HIStalk Interviews Doug Arrington

Doug Arrington, PhD, FNP is director of the Office of Billing Compliance of UT Southwestern Medical Center of Dallas, TX.  

Tell me about your work.

I am the director of billing compliance here at UT Southwestern, which means I am responsible for all the professional billing that’s done by our faculty and other healthcare providers. Also, the hospital billing that is done by our two hospitals. Also, all the research billing that is done. That’s what keeps me busy.

It was interesting to me that your background is as a nurse. Does that help you deal with billing and compliance issues?

Absolutely. It helps me in understanding the clinical situation that the providers are in, and the hospital is in, and the researchers as well. It helps me understand what they’re dealing with. It also helps me translate the compliance language, if you will, into an understandable clinical language that they can understand and apply. It makes that leap a whole lot easier for me to do with the providers.

Can you tell me about your team, how it’s set up, and how it reports?

I have a group of individuals that report to me who are compliance auditors. They are certified compliance individuals and certified coders who use the MDaudit tool from Hayes Management Consulting in reviewing the providers in the professional practice. They conduct audits on a quarterly basis of selected providers in their clinical departments that we have here at UT Southwestern. They share their findings with our providers.

I have another group from a hospital side that we do basic audits of the UB-04 claim forms that are done to ensure that the claims have gone out quickly, as well. Then I have another group that we’re just starting up right now that is on the research side, and they are in process. We’re developing our research compliance tool, which looks to make sure that we have billed a sponsor when we say that it’s a research item, and when it’s standard of care that we bill that out quickly to the third party, be it Medicare or Blue Cross/Blue Shield, or whoever it might be.

How would you say your operation compares to that of comparable facilities?

That’s a good question. I would probably say, on average I’m staffed about what most compatible large teaching organizations. I have about 1,550 active healthcare providers on the faculty side. Our hospitals are 100-and-some beds, and the other one is like 235 beds. So on the hospital side; I think for the type of audits that we’re doing on staff for the insurance side, as well.

Then for the research side, we’re just bringing that up. I’m just starting here doing the risk assessment and stuff, so I think I’m appropriately staffed for when you’re on the start up. Then as we go down, I’ll be adding additional staff as we move further into a more active auditing program. I think I’m pretty well staffed for an average organization of our size.

Can you give a high-level overview of the audits that you deal with; the RAC and the OIG audits, and what those means for hospitals?

On an annual basis I do what is called a risk assessment, which takes a look at all the different risk areas that we face here in compliance. For example, I do some data mining looking at basically, what is my top 15% in volume and cost by payer. I look both at federal payers and managed care payers. Then I also look at some data mining issues that are identified by our Medicare administrative contractor here. Then we have the recovery audit contractors and our comprehensive error rate testing, and our payment error rate measurement. Then we have the Medicare integrity group.

So we have a series of audits that are being conducted by external groups that we need to make sure we’re in compliance with. I follow them on a daily basis; go out to their sites — the CERTs, the RACs, the PERMs, and the Medicaid integrity — to make sure that there aren’t any issues.

Then obviously, every October the OIG releases their work plan that I need to be focused on. Throughout the year, they also release opinions and audits results that I need to be tuned in to and to take a look at. This applies not only to the professional practice, but also the hospital side, as well.

Then there are just general things, like the National Coverage decisions that are released by CMS, and the local coverage decisions. I need to make sure that those are programmed in to our claims management system.

Every institution has a hotline, and what we encourage our employees to do is any time they identify something that they may be concerned about is to identify that and to call us. They can be anonymous on that hotline and let us know that they are concerned about something so we can go in and do a complete investigation.

In a nutshell, that’s what I look at in building my audit. What are my priorities on an annual basis is some of those things that I take into consideration.

There’s a lot of activity out there by whistleblowers who get a percentage of the proceeds on claims that are eventually proven to be true. Did that change the way, or the scope, of what you have to do?

It certainly changes the way that I do education here at Southwestern. I make sure that in new employee orientation that we place a very high value on compliance and being compliant with federal rules and regulations. Then, for our key billing staff, we make sure that they receive at least 15 hours of compliance education on an annual basis.

We make sure that we provide ongoing education to our general population, as well. We try to do everything we can to ensure that our staff who deal with billing and coding, and our faculty members that are actually providing the service, have the necessary tools to make sure that they’re in compliance with federal rules and regulations and that they’re following the rules and regulations that we’re supposed to. Then we do audits on the back end to ensure that the claims that go out the door are going out quickly.

When the whistleblower type stuff started, that certainly changed the environment within the compliance area and made what we did, or do, on a daily basis much more visible to an organization when they see some of these large settlements occurring out there. It has something that also helps me, in regards to providing education, that I can use that to provide examples of education and why we place such a high value on it here at UT Southwestern.

If you came in cold to a hospital and were asked, “Tell us what we’re doing wrong,” What kind of things do you think you would find?

That’s a real good question. Probably, I think the hardest thing is keeping on top of the ever-changing federal rules and regulations that impact payment on a day-to-day basis, because the rules change frequently. Just about the time you think you understand the rules, we have new ICD-9 codes that come out, and we have new CPT codes that come out. CMS releases another National Coverage decision or a local Medicare releases a local coverage decision that impacts what we’re doing on a day-to-day basis. Then I have to make sure that information gets communicated down to the healthcare providers, to our claim payment systems.

That’s what I would look at in a hospital, is to make sure that they have someone who’s monitoring those things on a day-to-day basis to make sure that they have that plugged in and they’re following the rules — the CPT codes and ICD-9 regulations and stuff along that line. That would be the first thing – that I would make sure that they’ve got all that stuffed programmed into their claim payment system. That they can only bill out one of these on a daily basis and they don’t have somebody that has a keystroke error and they enter in 114 of them, versus 14 of them. You’ve got to make sure that you’ve got the appropriate fail safe on the back end to catch those types of errors. That’s what I would be looking for when I walk through the door of an institution.

You mentioned education. How much of what you have to operationalize involves having someone else do something, versus what you can do centrally?

We, on an auditing-type perspective, certainly use a little bit of that. But what we try to do is empower the clinical departments to provide education to their providers that is through the lens of their particular clinical specialty. For example, in orthopedics, I want them to be able to provide education to them that is specific around compliance issues that have the lens, if you will, of orthopedics; and then pediatrics that has the lens of pediatrics.

Being a healthcare provider myself, a nurse practitioner, I’ve learned that if somebody’s talking to me about a surgical procedure, I really have a hard time relating to that because I’m not that type of a healthcare provider. But if I’m dealing with something that I understand and I can apply it in my mind in a clinical setting to the type of patient I just saw this morning, that has a whole lot more relevance to me. That’s the reason why I try to make sure that when we provide compliance education, we’re putting it through the lens of that particular healthcare provider.

So in maternal fetal medicine, they see it through the lens of being a maternal fetal specialist. Or if it’s an urologist, they see it through that lens of being an urologist. They can understand that concept, but they understand it how it applies to them. The beauty of MDaudit is that I can build a case profile based on the risks that we talked about earlier. So I can assess that risk in urology that is specific to the urologist and I can provide specific feedback out of MDaudit that is specific to their practice in urology.

Can you tell me the toolbox of tools that you use and how they fit together?

One of the most important things I think I talked about earlier was the case profile that I built for each one of my clinical departments. What it basically does is it takes that risk assessment that I do on an annual basis, and it makes it very specific to each one of my clinical departments.

The MDaudit tool allows me to make one just for pediatrics, and one for internal medicine, and one for OB/GYN. It allows me to take that clinical lens that I was talking about earlier, and then build an audit tool around that so I can identify a specific area that they may not understand, or is a particular risk area that’s been identified by the OIG so I can make sure that we’re doing it correctly.

If I identify a problem, I can identify it as soon as possible and go in and intervene and educate before it becomes a big problem and we end up having to give back lots of money and stuff along that line. That’s the absolute beauty of the MDaudit tool is it allows me to take this risk profile, make my case profile that’s unique to my individual provider that I’m trying to identify in their clinical specialty, and then audit against that case profile.

In general, what advice would you have for hospitals and practices, related to what you do?

Keeping on top of the ever-changing regulatory environment. Make sure that you are hooked into the listservs that go out, and review the federal publications and what’s going on in the courts on a regular basis. There are a number of listservs from the compliance associations and other organizations that will help so you don’t have to go out and review the Federal Register on an everyday basis — that will actually provide that information for you.

Make sure that you have that information at your fingertips because one day that you may miss may have that absolute most important piece of information that can make the difference in your organization between doing it right or doing it wrong. If you end up doing it wrong and somebody comes back later and says, “Why didn’t you know about it?” It becomes pretty hard to defend when everybody’s looking to you to be the compliance specialist. So keeping on top of those rules and regulations is the absolute most important thing. I cannot emphasize enough.

Any concluding thoughts?

You know, I think that the compliance arena is an ever-changing environment. Education — my own personal education, as well the education as a provider — is absolutely critical. Tools that we have, such as MDaudit and MDaudit Hospital, help us communicate specific, filtered compliance education back to those providers.

I think that that’s the most important thing that we be able to do, is to provide feedback that is meaningful to that particular clinical provider. Be it a healthcare commission, or be it a healthcare institution such as a hospital or home health agency or whatever, that they can understand it through their particular lens.

News 2/24/10

From The PACS Designer: “Re: HIPAA Survival Guide. Deborah Leyva of the Health & Technology Blog has posted the Second Edition of the HIPAA Survival Guide for download.”

Just published by The Huffington Post Investigative Fund: FDA is “moving closer” to regulating EMRs after receiving reports of six patient deaths and 44 injuries related to system malfunctions. Examples included an OR system whose lockups forced nurses to re-enter data from memory and another that didn’t display allergies correctly (hardly news if you’ve worked in HIT for any length of time, but apparently FDA was surprised). An FDA official admitted that the agency has steered clear of regulating HIT, but says, “In light of the safety issues that have been reported to us, we believe that a framework of federal oversight of HIT needs to assure patient safety.” Reaction from vendor executives at the recent hearings was interesting: Epic’s Carl Dvorak was quoted as saying regulation wouldn’t necessarily ensure safer products or encourage innovation, while Cerner says it supports making voluntary safety reports mandatory because it’s “the right thing to do.”

I have a couple of interviews yet to post, so once those are running, I promise you will see fewer HIStalk e-mail blasts. All of the interviews were fun to do and I’m pleased to bring them to you. I’m hoping to clear the decks before HIMSS since you know I’ll be writing every day from there.

This is new at HIMSS: the naming of the HITmen (and women) of 2010, the most powerful healthcare IT leaders. There’s an invitation-only reception at the conference and some PR, I’m sure, for the winners. Some familiar names are on the host committee: Jonathan Bush of athenahealth, John Halamka of BIDMC, Steve Lieber of HIMSS, and the one that sticks out like a sore thumb, Mr. HIStalk – CEO of HIStalk (and yes, I’ve taken considerable e-mail ribbing about that, but I swear the CEO thing wasn’t my idea and I have zero delusions of grandeur). More to come.

Secure access vendor Imprivata announces the formation of a healthcare division and the hiring of HIMSS chair Barry Chaiken, MD as chief medical officer.

Here’s a shout-out for Software Testing Solutions LLC, a new Platinum Sponsor of HIStalk. The Tucson company’s RATIO tools perform automated software testing, which I hope you hospitals and practices are doing before simply moving vendor code to production (both unexpected bugs and manual testing are expensive, as I can vouch from unfortunately personal experience). You set the application environment, the scope, and the transaction volume, then let the script take over to perform and document the tests (it even works with Citrix). If you have Epic inpatient or ambulatory, Eclipsys SCM, or Sunquest, you could be validating your orderables, generating test billing transactions, and validating new vendor releases and interface changes with minimal effort and with documented consistency. Thanks much to Software Testing Solutions for supporting HIStalk.

HealthStream’s Q4 numbers: revenue up 12%, EPS $0.47 vs. $0.07, although some one-time adjustments threw the numbers off a bit.

Weird News Andy expands his media sources to video, locating this story about a Kentucky psychiatrist who attacked a patient in his office with a sword, with his only statement after the fact being “four quarts low on the truck.” His patient, unfortunately, sustained life-threatening chest wounds. The uncharacteristically somber WNA also finds this story that he captions as “Patients or Guinea Pigs,” describing the FDA’s OK to dispense with informed consent guidelines for EDs involved in a resuscitation study.

Wellmont Health System (TN) names Kent Petty as VP/CIO.

I figure it’s the least I can do to wish Encore Health Resources a happy first birthday since they’ll be buying a few hundred of you drinks and food next Monday evening at the HIStalk reception, so here’s to them (and their reception co-sponsors Symantec and Evolvent).

Redwood MedNet and Thayer County Health Services connect their respective HIEs as a demonstration of the Health Internet using Mirth Corporation’s Mirth MUx (Meaningful Use Exchange), built on ONCHIT’s CONNECT software.

The fight is on for Amicas, with Merge Healthcare putting a $248 million offer on the table next to the earlier $217 million one from Thoma Bravo. Amicas already agreed to the Thoma Bravo offer, so the company is urging shareholders to vote that way, saying it doesn’t trust Merge’s financing.

My upcoming guest editorial for Inside Healthcare Computing: Dark Side on Line One: If Cash Really is King, Now’s the Time to Leave That Hospital Job. A sample of its caffeine-fueled prose: “If you have a loving, loyal hospital spouse who makes you happy and puts up with your idiosyncrasies, then think carefully before running off with the tarted up, drug-seeking vendor stripper who is whispering in your ear to throw it all away to run off to Las Vegas with her to gamble. It’s not nearly as fun as it looks.” It’s not Camus, but it’s what I do.

Porter Medical Center (VT) gets a mention in the local newspaper for its planned Meditech implementation, which awaits certificate of need approval. I like the CFO’s response to possible ARRA incentives: “There are all kinds of experts at the state and national level that swear that this will save money. I’d be the last person to try to guarantee savings.”

Also getting a nice newspaper story on its EMR implementation: Stormont-Vail HealthCare (KS).

More on the pharma-sponsored depression “test” that WebMD ran, pitching Lilly’s Cymbalta: no matter how you answered the 10 questions, the response was always “You may be at risk for major depression.”

Nevada banks are pre-qualifying doctors for EMR purchases just like they do for mortgages, expecting a jump in Q2 purchases. On the one hand, banks say nearly all doctors are contemplating an EMR purchase. On the other, falling home values mean banks aren’t as willing to take personal guarantees for the loans. A nice article by the Las Vegas Business Press.

TriZetto launches its PHR for health plan members. The press release was full of a lot of product names that I wasn’t really interested enough to follow, but it does interestingly distinguish EMRs from EHRs (as I do).

Genesis HealthCare (OH) seeks $25 million in taxpayer-backed loans to Epic, which it hopes will quality it for $12.5 million in stimulus money.

A Maryland fire department’s computer system loses over 10,000 ambulance transport records and fails to file required reports when its computer system has problems in its first year of use. The $275K HealthWares reporting system has been scrapped, with the head of the firefighter’s union saying, “”I thought there was no reason to purchase this when probably an overwhelming majority of fire departments in Maryland use EMAIS for free. There was no reason at all to reinvent the wheel. It was a complete waste of money.”

Robert Miller is promoted to North American president of iSoft.

The White House wants to create a government-wide Federal HIT Task Force, chaired by David Blumenthal, that would coordinate healthcare IT among federal agencies. Those could include the VA, DoD, Social Security, CDC, NIH, and FDA.

Indian Health Service will upgrade its RPMS EMR system to meet meaningful use requirements, including addition of a master person index, a patient flow dashoard, and an event tracking tool to ensure follow-up of abnormal lab results.

Odd hospital lawsuit: a city judge held in a mental health facility for court-ordered evaluation of suicidal behavior files suit against more than 30 employees of the health system, the district attorney, other county attorneys, and Aramark. When contacted about the suit, his only comment was, “Payback is a (expletive), and I get to reform mental healthcare in the process.”

E-mail me.

HERtalk by Inga

Clearly HIT vendors and their PR companies are working overtime to issue pre-HIMSS press releases. Some of the news is meaty, though a fair number are a bit more ho-hum. Save yourself some time and peruse these highlights.

LSU (LA) expands its HealthLink project to include clinical data exchange between the LSU health system and its regional physicians. LSU Healthlink will use CarefX’s Fusionfx product to facilitate data access.

South Jersey Healthcare Regional Medical Center selects Patient Care Technology Systems’ Amelior Tracker to manage physician location and communication.

WellStar Health System (GA) selects ICA’s CareAlign Solution as its connected health technology platform.

Emergin, a division of Philips Healthcare, announces a new interface between the Emergin alert management platform and Voalte’s communication server. The integration will facilitate alert message notifications from the Emergin system to Apple iPhones and iPod Touches and provide real-time communication between caregivers.

HealthPort says it has added electronic delivery functionality to its release of information process.

Somerset Hospital (PA) contracts with McKesson for its PROmanager-Rx system to automate medication dispensing. Somerset is also McKesson Paragon user.

Northern Michigan Regional Hospital picks Medicity’s Novo Grid technology to provide electronic health information exchange among its hospitals and physicians.

PatientKeeper partners with NextGate to offer NextGate’s enterprise MPI solution for its customers. NextGate’s MatchMetrix Suite will connect with the PatientKeeper platform to provide a single view of patient information.

maxIT Healthcare announces a number of leadership changes,  including the promotion of Mike Sweeney from divisional VP of strategic partnerships to EVP of strategy and corporate development. Mark Fangman is maxIT’s new EVP of sales and operations and David Leaman is a divisional VP of sales.

Childrens Hospital Los Angeles plans to deploy GetWellNetwork’s GetWell Town solution when it opens in spring 2011.

McLaren Health Care Corporation (MI) signs a $3 million EHR contract with Allscripts for its 150 employed physicians. Initiate Systems will build McLaren an enterprise MPI across its multiple systems and databases, which includes McKesson’s practice management system.

Associated Cardiovascular Consultants (NJ) selects Sage Intergy, Sage Intergy EHR, Practice Analytics, and Practice Portal for its 38-physician  practice. Sage Healthcare, by the way, has its own channel on YouTube, which includes a number of customer interviews, including one with Associated Cardiovascular’s executive administrator.

CliniComp wins another deal with the VA, its third in the last four months. The New York/New Jersey Veteran’s Healthcare Network will install CliniComp’s Essentris ED and Essentris Critical Care solutions.

Former IDX exec Wayne Koch is named VP of physician services for Apollo Health Street.

The Valley Hospital (NJ) adds Summit Healthcare’s Scripting Toolkit to integrate with Valley Hospital’s MEDITECH platform.

Wellsoft shares word that the ED docs at Memorial Hospital (PA) are successfully using Dragon Medical to navigate and dictate within the Wellsoft EDIS.

As mandated by the HITECH Act, HHS posts a list of 36 reported health information breaches from private medical practices, hospitals, health systems, and public agencies. Most of the breaches were the result of theft or loss of a computer/drive/backup or other storage media. The breach affecting the most people involved the theft of hard drives from BCBS of Tennessee. The potential number of individuals affected: 500,000.

Here’s your HIMSS tip of the day: I see that Medi-Span is giving away a couple of trips to the Indianapolis 500. It’s labeled a “luxury trip package” but that’s still not much of a draw for me. I will forego entering Medi-Span’s contest and thus improve the odds for real fans. Of course, I expect you race car fans to return the favor when it comes the drawings for a nook eBook Reader (Dialog Medical) or Amazon Kindle (Brocade).

E-mail Inga.

HIStalk Interviews John Santmann

John Santmann, MD, FACEP is president of Wellsoft.

What are the key issues in the ED that you’re dealing with for your clients?

There’s lots of them. Operational efficiency is probably the single most important thing that we do. When we go into an emergency department, we really take a look at the whole department from the top down — not only the ED, but outside interfaces with other departments, registration, and so on — and provide a lot of essentially consultative services to improve the overall efficiency of how the department functions.

Of course, a lot of that involves folding in the software as a tool, but it really goes well beyond that. That’s kind of a comprehensive thing, but it’s very, very important.

ED patient satisfaction is always a key metric for hospitals. What are their typical problems?

Probably one of the biggest issues with patient satisfaction is length of stay. That’s a metric that we pay a lot of attention to. We have specialized reports that analyze it and break it down into different steps and so on.

After people implement Wellsoft, the length of stay typically falls dramatically, which not only impacts patient satisfaction, but it also increases efficiency and allows you to see more patients in a smaller space. In essence, it also helps overcrowding.

What should CIOs know about emergency department workflows that may not be obvious?

Boy, where do I begin? Emergency department workflow is not typically something CIOs spend a lot of time with. I think if anything, I would say it would be great if there was a heightened sense of awareness of the issues with workflow in an emergency department.

Everybody works in their own world. CIOs have a lot of demands and pressures and they get pulled in all directions. What we find is the details of emergency department workflow are not something that they have time, really, to address. They have a lot of other demands placed on their time, so I think it’s beneficial that they simply recognize the importance of the ED workflow.

We’re seeing more of that now. ED workflow, and also workflow in other parts of the hospital, are becoming recognized as an important issue. In fact, a couple HIMSS ago, the whole word ‘workflow’ — we’d been using the word workflow for as long as I can remember, but it’s really become a lot more popular in the last few years. I’m glad to see that.

What are hospitals doing with ED patient kiosks?

Mostly experimenting. We have several hospitals that use patient kiosks for registration. Not really registration, it’s to simply get yourself into the Wellsoft system so everybody knows you’re here. There are certain advantages to it. In general, in my opinion, if you have a good functioning, quick registration process, it really obviates the need for a kiosk to get the patient in the system in the waiting room.

So, you don’t see it taking hold across the board?

I don’t think — at least in an emergency department waiting room — the idea of using a patient kiosk as a way of getting them into the system initially; I’ve got mixed feelings on. I think that there are certain, select situations where it can be beneficial, but I think for the majority of facilities that have the resources to do what we call a quick registration process, I think it’s really not helpful.

What a quick registration is – basically, a patient walks into the department and is met by a human being who quickly just takes down their name, chief complaint, and date of birth. Usually, that’s about it. So it’s three or four quick pieces of information and that gets them in the system, which is really, for the most part, all you’re going to catch with a kiosk.

I believe that the personal touch of having a human being meet you, rather than a security guard pointing over at a computer in the corner of the waiting room, is a much more people-friendly way of doing it and probably safer too.

Some surveys claim that emergency departments are choosing to move toward the EDIS of their primary systems vendor. Are you finding that true, or is best-of-breed still alive and well in the ED?

I think best-of-breed is very much still alive and well. We’ve seen this pendulum swing back and forth several times now. I think the pendulum’s definitely swung more towards the pursuit of a single-vendor solution. I fully expect that pendulum … well, I think it’s already starting to swing back a little bit, and I think we’ll see it swinging the other way.

If you look at the KLAS ratings, for example, on EDIS vendors, virtually all of the top-rated EDIS vendors are niche systems, and all the lowest-rated systems are hospital-wide. You hear a lot of talk about the expense of integrating multiple systems, but what you don’t hear quite so much about is noise about the inefficiencies of a single-vendor solution. In terms of productivity in the emergency department, I think the niche vendors really have it, hands down.

When you look at the dollars associated with that, they’re huge. You’re talking about very large sums of money essentially being saved by using an efficient system like Wellsoft. It’s a relatively low cost for integration. I think when you take a real close look at the true cost benefit of a niche system like Wellsoft versus a hospital-wide system, that it’s a pretty clear decision.

There’s a huge marketing engine behind the larger vendors, so it’s a battle that’s been going on for 15 years that I’ve been involved with it. To me, it’s really nothing too new. It’s sort of more of the same all over again. I see the pendulum going back and forth.

What is the role of ED physician users in demonstrating meaningful use for hospitals? Have you figured that out?

I don’t think anybody’s figured that out. It’s still very ambiguous. The whole role of emergency medicine in meaningful use, in my opinion, is not clearly defined. They came out with the interim final report, same as last year, and it really doesn’t specifically address anything about the emergency department.

For that matter, it doesn’t even really address what individual vendors are supposed to be able to do. It really addresses what the hospital is supposed to do, and then what the private physicians are supposed to do.

Where we have some general idea of what the hospitals are required to do as an institution, I don’t really see much direction in terms of how they have to accomplish that. Which is really a good thing, because at least so far, it seems like they’re free to accomplish those overall goals in whatever manner they see fit. They could accomplish those goals with multiple niche vendors, or if they want to accomplish those goals with a single-vendor solution, they can try to go at it either way, providing that those vendors they choose are ultimately certified.

Of course, Wellsoft’s been certified since 2008 for CCHIT, but even the certification process still needs to be clarified further. Right now, the only thing that’s clear is that CCHIT will be a certifying agency, but there may or may not be others that are approved over the next years.

The typical cases cited in interoperability discussions always involve an unconscious ED patient. Is that a common real-life occurrence?

I’m not sure that the question is correct. An unconscious ED patient certainly is a common scenario that we’re asked to walk through as a demo process. There are certainly a large number of unconscious ED patients that show up, so I think it’s imperative that any EDIS be able to handle that situation.

But in terms of interoperability, the only thing that immediately comes to my mind is the idea of getting their previous meds and allergy list from an outside system. That’s one thing, but there’s a lot more to interoperability than that.

So to answer your question a little bit more directly, we have a multitude of different mechanisms by which we can enter a patient into the system that have either no identifying information, such as typically in a trauma patient, or somebody who has a limited amount of identifying information, perhaps a driver’s license.

The idea is you get them into the system and then you start working on them and doing what you need to do. Getting prior lists of meds and allergies, I can tell you as an ER physician, typically someone knows something … usually a spouse or a relative, or somebody with the patient. But in case there’s not, it would be useful if you happen to see a driver’s license, if nothing else, with a trauma patient, then you would of course want to pull the meds and allergies from any other system that might have it.

There’s two ways to do that, currently. One is to pull it up in Wellsoft, assuming you have a driver’s license with just the name. You can pull up any previous information that’s been entered into Wellsoft, and all of our sites support that currently. Secondarily, you can pull medications from other systems.

For example, we have a site at CentraState where we went live last month with a medication reconciliation process by which the outside system sends a Wellsoft medication list; it is modified inside Wellsoft; and at the end of the visit, we send it back to the central repositories. That’s a very rapid development in integration. We are spending a lot of time and energy in our R&D right now, expanding those kinds of functionalities.

Is that clear as mud?

Clear as mud, yes. I may have misunderstood what you said on this, but you said if the patient has been seen in Wellsoft. Is that any Wellsoft system or just the one in that particular facility?

Good question. That would be any Wellsoft system that is part of that hospital enterprise if it’s a hospital system, but it certainly wouldn’t be a Wellsoft system on the other side of the country.

Got it. You’re involved with several HIT standards groups. What developments are you seeing there and what remains to be done?

As you may or may not know, we have one of our VPs actually on the CCHIT EDIS group that helps define the CCHIT standards for EDIS certification. I don’t know how much you want me to go into it, but currently things are a little … let’s stay positive here. It appears that the whole certification process is at a stage of sort of reorganization and I don’t think it’s especially clear right now exactly how the details are going to fall out.

It’s a very challenging task, both technically and politically. CCHIT is, in my opinion, scrambling to reconfigure their certification process to conform with the interim final regs released at the end of last month. There are a lot of decisions that haven’t been made yet, let’s just put it that way.

I don’t think anybody really has a good handle on how all that’s going to fall out. But one thing you can say with a fair degree of certainty is that CCHIT will remain as, if not “the” certification agency, certainly one of the main certification agencies.

What’s it like going from being a practicing physician to being a CEO of a software company?

It’s different. I shifted gears for a couple reasons. One is I love technology and I love gadgets and software. The main reason is I love to take something and make it work better.

Practicing in emergency rooms, I just saw a lot of opportunity to help improve patient care and improve the practice of medicine. That was a very strong motivator for me to want to develop software; be involved with software development that takes a good functioning system and makes it a really great system, being the emergency department.

The challenges are certainly different. When you’re running a business, you’re never off duty. When you’re working an emergency department, at least at the end of the shift when you finish all your paperwork and you go home, you have a reasonable degree of certainty that you’re off duty. You’re always on. I’m a bit of a workaholic and work a lot of weekends and am very engaged in the process of product development here at the company.

It’s a lot of fun, a lot of great people here, a lot of challenging work. I think we’re blessed with the opportunity to make a really significant impact in the emergency departments that we work in. Both jobs are very exciting. Working as an ER physician is an exciting job. You get a real hands-on, minute-to-minute feeling like you’re making a difference. Working in a company like Wellsoft, I get a lot of the same feelings; they’re just bigger. I have an opportunity to impact more places more of the time.

What’s the average ED going to look like in ten years?

That’s a great question. I’ve been answering that for 15 years now. I think in ten years, every ED is going to have some kind of an EDIS. Or, I would say 80-90% of EDs will have some kind of an EDIS. I think care will be done more efficiently. I think systems will be better connected, and overall, patients will get better care. I’m very optimistic about the future and healthcare.

Notwithstanding all the political wrangling that’s going on now, I think that in terms of the actual administration of care in the emergency department, I think it will continue to improve. I think that the emergency department is a place that, as a rule, is filled with really hard-working, dedicated people that honestly want to see the best outcome for the patients.

I think if they’re given the tools that enable them to do that effectively, that they will recognize and grab onto those tools and do the job as best they can. They don’t always have the tools. There are often obstacles and problems and politics that get in the way, but if the political obstacles can be improved at both a local level and a national level, then I think the future looks very bright for emergency medicine.

HIStalk Interviews Cameron Powell

William Cameron Powell, MD is president, chief medical officer, and co-founder of AirStrip Technologies of San Antonio, TX.

Tell me about yourself and about the company.

My name is Cameron Powell. I’m actually an OB/GYN physician by training. I don’t practice any more; I haven’t for about two years. I currently serve as the president and chief medical officer of AirStrip Technologies.

We are a medical software development company that is completely focused on remote patient monitoring and telehealth, with a focus on mobility, primarily in our niche capabilities and technologies to deliver a real-time historical waveform information to physicians and nurses anytime, anywhere, on mobile devices like the iPhone, Blackberry, and mobile Google Android.

The company was actually founded about six years ago. We think we really started this past June when Apple chose to feature AirStrip during the Worldwide Developers Conference in their keynote address. Things really changed for us at that time.

Six years ago, we had a focus on trying to develop a technology that would clearly work to mitigate risk and improve patient safety and improve communication between physicians and nurses when physicians are temporarily away from the caregiver environment. Given my background in obstetrics, we started with the AirStrip OB product.

Tell me about the components of AirStrip Observer.

The AirStrip Observer suite is really built off of a platform referred to as AirStrip RPM or Remote Patient Monitoring. AirStrip OB was the first product that was built off of that platform. That platform is basically a completely reusable and scalable software platform that we spent many, many years developing, which allows us to very rapidly roll out additional mobility solutions.

AirStrip OB is actually the first FDA-cleared solution build off of the RPM platform, but we have additional solutions that we’re awaiting FDA clearance and have already been submitted. Those are the AirStrip Critical Care and AirStrip Cardiology products that are currently submitted to the FDA.

We have several other products that are currently in our pipeline that are being built off of that RPM or Remote Patient Monitoring platform that we developed.

How hard is it to get FDA approval?

It’s challenging. We certainly don’t mind that challenge from a competitive standpoint.

The thing that we like about FDA clearance is it really forces us to maintain a level of quality and control around our software designs that ensures that our hospitals and our physicians, as our end users, benefit from just a great solution that has a great user interface, is HIPAA compliant, and is very secure. But to get FDA clearance, you do have to know what you’re doing. You have to have the right people involved. So it’s challenging, but I will say the FDA’s been a very good group to work with.

Can you tell me more about the actual technology and what kind of folks you have to maintain and develop on it?

We do all of our development in-house. My senior partner, Trey Moore, is actually our CTO, and he is the lead architect behind the entire platform. He is supported by a team of in-house software developers that have really built out the rest of our platform and help us to support all the different mobile devices and the interfaces to various HIS vendors or CIS vendors that are required to operate the solution.

Our application works by interfacing to various vendors or device manufacturers. There are several different architectural formats, but essentially, there’s a system in the hospital that’s pulling that data real time and then securely exposing it through the Internet to our mobile client. I think where our real uniqueness is in how we handle the presentation and the user experience behind the waveform data; the ability to see and interact dynamically with virtual, real-time waveforms, to be able to scroll back over time and pinch and zoom and analyze those waveforms.

One thing that’s important to realize in healthcare, especially with the problems that we’re trying to solve, is that so many decisions are made based off of visual interpretation of data, especially with obstetrics. For example, a vast majority of adverse outcomes in labor and delivery are directly related to communication errors involving the fetal strip, or the fetal heart tracing. So the ability to close that communication gap and deliver that real-time historic data to the physician anytime, anywhere, we think will have a significant impact on patient safety.

The reality is we live in a world where there’s a relatively decreasing number of physicians and an increasing number of patients that need to be monitored. Anything we can do from a technological standpoint to allow physicians to be able to adequately monitor these patients makes a huge difference. We’re in nearly 150 hospitals right now across the U.S. with AirStrip OB and are beginning our international efforts with several large partners.

It’s great in the field of obstetrics to go to trade shows, to go to hospitals, and the physicians and the risk managers and the executives. They all know about AirStrip OB and they’re asking about it. That’s been very rewarding for us. If you look on our Web site, I think one other thing that’s really rewarding is just the enormous volume of unsolicited emails and stories we get from doctors that tell us how AirStrip OB is making a significant difference in their lives, and especially in the lives of the patients they care for.

We’re seeing large hospital systems actually create their own videos about AirStrip OB and promote them on YouTube and through other social networking efforts in the markets, to patients where doctors are talking about how great the technology is. That’s also quite rewarding for us to see that kind of take off in sort of a viral nature.

Do you see the boundary of your product being those applications that involve waveform data, or do you see yourself advancing beyond that at some point?

Oh no, not at all. Currently, if you look at the AirStrip OB product even just at its base technology, when a physician logs on …  First of all, no data’s ever stored on the device, it’s just available during the view session, but they’re able to see the labor and delivery census; the patient name, the cervical exam status, the most recent blood pressures, the admitting diagnosis, and vital signs. They can then drill in further and review all the nursing notes, they can look at medications, they can look at trended data, and then all the waveform data. 

Currently, we present a voluminous but focused amount of data to the obstetrician. When you get into the Critical Care and Cardiology applications, we also provide a whole host of patient monitoring data beyond the waveforms.

Now with the platform, the platform also allows us to pretty rapidly extend this technology to encompass imaging solutions, solutions outside of the hospital. For example, there’s a lot of interest right now in AirStrip with regards to what we can deliver on the ambulatory cardiology front, and in the home health monitoring front. 

We built our solution to truly be data independent. We don’t really care what the data is as long as we have access to the data through our partners or vendors / device manufacturers that we’re able to effectively AirStrip that data in the back end and expose it to the mobile client, really, in a way that hasn’t been done before.

Do you think it will be competitively important to be the one-size-fits-all single solution for doctors, or do you think there can be several niche applications that doctors run separately?

I think there’ll be niche applications, but we think from the broader remote patient monitoring standpoint, I think a single solution that would apply to everybody is very likely. Our idea is that our client changes dynamically depending on who the physician is logging onto the system. We eventually envision the obstetrician logging on to the client and they’re presented with what they have access to in labor and delivery; whereas the intensivist or the neurosurgeon logs on and they’re presented with the information they want to see in the ICU.

In the L&D market where you started, there probably wasn’t much competition when you started it. Do you think once you get into the cardiology and critical care modules that you’ll be competing against a broader array of competitors and also have to figure out how to transition the company into a whole different target market?

Certainly we’re not naïve enough to think that we’re not going to have legitimate competition, but the reality is what we’re really focused on is being first to market and continuing to advance our first mover advantage, from a software standpoint and a UI standpoint, try and stay several years ahead of the curve. I think we’ve done a good job at that and that’s our focus is to try and just stay out in front and continually iterate, continually innovate, listen to our customers, listen to our physicians.

One thing that’s nice about our development team and our development platform is that we can very rapidly iterate and make changes and dynamically adjust to what the market’s demanding, rather than going through traditional software development life cycles that require extensive rewrites. We have some proprietary technology that allows us to do that and adapt.

You’ve also got an advantage in that you have a big footprint in a small segment of healthcare, which I assume then can fund the development and also provide the experience to move outward as opposed to trying to develop the whole package and then sell it to the world.

Yes, sir. Our focus was if we can deliver a solution to the market that works really well that is fast, that is secure, that the doctor is able to use with relative ease that has … For example, even just delivering a solution that can be installed quickly. I mean, a lot of our installations can take a day or two at the most and most of them are done remotely, so it’s not like installing an entire HIS system in a hospital.

We knew if we could deliver something like that to the market from end to end, from the requirements of the hospital IT staff to the CIO, to how hard is it for a doctor to get logged on, to managing all that — if we could deliver all that and do a really good job of it with AirStrip OB, that we would be 80% done with every other solution that we ever wanted to create. Reusing and repurposing what we developed, that’s how it was architected from the very beginning.

Was the plan up front to do more than just L&D?

Yes. We had some very good senior executive guidance that forced us to put the blinders on and really focus on delivering AirStrip OB to the market first, and doing a really good job.

I think where some people fail … they’re tempted to go down every rabbit trail that’s presented to them. It’s really hard to maintain focus to get that last 5-10% done and to really do it right. We had some really good guidance and help along the way that coached us in how to do this just from a philosophical standpoint. It’s probably one of the best decisions we ever made, was to make sure we did AirStrip OB and did it right and made it available to anybody who wanted it.

I have seen the throughput from our company as we roll out these additional applications. It’s just been incredible to watch. I’m so proud of my team and my developers and everybody that I get to work with, to see them have such success as they’re having now. Really, they’re standing on the shoulders of a giant, Trey Moore, who knew from the very beginning that if this was architected in the right way and done correctly, and learning from mistakes he had seen other companies make in his previous career, that we would be able to do this some way. I’m now seeing that come to fruition and it’s really humbling actually, to work with such a great team.

How hard is the integration piece for hospitals to accomplish?

From the OB standpoint, fairly easy, because once we go to the hospital, we’ve already had that integration done with the perinatal vendor.

We have good relationships with almost all the perinatal vendors in the U.S. So if a hospital has any perinatal system — let’s just say it’s the Hill-Rom NaviCare WatchChild system — we can go and tell the hospital that, “You know what? We have an interface. The NaviCare WatchChild, it will handle it all for you. We’ll install the server, or we’ll virtualize it, or we’ll host part of it. The vendor will remotely install their piece, and we will remotely install our piece, and it’s very little required from your IT staff.” That’s one thing that the hospitals, I think, really, really like.

You definitely run into different environments, but from the OB standpoint, it’s pretty straightforward. For the Critical Care/Cardiology solutions, of course we’re not installed anywhere yet, but as those roll out of the FDA we have our beta site that’s already lined up and we will try and replicate the success that we’ve had with AirStrip OB.

Certainly, I think we’ll learn along the way, but we have some really strong partnerships with some great vendors and device manufacturers. They’ve been really great to work with. We think that makes it a lot easier on the hospitals if you can go in and present to them a solution that works, and it’s a breath of fresh air for them to install an AirStrip system.

How is the product licensed and hosted?

Currently, it’s a Software-as-a-Service model; a hybrid software and service model. Currently, the application server resides on site at the hospital. There have been some very large IDNs that will host the Web server component at a central location. That Web server will serve all the hospitals in that IDN around the country. We also virtualize so the hospitals are installed in a virtual environment.

As far as a fully hosted solution, that is definitely something that we’re looking to move towards. With some of our partners, that’s how it’s being designed from the beginning. But it is a subscription model — a hospital, they will pay a certain amount per physician, per month or per bed, per month depending on the product and size of the hospital, the number of physicians, and whether or not they belong to a GPO. There are a lot of different variables.

I think you mentioned earlier that you have applications for other caregivers, like nurses.

We currently have a lot of interest from nurses right now using AirStrip OB, but using it in a hospital. For example, a charge nurse who’s responsible for all of her nurses. Or, she may be in the middle of a C-section, or in a meeting, and she wants to keep track of what’s happening in labor and delivery. She can also use AirStrip OB even though she’s actually in the hospital.

But yes, we see a broader remote patient monitoring-based solutions being able to be used by a variety of healthcare givers in a variety of settings. Right now, the focus is really on physicians and nurses, but I could clearly see applications beyond that scope as we expand. I think those markets and those needs; some are already making themselves available to us just from a recognition standpoint, so we’re certainly interested in providing the technology wherever it’s useful.

I saw on the Web page that the application supports a ton of mobile devices. Which ones are the most popular?

Well, the most popular right now is the iPhone, but we also see markets where there’s a lot of strong demand from BlackBerry users, and some strong demand from Windows Mobile users. Our goal is not to be necessarily focused on the device, but to remain device agnostic. The reality is the market demands change and at this point and time, a large majority of our users are iPhone users.

Mobile applications, in general, improve the quality of life for providers. What’s the impact been for your users, and what opportunities do you see there in the future?

Honestly, because of our regulatory requirements and the nature of our application, we’re not really so much focused on the quality of life of a physician. The reality is where AirStrip becomes most useful, is when the demands of a physician’s day necessitate their periodic absence from the bedside. We’re not trying to ever keep a physician from the bedside.

However, the reality is that there are several times, and often, when a physician has to be away from the bedside. They may be at another hospital, they may be at the surgery center, they may be on call. In those instances, currently they’re limited to having to listen to an interpretation of what is going on over the phone. If they’re away from the hospital, we just want to be able to provide them with this data virtually in real time so they can better assess a situation.

I think, from a quality of life standpoint, that mainly helps them have peace of mind knowing that they’re looking at the same data that a nurse is looking at; and therefore, until they can get back to the hospital, they can more clearly understand the situation and hopefully, it provides a meaningful advice in the interim.

Now, do doctors tell us this does dramatically improve their overall quality of life having this access to this information? Yes, absolutely.

Where do you see the company going, strategically, over the next few years?

We really want to set the standard of care, both domestically and internationally, for remote surveillance from a mobility standpoint — for remote surveillance in healthcare. We currently are relatively agnostic to the market. We want to raise the bar as far as remote surveillance goes. We see ourselves helping to establish that standard of care.

Do you see that happening under the current business form, or do you see either being acquired or acquiring someone else?

I don’t really want to speculate on those types of events. Currently, we’re in a high-growth mode; really growing the company to make sure that we deliver the best technology that we can possibly deliver to both our doctors, who are the end users; and the patients, who quite frankly, deserve the technology. In that effort towards growth, certainly there are a lot of different things that could happen to a company like ours. We remain focused on growing the company, but also keep an open mind as to what might come.

Monday Morning Update 2/22/10

From Luke O’Voron: “Re: Privacy and Security Standards Workgroup. Their meetings are now open to anyone by teleconference. This week, Judy Faulkner of Epic was in fine form, defending her 30-year-old product as the only way to go. Look for transcripts.” They haven’t been posted yet, but I’m watching for them.

From All Hat No Cattle: “Re: Looks like HIStalk is now a source of news! Congratulations.” Healthcare IT News has been openly scornful of HIStalk in the past (“a sorry commentary on journalism today”), so I’m not sure how I feel about having them cite HIStalk (I know it didn’t result in many incoming hits). I don’t claim to be a journalist, so I likewise assume nobody there claims to be a healthcare IT expert. I sometimes glance at it during the more boring educational sessions at HIMSS, especially since early print deadlines mean I can read what the keynoters will say before their sessions are even held, making me feel temporarily psychic and opening up the possibility of a “Dewey Defeats Truman” collector’s edition if the speaker would happen to cancel or go off script with an unplanned rant.

From Kiley: “Re: CEO. You should check out this guy’s past. Nobody seems to question his background when he’s speaking or writing.” We’re on journalistic thin ice here, even for a non-journalism major. I did some extensive Googling and it seems the individual named recently pled guilty to big-time federal income tax fraud. I got copies of the court records, but received no response when I sent details (twice) to the organization’s PR e-mail address and asked for confirmation. I can’t decide if that’s fair game or not, although I’m leaning toward no.

Long-range weather forecasts are notoriously inaccurate, but the Atlanta 10-day version predicts highs in the lower 50s for the start of HIMSS. If it’s not too cloudy, that should be pretty nice, especially compared to Chicago last year (or Chicago right now – snow and highs in the 30s).

Looks like Sully’s HIMSS audience will be about the same size as when he made that “we’re going down in the Hudson” PA announcement, with 88% of us planning to be long gone from Atlanta by the time he hits the podium on Thursday. New poll to your right: given the government’s track record in fulfilling its financial promises to providers, do you think ARRA money will be paid as stated?

Listening: Crucified Barbara. Sometimes you just need beautiful, non-English speaking Swedish women playing nasty biker metal hard rock.

Inga asked our BFF Tammi from AT&T a reader’s question about iPhone presentations at HIMSS, of which there are basically none on the education track since annual conference proposals are due nearly a full year before the conference (it’s ludicrous to be paying to sit through year-old presentations just because HIMSS can’t shorten its lead time, but that’s always been the case – this year’s sessions were finalized by May 29, 2009). Anyway, she mysteriously suggests dropping by the AT&T booth to check out “exciting developments.”

Thanks to MedVentive for supporting HIStalk as a Platinum Sponsor. The Waltham, MA-based company provides a wide range of solutions that include pay-for-performance systems, registries, evidence-based algorithms for quality management, point-of-care decision support for physicians that integrates information in its repository with claims data, managed care tools, and scorecards and provider profiling for payers. It was started by CareGroup and BIDMC in1997, expanded for a broader audience as MedVentive in 2005. If you want to connect with their folks at HIMSS, shoot them an e-mail. I appreciate their support.

Inga has been working her pretty fingers to the bone getting ready for HIMSS. Somehow she found time to prepare this guide to what our HIStalk sponsors will be doing at HIMSS, complete with booth and contact information, a description of their products and services, and their message to you about their HIMSS activities (including some giveaways, charitable projects, and the all-important snacking opportunities). You can download a PDF version to print and take to Atlanta if you like. If you enjoy HIStalk or benefit from it, please click their ads, check out their HIMSS activities, and drop by their booths and say thanks. We have some super-nice people and companies who are fans of HIStalk, which we as amateurs with day jobs sure do appreciate.

I don’t know about your hospital, but mine is packed to the gills. It’s a good thing flu activity was a lot less than expected or we would be having patients sleeping in the hall instead of just the ED holding area.

England’s Accountancy and Actuarial Discipline Board will conduct hearings this week on an accountant for iSoft Group, whose former executives are themselves are the subject of an investigation related to accounting irregularities alleged to have occurred from 2003 until 2006.

Former RelayHealth VP Bob Katter joins First DataBank as VP of sales and marketing.

The Racine paper weighs in on the EMR implementation at Wheaton Franciscan-All Saints (IL), saying some doctors anonymously told reporters that its $67 million McKesson Horizon Clinicals implementation is “one of the cheapest, worst systems available.” The docs complain that Wheaton spent nearly as much as nearby Froedtert, which installed #1 KLAS-ranked Epic for $70 million. The hospital defends itself, saying its McKesson system (#7 ranked in KLAS, the paper says) is comparable to Epic and the #12 ranked Cerner system that another nearby hospital bought, neither of which had extensive problems (actually, that sounds to me like they defended their vendor pretty well, but themselves not so well). Since the hospital and its doctors were already fighting about unrelated issues, I’d take anything said there with a grain of salt. Other places run Horizon Clinicals just fine.

Strange: why is the non-profit Cleveland Clinic buying Google ads to brag on its technology and IT people on its own EMR site? This ad came up when I Googled “healthcare technology.” 

I’ve mostly quit reporting on government HIT handouts, you may have noticed. Truth be told, it makes me sick to my stomach to read, much less write, about all those undisciplined politicians bragging to the locals about how great it is they managed to snare taxpayer money to pay for local projects. Enjoy the economic party because it can’t last; the generations-long hangover is going to be brutal.

The Louis Stokes Cleveland VA Medical Center (OH), concerned about medical residents who clutter up the EMR with copied-and-pasted information, audits the notes of first-year residents and gives movie tickets to the best one. The newspaper article quotes a journal article: “The copy-and-paste function has led to a number of unexpected problems and concerns about electronic note writing and its impact on the culture of medicine, including reducing the credibility of the recorded findings, clouding clinical thinking, limiting proper coding and robbing the chart of its narrative flow and function.”

Facing a threatened libel countersuit, GE Healthcare drops its libel lawsuit against a Danish radiologist who had shared research findings unflattering to one of GE Healthcare’s contrast agents at a medical conference. The suit was featured Tuesday in The Globe and Mail in an article called London, sue capital of the world, describing “libel tourism” in which suits involving no English parties are tried there, mostly because unlike in the US, the burden of proof rests on the defendant and a libel defense costs 140 times anywhere else in Europe, leading to pocket-lining settlements for lawyers. At stake: self-imposed medical censorship, such as the Danish radiologist, who says, “I am not giving lectures any more in the U.K., where it seems you can be sued for telling the truth.” I liked this quote: “It’s acutely embarrassing for the government that various American states have passed laws to protect their citizens from English libel law.”

WebMD finds itself on the wrong side of Senator Chuck Grassley, who wants to know why the company’s TV ads pitch a pharma-sponsored depression screening test while it claims to provide objective medical information to consumers. WebMD claims editorial independence, but the Senator wants it to provide details on its drug company connections. Chuck’s all over the place, but I usually like his choice of targets.

Bizarre: the FBI gets involved in the case of a Pennsylvania school system that remotely activated the webcams of school-issued Apple laptops used by students. The school supposedly accused a student of selling drugs, providing as evidence a photo snapped by his school laptop from inside his house. The school claims the webcams were used only to recover laptops that had been stolen.

E-mail me.

HIStalk Interviews Kipp Lassetter and Robert Connely

James K. Lassetter, MD is chairman and CEO and Robert Connely is senior vice president of Medicity of Salt Lake City, UT.

  

What caused the dissolution of CalRHIO and what are the prospects are for the new group?

(KL) It’s really pretty straightforward. A lot has been made of it, but the reality is that CalRHIO was formed at a time when there wasn’t any federal funding. The mission that CalRHIO was working on was how to create a fully connected California. A big part of that was how they could build a sustainability model.

They woke up one morning in the spring to the announcement that the states were going to get funding to do HIE activities. CalRHIO’s business model was such that it would have had to be the SDE, State Designated Entity. They competed in that process. You can imagine that there was a lot of politics involved.

The state decided that they were going to form a new entity. At that point, it was a simple decision that CalRHIO would fold itself into that new entity. That’s the reality of what happened.

Technically, there was no purpose in keeping a staff on for an HIE model that wasn’t going to be deployed. The board remains intact and continues to meet. In fact, CalRHIO recently won the second largest Social Security Administration grant and has retained consultants to roll that out. We’re the participating vendor in that grant.

The whole concept that CalRHIO folded and went away makes for good blog content — not referring to your blog, of course. It really doesn’t reflect reality at all.

What’s Medicity’s role going forward with the new group?

(KL) The new group is moving forward. It’s essentially in the formation phase. We expect some announcements out of the state fairly soon. We anticipate that they will go to vendor selection. We hope to have a very good shot at that relationship.

It must be frustrating to have to win the business all over again.

(KL) When the funding came out for the state, we knew it was going to be good news/bad news. You go to bed playing football and you wake up and realize it’s now baseball and you look a little funny out on the field in your football uniform. [laughs]

Because there was no funding out there, if you wanted to be a sustainable HIE, you had to build a business model. CalRHIO had developed what I thought was a very innovative and substantive business model that was endorsed by CalPERS. Many of the largest health plans in California had looked at it and validated it. They were the ones being asked to fund the HIE because it was speculated that they would derive the biggest benefit from reduced utilization, thereby lowering medical cost.

We had RAND involved, Mercer, Watson Wyatt, and CalPERS as one of the largest purchasers of healthcare services in the country, many of the largest payers that have a national footprint. All were engaged and supportive of the model. However, when the federal government came out with the funding, then the game changed.

The business model as laid out by CalRHIO had a focus on bringing information as a starting point to the emergency room, where you have the highest acuity meeting the lowest amount of information. If you were to look at the one point in the healthcare ecosystem where information will have the biggest impact on both cost and quality of care, I think everyone would agree that the ED is ground zero. That was picked as the first point because the information could have the highest impact in lowering the cost of care. That was certainly something the health plans were very interested in as being a starting point.

With the funding, it was much more about pushing HIE for broad physician meaningful use adoption. There’s a significant shift in the first phase. The big problem right now is the states are going to go out and pick a vendor and deploy. Unless they’ve thought through a sustainability model, these are going to be a lot of bridges to nowhere.

Are business models still important or are people forgetting that fact?

(KL) Business models are absolutely still important because the federal government has given no indication that there is going to be a continuity of funding. What’s happened is that it’s taking a back seat. Before the funding became available, all the entities had to focus on how they would get started. Now they know how they can get started, but what many of them have not yet figured out is how they can remain functional.

Is it easy to get the money but then have to figure it out later?

(KL) Everyone is in different phases. There are people in the planning phase, people that are in an operational phase. The ones we work with emphasize building a sustainability model. I can’t speak to the ones we haven’t seen, but I know that some are very focused on that.

If you look at the big picture of where the federal government is spending money on interoperability and the Nationwide Health Information Network, how would you describe where the money is going and what means to the industry and your business?

(KL) There’s a broad picture. If you look at the first phase of meaningful use, there’s a real emphasis on getting the physicians prepared to exchange data. Simultaneous to that, they’re trying to get the infrastructure in place so they can exchange data.

While the meaningful use requirements for information exchange are coming later in the process, the government knows that these infrastructures can’t be built overnight. They need to begin in earnest right now to be building the infrastructure capable of exchanging that data.

There’s a lot of innovation going on, and I think we’re in the middle of a lot of it, that should have an impact on changing that paradigm. The money specifically is being distributed to the states for both planning and operation of all different flavors of HIE. When you talk to the states, it’s lot like the fable of six blind men and an elephant — depending on whether they felt the trunk or the tail or the side, it was a tree, a rope, or a wall. There’s still a lack of consolidation around the concept of what an HIE really is. A lot of that came through in the recent KLAS report.

How would you characterize the difference between an HIE and a RHIO in contemporary terms?

(KL) There’s a verb HIE, which is the act of exchanging clinical information. There’s a noun HIE where you are an entity that is trying to create the functionality or the action of exchanging information. A lot of people do health information exchange without an HIE or RHIO.

It really is the difference between talking about the noun, an entity that’s called a health information exchange, or the actual action of health information exchange where you move clinical data between one provider and another.

Obviously, you don’t necessarily need a third party. Many of our clients are hospitals doing health information exchange with their affiliated physicians. Many of these are rural areas, where there are not competing hospitals. De facto, it becomes a full community exchange without the need for a third party body to mediate that.

Where does Epic’s private exchange among its users fit in?

(KL) It is a special class or consideration. If two entities are sharing the same technology platform, then it would seem fairly straightforward to exchange that data. Unless those facilities are juxtaposed to each other in a geographical sense, I don’t see the real value in it, but if two facilities are across the street from each other and full Epic shops, then clearly it seems to make sense for them to exchange data.

(RC) One of our bigger efforts across the country is to integrate HIEs and sub-HIEs, small HIEs, and it’s amazing how many of them we are connecting to. Epic’s going to be another life form that is out there. I think we’ll be interconnecting them.

It will kind of resemble the Internet in the end — networks are not nice and pure and harmonious, but they do move data back and forth. I think you can only go so far. Once they reach the edge, even they are getting involved in standards-based exchange. So, they’re part of it. It’s not a model that scales.

Are you seeing new market entrants with all this money flowing in?

(KL) We have a joke — the HIE costumes are flying off the Halloween store shelves. Before there was federal funding, there were few true HIE vendors out there. Now, anyone who’s ever moved a lab result electronically is an HIE vendor. Or for that matter, anyone who has exposed eligibility or done claims processing is now an HIE vendor.

Tell me about the patent for the Medicity Novo Grid.

(RC) It was a patent to move data in a different way, in a distributed fashion, how we create these linked objects that can move data from Point A to Point B and keep the level of synchronicity. It’s actually the core technology around a new platform that we’re introducing at HIMSS called iNexx.

It gave us that architectural underpinning that we can build a massive amount of business on without having to worry about patent trolls coming along and taking it away. We have that core architecture that we’re building the next generation product set on, how we can share information and built systems on top of that open platform.

Where does iNexx fit?

(KL) We believe we have the largest HIE platform deployed in the US and I think the KLAS report substantiates that. We decided to open it up to third-party development. We think this is a really bold move because it allows many different applications to share the same connectivity into a physician’s office, whether it’s demographics or connectivity to the practice management system or clinical CCD connectivity to the EMR system, and it’s bi-directional.

Typically those connections serve one application. Typically they’ve served our infrastructure, but by opening it up, it becomes plug-and-play. We’re taking a page out of the iPhone playbook and exposing an application store, but these applications are certified to safely and securely run on the platform, can be downloaded … there may be three or four e-prescribing solutions. There may be many different components that are together.

One of the big victories we felt we won was when the meaningful use criteria came out and allowed for a modular approach as opposed to a monolithic application. Different vendors can participate and create the modules that in totality allow the eligible provider to qualify for meaningful use, which we believe is a big paradigm shift. We’re calling it, for a lot of reasons, the first Health 4.0 platform.

(RC) Health 1.0 is about content, Health 2.0 about community, Health 3.0 about commerce, and then Health 4.0 about coherence. This is where we tie it back around the patent we got.

What that patent allows us to do is to create a different type of record, a linked object, that we can distribute across the community and tie it together. Everybody has a copy of it and can see what others do. The patient can even be involved in this exchange. In fact, we’re about to undergo some projects in California that bring patients into this shared record that the care team can maintain and conduct business across. It’s a private social network, if you will.

That new thing where we’re tying everything together as Kipp described earlier, bringing in data from the PM systems and the EMRs, from the hospital distribution of things from reference labs … all this data coming together and then shared in a coherent fashion between the various care team members and the patient at the center of this universe. Because this whole platform is structured that way, it’s not a relational database. It’s really designed for distributed object community.

It’s a new approach. The whole concept behind the platform is the way it manages information exchange, making that a natural part of the data structure, not an add-on interface. It’s built at the core. We believe we can bring it to market at a very low price that is a disruptive innovation.

(KL) The iNexx platform creates a virtual, Kaiser-type infrastructure. Historically, to do that full bricks and mortar IDN, everyone needs to be under the same ownership and practices are owned and insurance companies, hospitals, etc. This model allows organizations and affiliated physicians that are not part of the same entity but work together in related health plans to collaborate on a platform and in effect, create a high level of collaborative and coordinated care, much like what happens in the top IDNs across America.

We think the technology has gotten to the point where you don’t necessarily require single equity ownership across an entire IDN. Unrelated entities can collaborate around a single patient and achieve similar results.

From a physician’s perspective, one of the very powerful things about the iNexx platform is that when I bring a patient in view, I have a lot of different applications that could be exposed by many different vendors that I can use to perform actions, such as e-prescribing. Running in real time and next to that view of the patient in focus is a real-time view of activities going on by the care team of that patient that are all on the grid. Whatever lab results, whatever pending actions are on that patient by other practitioners and other specialists, I have that view. That is, from a physician who used to practice, some of the most useful and helpful information you could put in front of a doctor.

We’re in the middle of healthcare reform and a real pressure to lower the cost of care. The average cost of care per capita in the US right now is around $8,000. As the US looks outside the country for models to emulate, when you look inside the US, there’s a massive disparity in spending and quality indicators between the different regions within the United States. If you were to look at California, most people would intuitively say that California’s cost per capita is higher than the national average. The reality is that it’s much lower.

One of the contributing factors is what some people call the Kaiser Effect, which is that highly coordinated, collaborative care IDN. In order to compete against Kaiser, you have a unique delivery model mostly unique to California where you have IPAs that are doing risk contracting, functioning at a higher level of coordination of care, contributing to the net effect of a much lower cost of healthcare per capita than the national average.

If you look at the states that have the lowest per capita cost and the highest quality indicators, it’s the state of Utah. Besides the fact that there are other contributing social factors, that’s also the effect of the IHC network and the dominance of that network in Utah. We believe this infrastructure can create virtual IDN infrastructures that allow that same collaboration and coordination of care. That’s a high-level macroeconomic look at what we’re trying to achieve within the company.

What was your reaction to the KLAS HIE report?

(KL) I think it’s a reasonable start. I don’t think any one vendor is probably completely satisfied with how they got presented.

Obviously we feel we came out of the KLAS report very well. We’re very happy with how we came out. We obviously don’t feel the full scope of what we’re doing or how we’re doing it was represented in that report, but I don’t think that’s unique to us.

The market is moving so quickly that they probably ought to generate one of those reports every other month. With all the federal funding coming in, there’s so much changing. From the time that report got printed, in our opinion, it was way outdated.

What will interoperability look like in five years?

(RC) I personally think it will change significantly, that the technologies that we and others I’m sure are working on will negate some of the higher cost elements of putting together HIEs. EMRs will evolve from the state of recording everything a physician does to get more inserted into the collaborative areas.

I think HIEs will evolve to a Google-like search engine. I think with the technology and the focus on nursing and staffing being more coordinated is going to have a big impact. It’s not really coming from the government as I think the private sector that’s putting the pieces together. The money’s going to just chum up the water for a while.

I believe we’re going to evolve to another state and it’s going to be much simpler, much more distributed, and much more organized. I think the future will be much more Internet-like than the large, monolithic architecture they’re trying to assemble today.

HIStalk Interviews Tom Yackel

Thomas R. Yackel, MD, MPH, MS is chief health information officer at Oregon Health & Science University in Portland, OR.

Tell me about your background and what you do.

I’m a general internist by training. I continue to practice outpatient and inpatient medicine about 30% of my time, but 70% is in a relatively new position here at OHSU called chief health information officer.

I started out at informatics. I actually came out to Oregon to do a fellowship with Bill Hersh in medical informatics, one of the National Library of Medicine fellowships. Did that for two years, got a master’s degree, and then was lucky enough to stay on at OHSU.

At the time, we really weren’t doing too much in health IT. We had Siemens Lifetime Clinical Record, we had a scanning system, and so we had a pretty good repository, but we weren’t doing any CPOE or anything really challenging or interactive.

After I was here for about two years, the medical group got interested in EMRs when they were building a new building and realized that record rooms would cost too much per square foot. That really kicked off our adventure into enterprise electronic health records.

I guess six years or so later, here we are and we have an almost fully-deployed enterprise electronic health record and the full suite of Epic applications; including e-prescribing and MyChart, and rolling this out to affiliates and all the billing and scheduling and good stuff that goes with it. Reporting, too. It’s just been kind of a neat and fun ride.

How important do you think it is for your credibility that you continue to practice medicine?

I think it’s important for a lot of reasons. Credibility, I think, is one thing, just in terms of making contacts with people outside of the context of the EHR is super helpful to me. Having some people actually come to me as their patients, who I also work with, is kind of an honor and something neat.

I don’t know how other people do this if they don’t actually use the system that they work with, but I would have to spend a lot of time learning a lot of details that you just kind of learn as a user. So I find it immensely helpful and fun to continue practicing.

What are the most important lessons you learned from the Epic rollout?

You pretty much have to do everything right. Health IT is not fault-tolerant, in terms of big projects. You really have to get all the ducks in a row in order to be successful. There are some exceptions to that you make and do better at some things versus others, but I think you really have to cover all your bases to keep the thing moving forward. It’s an uphill battle to do it.

Truthfully, a lot of it is attention to detail. Details are critically important in this. Keeping an eye on those details, making sure all the ducks line up, and trying to acquire the best talent that you can. People that appreciate those details that have a passion for doing informatics-type work. Pairing up with a vendor that shares that same attention to detail and understanding that you have, to get everything right in order to be successful, that has smart people.

Having leadership/ownership buy-in to everything that you do is crucial. We don’t implement health IT for health IT’s sake, we implement it for health systems’ sake. Getting executives behind that and understanding they need to understand a lot of the details too, because sometimes you look under the hood in health IT and it’s a little bit frightening what you see under there. They’ve got to be comfortable with that and be there to back you up when things get tough.

How is your project structured, in terms of ownership, and how did IT fit in the mix?

In terms of the rollout, IT was the project. I don’t want to say ‘owner’, but maybe we’ll say ‘steward’. We organized everything around IT. Once the project was done, we delivered things back to operations. In places where we didn’t have an operational owner, we created one.

The interesting part of this whole project was that initial kickoff. It was our medical group that actually wanted to do this and put up the money to do it. It was the physicians actually paying more than half of the cost. That was instant ownership for them.

Then we organized around IT for the project and for getting it rolled out. When we were done, really wanted to, again, turn the keys back over to the owners and say, “This is your tool, and now it’s yours to use and IT is here to help you.” In the places where we didn’t have an owner, we created one.

As chief health information officer, what I oversee now is a new department called the Department of Clinical Informatics. That group was created because as we sat around the table figuring out OK, now that we’re done, what goes where, we realized there was no owner for all the workflows that we had created in the EHR. There was no group that fronted the customer to IT, or owned the institutional organizational issues that basically came to light as a result of the EHR. So, we created a new department for that.

We also created the Department of Learning and Change Management too, because we didn’t have an operational institutional owner for projects of this magnitude and the ongoing training and change management that would be required for it. That was kind of neat because all of that bleeds out beyond just the EHR and you realize, “Wow, having an informatics department is helpful not just for EHR, but for things that you want to accomplish with electronic systems, or when you need to organize people together around an electronic system to make something happen.”

Likewise, in the learning and change management department, there’s operational changes that may be somewhat enabled by IT. But really, now you’re teaching people how to do their job differently. Not just the new tool, but really do what they’re doing differently, and then how to use the tool to do that. To achieve quality objectives, for example. That’s been kind of neat to watch.

The Department of Clinical Informatics, does that cover just the practice side or the whole facility? Also, what’s the structure and composition of that group?

It’s the whole, what we would call ‘OHSU Healthcare’. It’s both ambulatory and inpatient. It’s multidisciplinary. My title, chief health information officer, was chosen … we didn’t want to make it a chief medical information officer. We didn’t want to create separate silos of medical informatics, nursing informatics, etc. Put it all under one umbrella.

I have two roles. One is this operational person who has this department that I oversee; but then also, I chair one of the four subcommittees of our professional board, our governing structure. We’ve got four subcommittees: safety, quality, operations, and the new one, informatics. People really recognized how important informatics was, and that it really stood up against all those other things that we needed to work on.

In the informatics department we’ve got a director. Then underneath that we’ve got three main groups. One is our clinical champions: physicians, nurses, pharmacists, etc. that work on the project. Our entire HIM department, including coding, was brought in as well.

Then we’ve got a group that came from IT. The systems experts — people that were involved with workflow, design, clinical content creation, and reporting  — all came in as well. We created this team to try to make sure we had people covering the entire lifecycle of project changes and implementation, delivering stuff to users, and reviewing the contents of the quality of the record, which is obviously an important task for HIM.

That’s probably a bigger scope than the average CMIO, or even IT department, to have all of HIM plus the functional IT people. Was that difficult to sell, clinically?

I should point out that we also have about a dozen people that came from IT, and yet we’ve still got our whole IT department which is separate from us. We’ve divided up the responsibilities where we’re more content-oriented, we’re more workflow-oriented and we front the customer. So, we’re the ones that run all the subcommittees of the professional informatics board to figure out OK, well, what are the requirements that people need? How do we prioritize projects?

Then the idea is that we hand off to IT well-spec’d out details of, “Here’s what we need the system to do”, or “here’s what we need built”, or “here’s what we need you to work on with the vendor so they can do their IT role and not get too bogged down in trying to figure out what does the customer really mean when they say, we want this.”

But I think you’re right, in terms of the HIM part of it and really seeing HIM as  now part of informatics. I don’t know that everybody’s doing that, but we thought it was crucial. I think HIM is the glue that holds your record together. They’re the ones who are charged with doing quality reviews of the record.

People complain all the time, “I don’t like the record. I don’t like the notes. People cut and paste too much.” HIM oversees that. They have a huge role in scanning, and scanning’s another piece of glue that keeps an electronic system together because we’re still in a paper world and we interface a lot with paper systems.

Then coding, too — we create clinical content in informatics. The doctors use it, and then the coders read every single thing that they create. It would be a missed opportunity if we didn’t have the coders able to talk to the people that created the content in the first place and say, “Hey, I’m noticing people are using this well” or “They’re not using it well.” Or, “We could do a better job in our templating to accomplish our documentation requirements.” That’s how we thought about it when we put it together.

When you started the project, I’m sure you had some metrics in mind to measure before and after. What kind of measurements have you done, and have you seen the results that you had hoped to?

Looking back, I always feel like we could have done a better job with metrics; and also recognize that a lot of the things that you’d love to know when you do this, you never measured before. We looked at some of the standard things, and a lot of times, the data that we had.

I think one of the most easily available metrics that we had was our dictation. We were dictating pretty much 100% for all outpatient visits, all H&Ps on inpatient, all discharge summaries, all operative notes.

We watched each clinic as we went live and saw what happened to their transcription. It was so interesting. In primary care, it went from 100% to about 2% within a calendar month. In specialty care, it dropped down to more like 10% of what it was previous and then just kind of hung out there. It was an interesting marker of use of the system for me. To think, “Wow, people went from 100% dictation to 2% dictation. They must really be using the system.”

Although I learned that wasn’t really a statistic I should really share with my physician colleagues, because when they looked at that, they said, “Yeah, now we’re typing all our notes. We’re doing all this work. See that? We’re busting our chops to get this done. We don’t like that number.” So, I stopped showing them that. But to look at it as a measure of adoption, I thought it was pretty dramatic.

We saw that happen on inpatient, too. The same thing. We left transcription on. We didn’t take it away. Providers don’t suffer a penalty for using it, other than a workflow penalty of “now I’ve got to read this and authenticate it later”. But they were naturally drawn to it in just about every case, except the one area where it’s only fallen about 50% has been procedure documentation. Surgeons are still dictating a fair number of their procedures, but everything else fell pretty quickly.

Obviously, the financial people watched all those metrics very carefully. I’m probably not as versed in them as maybe I should be, but my gestalt of that is they’re all extremely pleased and happy with what happened. Then a lot of the other things that folks look at, I think, are more subjective and we’re still trying to actually figure out how to measure.

One of my major projects this year has been developing what we’re calling the Informatics Dashboard. There was this great article a couple of years ago that looked at how you measure the success of an informatics project. They looked to the management information systems literature and came up with these six dimensions.

So we looked at them and said, “It would be great to have a couple of metrics that we could describe, relating to each of these dimensions of system success.” Things like system quality — how good is it? Does it turn on when you turn it on? How’s the up time? How’s the response time? Information quality — sure it turns on, but is there information in there that you want and is accessible and you can use? The third one is usability, and how much usage does the system actually get? If it’s a really great system, people use it a lot, right?

Then there’s metrics for organizational impact and individual impact. Organizational impact like quality and how are you impacting that? And then individual impact, which is the thing I think physicians get very concerned about with an EHR, and it’s also the hardest one to measure. How much time am I spending documenting? Is this taking away from teaching or research? What about all this time doing notes at night when I go home?

We’re still struggling a little bit to figure out how do we measure that type of stuff and make it objective. When people complain about it, can we say, “Yeah, we really have a problem.” Or is this a problem of one instead of a problem of many, and how do we prioritize all those?

When you look at that, in context of the proposed Meaningful Use criteria, do you feel good about where you are?

Oh, yeah. I’m thrilled with where we are for Meaningful Use. In some ways, we got lucky. In some ways, it was vision. But for us, I think achieving Meaningful Use is going to be about crossing some Ts and dotting some Is. It’s very, very attainable for us, and so for that part, I’m really happy.

What are you doing with form factor stuff like mobile computing, or anything creative with nurses?

I don’t know how creative we are. We’ve got our devices on wheels. Pretty standard, like other folks have. We committed to having fixed devices in every patient care room, both inpatient and outpatient.

Being an academic center, we shied away from devices that could walk. Anything that wasn’t tethered. When you’ve got students and residents and people rotating through, our experience is if it’s not tied to the wall, it won’t be in the room for too much longer. It’s the same reason we have ophthalmoscopes tethered to the wall. Because after a year, if we handed out a bunch, they’d all be gone and nobody would know where they are; they wouldn’t be charged. So we focused a lot on fixed devices and trying to have them ergonomic so you can move around and stuff, but you couldn’t walk with them.

I think that’s been pretty successful. We’ve had some good luck with that, although there is always a lot of interest in the latest hand-held stuff. We had a lot of people who were interested in tablets when we started out. Of course that died because tablets weren’t really usable. Now it’s the iPhone and the iPad. I don’t know, maybe Apple will crack that nut a little bit better than some of the early PC tablet people did. We’ll have to see.

The industry is struggling a little bit to digest a couple of recent studies that tried to prove that the clinical information systems don’t improve outcomes or save money. Do you believe that those conclusions are accurate?

Yes, but I think we’re asking the wrong question. When we ask a question like, “Do EHRs work?” It’s kind of like asking, “Does surgery work?” What surgery? For what problem? In who’s hands? With what training? All those details are the things that determine whether or not surgery works, you know?

It’s the same thing with EHRs. Do they work? Well, they can work if you do the right things. The other problem with it is we wrap everything up and call it the EHR, but it’s really not. It’s not the software; it’s a process that we’ve developed. It’s a way of taking care of patients that we’ve codified, to some extent, in an electronic system. But when we look at all the studies that show effectiveness — or lack of effectiveness — what I try to look at is, OK, but why? What was it that made this one place really effective at doing this and not another?

I think informatics, as a science, is still pretty much learning those things. What are the necessary and sufficient conditions for success? It’s obviously not just about having a piece of software that does a certain thing. Otherwise, everybody’s experience would be the same with it. I’m not sure we fully understand … I know we don’t fully understand all the things that make it successful or make it not successful; such that we could develop a checklist and say, “Okay, as long as you do these 50 things, or maybe it’s these 500 things, you’ll be 100% successful.” I don’t think we have that yet.

What would you say your goals are for the next five years?

Oh boy, five years? I seem so focused on today. I think for us, it’s to build out the house that we’re ready to create. We’ve laid a great foundation here to do some really amazing things in medicine with the technology that we have. Over the next five years, I’m really excited to see how we will build that. What will it look like? Who will need to be involved? How will we fully engage caregivers? Operational departments like quality and safety to really see this as a tool that is their tool to use and operate and manipulate to achieve the ends that they want to see. I think that’s the most exciting part.

The other is to continue to refine the system, such that my colleagues who are nose to the grindstone, incredibly busy, by and large see this as a positive thing that enhances their ability to do a good job. Right now we see a lot of variability in people’s opinions along that line and we still don’t fully understand what the factors are that result in that variety of opinion.

I tend to think it’s that we still have a somewhat coarse tool that needs to be refined before people say, “Aha, this just works the way I expect it to. It works like Google, or it works like my iPhone.” I don’t know if we’ll get there in five years, but I’m sure we’ll be a lot closer than we are today.

News 2/19/10

From Pliny: “Re: Herb Smaltz, CIO of Ohio State University Medical Center. He is leaving the job on February 28 to run an OSU spinoff, Health Care DataWorks.” The company offers an off-the-shelf, pre-loaded data warehouse.

From Keanu: “Re: CCHIT. Has anyone heard of CCHIT events at HIMSS? Isn’t it a bit odd that they haven’t posted a town hall or something? With all the sessions on Meaningful Use, you would think they would have something to say.”

From The PACS Designer: “Re: disease outbreak alerting. The population of high quality healthcare apps for the iPhone keeps expanding. Outbreaks Near Me, an app introduced in 2006, recently created an iPhone version for mobile users. Software developer Clark Freifeld and epidemiologist John Brownstein started HealthMap in 2006 and designed Outbreaks Near Me for Childrens Hospital Boston."

From IKnowPlenty: “Re: AHA. Every day, more news comes out undermining Al Gore’s global warming hypothesis. For AHA’s upcoming Leadership Summit, they’ve added Newt Gingrich to share the stage with Gore. Now if we could just get someone who actually understands healthcare.” Newt makes good money from his Center for Health Transformation, so he must know something. In fact, he’s running an American People’s Online Health Summit as a counterpoint to President Obama’s meeting and most likely as an early step in a 2012 run for President (that’s my guess, anyway, now that his presumed opponent is obviously vulnerable).

Eclipsys announces Q4 results: revenue up 5%, EPS $0.07 vs. $0.06. Non-GAAP EPS of $0.17 beat expectations of $0.12.

Mary Horan, MD, chief of staff of Northwest Hospital (WA), will present “Med Rec: It Doesn’t Have to Hurt” at the AHA booth at HIMSS on Tuesday, March 2 at 3:30 p.m. She will talk about the use of MedsTracker from Design Clinicals, who will also offer private demos by request (at HIMSS or otherwise).

Picis announces a new version of ED PulseCheck and the launch of LYNX CareBridge, a documentation solution for medical necessity.

The Adoption/Certification Workgroup of HHS’s HIT Policy Committee will examine the safety of healthcare IT systems at an all-day meeting (warning: PDF) next Thursday from 9 until 3 Eastern. Executives from Cerner, Epic, and the VA will present, along with Ross Koppel, David Classen, and ePatient Dave (among others). You can participate remotely here without pre-registering. That should be interesting.

Thanks to Access, a new HIStalk Platinum Sponsor (actually Double Platinum, since they are also a Platinum Sponsor of HIStalk Mobile). The Sulphur Springs, TX company offers solutions that address patient flow, electronic forms, electronic signature, an e-Forms Repository, and portals that connect to media such as fax, e-mail, images, and universal documents such as EKG strips and other device output. We found out about each other when I did an HIT Moment with VP Chuck Demaree last week, which taught me stuff I didn’t know about electronic patient signatures and the capabilities of the Universal Document Portal for populating the EMR with data from biomedical equipment or even other applications. Being a barbeque connoisseur, I would find a reason to visit them at their place and then drop by Big Smith’s Bar-B-Q, but if that’s a stretch, they will be at Booth 4333 at HIMSS. Thanks to Access for its support of HIStalk and HIStalk Mobile.

Speaking of HIStalk Mobile, my colleague David Brooks is filling up his dance card to visit companies with mobile offerings (actually, he’s already got 20 appointments for Monday and Tuesday, so lay claim to Wednesday while you can). If you have the coolest mobile solution on the market, David says he will make time for you. I should also mention the fourth Founding Sponsor of HIStalk Mobile, 3M, which joins Vocera, Voalte, and another company not quite ready to be named. We really appreciate it.

I guessed wrong on the 2010 Grammy winner that MEDecision will bring to its HIMSS party. It’s Colbie Caillat, who has charted several times with some good pop tunes. Live video here. Their event is 6-9 Monday night at the Georgia Aquarium, It’s open to everybody, including those coming to the HIStalk reception who will need to leave early to hit Max Lager’s by 7:00. RSVP here to see Colbie.

And speaking of the HIStalk reception, thanks to sponsors Encore Health Resources, Evolvent, and Symantec. In fact, I notice that Ivo must have liked the looks of Max Lager’s since he’s hosting a Healthlink Alumni Pub Night there Sunday night.

Inga and I have done some good interviews that I’ll be posting each day for the next several. I want to get caught up before HIMSS and then feel free to collapse immediately afterward.

And Inga has obviously been a busy lady, putting together HIT Vendor Executives on HIMSS10, which features some fascinating executive predictions about the conference. How she got the top people at 42 companies to share their thoughts is beyond me (charm, I’ll assume).

Noteworthy Medical Systems is chosen by The Camden Coalition of Healthcare Providers (NJ) to power the Camden Health Information Exchange.

Strange: disgraced former Tour de France winner Floyd Landis, stripped of his title for doping, is the subject of a French arrest warrant for trying to hack into the anti-doping agency’s lab system to prove their results can’t be trusted.

General Dynamics wins a five-year contract worth up to $154 million to support the Army’s MC4 battlefield EMR.

Wacom launches a pen-on-screen display for healthcare professionals who need to annotate images.

An odd survey result: over 50% of Americans think other people’s health is going in the wrong direction, but only 17% said their own is. A third of respondents give themselves an A in the major health categories, while more than 90% of doctors grade them a C or lower. No amount of technology is going to fix that perception problem.

Jackson Memorial Hospital (FL) will lay off over 1,000 of its 12,000 employees, trying to avoid missing payroll by May.

You can tell HIMSS is upcoming. The fluff news is everywhere, but all the good stuff is being held to announce from Atlanta.

E-mail me.

HERtalk by Inga

Orion Health will use Merge’s Cedara WebAccess technology to bring images and information into its Orion Concerto Physician Portal.

The ONC selects Acumen Solutions to implement a cloud computing CRM and and project management from Salesforce.com. The solution will be used across all RECs nationally to help manage interactions with medical providers.

The ONC, by the way, names Joy Pritts, JD as its first chief privacy officer. Pritts will work with David Blumenthal to advise on privacy, security, and data stewardship issues. She was formerly on the faculty at Georgetown University.

athenahealth makes Fast Company Magazine’s “Fast 50” list of the world’s most innovative companies. I noticed that PatientsLikeMe and GE were also in the top 50, while Sermo, Kaiser Permanente, and Walgreens made the “also-ran” list.

Here’s something that sounds fun. Buzz Aldrin will be at the MMR Information Systems booth, taking commemorative photos with HIMSS attendees. Look for him March 1st, complete with a moon surface background in the Sea of Tranquility. If you participate, be sure to send us a copy.

EHR adoption in physician offices is up 3% over last year, according to a survey of 180,000 doctor offices. The numbers suggest a 36% adoption rate, with doctors using EHRs primarily for electronic notes. Not surprisingly, the larger the practice, the more likely the practice uses EHR. Hospital or healthcare system-owned practices are also more likely to EHRs that physician-owned groups.

A few sponsor updates:

• MED3OOO will incorporate data management and analysis tools into its MED3OOO Quality Management Suite. The application will be integrated  into MED3OOO’s InteGreat EHR to facilitate clinical data collection, help providers in determine HCC and PQRI scores, and meet other P4P reporting requirements.
• Sage Healthcare appoints Tony Ryzinski SVP of marketing. He previously worked for Misys in a similar role.
• MedAptus announces an expansion of its consulting services team to help providers and hospital to optimize financial and operational performance.
• e-MDs President and CEO Michaels Stearns, MD agrees to serve as board president of the newly formed Texas e-Health Alliance.
• Shore Sound Health System (NY) plans to undergo an accelerated activation of Eclipsys’ Sunrise Enterprise suite at two of its hospitals.
• Marietta Dermatology Associates (GA)  select the SRS hybrid EMR for its 13 providers.
• Sunquest completes a seven-hospital implementation at Cleveland Clinic.

I’d like to think that first there was Inga, then there was Barbie. Mattel introduces Computer Engineering Barbie, who carries a smartphone, a Bluetooth, and a laptop, plus wears stilettos. Any resemblance to me is pure coincidence.

E-mail Inga.

HIStalk Interviews Phyllis Gotlib

Phyllis Gotlib is CEO and co-founder of iMDsoft.

Tell me about the company and your products.

iMDsoft was founded in 1996 after a few years of development. We started with an alpha site in Tel Aviv and had our beta site at Mass General and Brigham and Women’s in 1997. Once we got clearance on our products, we decided to move to Europe and also to validate our implementation methodology.

Our first product was for ICUs. We went to Europe and decided on four different languages and four different countries. We received rave reviews.

Our first commercial installation with ICUs was in Lausanne, Switzerland in 1999. We went into the Netherlands in Dutch, Norway in Norwegian, and of course to the UK in English. Since then, we grew all over Europe, came out with a new product in 2001 for the entire perioperative environment — pre-op, inter-op, and the PACUs. We had a partnership with Fukuda Denshi, second largest medical device manufacturer in Japan, in 2000. We went back to the US in 2002 and set up our headquarters in Needham, MA where I spend most of my time.

Since then, we have close to 150 hospitals world-wide with more than 9,000 beds under license. We continue to grow beyond the walls of the ICU and OR as we expand outside of critical and acute care. We have a new product called MVgeneral that goes to the general floor.

We map the entire inpatient workflow in all these departments. Every type of ICU — all adult ICUs such as neuro, CCU, med-surg, NICUs, PICUs, and the entire perioperative environment, step-down, and general wards. We have supporting products that include MVmobile for ambulances and MVcentral, a tele-intensivist product, and others. All of our products share one database and provide a true continuum of care.

Most US healthcare IT vendors have customers outside the US, but most of their business is domestic. Is it an advantage or disadvantage to have a more balanced international footprint?

I see that definitely as a hedge. We started in Europe because, at the time, the R&D was in Tel Aviv and there was a blend of a lot of languages and people that came from the European countries to Tel Aviv. That was an easier way to start the company.

You can see similarities between territories. You can see similarities between the European market and Canadian market and between the UK market and Australia.

The US is different, but when we do user groups, the US customers are really happy to mingle with the European customers and vice versa. We believe in a sharing philosophy. Our US installed base is really high-visibility and very impressive, with Johns Hopkins, Mass General, Partners, Barnes-Jewish, Henry Ford, and so on. In Europe, we also have high-end academic hospitals, community hospitals, and smaller institutions.

They all like to mingle, to exchange protocols, and to share information. For us as a company, it’s definitely a hedge and allows us to lower the risks and to be able to answer the needs of the different regulations and initiatives in different countries.

You’ve described iMDsoft as a disruptive innovator, but I don’t know that many US healthcare CIOs are familiar with the company. Who are your competitors and what are your competitive advantages?

You will hear me quite often say that it depends on the segment and the territory. I would put them in buckets. The competition can be the old medical device companies like Philips and GE. Another bucket would include the bigger guys, like McKesson, Eclipsys, maybe Cerner. The others would be smaller, software-only companies like Picis. In Europe, in every country you can find a local vendor that is really specific.

You can differentiate the competition into OR competition, perioperative competition, and the ICU competition. But of course, I would tell you that we have very little competition [laughs].

Regarding differentiation, definitely I would talk about clinical data granularity. Secondly, I would say decision support. After that, our ability to customize — the flexibility of our products.

One of our fortes is interoperability. A good example is Barnes-Jewish Hospital. We are integrating and interfacing with eight different vendors. Giving you only US examples, at Lehigh Valley Hospital and Health Network, we have a full integration with, at the time, IDX Lastword CPOE, which became the GE product.

Another key differentiator for iMDsoft has always been our ability to impact not just the quality of care and clinical decision-making for our customers, but also to contribute meaningfully to their level of operational efficiency and resource deployment, and ultimately, to make a positive impact on the financial performance of their critical care department.

When I talk about customer impact, it can come from a number of different perspectives that cut across clinical quality, operational efficiency, and cost savings.

When I talk about clinical data granularity, every data item in our system is a user-defined and controlled parameter. They are stored in a hierarchical manner in the database, which allows them to have sophisticated relationships between them. Those parameters can be time-related or non time-related and can be from any type and they will have attributes … for instance, a formula can be a parameter, a drug can be a parameter, a change in position can be a text parameter, and so on.

A good example is saline solution, where the granularity will go down into water, chloride, and sodium. Every time a user gives one cc of such a solution, every minute you can see the trace elements in our system every minute. For instance, you can check the patient’s potassium minute by minute. These things are very important in critical care, where the patients are not eating or not drinking — they get intravenous nutrition or enteral nutrition and also all the volume that they get from drugs is documented.

A 2005 study I read described the use of MetaVision Event Manager to deliver alerts that are based on physiologic and order information in the ICU and the OR. What are the opportunities there?

It’s a huge opportunity. We hear that from all our customers. The Event Manager was endorsed by Harvard Medical School and by most of our hospitals. It’s a real-time decision support, a rules-based engine that provides alerts that can be clinical, administrative, or financial in nature. They can be delivered to the appropriate person and place as needed via screen, telephony, pager, and so on.

I can give you an example. First, we collect all the data. Once the granular data is in our database, you can then put rules on the data. You can write statements, like if-then statements.

One of our hospitals in the United States — I cannot say the name — conducted a study that showed that a certain generic anesthetic was as good as the brand name anesthetic for longer surgeries. The hospital gets reimbursed for the procedure at a set amount, paying for the anesthetic themselves. They did not have a reliable mechanism to remind anesthesiologists to use the generic drug in longer surgeries.

They programmed the alert to remind the anesthesiologist to consider switching to the generic if the surgery has already been more than X minutes. The statement was very easy. The alert took one day to produce, it took them a few days to test it, and in less than a week it was in production. Over a year, it saved them more than $500,000.

That’s an example of ROI using the Event Manager, but since every data item is a parameter, you can also use it to drive clinical improvements. In another hospital in the UK, they managed to reduce their drug costs per patient from $197 to $149 just by increasing generic usage, from 61% to 81% with MetaVision using the Event Manager.

I could go on and on with examples like that, but it’s actually using all the granularity, all the elements, all the parameters that we have in our very rich database and putting rules on top of them.

What about the use of reminder checklists and dashboards?

Our dashboard actually allows us to see the data in a global view, not only on the patient, but also on the unit. Along the way, we’ve also started implementing entire regions. We recently started an implementation for an entire province in Canada, another province in Australia, and also in Norway. Our dashboard provides a global view of a unit of a hospital, a region, or also something more like a network or province.

The checklist is something quite easy. It’s done all over the system. The entire system is rule-based and you can add alerts and mandatory fields. It’s really comprehensive and has all the functionality that is required to provide best practices and to give guidance.

Most of what I’ve written about iMDsoft involved the lawsuits with Cerner and Visicu over intellectual property involving remote monitoring technology. Did that turn out the way you hoped?

We are actually in the midst of our litigation. However, I can tell you that Visicu recently lost against Cerner for the same complaints and Cerner used our prior art to defend itself. So, I believe we are in very good shape.

A recent study, perhaps not very well done, concluded that remote ICU monitoring did not do much to improve outcomes or reduce costs. What was your reaction to that?

It was ambiguous. I’m never happy to see that the competition is doing a lousy job. If you look at the entire market and you see that we have only 10% penetration, we are beyond the early adopters. I need everyone to do a good job because if not, it will put up additional barriers. I know that we have ARRA, the stimulus, other regulations around the world helping us, but still, we need to do a good job.

So, there was something in my heart where I was glad to see that our competitors didn’t do a good job, but on the other hand, overall, that’s not the right thing.

It is interesting because, from our end, we have a study that shows in our tele-intensivist program, a customer was able to reduce the mortality rate by 30% by using MVCentral in their remote ICU.

You have some of the best hospitals in the US as your customers. Is the US market key to your strategy and if so, how will you get the word out?

Absolutely. I think our customers are our best advocates. We are investing in enlarging our channel distributors in the US and I hope that by the end of 2010, we will be able to have a balance between the rest of the world and the US revenues.

Do you think the stimulus incentives will affect your business here?

I think hospitals in the US will have no choice. The government, the payors, and the regulatory agencies have all begun to link clinical performance to reimbursement. It’s a first in the modern history of medicine. US government initiatives, such as PQRI, the various pay-for-performance initiatives launched by large payors, and European government initiatives have all been in the headlines.

Elected officials see these initiatives as crucial to contain health costs and improve quality of care. We at iMDsoft definitely believe the recent trend will continue and the amount of reimbursement at risk for hospitals will grow.

We see also that clinical data management and protocol enforcement now have important financial repercussions and making clinical information systems for critical care an even higher priority. There is not one CIO that doesn’t have this on his radar. They just need to prioritize it, whether it will be on the budget of this year or next year, but it’s definitely on the radar.

The start that everyone was hoping for the last 20 years is actually happening now, not so much because of the carrot, but because of the stick — the penalties and because it is impossible to manage so much data and so much information that is coming from so many different sources without having a clinical information system.

Final thoughts?

We are excited about what we are doing. We have a vision and a passion here. We are in 21 countries, supporting 18 languages, and hope to expand. We would like to continue to be a innovation leader and keep the level of quality of our products and services as we continue to grow.

News 2/17/10

From Nurse: “Re: Community Hospital South (IN). The CEO has announced that the hospital’s problems with GE Centricity Enterprise going back to August will cause it go back to the old GE CIS inpatient system next month. Deployment of Centricity Enterprise is on an indefinite hold.” Unverified, but the e-mail snips included look genuine. Maybe this would have convinced them to stay on: GE Healthcare announces that Centricity Enterprise EMR is now in the ecoimagination portfolio, which the announcement claims was “rigorously tested in-house and by a third party in order to provide optimal satisfaction to GE clients.”

From Kate: “Re: B52s. Who’s having them? I need to crash.” It’s an invitation-only HIMSS event (which I know only because I was invited), so I blurred the vendor name. Cindy and Kate were warbling hotties back in the day, although they are now 52 and 61, respectively, so they may not hop around like they used to. If I were this vendor’s customer and not planning to attend the HIStalk event (whaaaat?) then I’d probably check them out since I can sing along badly with all of Cosmic Thing, especially Deadbeat Club and Dry County, with a few beers in me.

From Zippy: “Re: articles in Racine, WI paper about All Saints. Doctors are not happy with administration and a number may leave.” Doctors and administrators are feuding, with a third of the medical staff ready to bolt. The final straw, apparently, was the hospital’s contracting with a Florida anesthesia company, replacing a local group after failing to reach an agreement about pay, on-call policies, and the use of nurse anesthetists. Also noted as a key issue: the 2009 introduction of an EMR system, which the doctors complain wasn’t well supported.

From Wake Up: “Re: McKesson’s problems. All listed before: HERM cost $150 million and still isn’t ready for prime time, ambulatory and HAC are a shambles, the 10.xxx upgrade is needed for meaningful use, but is painful for customers,and the company likes to replace quality employees with green beans.” All unverified, although I’ve heard them all before, usually from disgruntled former employees. Others have speculated that Pam’s downfall involved ongoing Horizon Clinicals integration struggles, of which ER 10 was an early warning of the challenges ahead (not surprising since all of those apps were developed by different acquired companies, as I remember: Vanderbilt, CliniCom, HCS, and others I’m forgetting). On the other hand, I’ve talked to one HERM site so far and they had nothing at all bad to say, other than to observe that the requirement to upgrade to Horizon Clinicals ER 10 wasn’t clearly stated upfront. I’m trying to connect with a second site.

From Stealth: “Re: Oracle’s Sun Division. I heard an unconfirmed rumor that it’s about to announce that it’s not going to support its JCAPS for EGate interface engine. Has anyone heard this?”

From G-Dog: “Re: articles. I thought this article might be worth discussing on HIStalk.” It covers board certification in informatics for physicians, with the authors concluding that it’s not really like other subspecialties since it covers all other specialties to some degree. AMIA is hoping initial review by ABMS will happen next year or the year after.

From The PACS Designer: “Re: Pogo Stylus. iPhone apps and other new mobile phone accessories keep getting innovative and the Pogo Stylus from TenOneDesign is the latest innovation. You can use the stylus to be creative and design artful stuff. Perhaps, we can get postings from Inga using the Pogo Stylus on her iPhone to entertain us HIStalkers, while Mr. H. uses his BlackBerry to organize HIMSS 2010 entertainment!” It’s $14.95.

The lab division of Fresenius Medical Care North America goes live on McKesson Horizon Lab.

EHRScope releases its Spring 2010 issue (warning: PDF). I really like this publication since it’s a lot meatier than the fluff the rags usually run, with some thoughtful articles and editorials.

This article describes a study in which researchers used CDC’s diagnostic algorithms for acute hepatitis B to search 16 years’ of ambulatory EMR data. It found 112 of the known 113 positive patients, but also detected an additional eight cases, four of which had not been reported to the health department. The next step (obviously) would be to turn those algorithms into real-time alerts.

Duke University Hospital chooses Simplifi 797 IV compounding QA software.

Fallon Clinic (MA) cites several improvements in making Dragon Medical part of its EHR implementation.

Jobs: EHR Project Manager (CA), Systems Administrator (AZ), Senior Systems Analyst (GA).

Sleep well knowing that Weird News Andy is guarding the gate. He finds this article, with the key line being, “Each time the two had sex, documents say, the doctor would bill her Blue Cross Blue Shield Insurance for their ‘sessions’.” The psychologist involved, who called himself RHL (short for Red Hot Lover), is being sued by his former lover and investigated by the state. WNA also likes this story (he threw in a Subway $5 foot long pun at no extra charge) about surgeons in Czech Republic who left a foot-long medical tool in a patient’s abdomen after surgery, which stayed there until five months later.

Former Eclipsys VP Charles Tuchinda, MD is named chief innovation officer, healthcare of Hearst Business Media. He’ll also be a VP at properties Zynx Health and First DataBank.

iSoft will distribute iMDsoft’s MetaVision suite in Germany. It offers clinical decision support, CPOE, and reporting for critical care environments. Among its customers, iMDsoft has four of the top 10 US hospitals at 13 of the top 50 European hospitals, with a 100% retention rate in its 11 years. Coincidentally,  I’ve got an interview coming as soon as I have time to post it.

Orion Health gets some coverage of its recent large sales in the New Zealand business paper.

An ED doctor’s article in an Australian medical journal urges that hospital executives who fake quality data be prosecuted the same as corporate book-cookers. He claims that hospitals have submitted phony data ever since they started getting paid for performance, including discharging patients electronically and then re-admitting them to hit quality targets.

Odd lawsuit: a patient care tech brings a baby to the hospitalized mom of a newborn. The mom starts breast-feeding the baby, but a nurse walks in to tell her it’s the wrong baby. The mother is suing Evanston Hospital and its parent corporation, even though no harm was done and even though she herself didn’t notice (she says she couldn’t see in the dark). The tech apologized in tears, but the father said, “It’s not enough”.

E-mail me.

HERtalk by Inga

From Forest Green: “Re: Sage again. I just heard of another executive departure — Kat Henry, SVP of customer service. I hope the new president can turn things around for them!” Sage has confirmed.

From George Geef: “Re: patient survey. Obviously, we don’t quite agree with the ‘goofy’ categorization of the GfK Roper survey. Compared with the CDC and NEJM surveys, actual patients witnessing computers being used for charting seems to me more accurate gauge of the shift than doctors self-reporting on partial or full use of EMRs.” OK, goofy was not the most eloquent and descriptive word I could have used. Let’s just say I am suspect of the conclusions drawn. Just because a patient notices a PC does not mean the practice has an EMR. The study also noted that older and wealthier patients said their doctors have EMRs more often than younger and poorer patients, concluding that doctors treating older and wealthier patients are more likely to have EMRs. Perhaps, though I could come up with a few other equally plausible conclusions.

Yesterday I came across a mention of HIStalk on a one of our reader’s blogs. The writer’s note made Mr. H and me smile: “I am anxiously awaiting my annual trip to HIMSS. Should be interesting to see what companies are doing around ARRA. At least CCHIT finally released their test scripts today so that there can be a lot of buzz. I especially can’t wait to go to the HIStalk reception. It has been the highlight of the trip the last 2 years.” I have to admit it’s been a highlight for me as well.

After six years of no price increases, Surescripts drops the price of its e-prescribing services for pharmacies, pharmacy vendors, and pharmacy benefits managers. Surescripts says the move is part of its ongoing commitment to improve operational efficiencies and the result of economies of scale. And I bet Surescripts found a price adjustment was necessary in order to remain competitive since the market is a bit more crowded than it was six years ago.

Speaking of Surescripts, the company sets up an advisory committee to help with the development of a prescription history service for HIEs. Committee members include the heads of five HIEs.

Members of a federal HIT advisory group recommend relaxing the number of measures required for providers to demonstrate meaningful use of EHRs. The group wants to drop up to six MU measures for 2011, which still leaves about 80% of the measures originally proposed. The advisory group says the currently proposed 2011 measures set the bar too high, making it difficult for providers hoping to qualify for 2011 stimulus money.

Coming soon: a new post in our ongoing vendor executive series on HIStalk Practice. Several dozen industry CEOs provide answers to the following question: In addition to ARRA-related items, what will be some of the hot topics at HIMSS this year? The insights are diverse and include musings on interoperability, rapid deployment of EHR systems, data collection, mobility, and industry alliances and consolidations. If you’d like to receive a notification when the series is posted, make sure you are signed up as a HIStalk Practice subscriber.

I have to admit I found this press release a bit opportunistic — or at least cheesy. After four introductory paragraphs detailing the Olympic and professional accomplishments of speed skater Eric Heiden, it becomes obvious the piece is really an ad for the records management software used in Heiden’s orthopedic practice. To fully appreciate the message, I think you need to imagine Jim McKay saying these words:

Just as athletes benefit from high-tech gear, clothing and equipment that enables them to be faster, better, stronger, Heiden says Records Studio utilizes superior technology to help optimize the performance of all departments of his medical practice, not just patient care.

East Orange General Hospital (NJ) purchases GE Centricity Enterprise for its hospital-based EMR. GE’s data center will provide the hospital with remote application hosting.

Enovate releases its Enovate Lite Medical Cart services, which includes CompactLite, StandardLite, and UltraLite models. I see the Enovate guys will be showing off the new cart at HIMSS.

Kaiser Permanente reports 2009 net income of $2.1 billion, which is a vast improvement over 2008’s net loss of $794 million. Q4 net income was $214 million, which more than doubles 2008’s number. The turnaround was largely the result of improved financial markets. Meanwhile, membership numbers fell by 64,000 in 2009 after falling 30,000 the year before. Total membership is 8.58 million.

Nemours/Alfred I. duPont Hospital for Children (DE) goes live on GetWell Town, the pediatric version of GetWellNetwork’s Interactive Patient Care system.

The Camden Coalition of Healthcare Providers (NJ) selects Noteworthy Medical Systems to be the information hub for their multi-hospital HIE.

Mediware announces that Oregon Health Sciences University will implement its BloodSafe system.

MEDecision launches a new collaborative HIE service called InFrame that facilitates clinical data sharing, including diagnostic quality medical images.

E-mail Inga.

CIO Unplugged – 2/15/10

The views and opinions expressed in this blog are mine personally, and are not necessarily representative of Texas Health Resources or its subsidiaries.

Meaningful Use Requires Meaningful Leadership
By Ed Marx

A few weeks ago, under authority of the Health and Human Services Secretary, the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator of Healthcare Information Technology (ONC) issued proposed regulations on the definition of meaningful use and the initial set of standards, implementation specifications, and certification criteria for EHR technology. Certification criteria specify the capabilities and related standards that EHR’s must include to support the proposed meaningful use Stage 1 requirements for eligible professionals and eligible hospitals. The comment period will end shortly with the final rules released this year. The industry’s wailing and gnashing of teeth is in full force.

As a taxpayer, I’m pleased with the IFR. My concerns that the industry would water down Stage 1 requirements have been largely dispelled. Meaningful use was designed as an incentive-based initiative. As such, it strikes a healthy balance between attainment and stretch. It’s not a welfare program, and not everyone reaches Stage 1 in year one. If that were the case, IFR would not be an incentive program. I praise the government for raising the bar high, and I urge them to stand their ground.

When does tolerance of low standards begin destroying value? Is not an underlying lack of fortitude detrimental to the overall fitness of our nation’s healthcare? I get invited to dozens of meetings and surveys all aimed at lowering the bar. Well-intentioned organizations exercise political freedom and amass collective resources (including financial and personnel). Online and traditional healthcare media are whipping activity into a frenzy. We’re inundated with position papers, press releases, mobilized lobbyists, and pundit opinions.

But I’m convinced that if we channeled the above energy and focus into meaningful use, more organizations would lift themselves over the bar.

Leaders. Avoid the temptation to jump on bandwagons that lower the bar. Make your opinion known and then get about the business of attaining meaningful use. While the lazy lament the IFR, you be the catalyst that makes meaningful use a reality for your hospital and physicians. Demonstrate meaningful leadership.

Ed Marx is senior vice president and CIO at Texas Health Resources in Dallas-Fort Worth, TX. Ed encourages your interaction through this blog. (Use the “add a comment” function at the bottom of each 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.”

Readers Write 2/15/10

Data Entry and Quality Health Care
By Al Davis, MD

The enthusiasm generated for EHRs by the 2009 ARRA legislation is almost palpable and hospitals across the country are scrambling to install systems at a breakneck pace. Behind the enthusiasm, however, are two issues, related yet disparate, that have been the confounding factors of EHR adoption in the past and will continue to be so in the foreseeable future.

EHRs offer the promise of data aggregation which can be used to refine clinical treatments for both improved quality and, possibly, lower costs, but this aggregation is dependent upon standardized dictionaries and, importantly, standardized data entry. EHRs currently offer standardized data via the use of templates, boilerplates, and pre-defined order structures. But the standardized data entry model often (usually?) does not completely and precisely conform to the observed signs, symptoms, and problems displayed by patients in the physician’s office, and therein lies the rub.

Patient care, especially when dealing with complex problems, requires the clinician to differentiate subtle distinctions among less than obvious alterations from normal physiology. Shortness of breath, one of the most common problems encountered in the emergency room, can result from problems with the lungs, with the heart, with the vascular system, with the blood, from medications, or simply from pollution or toxins breathed in by the patient, and those are the direct causes. Indirect causes such as intra-abdominal pathology, skeletal deformity or muscle weakness must also be considered.

While there is a high statistical likelihood that shortness of breath will result from one of a relatively small number of potential pathologies, assuming a diagnosis based on statistical likelihood will lead to poor or even dangerous patient care. The reason a pulmonologist trains for 12 or 13 years, and a nurse practitioner for six or seven, is to allow the pulmonologist to learn not only the underlying basis of the more rare causes of disease, but also to be able to discern the subtle differences that those more unusual pathologies may display. The use of template- or boilerplate-driven clinical notes negates the benefits of the more refined knowledge and experience of the pulmonologist. Requiring the use of such standardized data inputs is antithetical to quality medicine, yet allowing free text entry is equally antithetical to the as yet unrealized potential of the EHR. It is this contradiction which has slowed adoption of EHRs and will continue to hinder their use.

The challenge is for IT designers to work out a way for experienced clinicians to be able to commit to the record the sometimes subtle thought processes and observations that lead to their diagnoses, while maintaining enough control and/or discipline over the input to allow the potential of data aggregation to be realized. Monetary issues, regulatory compliance, and usability are important as well, but the paramount concern of the EHR must be to ensure that the best quality patient care can be delivered. If the cost of the input restrictions needed to allow data aggregation is the loss of ability to place nuance and subtlety into the record, the EHR fails that most primary of tasks.

Al Davis, MD is in private practice in Elmhurst, IL.

A Meaningful Ruse?
By Frank Poggio

At the risk of being a called a Cassandra, or at best a contrarian, I will attempt to explain why the federal government’s HITECH Act and Meaningful Use (MU) incentive program is a wolf in sheep’s clothing and why the better response for a provider would be to run, don’t walk, from this wolf.

First let’s review the basics. When a hospital or physician’s practice purchases and implements an electronic medical record (EMR) or Computerized Physician Order Entry (CPOE) before 2011 and files with the federal Department of Health and Human Services (DH&HS) the yet-to-be-developed regulatory documentation to declare their meaningful use (MU), then starting in 2011 that provider will be potentially eligible for an MU bonus payment. For physician practices, that could amount to a total of $44,000 over three years. For hospitals, depending on the number of discharges, somewhere between $2million to $3.8 million total. These incentive amounts are to be paid over three stages, or years, starting in 2011.

On the other hand, if a provider does not implement an EMR or CPOE, or purchases and implements a system but cannot show meaningful use, then a penalty will be incurred on Medicare payments in years 2015 thru 2017. This penalty will be in the form of a reduction to the legislated increase in Medicare payments for that year. Note: this is not a reduction in overall Medicare payments, but a reduction on the yearly Medicare inflationary adjustment factor. The first year the penalty is a 33% reduction of the adjustment, the second 66%, the third 100% (or in effect, you will get no adjustment at all).

Before I explain why I believe there is a wolf at your door, let me say I am a believer in the benefits of EMRs and CPOEs. There can be significant benefits in both, but not unless they are incorporate a sound work flow re-engineering processes prior to installation. Unfortunately there are very few if any MUs that are workflow-focused.

There are at least four major reasons why I believe your facility will never see an MU bonus.

1) MUs are, by the DH&HS’s own admission, a moving target. As stated in the Interim Final Rule (IFR) published in the Federal Register, December 30, 2009, on page 314, “We expect to issue definitions of meaningful use on a bi-annual basis beginning in 2011”. Hence, MUs will evolve over time. That will allow DH&HS to make them as easy or as onerous as they choose. How can you predict you will hit a moving target that you can’t even describe today? And if you believe the Feds may try to make it easier to foster participation, read on.

2) If you hit all but one MU, will you get the full bonus, or 95%, or 50%? Nobody knows and the question is not addressed in any IFR or other documents. I am willing to wager you will get nothing, and my reasoning follows.

3) The federal government has stated they are funding the HITECH program with $34 billion for MU bonuses. They also have stated repeatedly they expect to save over $200 billion to help fund the new national health plan. That’s about a seven-to-one expected payback in only a few years. When was the last time you had a seven-to-one ROI on any IT project over three years? If the feds do not see the seven-to-one payback in time, how many providers do you think will get to cash an MU check?

4) Our government is under extreme pressure to cut the federal deficit. In the President’s recent State of the Union Address, he stated he will freeze the government budget for ‘non-essential’ items to save $250 billion, to alleviate the trillions of dollars in deficits predicted by the OMB. Essential is currently defined as Social Security payments, interest payments on debt, entitlement programs, Medicare benefits, and the defense budget. These taken together make up over 80% of the total government expenditures. So the freeze has to come from ‘non-essential’ departments and programs. Medicare payments to providers are not considered part of Medicare benefits, they come under the DH&HS /CMS department operating budget. So, although the benefits to the seniors will not be reduced, the payments to the providers are fair game. And therein lays our wolf.

I noted earlier that if you fail to purchase and install an EMR / CPOE, you will be penalized by a reduction in the increase in Medicare inflationary adjustment in future years. Based on the above reasons, I believe there will be little or no adjustment increase in future years. If you don’t think this will happen, look at what Congress and DH&HS had allocated for the adjustment ‘increase’ in 2010 for physician Medicare payments. DH&HS wants to apply a -21% adjustment for physician payments. Yes, that’s minus twenty-one percent. Then, to get the AMA on board with the national health initiative, the Administration and Congress was going to delay this adjustment, but now even that agreement is up in the air.

On the hospital side of the world, look at what the Medicare adjustment increases have been over the last five years. The most they have been is 2% and the average is around 1%. If you run those numbers for a typical 200-bed community hospital with a Medicare utilization percent of 50%, the one percent increase amounts to about $300,000. Hence, reduce it by a third and you will miss out on $100,000 that year. Again, and that’s assuming there is any increase at all in future years.

Lastly, let history be your guide. I have worked in the healthcare world for 35 years as a CFO, CIO and multitude of other roles. As a CFO, I saw Medicare renege on many case mix adjustments, TEFRA adjustments, and DRG adjustments,all in the name of national budget deficits and health care cost controls. At one point, they set up a Medicare Payment Advisory Committee, then disbanded it when the Committee disagreed with too many DH&HS adjustment policies. I doubt the future will be much different, in fact probably worse.

So, run the numbers again, in future years if the Medicare adjustment increase is zero – because the feds and DH&HS say we can’t afford an increase due to overall deficits and budget freezes, then reducing the zero adjustment increase by 33% will incur how many penalty dollars?

What’s a shepherd to do?

The bottom line is there is no need to “horse in” a new EMR/ CPOE regardless of what vendors say. Secondly, horsing in a system as complex and far-reaching as EMR/CPOE and while hitting the expected glitches along the way is going to cost you far more than any Medicare adjustment penalty.

My advice … take your time, do it right ,and install components that will give you the most ROI the fastest. And watch out for the wolves.

Frank L. Poggio is president of The Kelzon Group.

Accurate Patient Identification and Privacy Protection – Not an “Either/Or” Proposition
By Barry Hieb, MD

 

Whether you support federal government funding of HIT or not, it can’t be denied that healthcare is undergoing a major revolution as more and more clinical automation capability is being adopted. Funding of HIE projects, building toward the Nationwide Health Information Network (NHIN), will further these efforts. And clearly progress is being made, as noted in the recent KLAS report that verifies 89 active HIEs across the US. The ultimate vision of regional clinical information exchange crosses political, operational, and geographic boundaries using the NHIN’s network of health information exchanges.

However, we’re not addressing one of the most significant challenges that must be overcome for this scenario to work: the ability to accurately identify patients whose information may be scattered across a number of providers using disparate HIT applications and platforms.

The current state-of-the-art approach for patient identification centers on EMPIs that identify patients using demographic matching techniques. But industry experience indicates that EMPI matching techniques are only accurate 90 to 95% of the time, introducing a variety of potential errors in care delivery within and across provider organizations.

We know the answer to the problem — issue each patient a unique identifier that would be used to label their information across all participating provider locations. In fact, the 1996 HIPAA legislation mandated just such individual healthcare identifier. But, in 1998, Congress reversed itself on the patient identification issue based on valid concerns about the inability to protect the privacy of this data, and forbade the expenditure of federal funds on further pursuit of this essential component for accurate patient identification and data exchange. Since that time, there has been virtually no progress on this issue at the federal level, although recently a number of states have begun to pursue state-wide identifiers to support their HIE projects.

Since I left Gartner in 2008, I’ve been working with Global Patient Identifiers Inc. to build out the Voluntary Universal Healthcare Identifier (VUHID) system under the umbrella of a non-profit, private enterprise. The VUHID system is based on over 20 years of patient identification standards work done by the ASTM international E31 medical informatics group, and proposes a solutions that is both inexpensive and effective.

The VUHID system communicates with the EMPI system at the heart of each HIE. It issues identifiers upon request and maintains a directory indicating the sites that have information for each identifier. The VUHID system has been specifically designed to enhance the privacy of clinical information because it has no identifiable patient data — only the locations where each identifier is recognized.

VUHID identifiers are globally unique and are designed to support activities that the patient or others indicate need to be handled with privacy. The VUHID system represents a secure, cost-effective, currently available solution to enable error-free patient identification that extends across political and organizational boundaries.

Barry Hieb, MD is chief scientist for Global Patient Identifiers, Inc.

An HIT Moment with … Chuck Demaree

An HIT Moment with ... is a quick interview with someone we find interesting. Chuck Demaree is vice president of product development with Access of Sulphur Springs, TX.

Absolutely. The focus of an EMR is to provide an electronic collection of medical information that can be used real-time during the clinical episode and historically as an archive. Generally, not all information will be fed electronically into an EMR. Forms provide a tool for the organized collection and presentation of information that will not be collected electronically.

In supporting the EMR, EHR and LHR, an electronic forms solution provides:

• Consistency in form quality, format and delivery.
• Accuracy in correct filing information through the use of patient-specific bar codes.
• Efficiency through the use of business rules by assuring that all the correct forms are generated (collecting ALL of the needed data).
• A standardized and structured presentation of data in the EMR, especially if COLD feed information is passed through the forms solution to provide a standard presentation.

Describe the typical workflows associated with using access-related electronic forms.

The most common entry point for Access EFM is in the registration area. A typical workflow would start with the registration of a patient. The resulting information generated by the registration system passes to the business rules engine in the Access EFM server where data elements are evaluated. The rules engine then determines what forms are required, what data needs to be applied to each form, and where and how those forms need to be distributed.

For example, a customer being registered as an inpatient would have a complete registration packet that is customized to them for this particular clinical event printed in the registration area, with bar codes and demographics applied. The only documents that would print there would be documents that the patient (or their family) needed to take with them or that needed to be electronically signed, such as consents. The bar codes on each form enable HIS staff to interface forms into the EMR with less effort, as the ECM/EDM system uses bar code recognition to auto-index the forms with the patient record. 

Electronic workflow would then route any other documents needed by the nursing unit, laboratory, pharmacy, patient finance and other departments directly to their location (or application) at the time of registration. Electronic notifications (via fax or email) would be sent to the primary care physician notifying them of their patient’s admission. 

In more advanced forms management projects, registration staff send forms to a monitor without printing. The patient reviews them, applies their electronic signature on an LCD pad, and the nurse submits the forms. They’re then interfaced into the ECM/EDM system, a paperless process that eliminates the financial and environmental costs of forms printing.

What is the Universal Document Portal?

The Universal Document Portal (UDP) is an interesting and exciting product. The purpose is to provide a method to feed the EMR electronically from systems or medical devices that do not have the ability to COLD feed today.

Some examples of how this is being used by our customers are:

• Passing medication orders which used to be faxed, from one vendor’s HIS system to a competing vendor’s pharmacy system.
• Providing an electronic import capability for clinical documentation from one vendor’s HIS system to another vendor’s EMR. This particular customer has well over 50 different feeds running through UDP
• Indexing the output from a 12-lead EKG system directly into the proper patient’s chart in an EMR.
• Migrating historical medical record information from a system that is being discontinued into the customer’s current EMR.

The uses for UDP are only limited by the output abilities of the system or device and the IT/IS team’s imagination.

How can electronic forms support patient safety?

The Access EFM system impacts patient safety both directly and indirectly.

Every form outputted from Access EFM has patient identification bar codes on it, enabling positive patient ID throughout the encounter. Bar coded wristbands are generated at registration and reconciled with bar coded medication labels also printed by the Access system, facilitating accurate bedside medication verification (BMV).

Documents that are passed into the EMR have a consistent structure which reduces search time for information. Because of patient and form specific bar codes on every form, all forms are accurately filed in the EMR
Notification of printed bar coded forms are sent to the EMR for the purpose of creating automatic deficiencies, which are resolved when the form is scanned in.

The indirect impact is the time saved by the use of the business rules engine and the staff efficiencies it produces. The business rules take the guesswork out of what forms need to be pulled and what data needs to be collected. If it needs to be done based upon the data entered for the patient, it gets done because of Access EFM.       

How common is it for hospitals to capture patient signatures electronically and how are they using them?

Electronic signature capture is becoming more common every day. The most common uses are obviously in the signing of consent forms, whether in registration or at the bedside. Other uses are the signing of discharge or patient teaching instructions, financial responsibility documents, and any other document that provides legal protection for the facility during the care delivery process.

The most important factor in choosing an electronic patient signature solution is how well those signatures will stand up in court. Basic electronic signatures like those used in a grocery store (TIFF on TIFF) are hard to defend if legally challenged as they could be copied, forged, or altered after signing. Access e-Signature creates a biometrics file that becomes part of the patient’s record and proves that the original signature was not forged or changed, positioning hospitals well for audits and e-discovery.

Monday Morning Update 2/15/10

From Conrad: “Re: Bassett Healthcare and their Stories of Success program. If it’s as good as the Go Red for Women/Put a Little Love In Your Heart video on their home page, they are doing all right. It’s clear they have employees who really like working there.” It’s kind of a Pink Glove Dance variant. Pretty good. I’m a sucker for this stuff.

From Talk of the Town: “Re: Allscripts. Two of the Allscripts sales veterans to leave were some of John’s boys from the original Medic lineup. The only thing surprising to me was that they have hung around this long. Combined with the exit of another of his sales guys from John’s golf company makes me wonder what John is up to these days.” He has five golf clubs now (the big real estate kind, not the sticks that badly dressed men hit balls with), although that may not be the best business in the world given the economy and lower property values. Not that he needs the money.

From Fact Finder: “Re: Sunquest. Take a look at the jobs posted to their Web site today. With that many sales jobs, it looks to me more than 30% left!” That’s quite a list — a clinical product specialist, two inside sales account managers, a regional VP, and six sales executives. Not the best timing with HIMSS booth duty coming up. From the “glass half full” side of the argument, they have jobs if you’re looking.

A physician’s Wall Street Journal editorial on EMRs ends with this:

If electronic records are only used to optimize billing and improve chart audits, patients will see little benefit. I doubt my patients received better care from the change.  Electronic records can only play a supporting role in a broader effort to change our troubled system. Until our health care system imagines patients as more than grist for billing, I will happily take my chances with a colleague’s inscrutable scrawl over a phone-book-sized stack of computer printouts.

HHS throws down another $1 billion for HIT, with $386 million in HIE grants (ranging from $600K to $38 million), $375 million for 32 Regional Extension Centers ($5.3 to $28.5 million), and $227 million for job training ($2 to $5 million). The jobs training one, in particular, has some odd recipients (Goodwill Industries and Spanish Speaking Unity Council, for example). I could write a bunch of stuff about this, but it’s kind of pointless until we see how those groups plan to spend our money. It better be good to be worth a billion dollars.

Cisco apparently fares much better than Microsoft and Google when it comes to healthcare, with nearly double their percentage of “positive” impressions. New poll to your right, for those going to HIMSS: what’s the last full day you’ll be there? I’m heading home Thursday, but the last I’ll see of the conference will be Wednesday (sorry, Sully).

Inga is putting together a list of HIStalk sponsors exhibiting at HIMSS. It occurred to us that Platinum sponsor O’Toole Law Group, aka Bill O’Toole who also writes HITlaw for us, would be a rather forlorn figure sitting alone in a booth looking wise and stern in a lawyerly way, surrounded by adjoining booths full of boisterous demo dollies and card trick magicians. So here’s the deal: Bill will be at the conference, but not in a booth, so you can read more on his Web site and make arrangements to connect with him at HIMSS to talk about HIT negotiations, non-compete agreements, and contracting (especially for Meditech shops). I told him I was going to mention (he probably thought I was kidding) that he will be at the HIStalk reception, so you can corral him there as well since that’s a good place to mix business with pleasure (if those terms aren’t synonymous, you’re doing it wrong). Bring your business cards.

One thing I like about having HIMSS in Atlanta: like Orlando and (formerly) Dallas, it’s cheap. Not just flights and hotels, but all-day convention center parking, gated and guarded, is only $10 or less. It snowed in Atlanta last week, but will be back up into the 50s by this weekend, which is the average daily high for March. The rooftop patio at Max Lager’s will be heated, so snow refugees can maybe get some outside air that won’t freeze their nose hairs. I also notice that some of the vendor bashes conflict with Sunday’s opening reception, which I think is a fantastic idea because I hate the opening reception.15,000 people elbowing each other to try to get a drink and an eggroll while a lame band plays isn’t fun for me, although I did like the San Diego one because the patio setting was so nice. Chicago was the worst ever, cramming a room with the charm and acoustics of an airplane hangar with bad music and a gazillion freezing people trying to get out of the ugly snowstorm outside. Can we admit, as HIMSS has tacitly done by vowing not to return to McCormick Place, that having the conference there in the first place was a really stupid idea like everybody kept trying to tell them? My almost-$300 hotel room was dumpy, everything from cabs to convention center coffee was overpriced, and there wasn’t anything to do except hang around the exhibit hall (which was the whole point of having it there instead of somewhere nice, of course).

Speaking of HIMSS events, soon-to-be announced Platinum sponsor MEDecision is having theirs on the same Monday night as the HIStalk one, but they are inviting HIStalk readers to drop over to their “HIStalk Pre-Party” from 6 until 7 Monday evening at the Georgia Aquarium. That event has the 2010 Grammy winner performing that I mentioned before, although I don’t know who it is (I would have guessed the Zac Brown Band since they’re from Atlanta and don’t start their tour until March 2, but really, I have no idea). The ever-diligent and protective Inga insisted on doing some research before giving me the OK to mention their event: “If you plan to go to both, you better drink fast and don’t go dunking in the shark tank. It looks like it is half a mile away, a 10-minute walk to Max Lager’s unless you are wearing your stilettos, in which case it is a two-minute cab ride.” Register here.

From the Weird News Andy vault: “at least he has a reason for not dancing.” A British hospital’s prosthetic limb specialist is fired after fitting an amputee’s right leg with an artificial left foot that was also one size too big. Paramedics noticed that the man was listing to one side, but he didn’t think much of it until taking off the fake foot’s protective sock five months later and saw a left foot on his right leg.

Last chance: please take my reader survey. Thank you. Speaking of which, a couple of readers had a good idea that I saw when I peeked at the results so far: a good time to read HIStalk (other than when it first comes out and you get the e-mail) is when you’re on a boring conference call or taking a lunch break at your desk. It’s like when I read the Howard Stern Show online recap at lunchtime: a guilty pleasure ideally suited for quiet time at work when you need a break (and this is even work-related, so you can read it guilt free).

Focus Informatics, Inc., a transcription provider that’s part of Nuance, has some job openings I said I would mention: a manager of US operations, account manager, team leader, and MTSO recruiter. Remote/virtual is OK.

Listening: reader-recommended Grace Potter and the Nocturnals, excellent Vermont-based throwback blues-rock with the female lead sometimes powering a vintage Hammond B3 organ or a big ole’ Flying V guitar. Video here. It’s cool that readers (some of them, like in this case, a top executive you would never expect) have figured out the music I like by my recommendations, then make their own back to me, generally with uncanny accuracy.

I am thankful that HIStalk’s sponsors nearly always stay with us. We lose one occasionally for one reason or another, but even then, they often find themselves missing the incessant good cheer of Inga the Sponsor Diva and end up returning to the fold. The InteGreat EHR folks have rekindled their Platinum flame after a short break and we welcome them back. As a refresher: the InteGreat EHR is modular, intuitive, browser-based, and CCHIT08 certified.

Speaking of sponsors for which we are grateful, here’s a new one: iSirona. The company specializes in capturing and delivering patient data: interfacing with stationary and mobile medical devices, providing  point-of-care charting screens, supporting positive patient ID, and streamlining charting and documentation workflow. Founder and CEO Dave Dyell said it better than I could in an HIT Moment With from May. Welcome and thanks to iSirona.

Nashville’s city government will spend money to buy clinical systems for Nashville General Hospital at Meharry, hoping to break even on the deal since the cost is $3.2 million and an even bigger government (the federal one) will pay it an estimated $4 million in return. Nobody’s mentioning any benefit to actual patients, but this is about stimulus.

Microsoft is opening some kind of health research center in Spain, interested in a location near a hospital that developed its “Florence” system using Microsoft technologies. This article says it includes smart phone access and SMS messaging. 

China’s $124 billion effort to move from socialized to US-like privatized health models is causing US-like problems: funding cuts, a dramatic polarity between services available to the rich and the poor, and rapid cost increases as doctors are financially motivated to order more drugs and tests. It’s so hard to get a hospital appointment that scalpers are openly selling appointment slots on hospital property (note to self – develop an eBay clone site to capitalize on this unauthorized secondary market).

Hospital-associated outpatient doctors can no longer qualify for ARRA meaningful use incentives after a Senate change to the HIRE Act. That may be addressed in other bills, however.

An odd situation caused by often-phony marijuana clinics: can an employee be fired for failing a drug test if he or she has a “marijuana card?” Marijuana is legal for medicinal purposes in 12 states, but only Rhode Island has a law preventing users from being fired for using it. Pot smokers are claiming they are being discriminated against, with theoretical legal claims under the Americans With Disabilities Act looming.

I’ve never heard of this: St. Vincent’s Hospital Manhattan, desperately trying to keep the doors open, lays off 32 medical residents as part of its 300 FTE headcount reduction. You know you’re in trouble when you can’t afford in-house physicians for 80 hours a week at $50K or so per year, or around $12 an hour.

Odd lawsuit: the family of a leukemia patient who died of Legionnaires’ Disease contracted from a water fountain gets a $1.2 million settlement from Ohio State University Medical Center. Nurses were told to give patients bottled water and to instruct them to avoid the fountains, but nobody put up signs. Strangely enough, the man’s daughter was nurse on the same floor and was with him at the time, but forgot to tell him not to use the fountain. Seems to me she’s responsible as well, but I doubt anyone is contemplating a lawsuit against her.

HIMSS posts its list of companies presenting at the all-day Health IT Venture Fair on Sunday, February 28. The list:

• Axial Exchange, an integration appliance vendor started by former Red Hat execs
• CareCloud, which offers Web-based practice management applications
• Clarity Health Journal, a PHR tool
• Dicom Systems, which offers a DICOM router and archive
• EDIMS, a vendor of emergency department information systems (and an HIStalk Platinum sponsor)
• Envisioner Medical Technologies, a personal medical imaging platform for endoscopic multimedia
• Heart Imaging Technologies, which offers a Web-based PACS, clinical trials system, and image sharing site
• Logical Images, vendor of a visual diagnostic system based on medical photographs
• Medical Diagnostic Associates, offering systems for electronic images and exam tracking for diagnostic imaging
• MedCPU, a clinical practice tool for high acuity hospital services including OB
• MedicExchange, a social networking and product review site for healthcare professionals
• MediViz Systems, a real-time decision support system for the OR
• Mensante, operator of FeelingBetterNow, a best practices site for Canadian mental health physicians and patients
• Polaris Health Directions, which offers behavioral health outcomes assessments and management systems
• Prodigo Solutions, a healthcare supply chain applications vendor
• Provider Advantage, EDI systems
• Sentient Health, supply chain systems
• Smart Association, smart cards
• Spring Medical, vendor of SpringCharts EHR
• TC Software, which sells an integration engine
• White Pine Systems, which offers a PHR
• Your Nurse Is On, an online tool that matches nurses to open shifts
• Zebec Data Systems, a IT infrastructure hosting and outsourcing vendor

The most common mistakes companies make pitching at the Venture Fair, from my limited experience in having crashed part of it once:

1. Not being able to summarize their offering in ten seconds.
2. Not being able to clearly explain right off the bat who their potential customer base is, what problem they intend to solve for them, and how they plan to efficiently reach those prospects with their message.
3. Saying “we don’t really have any competition” when inevitably asked.
4. Not knowing what it costs to get a customer (or worse, having no customers).
5. Pitching an unoriginal idea, an idea that’s interesting but not really much of a business to deserve outside investment, or an idea that requires competing against well-established competitors that could extinguish you in a corporate heartbeat.
6. Trying to hide modest numbers by not bringing any. Investors understand that early-stage companies aren’t often making a profit, but not having a handle on revenue and expenses is inexcusable.
7. Shooting for quantity instead of quality, spouting off an undisciplined array of ideas instead of focusing on one potential winner. Diversification comes later; focus reduces upfront risk.
8. Not really understanding the difference and expectations among funding options such as bank financing, friends and family, angel investors, private equity, and venture capital.
9. Taking up too much time with a product demo instead of talking numbers, management experience, and growth strategy.
10. Being an inexperienced, unpolished entrepreneur looking for a large investment (investors bet on the jockey, not the horse).
11. Trotting out wildly optimistic revenue projections that always start immediately after someone else puts their money in.
12. Asking for someone else’s money when they haven’t put in much of their own or when still running the business part time.
13. Having a management team made up of product people (i.e. geeks) and nobody with startup and management experience.
14. Not having an advisory board or mentor who has done it before.
15. Having only a vague story about how investors will get their money back and how the company will mitigate the risks that arise between the time they write you a check and the time when you return the favor.
16. Not having a detailed plan on what they plan to do with it (it better involve increasing revenue directly, not leasing an office or buying Aeron chairs for everyone).
17. Being too undisciplined or excited to stick to the venture fair’s limits on PowerPoint slides and session duration, or having glaring errors in the information sheet. This is speed dating, not courtship, so first impressions are the only kind.
18. Expecting to get someone else’s money without giving up some negotiable degree of control.
19. Expecting to walk out of the room with a deal or assuming that some degree of audience interest means you’ve scored. I don’t know what the hit rate is for the venture fair, but I bet it’s low.
20. Getting discouraged instead of vowing to learn from the experience, to make the business and the pitch better for next time, and to try again.

E-mail me.

News 2/12/10

From Spaghetti Eddie: “Re: VA and Cerner. I’m pretty sure the answer is that VA hasn’t decided yet, but it sure isn’t looking like a Cerner LIS decision. Still very very hung up on the issues associated with integration of EHR with DoD (AHLTA). Also, there’s a big study group of industry types (the Industry Advisory Council Vista Project) that was formed at VA’s CIO’s request to look at how to modernize VistA, clearly with an eye toward remaining open source. All in all, VA’s not there yet.” I’ve also read that the VA just opened up a program to solicit IT ideas from its employees instead of the contractors that are usually whispering in its ear.

From The PACS Designer: “Re: Google faster broadband. Google has announced that it is considering 1 gigabit per second broadband to the home as the next frontier it would like to conquer. Google said that speed would be fast enough to download a high-definition, full-length feature film in less than five minutes. Healthcare could also benefit from such a service as the medical image files can be  500MBs and larger.” I ran across this Extormity-like parody site that touts Google TiSP Beta, a free wireless broadband service that runs fiber optic cable in sewer lines. Incidentally, TPD is updating his list of iPhone apps for healthcare, so if you know of some cool ones, add a comment at the bottom of this posting and he will happily retrieve it.

From Ms. Curious: “Re: Sunquest. I hear they lost 30% of their sales force this week.” Unverified. I would be surprised if that were true.

From EHR Geek: “Re: Stanford Health Care. CEO Martha Marsh is retiring in August.” Unverified. I would be uninterested if that were true. Actually, only because I don’t know her and don’t know much about Stanford, but I assume I have readers who follow them.

From Joe: “Re: greenhorn manager. Reminds me of the old ‘three envelopes’ story that your younger readers may not have heard.” I thought everybody knew that one, but here goes (I’m using male pronouns only for convenience, not bias). A fired CIO’s replacement finds a note from his predecessor, saying he left three envelopes in the desk drawer to be opened only when things are going really badly. Six months later, the network goes down for most of a day, so the CIO opens up the first envelope and finds a note that says, “Blame the previous CIO.” Great idea! He makes up a convincing story about a historic lack of maintenance and capacity planning, saving his skin. Months later, the executive team complains about excessive IT operational and capital budgets, threatening to freeze expenses. Time to open another envelope. This one says, "Blame your coworkers." He does, arguing that the unchecked technology demands of his executive peers have made him the victim. Months later, doctors are pushing back against mandatory CPOE, saying that it’s typical CIO arrogance that makes him think he understands the challenges physicians face. He opens the third envelope, which says, “Prepare three envelopes.” I will also modestly add that several years ago, I won some local IT acclaim for embellishing the story with a fourth envelope that involved bringing in consultants, but I’ll stick with the non-customized version for the noobs.

From Lippy: “Re: greenhorn manager. It’s not just hospitals that like to stir things up. [vendor name omitted] just added an extra layer of management, making a chart that looked like the one from 4-5 years ago. The structure does not address sales-limiting problems inherent to most vendors — product limitations, support issues, and price. But, redoing an org chart makes upper management look like they are on top of things and justifies their existence.”

From Dulcinea: “Re: Wireless Life Sciences / Continua symposium in San Diego. Wish I had a recording of Patrick Soon-Shiang. He was all over the place from physics, biology, engineering, to healthcare integration based on the rail system network.” I can’t figure the guy out. He’s a drug company billionaire (some say a cutthroat businessman) claiming only benevolent intentions in getting involved financially (supposedly) with California’s interoperability project. What little I’ve heard him say publicly about it didn’t make a lot of sense to me either, but then again he’s at a level appropriate to a guy with a lot more zeroes in his net worth than me. I’d still like to interview him to see what he’s about.

Bassett Healthcare (NY) is recognized by the “Stories of Success” program sponsored by HIMSS and the American Society for Quality. Its submission involved quality and safety improvements using the SIS perioperative suite. 

Siemens renews its agreement with NextGen that allows it to sell that company’s physician practice systems to its customers. I hadn’t thought of it until now, but Siemens seems to be the only big hospital systems vendor that has done very little with regard to either acquiring or building practice systems. The market seems to be clearly indicating that those two previously separate demographics have quite a bit of overlap, so they seem to be at a disadvantage.

Medicity’s customer summit was last week, with half of its 700 customers in attendance and featuring presentations by David Kibbe and Marc Probst, among others. I had missed that, along with CEO Kipp Lassetter’s thoughts about California’s statewide HIE project and the transition of CalRHIO’s work to the state’s new governance organization.

Listening: good old anti-corporate, anti-government, Texas-based country from James McMurtry. I heard We Can’t Make It Here in a restaurant yesterday and was mesmerized enough to rush home and Google the lyrics to see who sang it. Turns out it was the son of Larry McMurtry, the guy behind the best Western ever made, Lonesome Dove. Makes me want a Lone Star, some brisket, and a pickup truck.

e-Val MD announces its H&P application for the iPhone and iPod Touch.

Confused by all the military HIT terms like CHCS, AHLTA, and VistA? Here’s a good overview and history, although not a very complimentary one when it comes to billions in costs and FCCs (fat cat contractors, for which I’ve decided to coin my own acronym) jostling each other at the taxpayer trough.

A gentle nudge: my reader survey awaits your electric touch, so titillate it, please. This is one of few times that your vote (and comments) make a difference.

Thanks very much to those several vendors who have invited Inga and me to their HIMSS shindigs. At least two of them are featuring some big-name entertainment that we’ve heard about (one has booked a 2010 Grammy winner, another will be rocking out with my favorite Athens beehive hairdo party band). I can’t speak for Inga, but I’m sure I won’t be able to go since HIMSS is really hard work for me with our own event and a ton of HIStalk writing that keeps me up late every night and eating McDonald’s (last year) and Subway (the year before), but it is delightful to be asked and I appreciate it.

Speaking the HIStalk event at HIMSS, I haven’t forgotten about readers who won’t be going to Atlanta. For the first time in HIMSS history (as far as I know), we will be streaming a party live over the Internet with full audio and video. We will have a little broadcast booth where our team will interview willing party-goers about whatever’s on their mind – meaningful use, who has the cutest shoes, or how many drinks they’ve had. The crew will have to swear not to let their cameras stray onto any scandalous behavior that may be taking place outside the broadcast booth since it may get a little bit rowdier this year with an open bar and a St. Patrick’s Day theme. More details to follow. For those who have asked, yes, there will be funny beauty queen sashes again this year (it’s an Inga thing that I gripe about since I have to assemble them, but it makes her happy).

I know I keep saying this, but if you’re waiting on something from me, hang in there — I am not ignoring you. My e-mail box is overflowing, I have HIMSS stuff to do, and of course I still have to make a living by day. I usually catch up over the weekend, but even that is threatened since I have interviews to do then.

Tony Cook joins GetWellNetwork as VP of marketing.

An interesting tidbit from the Cerner earnings conference call: the company had to reclassify some of its accounts receivable because it’s a subcontractor to Fujitsu, which is still duking it out with NHS in England. Cerner executives are clearly advanced when it comes to optimal buzzword deployment (they love words like footprint, space, and agile). Also casually mentioned: company president Trace Devanny is being relocated to London “to spearhead an increased focus on global markets and opportunity.” It seems curious that Cerner would allow its president to live and work overseas when only a tiny bit of its business comes from there, so I’m guessing there is more to that story.

Finally a healthcare jury verdict that makes sense: the Texas nurse who was fired and charged with “misuse of official information” for confidentially reporting concerns about a perpetually trouble-prone doctor to the state’s medical board is acquitted. The jury took less than an hour to dismiss the case, with the jury foreman saying, “We don’t feel that what she did was wrong because she had concern for the patients. Nurses are the eyes for the patient.” The nurse and a colleague who was fired over the same incident are now considering adding another claim to their lawsuit against the doctor, hospital, sheriff, and prosecutor: malicious prosecution. Reports are suggesting that the doctor not only peddled quack vitamins, but that perhaps also had previously hired as one of his salespeople the sheriff who went after the nurse.

Needless chemical nit-picking: this radio station’s headline trumpets that a family had “CO2 poisoning”. Those kids must drink a lot of soda.

As an IT guy, I’m fascinated by this article that talks about validation of embedded programming in medical devices. Pacemakers contain 80K lines of code and infusion pumps 170K, all prone to the same bugs as application code (memory leaks, improperly initialized variables, divide by zero errors, mishandling of variable type conversions). Those vendors, however, apparently have much more stringent testing methods than some of the hospital systems vendors I’ve worked with, where “compiled without errors” is synonymous with “passed a rigorous QA review.” (here’s an old RPG programmer’s joke I just remembered: hospital customer: “Are you sure this fix will work?” programmer: “Yes, I only had to set the gen level up once to get it to compile.”)

And speaking of that, I’m inspired to share my Five Answers You’d Rather Not Get from your Application Vendor When Reporting a Software Problem: (a) we already know about that and we’re working on it, so you wasted your time researching its cause on our behalf; (b) we don’t really want to look at it unless you can dedicate the resources to duplicate the problem and document it for us, even though we have a worthless QA department whose job you will be doing for free as a paying client; (c) we have a fix, but it’s going in a release you won’t be installing for at least a year since you wisely wait for all of our upgrade-related disasters to happen to other customers who don’t know any better; (d) that database error and file corruption problem is working as designed, so we will add your request to that list of enhancement ideas that we haven’t touched since 2001; and (e) you haven’t complained lately and we’re off doing enhancements for customers bigger, better, and newer than you, so can we just close your ticket so the suits won’t be all over us for bad metrics?

UVA chooses Sunquest Collection Manager for specimen collection.

Following disastrous financial performance, both the CFO and the VP of revenue cycle management of Jackson Health System (FL) quit. The board was not happy that the CFO’s numbers were off a smidge: he said the hospital lost $47 million in 2009, but the real number was $204 million. For 2010, the predicted loss is now pegged at $229 million.

Medicare fraud, Chapter Gazillion: a West Virginia coalfield clinic is raided and its non-physician owners charged for using a doctor’s DEA number to prescribe controlled drugs for four years, billing the government for physician services that were actually performed by extenders. Two doctors were also charged, one who admitted he knew Medicare bills were going out under his name even though he hadn’t seen a patient in 15 months. If you’ve ever been there, none of this will be at all surprising.

Microsoft may whine about all the attention Apple is getting for the iPad while nobody wants Windows-powered tablets, but their focus is apparently fickle: they shut down the Tablet PC Team blog, apparently dumping that group into the gulag that is the Windows organization. Or, maybe they’re just giving up without a whimper to Apple. I found this through OnTheRun.

HIMSS adds US CTO Aneesh Chopra to the conference keynote lineup. HIMSS always back-loads its keynoters hoping to get attendees to stick around, so he’s on Wednesday, meaning the audience will be somewhat diminished but still massive compared to the less-than-a-planeful that Sully Sullenberger will address Thursday at 12:30, long after most attendees are already back at work.

E-mail me (with only modest hopes for a quick reply).

HERtalk by Inga

From Tanya: “Re: Google Buzz. It’s like Facebook, only without any of my friends!” Buzz appeared in my Gmail account yesterday. So far, it looks like a me-too product without all the cool bells and whistles of Facebook and Twitter — and without the friends.

In light of NextGen’s announced acquisition of Opus Healthcare, I found it interesting that Siemens chose today to announce its renewed its strategic alliance with NextGen. Was Siemens wanting to ride the wave of NextGen’s five minutes of spotlight? Or did NextGen and Siemens want to reiterate that the Opus acquisition doesn’t have any affect on NextGen’s go-forward EHR strategy? In any case, it’s interesting to note that the Siemens / NextGen relationship (which goes back perhaps five years?) has resulted in 35 Siemens clients deploying NextGen software throughout their physician networks.

Continuum Health Partners (NY) selects Sunquest Information Systems for its LIS solution.

NuHealth, another New York health system, signs a $5 million contract with Allscripts to provide EHR, PM, and ED solutions across its hospitals and employed physician networks. The health system will also establish data exchange between the Allscripts solutions and the hospitals’ Eclipsys Sunrise, Sunquest lab, and Amicus radiology systems

Yuma Regional Medical Center (AZ) plans to spend $73 million implementing Epic EMR. The hospital says the five-year project will create 49 new jobs and includes creating connections with local providers.

This has to be one of the goofiest EMR surveys ever. A Practice Fusion-sponsor survey asks patients if their doctors stored their medical records digitally (48.4% said they did.) Now how exactly are patients making that determination when the “experts” can’t agree on what should be classified as an EMR? I mean, just because a doctor writes something on a piece of paper, does that mean the practice doesn’t have EMR? If the doctor types something into a computer, does that mean the practice has EMR (maybe he/she is simply checking up on e-mail). Does this survey tell us anything of value?

Henry Schein Medical says it will continue expanding sales of MicroMD, despite the recent death of founder Ajit Kumar. Kumar took medical leave in September, soon after being diagnosed with lung cancer, and died January 15th. VP/GM Keith Slater will continue to oversee operations at MicroMD, which is expecting 25%  sales growth this year.

Nuance rolls out a new bonus-incentive plan for employees that meet certain performance targets. Based on the current stock value, CEO Paul Ricci stands to earn an additional $7.25 million. To receive his full bonus, Ricci must also stay with the company through September 30, 2011. Nuance posted a 21% percent in revenue at the end of its fiscal first quarter.

Akron General Health System (OH) signs a strategic agreement with McKesson to provide Practice Partner EHR/PM to its PHO nd affiliated community physicians. McKesson reseller Complete Healthcare Solutions will provide implementation and support to a potential 500 community providers. The hospital McKesson’s Horizon Clinicals and is deploying the CPOE part of HEO.

Merge Healthcare releases  Q4 and 2009 numbers: $2.1 million loss for Q4, compared to last year’s $1.9 million gain; annual net income of $300,000 compared to 2008’s net loss of $23.7 million. Merge’s quarterly net sales grew to $19.3 million from $15.1 million a year earlier.

I see HIMSS has scheduled three separate “Meet the Bloggers Sessions” at the conference. They’re billed as roundtable discussion that give attendees a “behind the scenes” look at the responsibilities and dedication required to maintain a successful blog. Mr. H and I were invited to participate, but we opted to keep our low profiles. Now that I see the hunky John Halamka is on one of the panels, I am re-thinking that decision. (Gosh, what if I were able to sit right next to him???) Anyway, I might just sit in to learn what Mr. H and I should be doing since most of the time we’re just winging it.

HIIMSS also just posted the initial list of companies participating in the Health IT Venture Fair. HIStalk sponsor EDIMS is a presenter. I’ve sat in on a few of those sessions in the past and I must say that listening to all those financial projections mixed in with marketing hype requires me to keep the caffeine handy. Actually some of the new stuff is cool and it’s interesting to hear who companies view as their competition and why a CEO believes his company is well positioned to be the next industry superstar.

Potential good news for physicians who practice at hospital-owned ambulatory care facilities. The Senate is considering adding language to its current “Jobs Bill” that would allow some hospital-based physicians to receive ARRA subsidies. Current ARRA language excludes hospital-based physicians, much to the disappointment and anger of ER docs, pathologists, and physicians practicing in hospital-owned ambulatory facilities. However, the proposed bill would give physicians in this latter group a chance to qualify for ARRA funds (though pathologists and ER docs would still be exempt). For more details, see SEC. 620 under EHR CLARIFICATION.

The CEOs of four rural Texas hospitals claim their new rural RHIO is the first of its kind. The competing hospitals, which have a combined 104 beds, will share costs and clinical information using a single Web-based EMR from Prognosis Health Information Systems.

Halfpenny Technologies adds healthcare veterans Bob Cox and Mike Meyer to its leadership team.

Christiana Health Care System (DE) signs a three-year contract with Zix for the ZixCorp Email Encryption Service.

An Allegheny County judge okays a class-action lawsuit against UPMC on behalf of patients who said it overcharged them for copies.Pennsylvania state law allows “reasonable rates” to cover actual expenses for copies of medical records. The judge agrees that UPMC’s per-page fee of $1.50 may not be reasonable. OK, I’ll say it. Everyone knows UPMC has an EMR. So how time-consuming and costly is it to pull up a patient’s chart and hit Print? If it really costs them $1.50 a page, than UPMC has a much bigger problem on its hands.

E-mail Inga.

Quality Systems Acquires Opus Healthcare Solutions

Quality Systems, Inc., parent company of NextGen, announced this morning that it has entered into an agreement to acquire Opus Healthcare Solutions. Terms of the acquisition were not announced.

Austin, TX-based Opus offers the Web-based and ‘08 CCHIT inpatient EHR certified Opus Clinical Suite, an inpatient system that includes clinical documentation, order management, clinical data repository, and a laboratory information system. The company was founded in 1987.

Quality Systems will integrate the Opus product line with assets from its previous purchase of the assets of Sphere Health Systems, Inc., which included its Spirit Enterprise hospital information system. Both product lines will be operated as part of NextGen Healthcare Information Systems, Inc.

The acquisitions give NextGen an inpatient product line, which it says will sell primarily to hospitals with fewer than 100 beds.

Scott Decker, president of NextGen Healthcare, was quoted as saying, “We have seen demand grow in the rural and community marketplace due to the Stark relaxation, emergence of health information exchange initiatives and impending incentives resulting from the American Recovery and Reinvestment Act (ARRA). Through our many years of working with ambulatory providers closely associated with or owned by community hospitals, it became clear that we could meet this demand by broadening our offering to include both ambulatory and inpatient solutions. In addition, clients have expressed the need for a single, ‘cloud-based’ technology platform that can be leveraged across ambulatory and inpatient care settings. These new acquisitions afford us the necessary capabilities to address client needs and fill a void currently present within the rural and community hospital marketplace. When considered in conjunction with our complementary Siemens Strategic Partnership, this announcement completes a strategy for distributing NextGen solutions across the entire inpatient and outpatient continuum.”

We announced the acquisition last night on HIStalk Practice, thanks to a tip from Miss Lead.

HIStalk Interviews Dane Stout

Dane Stout is director of the connected health and biomedical communication practice of The Anson Group.

 

Tell me about the Anson Group and what you do there.

I joined The Anson Group last fall. I’ve known the folks there for quite some time. The company has been around about 14 years. It grew up in the traditional medical technology / medical device space. I’m pharmaceutical. They’ve provided a lot of services over those years in regulatory quality systems. Helping them to put clinical trial protocols together, all that kind of stuff.

We started talking a while back about some of the changes that were happening in healthcare and this convergence of all these different players, and so we said, “There really seems to be a need for our services that we would put together to bridge the gap, really, between the traditional medical device, pharmaceutical companies — who are very familiar with the pretty onerous burdens of the regulations inside of healthcare — and then all the newcomers that are coming out of consumer electronics and general IT and telecom and you name it.”

Everybody’s flocking to healthcare because of the stimulus, because of the size of the market, and because of some of the margins. But I don’t think they have a real appreciation for what they have to deal with. That’s why my job here is to drive the “connected health practices”, is what we’re calling it. We’re really looking at a very network-centric perspective. To say, “All these new players are going to come in and they’re going to need ways (people) to help them get their innovation to market and still comply with the law and all the regulations that are a part of that.”

Give me some examples of some of those converging technologies that would be running on a hospital network.

We break it into two components. There’s what I would call the mission critical — I’ve classified it as more biomedical communication — so inside the walls of the hospital, you now are going to have all these medical devices that are there. They’re either just a closed-loop system sitting over in the corner, or they actually now have a private network.

I’ve read where the average hospital has somewhere around 240 distinct, private networks. There really isn’t that much value to that. What they would all like to do is to have the medical devices communicating with each other, communicating with the EMR connected to the order entry system, and be able to collect all this data and be able to feed that into data repositories and be able to improve on their performance using that.

A very different model in terms of a high-performance, high-critical response requirements that would be a part of that network. Being on the hospital enterprise LAN, now you’ve got medical devices that were designed from the ground up to operate in isolation that now all of a sudden have to be good network citizens and make sure that their security updates and software patches and all that don’t disrupt the other devices around them.

When you go into a hospital, who engages you? Would you typically be working through the IT department or straddling between IT and biomed?

That’s part of the other issue. There’s that convergence of the biomed, the clinical engineering staff, IT, the medical device vendors. The FDA, while they haven’t made a real definitive stance on the regulatory requirements, which we’re all kind of waiting with bated breath for the medical device data systems — guidance, which they continue to say, will be coming shortly — they did come out in November and said, “Look, the spirit of the IEC 80001 risk management framework is that the device vendors and the hospital IT staff share a joint responsibility for making sure that these things work together. They collaborate on implementing them correctly to maximize patient safety and the effectiveness of the devices inside the hospital.”

If a CIO is unsure about whether they need your services, what are some warning signs that it might be time to bring in an expert?

I think there’s a lot of questions. Where’s this all going? Who’s going to be regulated? I think there’s just a lack of understanding, and that’s one of the things that we’re spending a lot of time on. Just really educating people as to the FDA or the federal government’s view of what is a medical device.

I think people have this misguided understanding that, “Oh, well that’s Boston Scientific or GE.” The traditional people that make these big medical devices that we all see. That’s them. We’re not regulated. In fact, it’s really based on the intended use of the device. Is it really intended to diagnose or treat a disease? And if so, what kinds of claims are being made about that and by whom?

There are lots of examples of where you could combine multiple devices and create a new device. Hospitals even cross the line themselves where they become, in the eyes of FDA, actually a medical device manufacturer themselves.

Part of what we’re doing through our alliance with Epstein Becker & Green, which is the largest healthcare law firm in the country, is to help them, from an end-to-end process, understand what all those requirements are and to help them with the risk assessment, the regulatory assessment. You know, what does this mean in terms of HIPAA and privacy requirements, all the way through the process.

We’re equal opportunity players. We’re looking at as anybody that’s participating in connected health could be a potential client of ours, because they’re all going to have some impact from the change that the network introduction really drives.

Are you seeing an increased interest by the FDA in what they could or should regulate?

I don’t think it’s an increased interest in what they could regulate. I think it’s more how.

I just came back from the FDA Medical Device Interoperability Workshop. It was co-sponsored by the Continua Alliance, CIMIT, and the Medical Device Plug-and-Play initiative that’s being driven out of the Boston area, Dr. Julian Goldman, and then FDA. This was a three-day event that I attended at FDA’s White Oak Campus.

The whole discussion is — we get it that this future of what we have to deal with, in terms of devices, really it’s not just ARRA/Hitech driving this. It really is a requirement. That to make healthcare better, we’re going to have to have devices talking to EMRs. We’re going to have the ambulatory side of the business. We’re going to have to have all these connected devices and we’re going to have to figure out a way to regulate that because our mission hasn’t changed — protecting the public health and safety. We’ve just got to figure out a way to do that.

I think they’re open to figuring out ways to work with industry and to work with other groups inside the government, to try to figure out how do we do this in this new world of networked connectivity; which is very different than what’s really happened over the last 30 years since they started regulating devices.

Did you get any sense from the FDA that they have any interest in regulating electronic medical records, or only this new connectivity to what would always have probably been some sort of medical device?

I think when it comes to regulatory exertion of what they’re able to do under the statutes; they have a broad range of discretion. It’s what they regulate. You could make an argument that an ambulance with all the connectivity devices on it could be regulated. That was an example that they used.

They’ve chosen, obviously, not to get that far. But software? Certainly software is prevalent in medical devices, and there’s clear guidance offered up by FDA about software that’s used as part of diagnosis and treatment of disease and all the software that goes into traditional medical devices.

I think they’re saying, “Look, we may or may not do that. There’s two ways you can get our attention. You can come to us with a submission that you feel like this could be a medical device and you want to go through that process because you clearly see that it’s a diagnosis or treatment — it’s a clear case of that. Or, something happens and we have to make some intervention in that.” So it really depends on those two kinds of factors.

I don’t think they’re looking for more to do. I think they’re overwhelmed with the social media and pharma. There’s a lot of stuff that’s on their plate … the globalization of research … but they made no bones about it that they’re there to safeguard the public’s health and safety. They’re watching very closely, with interest, what is the development of the HIT software industry. Longer term, I think it would be naïve to think we’re immune from that. We’ve never been covered.

It really depends on the statutory classification of the device and their interpretation of that. I guess at the end of the day, they determine what they regulate based on the law. The vendors don’t get to pick. I think there’s some that we’ve talked to that think, “Well, no, I’m not a device.” Making that declaration doesn’t necessarily make it so.

Should software vendors be afraid of what FDA oversight would be?

You know, that’s really the message; because I don’t want it to be, “Oh, we’re the onerous coming in with all the bad news that you’re going to be regulated.” I think what we’re really suggesting is healthcare really needs the innovation of information technology. It needs the new entrants from consumer electronics. It needs it from the wireless providers. It needs it from the general IT players. I think it needs the HIT vendors that are well established inside the hospital — all the guys that are going to be at HIMSS — to say, “You know what? We just need to understand what our role is and what our potential requirements are in this space.”

Our message is that you can live with this. I mean, look at the industry. There are thousands of medical device companies. They all make pretty good margins and are pretty successful businesses. They just deal with the regulations that are required. It’s just part of the table stakes to get into the game. I think people don’t need to be fearful of it, but they don’t want to ignore it.

I think our job is to help them understand those requirements and to set their business strategy based on that. Don’t wait until you come out with a product to go out and tell the market you’re in healthcare, and then try to figure out how to  deal with regulations. Make that a parallel effort right there up front as part of your strategy.

If you don’t want to be regulated, we can help you figure out a way where you totally stay away from that. You just provide components. Or, if you’re willing to accept the responsibilities with that and enjoy the really big margins, we can help you devise a plan to do that, too.

If you were advising vendors about practices they could voluntarily adopt that would prevent the FDA’s interest or would move them along the path that FDA wants them to take, what would you recommend?

I think following some of those quality system guidelines that are clearly laid out, which are a cut above ISO 9001. That’s another common fallacy, “Oh, we’ve got our supply chain; we’ve got our quality systems pretty well in hand with ISO 9001.” But it goes much more beyond that when you’re talking medical-grade systems.

I think there are some voluntary things that they could do to probably show the good faith of that, but there’s lots of ways to really strategize around that. That could be partnering with somebody that really has already embraced those requirements. If you look at GE, they have a broad footprint in healthcare. I think there are other examples. If you look at Intel, they clearly understand that they’ve moved in the device space. They did a 510(k) for Health Guide.

There are people out there looking at it saying, “This is something we’re going to take on directly.” There are some partnerships that other companies say, “I don’t really want to go to that extent. I want to stay away from that boundary line” that they can partner with.

I think the traditional players in software, the big EMR vendors and all, are going to really need to be monitoring this carefully and start thinking about the flipside of all of the interoperable health records. The connectivity inside the hospital does mean that things that were never involved before directly in diagnosing and treating patient illnesses now become a critical part of that.

I believe the folks in Washington are going to look at that very closely. Doing things the right way, maybe following some of those same processes that the device companies are already doing, and doing that voluntarily could certainly be a step in the right direction.

What kinds of innovation could run afoul with the regulatory environment if companies weren’t looking ahead?

I think all innovation is subject to that, but I think the ones that seem to be top of mind today are … I guess we really didn’t finish the first part. There are the two prongs of this. There are, inside the hospital wall, devices sitting on the enterprise LAN talking to the major software applications in place. There’s the other side of that, which is more of the remote monitoring care at home, monitoring of chronic conditions through wireless networks through your cell phone, connected to some other medical device to try to improve the quality of life, and to give people sort of this continuous monitoring of care and feeding that back to a call center where the nurse is.

There’s a lot of interest, there’s a lot of activity, and there’s a lot of great innovation that’s coming of that space, but I think there are some folks out there that may be pushing the envelope. I spent a long, 20-plus years in the traditional IT space and I know how IT marketing is. This one-upmanship. You’re always promoting your vision and you’re sticking it out there. You have to be much more deliberate about it when you start talking about marketing inside of healthcare, because you can find yourself backing into a situation where all of a sudden now you’ve completely put yourself in the purview of FDA regulatory requirements.

If you start making claims about things that your cell phone platform can do in terms of helping people monitor their diseases, you’re now involved in that. The same device … if you’re a manufacturer of a cell phone handset and you don’t make any claims about that and it’s just some of the other applications that are out there are using your device, then you can be exempt from that.

It’s an area that you can find yourself backing into it, and it’s a huge problem. Or, you can set that deliberate strategy and understand, “What are the areas that I need to stay away from?” That extends to not just marketing material you might have on your Web site, but it could be what your sales representative talks about, or what you talk about in a conference. There’s lots of ways you can communicate that, “Hey, I’m really involved in the care of patients” that companies need to be careful of.

The software vendors have traditionally just said, “We disclaim everything. We’re saying it’s not fit for purpose unless you say it is and it’s the clinician’s judgment.” Then bundle that with non-disclosure clauses, which would seem to be something the FDA wouldn’t want to see. Is that enough to keep the FDA away? Is just disclaiming your responsibility really a long-term solution?

No, not at all. It would have, really, no impact if there were a situation that they came up from somebody using one of these devices. Including software, because software clearly can be defined as a medical device under FDA current regulations — there’s no bones about it. They can step in and enforce that.

I think one of the telling things is if you look more deeply embedded in medical technology is this use of nanotechnology. On the Frequently Asked Questions page of the FDA Web site, they had a question about how you regulate nanotechnology. They said, “Look, we don’t regulate technology. We look at the statutes. We look at the claims. We look at all of the rules that apply to what our mission is, which is safeguarding the public’s health and making sure that the claims that are made about medical treatments are effective and valid and legitimate. That’s what we do, and we look at that regardless of what the technology is. So we’ll classify new, emerging technology according to our interpretation of the law.”

I think people are saying, “Well, they haven’t come out with any definition of how they’re going to regulate a network device.” Or, “They haven’t told us how we’re going to regulate nanotechnology.” But I mean, technology moves at such a fast pace. If you think about it, there were no medical applications for the iPhone until August of 2008. So the law and the regulatory requirements that move along behind that move at a much, much slower pace, but that doesn’t mean they don’t apply.

That’s really what we’re trying to help companies, our clients, navigate those two very diverse sets of reality. That you want to get that innovation out there; you want to continue to drive it. Again, there are some really interesting things that are going on in the connected health space, but at the same time you have to understand that you still have to play by the rules that all the established device companies have done for 30 years.

The connectivity to the devices will help hospitals accumulate large quantities of patient clinical information, which will probably have a lot more research value than anybody had really thought of. How do you see that tying together both the collection of data that maybe wasn’t really integrated with normal software-type data before, and then what the requirements will be to both collect it and use it?

Clearly that’s part of this whole notion of connected healthcare where we insert this interdependent network between all the different players. So you get the payer, the providers; you’ve got network participants right now that I think are pushing the bounds of … they’re both doing some really good things, but you start wondering about these decision support tools that you use based on some remote analytics engine and some big information repository out there in the sky. But now since it’s involved and the doctors directly rely on that and there’s some sort of workflow enablement that’s part of that, it really drives right to the heart of it.

To answer your question about the data … as it moves around, it can actually traverse different regulatory jurisdictions. So if you think about it, there’s a lot of interest by the big drug companies in looking at EMRs as the source for clinical trial data and for clinical trial participants. But as that data moves from an EMR to an electronic data capture system, let’s say, which is basically the same thing but it’s done for clinical trials, it’s now moved from the privacy rules of HIPAA over onto 21 CFR Part 50 and 56, which really governs the privacy and treatment of information for clinical trial subjects. So as data kind of moves around in the network, it can actually move between jurisdictions of different federal agencies.

Again, we want to provide a clear knowledge base so that people have a clear understanding as they’re setting up their strategies to say, “How I approach healthcare?” especially if they are new to this business. It’s very important to understand all the different layers of complexities, including one we haven’t really talked about much — how do I get paid for that?

As you know, inside the hospital, all those things are really being driven by how private insurers pay us. Is it medically necessary? If you look at CMS, it’s reasonable and necessary — and there’s very definite restrictions on that. I’ve talked to a number of companies that say, “We want to get into healthcare. We’re really excited. We’ve got all this cool technology.” Then we’re like, “OK, well how do you intend to get reimbursed for that?” “Oh no, we don’t even want to mess with insurance. We’ll just sell it to the consumer.” I think that’s a really flawed assumption when you’re moving into that space because most consumers are still going to look to their health plans to pay first. Even if it’s a comparable cost to maybe some big consumer electronics purchase, we’re just conditioned to look at that first.

So now they’re moved into this whole area of not only am I looking at FDA, but I also have to look at CMS, and then what do I have to prove to the medical directors at all the big insurance companies? Then, just throw in Meaningful Use along from ONC. There are lots of really small phrases that can have very impactful meaning.

I like to sum it up to say that with FDA, it’s safe and effective. CMS, it’s reasonable and necessary. ONC, it’s Meaningful Use, secure and interoperable. Those are fairly simplistic words, but they’re very complicated to actually deploy in real life.

Anything else?

Our big goal is that we have a vision, not to come in and be the bearer of bad news, but to say healthcare absolutely needs IT. When you put healthcare and IT together, it becomes HIT and it’s different.

What’s really different? I think it’s this aspect of clinical treatment of human beings. It’s different than retail. It’s different than manufacturing. It has important nuances to it that we want to make sure that they map into their strategies. We want to help them get that innovation to market and comply with the law and the regulations that are part of that. That’s our goal.