Curbside Consult with Dr. Jayne 4/2/12

Last week the Supreme Court heard an historic number of oral arguments as it considered challenges to the Affordable Care Act. Unlike other portions of the federal government, those responsible for the transcripts move at the speed of light. Some of them can be fairly enjoyable – the Justices have well-developed senses of irony, sarcasm, and humor.

Monday was essentially the challenge to the individual mandate provision requiring insurance coverage. One of my favorite exchanges involves Chief Justice Roberts, who says:

The idea that Congress has acquiesced in what we have said only helps you if what we have said is fairly consistent. And you, yourself, point out in your brief that we’ve kind of gone back and forth on whether this is a jurisdictional provision or not. So, even if Congress acquiesced in it, I’m not sure what they acquiesced in.

Is everyone clear on that? It just goes to show how complex this issue is and how the eventual ruling will involve the splitting of more than a few hairs.

Another great example is Justice Alito speaking to Solicitor General Donald Verrilli Jr. saying,

General Verrilli, today you are arguing that the penalty is not a tax. Tomorrow you are going to be back and you will be arguing that the penalty is a tax.

The challenges have certainly put the government in as many different positions as an advanced yoga class.

My favorite quote of the session is from Robert Long, arguing his case to the court and stating,

Not all people who litigate about federal taxes are necessarily rational.

I wonder if he includes himself in that assessment?

The hearing continued Tuesday with some interesting discussion comparing people’s need to enter into the healthcare market with their need to enter into the market for police, fire, or other emergency services. Chief Justice Roberts:

Well, the same, it seems to me, would be true, say, for the market in emergency services: police, fire, ambulance, roadside assistance, whatever. You don’t know when you’re going to need it; you’re not sure that you will. But the same is true for healthcare. You don’t know if you’re going to need a heart transplant or if you ever will. So, there’s a market there. In some extent, we all participate in it. So, can the government require you to buy a cell phone because that would facilitate responding when you need emergency services? You can just dial 911 no matter where you are?

The Solicitor General argued that it was different and what followed was a great exchange with Justice Alito asking Verrilli if he thinks there is a market for burial services. Alito went on to ask:

All right. Suppose that you and I walked around downtown Washington at lunch hour and we found a couple of healthy young people and we stopped them and we said:  you know what you’re doing? You are financing your burial services right now, because eventually you’re going to die and somebody is going to have to pay for it and if you don’t have burial insurance and you haven’t saved money for it, you’re going to shift the cost to somebody else.

With arguments like that, how can you not love these guys and gals? It’s like being on rounds with the Meanest. Attending Physician. Ever. At one point, Justice Scalia compared the individual mandate to forcing people to buy broccoli.

As the day progressed, Justice Breyer discussed the ability of Congress to regulate interstate commerce and used this example:

And I look at the person who’s growing marijuana in her house, or I look at the farmer who is growing wheat for home consumption…

Where in the world did THAT come from and what does it have to do with anything? It gets better:

I say, hey, can’t Congress make people drive faster than 45 – 40 miles an hour on a road? Didn’t they make that man growing his own wheat go into the market and buy other wheat for his – for his cows? Didn’t they make Mrs. – if she married somebody who had marijuana in her basement, wouldn’t she have to go and get rid of it? Affirmative action?

I tried to decipher the meaning but couldn’t. I’m not sure what Breyer is growing in his basement, but I think I want some of it. He did return to coherence a few paragraphs later:

So what is argued here is there is a large group of – what about a person that we discover that there are – a disease is sweeping the United States, and 40 million people are susceptible, of whom 10 million will die; can’t the Federal Government say all 40 million get inoculation?

The transcript is full of aphorisms that would make Ben Franklin proud. Justice Kagan asked one speaker whether his argument was “cutting the baloney thin.”

Arguments continued Wednesday morning around severability, or the premise that if the individual mandate is unconstitutional, then the rest of the Act has to go as well. Justice Kagan asked whether Congress wanted half a loaf and whether half a loaf is better than no loaf. I think that’s somewhat debatable, depending on the loaf. If it’s Nutraloaf, I’d personally rather have no loaf at all.

At one point Justice Scalia also referenced “cruel and unusual punishment,” asking a petitioner what happened to the Eighth Amendment when it was suggested that the Justices might want to look at all 2,700 pages of the Act to determine “what the text and structure mean with respect to severability.”

The non-stop action continued later Wednesday afternoon with the discussion of Medicaid expansion. The first 20 pages were pretty dry, until it came to the point where Paul Clement, representing 26 states, was asked by Justice Scalia,

Mr. Clement, I didn’t take the time to figure this out, but maybe you did. Is there any chance that all 26 states opposing it have Republican governors, and all of the States supporting it have Democratic governors? Is that possible?

There was laughter in the court as Clement admitted the correlation.

I met up with some colleagues over the weekend and had the chance to hear different opinions on where the Court might land. The only consensus reached was that although none of us can predict which way it will go, we were unanimous in feeling that it will be a 5-4 decision. Regardless of the outcome, it will be interesting to see how Congress responds and how the Presidential candidates respond. The summer promises to be anything but dull.

Have a question about legal precedent, jurisprudence, or what you have to do to file an amicus curiae brief? E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 4/2/12

From HMSUser: “Re: HMS CEO departure. The company confirms.” HIS vendor Healthcare Management Systems (HMS) confirms the rumor I ran here Friday from HMSUser: President and CEO Tom Stephenson, a 25-year company veteran, has left “to pursue some long-time interests.” According to his LinkedIn profile, he is now assistant grass cutter at Stephenson Landscaping Services LLC. Pretty darned witty if you ask me.

Survey respondents say that companies in the hospital and physician practice market will lag those that are working in interoperability and post-acute care. New poll to your right: how will the Supreme Court rule on PPACA? (no fair answering after the decision is announced.)

My Time Capsule editorial this week from the 2007 vault: Brailer’s Santa Barbara RHIO Baby Goes Down the Tubes. The expensive flop that was the Santa Barbara RHIO launched David Brailer into the first ONC job and got everybody stoked about interoperability despite not having one iota of impact on patients or providers. Some of my parchment-scribed words from way back then: “SBCCDE was a ‘big hat, no cattle’ kind of project that left two sad legacies: (a) it blew millions in grant money,  and (b) it seduced politicians and reporters into thinking they’d seen the Second Coming of CHINs, only destined for success this time. They were half right.”

Readers keep asking me to do some kind of “top stories” summary each week. I used to do that with the Brev+IT newsletter I started, in which I rattled off stream-of-consciousness cynical musings about the week’s top news, usually after I was tired from writing HIStalk for the weekend and therefore likely to blurt out just about anything to get finished. I’ll revive that practice at the bottom of this post and give it a try for a few weeks. I’ll kill it if I get bored with it, if I don’t have the time, or if nobody seems to care much one way or another. I’m not looking to create more work for myself, but I’m pathologically eager to please.

Welcome to new HIStalk Platinum Sponsor TrustHCS. The Springfield, MO company’s consulting expertise covers coding, compliance, ICD-10, and cancer registry. Vacant coder positions threaten financial performance and TrustHCS can help out with staff augmentation or full outsourcing of coding services, with every one of the company’s employees holding AHIMA and/or AAPC credentials. They can work on-site or remote, with flexible pricing to meet budget requirements. The company can help provider organizations take advantage of the ICD-10 breather by performing the assessment, analysis, and education that they might have skipped back when the implementation deadline was looming. TrustHCS works with hospitals, practices, ambulatory surgery centers, and any other provider organization that does coding, offering whatever level of support is needed to optimize the revenue cycle. The company can provide the oversight and coding compliance training needed to avoid headlines that throw the whole “bad press is better than none” concept into serious doubt. Relationship matters and experience leads at TrustHCS, whose support I gratefully acknowledge.

Weill Cornell Medical College establishes the Center for Healthcare Informatics and Policy, which will conduct HIT-related research and offer a two-year fellowship in quality and informatics. Rainu Kaushal MD, MPH, a medical informatics professor and director of pediatric quality and patient safety at New York-Presbyterian Hospital, will serve as executive director.  

A nice HIStalk Practice post by Dr. Gregg poses the question: are EMRs to blame for terse physician documentation, or are lengthy patient “stories” less common due to (a) lack of physician time, (b) wordy residents who grew up to be more concise, or (c) lack of value when documenting the same old acute conditions over and over?

Vince continues his HIS-tory this week with Part 2 on MedTake. These pieces aren’t just overly fond looks back at long-dead companies – they always contain lessons that might prevent someone from repeating the same mistakes.

HIT Application Solutions raises $2.75 million in a Series A funding round. The Exton, PA company offers the Notifi communications platform for alerts, broadcast communications, and critical test results.

San Francisco-based healthcare IT incubator Rock Health will expand to Boston in June, adding a program on the campus of Harvard Medical School.

Epic did its always entertaining April Fool’s Day page, even dropping in an Inga mention with ”The Shoe’s on the Other Foot: HIStalk’s Inga Disputes Rumor She Wore Birks to Symphony.” I like it because I did a similar HIStalk spoof years ago and referred to Epic as the Birkenstock-wearing crowd.

E-mail Mr. H.

The Healthcare IT Week in Review

1. Vocera IPO Shares Jump 50%, Meaning the Company Paid Good Money for Bad Pricing Advice

Musings

• Timing is everything when it comes to IPOs. Riding Facebook’s IPO coattails isn’t such a bad thing, at least unless Facebook stumbles.
• The company, like most hardware vendors that are anxious to avoid commoditization and increase margins and professional services income by turning themselves into software vendors (think RTLS and bed management systems), markets benefits around its “Star Trek” badge communicators that include care transition, patient transfer optimization, and patient discharge communication.
• Vocera made some key acquisitions in the past couple of years: Wallace Wireless in January 2011 (delivery of alerts to smart phones) and two White Stone Group spinoffs in November 2010 (handoff communications.)
• More acquisitions are sure to come now that the company has $94 million of IPO money in the bank and needs to feed the earnings engine. A priority will almost certainly be value-added software for nurses that can run on the company’s existing communication platform since nurses are its primary users and therefore are most likely to advocate new purchases to otherwise indifferent hospital executives.
• Chairman and CEO Bob Zollars, who joined the company in 2007, was best known as having run high-flying healthcare supply chain vendor Neoforma, and before that having executive roles at Cardinal Health and Baxter. He rode the irrational exuberance bubble hard in January of 2000, when Neoforma.com’s IPO, priced at $13 for 7 million shares, soared to $52.38 on their first day of trading. Not bad for a company with revenue of $464,000 in the previous nine months, in which the company lost $25 million but formed a complex ownership and incentive agreement with hospital buying groups VHA and UHC. Neoforma announced plans to buy Eclipsys for $2.1 billion of its stock in March 2000, but backed off two months later when its own shares dropped by 70%. He knows how Wall Street works and has a real company with strong revenue this time around.
• It’s interesting that the Vocera IPO did so well while investor interest in the HITECH-goosed side of HIT seems to be waning. But everybody likes IPOs, at least for the first few weeks before the quarterly earnings grind sets in.
• I don’t see Vocera getting into the mHealth market, but the successful IPO gives it a strong position in mobile apps for clinicians. It needs a doctor product, though, preferably one with direct impact on patient outcomes since that’s what hospitals will pay big bucks for.
  

2. Tampa Doctors, Hospitals Fight Over Which Group Will Lead Their Selfless Data Sharing Efforts

Facts and Background

A group of Tampa-area hospitals and the county medical association are pursuing independent efforts to share electronic patient information.

Opinion

Florida has quite a few active HIE/RHIO projects that haven’t made much progress, probably because competition there, particularly among large health systems, is intense. This is one of few times where the previously unstated suspicion and distrust came right out on the table, as observed by a perceptive local reporter.

Musings

• Neither group seems to be making much progress, which isn’t surprising when asking competitors to collaborate selectively with unknown benefits to each.
• Florida’s AHCA issued a four-year, $19 million contract to Harris Corp. in late 2010 to develop a statewide HIE. Two months later, Harris announced that it had acquired Carefx, which offers the Fusionfx data sharing technology for competitors that need to exchange information. The only progress I’ve heard of is the availability of a secure e-mail program for providers and limited patient look-up services among the Big Bend RHIO and a couple of health systems, but it’s only been a year. I don’t know who’s getting ONC’s HIE grant money in Florida.
• Hospitals bring most of the money and technical expertise to the table, while practices create much of the information that needs to be shared. Doctors also believe their motivations are purer than those of hospitals, which have a reputation for wanting to control anything they’re involved with for their own financial or strategic benefit. That plus the technical challenges may kill this initiative off early.
• The main benefit of interoperability comes from hospitals exchanging information with their affiliated practices, which they often undertake without going to a third-party interoperability project. Unlike in some areas, Epic does not dominate the Tampa market. That would be an interesting follow-up article for the reporter – how well do the hospitals that want to control this project interoperate with their owned or affiliated practices?

3. Post-Op Patients Love iPads So Much They Don’t Mind that their Surgeons Don’t Visit Them

Facts and Background

Henry Ford Health System implements telerounding, where post-operative patients are given iPads to communicate by video with their surgeons, who may be miles away.

Opinion

This is a really good idea since it seems cool and high tech, but basically frees surgeons of the requirement to actually make post-op rounds and makes them immediately available so that delayed actions don’t hinder the discharge pathway. But most of all because this is the first high-profile use of the iPad by patients since video projects usually involve Skype on PCs.

Musings

• Post-op patients are usually coherent and can report their own medical situation, so this is more like ambulatory telemedicine than remote ICU monitoring.
• Using iPads is a smart idea since they are portable and cheap. Installing telepresence hardware in individual patient rooms would be ridiculously expensive, and the enhanced video quality would offer no advantage when the intention is simply to chat with the patient. Observers often overlook the iPad’s price and maintenance advantage – it does a lot for $500.
• Cynics might say that a phone call would work just as well as a video call, but physicians like seeing and not just hearing.
• Once the iPads are in the hands of patients, their use could be extended to video-based patient education and self-documentation.
• Once again Apple products prove their medical value not because of more in-depth technical capabilities over PCs, but because they are easy and fast to use, especially since a lot more people know how to use iOS products like the iPhone than have Windows expertise.
• It’s easy to see how this project could be translated into home health or skilled nursing care, where it’s just not practical to have an ongoing physician presence. For that matter, a nurse could round with a single iPad as the physician participates by video.

Time Capsule: Brailer’s Santa Barbara RHIO Baby Goes Down the Tubes

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.

Brailer’s Santa Barbara RHIO Baby Goes Down the Tubes
By Mr. HIStalk

The nation’s first RHIO is officially defunct. The Santa Barbara County Care Data Exchange (SBCCDE) locked its doors and quickly took down its website last week. David Brailer’s child star died an ugly, lonely death at age nine.

SBCCDE was a “big hat, no cattle” kind of project that left two sad legacies: (a) it blew millions in grant money,  and (b) it seduced politicians and reporters into thinking they’d seen the Second Coming of CHINs, only destined for success this time. They were half right.

It wasn’t for lack of trying by the California HealthCare Foundation (CHCF). That organization gave CareScience, of which Brailer was then CEO, $10 million to create and run SBCCDE. Uncle Sam chipped in a few more bills along the way.

CHCF bragged, incorrectly as it turned out, that SBCCDE had solved the funding model issue, based on the assumption that providers would happily pony up to keep the lights on. They were wrong. With only two organizations sharing data, neither was willing to fund SBCCDE’s ongoing operation.

Actually, SBCCDE left one other lasting legacy. It focused nearly all the government’s interest in healthcare IT on interoperability to the exclusion of everything else. That’s hardly surprising since Brailer got the healthcare IT czar job riding his SBCCDE credential, with few critics remembering CareScience’s 2001 struggles, shareholder lawsuits, and eventual sale to Quovadx for just $14 million over its cash reserves in 2003.

Perhaps Brailer provided some hints of a cloudy future for his RHIO. In an early SBCCDE presentation, he listed “substantial first-mover disadvantage” as a concern. He was right: new entrant CalRHIO is hot stuff now, planning to spend $300 million to blanket California in interoperability. SBCCDE was suddenly yesterday’s news, falling behind even upstart RHIOs in actually moving data around to anyone’s benefit. For that reason, no one is mourning the dearly departed SBCCDE very much.

Brailer also hinted more than once that the entire RHIO movement could be a throwaway technology, an interesting experiment to kill time until the massively more expensive Nationwide Health Information Network comes online. We’ll have to see if he was right about that.

In any case, I predict that at least one-fourth of RHIOs will fail within 1-2 years. Not because they don’t have noble goals or sound technologies, but because reality is working against them just like it did SBCCDE and CHINs before them.

• Like the many other misaligned incentives in healthcare, providers have to pay for the common RHIO plumbing, but get little value from it. Patients and insurers get a free ride in many cases.
• A mishmash of federal and state privacy laws ensures that expensive lawyers will guarantee nothing when it comes to avoiding HIPAA violations, opt-in guarantees, and privacy lawsuits.
• Back-end interfaces are expensive and difficult to maintain.
• The lack of an information sharing pipeline wasn’t the only reason competitors didn’t hold hands and sing Kumbaya before.
• The primitive state of most provider computer systems means that information is often not available electronically. The least-capable hospital or practice reduces the value for everyone else. Clinical information is always of suspect quality and completeness.
• Providers have many more projects that are more fundamental to their survival that will always take precedence.

In other words, RHIOs have all the same threats that CHINs had, other than the advantage of using the Internet for connectivity.

Perhaps the best lesson from SBCCDE’s flameout is the one we’ve already learned from failed physician order entry, enterprise resource planning, and physician electronic medical records system implementations. Technology is rarely the problem.

News 3/30/12

Top News

Vocera shares gain 40% over the $16 offering price in the company’s Wednesday IPO. Shares were up another 19% Thursday to $24.91, giving VCRA a 56% jump in the company’s first two days of being publicly traded.

Reader Comments

From Max: “Re: Microsoft/Sentillion. The bloodbath is in full effect. Employees received either a 60-day notice this week or an offer to move to Caradigm. I’ve heard losses on the Amalga side were significant.” Unverified. I asked my Microsoft contact, who says that like most companies, Microsoft doesn’t comment publicly on HR-related questions.

From HMSUser: “Re: HMS CEO. ‘Resigned’ last Friday, rumor that more high-level people will be shown the door.” Unverified, but Tom Stephenson’s bio has vanished from the executive team page. HMS’s parent company, HealthTech Holdings, has been owned since 2007 by private equity firm Primus, whose other healthcare IT-related investments include InSite One, Medhost, and Passport Health Communications.

From Epic-urious: “Re: Epic leading the market and gunning for the big guys. I’ve only read a few new customer updates. Where are all of these new customers?” Just to be clear, Epic is the big guy now, so there’s nobody left to gun for in terms of penetration of patients and providers (not necessarily in  number of hospitals since it’s a lot easier to dominate the market selling to one 1,000 bed hospital than ten 100-bed ones.) The company doesn’t announce sales, so new customers come to light only casually, like at conferences with mostly large-hospital attendees, where just about everybody finds out simultaneously that they’re all implementing Epic. Another way to look at it: the lack of significant sales announcements from Epic’s competitors, who do indeed happily announce new sales when they can get them.

HIStalk Announcements and Requests

This week on HIStalk Practice: a physician being sued by his former practice resigns over “technology troubles” and “billing errors” that he claims were the caused by computer problems. CMS offers help to providers not deemed “successful electronic prescribers” in 2011. Nancy Pelosi’s connection (or lack of one) between Practice Fusion’s rapid growth and the Affordable Care Act as she cuts the ribbon at the company’s new building (above.) Brad Boyd urges providers to continue moving forward on their ICD-10 transition. In our reader survey, 85% said reading HIStalk Practice helped them perform their job better last year, so if you’re in ambulatory HIT and need performance enhancement, you should be reading.

Listening: new from The Mars Volta, complex, perfectionist progressive rockers from El Paso, TX. An Amazon reviewer said it well: they’re what Led Zeppelin would have sounded like time warped into 2050. Dead ringers for Manfred Mann’s Earth Band at the 4:10 mark of the video, but very Zeppelin-like at 5:00. And I’m reflecting on the amazing musical contributions of Earl Scruggs, who almost single-handedly gave non-hayseed credibility to both the banjo as a musical instrument and to bluegrass as a uniquely American musical genre and who died Wednesday at 88. Foggy Mountain Breakdown was the speed metal of its day and it still sounds amazing as I listen to it right now.

Acquisitions, Funding, Business, and Stock

ClearDATA Networks, which provides healthcare cloud computing services, secures funding from Norwest Venture Partners and several angel investors.

Seven-month-old hospice management software vendor Hospicelink of Birmingham, AL says it expects $50 million in sales by the end of 2012. Color me skeptical.

Ann Arbor, MI-based HIE vendor CareEvolution is expanding its 22-employee workforce to 38, expecting to hire three software developers per quarter. I notice from the company’s site that they claim a trademark on the term One Patient, One Record, which I would associate more with Epic than CareEvolution, which I’ve heard of only once when a reader said they did an impressive demo but still lost the West Virginia Health Information Network bid. UPDATE: the company clarified the newspaper article – it has 38 employees now (22 of them in Ann Arbor) and will add another 15. WVHIN did choose Thomson Reuters’ HIE Advantage, but that product actually runs CareEvolution’s HIEBus under an expanded agreement between the companies signed in February 2011, so CareEvolution is in place (and scheduled for go-live next month) even though the announced winner was Thomson Reuters.

BlackBerry maker Research in Motion reports sagging sales, a quarterly loss, and an executive housecleaning. The CEO says he won’t rule out selling the company now that he’s seen from the inside just how dire the situation is, although he’s hoping for a turnaround. The steep downward slope above is the one-year share price, down 75%.

Sales

Asante Health System (OR) selects iSirona’s medical device connectivity solution to populate patient data in its Epic system.

Memorial Hospital of Union County (OH) selects Wolters Kluwer Health’s Provation MD for its gastroenterology and pulmonology departments. In addition, Duke University Health System (NC) licenses ProVation Order Sets.

Duke University Health System (NC) selects M*Modal Speech Understanding technology to support the Epic system it’s implementing.

Two practices within the University at Buffalo School of Medicine select PatientKeeper Charge Capture, which will be integrated with UBMD’s GE Centricity Group Management PM product.

People

EMR vendor CareCloud appoints PowerReviews CEO Ken Comée to its board.

Online physician networking site Sermo names former Revolution Health president Tim Davenport CEO. He replaces founder Daniel Palestrant, who left the company in January to run Par80, a startup focused on patient referrals.

Aventura hires Brian Stern (NewsGator Technologies) as SVP of sales and marketing and Brandi Narvaez (Sentillion, Vitalize – above) as chief customer officer.

eMerge Health Solutions, a provider of voice-powered documentation systems, hires Trent McCracken as president and CEO. He was previously owner of a telecommunications software company.

Announcements and Implementations

St. Francis Hospital & Health Services (MO) will go live on Epic Saturday morning.

The Verizon Foundation donates $100,000 to launch a telemedicine pilot project at Children’s Hospital of Philadelphia. CHOP will offer community hospitals consults with its pediatric specialists.

Government and Politics

The New York eHealth Collaborative and the New York State Department of Health form the Statewide Health Information Network of New York Policy Committee, tasked with updating and creating policy measures to protect PHI while expanding the state’s ability to electronically share clinical data.

The White House announced Thursday that various government agencies will invest $200 million of taxpayer money in so-called “Big Data” R&D. A NSF/NIH project will look at large-scale health and disease databases.

It’s not healthcare related, but it’s another hugely expensive government computing foul-up: the State of California pulls the plug on a $2 billion court system that still isn’t fully rolled out 11 years after the project started. The project was originally supposed to cost $260 million, with a state audit last year finding that the massive overruns were due to poor management of contractors. An IT project failure expert said, “I am dumbstruck over the incredible waste and obvious poor planning associated with this system. This failure only adds to California’s reputation as the land of IT boondoggles”

Technology

Henry Ford Hospital (MI) implements telerounding, in which minimally invasive surgery inpatients are given an iPad to post-operatively communicate with their remotely located surgeons using the FaceTime video chat app.

Other

Weird News Andy likes this video story of a BYU nurse practitioner student whose professor, while observing her practice thyroid exams in her third week of class, happens to notice that she has a hard-to-spot tumor. The mass turned out to be highly aggressive, but she’s OK after fast-track surgery and radiation therapy. She will take a nurse practitioner job at the Thyroid Institute of Utah when she graduates this summer.

Hill-Rom joins Stryker and Zimmer in laying off hundreds of its employees to offset the cost of complying with a new medical device tax that takes effect next year. The 2.3% tax, enacted in the Affordable Care Act, is based on company revenue regardless of profitability. The industry estimates the tax will cost its members $30.5 billion and could result in the loss of up to 38,000 jobs.

Howard University Hospital (DC) notifies 34,000 patients that their health information was potentially exposed in January when a laptop was stolen from the car of a contractor who had downloaded the information in violation of hospital policy. The contractor had quit working for the hospital in December 2011, but reported the theft on January 25 of this year.

The government’s bet-the-farm idea of paying hospitals for quality didn’t move the needle on deaths or readmissions in its own demonstration project, a study published Wednesday in the New England Journal of Medicine found. The Harvard public health author says incentives are the right idea, but the metrics aren’t yet right. He also says it’s nice when processes are executed consistently, but the only thing that counts is that patients get healthier, and that didn’t seem to happen here.

It’s definitely not up to the high snark standards of The Onion, but this satirical article called Myanmar Embraces Facebook as Electronic Medical Record is kind of funny. “Whilst Facebook users can currently Add and Delete Friends, the updated site is going to allow users to Add Doctors, Nurses and other allied health professionals, who can be granted varying degrees of access to confidential medical data. ” You just know someone out there is working on this already.

I probably would find a new press release headline writer.

Here’s what HITECH has driven providers to. Physicians at Samaritan Healthcare (WA) gripe at a hospital board meeting about the hospital’s new Meditech system, which the hospital freely admits it implemented for only one reason: to get a $2.2 million HITECH check. According to one doctor, Meditech is “… time-consuming, it is frustrating, it is archaic, it’s hard to work with … It didn’t matter what we said, you were going to go ahead and implement this because there were the economic benefits being reaped by the hospital at our expense.” In response, the hospital CEO admitted that the system isn’t ideal, but says now that the money’s in the bank, Meditech is history, its replacement to be paid for by the HITECH money Meditech earned for the hospital.

Strange: two-thirds of respondents to an online poll run by the Chinese Communist Party’s newspaper choose a “smiley face” as their reaction to a story about a medical intern who was murdered by an enraged patient in a hospital, apparently because doctors are right up there with government workers in being hated for insisting on being paid bribes to do their jobs. The poll was quickly taken down. The government reported that over 5,000 medical personnel were injured by patients in 2006, the last year such statistics were published. Experts blame the anti-doctor mood to the lack of a medical malpractice system to provide compensation for errors, physician salaries that start at only $500 per month, and the fact that doctors are legally paid commissions for orders written. It was also reported that some doctors are taking kickbacks from funeral homes for promptly alerting them of the newly deceased.

Sponsor Updates

• EHRtv runs an interview with David Caldwell, EVP of HIE vendor Certify Data Systems, filmed at the HIMSS conference. We interviewed CEO Mark Willard last month.
• Salar and Transcend will participate in the Society Hospital Medicine 2012 Conference April 1-4, 2012, in San Diego, CA
• MedAssets launches its Population Health solution suite to support the industry’s transition to fee for service and accountable care.
• Greenway Medical Technologies announces the availability of PrimeMOBILE for Android and tablet devices.
• TELUS Health Solutions will license Get Real Consulting’s InstantPHRO to resell into Canada under the TELUS Personal Health Record brand.
• MEDSEEK announces that its eHealth ecoSystem V4.0 is 2011/2012 compliant and certified as an EHR Module.
• Queensway Carleton Hospital (Canada) is delivering ED records to more than 120 family doctors using TELUS Health Solutions’ CareShare technology. 
• GetWellNetwork announces its fifth annual users conference, to be held April 30 – May 2 in Orlando.

EPtalk by Dr. Jayne

All eyes are on the Supreme Court this week. Oral arguments for the cases challenging the Affordable Care Act concluded Wednesday. This has been a busy week at work so I haven’t been able to process the transcripts as quickly as I’d like. Stay tuned for my detailed reaction in Monday’s Curbside Consult. I find the whole process fascinating. It wakes up the non-medical part of my brain with the interplay of the Justices’ personalities and the complexities of legal theories of intent, severability, and judicial restraint.

The focus on PPACA overshadowed dialogue on last week’s ruling that state workers cannot sue their employer for violating a part of the Family and Medical Leave Act. A 2003 decision allows suits against state agencies for violations related to leave taken to care for family members, this decision involves leave take by employees to take care of their own health. There are already many loopholes in FMLA due to multiple court challenges over the past two decades. Additionally, states have made their own requirements and definitions, turning it into a patchwork. It’s a great example of what might happen to PPACA over the next few decades should it be allowed to stand.

My other exciting reading this week has been the recently-issued NIST protocol on EHR usability. The three-step process includes EHR application analysis, user interface expert review, and user interface validation testing. There are some interesting points in the document. Check out Appendix A, which discusses the use of human factors engineering by the Department of Defense, the Nuclear Regulatory Commission, and the Federal Aviation Administration.

It also provides questions used to evaluate an EHR’s “aesthetic and minimalist design” and “pleasurable and respectful interaction with the user,” including whether the EHR has artistic value. I never found that documenting as required by CMS (and now other payers) is particularly pleasurable, nor do I find artistic value relevant to patient care. I don’t care how ugly it is — I just want it to be easy to use and comprehensive.

AHIMA announces the Grace Award, which recognizes excellence in health information management. Nominations are open through June 30 and the award will be presented at the annual meeting in September. I give this new award a thumbs up for aesthetic and minimalist design (NIST would be proud.) It would look great on my credenza.

Wireless medical monitoring devices are highlighted in an article published yesterday. I like the idea of an edible sensor integrated into a medication that can document when it was taken, although I don’t want to receive patient information on my phone so that I can try to interpret it “all without a visit to the doctor.” Let’s take it one step further and integrate a monitoring sensor into every Girl Scout cookie produced, and if too many are consumed at a single sitting, it can send warning texts to purchasers. Having just found a stash of Thin Mints at the back of my freezer, I could definitely use the moral support.

More news: HIStalk Practice, HIStalk Mobile.

CIO Unplugged 3/28/12

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

Caught, Not Taught

As a parent, the most frightening rite of passage for me to tackle was not the sex talk, it was the car talk. As in watching my kids head down the street solo in a two-thousand pound, steel and fiberglass projectile. They had attended classes, studied a manual, and passed a test. But were they really prepared?

Not fully. They lacked one critical element.

In the workplace, I advocate professional development and have witnessed the benefits of classroom teaching. When I began to analyze this process, however, I realized traditional training suffered a maximum effectiveness. Think about this. After reading a book on teamwork, were you able to convert all the learned lessons into action? Why do some managers respond to training while their classmates do not? Why do leaders take life-changing courses, yet nothing changes?

Critical skills can only be caught, not taught. My children, for example, had the head knowledge for driving, but that information didn’t come to life until they took it on the road. Experiencing the streets helped them to catch—or ingrain—the skills for successful driving.

How do you help your team catch? Ability to drive is a necessity that comes with an inherent motivator—drive or be stuck living under my roof with my rules!

How can you create this driving-like context that motivates your staff to live out what they learned in the books? The following methods have worked for me.

Never fly solo. Do your best to always have a sidekick with you. If I have a team member in the hospital or a funeral to attend, I take an emerging leader with me to provide comfort. When I walk around to visit the team, I have a manager with me. They learn from the experience through observation and active participation.

Be vulnerable. When I have tough decisions to make or challenges to contend with, I open the kimono. I don’t shelter my team or pretend to know the answers. I include them. The young leader learns there is no voodoo or secret sauce. Some day they will face a similar issue and it will be familiar.

Share the stage. When I’m invited to speak, write, or interview, I often have one of my leaders with me. Sometimes observing, and other times co-presenting. One of our young directors had not presented before, so I had him observe me at a local university. The next time, we co-presented. Now he speaks routinely on the national stage.

Be transparent. Leverage social and business media. I Facebook friend any of my team who has interest. I connect with any on Twitter or LinkedIn. In the work environment, I mircoblog daily about what I am doing and why. This allows multiple avenues for insight. For instance, I may share my thought process on how I deal with setbacks.

Engage a mentor. Ongoing, planned partnerships focused on helping a person reach specific goals over a pre-determined period. Unfortunately, the art of mentoring has rarely caught on in the business world, healthcare included. Mentoring can be a difference maker.

Connect to others. As a leader, how do I impact the heart of my team? How do I create an environment where we can cultivate compassion? How do I help them view their job as more than a paycheck, but as a contribution to a patient’s life?

Ask questions. Whenever I’m around people I admire, I fire off a number of questions, then just listen and learn. I soak up wisdom.

Create hang time. It’s easier to talk when we’re not disguised in stuffy work attire. A non-business setting encourages conversation, but you must create these situations. I have surprised my team with an ice cream fest and invited individual members to attend employer-sponsored professional sports with me. I attend their symphony performances or listen to their garage bands at a local bar. I invite them to join my family for Broadway shows (we always buy extra tickets.) Make it happen!

Offer social opportunities. Do you learn etiquette from a manual? Emerging leaders who seek to become vice presidents should know how to handle themselves in a cocktail party situation and know the difference between red and white wines. My wife and I purposely host parties in our home to create a safe place in which to practice so they can learn to be comfortable mingling among executives. It’s also another occasion to get acquainted with and show appreciation to their significant others.

Outcomes?

I’ve had the joy of watching my directs blossom in their careers. Although I invested greatly in their formal training, their development accelerated during active observation. In the last couple of years, several became CIOs. Others took senior leadership positions in professional organizations.

My kids turned out to be pretty good drivers. But if you ask them how they learned, they’ll tell you they caught it by doing it – by making wrong turns, slamming on the brakes at stoplights, and bumping over curbs while parallel parking. The manual finally made sense.

It was caught, not taught.

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

News 3/28/12

Top News

Clinical communications vendor Vocera prices shares for its Friday IPO at $16, above the originally announced range of $12-14. That price values the offering at $94 million, giving the company a market cap of around $300 million.

Reader Comments

From Midnight Son: “Re: ICD-10 implementation delay. I’m hearing rumblings that ONC is mentioning a possible two-year hold. Have you heard anything?” I haven’t, but I will listen attentively to any reader who has and who wants to share.

From Jay: “Re: Capterrra. Rates EMRs using a ‘popularity index.’” This is yet another example of coming up with information that looks impressive in eye candy form without really meaning much. Capterra decided that market share wasn’t useful because it favors more expensive solutions (not to mention that the company doesn’t have exclusive use of that data and it wouldn’t look as cool on an ever-so-trendy infographic.) They don’t like rating EMRs as “the best” since needs vary (which doesn’t stop companies that rate cars, colleges, and places to live.) Instead, they went with the lazy method of just grabbing a bunch of unrelated publicly available data and mixing it up to give a conclusion: number of customers, number of users, revenue, number of Google searches, number of Facebook and Twitter followers, and Web site popularity rankings. The end result may or may not reflect reality, but I would say this: any provider who lets a cute infographic influence their EMR choice is a fool (do you really want to change your professional workflow based on vendor Facebook likes?) However, in fairness to the company, healthcare IT purchasers do indeed often line up like docile sheep behind whatever everyone else is buying, so perhaps this reflects reality.

From Charlie Enicks: “Re: job change. I debated sending you a note before any rumor was posted — too late! I am leaving to go to Georgia Health Sciences University in Augusta, Georgia starting May 1. As you know the searches take quite awhile. Our Epic project is going well and is on schedule. My leaving for an opportunity that is on the East Coast and closer to family had nothing to do with the project. Happy to give further clarification if any questions arise. Keep up the good work!” Charlie, who is CIO at University of Mississippi Medical Center, will take over that role in Augusta. I told him it was too bad that he will just miss the Masters Tournament. He joked that he tried to get that included in his offer.

From Indigo: “Re: end-of-life decision app. Recommended by Forbes.” The Best Endings site, started by former entertainment reporter Kathy Kastner with input from healthcare professionals, guides people into living their lives optimally before dying. It includes HIT-related topics such as specifying wishes for DNR and life support. I didn’t get much from the site, but I did follow one of its links to Death 1, Medicine No Score from the Canadian Medical Association Journal, which was really good, though predictably not exactly upbeat.

HIStalk Announcements and Requests

Over on HIStalk Mobile, Travis has written an insightful post, Free isn’t Free, that has generated excellent reader response. Dr. Travis says he’s OK with having his personal information used by a free app vendor as long as he’s told upfront, although he’s uneasy with fast-growing startups who haven’t figured out a revenue model and may peddle data down the road. Cyndee has a problem with companies that sell claims data to carriers to help them dream up reasons to deny claims payment, while Margalit doesn’t like non-free apps that sell your data without your knowledge. Finally, HIT Project Mgr states that consumers should have all of their health information available without paying for it, no different than being able to check their previous Amazon orders whenever they want. Good discussion. Sign up for the e-mail updates while you’re over there if you want to keep up with excellent doctor-written news and opinion about mHealth.

Ross Martin MD, who actually has a day job (Deloitte) that doesn’t involve writing fun songs or appearing as Elvis at HIStalkapalooza, is recruiting industry folks to complete the 2012 Deloite-AMIA Health Informatics Industry Maturity Survey by April 20. They hope to conduct it each year as a benchmark about what’s going on with health informatics. I think it’s a great idea and I started the survey with enthusiasm, but I’ll be honest in admitting that I quit early – the estimated time to complete is 30 minutes and I just didn’t have it to spare.

Acquisitions, Funding, Business, and Stock

Home health software provider Kinnser Software secures $40 million in Series A financing from Insight Venture Partners.

Predixion Software will present at a New York venture summit this week, discussing its predictive analytics solutions for payors and providers. The California company claims its Readmission Insight can predict up to 86% of readmissions. I Googled and found the above video interview with the company, filmed at the HIMSS conference in Las Vegas.

Sales

Kern Medical Center (CA) selects EZ-CAP, EZ-NET, and EZ-EDI from MZI Healthcare for health benefit administration.

MD Anderson Cancer Center (TX) selects Health Language Inc.’s Language Engine to automate mapping of patient data collected in its custom-built EMR, ClinicStation.

People

EHNAC appoints Luigi Leblanc (Zane Networks) and Deborah Meisner (Emdeon) as commissioners.

Former Carefx Chairman and CEO Andrew Hurd is appointed president and CEO of Epocrates. He takes over for Peter Brandt, who will step down as interim president and CEO and assume the role of vice chairman of the board.

As rumored by reader HairClub earlier this month, Hackensack University Medical Center (NJ) hires Shafiq Rab MD as CIO. He was previously VP/CIO of Greater Hudson Valley Health System (NY).

Former CMS administrator Donald Berwick MD, MPP is named a senior fellow with the Center for American Progress, a DC-based liberal think tank with historically close White House ties.

Laurie Gehrt, former chief nursing officer of Cerner Consulting, is named SVP at B.E. Smith, where she will lead the company’s interim leadership and consulting groups.

Announcements and Implementations

Riverside Regional Medical Center (VA) implements Phytel Transition in its ED to follow up with discharged patients.

NextGen Healthcare will resell Dragon Medical speech recognition software to its ambulatory EHR clients in an agreement with Nuance.

Cone Health (NC) takes 25 affiliated physician offices live in its $120 million Epic project. Its five hospitals will go live in July.

Drug data vendor PEPID announces that it has added maximum pediatric and adult drug doses to its medication content, allowing hospitals to create overdose warning alerts.

Government and Politics

CMS reports that through the end of February, hospitals and EPs have been paid $3.9 billion as part of the EHR incentive program. That includes almost $1.2 billion to 84,005 EPs and $2.7 billion to 2,355 hospitals.

HHS awards $50,000 to the designers of THUMPr, an Web-based tool that allows users to create personal heart health profiles, as part of its One in a Million Hearts Challenge innovation program.

The Office of the Inspector General finds that Brigham and Women’s Hospital (MA) received $1.5 million in overpayments from 2008 to 2010, primarily because “the hospital did not have adequate controls to prevent incorrect billing of Medicare claims or did not fully understand the Medicare billing requirements.” The hospital’s official response notes that the organization has since implemented additional controls, performed training, and implemented a new pre-bill monitoring system and more robust claims scrubber system.

HIMSS lists the HIT-related effects if the Supreme Court finds all or part of the Patient Protection and Affordable Care Act to be unconstitutional. If the whole thing dies, with it go certain HIE provisions, ACO demonstration projects, extension of PQRI, and Center for Medicare and Medicaid Innovation. However, the court could also find that only parts of PPACA are unconstitutional (specifically the part requiring that everybody buy medical insurance) and the rest could remain intact. None of this would impact HITECH or the Medicaid EHR incentive program, both of which came from ARRA.

Contractors building the behind-schedule, 314-bed Orlando VA Hospital say the agency’s red tape and design errors could add $120 million to the original $665 million project cost. That would raise the final cost to $2.5 million per bed.

Other

A Texas newspaper picks up on the year-old policy of Citizens Medical Center (TX), which bans the hiring of employees whose body mass index exceeds 35 (about 260 pounds for a man who is six feet tall.) The policy says a prospective employee’s physique “should fit with a representational image or specific mental projection of the job of a healthcare professional.” I personally enjoy the specific mental projection of George Clooney.

SCL Health System will move its headquarters from Kansas to the Denver, Colorado area, creating 750 jobs in accounting, billing, IT, and systems services over the next four years.

Board members of the Tennessee chapter of HIMSS create their own HIT workforce initiative, pledging on behalf of their employer organizations to offer 50 internships and 500 hours of collaboration with educators and students.

The Tampa newspaper covers competing interoperability projects that are underway, one led by big hospitals and the other by big medical practices. The president of the medical association says hospitals are too profit-oriented to share data among themselves. One orthopedic surgeon who was interviewed says he doesn’t really care which group prevails – he just wants to use his two-year-old EMR to exchange records with somebody.

Medline kicks off its 2012 Pink Glove Dance competition at the AORN conference in New Orleans Monday, with 1,000 OR nurses participating in the company’s Breast Cancer Breakfast.

Sponsor Updates

• AirStrip Technologies EVP Bruce Brandes is interviewed by the Nashville Business Journal (subscription required.)
• Sam Lakkundi, VP of mobile strategies of Kony Solutions, discusses Bring Your Own Device models in a video interview.
• Regional Medical Center at Memphis selects MedAssets to provide strategic sourcing and clinical resource management services.
• CTG Health Solutions expands several of its large EMR project engagements.
• API Healthcare hosts a webinar on the importance of role-based practice in staffing.
• Regional Medical Imaging (MI) becomes Merge Healthcare’s first radiology customer to receive Meaningful Use payment.
• US Representative Nancy Pelosi participates in a ribbon-cutting ceremony at Practice Fusion, which recently moved into a new building after completing $1 million in renovations.
• T-System posts a video featuring Baptist Healthcare System (KY) and its go-live with the T SystemEV EDIS.

More news: HIStalk Practice, HIStalk Mobile.

Readers Write 3/26/12

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!

If You Did It, Enter It in the EHR
By Mitch McClellan

I was recently asked the following by a colleague:

We know that every organization has some physicians who just will not fully use the EHR. They will have nurses, MAs, and other clinical staff do all of the data entry. They may just hand the staff a piece of paper and have them enter the problem list. A specific example would be the MU requirement for weight counseling – do you think it is acceptable for an MA to indicate in the record that the physician did the weight counseling? Clearly it makes sense to have nurses and other clinical staff enter medications and even other orders and even start notes, but where do you draw the line?

This question certainly walks the line between facilitating accurate data entry vs.what is appropriate.

If an organization is truly going to embrace this much-needed change in healthcare, they need to enforce that their clinicians do the right thing. In this case, it would be physicians taking 100% ownership of entering the documentation specific to weight counseling. They are the ones actually provided the counseling.

I understand that is a black-and-white response, but I strongly believe that if an organization’s culture accommodates physicians who choose not to do their complete EHR responsibilities (e.g. not documenting the counseling that YOU provided), then it defeats the entire purpose of what we’re doing.

The EHR revolution is strongly driven by the fact that paper is not efficient and creates too many points of failure. Not only is the medium (paper) antiquated, so are many of the policies and processes that support those paper workflows (e.g. documenting a note that you then pass on to someone else to then "document a note" on your behalf).

Unfortunately, I believe most physicians are put into a "get it done now vs. a get it done right" scenario due to the payers’ stringent reimbursement policies. I completely understand the time demands on these physicians. But the rule I try to instill with all of my groups is that, "if you did it, then you must enter it in the HER." Otherwise, the effectiveness and efficiencies of an EHR are lost if the old way of doing things is still embraced.

The groups that I’ve worked with would require the physician enter that piece of documentation themselves instead of the MA. The only groups that I’ve worked with that would allow this scenario to happen would be if it was the physician’s nurse — not an MA –entering the documentation. To me, the issue is twofold. The first is workflow (reasons already stated), the second is the lack of credentials of an MA. I know I’d want a higher-credentialed healthcare provider entering that information if it’s not the physician themselves.

Mitch McClellan is manager of implementations at MBA HealthGroup of South Burlington, VT.

Optimization
By Dave Vreeland

Cumberland brought together a select group of HIT executives from some of the nation’s leading health systems for a recent breakfast discussion The topic: optimization.

Now that many are on track for Stage 1 Meaningful Use and other compliance deadlines, the focus is beginning to shift beyond go-live toward getting the most out of HIT systems. The panel, made up of Cumberland’s Brian Junghans, HCA’s Dr. Divya Shroff, and Memorial Healthcare System’s Jeff Sturman, shared how non-profit Memorial and industry giant HCA are tackling optimization.

The takeaway: success largely hinges on solid communication and the collaboration of two very different worlds – IT and clinical. Clinicians are arguably the keystone in achieving effective system adoption and long-term optimization.

Junghans points out that IT folks tend to think in terms of projects, which have a defined beginning and end. When it comes to IT implementation projects, the end is go-live. In contrast, optimization is an ongoing effort.

Dr. Shroff points out that clinicians have more of an optimization mindset, with a continuous focus on improved quality of care, optimal patient outcomes, and best practices.

With techies and clinicians in different mindsets, speaking two different languages, communication issues are common. HCA has success placing physicians and other clinical professionals like Dr. Shroff in clinical transformation roles. Valuable insight and hands-on experience makes these clinicians effective ambassadors for both the IT and clinical teams. 

Sturman and the Memorial team have incorporated clinical aspects into their approach to optimization. The team makes regularly scheduled rounds to observe workflow, system usage patterns and identify opportunities for improvement throughout each of their six hospitals, clinics, and ambulatory practices.

The importance of a clear distinction between IT support and optimization teams was also stressed. HCA trains the IT support team to triage incoming calls, address specific break/fix issues, and refer optimization matters to the optimization team.

Both organizations have seen success with various efforts to improve clinical/IT relations and are on track with current and long-term efforts toward optimization.

In addition to a number of lessons learned and critical success factors to consider during and after the implementation process (summarized in our presentation Beyond Go-Live: Achieving HIT System Optimization), it was interesting to hear this room of executives from diverse organizations, representing both the clinical and IT fields, reinforce the significant impact collaboration between the two worlds has on the success of end-user adoption and achieving true optimization.  

Dave Vreeland is partner with Cumberland Consulting Group of Franklin, TN.

Stage 2: The Vendor View
By Frank Poggio

On March 7, 2012, a draft for comment on the new Stage 2 rules was published in the Federal Register. Actually there were two separate parts to the rules. They are:

1. The CMS part that is aimed at provider requirements necessary to meet Meaningful Use, and
2. The ONC piece that addressed proposed changes to the certification process for EHR vendors.

On the provider side, there are innumerable blogs and Web sites that are covering the provider issues, which deal mostly with a few added MU criteria such as electronic medication administration records, menu options in Stage 1 that are now mandatory in Stage 2, greater emphasis on exchanging patent care information across care levels, and greater patient access to care information.

This article will focus on the “second side” of the regulations — the elements that most impact the system suppliers, with emphasis on the impact to niche or best-of-breed (BoB) vendors.

The full text of the new ONC Certification proposed rules can be found at here.

Before we hit the high (and low) points of the rules keep in mind these are proposed rules. If there is anything you don’t like about them, have suggestions for improvements, etc. you have from now until June 7 to post comments on the federal Web site. Speak now or forever hold your price! (No that is not a typo … see the Ugly).

Here’s the Good, the Bad, and the Ugly of proposed certification changes for vendors.

The good news:

Privacy and Security — will it go away?

EHR Module certification gets a little easier for niche and best-of-breed vendors (BoB). The big change here is that Module certification no longer requires you to address any of the privacy and security criteria. In the past, there were eight P&S criteria (number nine was always optional), and in our working through many ATCB tests, if you said the right phrase, you could get a waiver on three others (Integrity, General Encryption, and HIE.) Proposed under the Stage 2 as a niche/BoB vendor, you can ignore all the P&S criteria. To get certified under Stage 2, it would seem all you will need to do is pass any one Inpatient, Ambulatory, or General criteria, just ignore the P&S criteria, and you’re home free.

ONC said they made this change because many of the smaller firms complained that the P&S criteria did not apply or were too burdensome. This may sound too good to be true. Maybe it is. Read what ONC says in other parts of the document:

Finally, we propose to require that test results used for the certification of EHR technology be available to the public in an effort to increase transparency around the certification process. We believe that there will be market pressures to have certified Complete EHRs and certified EHR Modules ready and available prior to when EPs, EHs, and CAHs must meet the proposed revised definition of CEHRT for FY/CY 2014. We assume this factor will cause a greater number of developers to prepare EHR technology for testing and certification towards the end of 2012 and throughout 2013, rather than in 2014.

This is classic ONC. They say you don’t have to get certified. There is no law that says any vendor MUST – even a full EMR vendor. They believe the market will tell you. And by the way, ONC will be publishing the details of your certification so the world can compare you against your peers.

As we tell our clients, the MU criteria you choose to test on is dictated more by your competition and clients, not by the ONC.

Gap certification for Stage 2

A question that we have heard frequently was if I was certified on 20 criteria for Stage 1, under Stage 2, would I have to be tested again for those same criteria? Under the proposed Stage 2 rules, you would not need to get re-certified on Stage 1 criteria. You will only have to be tested on new criteria you select, and tested on Stage1 criteria that has changed or been revised by ONC.

A good example is the encryption P&S test. The focus now will be on encryption for data at rest. They state:

EHR technology presented for certification must be able to encrypt the electronic health information that remains on end user devices. And, to comply with paragraph (d)(7)(i), this capability must be enabled (i.e., turned on) by default and only be permitted to be disabled (and re-enabled) by a limited set of identified users.

So if you tested out on encryption under Stage 1 and want to carry it forward into Stage 2, you’ll probably have to show how you default encryption for user devices.

Component EHR vs. Complete EHR

A typical misunderstanding we came across many times during past year taking our clients through the certification process was a CIO at a hospital would say to the vendor that he/she believed they had to install a full EMR from a single vendor to meet all the MU criteria. In the proposed regulations, ONC has clearly addressed this question. On page 104, they say:

Certified EHR technology means: 1. For any Federal fiscal year (FY) or calendar year (CY) up to and including 2013: i. A Complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition EHR certification criteria or the equivalent 2014 Edition EHR certification criteria; or ii. A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary for the 2011 Edition HER certification criteria or the equivalent 2014 Edition EHR certification criteria, and the resultant combination also meets the requirements included in the definition of a Qualified EHR.

In effect, a provider could meet the MU criteria using as many suites of BoB systems as they believe necessary. They do not have to be from one or the same vendor.

Now some bad news:

Criteria components

Many BoBs struggled with the make up of the criteria for Vitals and Demographics and several other clinical criteria. On the surface, they seemed easy to pass. The problem was they contained some data elements that were not typically found in BoB systems. For vitals, the hurdle was growth charts. For demographics, the hurdle is date and time of death. To pass these criteria, some vendors would use user-defined fields or create new inputs that they knew their clients would never use. Repeatedly I was asked by niche and BoB clients, “Why would you ask a patient during a registration process, ‘When did you die?’” Now there’s a comforting dialog!

Keep in mind several or the participants in building the HITECH/MU program were academics and researchers who would find that piece of information critical to their retrospective medical data analyses. Also, vendors of full EMR systems would easily have that piece of data readily available in their medical record abstract system. But for an ancillary or niche vendor, not likely. As far as I know, there were no niche or BoB vendors represented on any of the HITECH Policy or Standard Committees.

You may wonder why any firm would go through the trouble of adding a useless data element. Again, keep in mind what ONC said above: market will require certification. It can be virtually impossible to sell an ancillary system such as surgery, ICU monitoring, therapy, anesthesia, etc. if you had to tell your prospect your product was not certified for vitals.

Unfortunately this issue is still there for BoBs. The big change is on the provider side. ONC has greatly liberalized the granting of exceptions to providers for MU attestation if the MU criteria (or element of the criteria) do not apply to their practice of facility. As an example, a psychiatrist does not have to do growth charts for his patients — an exemption will be readily available. But the vendor who sold him the system still must!

Continuing this topic, in a recent interview Dr. Mostashari chided EHR vendors who "aren’t making meaningful use of Meaningful Use." Instead of attempting to seamlessly incorporate MU standards into their interfaces, Mostashari said "vendors did what vendors do—they slammed in the criteria and got certified.”

I submit that ONC slammed these regulations into being as fast as they could due to Congressional and Executive pressure, so one good slam deserves another. Maybe if ONC took a moment to look at the impact of certification on niche and BoBs — which are mostly the smaller, more innovative developers — and adjusted the criteria, we all could stop slamming.

And now the ugly:

As I mentioned in an earlier HIStalk post, ONC wants comments on vendor product price transparency. Here’s the ONC statement:

During implementation of the temporary certification program, we have received feedback from stakeholders that some EHR technology developers do not provide clear price transparency related to the full cost of a certified Complete EHR or certified EHR Module. Instead, some EHR technology developers identify prices for multiple groupings of capabilities even though the groupings do not correlate to the capabilities of the entire certified Complete EHR or certified EHR Module. Thus, with the transparency already required by §170.523(k)(3) in mind, we believe that the EHR technology market could benefit from transparency related to the price associated with a certified Complete EHR or certified EHR Module. We believe price transparency could be achieved through a requirement that ONC ACBs ensure that EHR technology developers include clear pricing of the full cost of their certified Complete EHR and/or certified EHR Module on their websites and in all marketing materials, communications, statements, and other assertions related to a Complete EHR’s or EHR Module’s certification. Put simply, this provision would require EHR technology developers to disclose only the full cost of a certified Complete EHR or certified EHR Module.

As a former CFO, I know that the through definition of ‘full cost’ would take at least another 500 pages in the Federal Register. After the vendors in the audience come down off the ceiling, you’d probably like to share your reaction with ONC. Just click here.

Frank L. Poggio is president of The Kelzon Group.

Curbside Consult with Dr. Jayne 3/26/12

I’ve been having a hard time sleeping lately. Maybe it’s the recent time change, or maybe there’s just too much going on at work. Maybe I’ve got spring fever or just a touch of unfulfilled wanderlust. I’ve enjoyed taking some long walks in the evenings and sitting out on the patio listening to mellow David Gray tunes as I deliberately wind down from the ever-lengthening days.

I suspect it’s the proverbial “too much going on” because I also developed a touch of writer’s block. A friend of mine works in the industry, so I asked him for inspiration with this question: as a person in the trenches, what kinds of things keep you up at night?

What he came up with was a question for me: will Meaningful Use really decrease the cost of healthcare and increase continuity of care, or is it just additional overhead where no one really knows how to administrate the benefit it could provide?

I’m going to take off my politically savvy “plays well with others” hat and put on my “doc in the trenches” hat for a bit here. The answer is I really don’t know. Many health systems have been practicing what Meaningful Use preaches for years prior to the incentive program. They’ve implemented patient portals, obtained unified data, and achieved transparency of the medical record. They conduct group visits, run non-traditional schedules, and encourage both patients and employees to use personal health records.

IT systems are in place which support evidence-based care and encourage disease prevention and health promotion. Providers are graded on the care they deliver and are presented with opportunities to intervene where care can be improved. Providers in these health systems are discouraged from ordering unnecessary tests and ineffective treatments through both payer and quality initiatives. In many organizations which are true integrated delivery systems, referrals are closed loop and carefully controlled as well.

Despite these efforts, many are not seeing overall costs come down. Patient insurance premiums definitely aren’t decreasing. We know that certain episodes of care can be made more cost effective and we can leverage technology to prevent many harms. We’ve all watched the recent debate over the Health Affairs article that showed that access to prior results didn’t decrease ordering of tests. We understand that test volume alone isn’t a reliable indicator of whether we’re successful. I have seen data on primary care practices whose ordering volume spiked after EHR implementation, but when you drill down, a large number of those tests were preventive. That seems to indicate that clinical decision support is working.

If you watch those practices over a few years or so, however, the ordering tapers off. It’s almost as if providers are playing “catch up” for the tests they missed while they were too busy addressing acute illnesses and complex chronically ill patients. If you look at labs that are ordered to diagnose illness or monitor chronic conditions, we didn’t see as many spikes. I wish hospitals and provider groups would have had the resources to do better prospective studies as they implemented, but unfortunately, most of us were focused on system build and implementation. It would be nice to look at it other than through the retrospectoscope.

I do think advances in healthcare IT have significant potential to increase continuity of care, but it is unclear whether MU is really a driver. Over the last decade, we’ve seen RHIOs fail despite significant clinical potential. I’ve seen the accessibility of information increase dramatically in both the ambulatory and acute spaces as well as between them. We have data at our fingertips instantly that would have taken hours or days to obtain previously.

We have the potential to avoid duplication of tests and therapies, with one caveat – caregivers have to be allowed the time to intelligently process the burgeoning amounts of information relevant to each patient and his or her care. Unfortunately, our payment system is still largely volume driven, often resulting in fewer and fewer minutes for each patient contact. Patients in the hospital are sicker and they’re going home sooner, making the task even more difficult.

Meaningful Use is certainly additional overhead. Of that there is no question. The cost to implement certified technology is significantly higher than the payments received. I hope anyone who actually believes differently is willing to share whatever psychotropic substance they’ve gotten a hold of.

Hospitals and providers are simply running to catch up and to make sure they avoid the payment penalties that are coming. Meaningful Use has derailed other initiatives as budgets have shifted to accommodate timelines which are faster than some groups were prepared to implement. I know that’s the point – to speed things along for laggards – but some groups and hospitals were simply proceeding at a more deliberate pace relative to their own goals and priorities.

I wonder how many people at ONC have visited a practice that has cut back on improvements to the physical plant, supplies, or clinical equipment due to the increasing IT budget? I know I’ve been to quite a few. I’ve seen state-of-the-art computers sitting on decaying countertops that can’t be properly sanitized. I’ve seen budgets for continuing education and clinical in-services eliminated in favor of application training and time spent in endless debate about the validity of various order sets.

I’ve seen much more, but it’s too depressing to put into words. The amount of money spent on MU consulting alone is absolutely staggering.

Physicians seem increasingly susceptible to burnout, and the cost of that unintended consequence can’t be readily quantified. This also applies to nursing staff, pharmacists, ancillary staff, and pretty much anyone who works in support of patient care. IT staff are also under increasing stress. We all know stress and burnout diminish productivity and put patients at risk.

Only time will tell whether Meaningful Use will be truly effective in changing the way we deliver healthcare and how much it costs. In the mean time, we’re all going to work longer and harder and get by with less in some respects. We’re going to do some amazing things, but not without a price. Fasten your seat belts, folks. It’s going to be a wild ride.

And for those of you who know your Disney history, remember this: Mr. Toad was only a C-ticket ride.

E-mail Dr. Jayne.

Monday Morning Update 3/26/12

From Fozzie Bear: “Re: University of Mississippi CIO Charlie Enicks. Resigned just a few months before going live with Epic.” Unverified. UPDATE: verified. Charlie tells me he’ll be the new CIO at Georgia Health Sciences University in Augusta starting May 1. He says Epic is doing fine at Mississippi – he just wanted to get closer to family.

From The PACS Designer: “Re: Epic at Yale. It appears that things are going well with Epic, according to Daniel Barchi, CIO at Yale New Haven Health System, who gives us his real experience using the new Epic EMR for a recent physician visit as detailed in the Yale Medical Group News. “

I’ll be making minor changes to HIStalk over the next year based on your reader survey responses, although there won’t be too many — most respondents urged me to not try to fix what isn’t broken. First up is the search function, which I’ve just replaced with a paid Google version that’s faster and cooler. Second: readers suggested bringing on two contributors if I can find them: (a) a frontline provider-side nurse with healthcare IT insight, and (b) a stock and business expert. I’m willing if I can find that rare combination of talent, insight, and the commitment to write even when life intrudes. Some other suggested ideas (new sites, new coverage, putting on conferences, etc.) were good, but not realistic to undertake as a part-timer. They do, however, give me a fall-back position if I ever get sick of my day job and need to scratch out a living on my own. Thanks to the folks who completed the survey – it’s important to me.

Listening: new from Nada Surf, catchy indie rock that’s more upbeat than some of their earlier stuff. They sound just as good in their acoustic performances, a rarity among bands who couldn’t sing Happy Birthday to someone without Auto-Tune help and whose high-ticket shows are more karaoke than concert. They’re on tour now.

Two-thirds of respondents side with Farzad Mostashari in predicting that physicians will order fewer unnecessary imaging tests when previous results are available and new orders are guided by electronic decision support. New poll to your right, inspired by my Pam Pure interview: what target market will offer the greatest HIT opportunity in the next 5-10 years?

Emerging confused and squinting in the first light it has seen in five years is this week’s Time Capsule editorial, EMRs: Free May Not Be Cheap Enough for Physicians, in which I opine, “Imagine what they’ll think when they first encounter hospital IT types, those grudging emissaries of a department built around rigid conformance to rules, perpetual understaffing, and a vision for the common good that squelches the individuality and self-determination that doctors thrive on.”

Cooper Health System (NJ) names Jayashree Raman, formerly of Stanley Healthcare Solutions, as VP/CIO.

Mr. Ciotti turns back the HIS-tory clock  to long-forgotten bedside system vendor MedTake.

Weird News Andy is fascinated by a $100 test that could predict heart attacks weeks in advance. It detects endothelial cells that have been loosened into the bloodstream by fresh artery damage.

Cerner will break ground on its new Kansas City campus this week, planning to start moving an eventual 4,000 employees into the new offices by the end of the year as required by state-provided incentives.

CMS will conduct a free webinar overview of MU Stage 2 on Monday, March 26 at 1:00 Eastern.

CVS Caremark blames a programming error for exposing the detailed medication and condition lists of 3,500 members of Tufts Health Plan to other members by printing the wrong addresses on the envelopes.

In England, Liverpool hospitals are running a “bring your own device” pilot for tablets, installing Kaseya’s device management software on them for security. The hospitals like the idea of cheaper alternatives to desktop PCs and are considering offering an employee subsidy for tablet purchases. Says the CIO, “Refreshing all that kit every three years is becoming cost-prohibitive. People already have really cool devices, which they do bring to work. They just can’t connect them.”

E-mail Mr. H.

HIStalk Interviews Pam Pure, CEO, HealthMEDX

Pam Pure is CEO of HealthMEDX of Ozark, MO.

Let’s get the obligatory McKesson questions out of the way. What are you proudest of from the time you spent there and what regrets do you have?

I look back at McKesson with great memories. I’m very proud of our team and I’m very proud of what we accomplished. 

We took a business that was basically going nowhere in the ‘98-‘99 time frame. We built a strategic plan and brought together a series of products — clinical products, imaging products — that we could deliver as a really robust solution to our customers. Over the eight years that I was there, we built great customer relationships, built a great working organization, and put some customers on the road to full clinical implementation and physician connectivity. It was a great time, a great experience, and I look back on it with a lot of pride.

In terms of regrets, I don’t really have any. I look at that as a great chapter in my career, a chapter that I’m very proud of. I learned a lot and it was a great launching point to this next chapter, which I recently started and I’m really excited about.

What led you to leave McKesson?

It was the right time, time for a new chapter. I left the organization and began thinking I was going to take a year off and just spend some time with my family. Things went on a whirlwind from there until I ended up HealthMEDX.

As you’re watching now from the sidelines, were you surprised by the announcement about Horizon Clinicals and Horizon Enterprise Revenue Management  being de-emphasized in favor of Paragon?

I know this is going to be hard for a lot of people to believe, but I really don’t spend a lot of time watching McKesson. I’ve made a conscious decision, like when you send your kids off to school. You have to let them go. A really important transition point for me was letting McKesson go.

There’s a lot of great people there, a lot of smart people there. I rely on them to make the best decisions for the company and for the customers. I hope they will continue to do that because I think we set a precedent of putting our customers and employees first.

But you know what? I really don’t follow it. I’ve tried very hard not to have an opinion on McKesson, but just to support their continued success.

What is it about HealthMEDX and the post-acute care market in general that simultaneously got you to come there and for investors to acquire the company?

I left McKesson and I had this grand plan that I was going to take off a year and travel with my kids and do things like exercise and get fit. Shortly after I left McKesson, my mom was diagnosed with a really serious Stage 4 cancer. She had a lot of surgery and a very long rehab, which she experienced in my home. 

And you know, here I am — I think I’m like Miss Healthcare, because I think I’ve been involved in healthcare for 27 years, so I must understand it — but here I was in the middle of helping someone I love recover from something very serious. It was the most challenging thing I’ve ever done, because it was very, very difficult to figure out how to manage her care.

My mom got back to the point where she could live at home with my dad. We went on a two-week vacation, came back, and my father had a heart attack in our driveway. He had quadruple bypass surgery and then he moved into the Pure Rehab Center, at which point over the door came up Pure Rehab Center the sign. We shipped him home about eight weeks later. 

Three months later, my mother-in-law had a stroke. In this very compressed eight-month period of time, I had three people — who are very independent, very successful in their own lives, very healthy — all go through these major post-acute events at three fabulous health systems. In every case, I was so disappointed and so stunned by the lack of follow-up support.

While I was at home dealing with the emotions of taking care of parents and in-laws, I had a very introspective time. I said, what am I going to do next? I don’t want to go back and do another very large company. I would really like to help figure out how to solve this problem in the post-acute space. 

I started spending time with my parents’ friends, my in-laws’ friends in trying to understand how they were dealing with managing their home care, moving to retirement communities, moving to assistant living organizations. As I started digging into this, I found that these organizations were very disconnected. It was confusing for my parents and their friends to deal with healthcare and follow-up. There are many people involved doing the same things, many different locations, and it was totally a paper system.

I approached the private equity firm and said, “I would really like to do something in the post-acute space to figure out how we can build a technology-enabled system that could be connected back to the health system. Post-acute care is going to be very strategic moving forward, and it’s got to be more connected and it’s got to be more automated.” That’s what began my journey at looking at companies in this space.

The question I should have asked you earlier but I was hung up on the McKesson questions is to describe what HealthMEDX does.

HealthMEDX provides an integrated technology platform that manages a patient in a post-acute environment. If they’re not in the hospital and they’re not in front of a physician, we automate it – home care, hospice, skilled nursing, assisted living, rehab, retirement communities, transitional care organizations moving from the hospital back out to the home. Anything that doesn’t occur in the hospital or doesn’t occur in the physician office — we can manage the patient through that experience.

What is most different about that client base compared to physician practices and hospitals?

For the most part, post-acute providers have more long-term patient care responsibility. I visit some of our customers that are skilled nursing homes. The patient might be there for 12 years. These post-acute providers or even a rehab center – these providers are kind of like the last check to make sure the patients gets as healthy as they can be. They finish the care. 

In the hospital or in the physician office, treatment tends to be very episodic — finish off and go. In the post-acute center, it’s more focused on how do we get the patient back, how do we get this person back as good as they can be, and where is the right end place? I think there is more focus on managing the patient back as opposed to managing an episode.

That’s changing in health systems, and obviously with risk-shifting and ACOs, there is a great focus on the patient. That’s why I think these post-acute organizations are going to become more strategically important.

That market wasn’t really considered all that sexy by most people, where institutions were perceived to have both financial challenges and technology challenges. How did HealthMEDX turned out to be the biggest vendor in it?

The uniqueness of HealthMEDX comes in two areas. Most technology players in the post-acute space focus on one segment. You’ll see a lot of home care companies, you’ll see a lot of rehab companies, you’ll see a lot of skilled nursing companies. Most of those companies do one thing.

I think the difference and the magic of HealthMEDX is it’s a patient-centered system that knows it has to manage the patients. Where they are doesn’t matter in terms of how the care is automated and delivered. 

If you look at our customer base, it’s very diverse. We do these large, national, senior living retirement communities. We automate the whole community. We do post-acute transition programs, where it’s a program for 14 days to get the patients from the hospital to home. We do home care, we do hospice, we do rehab. We have a large presence in all of the different segments of the post-acute market.

A big part of our strategic thesis was that post-acute care providers are going to diversify and consolidate. Nobody just wants to be a skilled nursing home or just an assisted living these days. They want to provide rehab services or home care services. The technology needs and the requirements of these organizations are changing.

Do you think federal reimbursement changes will encourage growth or consolidation, changing the way these organizations compete with each other as well as competing with hospitals?

We’re going to see a lot more networking between post-acute providers and hospitals. More sharing of the risk. When you look at readmissions and the health system focus on reducing readmissions, there are a lot of post-acute providers that can help them get there, in terms of managing the patient once they leave and trying to keep the patient form coming back. 

A lot of the changes in the regulatory environment and in the risk-shifting environment will cause the post-acute providers and the health systems to become more tightly integrated. Some health systems will acquire more post-acute providers. I see some purchasing nursing homes, assisted living, some building retirement communities where they’ll have full management of the patient. Then I see a number that are building very progressive networks with regional post-acute providers to manage their patients once they go home.

There was a time when hospital CIOs really knew next to nothing about physician practice systems because they weren’t relevant to their organizations. Do you think that they’re going to be pushed into gaining the same expertise in long-term and home care systems?

I absolutely do. It’s very interesting to watch, because we all watched in the ‘80s and the first half of the ‘90s as the hospital markets started to automate it. It started with financial automation, then clinical automation, and then connectivity. We watched the physicians go through the exact same evolution – financials, then EMR, and then a huge focus on connectivity. That became the continuum of care.

I think we’ll see an extension in the continuum of care. I think that extension will include the people who are responsible for the care of the patient after they leave the hospital and after they leave the physician office. I think we’re going to see the exact same thing. Those post-acute care organizations have billing today. They’re now beginning the journey for an electronic clinical record. I think the journey for that electronic clinical record and health system connectivity will almost occur concurrently because of their importance in an ACO environment.

Those of us on the hospital side might assume that we’re doing cool stuff that should find its way into nursing homes and home care. Are those organizations things that hospital people could learn from?

There will be a great deal of information shared and a great deal of learning on the health system in the post-acute side as we build this collaboration and extend the continuum. 

The hospital market today is much more experienced with implementing advanced clinical systems. The lessons learned in terms of process flow and workflow automation will be essential to the success of some of these post-acute care providers and will help us figure out the right way to make handoffs … what happens when a patient is discharged, what happens when a patient shows up in the emergency room. The health system and hospital clinicians are more system savvy and can help direct those handoffs, which I think will be great.

On the post-acute side, what’s very interesting to me is that the location of the patient is really insignificant in the care of the patient. For the most part, hospital systems and physician systems have been very visit specific and episodic in the way that the data is managed. Especially with HealthMEDX, the post-acute view is much more patient centered, just naturally patient centered in the way the product was built, with the assumption that the system has to follow the patient — the patient doesn’t follow the system. Just a lot more flexibility in how the technology can be deployed and the intelligence of the product to know the right way to bill.

Some of the biggest changes in healthcare IT have been driven by government changes, like reimbursement or Meaningful Use. Do you see that happening in the market that you’re in? Will hospital software companies need to build or to buy to get into that market or be left behind?

The post-acute market has similar regulatory requirements that are getting more complicated and more intense and I believe are driving the automation of the EMR in the post-acute market, very similar to what happened in the hospital and the physician market. Subtle incentives to automate, so you can electronically transmit clinical data and electronically transmit some more complex financial information. The regulatory push is definitely there.

Many of these post-acute organizations are selling “directly to patients,” quote-unquote, in terms of the value they can provide and the quality of care. In many cases, patients are making a very definite choice of where to receive their care and the technology infrastructure is becoming more important. Patients want families, want their parents in organizations that they feel are safe, with quality systems and services. Technology is becoming part of that decision process and the shifting reimbursement and relationships with hospitals.

We’re going to look back and see the next three years as a critical time in terms of hospitals and physicians being able to follow their patients home. To do that, the post-acute technology and post-acute connectivity is going to become essential. I think the progressive post-acute organizations realize that and are moving more rapidly than we expected.

How is selling and supporting customers in your market different than it was for hospitals and physician practices?

From a selling perspective, customers are very focused on three or four things that are very important to them. There is more clarity of what they are looking for. When you look at a hospital or health system, it is a very complex sales cycle with a lot of decision makers and a lot of stakeholders at the table. The post-acute environment tends to be more focused on exactly what’s required and is not as large and long.

When you look at the company over the next five years, what are your priorities?

It’s a great question, because I just really am excited about the potential to help build the technology-enabled post-acute world. 

When I look at the next three to five years, the first thing that we can do is help these post-acute care providers build an electronic medical record that includes all of the information for the patient, whether they’re receiving home care, whether they’re receiving rehab, or whether they’ve had to move to assisted living. We can build one integrated record to manage that patient. I think Job #1 is supporting the consolidation and the diversification that’s happening in the post-acute market with an electronic clinical record. It’s really essential.

The second thing that is going to happen — and it’s going to happen quickly — is helping health systems connect and build relationships with these post-acute organizations so they have the capability to follow patients home. That will require a lot of work with health systems in terms of setting up the infrastructure and the process flow of moving a patient home or moving a patient to an assisted living or a rehab organization. Also being prepared to take the patient back when they show up in the emergency room or have to come back for services. Health system connectivity supported by industry standards — I think that’s Job #2.

Job #3, once we get that going and these post-acute providers are automated and they’re connected, there will be great learnings in terms of analytics. Where’s the most cost-effective place to send a patient? How quickly do you discharge them into transitional care? How long should transitional care last?

I’ll tell you this great story. A post-acute customer who’s trying to develop a specialty in transitional care said, you know, if a patient comes in for hip surgery and it’s scheduled, and you look at that same patient is not scheduled — they fall down and they break their hip. The patient who falls down and is unscheduled spends 10 days longer in transition care. And you know what we figured out? They need mental health services, they need emotional support. The fastest way to cut those 10 days is support for dealing with the stress of the trauma and the unplanned medical experience.

I really believe, and what I’m most excited about, is once we are able to automate the post-acute space and connect it, we’ll be able to figure out questions like, where is the most cost-effective treatment location? How do you move patients through the continuum of care in a quality, cost-effective manner? Because now you really have the continuum.

Any concluding thoughts?

I’m very excited about the business. We’re about to open an office just outside of Boulder, Colorado, so we’ll be expanding to two offices. We’re growing quickly.

For me personally, I’m just thrilled to have the opportunity to focus on a segment of healthcare that I’m extremely passionate about after dealing with some very traumatic personal experiences. I wake up in the morning believing that a company like ours can impact the way that care is delivered in the post-acute environment. 

I would also say that I’m equally focused on building a company culture where people come to work and feel as excited and passionate about what they’re doing as I do. I’m really looking forward to that.

Time Capsule: EMRs: Free May Not Be Cheap Enough for Physicians

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.

EMRs: Free May Not Be Cheap Enough for Physicians
By Mr. HIStalk

Now that Stark restrictions have been relaxed, hospitals are rushing headlong into the ambulatory EMR business. It makes sense. Hospitals have a lot of technology expertise and private physician offices usually have none. The government wants to increase the embarrassingly small number of EMR-capable practices, so throttling back Stark is a free solution that makes almost everyone happy.

Are EMRs the peace pipe that will suddenly bring the traditionally wary partners / competitors together in a long-awaited passionate embrace? Probably not.

Community-based physicians are often scornful of hospitals, seeing them as a hotbed of meddling management, questionable quality, and carefully hidden profits. Imagine what they’ll think when they first encounter hospital IT types, those grudging emissaries of a department built around rigid conformance to rules, perpetual understaffing, and a vision for the common good that squelches the individuality and self-determination that doctors thrive on.

Hospital CIOs like service-heavy, expensive vendors that won’t get them fired. They also like standardization and vendors that offer the theoretical possibility of integrating office-based EMRs with inpatient systems and RHIOs. For those reasons, I expect most CIOs will favor EMRs from big-iron, old-line ambulatory vendors like Misys, Epic, and Allscripts.

These are the vendors that small practices studiously avoid in many cases. They dislike them for the same reasons CIOs love them.

I spoke about this with Jonathan Bush, CEO of athenahealth, at the HIMSS conference. He has an interesting perspective, although not surprising considering that his company sells simple, easy-to-use systems that increase physician income through reduced claims denials.

Bush described the EMR offerings of the big, inpatient-oriented vendors as “elephant’s ass systems.” The little two-doc practice sees the hospital IT truck back up and out comes a complex application with loads of customization options, stacks of thick manuals, and no direct support except whatever the providing hospital has decided to offer. Free or not, there’s training to attend, configuration choices to make, and conversion from existing systems to plan. Oh, goody.

Doctors aren’t that thrilled with EMRs. Most of their benefit goes to insurance companies, studies have shown. Until pay-for-performance kicks in, there’s not much incentive. Plus, docs are always paranoid that hospitals will see how much money they make.

Benefits aside, EMRs take more of the doctor’s time to use. Something that’s free but consumes an hour or two more of the doctor’s day is hardly a welcome gift. All the doctor has to sell is time, and suddenly there’s less of it available.

Bush predicts what he calls a “hairballing up” of these feature-rich EMRs. The hospital may spend the money, staff a support center, and hand-hold the implementation, but there’s still a good chance the doc will thrown up his or her hands and announce, “I’m not using this. I don’t have the time.” Then, they’ll either ditch the whole EMR idea or find an easier to use system that gives them a financial benefit.

Remember when insurance companies and hospitals gave away free PDAs with all kinds of supposedly doctor-friendly software on them? Docs lined up to get one. No one was smart enough to realize until afterward that asking for a free gadget was hardly a commitment to change practice patterns.

Perhaps hospitals have underestimated this hairball effect. They’re giving doctors systems that are mostly loved by hospitals: feature-rich, committee-designed for a large range of practice settings, and with extensive clinical capabilities that may or may not interest the physicians who are expected to use them enthusiastically.

It’s great that hospitals will help drive EMR adoption by private medical practices. Hopefully they’ll give the docs a voice in choosing systems that they’ll use before spending too much money on a monolithic system that may not fit all.

News 3/23/12

Top News

Thomson Reuters reportedly puts its healthcare data and analytics unit back on the market after shelving the process last year due to tough market conditions. Multiple bidders may be vying for the business, which is expected to fetch up to $1 billion.

Reader Comments

From Willy Loman: “Re: Imprivata. Being sued for patent infringement for its OneSign SSO.” I Googled and came up with a new suit brought by CeeColor Industries LLC claiming that Imprivata is infringing on its 1999 patent for proximity-based security using electronic sensors. Imprivata’s OneSign uses a webcam with optional facial recognition software to validate a user and lock their session when they walk away. I can find nothing about CeeColor Industries, which suggests that their primary business, if they have one beyond just owning a patent, at least isn’t extortion by litigation. Companies get sued all the time for reasons both valid and not, so I wouldn’t get too excited about this lawsuit just yet. I interviewed Imprivata CEO Omar Hussain a year ago and asked him about Secure Walk-Away and how the webcam aspect works. Above is a video that explains it.

From James: “Re: Roy the HIStalk King. We (Medicomp) had Roy’s HIStalkapalooza sash framed. He seems very happy about it ;)” Roy Soltoff from Medicomp was not only named HIStalk King, he also served as part of Inga’s security detail for her Quipstar competition. You can see Roy in action in the excellent HIStalkapalooza video that ESD put together (he wins at the 2:30 mark.) His beauty queen sash looks good up there on his wall and the color / black and white photo effect is cool (either that or Medicomp and its people are very drab.)  

From Roller Boy: “Re: Allscripts. Downgrades from Jim Cramer and JP Morgan have created the perfect storm. Night and weekend meetings with board and execs with talk of impending changes.” Unverified and unwarranted, I’d say, given that shares are down only 6% in the past month, although the Nasdaq was up 4% in that same period. Other brokers have stood by their recommendations and neither Cramer or Morgan said anything new – they just recited the obvious challenges the company faces in integrating and selling Sunrise after its $1.3 billion acquisition of Eclipsys, if indeed that’s such an important driver of their business. My interview with Phil Pead and Glen Tullman about the acquisition is here and worth a revisit since I asked some tough questions, like how their performance should be graded two years down the road (that date is coming up soon.) I also said this about Eclipsys when the deal was announced in June 2010:

Despite the arguably superior CPOE and clinical documentation capabilities of Sunrise, it has competed poorly against Epic and Cerner … Nearly 40% of ECLP revenue supposedly comes from about 20 big customers … Eclipsys most likely paid big money for its recent acquisitions, buying the former Medinotes/Bond practice EMR products, EPSi financial management, and Premise throughput management as it desperately sought to diversify away from its at-risk Sunrise user base. Those acquisitions didn’t seem to do much for the company’s performance … It’s late in the HITECH land grab to try to integrate companies and products in the hopes that enough hospitals are left that haven’t locked into their vendor partners to prepare for Meaningful Use. This would have been a much better deal a year ago.

From HITwatcher: “Re: system sales. A quiet year as everyone is hunkered down protecting their base while Epic continues to go after the huge brass rings. Will Partners really announce a choice of Epic by April 1? Dunno, but they will go that route, then on to HCA for the no pie-in-face lady.”

HIStalk Announcements and Requests

What you missed if you didn’t check out HIStalk Practice this week: Dr. Gregg’s recent cloud/hosted server debate. Joslin Diabetes Center (MA) offers national telehealth services. Practices adopting the PCMH model of care have higher staff morale but also higher physician burnout. EZ DERM incorporates Nuance’s medical speech capabilities into its iPad EHR. Practice Fusion offers free interfaces to 16 reference labs. While you are stopping by HIStalk Practice, take a moment to sign up for the e-mail updates because it will keep you smart and make make me feel loved.

My Internet (and cable TV) went out earlier this week, so I have resorted to tethering my laptop to my iPhone for Internet access. It’s not an ideal solution (the connection seems to drop at least once an hour) but it’s actually pretty handy. I’ve used the tethering option a bit in the past when I’ve bee in an area without free Wifi, but never before full time. I wouldn’t trade trade tethering for my high-speed cable, but it’s a surprisingly workable solution. Meanwhile, I keep wondering if no cable TV means no recordings of American Idol on the DVR.

On the Jobs Board: Release Manager, Consultant, Application Developer. On Healthcare IT Jobs: Director of Federal Health Business Development, Technical Project Manager, Health Information Systems Programmer/Analysts.

Inga, Dr. Jayne, and I are emotionally needy. We yearn for intimacy and fulfillment with our much-loved readers, but alas, our anonymity and geographic separation preclude such contact. Therefore, like a prisoner who proposes surreptitious visual stimulation from the other side of the telephone room glass or requests passionate mail in lieu of physical contact, may I suggest that you: (a) sign up for the e-mail updates; (b) engage in the mutually satisfying activity of liking, friending, and connecting via the appropriate online services in which we dwell; (c) send us news, rumors, or anything else that might serve as a fancy-tickler; (d) review and click some sponsor ads, marveling that otherwise button-down companies publicly support our unpolished journalistic style and sophomoric humor because their executives at times find as amusing and informative as a hyperactive, crude teen armed with neighborhood gossip; (e) check out the Resource Center for more sponsor information and the Consulting Engagement RFI Blaster to painlessly request consulting proposals; and (f) enjoy our fleeting moments together since one of these days when I’m no longer clacking the keyboard, you’ll be bereft of musical recommendations and HIMSS booth critiques. Thanks for reading, since without you all this typing would be pointless.

Acquisitions, Funding, Business, and Stock

On Assignment, a provider of temporary workers to IT and healthcare companies, will purchase IT staffing firm Apex Systems for $383 million in cash and $217 million in new stock.

Sales

Xerox’s IT division wins a 10-year, $1.6 billion contract to oversee claims processing for California’s Medicaid program.

WESTMED Medical Group (NY) chooses UnitedHealthcare and Optum to help it launch an ACO for its 220 physicians in Westchester County, NY.

People

The Huntzinger Management Group hires Nancy Chapman (ACS) as practice director of ICD-10 transition and RCM services. We also note that she is part of an exclusive group of 2,324 industry leaders who have joined the HIStalk Fan Club that long-time reader Dann started and maintains on LinkedIn.

LifePoint Hospitals (TN) appoints Karla Schnell (North Highland) as senior director of informatics and Paige Porter as senior director of pharmacy informatics.

National coordinator Farzad Mostashari will present the opening keynote address at the Summit on the Future of Health Privacy in Washington, DC on June 6-7, hosted by Patient Privacy Rights and Georgetown University. Security expert Ross Anderson PhD, FRS will also address the conference and Rep. Joe Barton (R-TX) will receive an award for his support of privacy and security protections in the HITECH act. Registration is free.

Announcements and Implementations

US Preventative Medicine announces an agreement to offer its wellness platform through Dossia’s Health Management System.

HIMSS names The Health Information Exchange Formation Guide, written by Laura Kolkman and Bob Brown, as its 2011 Book of the Year.

PerfectServe announces that its clinical communication applications are available for BlackBerry and Android smart phones.

iMDSoft’s MetaVision Suite for ICUs and ORs earns ONC-ATCB 2011/2012 certification.

Elsevier signs an agreement with ExitCare LLC to offer its patient education information via Elsevier’s Clinical Pharmacology electronic reference. Elsevier will also offer ExitCare licenses to its customers.

Air ambulance operator Mercy Jets implements iPad-based medical records, allowing its medical teams to monitor vital signs and to document care delivered during patient transport.

In England, Northumbria Healthcare NHS Foundation Trust goes live on NextGate’s Multi-Language EMPI for its clinical portal that links multiple systems.

Government and Politics

HHS launches a developers’ challenge to design Web-based applications that use Twitter to track health trends in real time, allowing officials to identify emerging health issues.

The FDA’s Janet Woodcock MD says the agency could do a better job of predicting the effectiveness and safety of new drugs if it were able to collect information from the field electronically rather than relying on voluntary drug company reporting.

The State of Maryland, along with the CRISP RHIO and the Abell Foundation, launches a competition to identify innovative ways to improve public health using clinical information available from Maryland’s HIE, either alone or tied into publicly available data sets (motor vehicle records, birth and death, boards of education, etc. or Maryland subsets of federal databases) Submissions can address either general public health issues or ideas related to the Million Hearts initiative to prevent heart attacks and strokes. Prizes are offered and submissions are due by April 16. If you don’t want to submit, you can vote – the first round of vetting and discussion will involve the public, who can participate right on the site.

Technology

Memorial Sloan-Kettering Cancer Center and IBM collaborate to combine the computational power of IBM Watson with MSKCC’s clinical knowledge and data to create an outcome and evidence-based decision support system.

Other

The Saginaw newspaper describes Covent HealthCare’s used of 14 locally trained scribes in the ED to interact with its Epic system while the physician focuses on the patient. Doctors say they save at least an hour for every 25 patients they see.

HIMSS clarifies that hotel rooms for exhibitors at HIMSS13 haven’t been released yet, so they aren’t showing up on the housing site. They says a “blog site” (obviously this one) said they’re full, which isn’t exactly true – a reader (two, actually) told me that rooms weren’t showing up and I said I don’t know anything about exhibitor housing since I’m a provider grunt, but I did see at least 10 hotels showing non-exhibitor availability. Like most everything else at the conference, high rollers (Diamond members) get first crack. It’s like college football programs that require a big upfront donation to earn the privilege of buying expensive football season tickets.

Epic is awarded a patent for a search method that provides a list of possible appointments that match require provider and resource criteria.

Federal agents seize documents and computers from the town hall of West New York, NJ, reportedly investigating possible insurance fraud by Mayor Felix Roque, a physician who runs a pain clinic. Campaign staffers of the mayor’s defeated political opponent admit that they provided information to federal authorities hoping to discredit him.

A highly regarded and long-established family clinic in Wisconsin becomes one of the first in the state to stop accepting Medicare, citing inadequate payments and increasing expenses that include $700K for a new EMR. Says the founder: “I love taking care of Medicare patients, but every time we treat them we have to dig into our wallets. What kind of business model is that?” The doctor’s wife says he says up until midnight at home some nights to finish up his EMR charts.

A former patient sues a just-closed eight-bed Ohio hospital, claiming the struggling facility refused to transfer him to a more capable hospital because it didn’t want to lose the revenue. The lawsuit claims that lack of prompt treatment of the man’s infection by Physician’s Choice Hospital resulted in gangrene that required surgeons to perform emergency surgery, which included removing skin from his penis. He said it hurt, of which I have little doubt.

Sponsor Updates

• T-System posts a new video showing its T SystemEV EDIS.
• Lifepoint Informatics announces that its March user conference was attended by over 40 clients, with a keynote address by Bruce Friedman MD on “The Continuous Search for Greater Lab Functionality: Best of Breed LIS versus Enterprise-Wide Solutions.”
• GE Healthcare will introduce Centricity Cardio Enterprise at next week’s 61st Meeting of the American College of Cardiology.
• TELUS Health Solutions announces the integration of HIPAAT’s privacy consent management services into its Assure EHR Integration Platform.
• API Healthcare sponsors the DAISY Foundation, which honors nurses through its DAISY Award for Extraordinary Nurses.
• MedAssets offers a case study of the $65.4 million it helped Texas Purchasing Coalition save from its supply chain.
• White Plume releases AccelaMOBILE, a free physician charge capture app for mobile devices.
• The Advisory Board Company launches its Innovations in Impact grant program designed to reward best practice-driven initiatives that articulate measurable, quantitative outcomes goals. The application deadline for the $20,000 per year grants is April 13.
• Houston Orthopedic & Spine Hospital achieves Stage 1 MU using the Healthcare Management Systems (HMS) EHR. 
• Gateway EDI earns full EHNAC Healthcare Network accreditation. Gateway also shares results of ICD-10 preparedness survey, which includes the finding that 56% of practices report are moving forward with ICD-10 preparation despite the enforcement delay.
• DrFirst congratulates 44 of its EHR partners who were awarded the Surescripts White Coat of Quality for 2011.
• Nuesoft posts a full transcript of its billing webinar series on third-party insurance billing.
• An article by Santa Rosa Consulting’s Matt Wimberley discusses the opportunity to improve a hospital’s financial outlook through participation in the MU program.
• Informatica highlights BCBS Michigan’s ICD-10 transition and Ochsner’s standardization on Informatica technologies for its HIE.    
• Recondo Technology partners with ZirMed to offer the ZPay credit card and check processing solution.

EPtalk by Dr. Jayne

Several readers were taken with my article on the caduceus vs. rod of Aesculapius debate. Several mentioned Nehushtan, the fiery serpent used by Moses to heal those who looked upon it.

CMS asks  providers who feel they have received an ePrescribing penalty in error to contact them. Impacted providers may have had their G codes stripped by billing clearinghouses or may have reported the wrong annual code. Problems with hardship exemptions may also be the culprit.

HHS’s Office of the Inspector General approves Ascension Health Alliance to form a group purchasing organization, allowing it to offer its contracting services to hospitals and health systems outside of Ascension. The 21-state Ascension, the largest Catholic healthcare organization in the US, says formation of the GPO “demonstrates our commitment to transform healthcare by 2020.”

A research letter in this week’s issue of JAMA discusses the prevalence of physicians using social media to post unprofessional content online. Surveying state medical boards, the authors found violations that included inappropriate patient communication, sexual misconduct, prescribing without a clinical relationship, and online misrepresentation of credentials.

IBM Research teams with an Italian cancer center on a new analytics platform that will personalize treatment based on pathology guidelines and past clinical outcomes as documented in hospital systems. The Clinical Genomics tool can also provide an aggregated view of patient care.

AMA Board of Trustees chair Robert M. Wah MD reflects on his recent trip to the HIMSS conference, calling it “a gathering of more than 40,000 of my closest friends and colleagues.” Dr. Wah has an interesting pedigree: Navy active duty, deputy national coordinator for health IT and founding staffer at ONC, chief medical officer at Computer Sciences Corp., and head of the Navy’s largest OB/GYN training program. He’s an interesting guy and I am glad someone with his experience is chairing the board. I hope the AMA will show real healthcare IT leadership to reverse the black eye it obtained by blocking ICD-10.

Speaking of ICD-10 codes, one of my Twitter followers keyed me in to this app available on iTunes. For $24.99 and it only one review, I think at this point I’ll take a pass.

Several readers responded to my mention of the allergist who closed his practice to join the Army as a lieutenant colonel. Rank is apparently based on experience and specialty. One reader told a great story about his own Army service, where he had to take away several service weapons from physicians who mishandled or misplaced them, including one major who left his Beretta in the PX while shopping. That’s a little different than losing your sunglasses or your keys.

A shout out to Children’s Hospital Los Angeles Medical Group, which is hosting its annual “Pediatrics in the Islands: Clinical Pearls” conference in Maui. It’s a great conference. but I think it’s time to include some health IT topics, hint hint. Perhaps a celebrity guest speaker?

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

An HIT Moment with … Andy Hoover

An HIT Moment with ... is a quick interview with someone we find interesting. Andy Hoover is IT director at WoundVision, an Indianapolis vendor of risk assessment software and thermal imaging tools for early pressure ulcer detection. The company recently migrated its platform from Amazon’s EC2 public cloud computing to a virtual data center.

What led you to originally choose cloud-based hosting instead of self-hosting for your application?

We are a small startup company, less than 20 employees. With limited financial resources and a small staff, there really wasn’t another option for us. We needed to be able to focus all of our attention on developing our line of products and rely on a vendor for providing a reliable hosting platform.

What did you learn about the differences among cloud computing providers?

Nearly two years ago we first looked at the big two in Amazon and Microsoft. Microsoft wouldn’t work for us because of limited capabilities with SQL Azure compared to SQL Server and the inability to install third-party software and tools on Windows Azure.

Amazon allowed us to run a little more like a traditional data center. We actually ran in the Amazon cloud for a year. But due to lack of readily available support, the learning curve of using the EC2 and S3 storage both from a development and administration standpoint, and limited monitoring and visibility options, we decided to look in another direction.

Once we decided we needed to check into other vendors, we looked at multiple vendors a little closer to home. The big thing we discovered is there are a lot of companies jumping into the cloud hosting business.

The key factors to us in selecting a new vendor ended up being the experience in the market, support options, and the physical data center itself. The provider we picked excelled in all of those areas. Bluelock has been around since 2006. Their support options and capabilities were far beyond what others could offer. There has been nothing we have asked for that they couldn’t provide or at least offer a contact for. Their data center is extremely impressive.

What special needs did you discover you needed to address because you are dealing with a healthcare application and hospital customers?

The question of "where is the data hosted?" always comes up. It became very import to be able to answer specific questions about where the data was hosted and how our data is being protected.  To be able to explain where the data center is at and exactly how it operates was very important. It helps boost our credibility when talking with clients about protecting their data.

Having readily available documents from our provider, such as a SAS70 certification or a disaster recovery plan which could be passed on to clients, is very helpful. With logging being so key in guarding medical data, we found we need to be able to gain visibility into all incoming and outgoing traffic.

What advice would you have to a startup considering EC2?

While cheaper than many other providers, EC2 will require more personnel time to build and maintain. When you have questions, you are left to figure them out for yourself via knowledge base articles or blogs. As a startup, it might make sense to pay a little more to work for a vendor that functions a more like a traditional data center, has better support options, and knows who you are as a customer.

What resources did you need to implement your current cloud solution and what’s involved with maintaining it?

We needed a highly available platform capable of running multiple Windows VMs, multiple VLANs, SQL Server, and a firewall in which we have visibility.

Now that we have been up and running at Bluelock for over a year now, not a lot of maintenance is required on our part. I use their monitoring portal to keep an eye on things such as performance, availability, and usage. We are able to ask for custom options, such as custom monitoring and alerts for metrics we care more about. Maintenance of the servers doesn’t included much on our part — monitoring, patching, and pushing new releases of our software. 

News 3/21/12

Top News

Misys, whose only remaining healthcare-related product that I recall is Misys Open Source Solutions, agrees to be acquired for $2 billion by Vista Equity Partners. Competing offers are possible despite a simultaneously announced Misys profit warning after Q3 revenue slid 12%. If the deal goes through, Misys will join a family of Vista-owned companies that includes Sunquest and Vitera.

Reader Comments

From HIMSS Benefactor: “Re: HIMSS13. Almost all the decent hotels are already booked. What happened? The W French Quarter has a few rooms left at $909 per night! Too much hassle … will have to skip this one.” I just checked the HIMSS online booking site and they’re showing 13 hotels available to attendees, starting at $155. The four-star Marriott on Canal Street is $230 per night and appears available, as is the close-by Courtyard at $180. I tried several of the travel sites to see if maybe HIMSS hadn’t locked down the whole block, but all showed no rooms available. Major concerns about infrastructure readiness abounded when HIMSS last went to New Orleans in 2007 and the experience was uneven in many hotels and restaurants. Having too few or too expensive hotels would give HIMSS a black eye it doesn’t need after massive attendance in Las Vegas. Let’s hope they just haven’t released all the rooms yet since we’re nearly a full year away. Otherwise, I’m going rent a house or two for the week, bring in sleeping bags, and run a HIMSS Hostel at exorbitant nightly rates. I don’t know where I stayed last time – I only remember that it was forgettable.

From The PACS Designer: “Re: SMArt. With the release of the iPad, TPD thought it would be the right time to mention The SMArt Platform created by the Children’s Hospital Boston and Harvard Medical School. Travis Good alerted us a year ago about it and mentioned that there is $5,000 prize challenge for the winning design. The SMArt platform is envisioned to be an app store for health, with applications geared towards both patients and providers.”

From Doreen: “Re: HIMSS. You should rent one of the tiny booths for around $5,000, use the fact that you have the greatest advertising strength on earth for healthcare IT to tell people you’ll be there, have guest booth hosts like Ed Marx and Dr. Gregg, and offer giveaways.” I had to embellish the idea, of course, by suggesting that (a) I set it up like a welcome center and offer information on HIStalk’s sponsors, or (b) I find some other company in tiny booth Siberia and tell them I’ll be their next-door neighbor and bring lots of traffic their way if they’ll pay for my space. Then I recruit volunteers to serve as my proxy to host the booth in rotation. I was excited about putting out kegs of beer until I Googled the price at the Morial Convention Center: $450 for crappy domestic brands.

HIStalk Announcements and Requests

Medicomp commemorates Inga’s participation in its Quipstar game on the HIMSS exhibit hall floor with a video. Note the Shoe Cam pictures, security entourage, the IngaTini in her hand, her green M&M snack, and the carefully placed reflector thingy that I bought her as part of her disguise. She was scared to death, but determined to earn Mobile Loaves & Fishes the $5,000 charitable donation offered by Medicomp in return for her involvement.

Welcome to new HIStalk Platinum Sponsor Jardogs. The Springfield, IL company connects patients, providers, and communities with its Jardogs FollowMyHealth Universal Health Record, an ONC-ATCB-certified cloud-based solution that aggregates information from disconnected organizations (it was recently selected by Iowa Health System, I recall). Patients become gatekeepers of their own information from anywhere in the world using a single comprehensive view instead of running around to a bunch of individual, proprietary patient portals. They can electronically complete physician-requested forms that are pre-populated with the practice’s EMR information, check in for appointments, and get real-time updates. Providers improve their patient relationships and address ARRA incentives for patient access (send reminders, provide electronic copies of results and med lists, share information per patient authorization, and connect to public health registries). The company also offers a patient kiosk that streamlines registration and data collection. Next up: home and wellness applications, such as for home physical therapy and potentially for home monitoring. Thanks to Jardogs for supporting HIStalk.

Acquisitions, Funding, Business, and Stock

RCM provider MD On-Line acquires MD Technologies, a provider of RCM products and the Medtopia Manager PM system.

Axial Exchange announces that its care transition solutions, Axial Provider and Axial Patient, are available for cloud deployment. The Raleigh, NC-based company offers care coordination and communications applications that connect first responders, hospitals, physicians, and health plans via a clinical dashboard.

In the UK, University of Lincoln and the local hospital trust develop a prototype of an orthopedic surgery training simulator that uses the Nintendo Wii to mimic the use of a surgical drill, allowing surgeons to improve their hand-eye coordination.

Sales

The non-profit United Health Organization (MI) will use video-to-handheld technology from JEMS Technology to connect patients requiring specialized medical attention with off-site physicians for consultation. Volunteer specialists who can’t leave their practices can visually examine the patient and provide treatment recommendations from their mobile devices.

DR Systems announces new contracts for its Unity CVIS with Twin Cities Community Hospital (CA), Good Shepherd Medical Center (TX), Healthcare Partners Medical Group (CA), and St. Luke’s Cornwall Hospital (NY).

The Maryland Department of Health and Mental Hygiene awards CSC a $297 million contract to replace the state’s Medicaid management information system and to provide fiscal agent services. The contract is for five years with three two-year options.

The Maricopa County (AZ) Board of Supervisors approves a $4.55 million contract to NaphCare for EMR licenses and installation services for its correctional healthcare system, which lost its accreditation in 2008 for issues that included poor recordkeeping.

People

Two weeks after agreeing to serve as CEO of Cal eConnect, Ted Kremer withdraws his acceptance and announces plans to stay on as executive director of the Rochester RHIO after learning that Cal eConnect’s funding is uncertain. Cal eConnect interim CEO Laura Landry will assume the CEO post.

Legacy Health System (OR) names John Kenagy PhD as interim SVP and CIO. He was previously with Providence Health & Services.

Healthcare analytics company Qforma appoints Valerio Aimale MD as chief of advanced products, William Howard PhD as SVP of new product development, and Delphina Perkins as director of client services.

Authentidate Holding Corp. names former Viterion Telehealthcare CEO Sunil Hazaray its chief commercial officer.

Announcements and Implementations

Cookeville Regional Medical Center (TN) implements MEDHOST’s EDIS.

Susquehanna Health Partners (PA) adopts Summit Healthcare’s Downtime Reporting System to address its business continuity and data protection needs.

Practice Fusion launches its research website to help public health agencies and physicians predict and manage outbreaks.

Objective Health, part of McKinsey & Company, announces the release of its Objective Scorecard performance dashboard and analytics solution for hospital executives.

UPenn Health System goes live on Brainware and Ascend solutions for accounts payable automation, helping it manage paper invoices and integrating with its Lawson ERP system.

The EZ DERM iPad EHR adds speech recognition using Nuance’s cloud-based technology. I accidentally strayed onto the cool new EZ DERM video above on YouTube. The company modestly calls its product “The Best EHR in the World.” I can’t vouch for that, but it might well make the best EHR videos in the world.

SAIC’s COO talks up the company’s Vitalize Consulting Solutions acquisition in Tuesday’s earnings call: “SAIC’s acquisition of Vitalize Consulting Solutions continues to support strong, double-digit growth in the commercial health IT arena.” In not-so-positive news, SAIC racked up a $161 million Q4 loss after setting aside $500 million to settle a criminal investigation involving cost overruns on a payroll system it developed for New York City.

Government and Politics

ONC releases a new version of its Connect software that incorporates updated technical standards and descriptions for the NwHIN Exchange. Connect version 3.3 supports such functions as patient discovery, document queries, and information retrieval.

Louisiana behavioral providers say that the state’s new Medicaid reimbursement software, which was supposed to make their claims submission easier, isn’t working. Providers say they can’t always enter new client information and some of what they’ve entered was lost, the progress notes function isn’t working, and nobody’s been able to bill for their services.

Other

TeleTracking posts a fun video of The Capacity Blues, a Cajun-flavored piano tune written and performed by one of its employees in honor of its upcoming New Orleans patient flow symposium.

Divya Shroff MD, HCA’s chief clinical transformation officer, writes a company blog post called Can Access to an EKG on your Phone Save a Life? in discussing the company’s collaboration with and investment in AirStrip Technologies. Her example involves door-to-balloon time for cath patients, with the potential to send EKGs directly from the ambulance to the cardiologist as both are in transit to the hospital.

I’m watching interviews filmed at HIMSS in Las Vegas by EHRtv that our pal Eric Fishman MD has been posting. Here’s one with Matthew Hawkins, CEO of Vitera, and here’s another with Shareable Ink’s Stephen Hau.

In England, hospital officials admit that they ordered the IT department to clone and snoop around the computer hard drive of a whistleblowing doctor who complained about unqualified staff and and was later fired. His boss justified the action, saying she had heard from employees that he was on the Internet a lot and wasn’t seeing enough patients.

The local newspaper interviews eClinicalWorks CEO Girish Kumar Navani.

Dr. Wes says EMRs bury doctors in data without giving them useful information:

There’s so much data that we risk doctors becoming lost in it. It is entirely possible that we are in danger of not being able to find our most important clinical signals amongst the noise and clutter of all the data. Worse: time with patients is disappearing. Our health care information gold rush has acquired teams of programmers to feverishly implement a myriad of bureaucratic information system requirements in just a few short years. To this end, these programmers have been extremely effective. But almost as incredibly, these same programmers have little perspective of what physicians do or how we interact with patients and THEIR data. As a result, doctors are not only confronted by all of this this information placed before them, but waste precious time sifting amongst the data and continue to be the fall-guy for data entry. Codes, quality measures, documentation requirements and, oh, yeah, the progress and operative notes, are all being entered by doctors. In return, our screens have become crowded intersections of buttons, flags, options, icons, colors, warning alerts and (if we’re lucky) text. Oh yeah, and a new “upgrade’s” coming next week.

Note to companies: just in case you can’t spell HIPAA correctly, at least leave it out of the press release’s big-font headline.

University of Louisiana at Lafayette is looking for healthcare geeks to participate in its free Cajun Code Fest on April 27-28. Speakers include US CTO Todd Park, Intel’s Eric Dishman, and the guy who founded Priceline.com.

A Crain’s New York study finds that the 25 highest-paid New York City hospital executives earned a combined $60 million in 2010, with New York-Presbyterian’s Herbert Pardes topping them all again at $4.3 million.

Sponsor Updates

• CapSite GM/SVP Gino Johnson will provide an overview of the HIE market at next week’s 4th Annual Health IT Insight Summit in Boston.
• Liaison Technologies will offer Preventice’s wireless monitoring technology to collect and transmit patient data via its cloud services.
• Bloomberg Businessweek profiles Digital Prospectors Corp.
• CTG Health Solutions will participate in the Allscripts Central Region Users Group meeting in Des Moines, IA on April 19.
• Trustwave completes its acquisition of M86 Security.
• Health Care DataWorks selects Health Language’s Language Engine to map disparate data into its data warehouse.
• BESLER Consulting will use the Inventu Flynet Viewer to give its hospital customers access to the Medicare Common Working File stored on 14 CMS mainframes, allowing faster and more efficient claims review.
• DIVURGENT’s David Shiple discusses the proposed MU Stage 2 emphasis on personal health records vs. low consumer interest in using them in a blog posting.
• The local paper discusses Premier Health Partners’ use of MEDSEEK’s predictive analytic tools for targeted consumer mailings.
• Merge Healthcare and AG Mednet partner to integrate AG Mednet’s image collection platform with Merge’s Clinical Imaging Management System (CIMS) to enable higher quality images and data flow directly into Merge’s CIMS and EDC solutions. 
• Capsule announces that it has surpassed the 1,000 mark for healthcare organizations using its medical device integration solution, including 200 new customers added in the last four months.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Curbside Consult with Dr. Jayne 3/19/12

I spent the better part of today taking a tree down. It might surprise some of you, but I do know my way around bow saws and chain saws as well as scalpels. Unlike the delightful specimen above, mine was extremely close to the house and required yearly maintenance. It also had some other unsavory features, and since today was a beautiful spring day with a light breeze and not too much sun, it was time to get it done.

It would have been easier if the tree were ugly or diseased, but unfortunately this particular tree was in full spring bloom. Most of the trees I’ve been involved with taking down were diseased, in wooded areas, or part of a service project where everyone understood why they needed to be removed. I’ve never had to do one right next to the house in full view of the neighbors and everyone else who passed by walking dogs or enjoying the spring weather.

Not surprisingly, people had things to say about the tree coming down, and I started to question my decision. To the casual observer, a beautiful tree was being removed. The casual observer, however, didn’t ever have to deal with the messy fruit that it dropped, staining the driveway before being tracked in to create a nasty gelatinous mess in the kitchen. He or she also wouldn’t have to deal with the birds that liked to congregate in the tree, eating the fruit and creating an additional level of mess that prevented anyone from ever parking in the driveway or walking on it during the better part of the year.

Passersby also wouldn’t know about the lovely herringbone brick walkway that was installed by the previous owner, and which the roots of the tree destroyed. They also wouldn’t realize the hazard that the now-uneven walkway caused to anyone who tried to visit in the winter – the destruction of the walkway made it impossible to clear snow or ice.

Initially the neighbors just thought this was a routine trimming, but after large limbs started coming, down it was obvious that this was more than that. I started feeling guilty. After all, it was outwardly a very good-looking tree. I had to remind myself that it was also a species that tends to split in high winds, and due to its size and proximity, if it split (as many trees of the same age in my area already have) it would likely come through the house. That certainly wasn’t anything I wanted.

As the work progressed (thanks to some strapping young men who offered to help) and I looked at all the blossoms littering the yard and the street, I choked back my guilt by remembering that had the tree remained, nearly every one of those would have turned into a piece of messy fruit. I also had to remind myself that the tree was in the way of a pending construction project on the house, which includes revising drainage to ensure that the foundation stays dry and the yard ceases to be a muddy pit.

Working on projects like this always makes me contemplative. This particular project went on for hours, giving me plenty of time to think about what I was doing as well as the parallels to my work life.

Dealing with this tree reminded me of dealing with a particularly difficult employee who ultimately had to leave the organization. From the outside, he appeared to be a solid worker. Gregarious and outgoing, co-workers found him likeable. His outgoing nature often proved to be an issue, however, when he couldn’t complete assignments due to excessive socialization. He needed frequent reminders to stay on task.

Unfortunately, early attempts to correct his behavior resulted in friction with other members of the leadership team who only saw the beautiful tree and discouraged his direct supervisor from formal corrective action. This worker frequently took credit for his colleagues’ work and directly reported these successes to those above his supervisor, putting the supervisor in an awkward spot. Maybe it’s all the time I spent studying human behavior, but aside from his direct supervisor, I felt like I was the only person seeing through his showy exterior.

As time progressed, our little tree dropped his proverbial fruit throughout the department, creating messes that others had to clean up. His roots grew into other departments, resulting in complicated entanglements with female staffers that created additional instability. We pruned and we pruned, but as much as we tried, he grew.

We began to carefully document every action taken because his twisted roots threatened to undermine his supervisor and his peers. Only when his continued presence threatened the future of several key projects could we muster the support to finally remove him.

I felt guilty throughout the process, but like today, had to remind myself of the current dysfunction as well as the potential for future damage and the ways in which he was impeding progress.

Once he was gone, I was pleasantly surprised. Other co-workers grew into the void and supported his replacement, like sheltering trees protecting a young sapling. The team regained its cohesiveness. Some members who had been in his shadow were finally recognized for their achievements.

Like dealing with my former employee, I know that taking down the tree was hard, but it was only the beginning. There’s plenty of work coming – branches to bundle, a stump to remove, French drain to install, and more. Once those things are stable, the new tree (non-fruiting of course) will arrive to be planted and nurtured, ultimately providing shade and beauty. The effort will be worth it and I’m looking forward to the future.

Have a question about arborists, making your own compost, or what’s the best way to store a face cord of wood? E-mail me.

E-mail Dr. Jayne.

Readers Write 3/19/12

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!

Sampling the Legislative Sausage
By Civics 101

Be careful reading the proposed Meaningful Use regulations. Note the “proposed” part. As a Notice of Proposed Rulemaking, it’s unwise to ignore any part of the document.

Every word in the document – even in the preamble — has survived numerous rounds of federal vetting. Every section is important, but especially so are those areas in which public comment is invited. Objectives may be added or removed, so don’t get hung up on those to the exclusion of the preamble or the overall intention.This is not a set of business requirements that is ready to be handed off to programmers to implement.

Read the NPRM as a big picture, keep an open mind, and try to understand the intention, not just the tentative objective list. And above all, don’t forget that while Stage 1 is locked in place, Stage 2 isn’t. My organization and yours need to study the NPRM carefully and comment on what we like or don’t like about what’s been placed before us. Remember all the changes that were incorporated between the Stage 1 NPRM and the final version? Every one of those came as a result of public feedback.

Using the iPad in Surgery
By Michael B. Peterson, MD

I use the iPad every day while rounding at work and connected to the encrypted hospital wireless network, finding web information for patients and showing educational videos. I use a Bluetooth keyboard and sometimes a stylus that fit into a netbook soft case when I need to do heavy typing.

We were doing a complicated vascular surgery, an axillary femoral femoral bypass. I had dissected out the blood vessels on the right groin, but the surgeon working on the left could not locate the critical arteries and branches. The patient did not have any pulses in the groins because of severe vascular disease.

I had the nurse drop the iPad into a sterile sleeve and seal it. I used it to pull up the CT scans on the table and paged to the proper level so we could compare the right to the left. Then we knew where to go. We could place the iPad right on top of the patient and visualize what we needed.

Then while my colleague and our PA completed the left side, I checked my Lotus Notes e-mail, went into the vascular econsult program and triaged some vascular consults to the appropriate clinics, and checked my inbasket in our Epic EMR to read labs and answer messages (the iPad runs Epic very well.) When I was done, we were ready for the rest of the surgery.  

The x-ray viewing is an innovative project on which we are partnering with with Thinking Systems.

We are using the latest Citrix Receiver to host our version of Epic on the iPad and other devices as well. Since the rollout of Epic Summer ’09 across the country in all Kaisers, the old web address we used for Spring ’06 access no longer works for the iPad. In addition, there are additional video requirements for Summer ’09 that our current web servers need that the Citrix receiver cannot handle. Attempting access to the Summer ’09 environment will result in a connection failure with a “USKIN” error message.

Fortunately our Kaiser web engineers were aware of this and understood the need for iPad functionality. They created special web addresses for Kaiser iPad users in Northern and Southern California, Hawaii, and Pacific Northwest. The official term is PNAgent Site. Setting it up is complicated, but the iPad works very well.  

Of course there are ergonomic challenges with a smaller screen, and accurate tapping is critical. But it is so fast and convenient — you don’t have to wander around looking for an unoccupied keyboard and computer. If I need to look up something, I just do it where I am. It has really spoiled me.

I don’t know if there is any way to demonstrate improved outcomes with the iPad. Kaiser is starting to roll it out to other medical centers with different specialties. My general feeling is that with the EMR, there is a 20% productivity hit with data entry and typing your note. It does take longer on the generic computer, but the the iPad is so much faster and it literally puts the medical record at your fingertips… or perhaps the patient’s.  

I plop the iPad down in front of the patient and point out pictures, diagrams, and a quick graphic plot of their rising creatinine. I run the lymphedema pump movie to show them how it works, or review the online video again to remind me or others how that endovascular closure device works again before I actually do it.  

I have invested the time it took to get comfortable with the iPad and arrange it the way I want. I could not do without it. I have very little specialized software on the iPad except for the VPN and the Citrix Receiver. And my medical apps, books, and games!

Michael B. Peterson MD is a surgeon with The Permanente Medical Group in Hayward, CA. His use of the iPad in the operating room was featured in the April 2012 edition of Macworld. Since Mike is an old friend of HIStalk, I asked him for more detailed information, which he provided above.

What Do You Do Regardless? Five ICD-10 Steps To Continue
By Torrey Barnhouse

The AMA lobby is strong. US government program delays are common. The two came together on February 16, 2012 when Health and Human Services Secretary Kathleen Sebelius announced a potential delay in the October 1, 2013 deadline for ICD-10 implementation.

The announcement, made just before the start of the HIMSS12 Annual Conference, left a lot of attendees scratching their heads and asking themselves, “Now what?” Most agreed a delay of one year or less gives everyone more time to prepare, train, and test. However, a delay of greater than one year spells chaos for healthcare providers and payers.

While at HIMSS, TrustHCS had the honor of sponsoring an executive roundtable on ICD-10. During the roundtable, speakers discussed five ICD-10 projects that should continue full steam ahead despite the delay. It’s a good list and worth sharing.

In general, the panel’s advice was to identify ICD-10 tasks that have collateral benefit for ICD-9 coding. These are the tasks that should be continued until such time as HHS makes another announcement regarding their plans, intentions, and deadlines.

Vendor and Payer Assessments

Continue checking with vendors and payers to see when systems will be ready for testing. Know what the ICD-10 upgrade will cost your organization, if anything. If your vendor simply can’t accommodate, start evaluating new systems to replace them. Conduct ICD-10 testing with your payers whenever and wherever possible to help reduce backlogs and denials upon go live.

Clinical Documentation Improvement

Any improvement in clinical documentation specificity and granularity will help support better, higher quality coding and reduce time wasted querying physicians. Coders can only code what is documented. This same core principle applies in ICD-10. CDI programs must be continued regardless of a delay.

Coder Biomedical Training

While educating coders in the finer nuances of ICD-10 coding can be postponed, strengthening their knowledge of the basics can’t. Many coders graduated from programs 10, 15, or 20 years ago. Medical science and our knowledge of anatomy, physiology, and disease processes has grown exponentially. Now’s the time to make sure your coders are brilliant at the basics. Anatomy and physiology training should continue to be conducted: online through a service provider or at a local community college.

Computer Assisted Coding (CAC) Technology

Coder productivity is predicted to drop by 50% during the implementation of ICD-10 and perhaps remain 10-20% below normal output for ICD-9 coding. CAC systems help offset this productivity loss by electronically “reading” the record and suggesting codes to the human coder. While CAC systems don’t replace coders, they do make them more productive and efficient. The delay provides more time for organizations to evaluate and implement this technology.

Assess and Refine Your Work Plan

Conduct a methodical step-by-step review of your initial plan. This process will identify which tasks can be pushed out and which cannot. The review will also uncover other tasks that have collateral benefit for ICD-9. For each task in your work plan, ask yourself, “Does the delay impact this task?”

Industry experts are already predicting the cost of an ICD-10 delay. Other experts are predicting lawsuits by providers to help recoup monies already spent. This expert simply suggests that you stay the course and keep working toward ICD-10 preparedness. We will all have to get there eventually. Better to be early than late on this one!

Torrey Barnhouse is CEO of TrustHCS of Springfield, MO.

Viva la CPOE!
By Daniela Mahoney

According to the HIMSS Analytics EMR Adoption Model , CPOE adoption remains steady at a rate of 13.2% for the past two quarters. And in recent months, many hospitals achieved the first stage of Meaningful Use. Congratulations to all!

However, looking at the story behind CPOE implementations reveals that adoption struggles continue —regardless of the vendor system. Many community hospitals expend great effort and many dollars meeting Meaningful Use criteria, but additional time and money is also spent avoiding a full-blown revolution within their provider community because of CPOE implementation.

Technology is really only 15-20% of a CPOE implementation. Process, acceptance, culture, and constant transformation are the parts that truly define the difference between CPOE failure and success.

At the end of the day, technology’s golden purpose is to support the infrastructure: devices, performance, remote access, integration/interoperability, streamlined single-sign-on, and ease of navigation. But even when working flawlessly, it’s still an uphill battle capturing provider adoption on that much-needed “voluntary basis.”

I can always hear the physician protests, even when left unsaid: “Why should I use it?” “What is in it for me?” “Show me the money, Jerry.”

The question remains: why? Why won’t providers embrace new CPOE technologies and take advantage of the wonderful features, such as clinical decision support or evidence-based order sets that streamline the admission process?

Truthfully, there is nothing wrong with the providers’ feelings here. They simply know what’s at stake. And the odds are not in favor of CPOE, despite the benefits we may see through our own rose-colored glasses:  “Oh, how it benefits the patient! Why don’t you providers just snap out of it and embrace CPOE for the people, or at least for the children?”

Kidding aside, what a new CPOE system takes away from providers is TIME.

… at least for a while.

Time is a provider’s most precious commodity. A new system changes the way they work and takes time away from office hours and family. Time is irreplaceable and invaluable.

But the Meaningful Use mandates say “so what” and to just do it and accept it. CPOE is a reality and must be part of every provider’s future in the hospital or in the office. With that, I sympathize. Providers may have cause to rebel.

I spent some time researching literature while preparing this article, looking at provider efficiency with CPOE. Many studies are relatively old, done in the ‘90s or early 2000s. Not to dismiss their importance, but many issues experienced then have been since resolved with today’s systems. In retrospect, they really aren’t relevant.

But one thing overlooked then and now, to me, is the most important question: what is the right value proposition to the provider?

The answer? One that fits a provider’s community and meets their conditions to accept CPOE into their domain.

With 22 years invested helping providers through CPOE adoption , I found only one simple and effective system pitch. Be truthful and realistic. That’s what works. That’s what opens door and also ears.

For example, we can’t deny that it typically takes significant time to adopt and adjust to a new system, and that efficiency improves only with consistent use. Additionally, never overpromise that CPOE is faster than handwriting an order or checking boxes on a pre-printed order set. I can tell you, that approach doesn’t work.

Once providers are engaged, gather the value proposition’s building blocks by talking and listening to them –  eliciting their concerns, needs, and requirements — and also identify opportunities for compromise.

Usually during interview sessions, similar things are voiced. And believe it or not, it’s less about Meaningful Use (understanding the “benefit” of hospital reimbursement is typically demonstrated by only a few) and more about the direction of technologies in healthcare and reporting requirements and how it affects the way they practice medicine.

For example, for some it is important to have remote access, and not just to CPOE, but to also do other tasks, such as signing their charts. And from others, I often hear how they would prefer using their own laptops or iPads, so they do not need to compete for devices.

Here are some very telling interview quotes from providers about CPOE adoption:

• “Access from outside of the hospital, home access would be great.”
• “CPOE should be a resource for us. It should not make us work harder to accommodate it.”
• “Ease to use and quicker order entry is most important.”
• “Online view of medications administered would be a great value.”
• “Reduces errors and provides clarity of medical orders. There must be a safety net if errors are made, especially with residents. Incorrect orders need to be stopped.”
• “A quick-pick list for providers would be nice.”

In the end, the right value proposition delivers the commitment of the hospital’s leadership to respond to what providers say and need. It engages all providers and can convince them to fully adopt CPOE as part of their workflow—especially with respect to efficiency in daily operations.

Providers become very reasonable and willing to compromise if engaged and their voices heard. Realistically, you cannot fulfill every need, but it is still important to listen and respond. The hospital’s leadership must be proactive and have a solid communication plan to manage expectations at different levels before, during, and after implementation. The direction of CPOE within the organization must be clearly defined, from the adoption and training to the deployment strategy. Lastly, completing a cultural evaluation the provider community provides tremendous insight into defining the value proposition which is the foundation of your CPOE success.

Let them eat cake, because we’re having crepes …

Here is a simple but delicious nutella-banana crepe recipe enjoyed by our family. Bon appetit!

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

Monday Morning Update 3/19/12

From Eric Rose MD: “Re: proposed MU rules. Like a lot of people, I get annoyed at how difficult it is to get to the actual regulatory text because the headings are embedded. I’ve extracted the actual text and marked them up with section headings. Turn on the Navigation Pane in Word and you can easily find the sections, particularly those with certification criteria or MU objectives. I created these for my own convenience, but others might find them useful. Feel free to share with the HIStalk community.” I’ve set up the certification criteria and MU objectives for downloading. Thanks to Eric, who is a clinical terminologist with Intelligent Medical Objects.

I’ve been having problems with the e-mail blast application that nobody can figure out, so I’m changing it to a hosted solution since I have no time for further investigation. The differences you’ll notice are: (a) the update notices will be HTML messages, which are a little bit nicer looking and easier to use than plain text; (b) the e-mails will look better than before when reading on mobile devices; and (c) hopefully the e-mails will go out faster and get delivered more often. I’ve learned way more than I ever wanted to know about the technical side of Exim, SMTP hosting, and server message queues and it’s not nearly as simple as just sending someone an e-mail. I’ve still got some fine tuning to do and I may need to change again if this doesn’t work as well as I’m hoping, so be patient and we’ll get through it.

Listening: Penelope Houston, one of the better female folk-rockers you’ve never heard of. She used to be singer of punk band The Avengers, but now does moody Euro-sounding 60s pop with mandolin, autoharp, some vintage Hammond B3 organ in the mix.

My Time Capsule editorial this time: US Healthcare Value is Low – Follow the Fancy Buildings, summarized by this snippet: “I’m not smart enough to figure out who the good guys and bad guys are in healthcare, so I look at just one thing: buildings. When I see stunning hospitals, vendor headquarters, insurance offices, and doctors’ houses, I figure they’re doing a little better than I’d like.”

A couple of readers chimed in on my comment about Epic implementations slipping from their aggressive, MU-driven timelines, saying they’ve heard of places having that problem. I think you’ll hear more about this. Big money at risk or not, system implementations are always harder and more complicated than they seem, and hospitals are notoriously bad at change management (although Epic leads them through it by the hand.)

This is encouraging in an “eat your own dog food” kind of way: 80% of respondents have primary care providers who use electronic medical records. My university-associated doc does and it’s made a huge difference in how my encounters work: I get accurate medication reconciliation performed at every visit with the system (even though all I take is a diuretic), he has all my history right in front of him (it’s fun to see how my weight has changed over the years, mostly because it’s gone down quite a bit), and we have avoided duplicated lab tests. The doc looks smarter, I feel like my entire health situation has been considered, and we use the on-screen information together as a teaching and planning tool. I’ll say something I would not have said a couple of years ago: I really think I’d sadly have to find another doctor if mine was stuck in the paper chart world. New poll to your right, in honor of the Mostashari vs. academic researchers flame wars: will wider EMR usage reduce the number unnecessary imaging exams? Maybe someone should just ask doctors themselves instead of trying to make inferences from sketchy data.

On the Jobs Board: Client Care Engineer, Mobility Software Engineer, Epic Inpatient Module Go-Live Support, Vice President Healthcare, Meditech CPOE Activation Support, Consultant. On Healthcare IT Jobs: NextGen Analysts and Consultants, Horizon Meds Manager Consultant, Assistant Health Services IT Director. I don’t know about your phone, but mine is ringing constantly from recruiter calls, although I do have specific expertise that’s hard to find. A lot of the calls are from folks looking for consultants.

Thanks the the following new and renewing sponsors that supported HIStalk, HIStalk Practice, and HIStalk Mobile in February (click on a logo for more information):

An article in the newsletter of the USAF’s Hurlburt Field describes the Air Force’s MiCare Portal, a RelayHealth-powered site that allows patients to send secure messages to clinicians and request refills, while the providers can send patients appointment reminders, results, referral information, and changes in clinic hours. The group practice manager says the goal is to make MiCare the preferred method of communication after in-person appointments, avoiding phone tag and missed handoffs. Other bases using MiCare: Hanscom, Langley, Nellis, Offutt, Scott, Seymour-Johnson, and Travis.

Weird News Andy offers his own flavor of March madness with this story, in which an enterprising urology group is offering a free pizza with each vasectomy performed in March. The practice says March is their busiest time as men figure they might as well recover on the couch while watching basketball games on TV. WNA finds the last line of the story, which describes the free pizza, disturbing: “It does actually come with one topping. Maybe you can put some meatballs on it.” He also adds his own joke: what did the urologist’s wife sing to her husband when he finished his residency? “Urine the money, urine the money, we’ll have a lot of what it takes to get along.” </rimshot>

Here’s Vince’s HIS-tory of CliniCom (Part 3.) Check out the resemblance of the 1980s-era CliniCare handheld nurse terminal to the iPad.

I remembered Friday at work to print off the Archives of Internal Medicine article that has generated all the simplistic rag headlines that meet their goal of being stupid-simple and sexy at the expense of accuracy in summarizing the original study (example: iPads: Increasing Doctor Efficiency, Decreasing Patient Wait Time). The actual University of Chicago study wasn’t nearly that conclusive. The university gave iPads to 115 internal medicine residents and taught them to use Epic on it, along with online publications and the internal paging system. Four months later, the residents were surveyed. Results: 90% were using the iPads for work (it’s interesting that 10% weren’t) and 75% of those were using them daily (meaning 38% of those given an iPad weren’t.) Three-quarters of those said they thought they were more efficient and 68% of them said they thought patient care delays had been avoided because of the iPad. Residents entered a few more (5%) orders before 7 a.m. rounds and within the first two hours of admission. Study weaknesses:

• A sample size of 115 residents in one academic hospital isn’t all that predictive and doesn’t cover other specialties.
• Residents work a lot differently than attending physicians and community-based docs.
• Asking residents if they thought their free iPads were useful may have encouraged them to inflate the results to avoid having to return the iPads.
• The difference in order timing was tiny and compared 2010 patterns with those of 2011, a time during which other factors surely changed.
• The team had no way to determine which orders were entered from the iPad vs. from a desktop or laptop, so there’s no proof that the “earlier” orders came from iPads at all. It was also not stated whether Epic was available on wireless devices in 2010.
• It was not stated which devices were in use in 2010 – wireless laptops or hard-wired desktops. If residents didn’t have their own individual wireless laptops in 2010, you would expect orders to be entered more quickly (no waiting for a device) and closer to post-call rounds (the device would be at hand in the conference room).
• Placing orders early doesn’t necessarily translate to better outcomes or increased patient satisfaction, although it’s still a good thing overall.
• Epic has a native iPad client that most systems don’t offer, so experience with a less-functional clinical systems client would likely be less positive.
• Still, all that aside, if you can make residents think they’re more effective (not to mention cooler) for just $500 and you even potentially avoid the cost of buying them their own laptops, why wouldn’t you?

Mission Health (NC) names Sulaiman H. Sulaiman, formerly CIO of Cleveland Clinic’s hospital in Abu Dhabi, as SVP/CIO, replacing the retiring Arlo Jennings.

Athenahealth will hire 80 people to work at its Belfast, ME office, raising its headcount by 20%.

An article in The Atlantic says innovators develop products for people who are like themselves, which is why mHealth apps influence only the already-good health of what it calls “The Social Network” (well-educated, technically savvy, and affluent whites and Asians living on both coasts) while having minimal influence on the behaviors of the more diverse and more healthcare-expensive population as a whole. As Dr. Travis has said on HIStalk Mobile, running apps are a lot more popular with runners than couch potatoes. Or as Bill Gates says, we already have healthcare technology that tells people that they need to change their habits, but unhealthy people just ignore what it’s telling them (bathroom scales.)

E-mail Mr. H.