News 4/11/12

Top News

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

Reader Comments

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

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

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

HIStalk Announcements and Requests

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

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

Acquisitions, Funding, Business, and Stock

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

Sales

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

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

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

People

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

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

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

Announcements and Implementations

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

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

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

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

Government and Politics

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

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

Other

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

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

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

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

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

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

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

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

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

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

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

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

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

Sponsor Updates

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

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

3M Acquires CodeRyte

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

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

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

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

Curbside Consult with Dr. Jayne 4/9/12

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Dr. Jayne.

Monday Morning Update 4/9/12

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

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

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

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

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

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

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

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

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

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

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

E-mail Mr. H.

The Healthcare IT Week in Review

1. Newt’s Think Tank Tanks

Facts and Background

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

Opinion

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

Musings

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

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

Facts and Background

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

Opinion

Choose your site visits carefully.

Musings

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

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

Facts and Background

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

Opinion

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

Musings

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

Time Capsule: My Secret Nostalgia for Small Hospitals

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

I wrote this piece in March 2007.

My Secret Nostalgia for Small Hospitals
By Mr. HIStalk

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

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

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

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

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

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

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

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

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

HIStalk Interviews G. Cameron Deemer, President, DrFirst

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

Tell me about yourself and about DrFirst.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

News 4/6/12

Top News

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

My initial reaction to CHT’s tanking:

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

Reader Comments

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

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

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

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

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

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

HIStalk Announcements and Requests

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

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

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

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

Acquisitions, Funding, Business, and Stock

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

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

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

Sales

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

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

People

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

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

Announcements and Implementations

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

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

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

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

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

Government and Politics

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

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

Innovation and Research

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

Other

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

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

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

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

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

Sponsor Updates

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

EPtalk by Dr. Jayne

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

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

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

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

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

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

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

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Gingrich’s Health IT Group Files for Liquidation

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

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

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

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

From a recent HIStalk post:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Problem with Scrolling

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Next Post

Overview with Details on Demand — a Versatile Design

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

News 4/4/12

Top News

A National eHealth Collaborative paper says that HIEs have great potential to improve care and reduce cost, but despite ONC emphasis and incentives, not a lot of value has been realized so far. Big issues remain funding, provider adoption, and difficulties connecting to the wide variety of available EMRs. They recommend focusing on patients above all else, build trust and a common vision among participants that often don’t particularly like or trust each other, ignore “one size fits all” proposals and listen to what the local community wants, and figure out how to make money once the grants run out.

Reader Comments

From Hardware Sue: “Re: Navin, Haffty & Associates. Heard that Park Place International is looking to buy them out.” Not true, NHA President John Haffty tells me. Park Place has expanded its technical offerings related to Meditech and NHA has collaborated with them on projects and will continue to do so since their work is complementary, but no acquisition-related discussions have been held or encouraged. Per John, “We have great respect for the old and new team over at Park Place, but we are committed to maintaining our independent status.” Norwell, MA-based NHA offers consulting services exclusively for Meditech customers.

From JayGlo: “Re: security testing firms. Know any that specialize in EHRs in general and Epic in particular? Who are the best white hat hackers?” I’ll defer to readers – leave a comment if you have suggestions.

From ForthePatients: “Re: Tampa Bay RHIO. Work has been dragging in the swamp for almost five years with a long list of special interests – academic medicine, lawyer, homegrown exchange vendor, and hospitals interested in connecting to their own practices. Who controls what is clearly a the crux of this one and not a focus on the patients or the community.”

Acquisitions, Funding, Business, and Stock

Santa Rosa Consulting announces that it has completed its acquisition of Nashville-based healthcare IT consulting firm InfoPartners.

Charge master vendor Craneware opens an office in Scottsdale, AZ.

Merge Healthcare shares dropped 16% on Tuesday after the company filed an SEC 8-K form indicating that a $2.75 million sale of kiosks was to higi LLC, a company founded and controlled by Merge Chairman Michael Ferro. Merge’s audit committee had cleared the sale. Merge topped the biggest percentage price decliner on Nasdaq list, shedding nearly $90 million of value for the day.

Sales

Cooper University Hospital (NJ) signs a three-year agreement with Newport Credentialing Solutions for its reporting and analytics software and back office credentialing solutions.

Southeast Michigan Beacon Community selects Covisint’s accountable care technology to aggregate regional health information.

DuPage Medical Group (IL) selects Humedica MinedShare to provide clinical benchmarking and analytics from its Epic EMR.

Einstein Healthcare Network (PA) licenses business analytics and patient financial services solutions from Streamline Health to monitor and drive revenue cycle performance in its 1,000- physician ambulatory care network.

Mount Sinai Medical Center signs with Siemens MobileMD for an HIE service agreement.

People

Cognosante names Eileen Cassidy Rivera (Vangent) as VP of marketing and communications.

Former Cigna VP of IT Marcus B. Shipley joins Trinity Health (MI) as SVP and CIO. He  replaces Paul Browne, who has been named Trinity’s SVP of integration services.

Nashville-based The Rehab Documentation Company, which sells therapy documentation systems, names Antoine Agassi as president and COO. He comes from Cogent Healthcare and was previously chair of Tennessee’s Governor’s eHealth Advisory Council and held executive roles at Spheris and WebMD Transaction Services.

Announcements and Implementations

Southeastern Med (OH) hosts a midnight ribbon cutting ceremony to officially launch its Meditech go-live.

West Calcasieu Cameron Hospital (LA) launches bedside bar code verification with McKesson’s Horizon Admin-RX.

Biggs-Gridley Memorial Hospital (CA) goes live on the Prognosis ChartAccess EHR.

Humana Cares completes installation of a 1,600 monitoring devices for a telehealth pilot project, where nurses will remotely check the vital signs daily of CHF patients in hopes of decreasing hospitalization. The project uses the Intel-GE Care Innovations Health Guide, a blood pressure monitor, and scales.

Government and Politics

A bipartisan group of House and Senate lawmakers introduces a bill proposing to link the prescription drug monitoring programs of individual states, allowing prescribers to look for patterns of prescription drug abuse across state lines.

VA CIO Roger Baker says the $4 billion joint VA/DoD EHR system could be available by 2014 and will be piloted at military installations in Hampton Roads, VA and San Antonio, TX.

The VA cancels its Software Assurance agreement with Microsoft covering its 300,000 users, giving the agency flexibility in seeking non-Microsoft alternative technologies, such as tablets and cloud-based systems.

The Coast Guard prepares to go live on its Epic-based EHR. It plans to provide mobile access via cellular network and to run cached copies of information from its vessels, which often do not have connectivity. The Coast Guard is looking for companies to provide service desk support.

Innovation and Research

A study performed in large UK teaching hospital finds that off-hours clinician response and satisfaction improved when pagers were replaced with wireless call handling and task management. Tasks were logged on a PC that sent messages to a coordinator’s tablet, who then routed the tasks via text message to on-call phones. Users liked the improvement in handoffs: task prioritization, the ability to monitor task assignment and completion, and elimination of handwritten notes.

Technology

Rochester, MN-based mobile healthcare apps vendor Preventice, partly owned by Mayo Clinic, expands into the medical device business with BodyGuardian, a diagnostic heart and respiratory monitor that patients can wear during normal activity. The company says the final product, when approved by the FDA, will be just 8×8 mm in size (about a third of an inch high and wide) and will attach like a Band-Aid for up to seven days, sending the physician a text message and EKG by Bluetooth when it detects cardiac events. The company plans to hire 15 employees and will move to new headquarters in Minneapolis.

Microsoft announces the 11 startups chosen from 500 applicants that will participate in its 2012 Kinect Accelerator. Among them are GestSure, which creates touchless interfaces for surgeons and interventional radiologists; and Jintronix, a virtual reality rehabilitation system for patients with motor control problems.

Other

The University of Arizona Medical Center will replace Allscripts and iMed with Epic at its two hospitals and outpatient centers. The project will cost $100-135 million, will require 87 full-time employees over the next three years, and will involve providing 12 hours of training to each of 6,000 employees. Four miles away, Tucson Medical Center is already running Epic, having completed its rollout in June 2010.

Partners HealthCare researchers find that the number of lab tests ordered for outpatients who were seen at both at Brigham and Women’s Hospital and Massachusetts General Hospital dropped from seven to four after implementation of an HIE that allowed previous results to be viewed by either facility. The full text article isn’t available online to non-subscribers and the usual disclaimers apply: the study sample appears to be quite small, the study data was old (1999 to 2004), and whatever correlation was implied does not prove causation. 

Despite a fall in net income from $158 million in 2010 to just $1 million in 2011, Novant Health (NC) will spend $600 to $700 million over the next four years on its Epic project. Novant expects the first of its 13 hospitals to go live by the end of 2013.

Several readers found this non-HIT story interesting enough to send over. The $4 million-per-year CEO of Pittsburgh-based insurance company Highmark is fired after an ugly love triangle fight over his 28-year-old girlfriend, who worked for him at Highmark. Kenneth Melani, 58 and married, showed up at the girlfriend’s home and refused to leave when ordered by her 48-year-old husband, resulting in criminal charges. Melani has engaged an attorney to determine whether his dismissal was legal, while the DA agreed to postpone his preliminary hearing provided he undergoes anger management counseling.

Leila Denmark MD died this past weekend in Georgia at 114 years old. She she was the world’s oldest practicing physician when she retired at 103, having begun her pediatrics practice in Atlanta in 1931.

Sponsor Updates

• Practice Fusion customers have received $22 million in EMR incentives through January, the company reports.
• Emdeon offers a free weekly webinar on Emdeon Vision for Claim Management.
• The HITR nursing technology blog is running a Bodacious Scrubs contest through April 25.
• Iowa Health System contracts with Hayes Management Consulting and Coastal Healthcare Consulting to provide legacy support services.
• MED3OOO’s IT and services divisions hosts a virtual job fair May 2. 
• Encore Health Resources names attorney Tom Luce to its board.
• ICA launches HIT Me Blog with commentary on current healthcare and HIT issues.
• Lifepoint Informatics will participate in the 2012 Executive War College on Laboratory and Pathology as a corporate benefactor. The event will take place in New Orleans May 1-2.
• Cognosante and 3M partner to provide 3M’s ICD-10 Code Translation Tool to state-sponsored health plans.
• MedHOK announces that its 360Measures V 2.55 has achieved 2012 P4P certification.

Contacts

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

More news: HIStalk Practice, HIStalk Mobile.

Readers Write 4/2/12

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!

Cloud-Based Medical Data Exchange: Promising Results So Far
By Michael Trambert, MD

At RSNA 2011 and since then, my colleague Mark D. Kovacs, MD and I have been communicating to our peers about the new cloud-based services for exchanging imaging and other medical files.

Based on our study of an early adopter, Virginia Commonwealth University Medical Center (VCU), we’ve concluded that cloud-based medical data exchange has, in its best form at least, neatly addressed all of the major issues associated with older methods such as exchanging files by CD or VPN.

The “new” approach – which is actually about two years old and used by over 400 facilities – works seamlessly. Files are exchanged in minutes – reliably, securely, and at low cost. That includes exchanges between proprietary IT systems that don’t normally “talk to each other.” The cloud mediates the exchanges as easily as if it was e-mail being sent.

To appreciate what an improvement the cloud services represent, it helps to understand previous methods. Before the advent of cloud services, medical institutions turned to workaround solutions to deal with the incompatibility of proprietary healthcare IT systems.

The most popular of these was burning files to CD and sending them by mail, courier, or with the patient. Facilities that had a steady need for such exchanges with each other sometimes used virtual private networks (VPNs). For reports and other non-imaging files, some institutions used faxes.

The inherent problems with each of these methods are well known. But let’s examine the additional downstream problems.

Take, for instance, CDs – by far the most widely used method. This approach fails a significant percentage of the time, for reasons such as lost or misplaced CDs and files that can’t be opened. The significant time delay and risk of loss and or damage due to physical transport also undermines the rapid diagnosis and treatment of critically ill patients. Physical media makes it impossible to access studies contemporaneously from far away and by multiple caregiver / consultant sites.

When imaging studies are not successfully transferred, frustrated physicians at the treating institution often order redundant imaging studies. Studies show this occurs as much as 10% to 20% of the time. This unnecessary imaging exposes patients to excess radiation, which can contribute to cumulative deleterious effects. It also adds billions of unnecessary dollars to national healthcare costs.

VCU has been using a cloud-based service since late 2010. The cloud-mediated file transfers (in VCU’s case using a service called eMix) has been disruptive due to ease of use, speed, and dependability. Transfers are trouble-free.

As with any new approach — even one this simple — minor workflow adjustments were made. VCU is a Level I Trauma and referral center, so data exchanges usually involve other institutions’ sending files to VCU rather than vice versa. Those facilities had to switch over from a workflow built around burning and sending CDs to one requiring uploads to a cloud server. This required a simple change in workflow, much more efficient than burning CDs or utilizing VPNs.

Based on what we observed at VCU, Dr. Kovacs and I feel that change is exactly the right choice in this case. Cloud-based medical data exchange represents a boon to patient care because a patient’s imaging files, reports, and other crucial medical data from multiple previous providers can be sent to the current care provider whenever they are needed – in minutes, not days and with no hiccups in usability. Multiple consultants in geographically different locations can access this data from anywhere they require to provide input for a patient’s care.

These services also represent the efficiency gains that advocates such as the Bush and Obama administrations have been promising for healthcare IT in general. Unlike other forms of IT such as EHRs, some of the cloud-based services require no new capital purchases. That is, an institution does not have to purchase hardware or software. They simply have to pay a metered fee, as they do for electricity and water.

Besides eMix, current cloud-based services include lifeIMAGE and SeeMyRadiology, among a number of others. I cannot speak to the relative merits of each. But I can say that it’s nice to begin seeing the era of CD-burning and VPNs in our rear-view mirror.

Michael Trambert, MD. is the lead radiologist for PACS reengineering for the Cottage Health System and Sansum Clinic in Santa Barbara, CA.

ACHE Impressions
By Darkened Room Observer

After attending my third straight American College of Healthcare Executives’ Congress on Administration in Chicago, I’ve come away with the realization that there is a large vacuum of leadership within our industry.

I have attended the majority of sessions in the healthcare information technology “mastery series.” Each year, executive after executive talks about their success in implementing healthcare IT projects. When the question is asked, “To what do you attribute your success?“ the response is usually, “Well, I’m not really altogether sure.”

The lack of leadership this year was clearly evident a session in which a CEO got up in front of a group of about 200 people and said they decided that they did not want to go down the road of modifying a solution so, “We contracted with a vendor that didn’t allow customization to their product.”

Another CEO boasted that they chose a vendor who required them to hire a certain amount of people with specific talents and skills. The vendor would give the customer a rebate if they met specific milestones.

In another session, the CEO and CIO expounded on how well they were doing, based on the vendor’s established criteria and reporting mechanism.

With both financial and political pressures being applied to the healthcare marketplace at unprecedented levels, leadership to ensure that we are not simply doing things right, but are doing the right things is imperative. Yet we seem to have leadership that is so focused on ensuring that everyone is “happy” that they relegate true leadership, vision, and goal setting to their vendor. Although none of the presenters were allowed to disclose their vendor, it was clear to me that these entities were going to have epic changes to their businesses.

It appears that it may not be the actual technology a vendor brings to the table since the company in question deploys relatively arcane language, hardware technology, and definitely not state-of-the-art functionality by today’s standards. It has much more to do with a their philosophy of leadership by contract that appeals to this crop of hospital executives who lack the intestinal fortitude to ensure that their clinical staff change how they practice medicine as a result of implementing this new tool.

Can you imagine if the people marketing laparoscopic technology were required to modify their products to allow physicians to continue doing business as usual? Yet most vendors, in an effort to sell more in the short run, allow their clients to dictate modifications, enhancements, or wholesale scope changes in their contracts to “keep” clients.

Eventually these vendors suffer from trying to support 300 clients with extremely customized applications, setting the vendors up for failure. Like parenting or growing a good business, strong leadership and discipline are essential for truly happy children. Appeasing clients (like a child) only creates spoiled children.

Every time I turned around, it seemed that the only people exposing the truth were either from outside healthcare or were retired and finally saying what they couldn’t say while still needing a job.

Why Mobile Device Strategies are Missing the Point of the iPad
By Jared Sinclair RN

A friend of mine who has been a bedside nurse for many years has to lock herself in her bathroom whenever she surfs the web so that her elderly mother won’t complain about her wasting time with her laptop. My friend’s mother lived most of her adult life on another continent and without access to a computer. To her, a laptop is just another household object. She observes her daughter using the laptop as if she was mindlessly staring at a hunk of plastic and metal, while in fact, my friend is doing all kinds of things: researching, reading the news, paying bills, etc. The intangible nature of software is missed by her mother, who sees only the physical qualities of the machine itself.

Some of us in the healthcare tech industry have been making a similar mistake by thinking of mobile devices like the iPad as defined by their physical form. The form factor of a mobile device — the lack of a keyboard or a mouse — is what makes a mobile device portable, but portability is not its defining characteristic. A touch interface is what make a mobile device unique. This may seem obvious, but it deserves thoughtful consideration.

For many years, the PC industry itself also misunderstood this fact. While the iPad is far and away the most successful tablet, it is not the first tablet. PC manufacturers have been making tablets for years. Their products were never widely successful. Their approach was, in essence, to remove the keyboard and trackpad from a laptop and call it a tablet.

Because PC manufacturers didn’t write their own operating systems, they had no choice but to ship these tablets with Microsoft Windows. This operating system was not optimized for touch screens, which meant that the hardware had to conform to the limitations of the software and not vice versa. In other words, they had to require the use of a stylus. Smart managers would never have released these products on the market. The mistake of the PC manufacturers was in thinking that the defining quality of a tablet is its form factor.

The defining quality of a tablet is touch.

The iPad does not ship with the same operating system that ships with Apple’s desktops and laptops. It never will. IOS, the operating system that Apple created to run the iPad and the iPhone, was designed from the ground up for a multitouch experience. Other mobile operating systems, like Android and Microsoft’s Metro, have followed suit.

Without a mouse and a mouse cursor, many of the conventions that we take for granted when using traditional desktop or laptop operating systems vanish. Touch-based operating systems have no concept for right clicking, or for hovering the cursor. Because the tip of the human finger is much less accurate than the tiny one-pixel tip of a mouse cursor, on-screen buttons need to be much larger. Because touchscreens tend to be much smaller than desktop or laptop screens, care must be taken to maximize efficient use of screen real estate.

One of the main reasons for the iPad’s success compared to previous tablets is that it uses its constraints as advantages to be enhanced, rather than limitations to be overcome with a stylus. Gestures allow users to swipe, pinch, rotate, and flick through apps. User-interface designers create novel ways for people to interact with their apps based upon these gestures. Angry Birds, an app that everyone by now has enjoyed (or at least endured the sound of it being played), is much more fun on a touchscreen than on a PC.

It’s frustrating to read about hospitals so anxious to use the iPad in a clinical setting that, rather than waiting for a native app to be developed, they deliver a desktop EMR interface via a virtual client like the Citrix app. The experience is always dismal. This is not the fault of the EMR vendors. Their software was designed for a mouse and keyboard. It’s not surprising to hear physicians report that on-screen buttons are too small, or that it becomes tedious to constantly pinch and zoom in and out of a virtual image of a desktop EMR interface.

Healthcare IT leaders need to understand that a mobile device like an iPad is not defined by its hardware alone. Sports fans don’t buy high-definition televisions because they are rectangular. They buy them so that they can enjoy watching games with a clarity that they could not experience with any other kind of TV. For the same reason, consumers buy the iPad because it allows them to use a computer in ways that they could not use a computer before.

"Going mobile" is not a strategy. Any HIT mobile device plan that does not include touch-optimized native apps as part of its mission is doomed to failure or mediocrity. Sheer portability alone is not enough. Rather than cramming software paradigms designed for desktop computers into these brand new devices, we should be using the mobile device revolution as an opportunity to re-think the way we interact with our EMRs.

By the way, this article was dictated on an iPad. In a few years, we will probably all be talking about voice interaction the way I’m talking about touch today.

Jared Sinclair is a registered nurse and an iPhone and iPad developer. He’s the founder of Splint, a startup focused on developing mobile apps for bedside nurses. He is also the creator of Pillboxie, a fun medication reminder for iPhone and iPad. He lives in Nashville, TN.

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.