Curbside Consult with Dr. Jayne 4/16/12

I cover the emergency departments of different hospitals. One of my facilities (part of a large health system where, thankfully, I have no responsibility for any of the IT decisions) is about to upgrade its ED information system.

Working there has driven me to near madness. The medication prescribing system is atrocious. It not only contains “do not use” abbreviations, but also doesn’t allow you to prescribe any medications that are not pre-built in the hospital-centric medication database.

Being spoiled by other vendors that use high-quality third-party medication content, it’s definitely a challenge. There’s no ability to free text notes to the pharmacist and no e-prescribing either. Half the time I end up taking the computer-printed prescription form and handwriting comments on it to avoid pharmacy callbacks (most of the patients I see have no insurance and pharmacies are constantly calling to substitute things due to cost — I like to give the pharmacists flexibility to substitute when needed.)

Because I’m a part-timer, I rarely work with the same nursing staff repeatedly. While challenging, it’s rewarding because I’m guaranteed to learn something new on every shift.

Last night, Nurse Tina introduced me to what I can only categorize as forbidden fruit. The drawer under the counter where the physician’s PC sits contains more than just pencils and paper clips — there are (gasp) pads of prescription blanks! Yes, Virginia, there IS a Santa Claus and he just brought me something good. Better than dark chocolate.

I gleefully spent the rest of the shift hand writing prescriptions whenever I ran into an issue with the software, something I hadn’t done in years. Because of the limitations of the prescribing system, not only was hand writing the prescriptions faster, it was better for the patients. I could write exactly what I wanted rather than trying to hijack a poorly built “default” medication selection. I had to find a suitable notes field in the system so that my handwritten scripts were documented and I did sacrifice allergy and interaction checking, so it wasn’t a perfect solution.

The system is due for a much-needed upgrade, which has been postponed twice previously. I hope this time it actually occurs. I will attend training in a couple of weeks and I hope there are good things in store.

I’m a little concerned, however, because I learned from Tina that the non-physician staff haven’t received any notification of the upgrade, nor have they been scheduled for training. That should make things interesting.

Because I’m just a hired gun providing clinical coverage, no one gives a hoot about my IT opinion. That’s frustrating,  but refreshing. It allows me to see the systems as the rest of the physicians do. I’m just  someone just trying to do her job and care for patients. This gives me greater perspective on how my own systems should operate and whether our communication plans, training, and upgrade preparations are adequate.

I’ll know more in a couple of weeks about whether we’ll really have improvements. Hopefully provider-specific medication favorites are coming, or maybe even an actual comprehensive medication database. I’m crossing my fingers and will keep you posted.

E-mail Dr. Jayne.

Readers Write 4/16/12

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

Making More Meaningful Use of Data Through Device Integration
By Stuart Long

Far and away, the main theme of Meaningful Use is an increased focus on making health information exchange not simply a capability, but a reality. As providers seek reimbursement for technology implementations designed to do just this, they need to take a step back to understand what is necessary to go beyond incremental improvements in order to see the larger picture – which means going further than Stage 2 to Stage 3 and beyond.

There has been recent discussion around the importance of medical device integration (MDI) as a necessary component on the path toward achieving health IT (HIT) initiatives such as Meaningful Use, HIE, and ACOs, among others. Healthcare providers need to understand the impact medical device integration can have across the entire hospital enterprise – “the big picture.”

While not addressed in Stage 2 (which takes effect in 2014), medical device interoperability is a stated 2015 objective. Stage 3 criteria are obviously yet to be detailed and finalized, but one of the criteria is for medical devices to be interoperable with EMRs and clinical information systems.

The theory of medical devices being interoperable is a good one. However, the chance of this actually being achieved across all device manufacturers is not realistic under the stated timeframe. Only a small fraction of devices today can send interoperable HL7 data. This means that many of the devices already installed within the hospital are not interoperable. Therefore, hospitals may be required to purchase new devices to meet the objective. With already strained budgets and resources, many hospitals would not be able to do so.

The most realistic means to meet the interoperability objective now and in the future is by implementing a vendor-neutral connectivity solution that would convert all data from all connected devices to HL7 so multiple people receiving information system(s) can accept it. Such a solution would enable interoperability, allow a hospital to use the equipment they have in place today, and minimize the points of integration for easier management, flexibility, and scalability – key ingredients to deriving real value out of required technologies like EMRs, CPOE and others.

Beyond Meaningful Use, the question is: how can hospitals fully leverage MDI to deliver the even greater benefit of transforming patient safety and outcomes? Imagine the ability to take collected data and compare, contrast, and analyze it from multiple sources, and then deliver it back to caregivers in a meaningful way. Imagine the ability to effectively manage smart pump connectivity and bi-directional communication. These are all possible through a middleware, vendor-neutral device integration solution.

However, let’s be realistic about the timeframe to make such possibilities a reality. For true end-to-end and bi-directional communication to become a reality, there are multiple factors that will have to come in to play. Multiple vendors with varying degrees of responsibility and intellectual property will need to communicate and operate with one another in order to make the data collected meaningful and to ensure that such data is presented back to the caregiver or other healthcare professionals in a meaningful way.

While this will take time, there really is only one way to facilitate this exchange of data – through a middleware provider who has established relationships with all the vendors in the mix: device manufacturers, information system providers, system integrators, and predictive outcome vendors. Having middleware that is vendor neutral gives hospitals the advantage of being able to bridge the gap between these worlds.

The point is, device integration is evolving. It is going beyond the simple connection of devices to systems. The next evolution will be using the data collected so it can be compared, analyzed, and delivered back to the healthcare provider and healthcare executives in ways that will truly transform patient care and outcomes. While it will take time, it isn’t a matter of whether it can be done — just when it will be done.

The beauty is hospitals can realize all the many benefits of device integration today (improved patient care, reduced errors, improved decision making, and even Meaningful Use) and position themselves to then realize the many benefits coming in the future. It’s a win/win, really, because device integration aligns with the ever-growing strategic approach to technology investments and implementations — to increase efficiencies and improve patient care.

Meaningful Use requirements will come and go, but hospitals will still remain. Decisions and investments made now will have a long and lasting impact on the future of healthcare. The best approach is to create an agile, scalable healthcare environment that can adapt to the changing needs of patients for years to come. Medical device integration is one technology that aligns with all of these objectives and more.

Stuart Long is president, North America of Capsule Tech, Inc. of Andover, MA.

Clinical Intelligence to Improve Quality and Reduce Costs
By Michael Weintraub

The business model for healthcare is changing very quickly and most providers do not have the information resources to support value and risk-based accountable care. What is needed now is longitudinal information that is patient / population centric, across the continuum of care, outcome and health status oriented. It must support performance improvement and cost management, particularly for disease states such as congestive heart failure, hypertension, diabetes, asthma and others, where better management impacts health status and reduces total costs.

Accountable care requires clinical intelligence – information resources and analytical tools – to improve care to populations, over time and across the care continuum. Analytics is a tool for extracting useful properties from data, but intelligence is about making sense of the data and figuring out what to do about the findings.

Quality improvement in recent decades has been aligned with a volume driven fee for service business model. Claims based data analytics and process measures were adequate, though their value in improving care has been disappointing despite the commitment and best efforts of so many. As Chassin and Loeb conclude, “Health care quality and safety today are best characterized as showing pockets of excellence on specific measures or in particular services at individual health care facilities.” ¹

As we move toward a value-based system with accountability over time, the focus of analytics is shifting as well. Historically the field of “analytics” only encompassed scorecards focused on traditional quality measures (e.g. aspirin on arrival for MI patients). But as the business model of health care shifts from fee-for-service to fee-for-value, organizations have also had to shift their analytic focus from “service” in the form of traditional process-based measures to “value” in the form of population health. This shift has driven expanded requirements for more robust clinical intelligence and predictive analytics to measure, understand and drive improved clinical performance tied directly to the bottom line.

Clinical data is the anchor for clinical intelligence and vanguard IDNs, hospitals, and medical groups are using clinical intelligence (CI) solutions that unlock the value of digital clinical data. Adoption of HIT is an enabling but not sufficient prerequisite for CI. Data warehousing and registries may also be enabling, but they are not CI. CI requires four advanced capabilities: data management, data quality, analytics, and shared learning.

Data Management

Even organizations with the most comprehensive EHRs find their data difficult to access and extract for analysis. Data formats and definitions are not standardized across IT applications or across entities even in the same enterprise. Extracting, organizing, and normalizing clinical, financial, and operational data from disparate systems and across the care continuum — inpatient and ambulatory — is key to unlocking intelligence in the data. Data management functions can be performed behind the scenes on a near real-time basis avoiding costly interfaces. They should tap valuable unstructured data using natural language processing to enhance the value of the extracted and normalized database for population management.

Data Quality Services

One of the persistent concerns of those who use data or are the subject of that data is concern about its accuracy and validity. These concerns are well grounded. The explosive growth of digital information with poor data governance has led to a state of disorder that has done little to improve trust and willingness to act on data.

This problem is compounded exponentially when trying to mine clinical data from EMRs. Unlike the well-understood structures and nomenclatures that support ICD, DRG, and CPT coding, clinical data are unstructured and unlimited in terms of their heterogeneity. CI solutions solve this problem by performing forensics that clean, validate, and map the data. These data quality processes provide insight into the areas ripe for data quality improvement in EHR and other data sources and enables monitoring data quality over time. The result of data management and data quality is a continuously refreshed database ready for use.

Analytic Technologies

CI employs analytic tools that are clinically and statistically rigorous and transparent so it is easy to access and understand the underlying data. Innovations in advanced data visualization and analysis guidance such as report libraries support a broad range of uses from clinical performance profiling to dashboards and analyses of at risk populations. For at risk patients and populations — for example, CHF patients — CI uses predictive analytics to identify where intervention may prevent hospitalization. Valid comparative data for benchmark analyses is an essential component of CI and a prerequisite for sustainable performance improvement. Smart analytic tools also help support employees who are learning to work with expanded data sets and new tools.

Shared Learning Resources

Over and over, it has been shown that quality and performance improvement benefits from collaborative learning. Using normalized and comparative data, CI leaders engage with one another through learning communities, such as those being convened through the American Medical Group Association (AMGA). With CI, the clinical comparative data and analytics are the glue for the community of stakeholders actively engaged in learning from one another.

Leading healthcare organizations preparing for value and risk-based accountable care understand they must move beyond limited purpose process measures and claims data to CI. They are leveraging their investments in HIT and unlocking the power of clinical data for population management and health system improvement.

[1] Chassin, M. and Loeb, J. “The Ongoing Quality Improvement Journey: Next Stop, High Reliability.” Health Affairs, 30, no.4 (2011): 559-568

Michael Weintraub is president and CEO of Humedica of Boston, MA.

How are you Managing your Revenue Cycle?
By John O’Donnell

The complexity of managing the revenue cycle has never been greater than in today’s healthcare environment. From the economic impact on an organization’s bottom line to the continued advancement of healthcare reform, the need to stay three steps ahead has never been more important for your organization’s financial health.

Staying ahead means knowing your strengths and weaknesses. Do you have the right talent? Do you know what the market conditions are doing to your revenue cycle? How do you approach declining reimbursements without impacting quality or strategic initiatives? These are not easy questions to answer.

Knowing what your organization does well and what it does not do well is one way to determine how to best approach your revenue cycle.

Take Business Intelligence (BI), for instance. It’s not just a term for reporting. It applies to the overall approach to your revenue cycle. BI can help you evaluate areas with the greatest impact to your cash—like denials management and follow-up. As you examine these areas, BI will begin to display a picture with areas of concern.

You may come to realize that outsourcing portions of your revenue cycle might be an option. For example, converting to a new billing system is going to impact A/R and denials no matter how good your organization. You cannot install and manage the old A/R at the same time.

Leaders need to look at what makes good business sense for the organization — especially regarding denials management — and ultimately, what’s good for the patient. Can you financially support growth if your cash flow is being impacted?

Cost pressures from staffing and IT costs are all having dramatic effects on the providers, not to mention ICD-10. The implications of ICD-10 on the billing process itself are staggering with regard to workflow, systems, and reimbursement. Documenting the clinical process correctly is critical.

Physician alignment is one area that will be crucial in transforming your revenue cycle. Whether inpatient or outpatient, the revenue cycle will impact physician compensation. This means you have to include physicians in any associated initiatives. Bring them into discussions about charge capture. Educate them on the impact on denials and eligibility. Have the physician sit down next to you as you both look at options in managing the revenue cycle.

The management of the physician practice does directly impact all aspects of your revenue cycle, and ultimately your cash flow.

The old manual models are a thing of the past. Technology is woven into our daily lives and needs to be integrated into the revenue cycle. This does not mean a minimal touch approach of writing off denials in advance. It means using people and technology to limit the denials ahead of time.

Accountability will force providers and the business office to work side-by-side to maximize reimbursements, especially as reform advances. Healthcare reform / accountable care organizations — it’s all here and it’s still advancing, whether you’re good, bad, or indifferent about it.

Today’s current economic factors are in some cases crippling providers. Throw in reform and without question a transformation of the current model is needed. Changing from fee-for-service to accountability is going to impact cash flow.

I believe this transformation is forcing mergers and acquisitions across the spectrum, which will impact both your inpatient and outpatient revenue cycles.

For example, if your hospital adds new physician groups to the mix, great. That will feed the inpatient cycle. But what does that mean to your existing revenue cycle? Does that mean a best-of-breed or an integrated system approach? And how do you scale the operations to support growth? You have to look at different options.

We’ve all heard the real estate mantra, “location, location, location.” Well, with your revenue cycle it’s all about cash, cash, cash. Without it, buildings don’t get built, physicians don’t get paid, and the patient is left looking for care elsewhere.

In the end, it’s about knowing how to scale the operations to meet the needs of the organization to support financial stability and growth. It’s also about using BI to monitor performance. None of this means your cash has to be impacted. You just have to know and understand your options.

John O’Donnell is president and CEO of SPi Healthcare of Tinley Park, IL.

Monday Morning Update 4/16/12

From ZZtop: “Re: Meditech ambulatory. Meditech is developing an ambulatory product written in part with M-AT (focus) and M-AT WebServer (unreleased and a SAAS application). It will be available in 2013 starting at the 6.1X product line as they are merging P/BR and B/AR into one application. The design is very un-Meditech with horizontal tabs. Looks a bit Epic-ish.” Unverified.

From Epic Dude: “Re: Nuance. Apparently sunsetting their RadPort imaging decision support service.” Unverified.

From Senor Ortega: “Re: [company name omitted]. Ceased operations on Monday, April 9 and will declare bankruptcy next week, according to an e-mail sent by a member of their board of directors.” Unverified, so I’ve left the company name out for now. I e-mailed and asked them to confirm or deny and will re-run with their name if they don’t respond.

From Dr. Beeper: “Re: Henry Ford Health System. They spent $150 million to replace the 25-year-old McKesson MIMS product starting in 2006, bringing in CSC, RelWare, and Siemens to develop Care Plus Next Generation (the intellectual property is still owned by HFHS and RelWare.) That product did not have revenue cycle capabilities and it captured, normalized, and stored data from over 150 interfaces. HFHS needed to replace 150 individual solutions with a single, unified record with full RCM, inpatient, and ambulatory. That’s why they are spending $300 million on Epic.” Above is a March 2011 quote from the HFHS’s president and COO, talking to the local TV station upon Care Plus Next Generation’s go-live. Eight months later, HFHS was finalizing its contract with Epic to replace the whole thing.

From Epic Envy: “Re: Epic. I get it, Epic is the best of a bad lot. They’ve copied the Meditech business model and have executed it well. But does anyone really believe their KLAS scores aren’t ‘engineered?’ Ask who is KLAS’s biggest paying customer while reading KLAS’ users comments. Ask yourself what effect their ‘good maintenance’ contract incentive has on muting malcontents. Finally, allow your mind to wonder why they don’t foster the use of social media customer dialogue. I am envious, indeed but not naive.” Point A, not effective – just because they’re a KLAS customer doesn’t automatically mean they get to fudge the numbers and I don’t think they control the results any more than other vendors who encourage certain customers to participate. Point B, effective, but I think there’s another factor that automatically quiets down any complainers – who wants go to public with gripes after you’ve just spend hundreds of millions of dollars on Epic? (the hospital’s board would not appreciate public second guessing after approving a decision of that magnitude and the messenger would undoubtedly be shot). Point C, not effective – customers can talk among themselves all they want and I haven’t heard any say that Epic’s giant user group meeting is full of bitter complaining like I’ve seen at similar events held by Epic’s competitors. Point B wins – nobody buys a Rolls Royce and then whines about crappy gas mileage or expensive oil changes because it would just make them look stupid for buying it in the first place. Compounded by the fact that Epic seems to be pretty open with its customers, so there’s not a lot to be gained by airing dirty laundry to a bunch of sideline-watchers, especially when the company is privately held and thus not too worried about negative publicity that might otherwise get shareholder attention.

From Deep Throat: “Re: Thomson Reuters Healthcare Division. Any news about who has purchased it?” I haven’t heard anything, but maybe someone has and will share.

From The PACS Designer: “Re: Windows 8.  Microsoft has released a consumer preview for Windows 8. The new version has vast changes from previous versions and will take some time to get used to if you are in the market for a new system.  In many respects, it appears that Microsoft is trying to challenge Apple’s iPhone/iPad user interface to create some marketing buzz amongst consumers.” Microsoft couldn’t possibly do like everyone else and post the intro video on YouTube or something that might involve a competitor – they had to run it in the non-shareable, proprietary Silverlight format. Luckily someone smarter than the Microsoft marketing folks (why wouldn’t you use a competitor’s free service to pitch your product?) posted an intro video to YouTube where someone might actually see it, which I’m including above. We’ll see on Win 8. Given the radical changes, I’m not convinced it won’t follow the “every other release sucks” pattern like Vista before it and Windows ME before that.

HIStalk readers apparently aren’t all that interested in the JOBS act and aren’t that optimistic that it will spur startup growth and create jobs. New poll to your right, from recent headlines: should hospitals decline to hire overweight people or smokers? The poll accepts comments, so feel free to argue your position.

My Time Capsule editorial this time around: Rogue IT Shops: Provide Rules, but Leave Them There. A flash of the goods: “As soon as IT gets in trouble or tries to hide staff shortages like a balding man’s comb-over, it’s all hands on deck to save the tanking projects, meaning those previously dedicated departmental resources will be yanked to put out some new fire, often self inflicted by poor planning.”

I periodically need to vent about a pet peeve, so here’s one: a character-based GUI is not the same as a DOS application. If you hear someone refer to Meditech Magic or a mainframe app as “DOS-based,” stop listening because they just revealed a startling lack of even basic IT knowledge. I’m also lately irked when I read, “I had a couple drinks …” or something like that where somehow the author feels the “of” separator is superfluous, which to me sounds like someone who’s talking after more than just two drinks.

FirstHealth of the Carolinas CIO Dave Dillehunt left an excellent comment he left on Travis’s HIStalk Mobile post on pagers that hits a point I’ve been trying to tell people about: one-way pager coverage sucks and is getting worse once you get even a few miles away from a reasonably sized city, just like cell phones of the 1990s. They work fine on a hospital campus, but not well for folks covering call from home or traveling even locally. Not to mention that if you aren’t in range when the page goes through – unlike a cell phone – there’s no notice to the sender or voice mail for the recipient since alpha paging is incredibly unintelligent technology. For example, above is a USA Mobility coverage map for Tennessee. They may well have statewide coverage, but only if you’re in the blue areas (which look to be maybe 10% of the geographic area), so if you’re on weekend call, the electronic leash is pretty short. There may be a way for the commonly used Amcom paging system to detect failed delivery or to allow users to forward to a cell number to have the page converted to an SMS text message, but I haven’t figured it out if so. Anyway, here’s what Dave had to say:

Because traditional paging technology is dying, and customers are leaving in favor of their smart phone texting apps, the industry is now milking what revenues they have left and are no longer repairing or replacing damaged and failing paging towers and equipment. As a result, paging coverage is rapidly deteriorating. This is now causing more people to abandon that technology, further worsening the problem. While cellular coverage is sketchy as well, technologies that send out through both cellular and wi-fi are a good start and probably provide better coverage than the current (worsening) paging coverage. Our physicians (and others) are now demanding something other than paging (beeper) systems. Personally, I predict that paging will be gone within 36 months.

Beaumont Health System (MI) promotes Subra Sripada to EVP/chief administrative & information officer. He was previously SVP/CIO.

The Healthcare IT Week in Review

1. Utah: Do These Breaches Make My Butt Look Big?

Facts and Background

European hackers penetrate a Utah Medicaid claims server, downloading files covering nearly a million individuals and stealing the Social Security numbers of more than 250,000 of them.

Opinion

Hackers can get into anything stored online given the proper motivation and resources. Breaches happen all the time. This just happened to be a very large one and the state  government just happened to be very wrong in its initial assessment of the extent of the breach.

Musings

• Of all the things you could profitably hack, why would you want to steal the identities of welfare recipients? Possible answer: health records are often complete and therefore a convenient package for stealing someone’s identify.
• An IT technician’s weak password was identified as being cracked to gain access. That illustrates two points: (a) trying to compose and remember a bunch of complex passwords means most people won’t do it, and (b) at least this was a refreshing way to hack since most PHI exposures are due to inappropriate server security settings rather than old-school password cracks.
• The more other industries beef up their information security because they can and must, the more healthcare becomes the target of choice because security is primitive compared to that used by banks and retailers. Not to mention that healthcare records may include valuable data elements these days, such as bank account and credit card information.
• Utah had better be glad it’s not two states west since California’s breach penalty would have triggered an automatic penalty of $800 million.
• The state is now warning consumers that scammers may take advantage of the situation by calling people up randomly, telling them their information may have been compromised, and asking them to provide personal information (like their SSN) to find out.
• Adequate security is probably an unreasonable target when possession of just a couple of numbers (SSN, insurance ID, date of birth, etc.) is presumed to be positive identification to receive expensive benefits.

2. DoD’s EMR, Out-Of-Control Psychiatrists Prescribing Blamed for Addicted Marines 

Facts and Background

Poor EMR medication functionality is partly to blame for high rates of abuse of both prescribed and illicit drugs in a program for wounded Marines, according to the Defense Department’s inspector general. Also blamed is overprescribing of addictive drugs, particularly by psychiatrists.

Opinion

It may well be that the multi-billion dollar AHTLA EMR can’t bring in data from community pharmacies or the VA to help prescribers identify overmedicated patients. However, that would put it right on par with the systems used by non-military doctors.

Musings

• For identifying patients who may have an addiction problem, why can’t the government ignore prescribing records and instead look at pharmacy dispensing records? The only ways the problem can be identified in the private sector are by doctor shopper databases and examination of claims records (which won’t work if drug-seeking patients get smart and pay cash).
• While illegally obtained drugs are mentioned in the report, the emphasis seems to be on those prescribed from a sound doctor-patient relationship. In other words, the real problem is the doctors doing the prescribing, who in the absence of other motivation must think they’re doing the right thing clinically (i.e, it’s an education problem).
• The problem here is the same as it is in private medicine: doctors are pressured by patients to overprescribe, use of addictive drugs is often anything but evidence based, and any crackdown means chronic pain patients with a legitimate need for aggressive pain therapy will suffer from under-medication.

3. 3M Acquires CodeRyte

Facts and Background

3M announced last week that it acquired CodeRyte, which offers medical coding tools based on extracting information from free text using natural language processing. 3M was already using CodeRyte’s technology in some of its offerings.

Opinion

CodeRyte had put together some attention-grabbing bullet points: 250 customers, heavy penetration into deep pockets academic medical centers, 3M’s reliance on its products, and a potential ICD-10 play. If you’re going to make yourself attractive to a potential acquisition partner, it’s nice when your attributes make a deep pockets partner the logical choice.

Musings

• CodeRyte’s #1 philosophy, according to its corporate overview, was to “stay private as long as possible to allow the technology to become ubiquitous rather than a benefit to a small subset of health care through one vendor’s client base.” I translate that to mean, “3M, you’d better bring a wheelbarrow full of money if you want to get our attention.” Which I assume was the case.
• The company had brought over some former Cerner execs: Glenn Tobin as COO and Don Trigg as chief revenue officer.
• CodeRyte’s board of directors had five members other than CEO Andy Kapit. Every one of them was from a different venture capital firm with investment in the company. Surely the company’s financial ambitions were obvious.
• 3M has a steady cash cow in coding solutions and it has made few obvious acquisitions or investments in that market. This move seems preordained.
• The integration of CodeRyte’s product into 3M’s was not all that great, at least according to folks I talked to. Now 3M loses both its barrier and its excuse.
• 3M and Nuance announced just over a year ago a deal to deliver computer-assisted physician documentation and coding solutions from speech recognition. I don’t know if 3M’s contribution of the coding technology relied on CodeRyte to take the Nuance-converted dictation text and apply NLP to it, but that seems reasonable.
• CodeRyte’s technology was developed by linguistics professor Philip Resnick PhD, who still advises the company.

Time Capsule: Rogue IT Shops: Provide Rules, but Leave Them There

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

I wrote this piece in April 2007.

Rogue IT Shops: Provide Rules, but Leave Them There
By Mr. HIStalk

An ongoing hospital IT dispute involves the common existence of so-called “hidden IT shops.” Those are pockets of specialized IT that, instead of reporting to IT, are managed within their individual departments, such as patient financial services, human resources, and laboratory.

I’ve been on both sides of that particular fence, so I feel qualified to opine.

More than once, I’ve been in an IT leadership role as we reined in rogue IT operations. We cracked down on non-rules following departments that were spending IT funds unwisely, exposing the organization to risk, and insulting our IT leadership by flaunting their minimally supervised existence.

Also more than once, I’ve worked for a clinical department’s rogue IT operation, born of necessity after a Dilbert-esque IT shop couldn’t meet our department’s needs. The IT suits talked endlessly about professional IT management, but they were mostly known for starting projects they could never finish, using help desk analysts as human shields to prevent users from talking to the few experts they had, and conducting endless meetings to grind down the rational opposition to whatever they had already decided to do behind closed doors. They were much like a questionably motivated vendor, in other words.

If I have to take a position, I’ll side with allowing user departments to keep their existing IT employees.

“Common plumbing” is an IT responsibility. Departments shouldn’t have their own network technicians, e-mail administrators, server experts, or database administrators. They should not negotiate IT contracts or make capital purchases. I’m sure we agree on this.

Beyond that, my experience is that departmental IT people do a better job than their IT counterparts. They have the luxury of working hands-on with their users, free of the distrust that IT departments often generate. Since they understand the workflow and the specific technologies in place, they excel at setting priorities, can develop creative system workarounds and extensions, and are unsurpassed at retrieving and analyzing system data.

They also are keenly motivated because they are judged exclusively by their departmental co-workers, who ensure their high performance by lauding them for even the most mundane and sometimes comically easy accomplishments that seem hard to a layperson (I think that last issue is what steams the IT guys.)

I know the IT arguments because I’ve used them myself, although only half-heartedly:

• IT systems involve risk that only an IT department can assess and manage
• Centralizing IT creates efficiencies and prevents critical reliance on an individual
• Project funding should be centrally administered based on overall organizational priorities, not the needs of a single department
• Standardized practices should be used for the help desk, change management, knowledge management, and project management

What I’ve seen in reality from both sides of the fence:

• All the logical arguments aside, the primary motivator for IT centralization is the ego of the IT department’s management
• The IT department’s insistence on rules is often at the expense of creativity and flexibility
• Despite all the available tools, the IT department can’t match the service levels of locally assigned and managed IT employees
• As soon as IT gets in trouble or tries to hide staff shortages like a balding man’s comb-over, it’s all hands on deck to save the tanking projects, meaning those previously dedicated departmental resources will be yanked to put out some new fire, often self inflicted by poor planning
• Department employees often despise working in the detached, command-and-control bureaucracy of the IT department, so they leave, taking years of specialized experience with them and disproving the theory that IT can provide more resource depth than was already in place

I have loyalties both ways. These conclusions come from multiple personal observations.

Certainly other less dramatic options exist. You can have local IT resources report via dotted line to the IT department, providing guidelines on what they can and can’t do. You can insist that those teams follow documentation and change management standards. You can steer them toward standard technical tools, provide them with training, invite them to meetings, roll up their budgets under IT, and even move their chairs to the soulless cubes that IT departments love.

If you do decide to absorb the hidden IT shops, beware. Unless your IT shop is superbly managed, you’ll probably set unattainable expectations that you can’t deliver.

News 4/13/12

Top News

The Defense Department’s inspector general finds that drug abuse among Marines in the Wounded Warrior Battalion at Camp Lejeune, NC is hard to detect because of shortcomings in its CHCS and AHLTA EMRs. Prescription information from the VA and civilian doctors are not visible in AHLTA. An Army doctor said AHLTA’s medication module is “a mess,” saying that it’s so bad that doctors just free-text in the patient’s medication list, especially after the most recent update that added interfaces to civilian pharmacies and the VA. The battalion also wanted to implement the EMMA medication dispensing system used by the Army at Fort Bragg, but the Navy nixed that idea over concerns that it might not be HIPAA compliant.

Reader Comments

From X-Ray Gun: “Re: Philips. In December, decided to discontinue their RIS product, XIRIS in NA. They have also decided to discontinue their Digital Dictation and VR solution.” Unverified. They live on at least as artifacts on the company’s webpage.

From WildcatWell: “Re: requirement to have health insurance like car insurance. Will it flood my TV with endless commercials such as we see now from Allstate, GEICO, et al? It’ll be worse than political season! But, imagine: ‘15 minutes on HIStalk could save you $15K or more on life insurance.’ Send me a royalty! Keep up the good work.” I would need to dress Inga up in all white with red lipstick like that loopy Flo chick from the Progressive commercials, which are indeed ubiquitous. I’m more of a fan of the Allstate ones since they feature Dennis Haysbert, best known for playing Pedro Cerrano, the Jobu-worshipping outfielder in Major League, one of the best movies ever.

From Recent Interviewee: “Re: interview. I’ve been answering very nice e-mails since the HIStalk interview ran. Congratulations on such a great service you provide to the industry. Everyone reads it.” Thanks. I do quite a few interviews and always let the interviewee know upfront that the result is usually quite a few reach-outs from folks who’ve lost touch over the years. I don’t think they generally believe it until it happens. Healthcare IT really is a small world and most of the players just move around in it without ever straying far.

From Gesundheit: “Re: Henry Ford Health System. The $100 million MIMS system was built in the 1980s, when there were no good vendor offerings. It lasted over 20 years – not bad in today’s environment. However, adding $300 million for Epic is insanity or some lack of governance process or client acceptance. I’d like to see the fact finding on this one.”

From Ixnay: “Re: Meditech. Heard they’re ditching LSS to create their own ambulatory product.” Unverified. That rumor has been going around for at least a year and they’ve bought the remainder of LSS in the mean time. I don’t know if it’s a competitive offering, but the rumors would suggest that at least some folks think it isn’t. Most inpatient vendors still have a weak ambulatory albatross hanging around their necks, not surprising for systems whose underpinnings go back decades when nobody in hospitals cared what physician practices did.

From Jonathan Grau: “Re: International Congress on Nursing Informatics. The meeting is one of the most important activities of the International Medical Informatics Association -Nursing Informatics Special Interest Group (IMIA/NI-SIG) and is held every third year to promote all aspects of nursing and health informatics globally. We expect over 800 in Montreal, June 23-27.” I don’t usually give free plugs since I don’t want to open the floodgates, but I’m feeling uncharacteristically generous. Jonathan is with AMIA. Attendees can hang around afterward and catch the Montreal jazz festival, with performers that include Norah Jones, BB King, Ben Harper, George Thorogood and the Destroyers, James Taylor, Liza Minelli, Seal, Stanley Clarke, old favorite Van der Graaf Generator, and an interesting group whose 1970s LPs populate part of my collection, Tangerine Dream. They put me to sleep every time with their all-instrumental space music that sounds like Pink Floyd taking an on-stage break, but I like the name and covers.

HIStalk Announcements and Requests

Catch up on your HIStalk Practice reading so you have the full scoop on these posts: PCMHs improve quality and reduce costs in New Jersey. CareCloud CEO Albert Santalo joins President Obama during the signing of the JOBS bill. AMA names HP its preferred provider for technology products. Dr. Gregg sends out an RFP for an EHR – and stirs some good discussion from readers. I am a firm believer that you can never be too rich, too thin, or have too many HIStalk Practice e-mail subscribers, so please either send money or diet tips or sign up for the e-mail notifications. Thanks for reading.

Listening: the brand new first album from Alabama Shakes, Joplin-esque (or is it Otis Redding?) Southern soul from Athens, AL, just in time for summer. Singer Brittany Howard, 23 years old, belts it out and leaves it all on the stage. Killer Led Zep cover here.

Travis is on fire over on HIStalk Mobile, with one excellent, meaty post after another. His latest: Pagers – There’s an App For That, which arrives at thought-provoking conclusions about the situations when hospitals can and can’t do like drug dealers did in the 1990s in dumping the typewriter of the communications world, alpha pagers, which surely have no market left other than in healthcare.

On the Jobs Board: HL7 Business Analyst, Director of Marketing, Director of Business Development. On Healthcare IT Jobs: PACS Application Coordinator II, McKesson Paragon Consultants, Cerner Go-Live Project Manager.

It’s a strange, strange world we live in, Master Jack. Reality TV that’s anything but real, rampant Facebook narcissism, crumbling economies, and celebrities whose IQs and morality levels compete like golfers shooting for the lowest score. One thing you can count on, though – like Big Ben or Old Faithful, I will be predictably spooning with my PC to bring you news, rumors, and Cerrano photos almost every day of the week just like I’ve been doing for nine (!!) years. How might one harvest this rich outpouring of prosaic potpourri, you might ask? Simple – just click the Subscribe to Updates link at the upper right of the page to get into the exclusive club of industry movers and shakers who read HIStalk but probably won’t admit it publicly, putting it right up there with pr0n in the guilty pleasure category. Should  you wish to take our relationship to a deeper level, may I suggest: (a) electronically bond with Inga, Dr. Jayne, and me on social not-working sites like Facebook and LinkedIn, where rejection is impossible because we accept connections from everyone; (b) send me rumors and secrets; (c) pay homage to the companies that pay the bills by perusing the Resource Center and the plethora of newly animation-free ads to your left, replacing heartfelt applause with mouse clicks to see what they all actually do; (d) if you are a provider seeking consulting help, broadcast your RFI to several companies in seconds via the RFI Blaster; (e) tell someone you know about HIStalk since they won’t hear about it otherwise; and (f) bow your head humbly as I strap on the Honorary Reflector Thingy in knighting you with gratitude as my tireless confidante and defender. Thanks for reading.

Acquisitions, Funding, Business, and Stock

Emdeon reports Q4 revenue of $284 million, up 3% from a year ago. Net loss for the quarter was $71 million compared to the previous year’s net income of $15 million. Emdeon, which went private last year, says the loss was “primarily due to costs and expenses, including increased interest expense.” The company also announces its intention to re-price its existing senior secured credit facilities to take advantage of current market rates and borrow $60 million of additional term loans for general corporate purposes, including potential acquisitions.

McKesson shares rose 4% to a 52-week high Thursday on news that its $4 billion per year drug supply contract with the VA will be extended for up to eight more years.

I recently interviewed Brian Phelps, the ED doc who co-founded iPad-based system vendor Montrue Technologies, whose Sparrow ED product won the Nuance’s Mobile Clinical Voice Challenge that I judged a couple of months ago. The company learned Wednesday that it had won the $160,000 Southern Oregon Angel Investment prize. It had already received $200,000 in angel investor money at a similar conference and some pretty nice prizes from Nuance.

CPSI will move some of its Mobile, AL operations to Fairhope, saying it has run out of room.

Sales

The State of Minnesota selects Hielix, Inc. to develop a statewide HIE.

Bayfront Health System (FL) signs an agreement with Unibased Systems Architecture to deploy its surgery management and physician order management solutions across more than 20 operating rooms.

Blue Mountain Hospital (UT) chooses clinical and financial solutions from Prognosis. 

Orion Health wins the HIE contract for North Texas Accountable Healthcare Partnership. Also announced: former T-System VP Joe Lastinger was named CEO of the HIE.

Franciscan Alliance selects iSirona’s enterprise device connectivity solution to integrate medical devices with Epic in its 14 hospitals.

Care Logistics sells something that sounds kind of software related to Catholic Healthcare East, but I can’t figure out what it is from this sly hint: “This comprehensive approach combines an organizational commitment to efficiency, systemwide process reengineering and enterprise logistics software to help hospitals achieve reliable and predictive operational performance in the areas of throughput, quality and patient experience.” Their site is similarly vague, but is clogged up with enormous blocks of dense text sure to send all but the most determined visitors fleeing.

People

Post acute care IT provider American HealthTech names David Houghton (Advocat) as COO.

Hospice and homecare IT provider CareAnyware names Ray DeArmitt (CellTrak Technologies, Allscripts Homecare) as sales VP.

Quest Diagnostics appoints former Philips Healthcare CEO Stephen H. Rusckowski president and CEO immediately after his resignation from Philips. He replaces Surya N. Mohapatra, who will join the company’s board.

Philips Healthcare promotes Deborah DiSanzo to CEO. She was previously CEO of Patient Care and Clinical Informatics for the company.

MediClick names Scott Pettingell (GHX) VP of the company’s new consulting services business.

The Healthcare Financial Management Association appoints Joseph J. Fifer its president and CEO, succeeding the retiring Richard L. Clarke. He most recently was VP of hospital finance at Spectrum Health.

Announcements and Implementations

The Hawaii REC names Curas its preferred eClinicalWorks vendor.

The Carolina eHealth Alliance (SC) announces that 11 Charleston area emergency departments are now connected to its HIE.

NexJ partners with Beth Israel Deaconess Medical Center (MA) to digitize the health system’s Passport to TRUST program and make it available through NexJ’s Connected Wellness Platform.

The New York Times profiles remote monitoring system vendor AirStrip Technologies in its list of companies it says are pushing healthcare transformation. Also on the list: Avado (Web-based forms and health status tracking); ClickCare (secure physician communication for consultations); ZocDoc (making physician appointments); and Telcare (cloud-based glucose meter data sharing).

Yuma Regional Medical Center (AZ) will go live May 1 on its $73 million Epic system.

Government and Politics

CMS Innovation Center picks seven states to pilot the Comprehensive Primary Care Initiative, which aims to strengthen coordination and collaboration between private and public healthcare payers to improve primary care.

Other

The athenahealth folks sent over this video entitled It Sucks to Be Me, which highlights why it’s not easy being a physician, nurse, administrator, and patient. OK, so it’s mildly cheesy like an overwrought, applause-milking truck show Broadway musical on opening night in Omaha  (check out the drummer’s cowbell and wood block work – think Waiting for Guffman), but you’ve got to love athenahealth for its out-of-the-box marketing.

Several members of the Medicare Payment Advisory Commission (MedPAC) express concern that federal incentives may not cover the true cost of implementing an EHR. Some specific worries are that Stage 1 requirements are set too high and some required elements are too expensive to implement and offer questionable value.

Allscripts CEO Glen Tullman writes a Forbes piece on how consumer technology can be used in healthcare. He mentions FaceTime, Kinect, and FitBit. He included a video from Madonna Hospital showing some futuristic ideas that I was going to run here, but I noticed it’s a couple of years old and I would hope they’ve come up with new stuff since then.

This seems like a bad idea: an Indiana hospital implements a Web-based incident management system, intended for use during tornadoes and other natural disasters during which Internet connectivity is often lost.

A laid-off IT security administrator at Waterbury Hospital (CT) is arrested for hacking into the hospital’s computer system hours after he was marched out, using his boss’s own e-mail account to send him threatening messages.

A newspaper’s investigation finds that five electrophysiologists – cardiologists with the Ohio State University Wexner Medical Center were each paid a $1.3 million bonus in 2011, raising their one-year pay to $2 million each. The only employee at the state university to earn more was the basketball coach.

Sponsor Updates

• EHRtv posts its HIMSS 2012 interview with T-System CEO Sunny Sanyal.
• Macadamian assists in the design of Elsevier’s Mosby’s Certified Nurse Exam Prep smart phone app and its development for the iPhone, iPod Touch, and iPad. 
• HealthMEDX provides an update on its HIPAA 5010 readiness preparations.
• Allscripts President Lee Shapiro participated this week in a TechNexus panel discussion on the changing face of technology in healthcare.
• A white paper from Care360 discusses the positive impact of technology on the quality of patient care.
• NextGen will integrate Entrada’s clinical documentation technology with its PM/EHR.
• GE Healthcare launches Centricity EDI Services 5.4,which includes support for HIPAA 5010 and stronger analytics.
• Beacon Partners expands its ICD-10 Assessment Service with the addition of an ICD-10 translator and business intelligence application from McGladrey.

EPtalk by Dr. Jayne

The Colorado Regional Health Information Organization (CORHIO) releases a report on integrating behavioral health information through health information exchanges. Although agreeing that information on mental illness is a vital part of the overall data influencing the health of a patient, a role-based tiered consent structure was recommended. Surprisingly, the roles weren’t based on physician vs. nurse vs. checkout clerk but rather the specialty of physicians involved. For example, participants in community focus groups felt that specialists such as OB/GYN or dermatology had less need to know information than did hospital-based physicians. Being a primary care doc at heart, I think any time you start excluding classes of providers (especially when drugs to treat mental health have a number of potential interactions and contraindications) it’s a detriment to patient safety. Who will be liable when harm occurs because a physician was denied information that would have made a difference? Needless to say, I’m not a fan of pick-and-choose consent policies.

CMS has compiled individual quality and resource reports for physicians in Iowa, Kansas, Missouri, and Nebraska. Practices have been e-mailed a link to the reports, but only 3,300 of 23,730 reports have been accessed. I reached out to at least 10 physicians in these states and none of them knew anything about it. My guess is the e-mails either went to spam folders or are sitting in some administrator’s inbox.

I’m a reasonably diligent reader of the Federal Register but somehow I missed this item. The Drug Enforcement Administration is increasing physician fees for the privilege of prescribing controlled substances by nearly 33% – from $551 to $731. This allows us the privilege of having drug-seekers hassle us for meds and increases scrutiny of our practice patterns (not to mention an increase in medical liability insurance premiums.) It seems like what the feds provide in MU funding just slowly erodes to other areas.

I’m a little behind on my reading, so I laughed when I came across this article about the recent Utah Medicaid data breach reported to affect 24,000 patients. As of today, the number is closer to 900,000.

One of the folks I’ve found on Twitter has turned out to be one of my new favorite bloggers. Skeptical Scalpel is written by a surgeon with considerable (40+ years) experience in the field. Worth a view, especially if you have a clinical background. And if you aren’t clinical, it may provide some good conversation-starters to help you bond with physicians who are generally ticked off at the world when all you’re trying to do is fix their laptops.

I enjoy reader correspondence and always like to try to share information when I can. Recently a reader asked, “I am looking for a good hospital BYOD policy for physicians. We’re enabling physician use of iPads and similar devices to connect to our clinical systems and I am in need of a policy that covers their use. Have you come across a good one yet? If so, can you share it?” Being from a strictly “don’t touch my network” hospital, I don’t have personal experience with the thrill of being able to actually use my own device on the network. I do however have much experience hooking to the patient access network so I can use the forbidden Twitter and Facebook. I also have experience carrying both my own smart phone and a hospital-issue BlackBerry, which really makes me look goofy at times. Can anyone help a fellow reader? E-mail me.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 4/11/12

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

Satisfaction—I Can’t Get No….

“You have a Masters in Computer Science?”

The hiring manager’s initial question took me aback. Human Resources had obviously misread my degree qualifications, yet my resume still passed the screeners.

Eager to land my first salaried position, I cleared my throat and hoped my answer wouldn’t displease. “Although I do know something about computers, my Masters is in Consumer Sciences, the philosophy and practice of customer service.”

Despite her realization that I had the “wrong” degree, the hiring manager looked past this and focused on talent. And thus began my journey into the convergence of healthcare, technology, and service.

This initial position was not IT, but rather an adjunct to the corporate strategy office. Specifically, physician relations. They wanted a person with a technical background who could market the IT applications, thus endearing physicians (and their referrals) to the hospital.

IT had only achieved 5% physician adoption. They lacked the service orientation and communication skills necessary for success. By adopting service-oriented practices and strategies, we increased utilization to 85%. It was during this time that I experienced my defining moment, launching my healthcare IT career.

Customer satisfaction is a passion of mine. A service orientation mindset changes an organization. I’ve seen the positive correlation. Not only are more customers satisfied, but the benefits extend outward. Employee morale increases. Productivity increases. The organization becomes more effective and efficient.

Here are a sampling of results achieved by customer-centric teams.

• In a mid-size hospital, we deployed several applications to physicians in our region with hopes of gaining market share. We poured service all over our offerings and reached a 91% customer satisfaction rating. In one year, we went from 45% to 55% market share in four strategic indicators.
• In an academic health system, we quadrupled “top box” customer satisfaction scores in four years. Financial and quality scores increased exponentially on the same slope. Employees who were once embarrassed to be part of IT now delighted in the honor of being part of the team.
• In an integrated health system, we increased “top box” satisfaction 30% in three years. While we maintained revenue targets, we exceeded many quality targets.

How do you achieve superior customer satisfaction and sustain the gains? My team identified nine keys:

Right people in the right positions. Everything rises and falls on leadership (Maxwell). The first thing you must do is ensure the right people are operating in the right roles. Although painful, you must remove some from the “bus” and have others change seats. The quickest way to change the direction and service orientation of your organization is to put people into positions that best utilize their natural talent.

Effective communication. Personally and sympathetically counter negative perceptions and battle anecdotal commentary with facts. Establish monthly reports with dashboards on service levels, project status, key deliverables, and achievements. Share the good, the bad, and especially the ugly. Deliver presentations whenever and wherever you can, evangelizing IT. Become a valued member of every management team.

Relationship building. Strong relationships cover a multitude of sins. Assign IT leaders directly to operational leaders and make routine calls and visits to address concerns. This allows operational leaders to have a single “go-to” person for all their IT interactions and reduces associated complexities. Involve IT leaders in organizational events such as blood drives, sporting events, service opportunities, volunteering, and charity work. Establish a program for connecting with clinicians.

Strategic planning. “Where there is no vision, people wander.” This proverb characterizes IT: a bunch of well-intentioned professionals without direction. Consequently, there is stifled progress, pent-up demand, and frustration. Solicit input from your enterprise and fashion a strategic plan. Review annually and ensure organizational alignment and convergence.

Comprehensive governance. Implement a formal but agile governance process comprised of and led by customers. This ensures IT alignment with organizational vision and gives you a level of rigor, accountability, and transparency not previously possible. Include rank-and-file customers, senior executives, and especially nurses and physicians.

Continuous quality improvement. Your survey vendor will provide in-depth analytics and recommendations based on the results. For instance, after learning that nurses represented our most dissatisfied customer group, we swept through nursing floors and made sure IT became a clinical care enabler. We added hundreds of mobile computers to patient floors to satisfy their greatest complaint — lack of devices.

Aligned incentives. Create a single key performance indicator on which incentives and raises are based … the annual customer satisfaction score. Everyone will become focused on service.

Execution excellence. Without excellent execution, all other strategies are moot.

The secret weapon. The secret weapon is heart. Heart is the wellspring from which motivation emanates. Empathy, compassion, and humility combine to mold a heart that seeks to serve. I’ll hire those with high talent and high heart but mediocre skills any day over someone who has low talent and no heart. Skills can be taught, heart is caught.

Superior customer satisfaction and information technology need not be mutually exclusive. It is less a matter of programs and more about a sustainable leadership imperative that transcends culture. It is a journey, not a destination, and requires a steadfastness of focus, discipline, and courage.

Unlike The Stones, you can get Satisfaction. Hey, hey, hey, that’s what I say …

How do you create a service oriented culture? Share your ideas below and I will send you a presentation I did on developing a customer service culture plus the accompanying Gartner case study.

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

HIStalk Interviews Shelli Williamson, Executive Director, Scottsdale Institute

Shelli Williamson is executive director of Scottsdale Institute of Minneapolis, MN.

Tell me about yourself and about Scottsdale Institute.

I have been in healthcare all of my life. I spent 21 years with the combination of American Hospital Supply Corporation and Baxter Healthcare in a variety of roles. I was fortunate to get a broad perspective on different components of the healthcare system through those years.

When I left Baxter, I joined First Consulting Group, where I was immersed in the IT world. I was introduced to the Scottsdale Institute through that relationship. I’ve been at the Scottsdale Institute managing our programs for about 12 years.

We are a 501c3 not-for-profit association, primarily consisting of large health systems. We are designed for networking and collaboration among our members. We’re here to help our members help each other. Scottsdale Institute acts as the convener for systems to learn from each other and share what they’re doing as it relates to strategic information technology-related initiatives. Boy, has there an never been a better time for talking about that.

Our programs consist of face-to-face initiatives, such as our conferences and collaborative meetings. A lot of virtual activities — we do about 80 teleconference sessions a year. Last year, about 10,000 people participated in our live weekly teleconferences. We do two publications a month. We really want to act as a convener to help people share what they’ve learned and hopefully help people avoid reinventing the same wheels that are being reinvented across many health systems.

How do you position your group against VHA, Premier, CHIME, and HIMSS Analytics?

There are many excellent groups out there. We’re not a GPO, so we have no GPO-like activities. Certainly many of our members belong to all these other groups as well – it’s not an either-or and I wouldn’t try to position it that way. 

Our meetings are designed for executives of all types, so we’re not functionally organized. It’s not just CIOs, CMIOs, CMOs, and CEOs, but rather all of the executive types together. I think people enjoy that idea of being able to exchange different perspectives based on the fact that chief nursing officers are in the room with CIOs and CEOs and others.

We do not technically do research. Some of the groups that you might think of publish research papers and do those kinds in-depth studies. Our activities are more peer to peer — networking, collaborating, sharing of information. It’s more in the trenches. It’s not academic in any way. It’s really how we’re doing things that we’re doing, what we’re learning, what we’re doing well, and what maybe we didn’t do so well and might do differently another time. It’s more those kinds of exchanges that we try to support and foster.

The other thing that might be noteworthy is that our membership is a flat fee. We do not have a limit to the number of seats or people within the organization that can participate and download and access and so forth. Some of these large health systems, such as Ascension Health, Trinity, and others … there are many hundreds even bordering on thousands of actual users within those organizations that access SI resources and participate in the weekly discussions.

From that perspective, it’s a great value for these large health systems who want to expose their team members to education and these kinds of collaboration opportunities, but without the cost of necessary travel and being away from the office.

Also, our benchmarking service is open to all health systems, not just SI members, and is no charge as part of our 501c3 mission.

I see on your website that you offer some conferences and publications. What kind of topics do you typically cover?

Our conferences in recent years have been focused around reform-related activities. Anyone can see all of agendas for our conferences on our website. Those links are public,  so anyone can feel free to browse the agendas.

The face-to-face meetings are small, intimate by design, and exclusively for the senior officers and senior management teams. While I mentioned that we will have a variety of title types at these meeting, this organization was started 19 years ago by a handful of CEOs who saw the writing on the wall that IT was going to be strategic and wanted to start this organization to provide a venue where people and executives can look at IT from a strategic point of view.

I think 19 years ago … that was very, very forward thinking. We take that for granted, but at that point in time, the genesis for Scottsdale Institute was the idea that IT was going be strategic. We still keep that as a main focal point of our conferences and publications.

The publications, in a similar vein, are written for the busy healthcare executive so that person — be it a CFO, CNO, or board member — can get a handle on what these challenges are around IT and begin to understand and appreciate things that all of us in IT know and are near and dear to our hearts. The publications are written in simple English. They are not in tech speak, and are purposely written that way so that busy executives can begin to get comfortable with the IT issues and solutions that their organizations are adapting and implementing.

My experience with IT benchmarking has been mixed. It’s always a tradeoff between doing a survey of reasonable length that someone can complete without becoming frustrated. Also, it’s tough to start up a program like that since you need enough organizations to give participants a good probability of finding benchmark partners that are like them. How do you approach that?

You hit the nail on the head when you talk about the tradeoff between getting every piece of information possible versus something that people are willing to sit down and fill out. We have tried very hard to keep it brief enough on critical elements so that people are able to sit down and do it in 30 minutes.

The purpose of our program is not to try to come up with industry averages or recommendations about what is the right amount of money to be spent on IT. We don’t believe that has any place, at least in the program that we have offered.

What we have done is create a tool where you and your health system or anyone can pick out two, three, four comparable peer organizations based on demographics and then normalize your data with them to see where you are. It creates more of an apples-to-apples comparison. IT budgets are not created equal. Some people include biomed, some include HIM, some include physician or patient portal and their IT budget, some have the CMIO in the IT budget and others don’t. Some have PACS, some have part of PACS, some have telecommunications.

What this tool is designed to do is compartmentalize all of those costs. If you count HIM as a part of your IT shop and I do not, I take your HIM number out, and then we look more and more apples-to-apples. Same thing with biomed, same thing with security and privacy. Even depreciation, which is a huge number. If that’s part of the IT budget in your world and it’s part of the finance in my world, the tool automatically normalizes that information. 

It helps peer organizations get closer. It’s certainly not perfect and nothing is, but it gets a lot closer to apples-to-apples comparison. If you and I are spending the same amount of money but you’re further along in Meaningful Use than I am, that tells us something. I need to learn something from you about what you’re doing.

The other problem with IT benchmarking is the people usually participate because they believe they’re above average and want to back it up so they can tell their organization what a great job they’re doing. But if their expenses are higher, they always question the methodology or the quality of the data from the peers who submitted. What do people typically do if their results don’t show that they’re above average?

Our approach is to help people if they wish to connect with their other peer organizations to see, once they normalize, what is driving the differences. If you’re at HIMSS Level 6 and I’m HIMSS Level 4, that explains a lot money. We have that point of comparison in there as well. Same thing with Meaningful Use data. If you’ve already attested and I’m a long ways away, that could be an explanation — you’re further along in terms of advanced clinical IT deployment.

All we’re trying to do is help people understand the differences. Then, if they wish, connect with these peer organizations to dig deeper into individually what’s going to help each person answer that question.

The end result of benchmarking is you always want to talk to the peer organizations to find out what the survey didn’t tell you. So you facilitate that contact?

Right. I think that’s where the real value is. It’s in the learning. The data is hopefully the beginning point for participants as they work with each other. We don’t necessarily get involved in those discussions. You would be talking to one of your colleagues from another organization without our intervention.

The other challenge that I’ve not seen convincing proof that IT cost correlate to — much less cause – a change in quality. Are you being challenged to help clients prove value beyond just having a reasonable expense?

That is an excellent point, and probably the future. We are not at this moment trying to address that, but certainly cost does not equate to value. That’s what we need to learn — how to equate this IT expense into value. Of course, it isn’t just the IT that does anything — it’s the people on the process. We can’t say cause and effect, but we can show correlation between IT and quality.

Thomson Reuters just completed a study which we’re going to be discussing at our Spring Conference in Scottsdale, Arizona. That actually shows some correlation between the Thomson Reuters Top 100 Hospitals — as the way they measure it — and the use of advanced IT. So again, correlation, not cause and effect, because obviously people have to make this stuff work. But there is a correlation there that we’re excited to be talking about next month.

Any final thoughts?

This is such an exciting time, as we all know, to be in healthcare, and specially to be in healthcare information technology, I feel that every day, somebody says to me, “Thank you for what you all are doing for us.” That just is a very motivating and thrilling kind of place to be.

News 4/11/12

Top News

HHS proposes a one-year delay for ICD-10 compliance, pushing the deadline to October 1, 2014 and giving providers and other covered entities more time to prepare and test their systems with the new code sets. HHS also issues a rule requiring all health insurance plans be numerically tagged with a unique health plan identifier, which it says would save providers and health plans up to $4.6 billion over the next ten years.

Reader Comments

From What Next?: “Re: Epic starting their own consulting business. Anyone heard that rumor? They’re supposedly trying to hire back former employees to provide supplemental staffing for application build and design, credentialed training, and go-live support. They would price this as part of the license cost under ‘enhancement implementation services.’” Unverified.

From Baldp8: “Re: Medicare reimbursement break-even in hospitals. How will this impact the IT capital and operating budgets? More spending to automate costs out or less spending to get to a number?”

From Lovin’ Sunshine: “Re: McKesson Practice Partner. Heard that Mel Coovert is no longer with the company, making us consultant folks wonder if Practice Partner is headed the way of Horizon Clinicals. Makes us go ‘hmmmm’ being right in the middle of an implementation.” Melissa Coovert left the company last month, according to her LinkedIn profile. That’s all I know.

HIStalk Announcements and Requests

I had a brush with technology at the doctor’s office this week. I had a minor procedure a couple weeks ago and the incision area has not healed well. Yesterday I decided I should have my doctor check it out, but she had taken the day off.  I saw one of her partners instead, who asked me to compare the site with its appearance a week ago. That’s when I whipped out my iPhone and showed him a picture I had taken. He then made his assessment (I’m getting better) and I went on my way. It’s the little things that get me geeked.

The folks at Imprivata sent over this brilliant item from their April newsletter.

Acquisitions, Funding, Business, and Stock

Cerner CEO Neal Patterson earned $5.6 million last year, a 10% boost over 2010. Compensation included a salary of $1.025 million, $1.6 million in cash incentives, and stock options valued at $2.8 million on the date they were granted. He also received $122,412 in “other compensation” that included $110,000 for his private use of the corporate aircraft, plus contributions to his 401(K), insurance plans, and private security systems.

Sales

Mercy selects Merge Healthcare’s iConnect VNA as its image archive solution for more than 200 facilities across the Midwest.

The 200-member IPA of Nassau/Suffolk Counties (NY) selects Greenway’s PrimeSUITE EHR/PM solution.

FirstHealth of the Carolinas selects Thomson Reuters’ Integration Discovery, powered by CareEvolution, to provide clinical interoperability across its system.

People

Cardinal Health names Donald M. Casey, Jr. CEO of its medical products and services business. He was previously CEO of the West Wireless Health Institute.

John D. Bennett MD, FACC, FACP, president of CDPHP, joins the board of New York eHealth Collaborative.

David O’Hara, COO of Microsoft Advertising, joins the board of Intelligent Insites.

Announcements and Implementations

The Hawaii HIE goes live on messaging and referrals using the Medicity platform.

Elsevier launches ClinicalKey, an online collection of clinical resources covering every medical and surgical specialty and including over 700 textbooks and 400 medical journals.

Capsule Tech releases the first of a series of videos called Connected Consultants intended to educate clinicians and IT staff about medical device integration. The first one is pretty funny.

UnitedHealthcare donates $700,000 to the California Telehealth Network to expand telemedicine training and support rural and medically underserved clinics and hospitals in California.

Government and Politics

CMS announces that 27 ACOs have entered into agreements to participate in the Shared Savings Program beginning April 1, 2012 and has selected five organizations for inclusion in its Advanced Payment ACO model. CMS is considering an additional 50 applicants for the Advance Payment program beginning July 1st.

CMS publishes a full set of proposed Clinical Quality Measures for 2014 as part of the proposed Stage 2 EHR rule.

Other

I loved this headline and yes, it prompted me to read the article. The Washington Post article discusses a letter recently published in the British Medical Journal, which highlighted the amount of data entered incorrectly into the UK’s medical system.

A class-action lawsuit is filed against St. Joseph Health System (CA), which in 2011 accidentally released information on 31,800 patients. At the time of the breach, personal and medical information stored in unencrypted electronic reports were searchable online. The suit seeks $31.8 million, following California’s mandatory damages of $1,000 per affected individual.

Weird News Andy spotted this major breach news. An IT tech’s weak server password allows European hackers to penetrate a Utah Department of Health Medicaid claims server, where they download thousands of files covering nearly 900,000 individuals, of which 280,000 have their Social Security numbers stolen. Here’s an interesting quote from RSA’s CISO:

Why do we continue to see these large aggregate databases? Why should hackers be able to steal 10 million credit card numbers or 700,000 personal records at once? We need to think about distributing that information so that when networks do get penetrated, we’re not looking an all-or-nothing situation.

WNA also likes this story about the geriatric ED at Mount Sinai Hospital (NY), of which there are several dozen nationally. He’s a bit creeped out by the dome in the photo, saying it reminds him of Edward G. Robinson in Soylent Green.

A state audit of SUNY Downstate Medical Center finds that only 10 of its 200 departments are using the $2 million purchasing system it implemented over a four-year period.

A Time article says that cash-strapped universities, following the lead of for-profit schools, are cranking out high-margin professional certificate programs that are attractive to mid-career students who don’t need financial aid or whose employers reimburse them. Healthcare technology management was mentioned. Experts question the quality and the career value to students.

HealthPrize Technologies, which encourages medication adherence through online games and rewards, brings on new staff to support what it says is major growth. Founder and CEO Tom Kottler’s first startup was revenue cycle vendor MedAptus.

The CEO of Sony, which just announced a $6.4 billion loss for the year, says the company may get into the medical products business.

Jack Tramiel, who bought a typewriter repair shop and turned it into Commodore, the company whose early computers (VIC-20, PET, Commodore 64) helped make home computing popular, died this week at 83.

The CEO of Henry Ford Health System (MI), reporting a 64% decrease in net income to $22 million, calls the past two years “transition years” as the organization spent $300 million on Epic less than a year after going live on its $100 million homegrown system.

Four former executives of iSoft, including former chairman Patrick Cryne, will be tried in the UK, charged with making intentionally misleading statements to inflate the company’s financial position.

An attorney and former employee of the Austin, TX-based Cancer Connection volunteer program sues her former employer for wrongful termination, saying the organization ignored her strong warnings that it needed to implement HIPAA training and to stop giving volunteer-prepared baked goods to cancer patients. One of the organization’s founders and board members, known as “the brownie lady,” told her the baked goods policy would not be changed.

Sponsor Updates

• In Turkey, Emsey Hospital implements iMDsoft’s MetaVision in its ICU.
• Culicchia Neurological Clinic (LA) selects SRS EHR and Patient Portal for its 17 providers.
• MEDecision announces details of its Client Forum 2012 conference May 1-4 in Philadelphia.
• Liaison Technologies completes all milestones required as part of a $30 million investment from Merck’s Global Health Innovation Fund.
• Kony Solutions appoints Harold Goldberg (Merced Systems) its chief marketing officer.
• Raymond Gruby MD, FACS, chief medical officer at Intelligent InSites, will present a session on RTLS in medicine at this week’s meeting of the SD/ND chapters of the American College of Surgeons.
• MEDSEEK and Microsoft co-host an April 12 Webinar explaining why healthcare reform strategies will fail without patient engagement.
• Kareo launches a Resource Center that includes webinars, white papers, and educational videos.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

3M Acquires CodeRyte

3M announced this morning that it has acquired CodeRyte, which offers natural language processing and computer-assisted coding tools. 3M has offered CodeRyte’s computer assisted coding products to its own customers since 2009.

CodeRyte offerings include Health System Coding (natural language processing and coding workflows); CodeAssist (automated coding using extracted text from physician documentation); CodeComplete (outsourced coding services); and DataScout (analytics using information extracted from both structured and unstructured records.)

3M Health Information Systems VP/GM Jon Lindekugel was quote as saying in the announcement, “This acquisition allows us to apply CodeRyte’s leading edge NLP technology to our new 3M 360 Encompass System. We believe CodeRyte’s powerful NLP engine combined with 3M’s deep expertise in coding, reimbursement and patient classification will foster further innovation in the application of NLP.”

CodeRyte’s 130 Bethesda, MD-based employees serve 250 customers, which the company says represents 85% of academic medical centers that use computer-assisted coding.

Curbside Consult with Dr. Jayne 4/9/12

The hot news around the non-virtual water cooler this week has been the call by many physician professional organizations to reduce unnecessary medical tests and procedures. The move is aimed at lowering health care costs and improving decision making. The campaign, called “Choosing Wisely,” hopes to engage doctors and patients in a dialog around the procedures and tests.

In my experience, even the most educated patients are reluctant to go along with guidelines and evidence-based medicine, frequently demanding tests “just to make absolutely sure” that a problem doesn’t exist, or even worse, “because insurance will pay for it.”

I have had countless arguments with patients over all manner of tests and treatments. It’s difficult to help patients understand that medical testing isn’t entirely harmless. There is always the risk of a false-positive test that can result in further unneeded testing, stress, and potential harm. Radiation exposure is cumulative. Tests aren’t necessarily indicated just because a cardiology practice that owns a CT scanner is running radio ads that offer discounted cardiac risk scoring.

Many of the tests on the list are obviously questionable, yet patients consistently demand x-rays for low back pain. I have many colleagues who order colonoscopies every seven years for low-risk patients.

I’m sure many think this list will be helpful to stimulate discussion with patients, but I’ve tried the literature and data route before. Patients have accused me of trying to ration care when I’m simply following evidence-based guidelines.

Every patient has a story about something that “the doctors missed” and is afraid it will happen to them. There is also the subset of providers who don’t want to get caught on the wrong side of a lawsuit should something be missed.

A glance at my local newspaper today revealed four of five reader comments along the lines of, “The doctor didn’t want to do the test, but I demanded it and it saved me from a life-threatening situation.” I appreciate these individuals’ stories, but ordering every test on every patient every time is not only poor patient care, but a recipe for economic collapse.

The participating physician groups are partnering with Consumer Reports and AARP to get the word out, but I’m not sure it’s going to make a difference. As long as payers continue to cover some of these items (such as annual EKGs for low-risk patients without symptoms) it’s going to be an uphill battle.

Additionally, hospitals still often require some of these tests – such as a preoperative chest x-ray for all patients regardless of risk – making it difficult for physicians to just say no. The entire list of 45 procedures (each of the nine participating specialty groups identified five procedures that are overused) can be found online at Choosing Wisely.

From an EHR perspective, figuring out how to work clinical guidelines into real-world workflows and ensure truly usable clinical decision support is tricky enough when the guidelines are clear cut. When they’re not so clear (especially when you have multiple bodies recommending strategies which are contradictory, such as the mammography guidelines) it’s nearly impossible.

I’ve been asked by individual physicians to re-code clinical decision support during EHR go-lives because they don’t agree with the national standards. Indeed, we are in America, but as long as providers continue to have cowboy attitudes this will be a struggle. Similarly, the transition from “patients as patients” to “patients as consumers / customers” has also created difficulties. When physicians are graded on patient satisfaction scores, the decision to deny unneeded antibiotics or a requested test becomes more difficult.

I’m interested to hear how these recommendations have affected you. If you’re a physician or provider, are your patients hearing any buzz on this topic? And if you’re in IT or software support, are you receiving requests to modify clinical decision support to reflect constantly changing guidelines? Let me know what you think. E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 4/9/12

From N2InformaticsRN: “Re: UCI Medical Center. Developed a program to bring staff nurses into the field of nursing informatics in support of their EMR implementation. It uses ONC’s Health IT Workforce Curriculum as its core.” Above is the video explaining the program.  

From El Pescador: “Re: HITECH incentives. I don’t disagree with you often, but I do this time. We are one of the systems that is going to get a ‘windfall’ in MU money without significant investment. Where I take issue with your response is that when the looming reductions in reimbursement are taken into account – surprise – it’s almost dollar for dollar. Zero sum game for our organization. Perhaps others don’t find themselves in the same boat. Enjoy your website immensely … best source of info in the industry.” I think my point is still valid. CMS may indeed take your money elsewhere, but that was not related to your unrestricted HITECH “grant.” Without it you would be in the hole rather than even. It’s like winning $2,000 on a scratch-off lottery ticket but blowing your car’s transmission at a repair cost of $2,000 on the way to cash it in. You still won the lottery, and the repair was going to cost you $2,000 in any case. WildcatWell’s original question was: is it fraud when providers use a free EHR to earn HITECH money? Answer: no, there is no requirement to spend anything to earn an MU check. Most providers will indeed spend money (and sweat) to earn their payout, but that’s between them and their vendor … Uncle Sam doesn’t care when he writes the check.

From WildcatWell: “Re: Jason Dufner. Would a Masters win bolster his sponsor’s footing? Doubt it. At Augusta, a Greenway label comes across like a landscaping company. Wasted marketing dollars.” Above is an Associated Press photo of him after the second round with the Greenway logo on his shirt. Like NASCAR drivers and football coaches, life is good when you get big paychecks just for wearing logo apparel in public. I don’t know how you’d calculate the ROI on wearing a PM/EMR logo in front of a golfing audience, but I assume there’s leverage opportunities with prospects who enjoy watching someone else play golf.

From Fish: “Re: Epic’s 2006 ambulatory sale to Capital Health in Edmonton, Alberta. Whatever happened to it?” Beats me. Readers?

Imprivata provided a response to 1Sign’s unverified rumor about Dell having discussions with the company about an acquisition. Here it is: “Not true.”

Our judicial handicappers expect the Supreme Court to strike down just the insurance part of the Affordable Care Act, with equal minorities saying it will be all or none. New poll to your right: how much impact will the JOBS Act have on healthcare IT startups and innovation?

In case you don’t know what the JOBS Act is, here’s a CliffsNotes version. The JOBS Act, signed into law last week, makes it easier for small business startups to raise investment capital. Anybody can offer the general public shares in their venture, which was previously illegal (investors had to be accredited, i.e. wealthy and vetted, before being allowed to buy their way in.) The new law lets anyone invest and allows early-stage and tiny companies to solicit investors, even via Web-based “crowdfunding.” On the downside, amateur investors are on their own to perform due diligence, some shaky companies are now going to be free to pitch to investors, and lawyers will probably make a fortune as would-be CEOs and their unsophisticated investors butt heads. The hope is that small businesses can grow faster with easier access to unrestricted capital, allowing them to hire employees earlier than they would have otherwise.

An article in Clinical Pharmacology & Therapeutics called Electronic Health Records: The New Vehicle for Drug Labeling, Safety, and Efficacy by Ed Fotsch MD, CEO of PDR Network, proposes that services like those offered by his company could increase safety and decrease liability by delivering up-to-date drug labeling, REMS, and adverse event reporting right to individual provider EMRs. It finds from its own database that 25% of brand name drugs have clinically significant changes in their professional labeling each year, meaning that paper-based literature used to make clinical decisions is often obsolete. The problem: most EHRs don’t have the capability to electronically receive these alerts and confirm receipt. The article also says that EHRs could be used to file adverse drug event reports with the FDA and improve patient adherence.

Note: I come home straight from work on Tuesdays and Thursdays and jump right in to spend an unbroken 4-5 hours writing HIStalk and I’m up pre-dawn the next day to go to work. Therefore, I will rarely be able to reply to any Tuesday or Thursday e-mail until the next evening at the earliest. Re-sending the e-mail doesn’t do anything except clog my inbox even further. I always catch up, but it takes time.

Thanks to the following sponsors, new and renewing, that supported HIStalk, HIStalk Practice, and HIStalk Mobile in March. Click on a logo for more information.

Law firms are using California’s Confidential Medical Information Act of 1981 to file profitable class action lawsuits against providers, who are required by that law to pay $1,000 for each person whose information is exposed. The article says McKesson lobbied to have the damages clause removed retroactively about a year ago, but failed. Courts will need to decide whether the law is appropriate since when it was written in 1981, breaches were both rare and small, but today a single breach could result in millions of dollars in payments, which the lawyers find irresistible. 

E-mail Mr. H.

The Healthcare IT Week in Review

1. Newt’s Think Tank Tanks

Facts and Background

The Gingrich Group LLC, doing business as the Center for Health Transformation, filed for Chapter 7 liquidation after struggling to maintain relevance once founder and former Congressman Newt Gingrich resigned last spring to run for the presidency. The for-profit group offered its strategic services to healthcare companies whose products and services addressed Gingrich’s big ideas themes, including healthcare IT. The company had pulled in $55 million by charging companies such as Blue Cross Blue Shield, Allscripts, HealthTrio, and VISICU up to $200K per year to gain access to Gingrich and his contacts.

Opinion

CHT was not illegal, just distasteful. It’s satisfying that it went down in flames, but unfortunately Pilot Newt had already done a DB Cooper and bailed out with the money. It’s too bad that the smoking wreckage still had employees who lost their livelihoods because Newt decided to run an unsuccessful political campaign, not to mention surprising that he didn’t just end his presidential run and go back to the one thing he’s been really successful at — selling his influence. It’s too bad that he presumably had at least some hand in  getting the $19 billion HITECH package inserted into the stimulus bill.

Musings

• CHT was like William Shatner signing autographs at Star Trek conventions. If you wanted Newt’s attention, it was going to cost you.
• Unlike Shatner, CHT claims it wouldn’t accept money from anyone whose agendas didn’t align with Newt’s, but offered no proof that Newt’s rich man’s club had standards that exceeded passing a mandatory checkbook inspection.
• Newt’s loyalties were apparently available even when for issues that would not typically enjoy widespread Republican support, such as pushing federally subsidized EMRs and mandatory health insurance.
• One of CHT’s most controversial clients was Freddie Mac, which paid CHT $1.6 million to advise it on potentially troublesome new Congressional regulation. He claimed he was hired as a historian, which probably encouraged historians everywhere to offer their services as a slight discount. Freddie Mac’s bailout will cost taxpayers up to $360 billion.
• Newt was adamant that CHT did no lobbying, which was critical to preserve his presidential run. That’s probably legally correct, but the average citizen would find it hard to believe that paying a former Speaker of the House to make introductions to his political pals and and to pitch client offerings in Washington isn’t pretty much the same thing.
• In a fit of stimulus schizophrenia, Newt called the stimulus package a “big politician, big bureaucracy, pork-laden bill” that should be stopped, but lauded the HITECH part of it that benefitted his clients as “a key part of the stimulus package.”
• After the stimulus bill passed, CHT set up regional meetings called the “EHR Stimulus Tour” with Allscripts and Microsoft, urging doctors to implement EHRs to get their taxpayer payouts.
• While running CHT, Newt kept popping up like Where’s Waldo at Washington events and even on the Capitol floor, but his former colleagues never questioned why he was entitled to have that access. Some said later they didn’t realize CHT was a for-profit organization, assuming from its name that it was a non-profit think tank with purely altruistic interests.

2. CSC: Pardon the $30 Billion UK Black Hole –What US Healthcare Needs is Lorenzo

Facts and Background

Government consulting CSC, a key player in the massive NPfIT failure in the UK, says it will use the lessons learned there to launch its Lorenzo product in the US.

Opinion

Choose your site visits carefully.

Musings

• CSC bought iSoft a year ago when that company, which was also the key supplier in CSC’s NPfIT contract, was about to go belly up after huge losses and government financial investigations.
• iSoft had a long record of missing its NPfIT dates, although it was an awkward arrangement between CSC as the contractor and iSoft as its most important provider.
• Once NPfIT was shut down, individual trusts could decide whether they still wanted the previously mandated Lorenzo. Many didn’t.
• When the UK government talked about the money that could be saved shutting down NPfIT, CSC said it would sue the government since it had spent $1.5 billion trying to get Lorenzo running in England and was planning to make an extra $3 billion for the planned one-year extension.
• The company’s UK problems triggered layoffs and investor lawsuits.
• CSC joins every other NPfIT contractor and supplier in nearly going under after winning what seemed like a windfall NPfIT business, but accepting such hardball contract terms that they couldn’t deliver.
• CSC named former Misys PLC CEO Mike Lawrie as president and CEO in February.
• Shares are worth half what they were five years ago.
• A key CSC healthcare acquisition was First Consulting Group in 2007 for $365 million.
• Much of the reason US vendors such as Cerner have struggled in the UK is because of localization issues, trying to get software designed around US healthcare processes to work elsewhere. Lorenzo will have the same challenge in reverse here.
• All that said, it will be fun to see if Lorenzo is competitive with the usual suspects (Cerner, Meditech, Epic, etc.) and whether CSC will offer a wide range of department and financial systems instead of just clinical systems. The market could use another choice.

3. Data Entry Error Kills Baby, Costs Hospital $8 Million

Facts and Background

Advocate Lutheran General Hospital (IL), which admitted that a pharmacy technician’s IV machine data entry error in 2010 killed a baby, settled the family’s lawsuit for $8.25 million last week.

Opinion

Many hospitals have electronic interfaces that connect their pharmacy system to their IV manufacturing systems. Why didn’t Advocate? Hospital system vendors often consider such interoperability only begrudgingly since there’s no benefit to them other than keeping clients happy, so it would be interesting to know whether that option was available.

Musings

• IV room automation is perhaps the least-understood, yet most patient-impacting technology a hospital owns. The final product is a clear solution that may or may not contain the intended contents in their correct amounts, and mistakes are often deadly and undetectable.
• IV compounder data entry errors are not uncommon, just not commonly reported and not always fatal. Any time you have people keying highly critical numbers into a machine there’s a good chance that they will eventually mess up. Allowing this work to be performed by unlicensed personnel is not a good idea, but the reality is that anyone – licensed or not – could have made the same mistake.
• IT departments are usually at least slightly involved in IV compounders because they require a server, but often they stop there and assume the pharmacy department knows what it’s doing.
• Potentially life-saving alerts on the compounder were turned off, but activated after the fatality.
• A lab tech sealed the baby’s fate by assuming that his high serum sodium level was a mistake, rather than what it really was – the last chance to catch the IV error before it was too late.
• Some clueless critics blamed CPOE for this error. That had nothing to do with it – the order was entered correctly by the prescriber and the pharmacist in the CPOE and pharmacy systems, respectively. It was the sometimes forgotten but most important step of actually preparing the ordered dose for the patient where things went horribly wrong.
• CIO lesson learned: don’t assume the world revolves around big-iron IT systems. Go to the sharp end of the stick (on the nursing stations, ED, and particularly high-acuity areas like the OR and ICU) and see what gets put into patients. Then track it backward to see where it comes from. Technology could be increasing the chance of mistakes, or it could offer opportunities to reduce them. Serious patient drug harm is rarely caused by drug ordering (which is where IT systems focus), sometimes caused by drug preparation, and often caused by drug administration.

Time Capsule: My Secret Nostalgia for Small Hospitals

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

I wrote this piece in March 2007.

My Secret Nostalgia for Small Hospitals
By Mr. HIStalk

I have a dream at least once a week. I’m working in a tiny hospital in a flyspeck of a town, an architecturally outdated cinderblock building plopped in a big field in the shadow of lofty mountains. I’m running my little department nearly single-handedly. I’m feeling good, relaxed, and confident that I’m making a great contribution. I like the administrators, the physicians, and my co-workers.

If you’ve ever worked in a small hospital, you know how honorable and satisfying a profession that can be. The commute is traffic-free and I just might stop off on the way to work to buy bag of biscuits for the people I work with. If anyone in my family has medical needs, I know they’ll be treated very well by my peers who are – dare I say it? – friends. The “we’re all in this together” feeling is universal.

In other words, I’m back in the 50-bed hospital I worked for right out of college. The soft gauze of time has probably softened the memory of low pay, stretched resources, and plain-Jane facilities. Still, I never had to attend meetings, I didn’t worry about being on the wrong end of a corporate back-stabbing, and I knew I could make a difference in just about any way I chose. I was on top of my game and I knew it.

I miss it, even though I’m sure it’s changed since then. Sometimes I think I shouldn’t have been so anxious to move up to bigger and allegedly better places with their layers of bureaucracy, unchecked egos, and big but sometimes poorly managed budgets and IT projects.

I like small-hospital IT, even though it’s the minor league of the industry. I keep reminding myself that the majority of hospitals aren’t sprawling medical complexes – they’re little buildings where proud locals are born and will die, with no interest whatsoever in heading off for an impersonal and often dangerous big-city medical center.

Any plans to raise healthcare’s technology bar must include that majority of hospitals that are small, poor, and under-resourced. They need simple, affordable technologies that work, not $25 million systems that require a small army of support staff and an ego- driven CIO making $400,000 a year.

Luckily, some very good vendors are happy to sell into these little hospitals at an affordable price. In fact, some of their customers have outdone their big- hospital peers in rolling out CPOE, paperless medical records, and IT-driven improvements in outcomes. I love to see that. Too often, they feel inferior at the modest scope of their efforts.

I’m sometimes guilty of getting on my high horse about big-hospital IT. That’s odd since, as an insider, I know how poorly it can work even in a big hospital. I’ve played a role in huge IDNs that bought little hospitals and haughtily tossed out all their highly functional systems just for our own IT convenience, i.e. “standardization,” knowing that they were actually way ahead of us with their little econobox IT stuff because they actually used it right. Too bad.

Maybe I’m just being uncharacteristically and overly sentimental, but I’d like to give a respectful nod to that great majority of hospitals that vendors, consultants, and member groups often forget about. Some of us in seemingly glamorous places have a secret: we recognize that you sometimes do a better job for your patients than we do for ours. And, in our dreams, at least, we sometimes come back home.

HIStalk Interviews G. Cameron Deemer, President, DrFirst

G. Cameron “Cam” Deemer is president of DrFirst of Rockville, MD.

Tell me about yourself and about DrFirst.

I started in healthcare in the pharmacy benefits management industry. I joined PCS Health Systems in the early ‘90s and spent about 10 years there, largely in product management. I worked in developing what were at that time brand new concepts, like tiered formularies, closed formularies, and performance-based programs.

After the fourth acquisition of PCS, I left and joined NDCHealth, primarily to help them get their e-prescribing initiative off the ground. At the time, they were very much aiming to be what Surescripts is today. I spent about a year working on that with them until they decided there really wasn’t much benefit in continuing to pursue that direction. I moved instead to working with their EMR and practice management system strategy. In 2004, I joined DrFirst.

To give you a little background on DrFirst, the company started January 1, 2000. It was founded by Jim Chen, who is still CEO of the company today. Jim a was one of early inventors of virtual private networks in his previous company, V-ONE . He believed that he could use that VPN technology he developed to deliver affordable systems to physicians in an ASP environment.

Toward that end, in the very earliest days of the company, he went out and bought a worldwide unlimited license to NextGen and set the company up as a NextGen VAR. He quickly realized that wasn’t something that DrFirst could scale. It wasn’t really going to get the company where he wanted to be.

In 2001, the company started working on an e-prescribing system, with some early pilots at MedStar Health System and Kaiser Permanente.  They eventually developed a product with a real nice workflow that became the core technology that would take the company through the next eight or nine years.

Around 2004, we decided that it really wasn’t going to be a long-term proposition to be an e-prescribing company. It was clear even then that the industry would eventually move away toward EMR, and e-prescribing would just be a part of a larger application. That was the year we started developing our platform strategy, that we would put together a set of technology platforms to try to fill some of the gaps that other vendors had in their capabilities or strategies. 

We started with our e-prescribing system since that’s what we had at the time. Tore it apart into its constituent pieces and offered it out as a platform for other vendors.

MediNotes was our first client. Since then, an additional 249 EMRs have selected us as a technology platform to build their e-prescribing on top of. Since then, we continued forward with e-prescribing. We’ve developed a modular EHR for Meaningful Use that we consider a step up from e-prescribing. And then we have this very large set of partnerships with EMR vendors to which we can transition physicians when they’re ready to make that next step to a fully paperless office.

On the application side, we’re pursuing a step-wise approach for physicians. In the broader scheme of things we’re developing, we’re continuing to develop a series of platforms to fill gaps that we see in healthcare.

The company was offering back in 2000 what we would call cloud technology today. Now you’re moving into something like apps, working with other systems to offer specialized functionality. That’s good foresight. Do you think other vendors will build products to plug into existing products that may have shortcomings?

We’ve seen a couple of other companies get into the space, primarily around e-prescribing. For us, all of the platforms we offer reinforce one another. We don’t think there’s a lot of benefit in going at it piecemeal, just picking a technology and saying, “Hey, we’re going to do that one.”

For instance, I mentioned that we started with our e-prescribing platform. About that same time, we also offered a hosting platform for payer information — eligibility, medication history, formulary. That way, as physicians adopted e-prescribing, if there were payers that weren’t hosted by Surescripts, we would be able to provide the hosting service, so that physicians in a specific area, whether they were in a hospital or in the ambulatory space, they would be able to access this payer data they wouldn’t otherwise have access to. And payers, who for whatever reason chose not to be hosted, would have access to the technology so they could get their information out to their physicians.

We subsequently offered another platform for hospitals. It provided medication history as the front end of a medication reconciliation process and discharge prescribing as the back end. Those, of course, are reinforced by the fact that we’ve got e-prescribing out in the ambulatory environment feeding into the hospital admissions process, and then have the information coming back out of the hospital available to all those e-prescribing physicians. 

All of our platforms are like that. They all tie together in some way that reinforces the community aspect of healthcare, as well as the different stakeholders and what they might want out of the processes. So yes, I think other companies will get into the apps space. I hope we’re doing it in a more integrated way that will have lasting value to people who participate on our platforms.

There are people who are critical of almost any given technology, from CPOE to Meaningful Use, but e-prescribing was such a natural that nobody seemed to rally a defense against it. Do you think the battle of getting e-prescribing adoption has been won?

Absolutely. It’s a very interesting point. It’s exactly true. If you think about the claims side of the business, pharmacy actually was well ahead of medical claims in getting their act together in that space. Again, I started healthcare with PCS, and even back in ‘90s, everything was pretty buttoned down as far as pharmacy claims. 

It was no big surprise to me that pharmacy got out ahead on the e-prescribing side as well. They had a well-established standards-setting organization in NCPDP. They had a track record of cooperation between vendors and payers. So yes, I think the battle actually was won a long time ago, but we’re just continuing to watch it play out now as we move to the mainstream of physicians.

The next level of value added could be detecting patient non-adherence, treatment conflicts, or medication reconciliation. You also have your RcopiaAC product that allows hospitals to get a full medication history from outside their four walls. Other than patient convenience, what do you see as the next level in terms of patient benefit and improvement of outcomes?

The next level of value that we’re trying to provide is what we call our Patient Innovations platform. This is where we look at the whole compliance and adherence process for the patient and we work to have some impact at each point in that. This is different with e-prescribing versus working off pharmacy claims. With e-prescribing, you have a chance to move the whole thing further forward in the process, because now you’ve got a record of the physician intent and not just what the patient did later.

We have an opportunity when the physician writes a prescription to really give the patient information they need to be comfortable with a therapy. Provide inducements to get that first fill done, which is a big part of the battle, with estimates between 20 and 30 percent of scripts never being filled. And then as the patient is out receiving therapy, we can continue to message the patient. We can provide additional information.

But most importantly, we can give the physician feedback in real time on how the patient is doing in compliance with their therapy.  The next time that the patient comes in to see the physician, they’re sitting face to face, the physician looks at his e-prescribing system, and he can see right there whether the patient has been compliant with therapy and can have an interaction.

Giving the physician the tools they need, helping the patient stay highly informed, and then providing rewards and incentives … we’re trying to put that all together into a single platform that we can offer out to the industry rather than just use it inside our own application.

It’s an interesting point from the physician’s perspective. They don’t know if the patient received what they ordered unless the patient tells them. In this age of trying to be accountable for overall coordination of care and wellness, that’s going to be a huge weak link if they don’t even know whether the patient had their prescription filled, their labs drawn, or their images taken. Are physicians ready to take that role on, to get all this information but then be required to follow up if something doesn’t happen?

I’ve been in a number of focus groups or informal discussions with physicians. DrFirst works with many large enterprise organizations, which gives us an opportunity to have talks with people who are pretty sophisticated about this. What typically happens in one of those meetings is the physicians will all agree right away, “This is a great idea. We want to know whether the patients are compliant with therapy.”

And then one physician will sit back, kind of cross his arms, and say, “Now wait a minute. Are you creating a whole new demand on me? Are you creating a liability, where I’m going to have to chase down my patients and make them do what I told them to, or that’s going to come back to me in court sometime?” That will generally start a big ruckus in the room. 

About half the docs will line up on that side and say, “Look, my patients are adults. They’ll make their own decisions. I just tell them what’s best in my opinion and it’s up to them whether to comply.” And the other half will say, “No, I want this information no matter what.”

This was confounding for a while. But we found that what would work for all the doctors we talked to was, “When the patient’s back with me, that’s when I want the information. I don’t have any problem at all knowing it when they’re sitting in my office. I just don’t necessarily want to be expected to track them down outside of my regular encounter time with them.” So we’ve designed our platform specifically to give the physician information when they’re actually engaged with a patient. That seems to meet everybody’s needs.

How would your platform fit in with interoperability projects like HIEs that try to collect a bunch of different information and put it all together?

It’s going to be a little funny to list off platform after platform here, but that’s really how we’re structuring the business going forward — as a series of valuable platforms that people can tap into for the APIs and be able to offer these things up in a way that makes sense within their own systems.

We have a messaging platform that hasn’t quite launched yet. That’s the product that will tie all of our data back in the HIEs. We’re in the process of just cleaning up the APIs and getting our software toolkit together. We’ll be making that available to the industry very soon. It’s a very flexible system, with some really exciting capabilities well beyond what anyone else is doing. we believe. We’re excited to offer that. We see the need and that’s why we put the additional platform together.

You mentioned that you’re looking at different elements of missing functionality. What areas do you think could be improved that there might be an opportunity for DrFirst?

In the industry today, there are just some structural problems because of the large number of EMRs, EHRs out in the market. We count about 600, of which 250 are our current clients, but we’re broadening our client base now to include EHRs who don’t necessarily want to do e-prescribing with us but would find some of our other platforms valuable. If those 600 EMRs, for instance, want to tap the data analytics market, there are a few very large ones who already have projects under way, but it’s questionable whether some of them are big enough to really do this in a serious way.

We hope to be able to bring things to the market that make it possible for a large number of EMRs to band together and access sources of revenue that wouldn’t otherwise be available to them, whether that’s revenue in the payer space or the pharma space. Help them have access to sophisticated technology.

Let’s say the sophisticated technology is related to patient communications. Things that they may not be able to develop themselves, but would love to have as part of the way they interact with patients. We want to bring those things in. The idea is to create a central point where every EMR in the country can come to get the service they would like to have. And on the other side of that, have a single point of contact for other entities down into the EMR community.

We feel DrFirst is very well positioned to do that by virtue of our track record of success in working with a large number of partners. We’ve clearly shown that we’re a company that can be trusted. We have the best interest of our partners in mind. We just want to continue to bring a series of valuable revenue and technology opportunities to both sides of the equations — to the EHR, EMR, hospitals on the one side, and to payers, pharma, patients, pharmacies, everyone else who would like to tap in to that community on the other side.

I noticed on your site that you have a tool where you can search for EMRs by capabilities. I suppose they are your customers more than the end users, although you can help them create demand for their products. Being in a neutral position supplying a number of them with technologies, how do you see those 600 EMR vendors differentiating themselves as the market evolves?

That was the purpose of that evaluation tool on our website. One of the things that we offer to bring to the EMRs that currently work with us on e-prescribing is that we would be more than happy to be a point of lead generation for them. We talk to physicians all the time through our own sales force. Often, physicians are not looking for e-prescribing or a modular EHR such as we offer. Instead, they’re looking for an EMR. We happily point them to our partners, because we like for them to be successful as well.

If you look through the tool, you can see they’re distinguishing themselves on the basis of specialty focus or functionality, support, certification. We try it to make it possible for them to be able to position themselves however they’d like to position themselves. We try very hard to not play favorites.

As a platform vendor, we would like them all to succeed. We’d like to be that rising tide that lifts all ships. They really do need to pursue their own individual business strategies as well.

If you look down the road five years, where do you see the industry going and what must you do to be competitive?

I think the whole industry will continue to be impacted by Meaningful Use for easily the next five years. We would expect to see a lot of creativity around EHRs going forward. A lot of startups — lots and lots of startups – are still entering the market. People are bringing in new technology to replace old technology. We’re pretty excited about the level of energy that’s still going in to this market.

I’m very encouraged by the direction the ONC is taking. They seem to be stepping back a little from a very onerous “one way fits all” strategy and instead are making room for people to do similar things, but in different ways. We think that’s very positive.

We as a company would really like five years from now to be a part of more than half of the EMRs– hopefully 75% of the EMRs offering one or more of our platforms. Helping them be successful in this space.

We really embrace the fact that there are such a large number of EHRs because it shows that no one’s quite yet figured out exactly how do healthcare IT right. There’s room for lots of differences of opinion. We’d like to help them all be successful at driving the business the way they want to drive it.

I get asked a lot about who our competitors are. It’s very difficult, I think, to find another company in this space that sees it quite the way we do. It is an interesting task trying to find a way to stay neutral, but yet help people really feel that you care about what happens to them as a business. But it’s a lot of fun seeing so many creative, smart people trying to figure out ways to do things better than other people. It’s been really great to have an opportunity to work with so many of them and be a little part of what they do.

News 4/6/12

Top News

From the earlier news blast: The Gingrich Group LLC, doing business as the Center for Health Transformation, has filed for Chapter 7 bankruptcy in a Georgia court. The for-profit organization, which makes up the majority of Newt Gingrich’s net worth in the form of money it owes him for his share of ownership, struggled to survive after Gingrich resigned as its chairman last year to run for the presidency. The organization listed its assets as less than $100,000, with liabilities stated as $1 million to $10 million. Several healthcare IT companies are listed among its creditors, including Cerner, Greenway, and Health Trio.

My initial reaction to CHT’s tanking:

1. So much for pretending that Center for Health Transformation was anything more than a way for Newt to sell his political influence to high-paying vendors under the guise of healthcare advocacy. The business folded almost immediately once he quit to run (badly) for the presidency.
2. How could CHT owe vendors money? Membership refunds? Or maybe the value of services not yet rendered?
3. Thanks to immediately available electronic images of the bankruptcy filing, you can learn Newt’s home address and read a list of the CHT staff members getting stiffed, like the recently hired project assistant who left her Dress Barn sales job to work there.
4. There weren’t many employees left by the time the bow slipped beneath the waves since most were apparently smart enough to have abandoned ship as soon as Captain Newt sailed off in his political life raft.
5. The most surprising aspect: why doesn’t Newt pump a few dollars into CHT to keep his seat warm since he’ll be needing a job shortly? That one seemed to have compensated him very well. Maybe political jab-taking had tainted the CHT name and his involvement to the point it was more of a liability than an asset.

Reader Comments

From 1Sign: “Re: Dell. After the Wyse acquisition, Dell is in discussion with Imprivata to complete their Mobile Clinical Computing solution. Imprivata is the last major SSO vendor not acquired and the Board is pressuring the leadership team.” Unverified.

From Rommel: “Re: shakeup coming at [vendor name deleted.] One executive gone in some manner, just the beginning. Q1 numbers are way off and the CEO is on the hot seat and may be clipped shortly.” Unverified, so I’m not comfortable naming the company. I would say the mood there probably is tense, though.

From Boston: “Re: Partners HealthCare. Enterprise-wide EMR decision has been postponed until later in the spring, probably June.” Unverified.

From K-Federal: “Re: [practice EMR vendor name deleted.] Heard from two reliable sources that it’s on the block to either Greenway or Allscripts.” Unverified, so again I’ll omit names. We snooped around a little and nobody’s talking, which may or may not mean anything. Supposedly a significant investor in the company may be selling some of its stake, but maybe there’s more to the story.  

From Loquacious: “Re: Vitera. Lee Horner is no longer listed as SVP of sales and marketing on their site. Is he still there?” His LinkedIn profile says he’s still there, although I’ve found that people often forget to keep those current when they change jobs.

From WildcatWell: “Re: HITECH incentives. If an EHR vendor offers their system as ‘free’ and a subscriber then demonstrates MU and pockets $44K, that’s not a cost-offsetting incentive, it is stealing from taxpayers. Where is the taxpayer outrage? Is anyone policing this stuff?” HITECH doesn’t require a provider to spend one penny to collect their check. Meaningful Use money is not a rebate or subsidy – it’s just free money from generous taxpayers helping subsidize some high-earning professionals and organizations. Practices or hospitals that are running systems they bought years ago get a surprise windfall, although they might have to use those systems more intensely to qualify. Enjoy that thought as you send in your tax form and as you watch the national debt rise from $16 trillion to who knows where as politicians bribe us with our own taxpayer dollars not to touch our Medicare, welfare, and social security. In the likely event that elected officials won’t suddenly grown spines, you just may get to see Greece-style fiscal meltdown and near-anarchy first hand without the pesky jet lag.

HIStalk Announcements and Requests

The latest and greatest from HIStalk Practice: CMS extends the deadline for EP Meaningful Use eligibility appeals. CareCloud’s Albert Santalo says the new JOBS bill may help his company go public sooner. E-prescribing payments jumped 83% and PQRS grew 65% between 2009 and 2010. Medical schools teach students how to stay connected with patients while using HIT. Dr. Gregg ponders whether the clinical narrative is really dying.  Julie McGovern of Practice Wise offers some great tips for successful EMR implementations and their ongoing success. None of these goodies can be found on HIStalk, so make sure you are receiving and reading your HIStalk Practice. Thanks for stopping by.

On HIStalk Mobile, Dr. Travis covers incubator Healthbox’s investor day.

Listening: Mew, brilliant, dreamy alt rock (or is it progressive?) from Denmark that’s reminiscent of Muse or Sigur Ros. If you like complex, almost orchestral music like early Genesis or Yes minus the overwrought excesses, they’ll hook you right in. Amazing stuff that you can feel smugly superior having discovered when nobody else has heard of them. And sometimes people ask what series I like on Netflix, so here’s what I’m watching at the moment: Frasier, Peep Show, and The Killing. Since I have 60 minutes of free time at most per day and that’s only if I sleep less than six hours, those will take awhile to finish.

On the Jobs Board: Soarian Clinical and Financial Go-Live Support, Epic and Cerner Resources, NextGen Go-Live Support. On Healthcare IT Jobs: Manager IS Enterprise Systems, Epic Principal Trainers, Technical Project Manager.

Acquisitions, Funding, Business, and Stock

TriZetto will build its new $40 million headquarters building in the Denver area, giving it space to house up to 750 jobs over the next five years.

CSC, trying to minimize the billions worth of damage it took from the NPfIT fiasco in England, now says it will use the knowledge it gained there to launch iSoft in the United States. A freelance journalist writing for ComputerWeekly doesn’t mince words in expressing his thoughts:

But from whence had its chutzpah come? Not only had CSC still not satisfied its NHS contract, it hadn’t even finished writing the software. Initial roll-out was due in 2007. Complete delivery was due this year. Hains told Wall Street CSC was now at last ready to roll out phase one but for a contractual settlement with the UK’s coalition government. But this was okay. Because CSC had a plan. This was not a plan for the reparation of 10 years of time and money the NHS has wasted on CSC. Nor was it a plan to recompense for the opportunity cost the NHS incurred while CSC dawdled over its clinicians’ request for better patient information. It was a plan to get its own finances in order, negotiate a firm settlement with the NHS and dazzle Wall Street with a come-back launch into what is tipped to be one of the few global growth markets: healthcare IT. Wall Street analysts privileged with the opportunity to ask Hains about this glorious transformation neglected to get his estimation of the value the British public subsidy had added to his corporation’s healthcare business in the last 10 years. British tax payers are due a share of this tremulous global growth machine, no?

Sales

Jefferson Radiology (CT) will implement TeraMedica’s Evercore Smartstore DICOM module at 11 regional imaging facilities.

Lutheran Medical Center (NY) will deploy PatientKeeper charge capture software.

People

Jean Schat, former of Curaspan Health Group, joins PerfectServe as a VP of sales.

South Dakota-based FQHC Horizon Health Care promotes Gin Wingen to director of clinical informatics.

Announcements and Implementations

The statewide ConnectVirginia HIE goes live with DIRECT messaging, free to registered providers through April 1, 2013.

Hurley Medical Center (MI) goes live on its $40 million Epic system.

Allscripts releases Wand, a native iPad app that extends functionality of its Professional and Enterprise EHR solutions.

OTTR Chronic Care Solutions launches OTTRbmt, a patient management system for bone marrow transplant centers that manage patients long term.

In Iowa, University of Iowa Health Care and Mercy Medical Center of Cedar Rapids announce plans to collaborate, including creating an Medicare ACO. UI Health Care, which has been live on Epic for more than three years, will help Mercy with its Epic implementation when it gets underway this summer. The organizations say they will use Epic to share information once Mercy is live.

Government and Politics

Members of the HIT Policy Committee express concern about several aspects of the proposed Stage 2 MU regulations. Specific issues:

• Requiring 10% of patients to receive secure electronic messages is too high.
• Public health agencies are not ready to receive electronic data.
• Communities with one dominant EHR vendor may make it difficult for providers to electronically exchange 10% of transition care summaries to other organizations on a different platform.
• Too many of the measures require EPs to collect data.

Innovation and Research

AHRQ is conducting a study about its offerings and is interested in talking to high-level professionals who either (a) develop health IT tools for patients, or (b) work for organizations that select those tools (hospitals, practices, health plans, government purchasers, etc.) They’re doing 90-minute interviews from mid-April through mid-May. Participants will be compensated for their time. If you’re interested, contact Jonathan Wald MD, MPH, director of patient-centered technologies the Center for the Advancement of Health IT for non-profit RTI International, which is working with AHRQ.

Other

A new KLAS report says that Cerner, Meditech, and Siemens are the only HIT vendors that provide their solutions to all world regions. Most purchasing activity is centered in Asia, the Middle East, and the UK. Few sites outside of North America are doing deep clinical adoption, largely due to economic and governmental challenges.

Weird News Andy wants to know if this is where we’re going. In the UK, a surgical practice drops an 83-year-old patient they had been treating for 30 years because of “green travelling issues” that make it “advisable to register at surgeries nearer to where they live.” The distance from her house to the office that raised the carbon footprint concerns: two miles. The woman thinks she was sent packing because she complained about a doctor.

Advocate Lutheran General Hospital (IL) settles for $8.25 million in a lawsuit brought against it after the death of a 40-day-old premature baby in 2010, caused by a pharmacy technician who incorrectly entered a post-op order into the IV compounder that overdosed the baby on 60 times the intended amount of sodium chloride. The hospital admitted that the compounder had the capability to issue automated warnings about potential entry errors, but they were turned off.

I’ve seen this several times recently at work. Someone who is offsite “attends” a meeting remotely by getting someone to conference them in on speakerphone. Everybody in the room forgets that person is on, and when the meeting is over, everybody walks out (more like “sprints” if the meeting was soul-sucking, as is often the case.) The person on the line, who has muted their phone in order to sleep or mow the lawn or whatever, finally pipes up, only to realize that a new group has taken over the conference room.

Adam Gale posts on KLAS’s blog about a Cerner turnaround that has moved them up the KLAS rankings from seventh to second in the past four years. He credits a new leader or two at Cerner, but I’ll offer my more cynical analysis: they didn’t have a choice unless they wanted to hand the keys to Neal’s soccer team over to Judy Faulkner, because Epic was tearing them a new one.

Sponsor Updates

• CTG Health Solutions announces an extension of its stock repurchase plan.
• Practice Fusion announces plans to add drug formulary and clinical messaging functionality to its EHR.
• Elsevier releases its 2012 spring eLearning schedule, which includes a revised ICD-10 Readiness Assessment tool.
• Premier Healthcare Alliance adds MedPlus to its ambulatory EMR software agreement portfolio.
• Kokua Kalihi Valley Comprehensive Family Services (HI), a FQHC, selects the e-MDs EHR suite for its 13 providers.
• Memorial Health System (CO) realizes a $2 million savings within three months of joining the MedAssets GPO.
• Mike Mistretta, CIO of MedCentral Health System (OH) details how his hospital’s use of SIS in the OR has provided data to control costs and improve efficiencies.
• Bill systems vendor AdvancedMD integrates its product with RaomSoft’s RIS/PACS.
• Aspen Advisors releases a case study on its work helping Akron General Health System (OH) develop an ICD-10 project management office.

EPtalk by Dr. Jayne

It’s all about the data. Studies indicating a decline in hospitalizations and deaths from pneumonia over time may not be due to better care, but rather a change in coding practices. Investigators propose that the coded diagnosis of pneumonia often took a back seat to sepsis or respiratory failure. As one who stalks the hospital floors, I know this to be true. We’ve been increasingly pushed to put more significant diagnoses first in our problem lists and discussions to indicate more complexity and support higher reimbursement. I wonder how the data would skew under the constraints of ICD-10?

It’s all about the audience. A recent study in the International Journal of Medical Informatics finds that EHR medication alerts are geared around how pharmacists think rather than prescribers – typically physicians and nurse practitioners. Alert fatigue is a constant danger and the authors recommend that alerts should leverage patient labs, balance the strengths of automation with human cognition, and support both pharmacist and non-pharmacist prescribers. My favorite of their recommendations: reduce alerts that contradict broadly accepted clinical practices. I hope this initiative succeeds, although I might be at risk for missing the lovely alerts that warn me that the diabetes medication I’m prescribing “might lower blood sugar.”

It’s all about perception. The New York Times publishes a piece about dressing for success. When subjects were told white coats they donned belonged to doctors, their attentiveness increased. When they were told the coats belonged to painters, no improvement was noted. The new phenomenon is being called enclothed cognition (the effects of clothing on cognitive processes.)

Speaking of dressing for success, one colleague shared news that her employer (a prominent health system) recently changed the dress code for physicians in response to patient satisfaction surveys. Previously recommending that neckties be avoided due to infection concerns, they have reversed course to now require them for male physicians because of a patient marketing survey that indicated that physicians with ties were viewed more favorably. Female physicians are not allowed to wear dresses without stockings or hosiery – no bare legs. I wonder what’s next – will they put nurses back in caps?

Being a patient and also a family member of patients myself, I take particular offense at one of their new rules – requiring surgeons to change into street clothes before they speak to a family after surgery. Nobody wants to be confronted with bloody scrubs (a true rarity) but I for one don’t want them wasting time changing clothes to come out and talk to me in the operating room waiting area. Just put on a cover gown or a white coat and come tell me what happened and how my loved one is doing.

Speaking of scrubs, Nurse TECH Talk launches its Most Bodacious Scrubs Contest. Entrants must join HITR and submit a picture of a bodacious scrub top to be in the running for the $100 gift card prize. I’ve got a crazy one that I’ll post just for fun if I can find it – on a transplant mission a few years ago it somehow made it into my bag because it was simply too strange to be believed. Think Nurse Chapel on the original Star Trek.

I’m happy to be surrounded by smart people and Weird News Andy is one of them, educating me on Wickard v. Filburn as the depression-era case responsible for Justice Breyer’s comments on growing wheat and its relationship to interstate commerce regulations. He also cites that decision as “a stretch worthy of Mrs. Incredible,” which made my day. Jonathan H. also commented that the home marijuana growing comment related to another precedent. Some happy Googling reveals that case to be Gonzales v. Raich.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Gingrich’s Health IT Group Files for Liquidation

The Gingrich Group LLC, doing business as the Center for Health Transformation, has filed for Chapter 7 bankruptcy in a Georgia court. The for-profit organization, which makes up the majority of Newt Gingrich’s net worth in the form of money it owes him for his share of ownership, struggled to survive after Gingrich resigned as its chairman last year to run for the presidency.

The organization listed its assets as less than $100,000, with liabilities stated as $1 million to $10 million.

Several healthcare IT companies are listed among its creditors, including Cerner, Greenway, and Health Trio.

Healthcare IT from the Investor’s Chair 4/4/12

From a recent HIStalk post:

Facts and Background 
Shares in mobile healthcare communications Vocera jumped almost 50% in their first three days of trading after Wednesday’s initial public offering, opening at $16 and closing Friday at $23.40.

Opinion 
The company either priced its shares incorrectly or intentionally undervalued them to create positive press from the price run-up. Either way, investors and not the company pocketed the $41 million price difference in the 5.9 million shares offered. Still, the company was smart enough to up the originally planned $12-14 price. A $100 million IPO yield is impressive for a company that isn’t all that widely known and that lost money in FY2011.

Sorry, Tim, not sure I totally agree with this assessment. 

With the benefit of hindsight, Vocera and its underwriters did under-price its IPO, but there’s no way to predict how a company will trade once it’s public. See my earlier post on the full mechanics of how companies go public here, but recall that the underwriters (led by JP Morgan and Piper Jaffrey in this case) had to take their best guess on how much investors would pay for Vocera stock at the time of pricing. The initial filing range is an even broader guess (albeit an informed one, based on how comparable companies are trading).

As the roadshow continued, there appeared to be more buyers than sellers (the offering was over-subscribed) so the underwriters raised the pricing range. Throughout the roadshow, JP Morgan built an “order book,” where each investor (typically mutual, pension, and hedge funds) indicated how much stock they would buy at any given price. Clearly the Vocera IPO was multiple times oversubscribed, which is the goal.

The art of pricing (and it does seem to be more art than science) is using that information to set the initial offering price. Too low and you’ve left money on the table (as VCRA apparently did). Too high and not enough funds purchase once the stock trades in the aftermarket and instead simply dump their shares rather than build a larger position. This results in the stock trading down and embarrasses and annoys all parties involved.

The trick here is balancing supply and demand precisely and in real-time and with very imperfect information (as investment funds don’t always reveal their intent, either). It’s interesting in that it’s one of the few businesses where the price of the product is directly affected by the customer to whom you sell.

That said, it’s also worth noting that underwriters have multiple incentives, and it’s not always clear who the client is in these situations. On the one hand, because they’re getting a 7% fee, they have a definite motivation to maximize the initial stock price. By pricing at $16 rather than $23.40, they missed around $3.5 million in fees.

On the other hand, any given fund can easily pay 10x that in commissions any given year, so there are those who feel that banks have an obligation to take care of their trading clients more than their underwriting clients. Suffice to say, there’s more than a little dynamic tension between different parts of the firms, but in my experience, pricing for a successful offering trumps the desire to maximize the fees for the specific deal under consideration.

As an aside, I believe the positive press effect is less the case now than during the dotcom days and not a motivator for either issuing companies or their underwriters.

One way of avoiding this phenomenon of under-pricing IPOs is by using what is known as a DutchAuction, which arguably creates the most efficient price. In 1998, an investment bank called WR Hambrecht began trying to use this method to price IPOs, calling it OpenIPO. With the notable exception of Google, it never really caught on. (I’ll try to do some research as to why for a future note, but I assume typical issuers remain risk averse and prefer the tried and mostly true IPO method.)

Because insiders rarely sell at the time of an IPO (and be careful if too many are doing so), it’s not as if management or the venture capitalists involved have a personal stake here, either. Further, in the long run, pricing the IPO with perfect accuracy just isn’t viewed as that important relative to the benefits of assuring a successful offering with a healthy balance sheet, good research sponsorship, and long term investors for the future .

Ben Rooks, founder of ST Advisors, spent ten years as an equity analyst, six years as an investment banker, and is now much happier (and adding more value) as an independent advisor to HCIT companies. He loves questions and feedback on his column. Incidentally, ST Advisors is pleased to count Vocera as a former (but not current) client.

EHR Design Talk with Dr. Rick 4/4/12

The Problem with Scrolling

Imagine that you are a member of an EHR software development team. Your team has been given the task of designing a new user interface that will provide an overview of an entire patient encounter in a single screen view.

Your current user interface requires clinicians to navigate to multiple screens to enter and review data for a single patient encounter. Many clinicians find that the navigation interferes with focusing on patient issues. Even worse, they can’t keep the relevant data in their working memory as they navigate from screen to screen (see my last post).

Your team starts out by drawing a rough sketch of what the new screen view might look like:

Each pane will display data. Your problem is how to display each category of data within the areas of these small panes.

Your team decides to start with the redesign of the medication pane. Your EHR’s current medication screen is shown below for a particular patient who is taking nine medications. I have resized your screen view to fit the width of this post, but in your EHR application you can easily see the entire medication table on a single screen without scrolling.

How do you display the medication data above using a much smaller pane size? One of your team members suggests a commonly used EHR design — vertical and horizontal scrollbars for each pane. Your team decides to explore this scrolling option first.

You sketch a pane with vertical and horizontal scrollbars, as below. The example below displays the upper left portion of the medication screen above. The red arrow to the right shows the position of the vertical scrollbar.

Right away you and your team realize that this design has problems. First of all, a clinician using this design would have to scroll down to two additional locations in the table (only one shown below) just to see the complete list of meds:

Similarly, she would have to scroll across to two additional locations in the table (only one shown below) to see the complete data for any particular medication:

She would have to navigate to nine different views within the pane to see all the data! As Alan Cooper points out in About Face 3: The Essentials of Interaction Design, scrolling is a form of navigation even though we don’t usually think of it as such.

Furthermore, the scrollbar design doesn’t solve the working memory problem. As soon as the clinician scrolls to a new position in the table, the previous information is gone from view. She might as well navigate to the full screen medication window.

You and your team note additional problems with the pane with scrollbars design:

• It does not display a summary list of all nine medications.
• The clinician can inadvertently scroll past critical information.
• Using the scrollbars requires fine motor skills and eye-hand coordination, interfering with the clinician’s ability to focus on patient issues.
• Text can be truncated both horizontally and vertically, making it difficult to read.
• The scrollbars and header bar waste valuable screen real estate.
• Depending on operating system speed, there can be latency between the scrolling action and the updated screen.

Despite the fact that the pane with scrollbars is a common EHR design element, the result is a computer-centered, not a user-centered design.

It’s back to the drawing board. In my next post, I will show some better EHR software designs for presenting multiple categories of data in a single screen view.

Next Post

Overview with Details on Demand — a Versatile Design

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