Time Capsule: Untethered Caregivers = Great Clinical Systems Opportunity

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 August 2007.

Untethered Caregivers = Great Clinical Systems Opportunity
By Mr. HIStalk

Networking hardware vendor Cisco made a surprising announcement last week. The company’s two-year-old hospital division has become its growth leader. Sales have doubled in those two years to a cool $1 billion annually. Much of that involves wireless networking. That’s an unqualified "great" for Cisco and a qualified "good" for hospitals.

Healthcare customers were already buying a lot of Cisco gear, so carving out a separate healthcare business may not have made much difference. Still, the company must see a lot of opportunity in hospital wireless, infrastructure upgrades, and new construction. They’re smart.

Cisco will learn from a hospital-focused division. The company supposedly ran afoul of FDA regulations after making meaningless claims about a "medical grade network." It backed off a little, but is now pushing the good concept of integrating medical devices via wireless connectivity.

Hopefully Cisco won’t misstep again when injecting its products between patients and caregivers. If the company backpedals on reliability guarantees or has a patient-harming episode and hides behind legalese, word will spread fast. Cisco has a couple of hot little competitors like Meru and Aruba who would be more than happy to snatch a few of its crumbs.

Anyway, what’s most interesting about the announcement is that, clearly, most hospitals now have some flavor of wireless network. They vary in coverage, reliability, speed, use, and user acceptance, but they’re out there in force. And because of that variation, Cisco and other vendors see a gold mine in replacement the early-generation 802.11b and 802.11g systems that are limping along unimpressively.

Expectations have changed. Wireless is mission critical. Entire clinical systems strategies have been crafted around mobile caregivers wandering seamlessly around buildings while using portable computing devices.

Software vendors haven’t quite caught up. Applications are sometimes mobile user-unfriendly, requiring carefully targeted mouse clicks and keyboard entry that doesn’t work well when cradling a tiny notebook PC in your arm. Less-than-youthful caregivers may have to squint painfully to read screens that were designed for 17-inch monitors. .

The writing is on the wall, however. Wired devices will soon be as antiquated as those early-generation VCRs that had a wire-attached remote control. Wire’s last advantage is about to be eliminated as 802.11n matches or exceeds its speed.

Hospitals will save a bundle by not hard-wiring buildings. It’s painful to sit through construction meetings trying to convince architects and construction project managers that network wiring requirements are just a bit more complex and expensive than running electrical power to wall outlets. That’s a concept you can tell your grandkids about some day, like when TVs had a picture tube or when music came from a store instead of a download.

The downside, as it always is, is cost. We’re re-buying all this gear from Cisco and other vendors, ripping out what we bought just a few years ago. That’s capital that could have been used elsewhere, like virtualizing servers or improving redundancy.

If all goes well, this second round of spending probably buys the performance you expected from the first round.

Still, wireless technology developments are exciting. Hospitals need to figure out how to improve patient care given untethered caregivers who carry an impressive arsenal of technology in lightweight devices. There is cool stuff yet to be done using VoIP communication devices, new bedside patient monitoring and diagnostics, and information systems designed to help deliver care, not just document it.

Clinical systems vendors, it’s a great time to rework or build applications without the assumption that users are sitting at a desk all day. Ubiquitous wireless connectivity changes the game. If you don’t believe it, think about what went on in coffee shops before Wi-Fi.

News 6/29/12

Top News

 

A GAO report finds that the VA and DoD have made progress in their pilot project to integrate care at the James A. Lovell Federal Health Care Center (IL), but delays in implementing the IT component have resulted in additional costs. IT investments have already surpassed $122 million and some initiatives are almost two years behind schedule.

Reader Comments

From Convener: “HIStalk’s announcement on the Supreme Court ruling. Once again you beat Modern Healthcare and all the others, and with a more comprehensive article.” Since Mr. H is busy traveling for his hospital job, we decided in advance that I would sit by computer and TV, listen for the announcement, and send readers a quick update. The moment MSNBC said the healthcare law had been upheld, I looked for an online write-up. Above is a screen shot of what CNN posted, which obviously left me mighty confused (obviously several so-called journalists hit the “post” button for their pre-written stories after reading only the first sentence of the ruling.) Thankfully I decided CNN simply had it wrong before I blast the news incorrectly to the HIStalk universe. Boy, Mr. H would have never let me live that down.

From SummerFun: “HIStalk Practice Advisory Panel. I liked the write-up. Great questions and interesting answers.” In case you missed it, our first HIStalk Talk Practice Advisory Panel post was published earlier this week. The participants, who are primarily physicians and staff in ambulatory care practices, shared thoughts on their EMRs and discuss other technologies. It’s a fun read and a good mix of positive and negative impressions, just like real life.

From Blue Eyes: “Re: healthcare reform act. What do you think of the news and its effect on healthcare IT?” I think people have forgotten that Thursday’s ruling affirmed only the legality of creating the law, not to assess it as a good or bad idea. I’ve yet to hear anyone claim to have read and/or understood the 2,900 pages of legalese, including the politicians who voted for or against it, and it’s discouraging that even the Supremes voted pretty much along liberal / conservative lines (it’s either legal or it’s not, but you wouldn’t know that from the 5-4 opinion). I don’t know if anyone of us know what it means beyond lots of newly insured people showing up at the doors of hospitals and practices (at least when they can find a primary care provider to schedule them). I’d bet healthcare costs will continue to go up, healthcare IT will ramp up for another year or two until the Meaningful Use wad has been shot and providers go back to buying only what boosts their productivity or bottom line, and we’ll nonetheless start getting some highly useful big-picture data telling us where we stand from a population health perspective but leaving us to actually do something about it (like finding a way to get Americans to lose weight, exercise, and manage their expensive chronic conditions wisely and cost effectively). Here’s where the crowdsourcing thing works well: click the Comments link at the bottom of this post and tell me what you think. For those who have never commented, you don’t have to register first and you can give a phony name to stay anonymous. My general assessment when wearing my HIT tunnelvision goggles is that it’s a good thing. As a taxpayer, I’m not really sure.

From Watcher of the Skies: “Re: HCA. Going Epic. I was in training in Verona and someone from HCA in my class said so.” Unverified. HCA originally said they were doing a one-hospital Epic pilot to decide between it and upgrading Meditech, but nobody’s told me definitively which way they’re going.

From Robbie Douglas: “Re: McKesson. Close to making an acquisition of [company name removed], whose offerings include an ambulatory EHR and billing and management services.” I removed the company’s name since the rumor is unverified, but it sounds like a done deal. It’s a pretty big outfit. 

From Cool Runnings: “Re: Drex DeFord. Leaving Seattle to take CIO position at Steward Health in MA. Steward’s for-profit 80-hour work weeks have taken their toll on a few CIOs in a short period of time. The CEO likes to call his leadership on weekends and expects them to work as many hours as he does.” Drex has updated his LinkedIn profile to list the Steward CIO job, so I’ll call that rumor verified. I worked for a for-profit hospital chain once for a short time. It was run by the biggest scumbags in the industry given my first-hand observation of their indifference to patient care and total worship of the bottom line. I wouldn’t care to repeat the experience, but to each his own.

HIStalk Announcements and Requests

Here’s some highlights from the last week on HIStalk Practice, in addition to the above-mentioned post from our Practice Advisory Panel: the biggest challenges of running a group practice. Alleviant announces plans to open a new facility in Vermillion, NC. The Office of the Inspector General finds that EMRs from Allscripts, eClinicalWorks, and GE Healthcare were products most widely used by physicians to document E/M services. Humana is the top payer among US health insurers in athenahealth’s Payerview Rankings. Aaron Berdofe discusses the federated model in the second part of his series on healthcare infrastructure data models. It takes so little to make me happy: a glass of nice wine, a new pair of strappy sandals, or a few new subscribers to HIStalk Practice. Make me merry, if you can. And thanks for reading.

On the Jobs Page: Software Engineering Manager, Project Manager, Web User Interface Design Engineer, Senior Buyer – Third Party Labor.

Listening: Lush, underrated alt rockers from England who had a 10-year run that ended in the late 1990s when their drummer killed himself. The music is rich, sweeping, and sweet, but rocking in a wistful sort of way (some place them in the “shoegazer” genre, but I’m not sure about that). I don’t know how I missed them, but it’s not too late since it still sounds fresh today. You’ll like it if you enjoy Cocteau Twins.

Everybody’s talking about voting of one kind or another these days, so here’s an urge to visit the (electronic) polls. Register to vote by signing up for e-mail updates. Cast your vote for progress by liking, friending, and connecting with the HIStalk party (Inga, Dr. Jayne, Dr. Travis, and me) via the social media ballot boxes. Send us your tired, you poor, and your rumors and news. Show your appreciation of our supporters by checking out the sponsor ads to your left and trying out the searchable, categorized Resource Center and Consulting RFI Blaster. As Alice Cooper says, I’m your top prime cut of meat, I’m your choice, I wanna be elected – as HIT’s go-to site for news, scandalous rumors, and occasionally irrelevant amusement. Thanks for your vote to keep me in (my upstairs spare bedroom) office for another bunch of years – I won’t let you down. I’m Mr. HIStalk and I approved this message.

Acquisitions, Funding, Business, and Stock

Practice Fusion secures an additional $34 million in Series C funding led by Artis Venture. The company has raised $64 million since it launched in 2007.

Carena, which offers webcam-based provider visits and other products, completes $14 million in financing led by Catholic Health Initiatives.

People

The Digital Pathology Association appoints Sharp HealthCare CIO Bill Spooner to its board.

Employee scheduling software vendor Avantas announces the promotion of Christopher Fox from SVP of growth and innovation to CEO and Jackie Larson from VP of client services to SVP. Fox takes over for founding CEO Lorane Kinney, who is retiring.

athenahealth appoints Charles D. Baker (General Catalyst Partners) and Jacqueline B. Kosecoff, PhD (Moriah Partners/Warburg Pincus)to its board.

Announcements and Implementations

Hoag Memorial Hospital Presbyterian (CA) implements Unibased’s ForSite 2020 RMS resource management and patient access solution across all of its diagnostic imaging locations.

The Pennsylvania eHealth Collaborative announces a grant program that gives providers a free year of DIRECT messaging services for secure health information exchange.

RiverView Health (MN) will go live on Epic July 1.

Ochsner Health System (LA) will go live on Epic this week ad its health center locations.

Government and Politics

Five senators introduce a bill that would create a national standard for notifying affected individuals about information security breaches. The bill, the fourth attempt to create national requirements, would also move enforcement to the Federal Trade Commission and allow that agency to levy fines of up to $500,000.

Other

The Bethlehem Area School District (PA) joins The Children’s Care Alliance, which maintains an EMR database of student health data supplied by school districts and made accessible to area hospitals.

Meditech President and CEO Howard Messing provides the opening remarks for the 11th Annual Pappalardo Fellowships in Physics Symposium at MIT, which is obviously supported by Neal Pappalardo of Meditech. Both are MIT alumni and physics fanboys. It’s a good talk.

Highline Medical Center and Franciscan Health System (WA) announce plans to explore a strategic affiliation, partly driven by Highline’s interest in using Franciscan’s Epic system that will go live next year.

University of Texas MD Anderson Cancer Center (TX) notifies patients that a computer containing patient and research information was stolen from a physician’s home April 30. The hospital says it will step up efforts to encrypt its computers, making you wonder how an organization as smart and rich as MDACC needed negative press to finally move the needle on encryption. Here’s a gentle nudge for their fellow fence-sitters: if you don’t encrypt your portable devices, you are being inexcusably irresponsible and deserve the inevitable headlines, CIO firing, and class action lawsuits that are likely to result when the “pay me now or pay me later” time bomb you allowed to be planted finally goes off. Everybody knows that healthcare IT is stuck in a 1980s time warp, but are we seriously still waffling on encrypting PHI-containing devices?

Meanwhile, the Alaska Department of Health and Social Services agrees to pay HHS $1.7 million to settle possible HIPAA violations stemming from the,theft of a USB hard drive from an employee’s car. The Office of Civil Rights determined that the Alaskan agency had inadequate security and risk controls in place and now must take corrective action to safeguard electronic PHI.

Is that a parachute in your backpack or are you just glad to see your surgeon? Mexican doctors remove a 33-pound tumor from the back of a two-year-old, 26-pound boy.

Sponsor Updates

• ICA announces that the Central Illinois HIE is live, with four up and running.
• Kony Solutions expands support of open standards with the release of its KonyOne Platform v5.0.
• Phoenix Children’s Hospital (AZ) chooses Access Intelligent Forms Suite to integrate data among its Allscripts HIS, electronic forms, and its MedPlus ChartMaxx content management application.
• Kareo releases a free iPhone app for accessing physician schedules online.
• Ingenious Med explains how its PQRS Registry is helping healthcare facilities to avoid penalties and improve revenue.
• Medicomp Systems CEO Dave Lareau  discusses five EHR considerations for organizations preparing for ICD-10.
• Julie Corcoran, principal consultant with Hayes Management Consulting, highlights five of the major issues facing hospital revenue cycle teams.
• MyHealthDIRECT expands its partnership with Amerigroup to include Amerigroup’s Maryland provider partners and giving them access to MyHealthDIRECT’s online scheduling services.
• Wolters Kluwer Health announces that Essentia Health (MN) is the 1,000th customer to deploy its ProVation Medical software.
• BridgeHead Software releases the results of a survey finding that only 26% of worldwide HIT leaders have robust disaster recovery plans in place. 
• Centracare Health System’s St. Cloud Hospital (MN) selects Merge PACS.
• New York eHealth Collaborative says it’s the first REC to hit 1,000 providers qualifying for Meaningful Use money.

EPtalk by Dr. Jayne

Like Inga and Mr. H, I sometimes become annoyed when my day job cuts into my HIStalk time. Unfortunately, this is one of those weeks. I had taken some time off this week to make sure I would be able to immediately respond to the much-anticipated Supreme Court decision, but it has been sucked up by a couple of hospital projects that have gone off the rails. I’ll definitely be responding to the decision, whatever it may be, but just not tonight.

HIStalk reader and contributor Micky Tripathi writes about “The Dangers of Too Much Ambition in Health Information Exchange.” He warns of over-architected HIEs that try to be all things to all people at the expense of short-term wins with real value. It’s a great piece that I hope obtains wide readership.

CMS will begin enforcing the use of version 5010 HIPAA transactions next week. Although it doesn’t seem there are continued widespread issues, anecdotal reports include ongoing tales of claims difficulties.

Physicians are subject to as many as 20 different varieties of payer audits. The American Medical Association has archived a webinar that covers the who, what, where, when, and why of auditing. Anyone who wonders about the high cost of health care and declining levels of provider satisfaction should take a peek.

No surprise: An online article in the Journal of the American Medical Association discusses the higher per-patient operating costs found in clinics with higher medical home scores. Medical homes can reduce overall health care spending, but there is little incentive to incur the upfront burden if the savings isn’t passed to those doing the work.

For Inga: a chocolatier says the  Massachusetts pharmaceutical gift ban is hurting its business. Their popular corporate gift: chocolate shoes.

PremierConnect debuted this week, allowing providers and healthcare systems to access data from payers, claims, lab, billing, and other sources to monitor clinical performance and perform predictive modeling. The aggregated database includes data from more than 2,600 hospitals.

I was in Canada recently and heard quite a few public service announcements on the radio encouraging blood donors to step up and give. I haven’t heard much at home, but blood supplies in the US have reached “emergency levels,”according to the Red Cross. Summer heat and vacations typically limit donations and only 3% of people in America donate blood. If you’re looking for an air-conditioned place to spend some time over the upcoming holiday, consider taking a trip to your local blood bank. Chances are you’ll leave with a cookie and some orange juice in addition to knowing you may have just saved a life.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Supreme Court Upholds Healthcare Law

The Supreme Court rules to uphold the ACA, including the individual mandate.

CIO Unplugged 6/27/12

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

Excellence, the Road Less Travelled

Another summer working for meager wages was no longer an option for John and me. Both married with kids, we searched for a breakaway strategy where we could make decent cash to hold us over until our first big break. Under-experienced and over-educated in the utopic college town of Fort Collins, this proved a herculean task.

Nevertheless, armed with respective degrees in psychology and Spanish (teaching certificate), we came up with a vision that would forever change our lives. We started our own company. Men… who do Windows!

We visited our local janitorial supply store. With 10 minutes of in-store advice and a $100 investment in buckets, soap, and squeegees, we were bound for glory.

After analyzing our competition in the Yellow Pages, we realized we’d need a bold approach. Competing with dozens of vendors and with no time or money for static advertisement, we took an unconventional approach. We created fluorescent-colored flyers and paid teens to deliver them to targeted neighborhoods. Our phone began to ring.

We bid each job in person and dressed in nice clothes. We parked our company car (a urine-colored Honda CVCC) down the road a few houses so as not to tarnish the high-end brand we strived for. Who would notice the 24-foot extension ladder strapped on top of an 8-foot car? We wore “uniforms.”

We priced our services higher than our competitors — a bold move. But we hoped to differentiate ourselves by stressing customer service and excellence.

Included in our bid was our happiness guarantee: “We not only clean your windows, but your screens and window sills as well. When we enter your home, we take off our shoes. We have towels under all of our tools so you never need worry about us leaving your home a mess. We will move all drapes and curtains and furniture as needed. Prior to us leaving your home, we will inspect each window with you. If you are dissatisfied with any, we will redo them until you are happy with our work.”

We closed 90% of our bids. Our window redo rate = 0.01%.

After a few weeks, we could not keep up with demand and had to stop all advertising. It became vogue in some neighborhoods to have the Men… who do Windows sign in their yard. A few customers insisted on serving us lunch on their decks overlooking a lake. Excellence creates demand.

With graduate school awaiting me and another summer break for John, we resurrected the business the following year with the same results. We grossed an average of $400 per day, with the cost of doing business a low 5%. Excellence is profitable.

John and I believe our success was attributable to the high quality we put into our craft. We encouraged one another to be our best as we honed our squeegee skills to ensure a streak-free finish. Why would people willingly pay a 50% premium for our window-washing services? Because they knew it would be done to perfection. Our customers knew we would meet expectations and not leave without their approval. Excellence elevates the performance of those around you.

We both replicated this value in our personal and professional relationships — John as a teacher and later a pastor and I in healthcare. This pursuit of excellence has blessed our families and careers. Moreover, the people and organizations we serve have benefitted. Excellence creates differentiation that separates good from great.

Ten years after Men…. who do Windows, I was invited back to Colorado State University to serve on the advisory board of the college from which I received my Master’s. During lunch, I was approached by a fellow board member who asked if I had ever cleaned windows. I revealed myself as the founder of Men. He looked me straight in the eye and earnestly exclaimed, “My windows have never been so clean!”

Imagine — 10 years later and he still recalled the service he received from our company for washing windows. Excellence is not forgotten.

Twenty years after Men, both John and I visited Ft. Collins with our families. The owners of Trios AVEDA Spa and Salon knew we were in town. They had a big social after-hours shindig taking place one evening, and yes, they asked if we could reprise Men and clean their windows so they would dazzle. We obliged. It was a great reunion, and we still had our skills. Excellence sets a pattern for future performance.

The Men experience was priceless. Alas, the time came for us to move into our chosen professions.

Rather than sell the business, we gave it away to others in similar circumstances as we had been in two years’ prior. We taught them everything we had learned, from window washing basics to customer relationship management. Even the happiness guarantee.

By the end of the first season, the business lost half its value. We mourned when Men folded midway through the following year. Excellence requires passion to attain and sustain.

A long time ago, a writer in Greece observed the games that would eventually become the Olympics. He said, “Do you not know that in a race all the runners run, but only one gets the prize? Run in such a way as to get the prize. Everyone who competes in the games goes into strict training. They do it to get a crown that will not last, but we do it to get a crown that will last forever.”

Excellence is doing everything you do with the very best you have.

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

News 6/27/12

Top News

ONC’s Director of Meaningful Use Joshua Seidman, PhD resigns to take a job as managing director of quality and performance improvement with Evolent, the ACO services provider spinoff of The Advisory Board Company and UPMC.

Acquisitions, Funding, Business, and Stock

Atlantic Health Solutions acquires fellow medical billing company DataSolv Services.

Sales

Lehigh Valley Health Network (PA) chooses MedAssets to provide RCM technology and consulting services, including MedAssets Charge and Reimbursement Integrity solutions and Collections Management product.

Bradley County Medical Center (AR – above), Ellis Hospital (NY), and Jamaica Hospital Medical Center (NY) sign contracts with QuadraMed for the ICD-10 compliant version of Quantim Coding and for QuadraMed’s 3-Learning and Education program.

The West Coast Regional Office of VHA and Penn State Milton S. Hershey Medical Center (PA – above) sign agreements with Avantas for the company’s healthcare enterprise labor management technology.

The VA awards Ray Group International a $4.9 million contract to support the Open Source EHR agent project, which allows developers to contribute software code for the VA/DoD integrated EHR.

The Texas Department of Information Resources (DIR) signs a contract with PatientOrderSets.com to use its solutions in public and DIR-eligible hospitals.

Summa Health System (OH) selects PatientKeeper Charge Capture software for its 300 physicians.

Lenco Diagnostic Laboratories, a New York reference lab, implements EMRHub from Lifepoint Informatics, which allows it to distribute lab data to an unlimited number and variety of EMRs through a single connection.

People

RCM provider Recondo Technology names Major General (Ret.) Elder Granger, MD (TRICARE) to its board.

GetWellNetwork appoints Beth Martinko (Avid Technology) SVP of client experience and Hugo Borda (NeighborBench) VP of enterprise architecture.

Medsphere Systems adds Mike Morotti (Validus Medical System) as VP of sales.

PerfectServe appoints George Pace (Verisk Health) RVP of sales.

Ernest & Young names The Advisory Board Company CEO Robert Musslewhite a winner in of a 2012 Entrepreneur of the Year award for the Greater Washington Region. Ernst & Young also names T-System CEO Sunny Sanyal a finalist for the 2012 Southwest Area North Entrepreneur of the Year.

Beacon Partners names Jon Mello (EMC) as EVP.

Greenway reseller iPractice Group names Monte Ruder (Integrated Healthcare Solutions) its VP of sales and adds three additional account executives. Last week iPractice announced that an undisclosed California company is investing $32 million in the company.

Announcements and Implementations

Kaiser Permanente and the Social Security Administration announce a pilot program to exchange electronic health information using the NHIN.

The Kentucky HIE, St. Elizabeth Healthcare, and HealthBridge announce their successful secure exchange of patient health information.

McPherson Hospital (KS) implements Meditech.

OTTR Chronic Care Solutions announces the arrival of its OTTR 6 release.

Merge releases its eClinical OS Platform for capturing any type of data from any source and over any modality.

Former BayCare Health System (FL) critical care nurses Cynthia Davis and Marcy Stoots form CIC Advisory, which offers strategic consulting services specializing in EMR-driven clinical process improvement. They were involved in BayCare implementations in executive roles.

Government and Politics

ONC releases a new version of its online Certified Health IT Product List that lists 1,700 EHRs and modules and includes several new features, including functionality to identify hybrid certified EHRs.

Other

Winter Haven Hospital (FL) says it has pushed backed the full implementation of its EHR system from last spring until October 1 in order complete physician training. Cerner, I believe.

KLAS takes a look at Epic consulting firms and ranks Impact Advisors highest in enterprise implementation leadership and advisory, Encore highest for team implementation leadership and advisory, and Nordic Consulting highest for staffing implementation and support. KLAS identified 45 firms with Epic consulting engagements and found that nearly every firm received good marks for consultants. Thanks to KLAS for allowing us to quote their report and include the graphic above.

The Wall Street Journal covers the failed EMR implementation of 25-bed Girard Medical Center (KS), which says it paid Cerner $1.2 million and still can’t quality for Meaningful Use money (we reported its lawsuit against Cerner back in January). The hospital claims that Cerner didn’t include quite a few items in its $2.9 million agreement, but also admits that it didn’t understand the contract it signed and relied on Cerner to tell its executives what it covered. According to the CIO of the IT department (which had only two employees when the hospital signed with Cerner), the additional costs were only $100,000 over the term of the five-year agreement, but the hospital decided to stop paying Cerner to get their attention over poor service. They did – Cerner e-mailed the hospital to say it was walking away. Based on the skimpy description in the article, I’m siding with Cerner – the hospital didn’t do its due diligence, bought way more system than it needed or could maintain, and then tried to play tough over a price discrepancy of less than 4% of the total contract value. Granted some vendors (Epic) wouldn’t have sold a deal like that knowing the chance of success was minimal, but it’s not Cerner’s job to advise the hospital as a neutral party. If someone deserves blame other than the hospital, it’s the federal government for financially baiting providers into buying systems they otherwise had been wisely avoiding as a bad fit.

The president of CVS Caremark’s MinuteClinic says its retail clinics support continuity of care by giving every patient a copy of their medical record, sending their physician a copy if the patient approves, and integrating with practices by either sending them electronic information or (for the large number of practices that don’t have an EMR) a nightly batch fax.

An article by early Epocrates executive Michelle Snyder observes that despite all the technology being thrown at physicians, they’re less productive now than 10 years ago. She urges the use of simple technologies that, like Epocrates, are easy to use and save individual doctors time – no more, no less. Examples: HealthFinch (lets doctors delegate prescription refills to staff); ImagingCloud (Webex-like medical image collaboration); and Doximity (LinkedIn-like physician referrals and consultation).

Sponsor Updates

• NextGen changes the name of its Practice Solutions Division to NextGen RCM Services. 
• Bulletin Healthcare Briefings partners with the National Association of Pediatric Nurse Practitioners to publish and electronically deliver its members-only daily electronic news briefing PNP Daily News.
• ZirMed and DoctorSites offer a free webinar entitled, “Online Marketing and Payment Secrets That can Make – or Break – your Practice.”
• Mowery Clinic (KS) selects NextGen’s EHR/PM and portal solutions for its 33 physicians.
• Imprivata scores a score of 88.4 on KLAS’s 2012 mid-term performance report.
• Emdeon announces that three of its RCM solutions have received HFMA Peer Reviewed designation.
• Allscripts reminds developers that the deadline for its Million Hearts Clinical Decision Support Challenge is July 13. The company is offering a $50,000 prize for the best publicly available app that optimizes cardiovascular disease care through clinical decision support.
• Passport Health adds its PatientTrack and PatientRisk modules to the Care Cycle Suite.

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 6/25/12

I maintain staff privileges at a hospital where I almost never admit. Even with my non-existent volume, I still have to attend training, so I wasn’t surprised a few months ago when I received the postcard saying that it was time to talk about finally going live on CPOE.

It’s kind of funny, because more than four years ago I served on the selection committee for this particular product. I remember at the time being shocked that we were even considering it because the user interface was so buggy at the hospital where we did our site visit. Meanwhile, I had moved on to greener CMIO pastures, but I still keep those privileges out of nostalgia (or maybe out of fear that one day I might have to go back into traditional practice.)

Luckily the final training blocks coincided with a couple of comp days I had already scheduled. I wrote about my recent Meaningful Use upgrade training a few months ago and I hoped that this would be a similar experience. However, I think I could use it to write a case study in how to alienate the medical staff.

Being a veteran trainer, I arrived 15 minutes early because I knew I’d have a logon / password issue since I rarely go to that facility. The training room was dark, so I poked my head into the room next door to make sure I was in the right place. The training team was sitting around and barely noticed me. In fact, they were talking about another physician – making fun of one who had arrived half an hour early because he was cutting into their break time. I pretended I didn’t hear them and asked if I was in the right place. I was told they’d be in the room shortly.

I went to the room and found a seat at a folding card table (no, I’m not kidding) with actual damp coffee on it. They finally walked in five minutes after training was supposed to start and began passing around a coffee-stained sign-in sheet for continuing medical education credit. That was a plus – I hadn’t expected to receive hours and it’s always good to have some “live” credit since I do most of my CME online. But the coffee was a turn-off.

Additionally, since the last time I rounded, the facility had gone to proximity badges. I didn’t have one, which created much hubbub, although none of the trainers could tell me who to talk to in order to get one. Surprisingly, my ancient logon and password were not expired.

After dealing with the sign-in sheet and the proximity badges (I wasn’t the only one without one – the other doc who had arrived 30 minutes early didn’t have one either) they finally decided to fire up the projector and went through a whole “how do I adjust the keystone” saga. My new Twitter BFF, @MeetingBoy, would have been proud.

Training finally started about 15 minutes late. To my chagrin, they not only accommodated late arrivals, but stopped class and rehashed everything that had been covered to that point.

I was given a cheat sheet with some patient names, one of whom was a 14-year-old male named “Samantha,” which added realism to the scenarios. The class moved at a glacial pace to allow for one of the more senior members of our class (whom I know to be at least 85 years old) to keep up. I felt so sorry for her – she is very sweet and is a fixture at the hospital, and they really should have offered her an individualized class.

About an hour and a half into the class, everyone was kicked out of the application. The trainers explained that the build team was still creating order sets and had a tendency of uploading their work several times a day “to keep the environment fresh.” I don’t know about you, but I’m pretty sure we didn’t need their recent (probably untested) build work to make it through class.

I was surprised to see that the version being deployed was the same version we looked at four years ago. I know this product didn’t make its vendor’s “go forward” list, but I’m pretty sure there’s been another release since then. I’m not sure about the rationale for taking outdated software into a live environment.

All the bugs and UI glitches that we had seen during selection were still there. Some orders were in alphabetical order when it would have made more sense to have them sorted by frequency of ordering or grouped by body system. Others were arranged by the order in which they were added to the database rather than being in alphabetical order. You could see what the “oops, forgot that one” tests were because they were at the bottoms of the lists. Seeing “do not use” abbreviations is always a treat as well. Several screens had such inconsistent use of color that it looked as if a bag of Skittles had been upended on the screen.

I was pleasingly surprised to see that the system had a button for logging bugs (really a glorified e-mail launch) and the other docs in the room got a kick out of that too. Docs were told to log anything they thought should be added and that it would be placed in the system. There was no mention of change control, governance, or peer review of the suggestions.

Laughs were had over the trainer’s warning that we shouldn’t try to use the embedded help files because the system had been customized so much that they weren’t relevant. The trainers took great pride in telling us how many hundreds of hours it took to build some screens vs. others and the hours quoted were really quite unreal.

Several common acronyms were used in the order sets, but unfortunately some elements were out of order and others were missing, making it hard to recognize the acronyms. With as many thousands of hours as were allegedly spent building, it didn’t appear that there was much clinical oversight. No surprise – the hospital in question does not have a CMIO and I’m not sure there were medical informatics experts involved in system planning and design either.

This was the fourth training session of the fourth week (only a few days prior to go live) and at least three of us noticed a major patient safety defect that had not yet been discovered. On some screens, patient demographic and vital signs data rounded up and/or down without reason. I’m not sure about you, but when a patient is documented as weighing 78 kg in the base clinical application, I don’t expect to see him rounded down to 70 kg in the CPOE module. Other areas of the system simply had garbage in the build (the ubiquitous ZZZZ added before pick list items to push them to the bottom) which always drives me crazy.

The doc seated next to me said she couldn’t believe we were forced to attend the class live. It could easily have been given as a 90-minute webinar instead. I didn’t disagree. I did receive two hours of continuing education credit for my four-hour tour, so it wasn’t a total loss.

The hospital went live on CPOE over the weekend. From what I hear, things went well, all things considered. I wish them the best, but hope the next rollout has not only better software but better training.

Have a training horror story? Does your system remind you of colorful candy? E-mail me.

E-mail Dr. Jayne.

Readers Write 6/25/12

Just as healthcare providers were getting serious about progressing toward the much-heralded ICD-10 era, the announcement of a potential deferral in the compliance deadline has spawned a new wave of delays and second guessing about how best to apply limited IT resources. Some organizations are freezing ICD-10 budgets and slowing down, or even halting work completely, until a new date is set. While a one-year deadline delay may be productive, it would be a mistake to assume that planning can be halted until this time next year and then resumed – primarily because most organizations are already far behind the curve in preparing for ICD-10.

Any delay or reallocating of internal resources in an environment where healthcare provider budgets are already tight can result in process inefficiencies and, ultimately, higher implementation costs. Many are concerned with how to make the extension beneficial to their organization. Providers should use the additional time to implement a more sound and strategic approach to collaborative testing with their primary trading partners – the most difficult and unpredictable segment of conducting a successful ICD-9 to ICD-10 migration. As it is, most large IT projects typically require more testing time than is usually allocated – and the current status of ICD-10 readiness demonstrates this case is no different. In fact, given that ICD-10 can have a tangible impact on revenue flows, providers should ensure that they work hard to mitigate their risk of disruption with trading partners that account for 80 percent or more of their revenue. Such systematic testing initiatives with key trading partners are essential for achieving the goal of financial neutrality.

Across the industry, we can look at the progress health plans have made to set the future for providers. This newly found year of extra time will be a critical period for internal and external testing. Collaborative testing should focus on maintaining the operational status quo. This means keeping the business neutral with respect to key performance indicators such as claims acceptance rates, support inquiries, electronic claim adjudication rates and aggregate claim reimbursement amounts. Many ICD-10 codes will result in an increase in clinical complexity and document specificity as compared to ICD-9. Through collaborative testing with health plans, both parties will be assured that migrating claims to ICD-10 will allow benefit and payment neutrality.

To test effectively, providers and their trading partners must develop scenarios that reflect use of high-risk codes, specifically claims that use codes expected to have high volumes, complexity, and high dollar values. The key is to minimize the risk to the business by focusing efforts on testing scenarios that could have the most impact.

Successful external testing requires new levels of collaboration and information sharing among providers and insurers. While it may be uncomfortable to collaborate on such testing, failure to do so may lead to big surprises in payments after the transition date, which will cause even greater discomfort for insurance companies and providers alike.

The ICD-10 transition is the most substantial effort the industry has faced. The scale of the project means that the testing required to fully ensure business readiness, as well as benefit and financial neutrality, is unprecedented. For those organizations that have the determination to keep moving forward as if the delay had never been announced, it will undoubtedly end up being a true gift on the testing front. Take advantage of the time afforded to realize a true benefit from the delay. And devote any newfound hours to ensuring that neutrality is achieved.

Deepak Sadagopan is general manager of clinical solutions and provider sector at Edifecs of Bellevue, WA.

Payback is a CPOE
By Daniela Mahoney

Right from the beginning of a project, I elicit the customer’s motivation for deciding to invest in CPOE. For meeting Meaningful Use requirements only? Or for what I like to hear, which is things such as “an organizational initiative for quality improvement,” or “to reach the highest level of patient safety goals” or even, in some cases, “cost reduction and avoidance.”

But if only about the money, we need to understand that the return on investment for a CPOE project — outside of incentive dollars — is difficult to calculate. Baseline costs of essential processes are hard to define, and often a number of benefits do not lend themselves to a quantifiable measurement process (i.e., improved communication across departments). Additionally, many organizations have difficulties measuring their medication errors and adverse drug events.

Although measurable improvement may be detected in well-defined areas, such as the use of expensive diagnostic and therapeutic procedures and compliance with core measures, CPOE should be viewed as an indispensable supportive technology and should be included in the overall quality improvement strategies of the organization.

And just how much will it cost an organization to implement CPOE?

For starters, we know CPOE is 80-85% clinical transformation, rather than tangible software, hardware, or infrastructure. Costs are more about people and processes than implementing technology. There are a few good studies published in the past few years that discuss the financial impacts of CPOE from a cost to ROI perspective.

One well-known study was initiated by the Massachusetts Technology Collaborative (MTC) and the New England Healthcare Institute (NEHI). The study was led by Dr. Bates and his team of physicians and nurses, who audited 4,200 medical charts from community hospitals in Massachusetts over a 12- to 18-month period. Once Dr. Bates’ team completed its work, PricewaterhouseCoopers did a complete financial analysis of the costs associated with each error identified and, if an error had been prevented, to whom the savings would have accrued.

Based on this study, most hospitals that have considered purchasing and implementing CPOE can expect a return on their investment within 26 months, a quick payback. The acquisition cost for a CPOE system was cited as being about $2.1 million, and hospitals could expect annual operating expenses of about $450,000 a year. After breaking even on the initial investment, hospitals with 70% use ratings for CPOE can expect a net savings of about $2.7 million per year.

Examples of cost:

In the example above, averages are from $7,000 to as high as $17,000 per bed as a total cost of implementation. Also, I looked back at the data I have accumulated over the 20+ years to compare the costs for hospitals I’ve worked in and some of the published case studies. Looking at the cost of the implementation per bed, there does not seem to be a significant difference between the larger facilities and smaller ones.

Looking at a range of lows and highs, I am seeing costs varying from $7,550 to $12,000 per bed, depending on how costs were estimated based on the initial project assumptions. In the latter case where the cost per bed is higher, we have accounted for other items as part of the initial capital investment; things such as servers, devices, end-user support staff, and training hours for staff and the entire implementation team members.

CPOE is not an inexpensive endeavor, to say the least. But in the end, it’s cost vs. effectiveness

Organizations will spend a great deal of their initial investment regardless of whether they implement the minimum requirements to meet Meaningful Use or implement to improve quality care delivery for the entire organization. However, one thing is certain: benefits cannot be anticipated if only a handful of providers are using the system and we constantly have to come up with workarounds to bridge the gaps. There are so many benefits to CPOE and real-time clinical decision support.

So I ask the question: what is more important to your organization, cost or effectiveness? This is a critical question to understand and answer to seek because it will help you fully recognize the value of medical technology and the likelihood of adoption by your organization.

We talked about money and the “richness” of CPOE. Why not take this a step further and complement our topic with a nice summer dessert? Extra-rich strawberry ice cream. I guarantee it you will enjoy it, and it will cleanse your palate from the bitter taste this topic leaves behind.

Daniela Mahoney, RN BSN is vice president of Beacon Partners of Weymouth, MA.

Monday Morning Update 6/25/12

From DCollins: “Re: WatchChild. Rumored to be up for sale. That would be a huge signal to the world of HIT – why divest in times of growth?” Unverified, but even if it’s true, I don’t know if I would draw too many negative inferences about the healthcare IT market as a whole. The WatchChild OB monitoring system is owned by Hill-Rom, mostly known for selling expensive hospital beds and a few other marginally related product lines. WatchChild was supposed to be a natural extension of the company’s NaviCare nurse call system. HRC shares haven’t exactly shone lately, dropping from $48 in July 2011 to $30 now, so Hill-Rom may simply see the frenzy of M&A activity in healthcare IT as a good opportunity to sell some or all of its IT holdings to focus on core business. All of this is speculation since they’ve made no announcement that I’ve seen. Hill-Rom used to be known as Hillenbrand Industries, whose humorously complementary business was Batesville Casket Company. I’ve always wondered if they might put some of their nurse call technology in those caskets as an upgrade for those who fear being buried alive.

From TopExecIT: “Re: MRO. Overheard that it has acquired smaller release-of-information vendor Discovery Health Record Solutions.” Unverified.

From Grammar Neighborhood Watch: “Re: grammar mistakes. Thought you would enjoy this WSJ article called This Embarrasses You and I.” You are correct – I did enjoy the article, which calls out the “epidemic of grammar gaffes in the workplace” as the grammatically challenged get even sloppier as encouraged by Twitter and similar stream-of-consciousness outlets for narcissism (especially the younger folks, taught by questionable educational methods to ignore long-standing rules suggesting that maybe it’s a good idea to spell words correctly and compose sentences that the rest of us can easily follow, for the same reason that traffic laws encourage societal harmony.) Worse yet is that people actually get snippy if anyone points out their mistakes, as though being careful about language is a character flaw. The article suggests that companies have become sloppy in allowing poorly constructed writing to be blasted out publicly. It brings up an issue that is one of few that I would defend physically if necessary: the Oxford comma, omission of which is indefensibly illogical. I nearly always have to fix that when folks send items to run on HIStalk. The other is equally illogical and indefensible — sticking two spaces after every period. Unless you’re writing on a typewriter that supports only monospace fonts and thus requires the extra space to provide a visual break, placing two spaces after a period is just plain wrong.

From Kermit Randa: “Re: question about Epic and FDA regulation of transfusion systems. I think the question warrants a broader discussion around software as a regulated medical device. The FDA has classified numerous specific products that perform data and information transfer, storage, display, conversion, and similar management functions, such as a LIS or PACS. Last year, the FDA raised more questions than it resolved when it issued a new classification, the Medical Device Data System (MDDS) which it defines as hardware or software products that transfer, store, convert formats, and display medical device data. The FDA, in its commentary, made clear the definition of an MDDS is narrow. For example, an MDDS does not modify the data or modify the display of the data, does not by itself control the functions or parameters of any other medical device, and is not intended to be used for active patient monitoring. However, the FDA was not clear about whether or how they would classify software that falls on the outside edges of the MDDS definition and does not fall under one of the earlier classifications such as LIS or PACS. Furthermore, the FDA made clear that a health care facility may be directly responsible for compliance with the FDA regs for an MDDS, not just its software vendors. So as we all work to streamline clinical workflows and achieve meaningful use, the intersection between different types of information systems is raising issues about medical device compliance. More here, or click here to see which companies have registered as a manufacture of an MDDS (enter OUG in the product code search field.)” Thanks to Kermit, a long-time reader and COO of Surgical Information Systems, for providing that explanation. It seems that the climate for FDA regulation of some aspects of healthcare IT is heating up, so it’s worth watching carefully.

From Privacy Shrink: “Re: sharing patient data in Boston. I like the comparison between mental illness and Parkinson’s disease.” The article describes how Boston area hospitals handle sensitive parts of the medical record, such as psychiatric notes. Partners HealthCare says every doctor needs to see everything, so patients must request that certain information be placed off limits and Partners makes the final call. BIDMC allows psychiatrists to restrict access to the information they create. Neither system described any capability for patients to become involved in the decision. Privacy is a tough issue, but I’m siding with the patient – why can’t I decide who sees my information? The Partners approach comes across as smug and paternalistic, with the patient serving as a low-ranking, inherently unreliable player apt to gum up the disease mitigation factory works.

From The PACS Designer: “Re: Microsoft’s Phone 8. Along with the upcoming Microsoft Windows 8 release this fall, we’ll also get Windows Phone 8. It appears that Microsoft wants a piece of the enterprise business for phone improvements and has structured Phone 8 as an alternative to Bring Your Own Device (BYOD) to give IT total control of phone security enforcement within institutional walls.” Good luck with that. Microsoft’s consumer strategy seems to be to imitate whatever Apple is doing, adding in its usual missteps, poor design, and uninspired marketing. The result is predictable. There was a time when Microsoft was a near-religion among geeks and businesspeople who dismissed Apple as a bunch of hippies building products used mostly by students and temperamental artistes, but even those former Gates fanboys now worship at the Cupertino altar.

The feds should make doctors and hospitals jump through only evidence-based hoops, 93% of respondents said. New poll to your right: are hospitals and practices applying good financial analysis and ROI calculations to make EMR purchasing decisions? Obviously your yes/no vote makes you one of the silent majority or minority, but you can overcome the “silent” part by adding a comment by just clicking the comments link right below the survey’s voting button.

A hospital in Northern Ireland finds that a problem with its radiology information system caused radiologists to miss reading 17,000 images over several years. They’re reading the images now and have set up a patient hotline.

Nominations are open for HIMSS board and nominating committee positions. I know several folks who have used their HIMSS positions as a nice career springboard, so that might be the additional carrot you need to throw your hat in the ring if you have something to offer HIMSS beyond unbridled ambition.

HealthCor, the Allscripts shareholder that threatened a proxy fight until the company gave it three board seats, raises its ownership of the company from 6.1% to 7.3%. Share price has been flat since it fell off a cliff in late April following several negative announcements. The hugely important next quarterly report is scheduled for August.

HIM/IT services and outsourcing provider Anthelio (the artist formerly known as PHNS) names John Dragovits as president and COO. He was formerly EVP/CFO of Parkland Memorial Hospital and was a Cerner VP before that.

Nordic Consulting, a Madison-based, Epic-only consulting firm, is ranked #1 in staffing and implementation support in “Navigating the Sea of Epic Consulting,” a new KLAS report.

In England, several NHS trusts join together to seek a replacement for their RiO mental health EMR, expecting spend up to $470 million.

Vince has more to say about Dairyland and several related companies this week. You can help him out by reminding him of other companies he can riff about, especially if you were around in the early days prior to 1980 or so. I offer Continental Medical Systems, Megasource, Dynamic Healthcare Technology, Atwork, and Visteon/Avio as a few old-time names I’ve heard recently. In another angle of attack, has Vince missed any big personalities of that era, folks who kept turning up in one company after another? He would appreciate your ideas and contact information for the pioneers he could reminisce with.

Aetna and Inova Health System (VA) jointly form Innovation Health Plans, which will offer new HMO and PPO services. Inova’s healthcare services delivery will be supported by Aetna’s benefits administration and technology (presumably Medicity) that will allow physicians to track patient care.

London-based SwiftKey releases its on-screen tablet or phone keyboard for healthcare that claims to reduce text input time by 49% by predicting the next word to be typed. Price for this version wasn’t given since I suspect they’ll sell through hospitals and software vendors, but their non-healthcare product is $1.99, and priced appropriately given mixed reviews. Watching the guy thumbing his way through entering medical text in the video above made me nervous – doctors don’t pay enough attention to on-screen defaults and choices as it is, so I can envision some major medical errors caused by too-quick approval of the wrong word.

More Accretive Health fallout: the Treasury Department proposes regulations that would require charitable hospitals to keep their collection dogs on a leash, improving their effort to help patients qualify for financial assistance before garnishing their wages or dinging their credit scores.

An FDA report finds that software problems cause 24% of medical device recalls, also noting that the engineering teams that build medical devices are often woefully ignorant of best practices for developing and distributing software. It mentions FDA’s Functional Performance and Device Use Laboratory, which will allow the agency to test user interfaces and analyze device usability.

E-mail Mr. H.

Time Capsule: "Best", "Most Wired", and Other Hospital Surveys: Good for Selling Stuff and Not Much Else

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 July 2007.

"Best", "Most Wired", and Other Hospital Surveys: Good for Selling Stuff and Not Much Else
By Mr. HIStalk

US News and World Report released its Best Hospitals 2007 list last week. Indecisive or brain-dead folks who can’t choose a movie, restaurant, or college now have yet another life decision they can outsource to faceless reporters who will tell them what to do for just the cost of a magazine (anyone who’s worked around reporters would question whether that’s a good idea.)

Few readers will care how "Best" was determined. Answer: a few hundred doctors were surveyed, Medicare mortality was reviewed, and two-year-old AHA survey results were picked through to see who had cool technology and who was really busy. Some kind of unstated weighting was applied and, voila! the Best Hospitals were extruded out the other end.

Best Hospitals isn’t as blatantly biased toward a specific industry sector as the annual Most Wired Hospitals ("Buy more of our products so you can get on our list.") They’re just trying to sell magazines, not multi-million dollar IT gadgets. But what does "best" mean when it comes to hospitals? Is there such thing?

It doesn’t mean much to the average hospital patient, as far as I can tell from those three survey sources. Doctors don’t know anything about most hospitals first hand, so that’s just a popularity contest. Medicare mortality may be relevant (or not) if you’re a senior citizen, but not so much if you’re an expectant mother or trauma victim. Using old AHA survey results to create a brand new conclusion seems iffy.

Not surprisingly, the physician "reputation points" question ensures that only big academic medical centers make the list. It’s like the Best Colleges edition: the only drama is whether Harvard, Stanford, or Princeton will bag the #1 spot in a given year. In fact, the Best Colleges issue itself influences reputation, so maybe the only thing that will ever change is the order of finish.

Rankings aside, you don’t know if your kid will get a better education or a faster meningitis cure just because you picked the Best instead of the local places that only non-magazine reading rubes would patronize. Nobody knows. It’s not predictive. But one thing’s sure: it helps sell magazines.

The bottom line is that we don’t really know, for a given individual or condition, which hospital is best. We don’t even know if it matters which one you go to. Maybe it’s your doctor, your faith, your preventive care, or your genes that has the most effect on whether you walk out happy or not. Whose building you sleep in may or may not play as much of a major role as us hospital types would like to think (except avoiding those that are prone to killing patients with a hospital- acquired infections or medical mistakes). Big hospitals have their share (maybe disproportionately so) of medical errors and poor outcomes.

The best hospitals (or, more precisely, doctors who practice in them) do just one thing obviously better: diagnosis. After that, I’m not convinced there’s much difference. In fact, in the typical giant medical center run by a liberal academic parent, you’re apt to find hordes of geeky diagnosticians wearing bow ties and vast armies of lower-ranking types who are likely to miss your meds and take their time responding to your call button (I like to think it’s because they’re not scared of an employer that deals with incompetent professors by offering them lifetime employment through tenure).

Juxtaposed with this story was hardly shocking news: according to a study, electronic medical records don’t improve patient care. Well, actually, that’s what the headlines said. What the study found was that EMRs didn’t improve compliance with standard practices that ought to improve care. The biggest shock to me was that somebody apparently thought they should. You can buy the golf clubs Tiger Woods uses, but that doesn’t mean you’ll play better golf. When it comes to EMRs, the hopes of the naive apparently needed dashing.

When it comes to what’s most important – whether you, specifically, will walk out of a hospital alive and well – maybe some reporter’s Best Hospitals or Best EMR or Most Wired lists don’t really make much difference. It’s not that easy. That’s a tough message for a data-driven, standardization-obsessed, sometimes sheep-following industry to hear, but I think it’s true.

News 6/22/12

Top News

The VA establishes a goal of conducting more than 200,000 clinic-based telemental health consultations in fiscal year 2012, offered to veterans without requiring a co-payment per VA policy that covers all videoconferencing-based encounters.

Reader Comments

From Overheard: “Re: HIT sales training. A friend tells me he just completed a sales training class led by one of the professional training and coaching organizations. His impression was that the course was developed by a ‘bunch of bitter nerds who are haters getting their kicks off telling the nice-looking popular kids that they are stupid.’” Ouch. Before begging Mr. H to hire me, I considered taking a position as a sales coach. At least in this gig I don’t think too many people call me a nerd and I can get away with telling just about anyone that they are stupid.

From Eros: “Re: Cerner and autocorrect. Have you ever tried typing ‘Cerner’ in a message on your iPhone?” It seems that Apple insists the correct word should be Cerberus, a mythological three-headed watchdog that guards the gates of Hades to prevent anyone from escaping. Perhaps Neal should invest in one for the employee parking deck.

From Printgeek: “Re: [free EMR vendor’s name omitted.] I heard its board and executive team has seen four departures. They are making good headway with physician enrollments, but actual usage is poor and eyeballs on the screen are not meeting expectations. Additionally, the model to generate revenue from data and ad sales isn’t coming close to investor expectations.” Unverified, so I’ve omitted the company’s name, not that most readers aren’t astute enough to know it instantly anyway.

HIStalk Announcements and Requests

The latest from HIStalk Practice: Medford Medical Clinic (OR – above) signs up with athenahealth. The AMA votes to evaluate ICD-11 as a possible alternative to ICD-10 for replacing ICD-9. The ONC plans to help small providers increase security on mobile devices. Offices with great EHR implementation had only slightly higher patient safety culture scores. Dr. Gregg reveals his interoperability nightmare. Give HIStalk Practice a test drive if you aren’t a regular. Thanks for reading.

Acquisitions, Funding, Business, and Stock

eMerge Health Solutions, a developer of a hands-free documentation and workflow solution for gastroenterologists, closes on $850,000 in seed funding from CincyTech and private investors.

GE Healthcare sells the assets of its Nurse Call business to Switzerland-based Ascom, which markets its own nurse call system outside of the US.

PatientKeeper raises $6.25 million from existing investors to expand professional services and support operations.

Etransmedia Technology acquires Associated Billing Services, a provider of RCM services.

T-System acquires Marina Medical Billing Service, which provides ED medical coding and billing services to 110 facilities.

Sales

Iowa Health System selects Explorys’s Enterprise Performance Management  applications to support its ACO initiatives.

O’Bleness Memorial Hospital (OH) chooses ProVation Order Sets as its electronic order set solution.

People

Former RelayHealth exec Matt Llewellyn joins BillingTree as its VP of sales for the healthcare market.

OTTR Chronic Care Solutions names Sandy DeRoberts (Carefusion) regional VP of sales.

Announcements and Implementations

Pacific Medical Centers (WA) installs Versus Advantages RTLS to track patient flow at its Totem Lake clinic.

St. Rita’s Medical Center (OH) goes live on Epic.

KLAS names Encore Health Resources the top-rated consulting firm serving Epic clients in the category of Team Implementation Leadership & Advisory.

CareFusion signs an agreement to support bi-directional connectivity between its Alaris smart IV pumps and Epic.

Kony Solutions releases a new version of its Mobile Health Plan.

In the UK, Rotherham NHS Foundation Trust begins implementation of Meditech.

The US Air Force will use SAS tools to support research and to deploy a global dashboard to improve operational and clinical decision support. An example given involves SAS Scoring Accelerator for Teradata, in which researchers can run query of 1.2 million patients to determine which 10% of those with diabetes are most likely to have an ED encounter in the next two months.

Three competing hospital systems in the Charleston, WV area (Thomas Memorial, CAMC, and St. Mary’s in Huntington) meet to discuss their use of Siemens Soarian. The article cites two examples of its use by Thomas Memorial’s CMIO Matthew Upton, one in which he entered patient orders from home before leaving for the conference and another where he followed his patient from a café in Italy using an iPad.

Government and Politics

ONC launches a pilot project to measure the effects of giving providers and pharmacies better access to drug monitoring programs in order to reduce prescription drug abuse.

CMS awards a $20.75 million Health Care Innovation Challenge grant to VHA, Inc, TransforMED, and Phytel for a three-year national project to expand the PCMH concept and test the viability of a patient-center medical neighborhood model.

Other

The Association of Regional Centers for Health Information Technology, or ARCH-IT, is formed as a national association for the country’s 62 Regional Extension Centers. I noticed, by the way, that of the 143,000 providers signed up with RECs, only 12,000 have received incentive payments. Maybe a bit more mindshare wouldn’t be a bad thing.

The Long-Term and Post-Acute HIT Collaborative issue a roadmap for HIT in nursing homes and rehab centers, focusing on care coordination with other providers, implementing quality measurement activities, and promoting technology education among LTC workers.

In New York City, merger talks between NYU Langone Medical Center and Continuum Health Partners break down after Continuum entertains a similar offer Mount Sinai Medical Center.

More Accretive Health news, all of it bad. Minnesota’s attorney general expands the suit against the collections company; Maple Grove Hospital (MN) fires the company at the request of its 25% owner, Fairview Health; and two US congressmen investigating the company’s practices say it has not replied adequately to their inquiries, failing to produce requested internal documents and ignoring their requests for a meeting.

A DrLyle blog post talks about EMR extender tools, postulating that EMRs have become somewhat stagnant infrastructure tools and that the innovation ecosystem will instead involve tools other companies build on top of their platforms.

Oracle CEO Larry Ellison buys himself a Lanai, but instead of being a tiny porch like that word would imply for most of us, it’s a 141-square-mile Hawaiian island of that name. The world’s sixth richest man will pay around $500 million cash for the purchase, which you might take a moment to enjoy vicariously the next time your hospital pays an Oracle invoice.

Weird News Andy muses about who the patient (especially for the all-important hospital billing) is in this story and others like it, in which an oral tumor was removed from an unborn child during the mother’s 17th week of pregnancy.

Sponsor Updates

• Pittsburgh Bone & Joint Surgeons (PA) selects SRS EHR and PM for its seven physicians.
• Emdeon launches Emdeon Payment Network, which combines electronic and print payment services for payers.
• TeleTracking announces a series of webinars on improving hospital operations and ROI using real-time capacity management. 
• The Minnie Pearl Cancer Foundation names Emdeon EVP/CIO Damien Creavin and Cumberland Consulting Group partner David Vreeland to its board.
• NextGen Healthcare’s Electronic Dental Record receives ONC-ATCB certification from CCHIT.
• Acusis introduces AcuMobile for the capture of patient encounters on the iPhone.
• T-System will showcase its RevCycle+ solution at next week’s HFMA’s Healthcare Finance Conference in Las Vegas.
• St. Joseph Health (CA, NM, TX) pilots AT&T Telepresence Clinic service.
• Kliniken Maria Hilf (Germany), SALK (Austria), Bakiroy Dr. Sadi Konuk Egitim va Arastima Hastanesa (Turkey), and Boston Children’s Hospital (MA) go live on iMDsoft’s MetaVision solution.
• Greenway Medical exhibits its PrimeRESEARCH solutions at next week DIA 2012 Annual Meeting in Philadelphia.

EPtalk by Dr. Jayne

I am humbled by the response to this week’s Curbside Consult. My e-mail has been overflowing with readers who know what it means to come from a farming background. Most of the themes revolve around hard work, perseverance, and living with the consequences of your decisions. There was even great story from one reader whose family ran moonshine to earn money after a tragic accident.

One reader stated she was going to post the 4-H pledge at her desk to remind her every day about striving to be better person. From the responses, it looks like there are some regional variations, but for those of you who haven’t Googled it yet, here is the 4-H Pledge:

I pledge my head to clearer thinking,
My heart to greater loyalty,
My hands to larger service,
and my health to better living,
for my club, my community, my country, and my world.

It’s kind of like the Everything I Needed to Know, I Learned in Kindergarten list, but maybe it’s something that healthcare should embrace as we slow the pace down and stick to the basics.

Another reader shared her love of trail riding and said that being on a farm is “the one place where I know I can keep all those untamed healthcare acronyms at bay for a while in favor of what my father would call honest work.”

Slightly surprising (but not really) was that nearly all of the responses were from women, several of whom cite their backgrounds as helping them make it in IT:

Being raised around country people, I was fully supported when I ventured into traditionally male roles like running a bush hog, planting, or working on engines. No one thought a thing about it – you did whatever you had aptitude for. I grew up “liberated” and was mystified by all the fuss in the 70s. How fortunate to grow up with the belief that you were only limited by the barriers you set for yourself.

Thank you again to all of you who wrote about the article. You’ve helped recharge my somewhat depleted batteries as I slog through a series of intense go-lives. And now, back to our regularly scheduled healthcare IT message.

John Halamka blogged this week about “meaningful consent” for health information exchanges. His institution is using an opt-in model where patients can choose to share or not share data originating from various institutions. There will be no clinical override or “break the glass” functionality. Although I agree generally with this patient-centric model, I’ve practiced under a similar one and found it to be less than optimal for monitoring basic patient data. When patients can choose to share some data but not all, it fragments the patient record making it very difficult to identify duplicate therapies, drug interactions, and redundant tests. Since this is the prime reason for having an HIE, it somewhat defeats the purpose.

A reader shared this write-up of the new website ChickRx whose tagline is Expert Advice to get Happy, Healthy, & Hot. The review describes it as “what would happen if WebMD met Cosmo.” Presented at a recent Rock Health Demo Day, it has some serious potential as an entertaining alternative to existing consumer-focused sites.

Both Inga and I picked up on this piece about the situation where the chief medical officer at Northwest Community Hospital was found to be lacking a medical license. A hospital administrator described needing a medical license as “irrelevant” for administrators. Although I don’t think physicians working in the tech space always need licensure, I feel it’s essential for hospital administrators. If nothing else, it shows solidarity with the physician community and gives the ability to emphasize with burdensome administrative requirements with which the rest of us have to comply. Working at a hospital yet allowing your license to lapse makes an administrator seem detached from the rest of the physicians who have to live under his or her policy decisions.

I found an interesting blog posting that discusses “cloned” EHR documentation. It’s a quick read and illustrates something providers should watch out for. In trying to avoid cloned notes, the author used different wording at each visit for the same physical findings. This resulted in an attorney trying to twist a stable disease into a progressively worsening condition. We’re damned if we do and damned if we don’t.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

EHR Design Talk with Dr. Rick 6/20/12

Special Edition: The ONC/NIST Workshop on Creating Usable EHRs — Part 2

If you ask clinicians which aspects of their EHRs drive them nuts, many can tell you in some detail. On the other hand, if you ask them how to improve those EHR designs, most cannot articulate the issues in ways that would lead to fundamental change. Relying on focus groups and implementing user requests turn out to be similarly unproductive.

If these methods don’t work, how should one design EHR software that meets the goals and needs of its users and thereby improves healthcare?

There are no simple answers. After all, EHR software is a very new cognitive tool.

An alternative to asking users for advice and feedback is to apply rational design methods collectively referred to as User-Centered Design (UCD). This was the focus of last month’s ONC/NIST Workshop.

Since my last post, I’ve been thinking a lot about the term User-Centered Design because it has two distinct definitions.

On the one hand, it can mean design based on our understanding of how the human brain best takes in, organizes, and processes information — in other words, Human-Centered Design. By this definition, UCD encompasses not just usability testing, but also the findings and methods of a number of related fields, including interaction design, data visualization, cognitive science, and human factors.

On the other hand, the term User-Centered Design can refer to a relatively codified method of software design that places emphasis on setting user performance objectives, conducting iterative user testing during development, and ultimately performing formal summative usability testing to evaluate the end product.

I prefer the first definition because it places more emphasis on the design process itself. A design process that brings together the findings and methods of several fields is more likely to foster innovative solutions. One comprehensive design approach I particularly like is Goal-Directed Design, as described by Alan Cooper, Kim Goodwin, and colleagues in their complementary books About Face 3 and Designing for the Digital Age.

The next question is what role, if any, should ONC play in regard to User-Centered Design and EHR usability. There are two basic philosophies on how to improve EHR design and safety.

One approach is to encourage innovation by allowing market forces, including those created by disruptive innovation, to work. The other approach is to regulate the evaluation process — for instance, to require summative usability testing, to have the FDA regulate EHRs as medical devices, and so forth.

While everyone wants safer EHR designs, in practice it’s not clear to me that more regulation will help. Because of the complex and interactive nature of software user interfaces, evaluating the safety of EHRs is orders of magnitude more difficult than evaluating the safety of physical devices.

An EHR can follow a long list of guidelines, pass all kinds of usability testing, and still present the user with terribly problematic interfaces. After having studied the NIST, AHRQ, and HIMSS documents related to EHR usability, I don’t see how mandating formal usability testing is going to make EHRs safer.

For one thing, one usability guideline inevitably conflicts with another. Furthermore, while summative usability testing is reliable and yields quantitative data, exactly what gets tested is highly subjective. Third, evaluating the safety of EHR software is a moving target, as the software development tools, the design patterns, and the platforms are all changing rapidly.

It is clear that ONC has been considering the role it should play in regard to EHR usability. While we don’t know what ONC’s final rules on User-Centered Design will be, we can glean some information from last month’s workshop.

In their presentations, National Coordinator Farzad Mostashari and ONC’s recently appointed acting Chief Medical Officer, Jacob Reider, made the following points:

• The UK model, mandating a particular EHR design, clearly didn’t work.
• Getting feedback from clinicians is generally a poor way to improve EHR design. As Henry Ford remarked about his cars, “If I had asked people what they wanted, they would have said faster horses.” The UCD process, broadly defined, is a better way to improve design.
• Market forces should work. The more usable EHRs will be the successful ones. Vendors who understand these issues will make User-Centered Design a high priority instead of focusing on new "bells and whistles."
• It has taken the aviation industry a hundred years to learn how to build safe planes. Health Information Technology (HIT) is a young industry. Transformation will not occur overnight.
• ONC does not see its role as defining how an EHR should look and feel. Rather, its main concern regarding usability is safety.
• The tradeoff between innovation and safety is not a "zero-sum game." With more usable designs, everybody wins.

It would appear this same perspective is reflected in ONC’s March 2012 Notice of Proposed Rule Making (pp. 13842-3). First of all, ONC proposes to limit the UCD process to eight certification criteria, all related to the high-risk area of medications. Secondly, the notice states:

… we believe that a significant first step toward improving overall usability is to focus on the process of UCD. While valid and reliable usability measurements exist … we are concerned that it would be inappropriate at this juncture for ONC to seek to measure EHR technology in this way … Presently, we believe it is best to enable EHR technology developers to choose their UCD approach and not to prescribe one or more specific UCD processes that would be required to meet this certification criterion.

Unless innovative designs are allowed to emerge, the next generation of EHR user interfaces will continue to have all the major usability problems of our current ones. From my perspective as a physician EHR user who also thinks and writes about EHR design, I’d say that ONC got its User-Centered Design policy just about right.

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

News 6/20/12

Top News

CMS says that as of the end of May, more than 110,000 EPs and over 2,400 hospitals had been paid a combined $5.7 billion in EHR incentives from Medicare and Medicaid. That’s about 48% of all eligible hospitals and 20% of eligible Medicare and Medicaid providers.

Reader Comments

From Jenny: “Re: Catholic Health Initiatives. The group is installing Cerner, but the Tacoma-based Franciscan group received permission to install Epic in five hospitals and will go live in April 2013.” Verified.

From Pillsbury DB: “Re: Lahey Clinic. They were installing Allscripts in the ambulatory environment and had a best-of-breed approach using Orion for the inpatient setting. I’ve attached an old case study.  Instead of implementing a true EHR product, they decided to pull data using Orion into a clinical data repository. Paper-based data was scanned and indexed into PDFs which were also available using Orion portal. This worked for clinician viewing, but made it impossible to implement CPOE. They were also scanning millions of records per year requiring many FTEs to perform the function. When HITECH hit, they had no hope of meeting any stage of MU.  To compound the problem, the Allscripts implementation was about a year behind and way over budget.” Above is an extract from the Orion Health case study from last year. I guess MU did reduce the interest in EMRs based on scanned documents quite a bit.

From The PACS Designer: “Re: Microsoft’s Surface tablet. The new challenge to the iPad has arrived in the form of a tablet PC called Surface. One unique aspect of the Microsoft Surface is the keyboard in cover of the tablet. While it won’t really be any threat to the iPad, it may draw interest from PC users who are more comfortable with a traditional keyboard versus an on screen keyboard.” Microsoft has been short on innovation lately (decades), but I don’t get why they used the Surface name on a tablet when it’s already being used by their coffee table gesture thingy. And unlike Apple, Microsoft is selling futures once again since nothing’s ready to ship. They won’t get bold on the pricing because they won’t want to diminish the already iffy prospects of the Ultrabook laptops, so you’ll be able to buy a me-too tablet running probably buggy software for double the price of iPad right as businesses give in and let people bring in their own at zero expense to the enterprise. Apple started failing dismally after firing Steve Jobs and returned to prominence only after they hired him back, but Microsoft’s problem is that Bill Gates isn’t coming back.

HIStalk Announcements and Requests

I’m doing some traveling for the hospital over the next few days (to a vendor location home to a great many HIStalk readers, in fact), so given the difficulty in achieving my usual prodigious output given limited time and connectivity, Inga is handling the brunt of the HIStalk chores. I’ll chime in with whatever is interesting to me as I have time. If you’ve tried to get in touch with me, hang in there until the weekend when I can get caught up.

Acquisitions, Funding, Business, and Stock

Shareable Ink secures $5 million in series B financing from Lemhi Ventures.  As part of the deal, Lemhi Ventures’ managing partner Tony Miller will assume the role of chairman of the board.

ESO Solutions, a provider of EMR software for the EMS and fire services industries, raises $4 million from Austin Ventures.

North Bridge Growth Equity invests $30 million for a minority interest in Valence Health.

Sales

Missouri Health Connection and the NY eHealth Collaborative select the InterSystems HealthShare platform for their health information networks.

St. Luke’s Hospital (IA) chooses Amcom Software for smartphone communications and Web-based on-call scheduling.

WakeMed Health & Hospitals (NC) contracts with MobileIron to provide mobile device security and enable the organization’s BYOD program.

The Newfoundland and Labrador Centre for Health Information sign agreements with Telus Communications and Orion Health to provide technology for a province-wide integrated EHR.

Allscripts Enterprise EHR  customer Summit Medical Group (NJ) signs a long-term contract for Allscripts Managed Services.

People

Bulletin News names Nick Tabbal (Resonate Networks) VP of analytics for its Bulletin Healthcare subsidiary.

PerfectServe hires Robin Borg (Optum) as VP of human capital.

Beacon Partners names Fernando Martinez PhD as national director for enterprise assurance services. He was previously with Jackson Health System (FL).

MyHealthDIRECT adds HealthWays VP and COO Tom Cox and SSB Solutions chairman Jacque Sokolov, MD to its board of directors.

Announcements and Implementations

Geisinger Health System and Merck announce a multi-year collaboration to develop solutions that facilitate shared decision-making between patients and physicians and improve patient adherence, engagement, and care delivery.

Corniche Hospital becomes Cerner’s first client in the United Arab Emirates to achieve full closed-loop medication administration. Meanwhile, Royal Berkshire NHS Foundation Trust goes live this week on Cerner Millennium after a three-month delay.

Government and Politics

The HIT Policy Committee’s Quality Measurement Workgroup and the HIT Standards Committee’s Clinical Quality Workgroup ask for input on ways in which Stage 3 MU may advance the delivery of high-quality care in diverse care settings.

The White House recognizes 82 providers for their successful implementation of EHR at a Health IT Town Hall in Washington, DC.

HHS awards $772 million to 81 providers, tech firms, and local organizations to advance healthcare innovations that lower costs and improve quality.

VA officials tell lawmakers at a House Veteran Affairs Committee hearing that it has processed fewer than 800 benefit claims despite investing $491 million in new technology. The current backlog is 913,690, which includes 575,773 claims older than 125 days. The VA originally promised a system-wide rollout of its Veterans Benefits Management System this year, but performance issues have pushed full implementation until the end of 2013.

The Military Health System issues an RFI for a system to track lab work within its integrated EHR.

Joe Goedert writes a Health Data Management article describes pending federal legislation that could be the first steps toward regulation of healthcare IT.

Other

The US Supreme Court refuses to consider an appeal by former McKesson Chairman Charles McCall to overturn his 10-year prison sentence for scheming to inflate company revenue.

Lehigh Valley Health Network , Cedars-Sinai Health System, Kaiser Permanente, Palmetto Health, and HCA make the top 25 in Computerworld’s list of 100 Best Places to Work in IT 2012.

The local paper highlights Greenwich Hospital’s (CT) recent $30 million implementation of Epic, which replaces Meditech and will eventually connect with other Yale New Haven Health System facilities.

UnitedHealthcare tops AMA’s fifth annual National Health Insurer Report Card, which considers the insurance billing and payment accuracy of seven of the largest commercial health insurers. Error rates on paid medical claims dropped from 19.3% in 2011 to 9.5% in 2012, saving health systems $8 billion in unnecessary administrative work to reconcile errors.

New from Ross Martin MD:  The Money Machine, which he says appropriately describes your financial hamster wheel, whether it’s the usual problems or EHR adoption or whatever.

Weird News Andy admires the dry analysis of a doctor describing a 16-year-old accidentally shot through the head with a three-foot-long stainless steel fishing spear: “It’s a striking injury, something you don’t see every day … the first obstacle is to not be distracted by the obvious sensational aspect of the injury.” The spear missed most everything important in the boy’s head, doctors removed it, and he’s expected to make a near-full recovery.

WNA also finds this story interesting. A man told by a hospital that his cancer left him with just months to live, along with his wife, rack up $80,000 in debt to complete a hastily compiled bucket list, giving away $30,000 worth of goods, selling their house at a loss, cancelling their health insurance, and traveling the world. The man even takes up smoking again, figuring he has nothing to lose. He then waits to meet his maker, vowing to kill himself if the pain became unbearable even as he questions why he seems so healthy. Finally his hospice worker told them the hospital had made a mistake but didn’t tell him – he’s fine.

Sponsor Updates

• Greenway pilots integration between its PrimeSUITE EHR/PM product and Microsoft HealthVault.
• ICA Informatics exchanges direct messages and trust agents with Cerner, Max MD, Mirth, NitorGroup and Techsant Technologies at the ONC Direct Summit.
• Capsule says that within the last six months it has added or updated more than 70 devices to its device integration list.
• Johns Hopkins’ director of enterprise services discusses his hospital network’s use of Imprivata’s SSO technology.
• The NY eHealth Collaborative announces that Stephen J. Dubner and Dr. David J. Brailer will be keynote speakers at its October Digital Health Conference in NYC.
• Emdeon hosts educational presentations on cost containment challenges at this week’s America’s Health Insurance Plans Institute conference in Salt Lake City.
• Picis announces a strategic partnership with billing and PM provider Anesthesia Business Consultants.
• All Imaging Systems partners with UltraLinq Healthcare to provide cloud-based storage services to UltraLinq clients.
• Medicomp and technology partner Northrop Grumman announced Northrop’s Clinician App integrated with Medicomp’s MEDCIN engine at last week’s Government HIT conference in DC.
• The 400-physician Rees-Stealy Medical Group (CA) lowered transcription costs $800-900,000 annually (80-90%) within 10 months of adopted Nuance’s Dragon Medical voice recognition software.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Dr. Sam 6/18/12

A Key Missing Element of EHRs

Nurses play a key — if not crucial — role in successful hospital EHR implementations.

• They are the first people that frustrated physicians complain to and often have to deal with borderline or actual abusive commentary or language emanating from an angry physician.
• They are often the initial super-users who can show physicians how to navigate through specified workflows that they may not have absorbed during EHR training (if they attended training sessions at all).
• They often have to enter orders or deal with verbal orders given by a physician who cannot (or does not want to) enter orders by Computerized Provider Order Entry processes (CPOE – please note use of the term “Provider” and not “Physician,” which is the true appropriate use of the acronym CPOE.)
• They are often the first users in the go-live schedules for clinical documentation.

In spite of their key role in patient care, by tradition (in both paper and electronic worlds), their clinical notes are almost universally unread by physicians. In spite of being the caregivers who spend far more time at the bedside than any other clinicians, their notes are either ignored, or at best casually reviewed by physicians.

As a result, both the paper and electronic environments are often replete with documentation contradictions with inaccurate information entered by either the physician or the nurse, or with information that conflicts with patient status. After cataract surgery, a nurse might enter “Pupils Equally Round and Reactive to Light and Accommodation (PERRLA) when one pupil is pharmacologically dilated or constricted, or a physician might document “Patient fully ambulatory and stable” when the patient is in fact unable to get out of bed or has had fluctuating vital signs. The number of possible conflicting entries is both unlimited and endemic.

This is where standard vocabulary becomes as important as accurate clinical observations. An EHR functionality that has been lacking since the early years of clinical information system design has been the ability to cross reference nursing and physician clinical documentation notes and to generate alerts when contradictions are present. This is not only of essential importance to patient care, but to reducing vulnerability to medical liability.

Sam Bierstock, MD, BSEE is the founder of Champions in Healthcare, a widely-published author, and a popular featured speaker on issues at the forefront of the healthcare industry.

Curbside Consult with Dr. Jayne 6/18/12

Yesterday was Father’s Day. I hope all the dads out there were able to spend time with their loved ones.

This is the first time in many years that I wasn’t able to spend it with my dad. I knew my summer schedule would be quirky, so I made a point of getting back to my roots a couple of weeks ago.

My dad always has a way of reminding me that no matter how hard I think I’m working, there’s always more work to be done. Nothing drives that home like spending time on a farm. In addition to having the opportunity to do lots of “farm things” (aka “work”) the best thing about being on the farm is that cell service is spotty. It forces you to spend time in the moment and focus on concrete tasks. I spent some quality hours behind the wheel of a tractor, which is always good for reflective thinking.

Everything on a farm is about cause and effect. Preventive maintenance is key. In a lot of ways, it reminds me of healthcare. (Farming also reminds me of healthcare in that I’ve learned I can handle anything as long as I have gloves on, but that’s a story for another day.). When you neglect something on a farm, it almost always comes back to haunt you. It’s important to pay attention and do the right thing the first time. Not just because someone told you to do it, but because it’s the right thing to do.

Doing the right thing is good for the land, your neighbors, and the community. You don’t do it because the government mandated it, but because you should.

Another key piece of learning on the farm is that when something needs to be done, everyone needs to pitch in. I check my MD at the door (well, actually when I turn off the paved road onto the gravel road) because higher education doesn’t exempt anyone from brush hogging, hauling wood, or any number of exciting activities. It does guarantee though that you’re the first person approached when there is a deer tick that needs to be removed.

One of my dad’s mantras is that if a job is worth doing, it’s worth doing well. Anything less than your full effort is unsatisfactory. I see a lot of people in healthcare IT that look like they’re just going through the motions, forgetting that we have people’s lives at stake. I try my best to model that work ethic for my team and to encourage them to practice it as well.

My dad also taught me that when things go wrong, the best thing to do is to stop, get your wits about you, figure it out, and fix it. And if you can’t fix it, at least come up with a solution that doesn’t make it worse while you find someone smarter to help you fix it.

Whether it’s the hydraulic line on the front-loader that decides to spray fluid all over you or whether it’s a complex laboratory interface that suddenly spews data where it doesn’t belong, neither overreacting nor being paralyzed by fear leads to a good outcome. I know about both of these first hand, and both require teamwork and careful thought to get things flowing back where they should.

Most days on the farm leave me dirty, tired, and generally achy. But there’s nothing quite like crashing in a lawn chair under a 70-year-old tree and watching the sun set over the fields. No matter how fast technology moves, when ICD-10 gets implemented, or what the Supreme Court decides to do, the corn’s going to keep growing. In the morning, there will still be plenty of work for everyone.

Can you name the ideals of 4-H? E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 6/18/12

From Pathological: “Re: Epic. How do they handle blood product orders (type and screen, specifically) that go to LISs? FDA requires 510(k) approval of any CPOE module that electronically touches a regulated, FDA-cleared transfusion medicine module and Epic doesn’t have that approval. What do they tell new clients?” I could use some reader help here, so please add a comment if this is your area of expertise.

From Neighbor Ned: “Re: Lahey and Allscripts. They’ve had problems and haven’t seen the post-acquisition synergies. Bruce Metz came on board as CIO and wants a ‘unified architecture,’ which sounds like Epic. Decision to come within a month.” Unverified, but from a non-anonymous second-hand source, which is the best I have since Bruce hasn’t responded to my e-mail.

Welcome to new HIStalk Platinum Sponsor Park Place International. The company offers cloud-based technologies and consulting services that give Meditech customers a stable, optimized, and sustainable reference architecture. OpSus|Live is the company’s cloud-based hosting service that provides customers with a solutions and services package tailored to their unique needs. Its OpSus|Recover cloud-based disaster recovery service offers several service level plans based on recovery point and time objectives. They can design a certified infrastructure solution for new customers, or for existing Meditech customers experiencing performance problems, their technical consultants can provide rapid remediation and intervention. Hospitals interested in storage virtualization, thin provisioning, data encryption, vendor-neutral image archiving, secure virtual desktops, single sign-on, or hybrid cloud integration can get all the help they need from a focused company whose experienced consultants offering fresh approaches. Thanks to Park Place International for supporting HIStalk.

A slight majority of respondents said that opening up government healthcare data could provide health improvement. New poll to your right, in honor of Dr. Jayne’s recent rant: should HHS (and ONC specifically) back up new provider measures of quality or Meaningful Use with evidence proving that they work to improve patient outcomes?

Listening: new from one of my favorites, Metric. I’m also enjoying the new Beach Boys album, which thankfully is (a) all of the surviving members together other than in a courtroom; (b) mostly Brian Wilson and not much Mike Love; (c) not a bunch of rehashed old demos and laurels-resting, but new music; and (d) full of amazing harmonies that sound like the 1960s, but with the wisdom and wistfulness inherent with band members now in their 70s. Live video here. How they still hit those high notes is beyond me. The final track, “Summer’s Gone,” might bring up a tear if you’re sentimental or worried that this might be their last hurrah after 52 years. The new album is #3 on Billboard’s chart, “That’s Why God Made the Radio” is their highest-charting single since 1965, and the ironically named ‘Boys have broken the record of the Beatles by having over 49 years of Top 10 records.

Michigan-based hospital users of Epic form the EHR Michigan User Group, with 150 attendees from all 11 Epic-using hospitals gathering at Beaumont Health System for their first meeting. An Epic developer gave a preview of future Epic versions, warning the group not to share details with the media or competitors, with the TV station’s summary being, “Suffice it to say the software basically tracks patients in the hospital like the screens over the patients in Star Trek’s sickbay – only you can get the information anywhere, securely, on a tablet or smart phone.” That same TV station, loathe to run a picture-free online story since nobody can read without pictures these days and the user group apparently didn’t send over a photo, lazily headed over to Wikipedia for a startlingly irrelevant screen shot of the VA’s VistA as “as an example of an electronic medical record.”

Speaking of Epic, it drives me up a wall when people insist on spelling it as EPIC for some strange reason, apparently missing the point that even though it’s a short word, it’s still not an acronym (and the fact that Epic itself clearly does not capitalize it). Confounding the issue is Mount Sinai Medical Center (NY), which is installing Epic but calling its project EPIC in a highly contrived acronym (Efficiency, Patient safety, In/outpatient communication, Care.) Given Epic’s legendary and legally enforced paranoia about its intellectual property (as in the story above that warns about loose lips), I’d be careful. 

A CareFusion site from which medical equipment firmware updates are distributed is found to be loaded with malware, triggering a Department of Homeland Security investigation. Google’s Safe Browsing program flagged several pages related to CareFusion’s ventilators as being infected with 48 separate Trojan Horse programs and two scripting exploits (the screenshot above is from when I ran it.) Kevin Fu of the Medical Device Security Center discovered the problem when downloading an update for AVEA ventilators. He reported the problem to the FDA, adding that CareFusion’s instructions advise users to just ignore the usual security warnings. Fu also points out that vendor people and hospitals have gotten lax about running updates for pacemakers or other critical medical devices from the Internet or from someone’s USB key without thinking twice about it. Homeland Security’s analysis found that some of CareFusion’s sites were running six-year-old versions of ASP.NET and IIS 6.0.

Congresswoman (and Nurse) Renee Ellmers (R-NC) sends a letter asking HHS Secretary Kathleen Sebelius if HHS has adopted recommendations from the IOM’s November report involving the safety of healthcare IT. She wants to see a plan to minimize patient safety risk, a list of HIT-related errors that have caused harm or introduced risk, and a plan for a mechanism to allow users and vendors to report HIT-related deaths. She sent Sebelius a letter in August 2011 asking for a study of healthcare IT adopt, benefits, cost effectiveness, and medical error rates.

A June 14 power outage at an Amazon Web Services data center in Virginia takes down several cloud-based businesses, including Pinterest, for up to eight hours.

This makes me cheer given that the “site errors” people complain to me about that nearly always involve bugs in Internet Explorer, the worst browser ever written, and 90% of the time it’s an old version they’re running (because hospitals are stuck in a Microsoft time warp, often standardizing on IE6 from 2001 or IE7 from 2006 paired with their 2001-vintage Windows XP). An Australian retailer slaps a surcharge on orders placed by customers using IE7 since his company spends a ton of development time “rendering the website into an antique browser.” The company says only 3% of users run IE7, but most of his Web development team’s time is spent trying to code around its abundant flaws. I’ve had to pay people several times to do the same for HIStalk “problems” that don’t exist in Chrome, Safari, Firefox, or Opera.

Vince’s topic this week is more about Dairyland, but he’s got some fascinating pricing information from a number of vendors that will shock industry noobs (a five-year total cost of ownership for a full-line financial system of $400K? Yes, please.)

Discussion at a summit organized by the Association for Pathology Informatics on June 8 addressed the push for enterprise-wide systems that creates headaches for lab managers. Bruce Friedman MD said hospital administrators and IT people don’t appreciate the complexity and criticality of what he calls T-LISF — total lab information system functionality — that includes the LIS itself, middleware, outreach support, and firmware. Consultant Dennis Winsten said he has worked with several clients whose labs were being pushed into switching to Epic’s work-in-progress Beaker LIS by the offer of a free site license, requiring the lab people to perform an assessment of whether Beaker could meet their needs. Interesting: Cerner, McKesson, SCC Soft Computer, and Sunquest had speakers or attendees at the conference, but Epic passed on its invitation. 

Steve Larsen, the federal government’s most powerful health insurance regulator responsible for consumer protection and insurance exchanges, quits to become EVP of Optum, part of insurance company UnitedHealth Group.

Strange: a nurse in a hospital in Scotland streams so much porn from his NHS-provided laptop that he drags down the entire hospital network, with noticeable problems in radiology and videoconferencing as he is enjoying “Busty Japanese Girls” and “German Lesbians, Very Hot.” Officials inspecting his office found dozens of unopened referrals for his services going back to 2004. He was fired and his RN license was revoked this week, ironically denying patients his services as a member of the addictions team.

Eric Topol MD lists five technology devices that physicians should know about:

The smartphone-powered ECG, which he used on a flight to diagnose a passenger experiencing a heart attack, resulting in an unplanned stop to rush the passenger to the hospital.

The smartphone-powered continuous blood glucose monitor.

The iRhythm patch for Holter-like monitoring of cardiac arrhythmias for up to two weeks.

The AirStrip Patient Monitoring system for remotely monitoring ICU or other critical patients.

GE Healthcare’s Vscan ultrasound device that he says has entirely replaced his use of a stethoscope for listening to a patient’s heart.

E-mail Mr. H.

Time Capsule: Private vs. Public Vendors: I’ll Take the Former

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 July 2007.

Private vs. Public Vendors: I’ll Take the Former
By Mr. HIStalk

It used to be that every company’s goal was going public. Now, it seems like they all want to go private.

Private equity was all the rage back in the 1980s, when companies like KKR ruled the roost with their leveraged buyouts and hostile takeovers of stagnant companies, often using Michael Milliken’s junk bonds to finance the raid.

Their goal was simple: strip the target company’s assets clean and sell the parts for more than the cost of the whole. Long-term strategy was for suckers. Real money came from flipping.

Private equity is back. You’ve seen the headlines about buyout kings The Blackstone Group, whose proposed initial public offering has even attracted the investment interest of the Chinese government.

Several healthcare IT vendors have taken the private equity route (Kodak’s health group, Surgical Information Systems, Dairyland, and quite a few more come to mind.) Do customers fare better under private investors as opposed to being publicly traded? My tentative answer is yes.

Going public provides obvious benefits: a mammoth influx of capital, easy distribution of liquid equity to early investors and executives, and access to customers and investors who prefer doing business with companies that meet rigorous financial market requirements (see: Enron).

Stock money isn’t free, though. Outsiders get a big piece of the action in return. Administrative costs skyrocket. Business must be conducted transparently, sometimes reducing competitiveness. Worst of all, fear of irrational investor decisions brings the strategy horizon down to about two quarters.

Private equity managers can bring in their own capital from a long line of salivating institutional investors. Their holdings can operate as secretively as they like, free of SEC oversight and even Sarbanes-Oxley (at least until some Enron-type bloodletting sends investors screaming to their Congresspeople). They can overcompensate executives, rake off huge amounts of money as management fees, and secretly plot the day when they IPO the formerly low-flying company for a quick buck (which some would say was their primary motivation in the first place.)

It’s still greed, which as Gordon Gekko and I always say, is good.

From a customer’s perspective, I’d rather see my vendor go private than public. Only a few vendors went public during my customerhood. All of them went from pretty good to pretty awful once they’d sold their souls. Maybe they would have tanked anyway, but innovation and responsiveness took a back seat to snaring new business and bringing in dispassionate Wall Streeters to manage their particular HIT widget. As a customer, I was suddenly less important than big- money investors because they’d already taken my money.

Private investment at least gives the illusion that the company resisted the urge to cash in. Their companies don’t manage quarter by quarter. Sometimes the equity firm has a good track record of being a benign steward, happy with slow, steady growth instead of yearning for a quick flip. They bring in far better talent than would have ever worked for the previous owners.

Your mileage may vary, but as a customer, I’ve never seen a company improve by going public. And while I’m sure vendors sometimes get worse by turning over the keys to private money, I’d take my chances.

HIStalk Interviews Sean Kelly MD, CMO, Imprivata

Sean Kelly MD is chief medical officer of Imprivata of Lexington, MA.

Give me some brief background about yourself and the company.

I’m a practicing ER physician in Boston at Beth Israel Deaconess Medical Center. I’ve been there for about 11 or 12 years. Emergency medicine is my specialty. I went to UMass Medical School and did my ER training down at Vanderbilt for three years, stayed as the chief resident and attending there for a year, and then moved back up to the Boston area, where my family’s from.

I have a bunch of interests. I worked for a while as the graduate medical education director of our hospital, which is the head of all the educational programs. I was in hospital administration half-time while I was practicing the other half-time doing academics and research, mostly around medical education and the effects of overcrowding and the effects of modern healthcare on education and training.

As well as clinical practice, I got to see the administrative side of the hospital. It’s pretty big, with a $65 million budget as far as all the different Medicare money coming through. It’s just interesting the macroeconomics of the world as they change how it affects the hospital and how we do our jobs and how much medicine has changed over the past dozen or 20 years since I have been involved in it.

One time I took a transfer call from a friend of mine who works out at Martha’s Vineyard. He was sending in a trauma patient. I started talking to him and he asked me to come moonlight out there at their hospital, so I started moonlighting there. They have a huge influx of patients that hits Martha’s Vineyard since it’s a vacation destination. They get overwhelmed in their healthcare. It’s like Hurricane Katrina every day.

I was working in the ER there and about a 100 times people would ask us, “Hey, could you be our private MD?” A friend of mine and I created something outside of the system, just a concierge practice, which was unique at the time.A couple of ER doctors doing urgent care. We started what’s called Lifeguard Medical Group, which is a concierge practice, an entrepreneurial venture which has been a lot of fun. It’s been up and running five or six years.

I addition to my ER practice, I do a private practice, which is old-fashioned medicine seeing people at their houses doing home visits, but combined with a bunch of very cool IT toys that we have these days. We have a PC-based EKG machine and an i-STAT for point-of-care testing. We can do most basic blood work that we can get in ER right at someone’s bedside in about five minutes.We have a portable ultrasound machine, a little bigger than a little laptop or a little kind of minicomputer. We have a lot of good capability right at the bedside.

This whole idea of bridging technology and medicine became more and more interesting to me. I’ll say off the bat that I’m not an IT expert. I’m not someone who writes code or grew up doing IT, but I’ve always been an early adapter of technology. Part of my job out there is to take care of people, and many of those people were venture capitalists or private equity guys. I started talking with them more and more, doing some informal consulting. That led me to Imprivata, where I’ve now worked over the past seven months or so.

I’m having a great time bridging that gap between medicine, healthcare expertise, technology, and business. I found myself gravitating to that more and more, because every conversation I was in with somebody who was an expert either from a business management side of things or from a technology side of things. It really brought synergy. That was what I was getting more and more interested in. How you allow people that have access and knowledge of great technologies to learn more about healthcare, what doctors want, how doctors think, what nurses want, how nurses think, and patients. That’s the world that I’ve grown up in and continue to work in. How do we make sure that the worlds, when they collide, that everybody leverages each other’s knowledge base maximally?

At Imprivata, it’s been a great fit for me. It’s been a very fun time over the past few months as we’ve integrated more and more into healthcare. Essentially, the problem that Imprivata solves is that there’s a big tension throughout healthcare between security and efficiency. The way doctors think is that they’ll do the right thing if they can.  They want to be secure and respect people’s privacy, but if there’s something that requires creating a workaround to systems that are in place in order to provide what we would think of as the best care, then I think that that’s where there’s this tension that comes up between hospital administration trying to make sure the people don’t use these amazing tools that are in their pocket, like their iPhones and their BlackBerrys, inappropriately because they’re out of band and not governed by the administration. 

We’ve become more and more interested in making sure that we leverage our huge partnership with our 900 to 1,000 hospitals across the world. We work with IT and with the end users — the doctors and the nurses and the patients — to figure out instead of creating this tension between efficiency or convenience and security, how do you address both, and how do you create systems that are very secure? And therefore, the right thing to do, but also efficient in design the way that doctors and nurses want to use technology to help patients.

As we get more and more into healthcare and become the healthcare experts in healthcare IT security, my role in the company is to act as a liaison and translator for all of our contact points at the hospitals around clinical workflow. We have a lot of good experience working with IT departments throughout the country and talking about specific technologies. But in my limited experience, technology is just a means to an end, and a lot of the endpoints that we’re striving for — if you ask patients and doctors, it’s about quality healthcare, and if you ask administration, it’s about quality healthcare, too, but also with a very keen eye on regulatory input and restrictions. 

I think having in-depth knowledge of all of those particular factors and making sure that each one is addressed to the right stakeholder is the only way that a lot of these solutions are going to come to bear and be successful. I think the more we are successful in healthcare, the more Imprivata continues to gain ground and knowledge in that area.

What’s Imprivata’s take on the risks and benefits of the bring-your-own-device movement?

Essentially it’s the same take as we have on our core product with single sign-on and authentication. The whole idea to allow people to use their own device, or to use devices which are taken in by the hospital when run, but leverage the power of those devices while still maintaining the security. We have designed a whole new product line called Cortext — which is a secure healthcare messaging platform — to leverage the power of everybody having these smart phones in their pocket.

There are plenty of cases where I’ve used my own smart phone with the patient’s permission and to snap a picture of something that I’ve sent out over the AT&T lines because there wasn’t a way to get our PACS systems to talk to each other, for example. We had one case where I was on Martha’s Vineyard. This woman who had polio as a child had had her leg intentionally re-broken by the orthopedic specialist in New York City, and they put a big extension brace on her leg and lengthened her leg little by little. But inside of there was a bunch of broken bones. She fell, had a trauma on Martha’s Vineyard. We met her in ER and got X-rays.

While we were reviewing the X-rays, we saw a bunch of broken bones in her leg. We knew she had had a bunch of broken bones in her leg, but we couldn’t get our teleradiology PACS system to communicate with the one down in New York. I was talking to the specialist on the phone in New York who had the old films, I had the new films, and in talking with the patient, I said, “Do you mind if I take a picture and send it to him?” He does likewise. I had them print out a hard copy of the film, put it on the old light box, took a picture with my iPhone, sent it to the New York orthopedics. He sent me back the old film. We compared the two. No changes, so she was safe to go. She didn’t have to fly off the island to go back to New York.

That’s just one of the many examples where technology is very powerful. People are used to their own devices. They like their own devices, but they bring a security risk. Rather than having theses texts go out of band where they’re not secured and they’re not technically auditable therefore not HIPAA compliant and someone could be out of compliance with regulatory oversight, we’ve created a system is double encrypted. There’s an audit trail, and it’s HIPAA compliant. Not only that, but it’s actually more functional than the regular texting systems that most people use because it has a lot of healthcare-specific features and it integrates directly with the hospital’s active directory as well.

We’ve created a whole product line designed on leveraging the power of bring-your-own-device while still making sure that the security aspects are addressed. Partnering with many hospitals, including Johns Hopkins, and approximately 60 hospitals volunteered to be design partners with us. They’re just begging for these solutions. That’s part of what Imprivata is trying to do — recognize that we have a whole host of great partners out there and a good solid knowledge base in healthcare, so we’re trying to address those.

Your concierge practice sounds like that Royal Pains TV show, where the ED doc goes out to the Hamptons to be a doctor for hire.

[Laughs] Tim, you know, I’ve never seen it, but I think they looked at our Web site and ripped it off. I’m definitely not getting royalties.

I wanted to ask you about that. Who was first?

[Laughs] It was us. We were first. Believe me, it kills me. And I’m sure it’s much nicer to be play a doctor on TV than to actually be a doctor. [laughs]

You’re working in the ED at Beth Israel Deaconess, which spun their ED software out as Forerun. Why did the hospital develop their own software and decide to commercialize it? 

John Halamka is an ER doctor.  He hasn’t practiced for a while, but he comes from our practice. There’s another guy named Larry Nathanson, who is fantastic and practices by us side by side, who I think is a brilliant IT person. It’s a homebuilt system that is a specialty best-in-breed system.

As much as there’s this movement out nationally to move to the Epics of the world where there’s cross-connectivity in a platform across the entire spectrum of healthcare whether it’s within the hospital even inpatient or outpatient — and that’s definitely a plus in many ways — it neglects to mention one very important thing. How useful is it for each part of a hospital? 

People outside of the hospital tend to think of a hospital as a uniform environment. It’s just super important to remember that the culture and the needs and the actual constraints for your everyday working situation is incredibly different in the ER than it is from labor and delivery, than it is from the floor, than it is from a psychiatry clinic, than it is from oncology procedure rooms. I mean, it couldn’t be more different in some cases.

Trying to come up with a one-size-fits-all tool is like saying that in a restaurant, the cooks are doing exactly the same job and need the same kind of tools as the wait staff and the hostess. IT at many of these high-powered hospitals has great capability and Halamka and Larry Nathanson and these guys have created great solutions.

Unfortunately, we’re like drinking from a fire hose. For every problem we seem to undertake and solve, there’s another hundred waiting in the wings and things change so rapidly. It’s a wonderful system, but when you try to commercialize it, it’s pretty difficult to then patch it into other systems, because so much of it depends on how you communicate with a legacy system. Are the labs is coming from Meditech, or are they’re coming from somewhere else? How do you communicate with that or the HL7 feeds? There’s a lot stuff that I don’t understand, necessarily, in the black box that’s sometimes hard to coordinate. The old adage is, “If you’ve seen one hospital, you’ve seen one hospital.” The set of circumstances in many other hospitals is very different.

For our particular case, we found something that really works and they’ve spun out to try to put it elsewhere. But it’s funny — I’ve seen the reverse happen with Imprivata, where there’s a solution that we have found has worked very well. It works to get people in the front door to all those systems. The more you have these different, disparate systems throughout the hospital, and the more you’ve got these trends towards ACOs or other integrated healthcare networks, the more you need the ability to jump on, move between applications quickly, and make sure you have authentication in place so you can see what people are logging onto and when and why.

The ED is really different. Lots of times you’re seeing patients that have no history available, or they have no history with your organization. You have to make quick treatment decisions, you’re expected to be right all the time, and you may never see that patient again. How do you think that’s going to change with the accountable care model? Is it going to be just like it is today, only with a different patient mix?

In Massachusetts, we are a bit of predictor for some of the movement nationally, because we had guaranteed health insurance before healthcare reform dictated that nationally. We saw the effects of giving everybody access to healthcare insurance. We expected it, but it didn’t get much press ahead of time. One of the issues is that giving people healthcare insurance doesn’t necessarily mean they have access to healthcare. There’s such a shortage of primary care physicians and even specialists that people can’t get in to see them, particularly the ones with the poor payer mix. 

You had one barrier keeping people from using the ER — that they would get this exorbitant charge. If you take that away and replace it with a co-pay, now these same people who have insurance, they try to do the right thing. They try to get an appointment with the doctor for their sore throat or for their abdominal pain or whatever it is, but they can’t get in to see him, or they have a month wait. So they end up guess where – back in the ER. 

I  don’t know if that problem is ever going to go away entirely. The better we try to capture people into the system and keep them in correct systems so they can have their care well managed and prevent disease is a great long-term goal. I’m not sure how long that’s going to take. Certainly it’s not going to be any time in the next five years that we have the supply-and-demand curve figured out for giving people access to good healthcare. I think there’s always going to be a spillover.

The second part of that is if people are going to show up on your doorstep in the ER, isn’t there an easier way to jump online and see what they are with HIEs or something else? We’re suspicious as to whether that will actually happen, because on the one hand, everybody’s clamoring for collaborating and sharing of data. On the other hand, you’ve got many different EMRs that don’t particularly want to share data. You’ve got all the concerns about risks, about data breaches, and letting data get out there. What is the authentication and security process around that data and those HIEs, and who agrees to let it get shared, and how do you control access to it?

So I think that there are some steps in that direction. It’s very unclear how it’s going to shake out, but I don’t see it as a problem that’s  going to go away realistically any time soon.

What percentage of patients that you see would you say truly need to be seen in the emergency room?

It totally depends. We work at several different ERs, including community ERs, and the mix is somewhat different. The appropriateness of their visit depends on the time of night, the time of day, the access to the other doctors, economic incentives to those other doctors. But in general, at least 30% and sometimes up to 60% or more of those people really don’t need to be there.

I remember I had a great day when I was training down at Vanderbilt. A tornado hit Nashville. When I say great day, it didn’t really do this much damage as people thought, so I can actually say that. This tornado came basically right through the center of Nashville and it took out part of this rehab hospital. We were the main trauma center in Nashville, so we had permission that day to go on disaster duty, and we went through the ER. As the senior resident, it was my job to go through, and like duck-duck-goose, tap everybody on the shoulder who didn’t need to be there and kick them out. It was immensely gratifying to walk down the line and say, “Room 7, sore throat, discharged. Room 8, belly pain, discharged. Room 9, here for Percocet, out.” Probably eight out of 10 people just got jettisoned to prepare for this onrush of disasters that we’re expecting to get sent in. That was a gratifying day and not a typical thing.

When you teach medical residents, how are they different in how they view and use technology than their counterparts from five or 10 years ago?

It’s fascinating. They’ve grown up on Facebook and Google. It’s funny, they actually create things when we haven’t thought of it. One of the main issues is, where can you put information that you as a group or several groups subdivided can look at and parcel out in a way that makes sense from a specialty perspective and also a security perspective? They created a wiki. The residents created wikis in medicine, in emergency medicine, OB-GYN. Sometimes there’s crosstalk between them, sometimes they’re their own thing because of that whole phenomenon of the microenvironments within the ER.

But they’re very clever. They’ll go pull YouTube videos about how to do a procedure that are out there, that are part of some textbook, or a Netter diagram of anatomy that is particularly helpful, or a list of supplies that you need to get together when you’re doing a central line. How do you teach people to synthesize data and to learn how to reach for information rather than just memorizing things? Because you can’t memorize everything any more.

Back 20 or 30 years ago, there were something called blood disorder. Now blood disorder turned into leukemia, and now there’s like 69 different kinds of leukemia, and each one of them has a different cause and a different kind of treatment. Even the ones that have the same treatment have subsets depending on what they respond to, as far as the oncology and the chemotherapy. It just keeps getting enormously more and more complex. You can’t memorize everything, so there’s all these systems out there.

A lot of people go to UpToDate, go to Epocrates, go to all these specialty apps. At Imprivata, one thing we’ve noticed is that even places where EMR — Epic in particular, when they bulldoze the landscape and take over and a whole place goes to a single EMR — even in that case, there’s a ton of other apps that people go to that they need to go and find information on. It’s just continuously evolving. 

It should evolve. People should be able to use technology to its fullest. We do it socially. We do it for every other place in our lives. When we get our car taken care of, the mechanic seems to be able to know a lot more about that car than I can tell about a patient who hits the ER. To continue to provide easy, smart, and quick access to these different systems is really important.

I want to bring up one aspect of what Imprivata does that I think is key to understanding why I think we’re so sticky and have gotten so much leverage into the healthcare market. People talk all the time about saving clicks or saving time when you’re allowing a clinician to optimize their workflow. It is about time, but the big factor that I don’t hear mentioned enough is that it’s not just time, it’s the interruption and the cognitive dissonance in interrupting your thought process. I’ll give you an example.

We had a very high-stakes stroke patient. A clinician who passed out during rounds. He had a massive stroke and had a bunch of medical problems unbeknownst to everybody around him. He essentially dropped in front of the team while he was upstairs in the surgical ICU. They rushed him down to the ER.

We all gathered around him. This is what you trained for. You’ve got this person who comes in, who’s young and healthy, who’s got complete paralysis on one side, who can’t speak, and literally was down taking care of a patient next to you.

You’ve got this case and you just want to mobilize everything as quickly as possible. Your brain’s going a thousand miles an hour and you need to do several things. Stroke care is very time dependent, so you need get a CT scan very quickly, get a consult with neurology. You want to get the best neurologist around to look at the studies very quickly. You need to find out if the person has a medical history, including allergies to certain dyes you might use in the radiologic studies. You need to find out if they’re on blood thinners, and if there’s any contraindications to using thrombolytics, which are the clot-busting drugs. You have to do all these things very quickly. 

As you can imagine, he hadn’t received his regular care at our hospital because it’s a privacy issue. He wanted to be somewhere else. So we couldn’t look up his old records. It’s just what you intimated before about ER – some things just get dropped into your lap. You don’t know the patients and it’s a difficult problem right when it matters most.

To get stopped because you don’t have the right password, you can’t remember a password, your password changes, or you’re just logging on and off a multiple systems … there is a time factor, but it’s not about the return on investment of gaining 45 minutes a day at that point. It’s really about keeping your thought process and being allowed to think on the things that are truly important and complex, and as you’re moving through the paradigm of care and trying to figure out like, “OK, I’ve figured out these seven of the eight factors. The one more thing I’m going to do is…” and you hit the button and you get locked out because you need to reset your password or you put it in incorrectly and it locked you out of the system. You’re calling the ITS help desk.

That kind of breakage in your thought process is very dangerous for patient care, and very frustrating. When you have well-designed systems that allow you to jump on and navigate quickly between all these evolutionary systems that we’re coming up with, which have great capability … you know as well as I do that sometimes with all the information out there, you’re starving in the sea of plenty, where you just can’t find the one thing you need. Being able to get on there and navigate quickly around those different things –  it really helps.

We end up taking very good care of this guy. He had all the things he needed very quickly. He actually got a 100% recovery, which was a great outcome. But it’s not always that way, and the IT systems and the ability to navigate on and off of them can be a significant contributor in how well people do. It’s a cool thing to be part of an innovative company that helps people optimize their workflow and use their EMRs better and is having a lot of success because of it.