implementation Project Manager, Account Executive Northeast, Services Implementation Consultant.

Welcome to new HIStalk Gold Sponsor Velocity Data Centers. The Chelsea, MI company offers economical, quick-to-build modularly constructed data centers installed on site. They’re bulletproof, hurricane tested, suitable for any climate, and less expensive than building from scratch or using valuable hospital square footage for data center space. If you’re worried about cloud security or service levels, you can build your own private cloud instead of renting someone else’s. if you’re struggling with technology expansion, obsolete disaster recovery capabilities, or need space for big data storage or research computing, you can get the data center capability you need for less money and time. Thanks to Velocity Data Centers for supporting HIStalk.

I found this really cool time-lapse YouTube video of a Velocity Data Center being built in 90 days.

Acquisitions, Funding, Business, and Stock

Two of the Quality Systems directors who were nominated by dissident board member Ahmed Hussein in a proxy fight have been elected, along with seven of the company’s eight nominees. Names have not yet been released pending certification of the results. The company also announced that Scott Decker, president of its NextGen subsidiary, has resigned effective September 7 to take another job with an unnamed healthcare IT vendor that the company says is not a Quality Systems competitor. QSII shares dropped another 4.5% Thursday to $17.39, above their 52-week low of $15.04, but down 66% from their 52-week high of $50.70.

Data analysis tools vendor Apixio raises $5.8 million of its $7.8 million goal from at least 10 private investors.

Michael Kluger, an Allscripts board member since 1994, resigns because of what the 8-K form says is, “His desire to spend time on his professional responsibilities.”

Roper Industries completes its previously announced $1.4 billion acquisition of Sunquest.

HP reports the biggest loss in its 73-year history, writing down a mind-boggling $8 billion of its $13 billion acquisition of Electronic Data Systems from GM in 2008 (GM had bought it from Ross Perot for $2.5 billion in 1984). Excluding one-time charges, the company’s revenue dropped 5% and earnings declined by 13% as its PC, printer, and notebook sales all dropped by double-digit figures. CEO Meg Whitman says she’s confident of a turnaround, but analysts are looking warily at the company’s $30 billion debt load. Above is the five-year HP share price (blue) compared to Microsoft (green) and the S&P 500 (red). Shares are at $17.64 after dropping more than 8% Thursday on the news, 41% off their 52-week high of $30.00.

Sales

Union General Hospital (LA) selects the Healthcare Management Systems EHR and EDIS.

Walgreens will deploy its WellHealth EHR, built on Greenway’s PrimeSuite, to 8,000 locations, allowing pharmacy employees to view the immunization and health testing history of patients.

EHealth Saskatchewan awards SAIC Canada a three-year, $16 million contract to provide implementation and maintenance technology services in support of the province’s EHR.

West Virginia Health Information Network launches its statewide HIE, with Truven Health Analytics (the former healthcare business of Thomson Reuters) as its technology provider.

Mountain States Health Alliance selects the Siemens perioperative management solution by Surgical Information Systems for its 13 hospitals in Tennessee and Virginia.

Franciscan Alliance (IN, IL) selects Merge Healthcare’s iConnect imaging solution. Children’s Hospital & Research Center (CA) also contracts with Merge for its iConnect Access and Share solutions.

Rochester General Health System (NY) selects Wolters Kluwer’s ProVation Order Sets powered by UpToDate Decision Support for its eight affiliate hospitals.

People

The University of Michigan Health System names long-time Brigham and Women’s Hospital CIO Sue Schade as its new CIO, effective November 1.

Physician networking site QuantiaMD appoints Mike Coyne (Verisk Health) as president.

Hayes Management Consulting names Shawn DeWane (Emdat) as EVP of business development.

Cumberland Consulting Group names Jeffrey Sturman (Memorial Healthcare System) as partner.

Announcements and Implementations

Hospitalist management company Cogent HMG will extend its use of athenahealth’s athenaCollector.

The University of South Carolina School of Medicine completes its implementation of Cerner Ambulatory EHR for 143 providers and 1,200 users. Affiliate Palmetto Health will bring another 153 providers live over the next 13 weeks.

The local paper mentions that Providence Medford Medical Center (OR) has implemented a Modified Early Warning System that scores vital signs entered into the EMR and pages the charge nurse if the score indicates possible problems. The article doesn’t give specifics, but it may be Caradigm Amalga that they’re using.

Government and Politics

CMS selects 500 primary care practices across seven regions to participate in the Comprehensive Primary Care initiative, which will pay primary care practices a care management fee of $20 per month per beneficiary to support enhanced coordinated services on behalf of Medicare FFS beneficiaries.

Open health and VistA advocate Matt McCall was honored Thursday by the White House as a Presidential Innovation Fellow. He’s working on the Blue Button initiative, the HealthME PHR, and formerly the VA’s OSEHRA VistA community.

In England, the Department of Health is reportedly pursuing the replacement of Cerner Millennium for its Choose and Book scheduling system, hoping to eliminate its dependency on commercial software products to reduce costs. It hopes to own the intellectual property outright.

The US Army creates an open encounters report for its MC4 battlefield EMR in Afghanistan using a Business Objects query that finds open encounters that are more than three days old. The weekly reports, along with toughened policies, reduced open encounters by 72% in the first month, which it says will allow better care because encounters not closed per policy by the original physician were being cleaned up afterward by someone else.

Other

Greenway has put out a summary of the Meaningful Use Stage 2 rules for EPs.

Microsoft unveils a new company logo, its first in 25 years. According to the company, the font is Segoe, while the symbol conveys the company’s diverse product portfolio. The video is running 3,530 likes to 670 dislikes so far. Personally, I like it.

Epic is awarded a patent for, “A system for facilitating patient ownership of his or her medical data through the use of third-party health repositories that preserves the maximum information content of the medical records by displaying information relevant to the authority of the medical data as reflected by its source and types of modification as it has moved between institutions, as well as the data itself. In this way, improved use of this data is made possible.”

United Memorial Medical Center (NY) eliminates five transcriptionist jobs, blaming its financial losses and electronic medical record as good reasons to outsource the function. Two of them complained to the local paper, saying it “added insult to injury” that Intivia, the company chosen to take over the function, offshores some work to India.

In Malaysia, the University of Malaya Specialist Centre is developing clinical and imaging systems for its new campus that will scale up from the current 100 concurrent users to 4,000. The CIO estimates that 80% of Malaysian hospitals are still paper-based and the remainder keep their electronic information in silos. He’s using VMware products to virtualize servers and desktops, including thin-client touchscreens for the OR that have washable mice and keyboards. He says desktop PCs are “irrelevant” with triple the three-year cost of a terminal, plus they support the “bring your own device” movement. The hospital is spending 4% of its annual revenue on IT.

Dan Mandy from Winthrop Resources tells me that CMS has changed its rules that previously required critical access hospitals to purchase hardware to be eligible for the Meaningful Use incentive. CMS apparently announced in July that a capital lease will meet the “purchase” requirement.

An Arkansas nursing home installs a telemedicine station that allows residents to be evaluated by a physician quickly instead of in several weeks. They’re using a digital stethoscope and cameras, while the vendor (IntegrateMD) will also offer wireless stethoscopes and iPad access.

The city of Alpharetta, Georgia forms a commission to attract and retain technology companies, hoping to brand itself as the “Technology City of the South.” The commission’s members include executives representing several companies that sell healthcare technology.

Grady Hospital in Atlanta suspects that a a married couple holding senior financial positions (payroll director and budget director) stole $500,000 from the hospital. They had been laid off and then sued the hospital for discrimination.

A fired account representative of a Chicago-area psychiatric hospital admits that she stole copies of patient files and used the information to send harassing letters to the hospital’s patients, which the police said included “vulgar comments, references to confidential medical information and psychiatric treatment received by these patients.” She also threatened to expose the information to the friends and families of the patients.

The State of Missouri will provide $4.6 million in incentives to Sporting Innovations, which will hire 120 people and spend $20 million renovating a Kansas City, MO building for building smartphone sports apps. The company is an offshoot of Kansas City’s professional soccer team, which has as two of its five owners Neal Patterson and Cliff Illig of Cerner. The soccer team famously chose Kansas City, KS for its stadium and a new Cerner complex after Kansas outbid Missouri with $230 million in “border wars” incentives. Illig says Sporting Innovations will deliver the same technology improvements to sports as Cerner has done for hospitals, allowing fans to view multiple video feeds of sports events and to scan QR codes on stadium seats to order team apparel. According to Illig, “What we see in sports is similar to health care. You have stadiums with 30 different technologies that don’t talk to each other. This will enhance the fan experience and be a platform for innovation.”

Strange: a male porn star named Mr. Marcus admits that he convinced a medical testing service to omit the positive result of his syphilis test, which he calls “the Scarlet Letter,” so he could continue working. The company denies his claim, saying their software does not allow employees to omit specific test results. Nine cases of syphilis have been documented in investigating an outbreak, with one trade group urging a temporary national moratorium on the production of adult films until all performers have been tested. I was highly entertained by the performer testimonials (especially their hilarious phony names) on the testing company’s site, including one enthusiastic Ms. Bailey Brooks, who said, “I have such a hectic life between kids, college, and travelling to shoot that I LOVE TTS!!!”

Hospital district officials checking up on complaints about taxpayer-funded 269-bed Salinas Valley Memorial Hospital (CA), best known for the $5 million retirement package it gave to its CEO last year followed by extensive layoffs and losses, say they have no problem with the hospital’s interim CEO turning in $4,000 in receipts from “Airport Town Car” since his contract guarantees him a car service. The driver providing the service: his daughter. They’re also happy to pay his commuting expenses from Seattle, his rounds of golf, and the candy bars he buys at the airport.

Sponsor Updates

• Attendees at the all-employee annual meeting of Ignis Systems on August 9-10 pitched in at the Oregon Food Bank, repackaging two tons of bulk pasta for distribution to families in need.
• Santa Rosa Consulting reviews the 2012 impact of the CMS hospital readmission reduction program in a blog post.
• The State of Florida awards iSirona $530,000 in grant and tax incentives to create jobs in the Bay County, FL area.
• Greenway Medical VP Justin Barnes reflects on the eight-year journey to accountable care in a blog post.
• Wolters Kluwer Health’s Sentri7 Patient Surveillance software earns high marks in two recent KLAS reports.
• Intelligent InSites offers a free August 29 webinar titled How to Better Manage Consumable Medical Assets with RTLS/RFID Solutions.
• Medicomp Systems CEO Dave Lareau discusses the need to make clinical data usable in order to enhance patient outcomes in a guest article.
• Nearly 200 volunteers from GE Healthcare helped prepare Milwaukee-area school buildings for the new school year on Wednesday.
• eClinicalWorks expands its Westborough, MA headquarters with the purchase of a 61,000-square-foot building in the same complex.
• Medical billing technology vendor Healthpac will offer products and services from simplifyMD to its customers.

Inga’s Quick Skim of Meaningful Use State 2

Inga came up with this after a quick skim of the rule as published. She and many others will be poring over the rule in more detail, so please leave a comment (as will Inga) with anything interesting you find.

• A special three-month reporting period rather than one year of reporting for providers attesting to either Stage 1 or 2 in 2014.
• A delay in the Stage 2 timeline probably is the most important to EPs. In the Stage 1 final rule, CMS established that any provider who first attested to Stage 1 criteria in 2011 would begin using Stage 2 criteria in 2013. This final rule delays the onset of those Stage 2 criteria until 2014, “Which we believe provides the needed time for vendors to develop certified EHR technology [CEHRT].”
• For 2014 only, providers that are beyond the first year of demonstrating MU will have a three-month quarter reporting period to allow up to nine additional months to upgrade certified EHR technology to the 2014 edition.
• Nearly all of the Stage 1 core and menu objectives included in the proposed rule are being finalized for Stage 2.
• Adds “outpatient lab reporting” to the menu for hospitals and “recording clinical notes” as a menu objective for both EP and hospitals.
• There will be 20 measures for EPs (17 core and 3 of 6 menu) and 19 measures for eligible hospitals and CAHs (16 core and 3 of 6 menu).
• New core measure for EPs: use of secure electronic messaging to communicate with patients on relevant health information.
• New core measure for EH/CAH: automatic tracking of medications from order to administration using assistive technologies in conjunction with an eMAR.
• Ability to use a batch reporting process for MU, which will allow groups to submit attestation information for all of their individual EPs in one file.
• CMS is requiring providers to send a summary of care record for 50% of its patients rather than more than 65%.
• Providers electronically transmit a summary of care for more than 10% of transitions of care and referrals, but eliminated the requirement that the summary of care be electronically sent to a provider with no organizational or vendor affiliation.
• Lab reporting for hospitals as a menu objective.
• EPs who can demonstrate that they fund the acquisitions, implementation, and maintenance of CEHRT, including supporting hardware and interfaces needed for MU, without reimbursement from an eligible hospital or CAH —and use such CEHRT at a hospital, in lieu of using the hospital’s CEHRT—can be determined non-hospital based and receive an incentive payment. Determination will be made through an application process.
• EPs must report on nine out of 64 total clinical quality measures (CQMs).
• Eligible hospitals and CAHs must report on 16 out of 29 total CQMs.
• All providers must select CQMs from at least three of the six key health care policy domains from the HHS’ National Quality Strategy: Patient and Family Engagement, Patient Safety, Care Coordination, Population and Public Health, Efficient Use of Healthcare Resources, Clinical Processes and Effectiveness.
• Beginning in 2014, all Medicare providers that are beyond the first year of demonstrating MU must electronically report their CQM data to CMS.
• Added four categories of exceptions for EPs to avoid Medicare pay adjustments: in a geographic area without sufficient Internet access; new EPs; unforeseen circumstances, such as a natural disaster; and, specialist/provider type, such as those that lack direct patient contact of follow-up needs with patients.
• Made 12 additional children’s hospitals eligible to participate in Medicaid incentive program, despite not having a CMS certification number since they don’t bill Medicare.

EPtalk by Dr. Jayne

The Food and Drug Administration approves the Ingestion Event Marker, or so called “smart pill,” for marketing as a medical device. The sensor is embedded in a pill and is activated by contact with fluid in the stomach. A signal is sent to a wearable water-resistant patch that wirelessly transmits the data to a smart phone or computer. Manufacturer Proteus Digital Health Inc. will begin direct-to-consumer marketing in the United Kingdom with the sensor embedded in a placebo taken at the same time as the patient’s regular medication. The company hopes to gain FDA approval to embed it in therapeutic medications by 2014.

The Archives of Internal Medicine publishes a study that not surprisingly shows that burnout is more common among physicians than other types of workers in the US. Frontline specialties such as internal medicine, family medicine, and emergency medicine are at greatest risk. I’d be interested to see how healthcare IT workers fared on the same screening instrument.

HIStalk reader Evan Steele blogs about the “arduous task” of having hundreds of EHR vendors each programming more than 100 clinical quality measures. Software companies are spending their time jumping through hoops rather than advancing usability and innovation.

Hi tech, low tech: Dallas County declares an emergency with the recent outbreak of West Nile virus. Aerial spraying crews are deploying synthetic pyrethroids (chrysanthemum extract) to combat mosquitoes. If you’re going to be outside at dusk, it’s not a bad idea to break out the insect repellent.

Weird but true: Molecular geneticists translate an entire book into 55,000 strands of DNA, then convert it back to text. Researchers propose that “a device the size of your thumb could store as much information as the whole Internet.” The text used in the project was a book on genomic engineering. There are several other fun facts in the article, including discussion of sequencing Disney’s most annoying song, “It’s a Small World,” into a micro-organism.

Weird News Andy wannabe: This wasn’t from him, but it’s worthy of his name. The FDA recalls surgical bone putty that can ignite during surgery.

Medicare announces the completion of updates to its website. The list of accomplishments includes better design, increased compatibility with smart phones, and improved access to key parts of the site.

I had the privilege of hanging out with one of my favorite CMIOs as he was passing through town this week, and I’m especially pleased that he noticed my shoes. That’s the mark of a true Renaissance man, if you ask me.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

CMS Releases EHR Incentive Program Stage 2 Rule

CMS publishes its 672-page Stage 2 Final rule in the Federal Register. A statement from HHS Secretary Kathleen Sebelius also notes:

• Stage 2 will begin as early as 2014. No providers will be required to follow the Stage 2 requirements outlined before 2014.
• The announced requirements include certification criteria for the certification of EHR technology.
• The certification program has been modified to cut red tape and make the certification process more efficient.
• Current “2011 Edition Certified EHR Technology” can be used until 2014.

CIO Unplugged 8/22/12

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

Elevation (Part 1 of 2)

Leaders elevate to reach summits. As slope rises, so must leadership.

I soaked in the view from six peaks in 14 months. Some were well-marked, long trails that were more hike than climb (Pikes Peak, 26 miles). Some stood tall, surpassing 19,000 feet (Kilimanjaro). And others involved steep alpine terrain that required technical equipment (Rainier). Each one spawns cherished memories and a bit of bravado.

But here is the truth. In every climb, there came a point I wanted to quit.

At the start of each ascent, I have a good attitude, ready to lead teams to the top. Easy street. Gear is not an issue and my body is fueled and rested. The terrain is normally flat and the weather agreeable.

But invariably, the pitch steepens and the pace slows. Breathing becomes intentional, and team chatter dissipates. Enthusiasm wanes as fatigue sets in. Uncontrollable variables heighten the challenge. Snow, rain, wind, and freezing temperatures bore through my clothes. Covered crevasses, possible avalanches, and wildlife prey on my senses. Equipment failures attack when I least expect it. And when I need strength the most, I don’t feel like eating or drinking. Negative self-talk creeps in. If no one could find me out, I‘d stop and turn back.

On August 7, we left Muir base camp just after midnight. We awoke to howling winds blowing ice and sand into our faces. We immediately threw on ski masks and added insulating layers. Despite fresh batteries, my head lamp failed. This was going to be one tough climb to the top of Rainier. And so we began.

After crossing the Muir snowfield, we had our first break at 2 a.m. I was already thinking, “What the heck did I get myself into?” Guides checked on their teams and warned that the most difficult sections were still to come.

Some turned back to Muir. If I turned, would my team give up as well? If I continued without inspiration, would I put my team in danger?

The unwritten covenant of leading people: To be the leader I aspire to be, I must elevate to match the slope before me.

Settle the mental gymnastics before you even get in the situation. That’s what saved me on Disappointment Cleaver. When I became discouraged, I fell back on the truth. It is imperative that leaders have bedrock beneath them for times such as these. Climbing mountains figuratively or otherwise requires self-assurance. Here are some techniques to ensure truth and sure footing when your toe nails turn black and your feet get sore and blistered.

• You will rise to your level of training. Conquer smaller mountains in preparation. Listen intently to your instructors and learn how to self- and team- arrest in the event of a fall. Be ready for anything.
• Extreme endurance. You’ve trained hours per day for years. Despite your screaming hamstrings, know that you have the physical endurance to succeed. Be fit to lead.
• Mind over matter. Climbing is 75% mental. Win the battle of the mind first and know you can handle the stress of difficult situations.
• Zero defects. Invest in the tools and clothes required to handle variation in weather and terrain. Cut no corners, and pursue only perfection.
• Fanatical self-discipline. From proper planning to mimicking our climbing guides’ every move, radical discipline separates the boys from the men.
• Care of self. Even if you lose your appetite or feel the pressure to meet a deadline, eat, drink, and rest at breaks. I can only take care of others after taking care of myself.
• What can stop you from elevation? Nothing except yourself.
• Dig deep for the strength within, and continued your march across the glaciers of MU and up steep snowfields of CPOE. Resist the wind and cold of opposition, and crest the summit with elation. And don’t forget to celebrate.

With all these summits you face, you’ll learn more about yourself and your leadership abilities. Learn to elevate as the slope rises. Make it an unspoken covenant with those you lead.

Climb on!

Elevation Part 2 will contain 20+ key actions to help you move from base camp to summit.

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

HIStalk Advisory Panel: IT in Patient Harm, Patient Outcomes

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

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

What are the biggest lessons we’ve learned from cases where IT contributed to patient harm?

Common Themes Expressed

• System redundancy is sometimes poorly planned.
• Systems and system changes (especially those involving upgrades and application setup) are not adequately tested.
• IT systems management needs to be more formalized (change management, communication, quality assurance).
• System design should be user-centered and should make it easy for clinicians to do the right thing.
• User application training needs to be not only more comprehensive, but also tied to the workflow and job role changes that are involved.
• Clinicians are not represented in the IT governance process for changes that are seen by IT as purely infrastructure related.
• Clinicians need to take ownership of workflow analysis and get involved in IT projects that affect them and their patients.
• IT is specifically related to patient harm or patient safety – it’s an enabler of management and processes, whether good or bad. Technology is not a panacea.
• Clinicians can’t let the computer override their critical thinking, yet computer systems encourage them to.

Individual Comments

• Need for better and more effective education; misuse and system workarounds for the sake of saving time, catching up, or general lack of change; poor IT change management (including maintenance, communication, etc. – all the ITIL stuff) – inadequate QA, communication of changes, poor / under maintenance.
• Testing, testing, testing.
• Redundancy (or lack thereof). Cerner’s recent cloud issues are a great learning lesson. I think that wireless is also an important lesson. Done right, it can save lives. Done cheaply, it can be deadly.
• Patient care and their flow through a hospital is so complex that no healthcare IT solution can completely avoid the unforeseen design flaw, non-intuitive workflow mistake, or inadvertent bug that ultimately harms a patient. Despite the overwhelming benefits of HIT solutions, they’re just as good as the humans that programmed them, and unfortunately, humans can err. Thankfully, with strong clinician input and deep “real world” testing, you can minimize the chances of these occurrences. One big difference with HIT solutions is that when something unforeseen and detrimental does happen, humans can quickly adapt and self-correct. Technology solutions are limited to whatever potential issues the developers and users have foreseen. This has the potential to lead to mistakes of wider consequence. Knight Capital’s near-bankruptcy due to its recent loss of $440M over two days due to a glitch in its trading software is an extreme example of this. Healthcare organizations need make sure their HIT vendors have strong clinician input into their solutions, ensure any solution is vetted thoroughly with “real-world” testing, and processes need to be in place to minimize the breadth of negative patient impact when the unforeseen finally does happen.
• There is a need for interoperability and data standards so that information collected across the patient care spectrum can be safely and securely made available to the proper healthcare providers. There is momentum on this front as groups form HIEs. There is still work to be done to ensure that a doctor or nurse treating a patient has all relevant information to help the patient, not harm them. From patient allergy and drug interaction data to proper condition diagnosis, the underlying up-to-date information and data needs to be made available at the point of care.
• No matter how much you think you’ve trained physicians on a system, they will figure out a way to circumvent the standard processes if they are hard to perform. We need to always make it "easy to do the right thing"… because if we make it easy to do the wrong thing, it will invariably happen.
• Lousy interfaces can and do kill patients. Hopefully not much, but it probably happens more than we realize. The system has to make it easy to recognize problems and, quite importantly, provide a feedback loop for providers to realize what they’ve done e.g. order entry feedback / confirmation / review.
• Assuming here that the harm can be directly attributed to IT and not to clinical practice, the biggest lessons learned from my experience relate specifically to how IT is integrated with clinical departments. I have seen IT make changes to a system that were not properly communicated, documented, and trained on; this led to a compromise in patient safety. I have seen changes in infrastructure, servers virtualized without communication, and suddenly the drug-to-drug allergy checking was not happening in the background unbeknownst to the clinician. These types of things can be catastrophic, and without proper governance in place, can lead to an increase in patient safety or patient harm issues.
• The biggest factors in IT contributions to patient harm are a lack of provider workflow analysis, a lack of proper training and support (could be related to either the trainer or trainee or both), and, rarely, improper testing and configuration of the system. Depending on your philosophy of ownership of these particular issues, IT contribution to the problem could be minimal or significant.
• There are very few documented cases in which problems with the technology specifically (e.g., software bugs) were linked to patient harm. In fact, the few studies that have been done do not separate the technology from the processes in which the technology was used, so in most cases we really don’t know whether the problem was with the technology, the processes, or how the technology was used in a particular set of processes. One might say that where there is significant unscheduled downtime and clinical processes have become dependent on electronic capabilities, that the down time might have the potential to contribute to patient harm. On the other hand, if there are inadequate downtime procedures and a hope that systems will never fail, is this a technology issue or a management issue?
• Similar to the reports we have learned from pilots of crashes or near misses on technically advanced aircraft, the information provided by their systems should be used to help guide decisions and monitor / verify expected outcomes. However, the information provided by systems should not override the learned skills and experiences of aviators. If they do, bad things can happen, as was the case in the Air France Flight 447 disaster.
• I’m not sure we’ve truly "learned" anything. What we should have learned is that you cannot put technology in place and expect it to eliminate patient harm. The process must be fixed before you add technology or you’ve just created another set of issues.  Technology does what we program it to do, so if we (humans) don’t validate the technology that goes in place and provide (and execute) quality checks, we’ll continue to harm our patients. This isn’t news to the technology crowd, but we’re having a hard time communicating it to the clinicians. I have frequent conversations with clinicians that think technology is the panacea for our patient safety issues. They are not very happy with me when I point out the other potential issues or insist that workflows are done both pre- and post- conversion. They are even less happy when I insist that we (IT) don’t own these projects and must have significant engagement from the clinical area in order to be successful. 
• Safety must be job one no matter what we do. Deploying a new healthcare IT solution requires a significant investment of time and energy on the part of many many people — including physicians, nurses, and all members of the care team, along with their administrative partners — to ensure we are making the environment as safe as it can be. It is critically important that we invest appropriately in testing and training in the spirit of this safety-focused partnership. Everyone in the equation should have an opportunity to "pull the cord" at any point if the product isn’t safe. But training is no longer enough. "Training" is no longer even accurate. We must focus our energy on workforce development. We must ensure that every member of the care team has every opportunity to learn how to perform their job in a new way in the presence of our new and emerging technologies. It isn’t enough to learn how to use a new system. It is critical that we learn how to do our work differently, in a way that is more efficient, more effective, more collaborative and more safe in the context of our new systems. 
• To quote former Defense Secretary Donald Rumsfeld, "There are unknown unknowns." The shortcomings of health IT only come to light when someone has been harmed and then we generally create some sort of electronic or paper work around to make sure it doesn’t happen again.  I think there will always be "unknown unknowns" when it comes to health IT. Hopefully, the number of these unknowns will decrease with time. Then there will be an acquisition that will create more unknown unknowns.
• Processes and Human Factors (training, effort on the end-user’s part, etc.) are the most important to "get right" with any new technology implementation. The technology is just a tool and is only as good as the people using it and the situation / processes in which it is used. An analogous situation would be a surgical scalpel – used appropriately in the right situation and the result is good, while used incorrectly or in the wrong situation and the result may be dire (e.g. wrong side or wrong site surgery).
• Certainly the recent Cerner system down experience–where one IT person made many hospitals’ data inaccessible, due to independently correcting something in production with no checks and balances. Users getting so used to computer systems providing information that they don’t question if the information is valid. Users who previously knew how to do drug calculations / titrations now relying on computer systems (once again, not checking the validity of data). Data conversions, especially EMR conversions– really still dependent on manual data abstraction in most instances. No one has really done a great job of electronically converting all data correctly.
• Healthcare is human. We need to provide tools that help clinicians provide better, more consistent care and provide them ‘actionable data’ to help avoid mistakes.
• Analysts assume that doctors will override anything that is wrong, and doctors assume that clinicians created the implied logic in the EHR. At our hospital, the model production system of our brand name EHR including a default route of IM for Lasix. This was promptly noticed and fixed. The far more subtle error of diltiazem IV dosing went unnoticed, and diltiazem was routinely then given in much lower doses than previously, until one of the physician champions went "hmm, that’s funny."

Which hospital uses of IT have driven the biggest improvement in patient outcomes?

Common Themes Expressed

• Hospitals need to define their quality goals, track their baseline quality, and then go after improvements.
• Real-time alerts and notifications can affect patient outcomes dramatically.
• Population health analytics can drive some of the biggest improvements beyond systems that just affect inpatient stays.
• Well-defined and closed areas have the most impressive IT-driven improvements: ED, pharmacy, and OR.
• Pharmacy-related IT has driven major patient care improvements: electronic medication administration record, barcode checking of drugs at the bedside, alerts for drug-drug interactions and other patient-specific problems.
• Telemedicine makes it possible to use hard to find expertise more broadly.
• PACS has dramatically changed how clinicians use diagnostic images and how radiologists work.
• Data analysis can pinpoint areas of potential improvement and allow ongoing monitoring.
• Technologies, even simple ones, that allow clinicians to communicate more effectively can have a significant patient impact.

Individual Comments

• I would look to the bigger, more sophisticated systems – Trinity and Kaiser come to mind – for the success stories.  These system have invested in “benefits realization” and track quality and benefits.  All the improvements and benefits are there for mid-size and smaller providers, but they do not even baseline current performance and most don’t adequately go after actually tracking quality and benefits. Hence it becomes a big subjective conversation.
• While not yet a contributor to the biggest improvements in outcomes, Rothman Healthcare’s product is impressive as one that directly affects outcomes. By pulling from nursing notes and vital signs, it has a strong predictive capability of a patient’s impending state of health. It alerts caregivers to a potential change in status hours before they might otherwise pick up on it. The implications for quality of care, and therefore outcomes, are significant.
• Those organizations that are data driven and create actions around the work. They also are fearless in holding clinical staff accountable for their practice. Some organizations won’t fire clinical staff due to the notion of not being able to find replacements.
• Alerting, communication, and messaging is at the forefront of what HIT can do to improve outcomes. Access to data-driven alerting allows clinicians to be informed, combined with the interaction of a communication workflow solution, allows care team members to collaborate to provide a more informed response. Delivering information based on changes in data and allowing users to interact with those data and with other care givers — those two things improve outcomes in big ways.
• Some of the biggest improvements in healthcare come when patient outcomes are relatively improved across a population. Population Health Management (PHM) has become an important topic as providers and payers are moving toward compensation for outcomes. A key pillar to effectively managing and improving the healthcare outcomes of a population is predictive analytics — the ability to leverage historical data and care patterns to be able to rationally intervene in cases when a patient’s health may be
  deteriorating. For example, by being able to predict the likelihood that a patient will develop Type II Diabetes based on historic and current clinical, pharmacy, and lab data allows a care coordinator to be alerted when the likelihood reaches a high threshold.  The care coordinator may then work with the patient and other care providers (doctors, nurses) to develop a plan to properly manage or even delay the diabetes onset.
• Defined and somewhat closed settings (e.g. ED, pharmacy, OR) can produce very simple and dramatic data, but it’s hard to judge the potentially much broader and long-term effects of patient-centered medical homes + disease registries and population health management.  I can say that "we" have seen incredible reductions in length of stay within the ED due to complete transparency/visibility of patient flow within the department.
• Bar coded administration of pharmaceuticals. Drug interaction alerts. Alerts from abnormal lab values. 
• In my experience, I would say the pharmacy department. One of the best immediate workflow improvements related to pharmacy was when we went live with eMAR. A patient wait time for meds decreasing by at times over 20 minutes or more is substantial. This may not lead directly to outcomes, but it leads to a significant increase in patient satisfaction.
• Unquestionably, I have seen pharmacy usage as the biggest benefit producer – significantly shortened turnaround times improve patient clinical outcomes, better decision support alerts result in drastic reductions in adverse drug events (ADEs) which improve patient safety – you can see immediate results in these areas when technology is properly deployed.
• Reporting from the data collected that have allowed us to identify trends and opportunities for improvement.
• Ironically, I would guess that the biggest improvements in patient outcomes where technology can be linked have come from the simplest capabilities that IT brings: improved communications among providers. These are not very sophisticated improvements, but rather represent areas in which the technology itself can be said to have contributed to (enabled?) the potential for better outcomes. The question of how the data is actually used in decision making is not a technology issue but a cognitive one, and I would be suspicious of any study that claimed a primary contribution by IT to patient outcomes without a clear understanding as to how IT is actually used. from electronic notifications, and requirements to “sign off”; ability to actually read what someone wrote due to the elimination of handwritten notes (although dictation / transcription processes probably had a lot to do with this); ability to view electronic data from anywhere at any time, rather than hunt for a paper medical record.
• Even though it has been around for several years, electronic medication administration and recording (eMAR) at the bedside has by far had the biggest patient safety impact. It is the single most consistent (not anecdotal) source for improved outcomes with patients on a grand scale.
• This is often truly difficult to quantify or qualify, often because we are (or are forced to) utilize surrogate endpoints for patient outcomes rather than the outcomes themselves. An example would be core measures compliance – greater compliance is seen as success and benefit, although the actual outcomes of those patients may or may not be effected at all. However, one example that does seem to have fairly provable positive benefit for patients would be telemedicine-enabled neurologist evaluation for emergency department patients suffering possible stroke. Obviously such situations are not an ideal replacement for a neurologist being on site to perform the evaluation in person, but in reality that is not a possibility in many areas across the country (even some that are not that "rural"). In such cases, the telemedicine encounter / consultation replaces the only existing timely alternative – a consultative conversation over the phone between an ED physician and neurologist. In such cases, the technology allows for an appropriately trained specialist in the care of stroke to perform a more detailed "eyes-on" evaluation of the patient and provide improved medical decision making as a result of more and better patient information (e.g. stroke or no stroke, to give or not to give TPA). Due to the high risks associated with giving TPA in general, those cases where the TPA is NOT given when it otherwise might have been were it not for the direct telemedicine video evaluation are probably even more important than those cases where the decision is made to give the TPA.
• Laboratory systems have been around longer than many others, so often have more maturity re how data is processed and used. Clinical flowsheets for lab results are pretty standard now. Pharmacy systems also are fairly sophisticated, especially:  drug / allergy checking, dosage calculations, and alerts.
• A good friend of mine is the chief of anesthesia and also the surgical suites medical director at a major health system in my home state. He is excited about the possibilities of having rich information available to him for analysis. He believes using tools such as regression analysis will allow his organization to target specific data points that will enable them to improve patient care. The ability to review surgery types, preparation processes, material usage and other important elements will enable them to adjust how, when, where and why adverse patient experiences happen. Without the use of information technology this type of analysis would be almost impossible in a meaningful timeframe. Now they will be able to complete analysis and create change in a fraction of the time it would take in the past. This reduction in reaction time will improve the outcomes for many patients.
• At MUSC and Indiana Heart Hospital, they are leveraging health IT to prepare heart failure patients more effectively prior to discharge — and they are seeing outstanding outcomes improvements in readmissions.
• PACS, without a doubt. Over the last 20 years, having images immediately available to clinicians has completely demystified radiology (to their detriment), and given bedside clinicians access to more information in a more visceral way (sorry). Can’t prove it, but I got anecdotes…

News 8/22/12

Top News

MModal becomes a wholly-owned subsidiary of Legend Parent Inc., an affiliate of JP Morgan’s One Equity Partners, following the completion of Legend’s tender offer for all of MModal’s outstanding shares.

Reader Comments

From PCP Doc: “Re: specialists. In my community, 40-50% of specialists are practicing primary care because there are too many of them. It makes coordination of care more difficult. One patient sees a cardiologist for blood pressure and another who had breast cancer two years ago sees an oncologist, radiation oncologist, surgeon, OB-GYN along with her primary care doc just to get a breast exam, mammogram, and CBC. Specialists have said they’ll do primary care if the pay goes up, but they’re a bit rusty at it.” I suppose that’s the downside of luring the procedure docs back into primary care – many of them have never done it and more than a few are probably going to be lousy at it because of personality type or lack of interest. Can you imagine retooling a cardiac surgeon into a pediatrician?

From Leopold: “Re: hospital software lineage. I’m looking for the link posted earlier this year showing vendor consolidation.” Constantine Davides of JMP Securities created the HIT family tree for HIStalk readers (parenteral alert: it’s full of HIT incest that spans decades.) I think he’s sorry he opened this particular can of worms since it was pain to create and then update with reader-suggested additions.

From Scott: “Re: Tableau data visualization free trial. Altosoft also offers a free download, but with no registration required. Clients include Cleveland Clinic, Geisinger, Memorial Sloan-Kettering, Yale, etc. We have pre-built dashboards for AP, CP, radiology, leadership, charge nurse, etc.” Scott’s from Altosoft.

From Oh the Humanity: “Re: PlatinumMD. I heard they’re calling practices with a ‘courtesy call’ from the ‘Stimulus Recovery Department’ and asking to have the doctor call them back about ‘the doctor’s reimbursement checks that come from CMS.’ I can only imagine how they respond once they find out that the company is a MU consultant and not the government calling to reclaim their stimulus dollars.” Unverified, but their site does have a page called Stimulus Center.

From Nicole: “Re: hospitals forced to share records. Two New York hospitals were told by the state that their certificate of need requests for construction would be approved only if they join a RHIO.” Nicole sent the article over, which is available by registration only on the Crain’s site. The Department of Health’s Public Health and Health Planning Council told Hospital for Special Surgery and Memorial Sloan-Kettering that their construction projects (valued at $859,000 and $339 million, respectively) would be approved only if they agreed to join a RHIO, observing that they are the only two hospitals in New York County that haven’t already done so. Council member Jeffrey Kraut said, “The time has come to make all CON applications join,” and when another member said their reasons might be financial, Kraut shot back, “You mean Sloan-Kettering is too poor?”

HIStalk Announcements and Requests

Listening: Pentagram, after watching a documentary on Netflix about their singer’s 44-year drug addiction and the band’s recent comeback attempt after years of self-inflicted lack of commercial success and endless membership changes. I’ve played this magnificent song, recorded during a 1976 basement practice session on a cheap reel-to-reel recorder, least 100 times in the last three days because it sends chills up my spine (it really kicks in at 1:50). Pentagram is like a mix of 70s heavy metal bands from my vinyl collection that you’ve probably never heard of, like Captain Beyond, Sir Lord Baltimore, and UFO. I may get a Pentagram tee shirt as my tribute to non-conformist failure in the presence of ample talent.

Acquisitions, Funding, Business, and Stock

The Outsource Group, an RCM provider for hospitals, acquires XAM/MAX, a provider of self-pay collection and insurance follow-up services.

Behavioral software vendor Netsmart Technologies, whose CEO is former Cerner COO Mike Valentine, acquires Behavioral Pathway Systems, which sells behavioral provider benchmarking services.

Sales

Arkansas Heart Hospital signs a 10-year, $10 million agreement with Siemens to implement Soarian clinicals, financials, pharmacy, and med administration check. Siemens Financial Services division financed $4.8 million of the purchase.

Jordan Hospital (MA) selects Mediware’s Insight Performance Management software for monitoring enterprise performance programs.

Trinitas Regional Medical Center (NJ) chooses Hyland Software’s OnBase enterprise content management to integrate with its Allscripts Sunrise EMR.

University of Iowa Hospitals and Clinics chooses Voalte’s iPhone-based communications system for use throughout its facilities.

People

Home health software provider Procura appoints Rebecca MacKinnon VP of US sales. She was the founder of BeyondNow Technologies, which was acquired by Cerner in 2003.

PracticeMax, a provider of practice management services, announces the retirement of Rick White as president and the promotion of Patrick Lukacs (above) from VP of software services to VP of operations.

Press Ganey Associates names David Costello, PhD (SCIOinspire) chief analytics officer.

Consumer health engagement firm Silverlink Communications names Adam A. Hameed (Emdeon) chief revenue officer and Paul G. Fitzgerald (ITA Software) CFO.

Natalie Sensabaugh (Picis/OptumInsight) joins PerfectServe as a clinical advisor.

Elsevier/MEDai names Peter Edelstein, MD (Adventist Health System) as chief medical officer and Gerald Osband, MD (Trizetto Group) as director of product strategy.

UNC Health Care System (NC) promotes Donald Spencer, MD to VP/CMIO.

Announcements and Implementations

HealthBridge and the Greater Dayton Area HIN announce the launch of secure, electronic transmission of immunization data from two primary care practices to the Ohio Department of Health.

Arnot Health (NY) joins the Rochester RHIO.

Healthcare Quality Catalyst says its data warehouse solutions sales increased by 1,100% in the first half of 2012 vs. 2011.

Microsoft announces release of an iPhone app for its HealthVault personal health record, which also includes a list of compatible apps such as iTriage and CareCoach.

Government and Politics

The Department of Defense and the VA eliminate an RFP requirement that proposed pharmacy systems for their combined EHR use First DataBank’s drug database.

HHS awards $48.8 million in grants to bolster epidemiology, laboratory, and health information systems in state health departments to help states fight the spread of infectious diseases.

ONC’s Consumer eHealth Program announces a contest for a mobile app that mashes up an individual’s Blue Button personal health data with open public health data to promote better personal health and lower costs. The top entry wins $45,000.

In England, the Department of Health and the trade department will encourage hospitals to open clinics abroad under the NHS brand to bring in additional revenue. They want to model their services after Mayo and Hopkins in providing services in India and China under the direction of Healthcare UK, an oversight board that has already been created.

Innovation and Research

In the UK, Birmingham Children’s Hospital is testing car-monitoring software that was developed for McLaren’s Formula 1 racing team. Input from 130 sensors provide 750 million data points during a race (fuel use, temperature, and tire wear) and the hospital is using it to monitor the vital signs of its pediatric patients. Says a PICU doctor, “Formula 1 engineers do lots of real-time monitoring during races and look at performance and modeling to see when they should change tires and have pit stops. They’re predicting, essentially, which we don’t tend to do in healthcare. Although we can see what is happening at the bedside, we can’t see trends over time.”

Sotera Wireless receives 510(k) clearance for its ViSi Mobile wireless vital signs monitoring system, whose body-worn sensors use hospital WiFi to allow monitoring to continue as the patient is ambulating or being transported. The company says the device’s output can be sent to an EMR.

Other

Hospital leaders rank WellPoint the worst health plan in the country, with BlueCross finishing last based on payment rates.

A former Florida Hospital Celebration ED employee is arrested following accusations that he sold the information of 700,000 auto accident patients to chiropractors and attorneys.

Sunquest held its annual executive summit on August 6 as the kickoff of its user group meeting, with presenters that included CIOs Dave Pecoraro of Exempla Healthcare and Allana Cummings of Northeast Georgia Health System along with Steve Lieber, CEO of HIMSS.

An article in The New York Times describes the secretive use of e-score, a “digital ranking of American society” that’s calculated as people cruise the Web. The CEO of eBureau says his product can predict whether a given person is likely to be a good or bad prospect in less than a second, scoring 20 million people a month and selling the names to interested companies. A spinoff uses similar information to decide which online ads to display. Clients send lists of sales leads they’ve bought, then eBureau extrapolates and adds details from other databases to generate up to 50,000 variables per person, which it then grades against similar factors for existing customers. Sounds harmless enough until they start selling scores to insurance companies or employers.

MD Anderson (TX) notifies 2,200 patients that their information was compromised when a trainee lost an unencrypted thumb drive on the employee shuttle bus. The feel-good part of the notice says they’re working at device encryption and have purchased encrypted thumb drives, probably hoping that nobody will remember that an unencrypted laptop was stolen in April that contained information on another 30,000 patients.

The State of California sues a plastic surgeon (who also apparently graduated from law school) for using strong-armed collection tactics on ED patients whose insurance doesn’t cover the full amount of her bill. She has sued more than 50 patients, taken out liens on their homes, and damaged their credit ratings, the state says. Her attorney admits that she is “very persistent” in her collections effort, but says she’s entitled to be paid. Other attorneys say so called “balance billing” isn’t common the ED because the patient doesn’t really have a choice about who to see, plus California law specifically requires doctors to settle their payment disputes with the insurance company and not the patient. Her lawyer has an answer for that, too: the patients were stable in the ED, so these weren’t emergency situations.

And administrative director at Maine Medical Center sues his employer, claiming they fired him for speaking out against the tradition of taking sports medicine residents attending an out-of-state conference to strip clubs. He says the hospital retaliated by moving his office to the attic of an old building that has bats. The hospital says he wasn’t very professional in raising his concerns, piping up at a department leadership meeting and addressing a physician in attendance, “So, what do you want to tell us about the lap dances at your conferences?”

Strange: a hospital in Israel recognizes clowns as members of the healthcare team, with up to 20% of surgeries featuring pre-op clowns to reduce tension and thus the amount of anesthesia required. A study found that in vitro fertilization success rates increased from 20% to 36% if the patient received a pre-procedure visit from a clown dressed as a bumbling chef. An American doctor says it probably won’t work here since a lot of us find clowns annoying.

Sponsor Updates

• Billian sponsored last week’s Lekotek of Georgia Run 4 Kids that benefits special needs children, with its team receiving a bronze medal for participation in the four-mile run.
• Virginia Physicians selects eClinicalWorks EHR for its 58 providers across eight locations.
• Visage Imaging announces GA of an upgrade of its Visage 7 Enterprise Imaging Platform with enhancements that include lesion tracking, drag-and-drop support, single-click attachment of non-DICOM images, and integration with Nuance PowerScribe 360.
• Capario launches an integrated patient pay solution in partnership with TransFirst that facilitates the collection of patient payments, including co-pays, deductibles, and balances after insurance has paid.
• CommVault announces the integration of Nimble Store CS-Series with CommVault Simpana snapshot management software as part of the IntelliSnap – Connect Program.
• Kony Solutions acquires Sky Technologies of Melbourne Australia to expand its global enterprise mobility market.
• Prognosis Health Information Systems sponsors a Webcast featuring National Rural Health Resource Center CIO Joe Wivoda discussing EHR for rural health leaders.
• The Nashville Area Chamber of Commerce names Cumberland Consulting Group, Emdeon, HealthStream, and Shareable Ink among the finalists for its second annual NEXT Awards.
• dbMotion and Allscripts host a webinar on preparing for accountable care.
• Anesthesia Business Consultants partners with Surgical Information Systems to integrate data captured in SIS’s AIMS with ABC’s anesthesia billing tools.
• Inc. names the following HIStalk sponsors to its list of 5000 Fastest Growing companies:  Beacon Partners, Culbert Healthcare Solutions, eClinicalWorks, Enovate, ESD, etransmedia Technology, GetWellNetwork, Greenway Medical, Hayes Management Consulting, Healthcare Growth Partners, Iatric Systems, Impact Advisors, Ingenious Med, Intellect Resources, iSirona, Kareo, maxIT Healthcare, MED3OOO, MEDSEEK, Virtelligence, and Vocera.
• A Wolters Kluwer Health Survey finds that a third of Americans have experienced a medical mistake, with two-thirds of them  firsthand or from a third party. The majority of respondents expect new technologies to reduce errors.
• CPU Medical Management, a division of MED3OOO, announces a vendor partnership with eBridge to offer a combined PM and document imaging solution.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

HIStalk Interviews Darren Dworkin, CIO, Cedars-Sinai Medical Center

Darren Dworkin is senior vice president for enterprise information systems and chief information officer of Cedars-Sinai Medical Center of Los Angeles, CA.

Give me a brief overview about yourself and about the health system.

I’m the chief information officer at Cedars-Sinai Health. I’ve been here for almost seven years. Before that, I was the chief technology officer at Boston University Medical Center.

The health system itself is made up primarily of our large hospital. We’re a single-hospital facility located in Los Angeles, California. Like most large organizations, we’ve diversified through physician groups and other stuff that made us more of a health system.
We’ve been spending most of our time over the last four or five years setting and implementing our clinical IT strategy.

What’s different about working in a hospital that some people call “The Celebrity Hospital” or “The ER of the Stars,” where you got a lot of movie star patients and their supporters?

We don’t really think of it that way on a day-to-day basis. The reality is that we have a small percentage of famous clientele that use our organization, but for the most part, we try to define ourselves through the quality of care that we deliver and the programs that we offer.

That being said, I think there is no question that being here in Los Angeles, we end up having a little bit more scrutiny or an eye on us that sometimes weaves itself into our planning and even some of our communications. When it comes to implementing clinical IT, we try to make sure we do things well, but I think between our past CPOE failure and the media market it can sometimes feel a little like a fishbowl.

The one case where the Hollywood connection definitely worked against the hospital was the heparin incident with the Quaid babies. That must have triggered quite a bit of internal review. What was the IT involvement in those discussions about patient safety?

For obvious reasons, that is a hard question to fully answer, but I think that’s where Cedars has been good to not to look at errors specifically through one department, but really approach them as a system review. There’s no question that highlighted a system failure

The incident had us look at lots of different components that were part of the chain of events. But back then very few of them were directly IT related since we were busy implementing and most was not live yet.

Not to brag, but today we believe we stand in the top 5% with our use of barcoded med technology at the bedside. We scan in the high 90s on a fairly regular basis. But your readers are well informed about the complexities of the real workflows in a busy hospital, so while having bedside barcoding is great, it far from solves every problem.

The hospital has come a long way since back in 2003 when the decision was made to shut down the CPOE system after physicians protested. What do you think were the lessons learned that helped you get where you are today?

The decisions to implement and ultimately build the CPOE system are complex. They’re complex now and they were complex then. That story really starts in 1998 or 1999, as the Medical Center began looking for the right system for itself. I think back then, looking at the choices of what was available and the complexity of the organization, I think Cedars made a good decision to try to self develop.

Obviously, it didn’t end well. That story is well documented, maybe even over documented. But a lot of good lessons were taken from that failure that have since helped us, we could probably write a whole book.

It’s cliché now to talk to the idea that you have to involve clinical teams and make sure you do the right things from a training and engagement perspective, as today I think everyone understands that. Back then, these projects were seen much more as IT-centric things. 

As much as we knew we had to keep everyone engaged this time around, it was still hard to keep applying it. Especially the discipline to really focus on training — which by the way if someone insisted on me giving them only one piece of advice for a successful CPOE project, I would say besides the idea that there is not just one thing, focus on training.

The second area is the idea of a pilot and what you really want it to mean. The first time around, we used pilots as a substitute for a phase with the intention and plan to carry on to the next step regardless of the outcome. This last time around, we left real time to get input and to modify our approach.

We installed in seven phases. Epic tells us that is a record for a single site. While I would not recommend it, as we had too many, it allowed us time to tweak our approach. By the time we rolled out CPOE big bang in the hospital as the last phase, we did pretty darned well. We hit over 90% utilization — using real math — our first weekend ,and have stayed that high five months later. Remember, this is with very large private medical staff.

The last stuff is around how hard it is for organizations like hospitals to build and sustain large development teams to design and implement good clinical software. At the end of the day, a big problem of the original CPOE system was it was not great software. This drove us to select a vendor-based system as a core requirement. We chose Epic and are very happy with it.

Speaking of that, if a peer asked you what it was like to go through the selection, implementation, and now the support of Epic and to manage an IT organization throughout that process, what would you say?

For every organization, it’s different. A lot of it is where you’ve been that will shape how you decide you move forward. For us, obviously, given our history as a failed implementation, we spent a lot of focus on selection.

Selection for us was purposely run for a fairly long period, probably longer than other hospitals. It was a way of building initial engagement across the medical center in terms of helping people understand what the right type of system was for us.

The story I like to share is that shortly after selection, the good news was that it was unclear whether nurses had picked the system or the physicians had picked the system. Both constituencies thought they had played the pivotal role. I think it’s an example of having known where we started, we spent a lot of time focused on making sure that selection was done just right. We made sure we involved everybody that needed to be involved in participating in what ultimately became large-scale enterprise workflow design sessions.

People always want to know about what Epic’s secret sauce is in getting their customers live in a predictable fashion without too many surprises. How are they different from other vendors?

There are a couple of things that are unique with Epic. It’s strong software that delivers what it says it’s going to deliver. It has a strong user interface which clinicians relate to so when they’re demoing the system, they can more easily imagine how they’re going to use the system.

But most important — and I think to Epic’s credit — their secret sauce is that they rolled in an implementation methodology into the product itself. Very few people will implement Epic in a way that doesn’t use some portion of Epic’s methodology. I think that they really appreciated and understood well that it’s not just about the software. It’s how you put it in and how you ready your organization to begin to accept it.

How are you engaging with physicians now vs. before?

It’s hard for me to answer directly because I wasn’t there then, but I’m certainly part of it now. What we’ve done is more than just say we’re going to involve clinicians, which as you know sometimes involves showing it to physicians and nurses in the eleventh hour. They were part of the work teams. They were part of the teams that helped validate design. We had physicians as part of testing. We had physicians as part of the design sessions.

What we did effectively was bring together all the different members of the hospital into the same room, so that as things were worked on between the different constituents, they didn’t change so that people couldn’t recognize them as they went through a committee.

As much as possible, we brought all the people to the same place at the same time. In some ways, that resulted in 200-plus people being involved in a hotel ballroom going through something. But in the end, while at the time felt rather tedious, it paid off in terms of making sure that things were well integrated together.

Of course our challenge now, with a little bit of irony, is that as we continue to optimize the system. The number of people that want to come back into the room to really address system changes because the system is so integrated is enormous.

How did that get you on your journey to Meaningful Use and where do you see that playing out?

I’d characterize Meaningful Use more as a side trip for us rather than the journey. What I mean by that is that Meaningful Use was and still is a very important catalyst in driving IT adoption around the country, but for Cedars, our plan was well in motion and our strategy — and frankly, the tactics underneath that — were well understood prior to meaningful use being created. While we certainly knew that Meaningful Use was an important piece of the equation, we didn’t retool tactics to accommodate Meaningful Use. We knew that the end points would ultimately lead to the same destination.

When you’re looking at projects, especially when you talk about multi-year ones, you really have to make sure you demonstrate a discipline and a commitment to make sure you get to your goal as originally designed no matter how tempting the side trips may be.

You mentioned changing conditions. There’s a lot going in state and federal government. How do you see the developments that are happening changing the long-term strategy and thus the IT strategy of Cedars?

Some stuff is having a big influence. Some stuff is still yet to be defined.

Maybe speaking to the popularity of the product that we chose, it’s an integrated system that brings together ambulatory and inpatient as well as financials. As organizations ready to look at what it will take with accountable care, there’s no question that all those pieces of the puzzle need to come together. The better organizations are positioned in terms of seeing that information across the continuum merged with financials, the better equipped they will be. To that respect, not a lot has changed. I think that will continue to position ourselves to leverage our investment.

With regards to what’s ahead, there’s no question that as the demand moves higher upstream and organizations are transitioned from a fee-for-service world to accountable care, where you begin to blend in more population health management tools, we’re going to need to make sure that IT is at that center point to be able to provide it. The way we’re seeing it take shape, our agenda going forward is very much focused on the tools that will help us manage risk as we begin to take on risk in the new world and whatever form of contracting or arrangement that takes. As well as just become smarter and better at using the data that we have in a way maybe a little bit outside of that transactional lens that for a lot of years — probably going back four or five years ago — people really thought of as the objective or the goal.

Said maybe a slightly different way, I think that four or five years ago, it might have been a little bit easier to craft a goal around some of these projects — EMR projects — because you’d measure them in terms of physician orders written electronically or nurse documentation. The goals are moving well beyond that and the focus will be on the outcomes of the data that you’ve now collected.

That’s a criticism of Epic, that they were late to the database party and use a lot of gimmicks to move the data from their non-relational database to a usable form. What technology will you need to take advantage of your data?

I’m not sure I so much agree with the context of the question. We’ve not been struck by a challenge to get our information. I think our challenges have been more in terms of how we want to begin to use that information.

The reality is that perhaps for some smaller organizations, it’s true that out of the box tools or the automagical buttons might not exist in sufficient quantity to produce the data. But At the end of the day for us, the name of the game is trying to understand what we want to do with the wealth of the information we have.

To be perfectly candid, it’s relatively new to us. We went live on March 2 with CPOE , so we’re still learning which data we should begin to mine first and what we want to build.

I’ll give you a small example. For a very long time, we held back on a lot of decision support, largely because our focus was around engagement, usability, and adoption. While we knew that decision support is certainly an important tool of any EMR, we wanted to make sure we were very conservative in what we applied to maximize the usability. Now that we’ve lifted that veil since we’re successfully live, it’s been an interesting journey for us to figure out how to decide what decision support gets thrown into the system and how to ultimately prioritize that. In the end, as we better learn to manage the data that we’re collecting, I think that’s where all the work will be.

To go back to your question though, I think I would add that we do see, at least for ourselves, always a place to externally keep all of this information since it’s as critical as the EMR is for us. Our teams, have a long history of managing a clinical data repository. We will continue strategically to imagine ourselves as holding that data at a higher level than the transaction or application layer.

There’s a debate over whether implementing Epic means you’re being innovative or in fact being anti-innovation. What do you think innovation means in a hospital or health system environment and how do you practice it?

Our philosophy with Epic is that Epic does a lot of things great. Frankly, Epic provides us the innovation out of the box, which I think is maybe the theme of some of the accusations out there. But we embraced that as an opportunity in that, “Great, if somebody else has that covered, we’ll work on the next thing.”

We think of one of our roles in innovation as filling the white space between functional modules or between applications. But we try not to take too much pride of ownership in the innovation as when we see a commercial vendor — either an existing one or a newly emerging one — meeting the need, we are happy to yield the space back and look for the next opportunity.

Our challenge lately has been that healthcare IT continues to be such a hot sector that younger companies that we often look to partner with aren’t surviving long enough in their core ideas. The popularity of the sector has brought in a lot of new money with sales and growth expectations that are hard to deliver with providers. Everybody wants to expand quickly into other areas to make numbers. Nobody wants to stay and innovate in their box long enough to deliver complete end-to-end workflows. 

As we work with some of the smaller companies that start with a really good idea and fill a need, they quickly can represent to us a collection of functions intertwined with companies with intersecting business plans and colliding products. It makes you think about how private companies with strong backing can probably stay focused for longer and might be better positioned to grow an end-to-end workflow company.

How do you see the market playing out over the next 5-10 years?

I think parts of the market — as others have predicted and I will tag along — will continue to consolidate and some parts of the market will likely dwindle away. The EMR market just feels ripe for more consolidation. The niche clinical product market that’s out there — my guess is we’ll start to see that continue to dwindle away as enterprise clinical systems take over.

I still have lots of faith in the capital markets and innovation. I think that as new problems emerge, there’ll be new companies that will come up and help hospitals and health systems solve them. I have little doubt that we will continue to see data intelligence as a big focus for the next few years.

The tricky part is going to be how some of the bigger organizations like Cedars and obviously many, many others continue to learn to manage the integration challenge. Especially as health system appear to be acquiring. While we think internally that we moved away from best-of-breed, we have not moved away from deep investments in our integration technologies. Because we know that ultimately there’s always going to be a role for putting small pieces together to serve the whole. I believe this will be a big area in the next few years as well.

Does it worry you that an awful lot of hospitals have chosen Epic and that its large application set means you’re putting a lot of eggs in their basket?

I think at times there are some things we worry about, but overall I wouldn’t say that it’s a worry. I think that healthcare is still new in the consolidation business. While Epic is big, it’s not uncommon in other industries to start to see dominant players like that.

In a lot of ways, I think there are some positives with it. California is just beginning to see the potential of leveraging Epic for information exchange. Other states have been able to leapfrog some other efforts by joining together already. I also think there has been some great group think and group input that we’ve benefitted from in terms of more rapid maturity of the applications because there’s such a wide and diverse customer base.

In the end, it always gets measured in terms of what organization’s specific needs are. For us, we’re comfortable– and in fact, frankly pleased — to see a large, healthy vendor behind what is obviously a fairly large and significant investment for us. We’ve not been afraid to innovate or seek small partners if we were looking to do something that was out of their sphere.

Any concluding thoughts?

Yes, two.

The first is on people. It may sound weird, but it’s still amazing to me how much people play a big part in everything that we’re trying to accomplish. I know that there’s a lot of focus often on the software vendors and the products, but I’d tell you the same thing that we talk about internally. The largest reason for delay or the largest inhibitor to moving forward with a new project — besides funding — is most often the ability to find the right people to work on the project with the right skill sets. We spend a lot of time encouraging and growing our own teams, knowing that ultimately that’s the secret to our ability to deliver. We are recruiting and so is almost every fellow CIO I meet. We need to find a collective way to start to solve our people shortage.

And second, thank you for interviewing me. You have a great product with a rather shocking reach.

Curbside Consult with Dr. Jayne 8/20/12

Mr. HIStalk, Inga, and I don’t get to see each other in person very often – usually just at HIMSS or in the odd instance our paths cross while traveling. It’s always a nice surprise though when one of them publishes on a topic that parallels something I’m doing at my day job. It happened this week when Mr. H ran one of his Time Capsule pieces on hospitals aligning with private practice physicians.

Not unlike other hospitals and health systems across the US, my employer is no stranger to the relaxed Stark anti-kickback rule. They’re using the EHR exception to offer a variety of subsidized EHR products to community physicians. One tenet of the exception is that the software being provided must be interoperable.

It would have been nice if the hospital simply offered the same EHR that the employed physician group uses so that we could all begin exchanging data immediately. This would potentially have had an immediate impact on reducing duplicative testing, ensuring referrals arrived with appropriate clinical data attached, and strengthening referral patterns. Throw in a couple of laboratory interfaces and it would have been a winner.

Instead, the hospital chose to do what Mr. H suggested and let the recipient practices choose their own EHRs. Trying to connect different platforms via point to point interfaces can be tricky, so the hospital decided to throw a health information exchange into the mix as well, promising quick connectivity. Community physicians chose four different EHR systems which vary dramatically in quality, comprehensiveness, and production of discrete data.

A wise CIO would have allowed third parties to implement these physicians on their systems of choice. Ever eager to curry favor with the various regional administrators and informal power-brokers, our CIO chose to form a “tiger team” to implement and support all four products as well as the yet-to-be-deployed HIE.

Several years have passed, and as you can imagine, the project has been somewhat of a mess. I’m glad I haven’t been involved and can’t believe they’ve staffed it with only three people. Frankly, I don’t know how those poor souls cope. I only have to deal with two EHRs (one ambulatory, one inpatient) and that can be a challenge in keeping up with different releases and features.

Even in ideal circumstances, I can’t imagine trying to learn, implement, and support multiple ambulatory EHRs. This team is not working under anything remotely close to ideal circumstances. They’ve had to cut corners just to stay afloat and haven’t fully implemented the features of even one of the systems.

Like those mentioned by Mr. H, the physicians taking part in this subsidy program are largely unreasonable and haven’t been terribly cooperative with practice reengineering or making sure office staff members are held accountable for learning the systems and using them correctly. They complain bitterly about how much money they’re spending (even though they’re footing between 15% and 30% of the total EHR bill) and how little they’re getting for it. Enter Dr. Jayne, who has been placed on temporary duty assignment to “find out why those doctors are so unhappy and fix it.”

I’m pretty sure the CIO thinks I have some kind of magic wand that I can just wave and make this whole thing go away. After visiting with a handful of providers, however, it’s going to be a lot more complicated. I’m pretty sure it’s going to involve the practice management and healthcare IT equivalents of a backhoe, a steam roller, and seven sticks of dynamite.

I’m not confident we’re going to improve things unless the providers learn to check their egos at the door and the practice managers start running the practices like businesses. The hospital administrators leading this project need to learn to hold the practices accountable. Even if all of these pieces fall into place, I still give it no more than a 50% chance of success.

Without a change to the regulations, the Stark exception is set to expire at the end of December 2013. The hospital administrators and the CIO are confident that the provisions will be extended. HIMSS has lobbied that the EHR exception be made permanent. Although I don’t see the government announcing any extension until at least 2013, I know of three people eagerly waiting for this project to die a timely (if not early) death. Depending on how long this “temporary” assignment lasts, I’m going to be counting down the days alongside them.

Have an EHR exception horror story? Have a fantastic tale of success? E-mail me.

E-mail Dr. Jayne.