HIStalk Interviews Jessica Berg, Professor, Case Western Reserve University

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any concluding thoughts?

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

Monday Morning Update 9/20/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

Sponsor Updates

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

News 9/17/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

HERtalk by Inga

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

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

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

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

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

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

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

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

Sponsor Updates

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

E-mail Inga.

Readers Write 9/15/10

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

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

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

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

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

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

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

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

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

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

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

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

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

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

Regaining Control of Disaster Recovery
By Tony Cotterill

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

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

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

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

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

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

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

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

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

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

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

RTLS and Temperature Monitoring Mania
By Fed Up with the Fever

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

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

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

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

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

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

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

News 9/15/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

HERtalk by Inga

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

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

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

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

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

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

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

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

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

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

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

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

Sponsor Updates:

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

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

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

E-mail Inga.

HIStalk Interviews Hamid Tabatabaie, President and CEO, lifeIMAGE

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

Tell me about lifeIMAGE.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any final thoughts?

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

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

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

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

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

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

Monday Morning Update 9/13/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

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

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

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

That frames up the book nicely.

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

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

I extrapolated his thoughts into IT:

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

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

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

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

News 9/10/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

HERtalk by Inga

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

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

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

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

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

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

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

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

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

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

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

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

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

Sponsor Update:

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

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

E-mail Inga.

CIO Unplugged 9/8/10

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

Does IT Matter: Six Years Later

In a 2003 opinion piece for the Harvard Business Review, Nicholas Carr threw a grenade on the IT dinner table. Carr argued vehemently that IT no longer mattered. He leveraged this high-profile editorial into a best-selling, thought-provoking book in 2004, Does IT Matter?

Carr’s central argument states that the strategic importance of IT has diminished over time; that IT has become nothing more than a commodity providing little competitive advantage. Consequently, according to Carr, companies should rethink their investment in IT. He also laid out his agenda for IT management, examining implications for business strategy and organization. Carr’s thesis was both embraced and vilified.

Written in the IT boom years, post-Internet “bubble,” does the economic downturn change the game? What about healthcare reform implications? Are we any different?

As I observe and research, I see fatalists and opportunists at odds.

The fatalist has accepted Carr’s pronouncement as fact and has become complacent, allowing the administration to marginalize IT. Opportunists, on the other hand, see the circumstances as the tipping point to reinforce, or for the first time, to position IT as strategic.

I interpret Carr’s compelling arguments as a call to action.

During these dour economic times and the uncertainty of healthcare reform, IT has a heroic opportunity to be a catalyst for prosperity, a key differentiator. This means I cannot sit back and accept current fate, allowing IT to dissolve into a simplistic commodity or back-office function.

To advance my organization, I hunt for and seize strategic opportunities. The economy will not determine my destiny if I choose to leverage it as a clarion call and make every effort to expand our services while lowering costs.

Our department reaches out to select vendors, changing our value proposition from transactional to transformational relationships. I shared this in-depth in Maximizing Vendor Relationships. It’s not about broad generalizations. Success is about the individual organization; its circumstances; and ultimately you, the IT leader.

As organizations look to cut spending, IT is not immune. Continual across-the-board expense reductions will underscore IT as a commodity and a cost center to be managed — Exhibit #1 for Carr.

Call me competitive, but I believe that companies that lay low and marginalize their IT will have a much lengthier recovery period. Especially when it comes to seizing the initiative on healthcare reform dynamics that are fundamentally changing the value equation of cost, quality, and revenue.

In contrast, those companies that seize the opportunity and invest in IT strategically will not only perform better, but will do so at the expense of their competitors. Some of our current work is going to change the competitive dynamic.

Think. Brainstorm. Mashup. Research and develop strategies that will propel your organization forward. Even if your company is panicking and relying solely on expense reduction tactics, present ideas that demonstrate bottom-line reduction, improve clinical outcomes, and support top-line growth. Innovation that will set your organization apart in dealing with the nuances of future payment and care delivery models. Insist on having your voice heard. Demonstrate ROI through IT’s transformative and innovative power.

For competitive reasons, I cannot share details, but we are doing these things. A risk-free example from my past happened at a community hospital. Our historic 45% market share in this two-hospital town was starting to plunge. Our cross-town rival was replete with cash, given their enviable position as part of a regional health system. Our board decided that the best antidote was not to reduce expenses, but rather to make strategic investments in IT.

One year after the implementation of affiliated practice-based EMRs, clinical inquiry application, and software to link referring physicians, our market position flipped. We saw a 20% swing, especially in our target areas of hearts, births, orthopedics, and neurosurgery. We were featured nationally.

I have additional career examples, but I believe the point is made. Yes, the economy is tough. Healthcare reform is a bit fuzzy still. Fatalists seek to marginalize IT. But the time is right to forcefully lay hold of this opportunity and (re)establish IT as strategic and foundational for your organization’s long-term success. IT is not back office!

Demonstrate the strategic power of IT.

It matters.

Update 9/14/10

Good debate on IT value. My leadership team just started on our next book, also by Carr, entitled The Big Switch…Rewiring the world from Edison to Google. Whether you agree or not with Carr, it is healthy to debate his ideas and come to grips with his messages. Is IT strategic? Will cheap utility-supplied computing change the game? Does the Internet take away our ability to think deeply? Are we losing our capability for concentration and reflection?

I still maintain that we can leverage even the most common of tools in a strategic fashion. It comes down to culture, risk, vision, innovation and leadership. Give me two organizations that each implement the identical EHR and I can show you two radically different approaches…and executed well, one can be a strategic differentiator over the other.

I do not agree that IT is purely a support function. Sounds good on the surface but, short sells the innovation and passion we have been endowed with. I have been fortunate to work with incredibly talented individuals who have taken common tools and developed these to improve patient safety and increase the quality of care. I have also witnessed similar gains on the business side. As a by-product, these have helped grow IT and proven to help us differentiate ourselves from competitors.

Not everyone will adopt or deploy it as strategic, nor should they. But it can be done.

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 9/8/10

From HIT and Hockey Fan: “Re: Bobby Orr will enjoy this. Use meaningful useful EHRs (Epic in the office) to win a night at the UPMC Health Plan’s luxury box at the new Pittsburgh Penguins Arena. If successful in enticing the doctors to provide care as defined in the letter, UPMC Health Plan and UPMC will be paid a bonus from your tax dollars by CMS, which will more than cover the cost of the luxury box for the entire season.” I think I’ve mentioned before that I was UPMC’s box suite guest once at a Steelers opener at Heinz Field, which was somewhat wasted on me since I don’t get the point of watching someone else play sports (especially millionaires), but the atmosphere was interesting. There was lots of food, drinks, and nattily attired male UPMC executives talking shop and watching the game on the TV monitor while their carefully coiffed wives chatted harmlessly in the living room area. Just outside our hermetically sealed and climate controlled luxury digs were people (their patients, most likely) cheering, waving Terrible Towels, and actually paying attention to what was happening on the field. It was pretty enjoyable once I got over the irony of a non-profit hospital system spending money to support a billionaire’s sports team. 

From Ricardo: “Re: Napochi. I’m curious about your impressions. Someone sent me a link and they are new to me.” Never heard of them. They sell PM/EMR, but they don’t call them that exactly. The company has offices in Alabama and China (there’s an odd pairing). Their Web site isn’t ready for prime time if the number of placeholder pages is any indication. They claim 300 hospital and practice customers, but I bet most of them are in China (just guessing).

It defeats the purpose of a survey asking about compassion and spiritual beliefs when an atheist blog urges its readers to barge in and vote predictably, so take the above results with a truckload of salt. Before the ballot box stuffing commenced and real HIStalk readers were voting, it was running about 50-50. New poll to your right: is the typical practice-based EMR capable of collecting and presenting the information needed for practices to assume and manage population-based risk?

University of Mississippi Medical Center chooses Epic for a $36 million project. They expect Uncle Sam to pay $20 million of that in HITECH money.

A University of Rochester Medical Center doctor loses a flash drive containing the PHI of several hundred patients. In typical horse-left-barn fashion, the medical center vows to start using encryption. Maybe losing a drive is the best thing that ever happened when it comes to information security — embarrassing publicity apparently launches more encryption projects than any kind of thoughtful planning and it only takes one episode per hospital.

Healthcare Innovative Solutions (HIS) is supporting HIStalk as a Platinum Sponsor, I’m happy to announce. The Seville, OH company provides clinical systems implementation, process optimization, CPOE and EHR consulting, medication safety, order set, and clinical decision support services. They also do HIPAA security, strategic planning, selections, and HIE work. Here’s a white paper (warning: PDF) describing their CPOE work at Mercy Health Partners (OH). I ran across this profile and video about founder Daniela Mahoney, RN whose story is quite interesting and worth watching. Inga and I thank Healthcare Innovative Solutions for supporting HIStalk.

AMIA is offering prospective corporate members free attendance at its Industry Day, held during its annual conference in Washington, DC on November 15. They have a few spots left.

Misys shareholders won’t get their $1.2 billion in Allscripts stock proceeds immediately, as the IRS evaluates whether Misys is on the hook to pay $170 million for what may be interpreted as a material reorganization of its corporate structure.

Scotland-based charge master vendor Craneware, flush with cash after a good year, is on the hunt for acquisitions valued at up to $30 million. Nearly all of its business is in the US and the company is looking for a bigger piece of the healthcare reform pie.

mdHub launches the mobile version of The Little Blue Book, the physician directory formerly distributed on paper by WebMD. It also includes pharmacies, hospitals, and health plans. I don’t exactly understand the pricing model, which is based on regions, but I’m sure you can figure it out if you’re interested.

Everybody’s getting into the physician recommendation business, apparently. A reader says Angie’s List (of which she’s not a member) has sent several solicitations about doctor ratings, some of which seemed curiously timed to her Google search activity. I can’t imagine paying for reviews, but apparently some do (and some complain about the result, Google tells me).

In Canada, Northeastern Ontario Network (NEON) adds six new hospitals to its Meditech hosting service, bringing the total to 19.

WellStar Health System (GA) fires its CEO following settled charges of Medicaid overbilling, which he had blamed on its billing systems.

New CMS head Don Berwick plans to start using his agency’s $10 billion innovation money to fund 100 to 300 sites testing new models of patient care, which I assume means accountable care organizations.

Google is looking for volunteers to translate chosen healthcare articles into Hindi, Arabic, and Swahili on local language versions of Wikipedia.

Big German healthcare software vendor CompuGROUP will purchase Visionary Healthcare Group, which includes Visionary Medical Systems, a Tampa, FL PM/EMR vendor. The company’s first US investment was majority ownership of Noteworthy Medical Systems 18 months ago. I think it’s safe to assume that more acquisitions will follow.

HP’s board fired CEO Mark Hurd even after finding that he violated no company policies, triggering a severance payout worth up to $40 million. Oracle hired him on Labor Day as co-president. Now HP is suing him, claiming he violated his confidentiality agreement by going to work for a competitor. HP doesn’t like Oracle now that it sells its own servers, courtesy of its acquisition of Sun last year.

A British study finds that pharmacists could reduce nursing home medication errors by over 90% if put in charge of the process. The study found that 70% of patients had at least one medication error on any given day.

New Zealand will pilot e-prescribing next year.

Thinix releases a touch-friendly, iPad-like user interface for Windows-based virtual desktops, providing as a press release example a nurse working both remotely and on the desktop.

The former president and CEO of Perceptive Software, acquired by Lexmark in May, explains why the $280 million, all-cash deal makes sense using a healthcare example. That’s not surprising since Perceptive always had a fairly strong healthcare presence with its ImageNow scanning and barcoding products. 

England-based Avia Health Informatics PLC announces executive changes to support its plan to enter the US market with its odd lot of products sold under the Plain Healthcare and Odyssey brands: ship telemedicine, patient symptom self-assessment, paramedic fall evaluation,  prison healthcare, and nurse triage.

Exciting, to me anyway: the sequel to Wall Street hits theaters September 24. No Bud Fox, but GG’s back 23 years after the original.

E-mail me.

HERtalk by Inga

Mount Kisco Medical Group executes an agreement to deploy NextGen’s EHR, PM, and Patient Portal for its 230-physician practice. Looks like they are replacing Misys Vision and EMR.

Nassau University Medical Center (NY) adds Streamline Health’s Enterprise Health Information Management suite to integrate with its existing Eclipsys Sunrise Clinical Manager. Nassau already utilizes Streamline’s accessANYware product.

ASC software vendor AmkaiSolutions completes a $3 million round of Class E equity financing. The company plans to pursue “a broader sales and marketing program.”

Central Texas Medical Center (CTMC) goes live on CPOE. CTMC is part of Adventist Health System, so I assume it’s a Cerner install.

Data point: more than half of the 354 million doctor visits each year for acute medical care are not with a patient’s primary physician and more than a quarter are in hospital ERs.

Emdeon announces plans to acquire Chamberlin Edmonds, a provider of government program eligibility and enrollment services. The $260 million purchase expands Emdeon’s offerings for hospitals.

Medical scribe is one of the hot, up-and-coming healthcare jobs that has become especially popular with young medical and nursing students. The pay isn’t exceptional — $8 to $10/hour — but the job gives scribes the opportunity for up-close exposure to physicians providing patient care, particularly in the ER. Several enterprising companies are establishing offices close to major universities in order to attract ambitious pre-med and nursing students. The scribes receive basic training on medical terminology and coding before hitting the front lines.

University of Utah Medical Group selects Practical Data Solutions to migrate its data warehouse and analytical reporting to Epic. The academic health system goes live on Epic November 1st.

Carestream Health acquires Quantum Medical Imaging, an x-ray imaging provider with a strong base of community hospitals and smaller clinics.

Catholic Health Initiatives (CO) hires Sheryl Rose for the newly created position of Chief Information Security Officer.

A George Washington University ER physician initiates a study to see how accurately ER docs and PAs diagnose wounds from patient-generated cell phone images. Five months into the study, the data indicates a 90% accuracy rate. And, accuracy increases with better quality images.

Sponsor Updates

• Carolinas HealthCare System selects Medicity to help build a multi-state HIE that encompasses the health system’s 32 facilities, plus community physicians and other caregivers.

• Mayo Regional Hospital (ME) chooses Sage Intergy EHR of its eight physician practices.
• Across the pond, King’s College Hospital goes live with iMDsoft’s MetaVision in its critical care unit.

E-mail Inga.

HIStalk Interviews Ramsey Evans, President and CEO, Prognosis

Robert Ramsey Evans III, MBA is president and CEO of Prognosis Health Information Systems of Houston, TX.

Tell me about Prognosis.

Prognosis is an EHR software company. We deliver a comprehensive software solution to our hospital clients. The ChartAccess EMR/EHR is a Web-based software application that provides clinicians with a complete view of the patients and their data and to support the optimal safe patient care.

I know of only a couple of handfuls of vendors that offer inpatient EHRs and I’ve heard the least about Prognosis. Why is that?

We were founded in 2006 with the development of the certification criteria. The genesis of our company was a medical records service company, a clinical informatics specialist — mainly out of the Houston Medical Center — along with a software group came together and developed a software application called ChartAccess in 2006, with the advent of that certification criteria. We looked at it as an opportunity of leveling the playing field with there being so many established vendors in the inpatient side.

Most vendors started as technologists building custom hospital applications and then taking it from there. Your approach sounds more like you started with the traditional paper medical records or some form of electronic medical records and built the application around that. How was your approach different?

You nailed it. We married what the medical record looked like in yesterday and today’s environment with a clinical perspective and brought the Web 2.0 web services technologies to marry our application. We started with CPOE and eMAR. That was the first certification criteria focus in 2007. Then we built out from that clinical base CPOE.

What advantages did that give you, having not gone through those generations of rebuilds where the technology changes? You are, I assume, still on your original technology. Has that been an advantage from a maintenance standpoint?

Absolutely. From a support standpoint, our infrastructure requirements are very limited. We can do traditional on-premise. A lot of our hospitals aren’t ready to get rid of their servers yet, but we also can do the SaaS model but it has reduced our maintaining of hardware. Also, with the updates that go to our clients, it’s seamless. There’s no PC to update, it’s just through the Web.

Are your sales primarily hospitals implementing their first EHR system, or is it a replacement market?

Almost all of ours are first-time. They’re in a paper environment. They may have some ancillaries — you know, lab information system or a RIS or PACS system in terms of clinical — but in most cases, they have nothing in terms of a CPOE, the core medical record.

Does that make it easier or make it harder for you to implement, where you’re not replacing someone else’s system?

I would say we have clients that are net new hospitals that are just opened. That’s like a whiteboard. Those clients actually are the easiest. They don’t have a system and they don’t have a paper process. But then when you go into the implementation phase for a hospital that’s doing a paper process, the biggest piece is change management.

You can deliver a great product in the newest technology, but we spend a lot of time on that workflow migration from the paper to the pure electronic. That part of it is, I guess, a little more difficult up front, but that carries big-time dividends when you go live, as long you’re able to take care of the people.

Small and rural hospitals are pretty underrepresented in the land of HIT, so you don’t hear a lot about them. A lot of folks think a 300-bed hospital is tiny. How would you explain what it’s like in the hospitals of the size that you implement that might not be what people would expect?

Most all of those folks are wearing two and three hats. They don’t really have a whole lot of time to spend learning new things. Your IT directors, a lot of times, are also doing something else like running an ambulance team, etc.

You have to be able to come in and work around their schedules. In most cases, it’s like a small business. They’re having to do a lot of other things, so you have to make the implementation process and the training and go- live process as flexible and easy as possible.

The other perception might be that because they’re small, they’re expectations are lower as far as the systems that they purchase. Do you find that to be true?

Absolutely not. They have the same needs as a large hospital. They still have the same emergency departments. They have Level 4 trauma. Their needs are just as great as a big hospital. It’s just they have fewer folks to take care of.

A lot of the HITECH money is probably going to go to these small hospitals that are finally encouraged enough to really be interested in automation. What advantages do think that Prognosis offers them over your bigger and more established competitors in that small and rural hospital market?

We can get them to Meaningful Use from start to finish and in a rapid fashion. We have clients that have made it in 4-6 months and less. Then, with Meaningful Use Level 1 attestation starting October 1, there’s a squeeze here. We’re seeing that in the marketplace and able to help them on keeping those implementation cycles down so that they can achieve their stated goals.

Do those customers perceive that a fairly new, privately-held company holds more risk to them than a vendor that is larger and publicly traded?

Yes, we had to deal with that on a very regular basis earlier in our life cycle. As we have gotten a bigger reputation in terms of delivery, that has gone away at some levels. But in our target market, most of those hospitals require the same type of due diligence of a small, private company versus a big company in terms of their ability to deliver, like checking references. That’s where we have focused in making sure that all of our sites are reference sites.

Can you give me some idea of the size of the company in terms of number of installed sites or employees? Whatever you’re comfortable sharing.

I can. We’re working with about 60 or so hospitals right now in various stages, either all the way fully implemented all the way through to early stages of contracts.

You just had an announcement not very long ago about a relationship with Order Optimizer. What value does that bring to your customers?

That really enhances our CPOE since, as we mentioned earlier, CPOE is where we were born. Those clinicians that elect that option — that upgrade, if you will — are able to merge order sets and code morbidity, and it really cuts down on their amount of time they have to be in the system and they can get back to their patient.

We have found that most of the clinicians that are using our system, as they get very acquainted with the electronic process, that is a natural step in achieving evidence-based medicine.

If you look at your technology advantages in areas where you’ve innovated, what would you say are the benefits that you offer there?

We’re Web-native. One of the biggest pieces in this puzzle, from our perspective, is mobility — being able to access the system from anywhere, wherever the clinician is in the hospital or outside the hospital.

We’ve already developed our platform on the iPhone. The iPad will be next month. In terms of being able to give the clinicians the access to the system from wherever they are, and being able to have that user interface where they can stay off of the keyboard and can be taking care of the patient.

Sounds like you’re pretty comfortable with the status of certification and Meaningful Use and that your customers will have time to ramp up and get going in time. Is there anything that concerns you, or that you were disappointed, at what came out of Meaningful Use?

We made a calculated step. We built in almost all the recommended Meaningful Use pieces into our product, before April, after they were announced in January. So when the announcement came, almost all of our clients were absolutely happy because we were already on our way. The reduced list makes them feel even more comfortable with achieving it if they’re not already there. But we all know they’re coming and we’re planning ahead and staying ahead of that curve instead of reactive.

There is at least anecdotal evidence that hospitals are driving some of the physician practice decisions for EHRs through some type of support. What do you say to a customer who comes to you and wants to integrate their physician practices that are either owned or affiliated with their inpatient practice?

We think the open architecture approach … we offer the whole solution, but we don’t force hospitals and their clinics to replace anything if they’re happy with it. So, we take both ways. If they want that to happen, then it’s not a big hurdle for us because of our architecture. Then if they want to replace, or if they don’t have something, we know that you have to come with a total solution.

Tell me the modules that you have and those that you generally have to advise the customer to seek elsewhere.

We have everything from billing/financial from the front end registration: general financials, general ledger all the way through everything in the clinical world: CPOE, eMAR, radiology, lab, pharmacy, and HIM. We do not have PACs. We recommend PACS solutions.

And you have clinical decision support, I assume?

Absolutely. That’s one of our strengths when we’re talking to our users. It provides plenty of clinical decision support as well as care plans so that they can meet their measures.

When you look at your reference sites, what results have they seen from their implementation?

In all of our reference sites, they’ve been able to access the information at the point of care. That’s the biggest pat on our back we get is that they are able to see everything in real time and be able to make better decisions at the point of care. That’s the biggest we’ve seen.

Then, access to data. They’re all looking at the same thing. Maybe if a doc is on the phone with a nurse from wherever he or she is, they’re able to view the same information in the same system, whether they’re in lab or radiology, and be able to make real-time decisions.

One of the difficult parts of why vendors typically failed at selling to small hospitals is they’re a hard group to market and sell to and they’re also a tough group to implement in a cost-effective way. How do you do it differently than a big vendor who just tries to take the same product and stick it in a 50-bed hospital?

We take the approach that every hospital is an individual and is different. But in our product, you’re able to, instead of customize, we configure. Our architecture allows everyone to have their own workspaces. We take their desk setting, if you will — a nurse’s desk setting — and we convert that, somewhat, into their landing screen. Their landing screen allows them to match their workflow.

It’s not hard coded, it’s just a configuration at the client level, the individual level, and that remains throughout. It recognizes their permissions, etc. so they don’t have to come back. On the cost side, that is one of the things that the intuitiveness of our system allows folks to … if a clinician is able to use normal applications like Outlook, in a relatively short time they can figure out about 80% of what they want with support and training from us.

Where do you take the company from here?

We’re very excited about Meaningful Use being defined on July 13th. We’ve already seen a big increase in requests for demonstrations, so we’re going to continue to execute our plan to deliver our solution to the hospitals and stay at the front on the development side of Meaningful Use and the newest and best practices using the newest tools that we continue to embed into our product.

Any concluding thoughts?

We are very excited to be a part of this transformational time in healthcare and look forward to participating. As we look back, although challenging for the hospitals in terms of change management, we’ll surely help on the cost and patient care side.

News 9/3/10

From Bobby Orr: “Re: the new Allscripts. They rang the Nasdaq bell. Hopefully it’s not too late to have a real challenger to the mighty Epic.” Glen has rung that bell a few times, I found by Googling. Since I couldn’t find a picture from this week and their Web site seems to be down, the one above is from one of the several previous “new Allscripts”, this one from 2008. I’d like to think it’s not too late to compete with Epic either, but I think it is, at least if the goal is to match up head to head. The Eclipsys clinical apps are better in some ways, but prospects are eating up Epic’s “one record” pitch and looking that the avalanche of new Epic business compared to long, slow decline of the Eclipsys Sunrise customer base. On the other hand, those Eclipsys apps have never been in better management hands than they are today now that the acquisition is finished, so maybe Glen can turn it around. When I asked him about that, he was pretty confident that Epic is vulnerable, but then again, former Eclipsys SVP (now Allscripts president) John Gomez said the same thing right before a stunning string of Eclipsys showcase accounts announced plans to displace Sunrise with Epic.

Speaking of Allscripts, here’s an insightful comment from quadwatch on the Yahoo stock board: “We are seeing what drove this merger — Eclipsys’ inability to compete with a weak ambulatory product and Allscripts’ lack of a hospital system. Given MU requirements for hospitals (in particular, CPOE adoption) the reality is you have only three products with proven adoption rates that don’t make a new purchase a crap shoot for the CIO: Epic, Cerner, and Eclipsys. It becomes a Epic-Cerner race if the facility has employed MDs or is looking to establish a community model. This one of the most logical mergers that I have seen in this segment.”

And while I’m quoting from stock boards, here’s another excellent one from my favorite industry analyst, sonomaca, on Glen’s bell-ringing: “Not surprised he decided to go and ring the bell. This is his triumphant return to control of MDRX. He’s proven himself to be a master of the game, starting with the secondary offering back in 2000 which ultimately saved the company. You’ve got to marvel at how he took a near-bankrupt MDRX in 2002/2003 to the top of the heap in 2010. Amazing. My guess is that, in the end, ECLP will be integrated without too much trouble. In the next couple of years, US market share will be pretty well divvied up between Epic, Cerner, Allscripts, and some of the lumbering giants like McKesson. No doubt, GT is already thinking ahead. And, what’s ahead are myriad tuck-in acquisitions and, most importantly, overseas.” Above is the ten-year share price, peaking at something like $80 in 2000 and bottoming out at less than $2 just three years later, now back to $17. Glen was CEO that whole time and before. He’s got $19 million worth.

From Price Checker: “Re: UPMC. I love this creative, airline-like a la carte approach to paying for the EHR at this paperless hospital.” UPMC, like other hospitals, is charging patients a “facility fee” for being seen in a physician practice it owns, even though patients may not even know that UPMC is involved. The patient profiled in the article noted that the reception area bears a plaque thanking the donor who paid for it, making her wonder why she has to pay again. She had no choice since UPMC threatened to turn her account over to a collection agency, but she vows to steer clear of that doctor and building for her future medical needs.

From The PACS Designer: “Re: Apple TV. Apple has announced their latest Apple TV configuration containing a faster custom built processor called the ARM A4. With a hookup to an HDTV, could medical image viewing find a place in the home viewing schedule? Only time will tell if it catches on with practitioners! This iTV device also has an Ethernet port and 802.11B/G/N Wi-Fi for streaming.” I’ll say that my Roku box was a game-changer for me. I haven’t watched a minute of DirecTV or even DVRed stuff since I got it – everything else seems so primitive compared to free, on-demand Netflix streaming. I’ve discovered great TV shows and movies I would never have found otherwise. I think I saw there’s some kind of medical channel on there.

From Mya: “Re: weird medical news stories. Did you hear about this one?” Sad: a female doctor, apparently drunk, tries to break into her former boyfriend’s house while he is there. He leaves out the back door to avoid a big fight, but in the meantime, she climbs on his roof and tries to slide down his chimney. Three days later, someone checking on the man’s fish notices a smell coming from the fireplace and finds her dead a couple of feet up the chimney, where she had died of asphyxia.

From Irving R. Levine: “Re: EHR vendor. We’re converting from [vendor name omitted]. They don’t understand why an IT shop needs access to clinical data in the SQL tables, so we can’t access our clinical data on our servers on our network without using their UI. They also don’t understand why we want to do our own backups instead of using their service.” This kind of issue is going to pick up steam as people starting switching out EMRs. Small practice vendors don’t usually understand clients with real IT people on board, so they distrust their intentions in a rather parochial manner. Like Bill O’Toole said in his HITlaw, if it’s important to you, get it into the contract.

The proposed Healthcare IT site on Area 51 (geeks know what that means) needs reader commitment to move ahead, being 15% of the way there so far. If you’d like to see an place to have HIT-related questions answered by experts (or to answer questions if you’re the expert), then sign up.

Marty Larson is named executive director of the Greater Dayton (OH) HIE.

GetWellNetwork will announce that it has developed the first digital care plan for reducing admissions for pediatric asthma, including multimedia patient and family education covering triggers, medications, and equipment.

Jobs on the sponsor job page: Technology Account Executive, Epic Certified Consultants, Account Manager, Eclipsys Orders/Results Analyst. On Healthcare IT Jobs: Cerner SurgiNet and Power Orders PMs, McKesson HEO I-forms Consultants, Development Manager, Epic Report Writer/Programmer Analyst.

Listening: reader-recommended The Sensational Alex Harvey Band, 70s glam rockers from Scotland. The namesake died 28 years ago, but even though he hasn’t been reincarnated, the band has. He was quite a showman.

HIStalk stats for August: 102,047 visits, 145,694 page views, and 6,114 verified subscribers. All are new highs. Thank you for reading.

Metropolitan Health Networks and Senior Bridge start a year-long pilot project to evaluate the use of telephone-based telemedicine and specially trained staff to manage 100 Medicare Advantage patients who require frequent hospitalization. Each individual is assigned a nurse and a social worker to work with the patient’s physician to develop a care plan and to conduct in-home assessments for safety and patient evaluation.

This is ingenious: Kerry from Network Management Solutions of Garner, NC e-mailed to tell me he’s figured out a cool way to use his iPad. He downloaded the free Remote Desktop Lite app (which also works with the iPhone) and remotes into his home PC, meaning he can run all of his Windows apps on an iPad from anywhere. That sounds like it might have some possibilities for small-scale hospital or practice apps, as long as each iPad user has a dedicated PC to remote into (it’s like a poor man’s Citrix farm, although the non-poor man might run Citrix Receiver to run apps directly from a Citrix server). I bet the wheels are spinning in the heads of some readers even as we speak.

Why haven’t EHR vendors done this? A chiropractic software vendor partners with the creator of the Facebook Fan Page Generator to get its customers into social networking and promotion, or as the press release says, to create “an automatic new patient referral generating machine.”

The Community College of Allegheny County (PA) will offer free, non-credit HIT classes to qualified applicants, courtesy of $16 million of federal taxpayer money.

The presentation was from an Australian HIT executive, but the message is familiar when it comes to IT challenges in hospitals: IT gets heat to finish projects even with insufficient resources, they patch old systems together instead of buying new ones, and the IT people don’t have the clinical knowledge to run the systems used by clinicians. But it was an audience member who got big applause for describing health department IT procurement practices: “[It’s like] taking a 17-year-old and letting them buy any car they want, with any sized engine. We get clinicians to dream up what they want, then they go and buy it without even thinking about whether it will or won’t work. We have people who don’t know what should and shouldn’t be used, who have the power to make the decisions on buying".”

Odd lawsuit: a surfer hospitalized in Hawaii after a shark bite claims the hospital posted his picture of his leg wound on the Internet. He’s filed a suit alleging HIPAA violations and several more potentially lucrative charges.

More iSoft struggles: the company’s major shareholder says it will decide in April 2011 whether to unload its shares.

I haven’t quite decided whether to do a Monday Morning Update. If I don’t, or if you won’t be around to read it even if I do, have a wonderful end-of-summer holiday (just my US readers, I keep having to remind myself since that’s not all of them). I will be laboring on Labor Day in any case since I am extremely behind, so as Inga suggests below, you can always send us a Facebook or e-mail message if you are feeling lonely, unappreciated, or unfulfilled. 

E-mail me.

HERtalk by Inga

From KP Duty: “Re: Sutter’s iTriage app. Looks like a great tool for consumers, except for one thing (disclosure: I’m with Kaiser Permanente). When I clicked on the Find Emergency Department link to see the EDs closest to my house, is it a coincidence that the largest Kaiser Medical Center in Northern California is absent? I would have to drive by this large and well-established facility with its gigantic emergency department to get to the one listed. To be fair, I put in the address of one of the other Kaiser hospitals and it came up in the right order.” Is it a conspiracy or a bug? I’ll go with bug since I did a spot check on a couple addresses and KP sites definitely popped up prominently.

In what may be the first of similar announcements, ChartLogic reports it has applied for EMR certification with Drummond Group. I reached out to ChartLogic and asked them why Drummond was selected over CCHIT. Here’s the reply from Eric Sorenson, ChartLogic’s VP of marketing:

Our choice for Drummond over CCHIT came down to timing. We believe we are ready to be certified today. CCHIT has indicated that they will launch their program on September 20, and begin receiving applications then. Additionally, they’ve previously indicated that they will give certification priority to their CCHIT 2011 and their “Preliminary ARRA” certified products. We believe this would push our testing date and certification to a date much later than desired. Conversely, Drummond has indicated that they are taking applications immediately, and can begin testing within a few weeks. They have no backlog. We believe this will give us the best opportunity to be certified immediately. CCHIT has a 5 year head start on marketing their products and services, so we weighed the value of a certification with CCHIT vs. Drummond and felt we could overcome any of possible difference in marketing value by being one of the first companies certified, if not THE FIRST. Additionally, Drummond has been certifying other software for a longer time than CCHIT, so we agree with ONC and don’t believe their lack of EHR certification experience is likely to cause us problems in the certification process.

Southwestern Vermont Medical Center says it spent $1 million on its Picis periop system.

Valley View Hospital (CO) goes live on Meditech 6.0.

Actor Michael J. Fox will provide a keynote at HIMSS11, sharing his experiences as a patient and telling healthcare IT experts how IT impacts healthcare. Sadly, he’s got the dreaded Thursday a.m. slot, which means only 200 people will be in the audience. What I want to know is whether Jonathan Bush will try to schedule a meet-and-greet with his look-alike.

Memorial Hermann (TX) selects FairWarning to monitor patient privacy.

Former Streamline Health and Misys VP Scott Boyden takes over as VP of new client sales at TSI Healthcare. Kermit Copley also joins the company as CFO.

Hoag Hospital (CA) opens its new $84 million, 154-bed facility in Irvine. That’s $545,000 a bed if you are the calculating type.

HHS names its final two Beacon Communities: Greater Cincinnati HealthBridge and Southeastern Michigan Health Association. HealthBridge will focus on pediatric asthma and adult diabetic care, while Southeastern Michigan will concentrate on diabetes care and prevention.

UnitedHealth Group is loaning $10 million and donating another $1 million to help rural hospitals improve their HIT and add EHRs. Between this program and the recent Ingenix acquisitions, it sounds like UnitedHealth is trying to unload some cash.

This week on HIStalk Practice: Dr. Gregg Alexander shares the EHR-laced lyrics of some of his soon-to-be-hit tunes; Jonathan Bush tames an octopus; and an Iowa REC shares the cost of their consulting services (between $300 and $2,000 for two years’ worth.)

Stanford Hospital and Clinics commits to a seven-year agreement with Accenture to take over some  of Stanford’s IT functions. Accenture will manage applications and infrastructure and provide data centers, network, help desk, and device support. We said this was happening a couple of weeks ago, courtesy of a reader rumor from Scatman Crothers.

Memorial Hospital at Gulfport (MS) lays off 47 workers, including 10 nurses. The staff reductions are part of cost-cutting measures to offset an $11 million budget shortfall.

The Massachusetts attorney general recommends that the board of Beth Israel Deaconess Medical Center do “some soul-searching” about CEO Paul Levy’s ability to lead the hospital.This follows her office’s conclusion that his long-time personal relationship with a female employee “clearly endangered the reputation of the institution and its management.” Board chair Stephen Kay responded by saying, “We are having a great year. We have more patients than we’ve ever had before. He’s made some wonderful alliances with some quality places. He has great credibility. He’s a national leader.” I’ll bite my tongue as it relates to this toxic topic.

Sponsor News

• Enterprise Software Deployment (ESD) ranks #561 on Inc.’s list of the 5,000 fastest-growing companies. ESD, by the way, just hired former maxIT director David Tucker as its national VP of sales.
• MetroSouth Medical Center (IL) goes live with iSirona’s medical device integration solution, transmitting data from over 100 GE Unity Network devices.

If you have a three-day weekend, I hope you are not in Earl’s way and are able to enjoy the fruits of your labor.  And if you are laboring, remember you can always sneak into Facebook and drop us a note.

E-mail Inga.

HITlaw 9/1/10

Software Contracting with Meaningful Use in Mind

The final rule has been published, the incentive structure is in place, and hospitals and physician groups are investing in EHR technology. Here are some straightforward thoughts on contracting for the successful implementation of your chosen EHR.

Care must be taken by the provider customers. Some will be investing capital based solely on the prospects for reimbursement. Protection of their interests is important. This is by no means a complete list.

Certification

The best situation would be for the vendor to warrant that its EHR technology has been certified by the appropriate authority and is installed and live at more than XX (vendor to fill in the number) sites. The fallback position today would be a warranty that the product will be certified in the appropriate timeframe for full reimbursement eligibility.

Further, they must warrant that certification will be maintained throughout the reimbursement periods (note that the timelines for provider reimbursement differ for Medicare and Medicaid participants). It is technically possible for a provider to lose a year or more of reimbursement if the vendor’s EHR product was initially certified, but then misses certification during the reimbursement period. The year of ineligibility still “counts” for the provider, but they will not receive associated funding.

Be wary of “best efforts” clauses. Some vendors will take care and be uncomfortable warranting that a product will be certified, and for that they should be applauded. Others will take the “we have no choice” approach and provide the warranty. Their gamble is weighing a potential breach of warranty against lost business today when the customer selects an EHR vendor that provides the warranty. The customer has little practical choice. The warranty is essential.

Delivery and Live Status

The delivery date for certified EHR product, together with the implementation timeframe for the product, must result in the EHR in use in live environment so as to enable customer to achieve Meaningful Use. Keep in mind, though, that for long projects with work to be done on both sides, a vendor should not be expected to warrant that something will be live when considerable work must be done by the customer. That work which is completely out of the vendor’s control.

This one factor is greatly reduced as a consideration when dealing with an EHR provided in the SaaS model since time from delivery to live is in some cases negligible.

What you should look for is guaranteed timelines that, if all is accomplished on time by both vendor and customer, will allow for live use by a certain date. This is very reasonable.

Payment Terms

Assuming a certified product is delivered on time, payment should flow accordingly over the implementation timeline. That is fair.

However, some implementations will be quick and some will not. Delaying payments until reimbursement occurs would be outstanding for the small providers, if you can find a vendor that will take those terms.

Undoubtedly the primary concern for some providers is laying out capital on a project and counting on reimbursement when the possibility exists that reimbursement may not occur. If the circumstances are solely the fault of the vendor (failing to maintain certification, for example) then the customer should be protected and monies should be refunded. The requirement to make payments on a product that ultimately does not qualify the provider for reimbursement is patently unfair to the provider customer.

Some accommodation must be made for the hopefully never-to-occur failure of the project. Keep in mind that some of these contracts will be executed with the full intent and purpose of obtaining reimbursement, otherwise the investment would not be made at this time. That one major factor cannot be ignored.

Finally, Meaningful Use

The items above are tailored toward protection of the customer provider, while hopefully acknowledging the fairness factor to the vendor. Meaningful Use is another situation entirely.

In my opinion vendors cannot guarantee or warrant that any customer will achieve Meaningful Use. Vendors only provide the tools needed for that process. The customers are responsible for the work on their side, using the certified EHR tool acquired from the vendor in their operations necessary to achieve Meaningful Use.

The best I could do if writing the warranty for the vendor would be to warrant that the certified product, delivered in the appropriate timeframe, will enable the provider customer, through its efforts and implementation, to achieve Meaningful Use, but that the vendor cannot ultimately warrant that the customer shall achieve that goal. Achieving that goal is the responsibility of the customer providers that will receive the reimbursement if all goes well.

William O’Toole is the founder of O’Toole Law Group of Duxbury, MA.

HIStalk Interviews Nancy Ham and Nancy Brown, MedVentive

Nancy Ham is president and CEO of MedVentive of Waltham, MA.

Nancy Brown, formerly senior vice president of business development and government affairs for athenahealth until July 1 of this year, has been named chief growth officer of MedVentive, where she will head up the company’s sales, marketing, and business development efforts.

Tell me what MedVentive does.

Nancy Ham: MedVentive provides a physician performance management solution for whoever is clinically at risk. Traditionally in our industry, health plans have been at risk, but there’s a huge trend towards providers taking risk and becoming more directly responsible and accountable for both the quality and cost of care.

One thing that we think is interesting about our company is that we support providers and health plans, and in fact are trying to bring them together into a more collaborative environment around managing populations and managing the cost on top of those populations.

Our passion around this springs from our history. In the mid-90s, here in Boston, we started as a mega at-risk provider organization affiliated with CareGroup, which is an integrated health system with eight hospitals and 3,500 physicians. At the time, it was the leading marketplace around providers assuming risk. We were bearing full global capitated risk for about half a million patients, managing about a billion dollars.

Everything that we have today, that we believe today, was really forged in that real-world environment managing our own patients, managing our own data, engaging our own physicians, and trying to learn how to do that successfully in a provider-oriented environment. The challenge was that model was really prevalent only here in Massachusetts and in California.

What’s so exciting about today for us is that we see the whole market opening up and moving away from payer-side risk, fee-for-service risk — which hasn’t served our industry well — and into these new risk models. We’re here with 15 years of experience and a very mature product to bring to that problem.

It seems like that whole assumption of risk idea has come and gone for practices. Do you think this time they’re ready, both organizationally and technologically?

Nancy Brown: No, not generally. There have been a number of organizations who have grown up in this model. The one that Nancy Ham has just described. I grew up professionally at a staff model HMO called Harvard Community Health Plan, which is very similar to Kaiser, where we were totally at risk for a population of patients and everything about our work, our DNA, was all around thinking about populations — how to keep them well and how to deal with their illnesses in the most efficient and effective way.

The vast majority of organizations are not incented that way, are not aligned that way, and don’t have that DNA naturally. This is a major shift, meaning a shift in the industry, where more and more risk is being pushed back down to providers.

I would say the answer to your question is no, they are not generally prepared for this. Just imagine doing work the way you do it every single day being more and more oriented towards seeing the patient who’s sitting in front of you, getting paid for each encounter, and then going to a model that is really completely different. That is exactly why tools and services need to be brought out to these provider organizations to ensure that they won’t hurt themselves in the process of converting over.

Nancy Brown, let’s talk about the announcement that you are joining MedVentive. What discussion did you have with Nancy Ham about her long-term plans for the company and your contribution to them?

Nancy Brown: It’s been a really exciting couple of months, to say the least. I’ll answer that question directly, but let me start by saying that what really motivated me to go back out into the market and to leave athena was this trend towards what has really been established by all the work being done through Obamacare or the Healthcare Reform Act, which is to really think about how healthcare is delivered and to really think about how to change incentives in order to get people to think about cost and quality.

Having grown up, as I said, in a staff model HMO, it was a little bit counterintuitive to me that the management of patients was being carved out and handed to payers and third-party organizations when in fact, there’s no one better than the physicians who are in front of the patients, who really know what care should be delivered, to be the ones that think about the approach to patient care and to think about quality and cost.

I am absolutely thrilled that the country is moving away from fee-for-service and moving back towards accountable care or sharing risk and putting risk and quality back into physician hands.

I was approached by a number of people who knew my background who wanted me to either join large companies who are thinking about establishing toolsets to serve this market, or venture capitalists who were thinking about starting brand new companies that would serve this market. Honestly, the entire time I was going through that process, I thought, well, there is actually an absolutely fantastic company that has been around for over a decade that not only has come up with tools, but has lived and walked in the shoes of at-risk providers, and who has been through many, many cycles of the product. We all know, those of us in healthcare IT, that products all need to go through at least three or four life cycles before you get it right.

The conversation I had with Nancy and with Dr. Jonathan Niloff, the founder, was perfectly aligned with what I thought the market needed. I thought, here’s a company that has existed, that has had terrific tools. The market has not been huge, quite honestly. They’ve taken care of probably a lot of West Coast and East Coast clients, and now they’re perfectly positioned to fully take advantage and really educate clients as to what the needs are to take on risk.

What lessons would you say you learned from your time at athena that will be useful to you at MedVentive?

Nancy Brown: I was at athena for six years and it was a wonderful experience. I consider them to be the closest of friends. I learned about a service model. I think a lot of what we talked about in my conversations with Nancy Ham and others is that you cannot just hand a toolset to an organization — in this case, an analytics toolset — and expect them to do everything that they need to do perfectly.

What I hope to bring to MedVentive that I’ve learned — and actually, it’s really part of my DNA now, based on my time at athena — is two things. One is that we’re going to have to get even more involved with our clients to really help them through these significant transitions.

A specific example of what I mean is when you give them dashboards and toolsets, which MedVentive does now, and you point them in the direction of where they are in terms of a red zone around a particular business problem, I think we hope in the future to be able to actually be in there with them, almost as a virtual chief medical officer, to be able to get them through the ongoing change or the overall change; and then the day-to-day work that they need to get done.

Nancy Ham: Nancy’s experience — her whole career — is of incredible relevance and resonance, as you’ve been hearing. We’re very excited about the service model coming into greater use among our customers because we are very focused about real results in the real world.

We don’t build software for theoretical purposes. We’re not an IT company who’s just building something because we want to sell it for revenue. We’re a healthcare company that forged everything we do in the crucible of the real world. That meant moving the needle on cost and quality. Whether it’s pretty dashboards or beautiful analytics was really irrelevant unless we accomplished the business goals.

We have a very strong ROI story for our customers today. Along the way, for example, we were profiled by the US Department of Health and Human Services as one of the five best national practices in pharmacy cost control. Last year, we were honored to win the Microsoft Healthcare User Group Award with a lovely customer of ours, Northeast PHO, for driving breakthrough levels of quality while reducing costs.

So to Nancy’s point, we have customers today who are independently very capable-mature in their ability to take risk and to execute on risk. But as that model broadens across the country, marrying that proven experience in that ability to drive an ROI with more supportive service capabilities, I think, is going to be key.

Nancy Brown mentioned that venture capital wants to get into this and other companies want to start something up. Who would you say is the competition now and what are the barriers to entry going to be for someone who wants to be in the position you’re in?

Nancy Ham: The barrier to entry is the relevant domain expertise. Not from reading about it, not from going to conferences about it, but from living it. There is no substitute for the fact that for ten years, we were the customer. We were in the real world bearing risk for almost half a million patients and driving positive changes against our budget and our risk and our quality and our population.

There is just no substitute for that. So in one sense, unless you’ve come from that environment, it’s really hard to say you have the same relevant experience and DNA that we bring to the opportunity.

That’s what differentiates us with our customers. They come and they see and they listen to it and say, “You guys really get it. You understand what we need to do, and we take comfort in the fact, frankly, that you’ve traveled this path ahead of us and you can share with us the lessons learned — good and bad. And you can share with us how you engaged your physicians in a way that they found appropriate and relevant and caused them to change behavior in a positive direction.”

Nancy Brown: I would just add to that what I observed is this practical-tactical way of thinking about how to deliver information to physicians. But this is all about helping physicians understand what’s going on with their population and guiding them toward the right decision. That’s not easy to do. A lot of the information that comes out of these analytic tools, generally, can create a lot of noise that they tune out.

I’ve been very impressed in the exposure I’ve had from MedVentive to see what Jonathan Niloff and the team here have done to really make sure that they’re getting the most important information to the physicians and making sure that the feedback loop is staying intact. And, that it’s a practical tool that can be used versus just one of these things that the administration has bought, but that in no way, shape, or form will ever be useful at the point of service.

When you talk about the business model as a service, is there any contemplation of selling service as a percentage as athena does?

Nancy Ham: I think it’s a great question. Historically, we have been focused on wrapping services inside of our software subscription fee. Lately, we’ve been really dialing up our capabilities around clinical consulting. We just hired a new senior director to lead our practice. In there, we are starting to go at risk for the actual results that we’re able to drive.

How that evolves towards a different model or towards the athena model, I think, is something that Nancy Brown and I will be working on and thinking about over the upcoming months and quarters.

Everybody wants to talk about Accountable Care Organizations. What technologies do organizations that want to go in that direction need?

Nancy Ham: To start on the journey of taking risk, organizations need a lot of things. They need a culture of quality. They need a transformational ability. They need to think through physician alignment and reimbursement. There’s a lot they need to think through from a services and strategy perspective.

When it comes to technology, there’s really two ways that an organization can begin to assume risk. One is if they’re already financially integrated, they can jump into becoming an Accountable Care Organization. There you need a suite of tools to manage for cost and utilization and quality from a whole new perspective because it’s not about fee-for-service now, it’s around episodes of care. This was a heart attack, not a series of disconnected claims. This is a population of diabetics and I need to be able to look at them as a population — cost utilization, quality, and engagement — because I’m going to be reimbursed on it as a bundle.

If you’re going into true global capitation, you need to be able to look across the entire spectrum of care no matter where delivered, no matter whether it’s in your network or out of your network, ambulatory or inpatient, and budget it and predict it and price it and manage it very differently than what you’re doing today.

If you’re not already financially integrated, then you actually have a step before that, which is to become clinically integrated, which gives you a safe harbor, if you will, from the Federal Trade Commission. There, you really need an intelligent, patient-centered disease registry that can be distributed across the community to promulgate your quality program and to engage physicians in an interconnected network focused on driving guideline-compliant care.

We’re fortunate at MedVentive that we offer them a spectrum of solutions no matter where you are on your journey to risk. We have a technology and a capability that matches up to where you are and what you need to do next to move forward.

Who helps organizations are assess their capabilities to enter into these agreements? Are they going to become standalone at some point, or are they always going to need some sort of support — technology or otherwise — to have ongoing success in being part of an ACO?

Nancy Brown: What I’ve observed in my journey over the last few months in looking at a lot of organizations focused on this market — there’s an equal number of consulting firms that are spitting up new practices to focus on all of the human capital issues. So if you parse apart everything Nancy Ham just said, underlying it is that technology is important. MedVentive has done fabulous things, but I’m sure if Jonathan Niloff was sitting here, he would tell you that it was the people side of it. Once you get the information in front of you, it’s really getting the teams built and the mindset in place to do the right thing.

So to answer your question, I think hand-in-hand with the technology will be folks who come in — and I already see it happening — that will work a lot on everything from organizational design to organizational behavior and the creation of probably all-new incentive plans beyond the medical incentives. I think it will be ongoing, absolutely.

I also think, as I talked a lot about during my days at athena, that there will be an ongoing evolution of these reimbursement plans over time. This is yet another set of ideas that people have, from Medical Homes to P4P to accountable care. Somewhere in all of this there will be a model that begins to effect really positive change. What I mean by that is it will incent providers to actually go in and make changes to workflows and to their approach, which is what Jonathan Niloff probably observed at CareGroup and I observed at Harvard Community Health Plan.

That it is an ongoing journey of give me the data, let me observe. Then, what’s going wrong? Let me improve my processes. Give me the data, let me observe what’s wrong … it’s an ongoing effort that never ends.

The HITECH Act has stolen everybody’s attention, so everybody’s focusing on EMRs or HIEs or whatever it is. How do you expect the vendor landscape and organizational strategic priorities to change as we get past that first total focus on just EMRs?

Nancy Brown: You couldn’t have asked me a better question. I won’t get on my soapbox for too long, but I often said in Washington and other places that I felt like the HITECH Act was a little bit of a distraction. While people were busy looking at it and going out after their $44,000 and had their backs turned, they’re going to get hit by a train and the train was going to be changes in reimbursement, as well as other major changes to how people are dealing with the administrative side, such as ICD-10.

It’s very interesting because it’s very hard right now to quantify how much business is shifting from fee-for-service to these quality contracts. What I say to anyone who will listen is don’t worry so much about the percentages because right now it’s definitely a very, very high percentage still in fee-for-service.

But let’s look at the reality. You can’t bring all of these uninsured into that coverage to have insurance coverage, and then also — simultaneous to bringing this new population of patients in that will now have insurance coverage — mandate that the insurance companies cannot increase premiums and then not expect that the costs are going to go somewhere. Those are going to be really put onto the backs of the providers. The insurance companies really don’t have any other way to get the money other than to assert change reimbursement.

The accountable care concept is owned by Medicare, but I think we’re already seeing a rapid acceleration of a risk shifting by commercial payers. As that risk shifts, people are going to have to be prepared. Compared to taking on an EMR, that’s child’s play in my opinion. This is very, very serious. Meaning you have to have a lot of information, a lot of guidance, and a lot of change in behaviors to be successful.

The other thing I’ll add about the EMR side, which was a big focus at athena, is that the EMRs need to be prepared to take the information that comes out of systems like MedVentive. These are things, to be specific, like gaps in care, for instance. When they tell you that Nancy Brown has not had a particular test or is at risk for a particular disease state, that information needs to be showing up at the point of service, ideally.

Many of the systems, most I would say, the majority of them do not have the capability to take that in and haven’t even reformed themselves in a way to think about population.

I think it’s going to be a very exciting time for those EMR vendors who really step up and think about themselves as being in a continuum that starts with taking risks, managing populations, and then intervening at the point of service.

You’re right, it’s an EMR-centric world out there, and those vendors typically don’t like to acknowledge that there may be contributions from other systems or other vendors. How do you intend to work around that, from the MedVentive standpoint, to convince them that it’s in their own best interest to collaborate?

Nancy Ham: We see, in our current client base, a very interesting spectrum of organizations. We have clients today who are 95% deployed on single EMR, so they’ve already climbed that mountain. But what they have found, to Nancy Brown’s point, is that the EMR does not provide them this horizontal capability to look across their population, to manage populations in an episodic or disease-centric way. It does not allow them to look at their cost in a capitated fashion; to look in-network and out-of-network to control all the levers they need to control to be financially successful.

We have in-the-middle organizations, those who are building broad-based networks in which their physicians are on many EMRs. So there, you have a bit of a Tower of Babel approach where there’s no source of truth, no central view, no view that goes across the continuum of care and across the community.

And then we have customers who have said that $44,000, frankly, is not compelling. We’re looking for tools that we can acquire and implement rapidly to allow us to step into risk because what we hear is forward-thinking organizations know fee-for-service is dying. So whether it dies tomorrow or dies two years from now or four years from now doesn’t matter.

They know now they need to get control of their data. They need to start measuring themselves. They need to get ready so that whatever form risk takes in their market — it could be heavy pay-for-performance, it could be episodic or population, it could be true global cap — that they can’t be ready overnight to spring into that environment.

They have an urgency about that to get started now, and that’s very exciting for us as a company because as we said, we started — Nancy and her path, and MedVentive in ours — in provider risk organizations more than a decade ago. It’s exciting to us to see that model, which we know works in improving quality and reducing costs, spread across the country. We couldn’t be more excited about the possibilities in front of us to help organizations learn how to do that and to be successful.

What are the long-term plans for the company?

Nancy Ham: With Nancy coming on board as chief growth officer, our plan is clearly to execute on our growth strategy and to leverage the fact that we think we have a very unusual capability born on the provider side, but ambidextrous, if you will, because we can serve whoever’s at risk — the self-insured employer, the health plan, the provider — and bring them together on a collaboration platform, a much-overused term that rarely exists in the real world. We think it’s the right model, which is we need to be sharing and looking at the same data with a focus on changing what is a societal ill at this point.

Our collective failure to create a universal model that reduces the healthcare costs in this country is impinging our growth as a society. Really, the ability to bring that all together, we think, is unbounded in terms of size. Our focus is just on getting the word out about what we’re able to do and to do it for more people. And with Nancy Brown on board, I’m sure that that’s what we’re going to be able to do.

News 9/1/10

From Redzenskyca: “Re: Allscripts/Eclipsys merger. New company name: Allscripts. New color: green.” The announcement is coming tomorrow, reliable sources tell us (nobody official, but people who should know). Green is my favorite color, though. Here I was criticizing the sea of orange at ACE and now it’s going to be a collector’s item or something (or sold on eBay just in time for hunting season). UPDATE: the Allscripts site has been updated with the logo above and a welcome to the merged companies.

UPDATE 2: The company’s leadership team is listed as Glen Tullman as CEO (Allscripts), Lee Shapiro as president (Allscripts), Bill Davis as CFO (Allscripts), Eileen McPartland as COO (Allscripts), John Gomez as president of product strategy and development (Eclipsys), Jeff Surges as president of sales (Allscripts), Diane Adams as EVP of culture and talent (Allscripts), Laurie McGraw as chief client officer (Allscripts), Dan Michelson as EVP and chief marketing officer (Allscripts), Kent Alexander as EVP and general counsel (Allscripts), and Joe Cary as chief of staff (Allscripts).

From Curious in Texas: “Re: MD Anderson in Houston. I’ve heard they will be installing Soarian Financials. This surprises me because I thought the UT hospitals were all converting to Epic. Can you verify this rumor?” Verified. MD Anderson hasn’t signed the contract yet, but they are planning to migrate from Invision to Soarian patient accounting, ADT, and scheduling. Their primary motivation is its service-oriented architecture.

From Boomer Later: “Re: Maine Medical Center. I heard its board will meet Wednesday on a proposal to migrate from Eclipsys to Epic on a 20-month timetable. Approval is expected. It’s a blow for Eclipsys since MMC is one of their most progressive and active customers and was customer #6 on the old TDS product.” Verified. They were already using Epic on the MaineHealth ambulatory side, so this will be the next step toward their “One Patient, One Record” philosophy. Epic Enterprise will be implemented in their six member facilities in addition to Maine Med.

From Lizard King: “Re: HITECH. AAOS average member salary: $$$$. GP in private practice: $. Meaningful use is the gateway to federal $$$ to pay for HIT that providers might not otherwise be able to justify as an ordinary practice investment. Generalizing, specialists have more profitable operations and seem to have much better ROIs on HIT than GPs, so it is no surprise that MU is headed this direction. Which seems about right to this taxpayer and consultant.”

If you’ve been following the current poll and comments on Ed Marx’s Blessing of the Hands post, you may wonder why the comments suddenly turned ugly. An atheist blogger linked to it and his followers dropped by to vote and opine. Since the point was to find out what industry people think, here’s the stat that counts: the poll was running 50-50 when it was just real readers voting.

Inga interviewed Chet Speed of AMGA about Accountable Care Organizations on HIStalk Practice. It’s a hot topic, so we’ll have more soon from the hospital point of view. Hats off to her for drawing readers to HIStalk Practice, with visits up 50% or so compared to a year ago.

A Member of Parliament in England wants to know if BT was paid hundreds of millions of pounds to persuade it to stick around with NPfIT instead of bailing out like other companies did.

In the News of the Obvious, a small study finds that Facebook is a big draw for narcissists prone to encouraging shallow relationships by carefully controlling their image, bragging on themselves in their Info section, and in the case of females, posting revealing and/or doctored photos (not that there’s anything wrong with that). The conclusion is somewhat profound: “As we abandon the fake avatars and cryptic usernames of years past and begin associating our online identities with our real-world lives, our online activities begin to have more relevance to our true personality traits.”

Mike Cannavo, the one and only PACSman, cranks up a blog: The PACSman Pontificates. He was darned funny, irreverent, abrasive, and always informative when he wrote for a rag-sponsored blog, but says he got tired of being forced to change his posts every time an advertiser complained. I can only imagine what he’ll say unmuzzled. Also in the PACS and radiology world, Mike’s occasional partner in crime Doctor Dalai celebrates 200,000 blog visits. I like those guys.

Newly named EHR certifying body Drummond Group releases testing guidelines and cost (warning: PDF): $19,500 for inpatient or ambulatory remote testing, $23,500 plus travel for on-site testing.

In Australia, iSoft CEO Gary Cohen will resign after the company posts a $383 million fiscal year loss and a 20% drop in revenue. Shares are down 83% year to date to around 12 cents. I interviewed Gary in April.

WellStar Health (GA) will pay $2.7 million to settle Medicaid fraud claims, admitting no wrongdoing and blaming its claims processing software.

Ambulatory EMR vendor iSALUS names (warning: PDF) Richard Noe as president and CEO. I don’t see any mention of previous healthcare-related employment. He says he’ll double headcount there.

Retired Army General Hugh Shelton, the former chair of the Joint Chiefs of Staff and a Special Forces veteran of the Vietnam War, is named chairman of the board of Red Hat.

Detroit Medical Center says its EMR saved it $5 million last year, $4.5 million of it coming from reduced length of stay related to pressure ulcers. That’s not a great ROI for a $50 million system, but it’s a good start.

I don’t look at LinkedIn often except to verify where someone works since it’s kind of junky looking and always trying to upsell additional features. Still, I was happy to hear from Dann that the HIStalk Fan Club he started there has 1,088 members, some of them spamming my hard-won audience with their own pitches, I notice, which seems kind of tacky but common for LinkedIn. Anyway, since I seldom mention LinkedIn, feel free to add Inga or me to your network (just search for HIStalk). I even added a spiffy new photo since they removed my old one. We’re more Facebookers these days (there’s that narcissism thing), so ditto: just search for HIStalk and you’ll see individual profiles for Inga and me plus our HIStalk page. I’m feeling loserly since I have only 89 friends (although I appreciate every one) vs. Inga’s 112.

The CEO of Naples Community Hospital (FL) writes an editorial bragging on the hospital’s use of its Cerner EMR. Actually he mostly seems to be bragging on the possibility of getting taxpayer money for using it, saying the hospital will be an “early applicant” for money and hopes to get nearly $12 million continuing to do what it was already doing. He says Cerner told him Naples is the second most MU-ready Cerner site.

Markle Foundation assembles (warning: PDF) 45 organizations who advocate that HIT vendors offer the “simple, but rarely offered” ability for people to download their own health records, the so-called Blue Button.

The SVP/CFO of Danbury Health Systems (CT) is charged with defrauding his employer of more than $140,000 by directing health systems payments to a software company he ran out of his house.

IBM and Dell chase the Chinese equivalent of HITECH money. Interesting: one hospital has more than 10,000 patient visits per day.

Bizarre: an auto accident patient says he awoke in Prince George’s Hospital (MD) and asked for food, only to be told by a nurse that he was NPO for cancer surgery, which was news to him. As he was being prepped, he noticed that another patient’s wristband had been placed on him. His wife helped him pack up with intentions of getting out fast AMA, but he claims two hospital security guards beat him and advised him that “Hell, no, he don’t come up in here and be telling us what the f*** to do.” He says a hospital manager acknowledged the incorrect wristband and invited him to have “any type of drug he wanted, just to name the painkiller.” He was diagnosed with broken ribs, a sprained shoulder, a ruptured spleen, and a concussion. He’s suing for $12 million.

E-mail me.

HERtalk by Inga

From Roger Sterling: “Re: DocSite. News has it that Covisint is buying DocSite. Covisint wants to add it to the AMA portal project being rolled out in Michigan.” Unverified. I have a message out to the Covisint folks.

HealthInfoNet, the HIE for Maine, partners with Health Language to provide clinical content integration.

EDIMS licenses First DataBank’s National Drug File Plus database to integrate into its emergency department EHR.

Quincy Valley Medical Center (WA) commits $200,000 for computer hardware in advance of selecting a an EMR application. Software finalists include Meditech 6.0 and CPSI.

Sisters of Mercy Health System launches a $60 million data center in Washington, Mo. The 42,500 square-foot center will host EHR and other applications for all of Mercy’s sites. The regional business journal also points out that the medical information is secure, as it relates to “HIPPA.”

The 16-hospital system IASIS Healthcare selects QuadraMed’s coding, compliance, and reporting tools in preparation for the transition to ICD-10 code sets.

St. Mary’s Medical Center (WV) contracts with Wolters Kluwer Health for its ProVation Order Sets.

Matt Grill, Sunquest’s former manager of technical training and publications, takes over as VP of Global Client Support for MRI Software, a developer of real estate management software.

Patient education material from Thomson Reuters and its Micromedex CareNotes system is available in 15 languages, including Arabic, Chinese, Russian, and Turkish.

On HIStalk Practice: an interview with 20-year-old Greg Waldstreicher, founder of DoseSpot. Everyone who was running a viable business at age 20 while going to school full time, please raise your hand.

Sutter Health (CA) activates iTriage, giving consumers the ability to check systems and find out detailed information about doctors, hospitals, clinics, and ERs via a free mobile application.

The average American hospital barely breaks even, but some have operating margins of 25% or more, according to a Forbes survey of the country’s most profitable hospitals. HCA owns 11 of the top 25 hospitals; two of Mayo’s main facilities make the list as well. Flowers Medical Center (AL) topped the list with its 53% operating margin. Fifteen of the 25 hospitals were for-profit.

Baptist Medical Center (MS) lays off 186 workers, including 14 in management. Laid off workers are being offered a chance to apply for the 136 current openings.

Sponsor updates

• Greenway Medical Technologies says four additional HIEs, IPAs, and regional medical centers have selected its PrimeSuite EHR/PM solution.
• Cumberland Consulting Group has been named one of the 2010 Best Small Firms to Work For by Consulting magazine, having made their list every year since it was started.
• For the second year in a row, the Central Penn Business Journal names MEDecision to its 100 Best Places to Work in Pennsylvania.
• Sierra View District Hospital (CA) hires MEDSEEK to develop and deploy its Web site and clinical portal.
• Access has a new Web site at accessefm.com.
• MaxIT Healthcare makes the Inc. 5000 list, as well as being named #56 on the HCI 2010 Top 100. The company has over 430 consultants.

A baby in Italy suffers heart problems and possible brain damage after two doctors involved in his birth get into a fist fight in the operating room over the appropriateness of doing a C-section. The mother had to have her uterus removed. The region has a 60% C-section rate.

E-mail Inga.

Readers Write 8/31/10

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Meaningful Use:  Specialists Still Not a Priority
By Evan Steele

The HIT Policy Committee’s creation of a new Quality Measures Workgroup last week is the most recent in a string of actions confirming that meaningful use has not been defined meaningfully for specialists — and that it is not likely to be. Despite the fact that this new workgroup is charged with prioritizing Stage 2 quality measures and analyzing gaps in Stage 1 criteria, the 18 physicians selected for the 24-member group are primary care providers* — a fact that surely raises concerns among specialists.

The appointment of this workgroup comes on the heels of a growing response to the Stage 1 definition of Meaningful Use from specialists and their professional organizations, commenting on the lack of fit with the way specialists routinely practice. Every one of the six core clinical quality measures are primary care-related, and many specialists will be hard-pressed to identify three of the 38 additional clinical quality measures that are relevant to their practices.

At last month’s HIT Policy Committee meeting, committee member Gayle Harrell commented that much of the input gathered from the specialist panels convened last October seems to have been ignored, She contended that in the final rule, CMS made it more — rather than less — difficult for many specialists to comply with Meaningful Use.

This position was echoed by Thomas C. Barber MD, EMR project team leader of the American Academy of Orthopaedic Surgeons (AAOS) in discussing the Academy’s EMR position statement in the most recent issue of AAOS Now:

Orthopaedic surgeons will have great difficulty in meeting the current 25 Meaningful Use standards. Orthopaedics would derive greater benefits from standards promulgated by our medical specialty society rather than a set of generic requirements that mostly do not apply to musculoskeletal patient care.

This is not a new issue. The primary care focus of the legislation and regulations has been intentional from the outset. President Obama appointed an internist, David Blumenthal MD, to spearhead the program. There was only one private-practicing specialist among the committee members that crafted the recommendations to CMS.

It is not surprising that the Meaningful Use criteria do not reflect the practice patterns of specialists. Federal funding to assist physicians with EMR adoption has been directed towards primary care. The $357 million allocated for Regional Extension Centers, for example, was earmarked to “provide outreach and support services to at least 100,000 primary care providers and hospitals.”

The definition of Meaningful Use is not the only obstacle for specialists. The EMR products themselves are not tailored to the needs of specialists. The AAOS EMR Position Statement correctly suggests that in developing certification standards, it is essential that “the different needs and uses of EHR by disparate medical specialties should be recognized. In particular, the differences between surgical specialties and primary care specialties should be acknowledged.“

Unfortunately, because the certification criteria are linked to the Meaningful Use requirements, they are similarly primary care-driven. The EMRs most likely to be certified for Meaningful Use are predominantly those that were created and developed for primary care physicians — those of vendors that, from 2004 until recently, have devoted their development resources to meeting CCHIT’s 467 largely primary care-focused criteria. The AAOS statement continues: “Many systems are geared toward primary care medical practice, which can limit the utility of EHRs for specialty surgical practice.”

Specialists are no different from other physicians in their desire to participate actively in the evolution of the country’s medical care delivery system. But until Meaningful Use is defined in a way that is applicable to the way they deliver that care, they will participate on their own terms — adopting specialist-focused EMR technology that increases their productivity and enables them to provide the highest quality care and service to their patients.

* Includes internists, family practitioners, pediatricians, preventive medicine, an internist/hematologist, and a psychiatrist.

Evan Steele is CEO of SRSsoft of Montvale, NJ.

Safeguarding EMRs Against System Failure or Downtime
By Arthur Young

Using time-saving information technology and automated patient records management ensures clinicians have faster access to the most up-to-date patient information, enabling timely diagnoses and treatment and maintaining a high quality of care. However, if the network goes down, the system fails, or a planned or unplanned system downtime occurs, clinicians are unable to access critical patient information.

Whether they are planned or unplanned, system downtimes can occur for any length of time — from a few minutes to a few days. Downtimes can also be very costly if there is no system for preserving and accessing up-to-date patient information and maintaining uninterrupted patient care. Healthcare organizations have implemented systems for recovering from disasters, but not for protecting data and continuing operations during downtime. Without such a system, downtime can become more than an annoyance — it can be a life-threatening event.

Distinct from disaster recovery — which helps get systems back up when they go down due to a power outage or property damage — business continuance keeps vital business operations running at or near normal capacities in the event of any network or system downtime. That includes the downtime that occurs while disaster recovery mechanisms are being executed.

There are various solutions available that can help healthcare organizations remain functional during downtimes. However, they have drawbacks. Redundant or fault-tolerant systems can keep computers running and available during a system failure or power outage, but if they are the only system being used for business continuance and the network also goes down, clinicians will not be able to access patient data. Printing patient reports periodically allows clinicians to have the current data on hand, however it is a time-consuming and cumbersome task that diminishes data security, not to mention a waste of paper, ink, and other resources.

To maintain access to patient information from the location its needed, healthcare organizations need to select a business continuance approach that will provide the most protection in the most circumstances. Ideally, a business continuance solution should enable healthcare organizations to do the following:

• Identify critical information and automatically distribute it to areas it will be needed in the event the HCIS is unreachable;
• Ensure the information is secured but available on local machines;
• Maintain seamless operation in the background, notifying administrators of any interruptions; and
• Eliminate the storage of data in paper form, saving paper, ink, and printers.

Intelligent report generation and distribution decentralizes data in the event of downtime by sending the latest reports from the HCIS to its system and creating secure databases in multiple locations. The information is indexed in the database so clinicians can search and find the data they need whenever they need it.

With access to critical data during periods of system failure or extended downtime, clinicians can provide uninterrupted care and healthcare organizations mitigate risks to patient safety. Patients can be assured their health records are up-to-date and secure and confident they are receiving the best possible care.

Arthur Young is the president of Interbit Data of Natick, MA.

Ode to the Dumbwaiter and Robo-Butt
By Frustrated Farmacist (Female)

I saw your blurb about the Aethon TUG delivery robots installed at El Camino Hospital. The old ECH had an awesome dumbwaiter delivery system in place.

It is rumored that the Aethon TUG delivery robot solution was something of an afterthought that came six agonizing months after the grand opening of the $470 million hospital. Apparently earlier plans to integrate a delivery system may have been (ahem) overlooked. You can see from ECH documents that the robot contract was drafted in January 2010, several months after the new hospital opened. Early reports said the robots didn’t work for all departments and some ended up using volunteers, auxiliary staff, temporary workers, and other solutions to get medications and lab materials delivered.

$470 million and NOBODY initially planned an integrated medication delivery and lab transport system for a brand new, ultimate-in-high-tech 400-bed hospital! It doesn’t take too much imagination to extrapolate how important timely medication delivery is in the patient care scheme of things and why it’s the top complaint and employee satisfaction issue for nurses.

ECH’s competitor down the road has been using a similar robot system from Pyxis for the PAST 22 YEARS. It’s on its third generation, fondly named Robo-Butt. He travels in elevators and down halls to six floors and 15 departments. He is guided by sensors in the walls and speaks aloud to nurses to alert them when he arrives and when he commandeers the elevator. He steers around obstacles. His compartments are locked and secure, requiring a numbered password to open. He’s powered by six car batteries that are recharged and swapped for backups 2-3 times daily.

He breaks down every now and then. The elevators break down more often, grounding him on the first floor. Pyxis no longer supports these robots, so parts were scrounged from the basements of other hospitals and from a hospital supply house in Hawaii. But Robo-Butt WORKS. Here’s a picture of this bad boy:

The average hospital pharmacy department dispenses at least 40% more meds than were ordered because of late deliveries or items that are misplaced. The overhead and amount of wasted labor and supplies is unacceptable and frustrating for everyone involved, including the patient, nurse, doctor, pharmacy, and departments like lab and surgery that are held up because of medication delays.

With pneumatic tubes, you place meds in padded bullets and shoot them to the receiving department. Fragile ampules and vials can be broken — think about Epogen, a blood booster whose fragile proteins are destroyed by a violent trip in the tube system. It used to cost $6,000/vial and is still in the $600-900 range. Can I tell you how many bullets have exploded inside the pneumatic tube tunnels? Can I tell you what I think about the ER department tubing patient urine and blood samples to the lab inside this system?

We still have bullets that wind up in the basement due to malfunctioning suction or drivers. It’s hilarious when it’s a $45,000 rattlesnake venom antidote. But the bad part is that sometimes meds lie in piled up bullets in the tube receiving bin. Worse, the staff goes to send an “empty” tube to lab or ER and accidentally send a bullet filled with meds. The worst part is there is no “track-ability” or accountability — we can never tell whether someone received a bullet. If they “say” it never arrived, we have to send it again.

Here’s why I think dumbwaiters may be the ultimate smart medication delivery system with the fastest turnaround times, the least amount of waste, and minimal lost meds and lost charges. The pharmacy staff places labeled / bagged medications into little sectioned trays (like your silverware drawer’s insert) and leave them in the little locked elevator. The nurse that needs meds comes to her department’s locked elevator door, calls up the tray, and REMOVES ONLY HER PATIENT’S MEDS. She leaves the other meds in their little slots.

Think about this. You don’t have one nurse removing meds for her entire department and then misplacing them, storing them improperly (oops, that expensive IVIG that cost $20,000 belonged in the refrigerator?) or just putting them in her POCKET and forgetting to put them in the med room altogether. Then the Pharmacy can call the dumbwaiter down later and retrieve unused meds, credit them back, and recycle them. 

You can imagine that the number of missing med phone calls drops in half. Anyone in the pharmacy can check the dumbwaiter and see if missing meds are there before re-making them. Can I tell you how much time I waste every day re-doing the same missing med that simply gets misplaced or misdelivered and there’s no way to track it? It’s cheaper to bag up another blood pressure pill with the patient’s name and send it again sometimes. And then we get to retrieve all the duplicates, sort them, and restock them in the pharmacy bins…

I have nightmares about this.

A reliable well-planned medication delivery system is worth $$$ millions and makes up 80% of the nursing / customer satisfaction basis. I swear this is true! Any healthcare organization that builds a state-of-the-art facility without planning a delivery system is completely ignorant.

Done with my rant. 😉

ONC-Authorized Testing and Certification Bodies Named

The Office of the National Coordinator for Health Information Technology has named two ONC-Authorized Testing and Certification Bodies (ATCBs). They are Certification Commission for Health Information Technology of Chicago, IL and Drummond Group, Inc. of Austin, TX.

Authorized by the National Coordinator, ONC-ATCBs are required to test and certify that certain types of EHR technology (Complete EHRs and EHR Modules) are compliant with the standards, implementation specifications, and certification criteria adopted by the HHS Secretary and meet the definition of “certified EHR technology.”