HITlaw 3/9/10

Non-Compete Agreements

Non-compete agreements (NCAs) are designed to prevent individuals from leaving a company with valuable information and then using that information in a new job with a competitor of the company to the detriment of that original company/employer.

Sounds reasonable on its face. On the other side, what if you are the employee that with no malicious intent whatsoever, elects to change jobs and move on to bigger and better things? You should be free to do so, right? If on exiting your current job you are presented with the NCA that you signed when starting (and may have forgotten or misplaced) and you are a valuable developer, your soon-to-be former employer may be dropping more than a subtle hint in your lap.

So what is fair and reasonable in light of the two justifiable yet opposing positions?

This is the essence of the determination that courts must make in cases involving NCAs. In general terms, in order for an NCA to be “reasonable” it must protect an employer’s legitimate business interests while not unduly restricting the employee’s ability to work elsewhere. Other key considerations are length of time and geographical area (historically). The first part, protecting legitimate business interests, is satisfied if the employee involved had access to trade secrets of the former employer. Further, if the employer uses NCAs for only certain employees that have access to confidential material or trade secrets, they strengthen greatly their likelihood of support from the courts. As for length of time, six months to two years depending on the situation, is usually found to be acceptable. Anything longer than that would require a stiffer business reason for the restriction. Finally, geographic scope is considered. In the technology industry however, geographical area could include the entire US market. There has been some relaxing of the geographical scope restriction, which is why I used the parenthetical “historically” above.

Note that the NCA is a contract. All contracts must have “consideration”, or something of value, offered by each party and consequently accepted by the other party in order for the contract to be valid. If the NCA was a condition of employment at the point of hiring, then the promise of a job fills the consideration requirement. Introducing the NCA in an existing employer/employee relationship is different. Some courts have held that continued employment is sufficient consideration. In other cases, the execution of the NCA in conjunction with a raise or promotion has served to establish that sufficient consideration is present to enforce the NCA. An employee faced with the new (post-hiring) NCA requirement may not have any reasonable opportunity of negotiation. Some may however. If the employee is a valued software scientist, then ideally that individual could seek a severance package, providing an amount of money sufficient to offset the period of time in which they are prevented (by the NCA) from working in the same field for a competitor. As a general statement, the employee should always review the NCA carefully, even seek legal advice, in order to determine the restrictions imposed and the reasonableness of those restrictions.

The employer should make sure it is seeking to protect a legitimate business interest, and NOT just that it does not want competition. Lack of a justifiable business reason could be argued in the case of an employer having all employees sign an NCA, regardless of position, from receptionist to software engineer. Limited duration and geographical area are also helpful. An NCA of unlimited duration, where the employee can never work for a competitor, would work against the employer. In short, if the employer is careful to make the NCA as tight in scope as possible, in order to make the burden on the employee as little as possible, then they are in much better shape if the NCA is contested. If an NCA is too broad and lacks a sound business reason, its enforceability is strongly suspect.

Where a valid NCA exists, the new employer may also be susceptible to legal action by the former employer. Employers that lose key personnel to competitors often bring action against both the former employee (for violation of the NCA) and the new employer (for tortious interference with the prior relationship evidenced by the NCA). It is not unheard of for a new employer (that lures the key employee away) to belly up and take care of the employee’s anticipated defense, legal bills, and settlements with the former employer. I am not trying to scare people, but it should be understood that if an NCA is valid and you breach it, you are potentially liable for damages to your former employer. In addition, the former employer could seek an injunction preventing you from working for the new employer while the case is decided. Finally, if everything goes the former employer’s way, you could still be prevented from working for the competitor into the future. If you are the employee considering a job change and you asked directly if you signed and NCA, then obviously you must reveal the fact. If not asked and you do not volunteer the information, and the former employer sues the new employer, then the easiest way for the new employer to reduce its exposure is to terminate you. Not a welcome thought.

An interesting twist to consider is the situation where the employer terminates the employment relationship. Assuming that the NCA is valid and reasonable (see above), and would probably be upheld if the employee were the one terminating the relationship, then the issue really comes down to a restriction on the employee’s ability to make a living when the employer terminates employment other than for cause. Keeping in mind that we started with the assumption of a valid NCA, then strictly speaking, the employee is not free to ignore the NCA and the former employer could sue the employee, but then the court would have to look at the fact that the employee did not leave voluntarily and determine the reasonableness of limiting that individuals livelihood. My point is that being “let go” does not nullify the NCA, but enforcement by the former employer will be more difficult than if the employee left on their own.

Note that NCAs should not be feared, but they must be understood. In the HIT industry companies invent things and they try to sell more of these things to the industry than their competitors. They have a right to protect their inventions, know-how, trade secrets and customer bases. Anyone seeking to join such a company really should understand this going in. That said, it is not reasonable to expect a person to work for only one company in a given industry for their entire career. Some do, most do not. There is also the consideration of the type of work that the employee performs. The software scientist should have far more expectation of restriction on the ability to switch to a competitor than an administrative staff member.

Final Comments:

NCAs are not bad. If a company has something worth protecting, something essential to its business that if shared with a competitor would be damaging to its business, then they should be able to protect it. I don’t know how an employee would consider it “OK” to take that information elsewhere. I know it happens, but that does not make it right. Separately, we are all free to work wherever we choose. Absent the malicious factor, people should not be restricted from working for a competitor.

The problem is that you cannot unlock the brain of a software scientist, extract all they have learned at your company, then let them go on their way. Knowledge is retained and there is nothing we can do about that. I once saw it referred to by a BIG hardware/consulting company as “intellectual capital” (and I knew it was time to put that file down for the day). So even if nothing is physically removed, the secrets go right out the door in the scientist’s gray matter. Keeping them from using that knowledge to a competitor’s advantage is fair. Keeping them from earning a living doing what they like is unfair. It is a balancing act, a weighing of the consequences to each side, and a determination of fairness that the courts must perform when ruling on NCAs.

Please understand that even though I expound on valid or enforceable NCAs above, you must note that certain states basically do not permit NCAs (like California), others do but only in limited circumstances (New York and Virginia), while in others enforceability depends on the circumstances. This article has focused mainly on the individuals involved in the technology aspect of healthcare. Many states (like Massachusetts) clearly prohibit by law NCAs for physicians and nurses due to the fact that such agreements restrict a medical professional’s right to practice and also limit the patients’ right to choose their caregivers.

The NCA issue is heating up. Legislation has been proposed here in Massachusetts that would dramatically restrict NCAs by instituting strict guidelines, brightline determinations (clear “black & white” language) as well as safe harbor provisions. One very interesting aspect of the proposed legislation is that it would protect the employee residing in Massachusetts, even if the employer is not located in Massachusetts. I am watching closely as the bill winds its way through the legislature.

Finally, if you are faced with a situation involving an NCA and have serious concerns, please consult with an attorney or your local US Department of Labor office.

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

Monday Morning Update 3/8/10

HERtalk by Inga

From: HIS user “Re: Rumor. (The CEO for the HIT business unit) of a (large, international technology company) has resigned. Heard from multiple direct sources at the company. Was announced there Friday.” The CEO was at HIMSS and had a press conference as recently as Monday. I sent a note over the weekend to the company but not heard back. If it’s true, I suspect the company will share the news Monday.

From: Bean Town Gal Re: Highlights. “We attended the HIStalk party and it was a highlight of HIMSS. Nice to be in the fishbowl; surrounded by friends and competitors — and truly enjoying it. Great vibe — thank you to the sponsors — the spinach & artichoke dip was yummy, GREAT to sit down and rest the paws after a very long day …. but most of all, the intrigue and credibility that you & Mr. HIStalk create, will keep us coming back again.  Truly appreciate what you both do. Kudos and …. Love the shoes.”

From: Beastly “Re: Press Releases. As PR professionals we are compelled to issue press releases when our companies bring new products to the market that are worthy of acknowledgment. A true PR professional knows the difference between newsworthy and wasting a journalist’s time. We also have an ethical responsibility to advise our clients if and when their perception of news doesn’t merit coverage. Issuing press releases about non-news compares to the ‘boy who cried wolf,’ syndrome. For many within the healthcare industry, HIMSS is our Super Bowl. The opportunity to showcase the products we developed, believe in and are proud of. The media and most importantly our customers expect to see us with our best game. Companies don’t indiscriminately issue press releases – they plan product releases so that they coincide with HIMSS. If a product is ready two months before HIMSS, the HIMSS exhibitor companies traditionally wait for HIMSS to show and announce it.  And if the product won’t be consumer ready until a few months after HIMSS, the exhibitor will often develop a mock-up or engineering sample so it can be shown to the audience at HIMSS. The majority of us aren’t trying to waste your time; we’re inviting you to share our exuberance.”

From: Pat Avatar “Re: HITmen event. I was unimpressed with the “boys club” HITmen event. I think it was very unimaginative. Same people named over and over. A while back, Colin Powell was quoted along the lines of if any area was in need of imagination, it was healthcare. If we keep trotting out the same handful of people – we are truly in trouble. Enough of Tullman, Bush, the government appointees who are elevated only by title and not by progress, Halamka, and the usual short list. Why not have someone meet the challenge of recognizing the worker-bees – the ones really getting the job done – while the same people are the headliners. Besides, Inga and I are going to take over the world of healthcare and get something done.”

Note sure that I am going to take over the world of healthcare (or that I want to) but I am taking over HIStalk for the week. An exhausted Mr. H is taking took some well-deserved time off and hopefully cleansing his mind of the HIT world. If you have any news to share, be sure to send it my way since Mr. H is avoiding e-mail this week.

Last week MS HUG and Microsoft announced four winners of its annual Innovation Awards. SingHealth earned honors for the best use of inpatient clinical records use for levering its implementation of  Eclipsys Sunrise Patient Flow and CADI Scientific. Other winners included Brigham and Women’s Hospital, Doylestown Hospital, and Premera Blue Cross/Get Real Consulting.

Former McKesson Charles McCall is sentenced to 10 years prison and ordered to pay a $1 million fine for his part in a $8.6 billion fraud scheme.

Medicity and Emdeon collaborate to create the first “converged national HIE, leveraging Emdeon’s network of payers, providers, and pharmacies and Medicity’s iNexx Health 4.0 platform.

The Advisory Board Company enters an agreement to acquire Concuity, the healthcare-focused RCM software and services division of Trintech Group. Price: $34.5 million.

The Wall Street Journal reports that shares of Nuance Communications rose 5.7% Friday on rumors that Google is interested in buying Nuance Communications. There are lots of reasons why such a marriage would not make sense, but an acquisition of Nuance would certainly help Google increase its presence in the healthcare space.

McKesson is named the “World’s Most Admired” company in healthcare wholesalers sector in a survey by FORTUNE magazine and the Hay Group.  McKesson also made Corporate Responsibility Magazine’s list of 100 Best Corporate Citizens.

Start queuing up at your local Apple store: the Wi-Fi-enabled iPad goes on sale April 3, with pre-ordering starting March 12th. Suggested retail prices will range from $499 for the 16B model to $699 for the 64GB. The 3G equipped models will hit the market in late April, though you can also pre-order starting March 12th.

Lumetra PSO agrees to provide iSOFT’s AIMS incident management software to US healthcare organizations.

Bridgehead software unveils preliminary results of its Data Management Healthcheck 2010, reporting that only 6.5% of respondents use cloud storage as the destination media for their organization’s data. Only 33% say they are planning to adopt a cloud storage strategy for any data over the next 12-24 months. The biggest concern is security and availability of data using a cloud strategy.

A couple HIMSS education sessions I missed: “A Big, Hairy Audacious” CPOE Goal, and, It’s More than Pizza! Improving House Staff Adoption of CPOE. I wonder if the presenter for the second one got any snack tips from Mr. H.

Former RelayHealth COO Jeff Bairstow joins Journal Register Company as CFO.

RWJF awards over $2.4 million to five research teams studying how patient-recorded observations of daily living can be captured and integrated into clinical care.

Wellmont Health System (TN) names Kent Perry CIO and VP and Dr. Troy Sybert chief medical information.

Verizon Business launches The Verizon Medical Data Exchange, a platform that gives transcriptionists an interoperable tool for sharing digitized patient notes.

A fan files suit against the Kansas City Royals after being hit in the eye – by a hot dog. The team’s mascot (Sluggerrr) regularly fires hot dogs into the crowd, but one last year hit John Coomer in the eye, resulting in a detached retina and cataracts.So far his medical costs have exceeded $25,000. It’s unclear whether Cooner actually ate the errant hot dog.

E-mail Inga.

Merge Healthcare To Acquire AMICAS

AMICAS has agreed to terminate its previously announced agreement with Thoma Bravo and instead has entered into a merger agreement with Merge Healthcare, the company announced this morning. Merge will acquire all outstanding shares of AMICAS in an all-cash deal valued at $6.05 per share, a 35% premium to Thoma Bravo’s offer and a 39% premium to the average monthly share price.

"We are very pleased with this significant positive step toward successfully combining these two great companies," said Justin Dearborn, Merge CEO.  "Merge and AMICAS have strong histories of innovation in medical imaging software, experienced employees and engaged customers.  As a combined company, our suite of health IT solutions will encompass a broad range of medical and biopharmaceutical imaging solutions to meet the needs of today’s medical imaging providers.  In addition, Merge’s OEM and CAD technologies, international and eCommerce distribution channels, and additional market segments such as clinical trials provide new opportunities for AMICAS products and customers. On behalf of everyone at Merge, I look forward to welcoming and working closely with the AMICAS team."

HIStalk Interviews Charlie Harp

Charlie Harp is CEO of Clinical Architecture.

Tell me about the company.

I started Clinical Architecture about two and a half years ago, with our focus being primarily — I always use the term “plumbers” of healthcare information. What I mean by that is having worked in the industry, both from an end user perspective when I did clinical trials and hospital labs, to when I spent time at Hearst Business Media at First DataBank and Zynx on the content side. I’d worked with a lot of vendors that worked with a lot of organizations and I really thought that by creating a company like Clinical Architecture, we could help be a catalyst to improve the effectiveness of the implementation of content in the healthcare environment.

With Clinical Architecture, we started out doing mostly consulting, where we would work with content vendors and system vendors and end users to really focus on the problems they were having either with content design, integrating of clinical content or terminologies into their environments, or helping to manage some of the unexpected aspects of working with clinical content in a live environment. As we went through that process, we started seeing the same patterns over and over again. What we do as a solution provider is we try to provide what I call “plumbing solutions” to help with those common patterns of disconnection or dysfunction.

Most doctors do not find clinical warnings useful, even overriding most of the allergy warnings. How can that content be better used?

From my perspective — and I’m a simple country programmer, I’m not a clinical person — I’ve just been in this field for a while and I’ve seen a lot of dissatisfaction. I think a lot of it revolves around the fact that when you look at the content we have today and you look at the way that these healthcare systems have evolved, the content, when it was built and the structures that are still in use today, were built for a different audience. A lot of the clinical content that exists today, and a lot of the terminology, started out to support retail pharmacy, at least in the United States.

What happened is those content modules migrated their way into the inpatient and the practicing setting. It was put in front of physicians how a pharmacist, especially a pharmacist in a retail setting, deals with interruptions and deals with alerts. It is extremely different from how a physician does, or a nurse does, because their time constraints are very different. A physician is right there at the point of care trying to make decisions, and so if something isn’t really relevant, it’s not going to be perceived as useful.

I think that is where we are today. There’s another aspect there, too. Just to clarify, I think part of it was the electronic medical record was really not something that people felt was comprehensive. In fact, I remember speaking to a physician once who said that, “You know, Charlie, 40-60% of what I know about the patient is not in the computer — it’s in my head.” I think that’s been true for a long time.

I think that we’re at a point now where these electronic medical record systems are evolving. Whether they’re being driven by some of these incentives coming out of the Administration, or whether they’re being driven by just the need to resolve a lot of these medication problems or medication errors we’re having in healthcare — I don’t know, but I think the industry’s evolving. EMRs are evolving, and so that creates an opportunity for the clinical decision support content to evolve to be much more relevant. I think we’re just at the beginning of that era.

Do you think software vendors were too complacent in just letting the content providers tell them what they had and then just throwing it on the screen and calling it clinical decision support?

I don’t know that I would use the word complacent, but I think you’re right in that the content providers maybe didn’t have the content that the system vendors needed. The system vendor is in a Catch-22 because they develop this next-generation, cutting-edge system that requires a certain complexity and content to drive it and there’s nobody providing that kind of content. They’re on the hook to do it.

I’ve worked for content companies for a long time and it’s a lot of work. Building content and managing terminologies is definitely non-trivial. Clients might not like your content, so they might want to have the option to switch. You’re almost forced into a least common denominator position where you have to accommodate what’s available.

I’ve worked with a lot of content provider folks over the years. They’re all very noble and they’re trying to do the right thing and they work real hard, but when you try to introduce some new content, if there’s no place for it to go because no system is advanced enough to utilize it, that’s a Catch-22 as well. Developing new content is a non-trivial investment, and developing systems that are being driven on new content that doesn’t exist is a non-trivial proposition.

I think between the two, that’s where we’ve been stuck for a little while. I’m hopeful that a lot of the changes that are happening in healthcare today around improving the medical record will be the tipping point that we need to move forward.

I’ve always argued that there’s an attitude built into clinical decision support that says physicians can’t be trusted to determine what they need or find useful. What do you think would happen if individual doctors had the option to either detune the warnings for themselves personally, or to turn them off by saying, “I don’t want to see any more like this”?

I think that there’s nothing wrong with that. Once again, I’m not a clinical person, but I think that a lot of the clinical decision support is local. I think that the objective of a content provider is to provide a framework and a starter set and having the ability for the local population to tune certain things out. I mean, when you look at clinical alerts, there’s certain things that should never be done. Whether or not people should be allowed to turn that off and then woe be unto them if it results in something negative.

I guess that’s the option, but I think that the first thing we need to do in clinical decision support is make alerts that are much more contextually aware, because I think the physicians will be less likely to turn something off if every time they get an alert it was relevant to their patient and to what they’re doing. The other thing I think happens sometimes is you’ll have people that turn alerts off — so they give the physician the ability to just turn of a particular alert — because it’s not relevant to that patient, but it might be relevant to the next patient.

I think a lot of it has to do with our ability to apply alerts in a granular and effective way. If we can get better at that, then the physicians will be less likely to turn it off because every time it fires they say, “Wow, I’m glad I got that alert.” I don’t think that is the reaction you get today.

Do you think the content providers are concerned about their own legal liability, or some FDA interpretation that maybe they’re offering what sounds like a medical device? Do you think their incentive is to just alert for everything because not doing that could get them in more trouble?

I think that whenever you’re dealing in this space, there’s concern about liability. I think for some people, to err on the side of over-alerting in order to protect yourself. I don’t know that I would say that’s necessarily the case, but I think that part of the problem is when people create clinical content, they’re getting the content from somewhere.

For example, if I’m going to the package insert to drive all my clinical decision support, well, the package insert is really something that is designed around liability. So, one could argue that if something’s purely based on the package insert, it’s going to be alerting more often than not. I think the issue though, is I think it really has to do with what sources are available for information.

I remember once I was somewhere and somebody really wanted accurate pediatric dose checking and for neonates and for preemies. The problem, of course, is a lot of the data you get to drive clinical decision support comes from human trials and comes from case studies. Not all populations have case studies, and so sometimes it’s hard to come by really good information. So then you start leaning more on expert opinion, and sometimes people are concerned about how their advice is being carried forward into the point of care setting. But just in general, I don’t know that I would speak for how the content providers are positioning themselves in their content.

Given that whole emphasis on some grading of the studies and weighting of the evidence and the severity and all that, do you think there are opportunities for individual providers to create their own content based on local experience? In other words, I go to a doctor and say, “Here are some things we might do. Tell me what would be important to you in your practice.” Or is there any new use of content that isn’t the same old stuff? Is anybody doing anything creative with it?

I think what’s going to happen is … I mean, even when I was in my last job at First DataBank, we were seeing a lot of people who would use our content as a starting point, but they would also have you build and localize it. We actually built tools around localizing, and I think a lot of the system vendors and content vendors are moving to accommodate that.

I think it has to do with the fact that if you’re at a large teaching institution, you might have some additional rules in clinical decision support that you want to use to augment what’s coming from your vendor. You might also want to be able to turn off some of the things that are coming from your vendor because you just don’t agree with it. I think localization is something that’s going to start to happen.

But the other thing I think that’s going to start to happen is, as we improve the plumbing and we lower some of the barriers that the terminology creates, I think it creates an opportunity for other folks with new content to put that content out there; whether they’re a university or whether they’re a particular collaborative group. To put together content and make it available to people.

We’re not there, I don’t think, today. But I think that’s something that could happen in the future. I do believe that clinical decision support is local. In fact, when you look at the ARRA Meaningful Use, I like the introduction of the five rules because it almost says, “You really should be thinking about local and what kind of local things you need to look for.”

There was that point, maybe ten years ago, when Eclipsys bought the BICS rules from Brigham and Women’s. That never seemed to go anyplace and neither did the idea that there’s some open standard where individual providers can exchange Arden Syntax or whatever they’ve written their rules in. Is that ever going to catch on, that people will use rules that were created elsewhere? Or share rules via some sort of exchange process?

I’d like to see it happen, but I’m not sure it’s going to happen in the public domain. The only reason I say that is, building content … healthcare is constantly changing and building content is not easy. I really think the public sharing of information without some way to fund it and some dollars to help cover the costs of the content’s development, whereas I think it’s a great idea and I would like to see it happen, I just don’t know if it’s financially feasible. What happens is you create content and that content has a half-life and you need to be updating the content, and you need to maintain the content.

The other problem is if there’s some kind of sharing environment that’s driven by Sponsor A or Vendor A, Vendor B, if they’re a competitor, is not going to want to promote that and be compatible with that because it’s their competitors offering a standard. In fact, with Clinical Architecture, one of our goals was to be a neutral plumber to maybe help bring about a time when people can have general plumbing for sharing clinical decision support content without having to worry about their competitors and whether or not their competitor is behind it or not.

You mentioned the Meaningful Use proposed criteria. Do you think those proposed criteria and the reimbursement guidelines say enough about clinical decision support, and also the specific taxonomies and the architectures that they’re suggesting that is needed to go forward with it?

I think that they started us down a path where just saying that Meaningful Use means that the computer needs to do some of the heavy lifting, is really the way I read the direction of Meaningful Use. I think that there are things that computers and software are really good at when it comes to minutiae and tracking details and correlating data, as long as it has meaningful information with which to do it. I think that moving in that direction is good.

There are a lot of different definitions for what clinical decision support is. So I’ll be kind of narrow and say, “computerized rule checking around patient context to provide advice and alerts about something going on with a patient.” I think that there’s still a ways to go to evolve clinical decision support to be meaningful, because I think if we just perpetuate what we have today, you’ll still have people who get frustrated and turn it off.

I think when it comes to terminologies — I think that we’re a ways off from getting to the point where we don’t have multiple terminologies out there. Part of that is because of just the rate of change in healthcare is slow, and a lot of it has to do with the criticality of these systems. You can’t just unplug one and plug another one in, as I’m sure you well know. When you introduce something new, it takes time.

A lot of these third party terminologies are pretty ingrained; whether they’re a local terminology that someone builds, or whether they’re one they bought — they’re pretty ingrained. So, getting them out, if that ever happens, will take a while. The standard terminologies that are promoted in ARRA, whereas I think they’re a good start, need to evolve to really meet the demands of what we’re going to be asking them to do, as well.

Are we’re relying too much on content that was designed for billing, like ICD-9 and CPT codes, and trying to make it into something it never was intended to be?

Oh, I think so. I think that when you look at the general codes that are used most in healthcare today, the CPT, the ICD-9, and in the drug world, the NDC code — those were all really built around transactions and billing. But that’s kind of our roots. That’s where the US healthcare system came from is transactions and billing. What we’re trying to do is evolve into systems that are based upon a clinical framework.

If you look at other countries where they didn’t come from there, it’s very interesting to see how those systems have evolved because they look different than the systems we’re used to here in the states because they don’t have those aspects. Whenever you try to take data from the states and introduce it into those other countries they go, “Well, why does it look like this?” It’s because of where we came from.

I think that the danger is when we create new terminologies that are designed to be clinical terminologies, we need to evaluate the characteristics of those terminologies. I’ll give you an example, and I think I have a blog entry on this.

ICD-9 has a bunch of concatenated terms in it and they’re conditions or problems that are put together in a particular order because it facilitates billing activity. Well, when you look in SNOMED, we’ve started introducing those same types of concatenated terms. The problem is the concatenated term is very difficult to leverage when you’re doing clinical decision support because you’ve created a term with multiple meanings. Any time you have a term with multiple meanings; it results in things getting a little fuzzy.

It almost looks like, in some of these cases, the SNOMED CT codes — and I don’t know this for a fact — but it looks like they’ve shadowed ICD-9 to a certain degree. If SNOMED is going to be our clinical terminology, we shouldn’t be doing that. We should be saying, “Well, we want to treat this differently.” But it’s difficult because you can’t be precognitive and know everything that’s going to happen. There are a lot of unintended consequences when you create a terminology, but I do think that a lot of the problems we have stem from where we’ve come from with these terminologies.

You would think that the one giant test bed that’s out there that could maybe take a different direction would be the VA, since they don’t worry so much about billing and they’ve got clinical systems that are mature. Are they doing any work that would be innovative that might find its way into the average hospital?

They may be. I haven’t done a ton of work with the VA in these last couple of years, so I don’t know that I could give you a meaningful answer in that respect. If they’re not encumbered by some of the issues that a lot of these other systems are.

I actually think a place where things would be interesting is some of these newer systems, especially some of these Web-based systems that don’t come from a background of being charge capture systems. That’s one place to look. I think looking at the systems that are coming from other places, just to see what patterns they’re using to capture and deal with clinical information, I think, would be interesting.

Is metadata and semantic interoperability the next hurdle?

I’ve spent a lot of time in the last year working on interoperability, and I think that there’s a lot we can do with interoperability to get us to a next evolutionary step. I think, ultimately, if you have systems that are using whatever code they’re using locally and are loosely coupling to a standard for data exchange, interoperability becomes a lot easier.

For example, if I’m using content vendor code A or my own local codes, but in that dictionary in my system I also have the RXCUI. When I go to exchange data, if RXCUIs are comprehensive from RxNorm, then I can exchange data meaningfully. I think that between those points, in our utopian future and today, I think that there are some roles for metadata in understanding and correlating terms.

I think that the UMLS Metathesaurus and RxNorm are a good start, but a lot of people go to them thinking they’re the ultimate key to fixing the problem, but they’re really not, at least, not yet. It’s one of the reasons why we built our SYMEDICAL product. We were working with a bunch of clients and seeing the same pattern over and over again where they’re trying to exchange data.

There are really two problems today. One is to map from one terminology to another is an extremely manual and time consuming process. Because of that, the second problem occurs; which is if there’s something you don’t want to do because it’s long and painful, you put it off. So a lot of people will build a map and it’ll cover a certain percentage of the things they’re trying to exchange, and then two years later the map is severely out of date because code sets are constantly changing. Much more so than people think they do.

One of the reasons we built the product we built was to let the computer do some of the heavy lifting. It really leverages metadata and contextual parsing to do that, and it actually does a fairly good job. I think that when it comes to interoperability, having tools out there in the public domain like UMLS Metathesaurus and RxNorm help. Having tools that help domain experts at institutions, or vendors and facilitates the mapping process also helps. Then staying on top of it and not letting things go for a year before you get it updated again, especially now that we’re leveraging the electronic medical record and really pushing it more and more.

Who is your customer, and has their interest changed with the emphasis on clinical systems and Meaningful Use?

Our customer — like I said, we’re kind of a across the field. We work with content vendors, we work with system vendors, and we work with end users. But when it comes to the changes I’ve seen in the last year because of the HITECH initiative, I think that a lot of it has to do with it drives or prioritizes certain things to the top. There are a lot of things we should do as a healthcare industry. There are things that we should do, and then there are the things that someone’s willing to potentially pay us to do. What I think has happened is number one; raised more awareness, and it has given people an incentive to accelerate the process, which I think is good.

For example, we also help people implement content and get decision support up and running. In the last year, we’ve seen a lot of people who previously didn’t do decision support, didn’t have structured terminologies, are now really feeling the pressure to do so — which is good, because before everything was free text, and if people wanted to do checking, they really couldn’t, at least not in a computer-assisted way.

I also think when it comes to interoperability; there are people who probably don’t want to deal with interoperability. This forces the issue, which is also good. We’ve still got to sift through and decide about standards and formats and all those things, but putting the notion of interoperability forward is good because ultimately, for me, it drives Clinical Architecture. It’s one of our primary goals, which is about making healthcare more effective and improving patient safety. With interoperability the way it is today, there’s a lot of manual reentry, there’s a lot of free text information, there’s a lot of potential clerical error and human error.

Whereas, if you can increase the fidelity with which systems communicate with each other, and those codes are being exchanged more accurately, you increase the efficiency of the people that are actually trying to manage the movement of data. You increase the accuracy of the data that’s in the patient record. Therefore, when you do clinical decision support, or when you’re looking at things about the patient, you’re actually going to have a better picture of what’s going on. No clinical decision support will help you if you don’t have any coded data that can drive it.

Any final thoughts?

There’s a lot of people that build really good systems, and there’s a lot of people that build a lot of really great content. What I try to do with my contacts in the industry is to push them a little bit and say, “You know, I think we could do better.” I think there are things we can do, and it’s not easy.

Another quick sidebar is I think that one of the things that people aren’t really ready for, which I’m not sure they are, is if we ratchet up the electronic medical record, there’s a lot of housekeeping. In the past, and electronic medical record for a lot of systems, was probably an episodic transitional thing where the patient comes in, they leave, and you might pitch the electronic record until they come back the next time and they fill out the form again. But once you start persisting that and you’re relying on it over time, there’s a lot of housekeeping that goes along with that. There’s a lot of cleanup because the codes are always changing behind the scenes. Information’s always changing, rules are always changing.

I think the next big thing that’s going to happen to the industry is once they really start persisting and dealing with the reality of the medical record that’s coded and structured, they’re going to have to deal with “how do I make sure that it’s accurate as time goes by” I think that’s going to take a village. That’s where interoperability comes in, because ultimately, your electronic medical record is not just your doctor’s office, not just your pharmacy, not just the hospital. It’s the meaningful combination of all those things put together. It’ll be interesting.

News 3/5/10

From JT: “Re: speech recognition. I know of patient populations that might be able to use it because of disabilities. Any information you can share is greatly appreciated!” Dragon Naturally Speaking is the standard and the one I bought. It not only does an amazing job of hitting 99% accuracy right out of the box, but also allows controlling Windows functions by voice (like using Word’s menu bar, navigating files, etc.) I know the military puts it on laptops for recovering soldiers who can’t use their hands, giving them a way to use the PC, use e-mail, etc.

From The PACS Designer: “Re: Microsoft Windows Phone 7. InformationWeek has posted a video gallery for the new Windows Phone 7 application. It should give us a good comparison to Apple’s iPhone.”

From Anon: “Re: Epic. Last Monday, Luke O’Voron reported that Judy Faulkner used the HIS Policy Committee Privacy and Security Workgroup call that week to shill for Epic. The transcript is posted (warning: PDF) and I can’t find anything in it remotely like what Luke said. Do you read it the same way?” I don’t see anything that looks like shilling, so I’m not clear on the original reference either.

Listening: Band Marino, possibly defunct indie pop from the Orlando area. They sounded good on the Clemson radio station I was playing in the car this morning, so I checked them out. My favorite tune is here (video).

The strange courtship of Amicas continues. The Amicas board now decides that Merge’s offer of $6.05 is better than the $5.35 one from Thoma Bravo it previously supported (duh). So now it’s back to Thoma Bravo to make a new offer by Monday, which of course they should have done immediately instead of sitting around waiting to have their hand called. Amicas has pushed its shareholder meeting back from March 4 to March 16. PACSMan weighs in on Dalai’s PACS Blog, using one of my favorite movies (Wall Street) as a backdrop. He even quotes the Greed is Good speech that I could recite nearly verbatim like the guys in another great movie, Boiler Room.

Here’s Dr. HITECH, Ross Martin, MD, doing the world premiere of his excellent Meaningful Yoose Rap at the reception.

The VA and DoD disconnect their shared EMR connectivity after after data errors are discovered, first noticed by a doctor who wondered why a female patient had been prescribed an erectile dysfunction drug. As a risk manager pointed out, it’s a good thing at least one error was obvious enough to raise a flag.

Prompt Medical Systems, a “vendor” whose only asset is a CPT entry patent and whose only business is suing other vendors (it doesn’t even have a Web site that I could find), files suit against nearly everybody selling an EMR, extending a string of lawsuits going back to 2005. A Virginia investment banker apparently funds the lawsuits, filed in friendly Texas courts.

Lakeland Regional Medical Center (FL) selects API Healthcare’s time and attendance and remote hosting solutions. API also announces go-lives at seven provider organizations.

A Microsoft VP makes an odd suggestion: treat PC security as a public safety issue and collect taxes to fund “hospitals” that will remove viruses and reduce their spread. Seems like that’s their job, especially since Apple users aren’t having problems.

A survey says 58% of doctors not using EMRs now plan to buy within two years, but would prefer a hospital help cover the cost. Federal incentives and penalties were cited as the main adoption drivers.

Eclipsys announces Helios, its open architecture platform that exposes Sunrise Enterprise 5.5 to third-party developers. Already building add-ons: Microsoft, Capsule Tech, and Hill-Rom. A reader asked why I hadn’t mentioned it, with the main reason that John Gomez already talked about it here when I interviewed him right before Christmas. ECLP calls developers out in the Helios site: “An open invitation to innovate. Competitors welcome.”

Merge Healthcare and Mass General will partner to build a testing environment for mobile healthcare applications.

Odd lawsuit: an IHOP cook accidentally cuts off his fingertip, which nobody can find. It turns up in the fried chicken salad of a woman eating after-church brunch. She suing for $20.5 million.

E-mail me.

HERtalk by Inga

From Midwest Doc: “Re: roundtable with Blumenthal. I was one of about 40 physicians who somehow earned an invite to a roundtable with Dr. Blumenthal. I was impressed that he cared enough to ask our opinions. He had a politically correct answer for every question we posed of him, so maybe he is well suited for his job.”

From Day Tripper: “Re: ambulatory EMR vendors. I asked several EMR vendors if they have seen a big increase in buyers, especially now that we at least have the interim final use definitions. The general consensus is that many physicians are still dragging their feet.” I’ve heard that comment as well. Either because of fear or because it sounds like a good excuse, many physicians are waiting until the MU guidelines are truly final and the certifying entities are identified. Perhaps a minority of physicians are savvy to understand that the RECs will offer some free implementation services so they are waiting for those to ramp up. And, likely others are waiting to see what opportunities their hospitals may offer to affiliated physicians. In other words, if you are looking for an excuse to not move forward, there are plenty to choose from.

From Samantha Brown: “Re: shoe patrol. Inga, please tell me. Was Judy wearing Birkenstocks?” Gosh, I was so excited that she was there I failed to notice the shoes!!

From Justen Deal: “Re: HIStalk party. Overheard: ‘Judy and Jonathan in the same room? Isn’t that like matter and antimatter?’? One observation: The fact that Jonathan Bush was able to charm a crowd made up mostly of his competitors says a lot about his comedic timing. Secretly, nearly everybody in the room is terrified of him,since his business model scares the scheiße out of them. I think the atmosphere (read: the lager) helped reduce their fears, at least for the evening.”

From BFF in Footwear: “Re: Inga Loves My Shoes! I must say that last night’s party was incredible — two of my dreams came true. First, I got to meet and chat with a very gracious Judy Faulkner, a woman who has been my inspiration and a role model for building and growing my software company. And second, I received the industry award that I have coveted for years — the Inga Loves My Shoes. I will wear my sash proudly and strive to always be worthy of this honor.”

From Inga BFF: “Re: great reception. The venue was wonderful and good beer was involved, to boot! It was a high-powered crowd, and yet everyone was friendly and cordial. Please let your reception sponsors know that we truly appreciate what they did.”

Before HIMSS, I was sent a notification that I might want to attend the “CCHIT EHR Certification Town Hall.” I was quite frustrated Monday because I could not find the session either on the navigation kiosk or the paper schedule. I eventually found it, but learned the session had been renamed “EHR Certification Town Hall.” The CCHIT folks were still leading the session, but it was interesting that either CCHIT or HIMSS decided to drop CCHIT from the title. One of the more troubling points made was that the ONC is not expected to designate CCHIT or any other entity until late 2010, or even into 2011. Everyone assumes CCHIT will be one of the certifying bodies but until it is etched in stone, plenty of conservative buyers are going to wait for the final, final declarations.

I wonder if Mr. H and I were the only ones who noticed the HIStalk signs displayed at many of our sponsors’ booths? Thanks for the promotion.

I’m still wading through the endless number of e-mails and need some PR person to answer me this: why does every single vendor feel the need to issue press releases during HIMSS? Don’t companies realize their news is more likely to be overlooked because of the sheer volume being churned out by companies, PR people, and media outlets?  But what do I know? I’m just a blogger. If you haven’t had a chance to see some of the news highlights, hang on for these brief updates:

• CynergisTek announces a new data loss prevention solution that leverages its partnership with Code Green Networks.
• Gartner places Compuware in the “leaders” quadrant of its “Magic Quadrant for Application Performance Monitoring” report.
• The AMA and Ingenix form a partnership to offer the web-based Ingenix CareTrack through the AMA web site.The AMA says that they will be offering additional new technologies to help enhance physician practices. The AMA also announced a collaboration with Dell, which sounds as if it is part of this same physician-automation initiative.
• UPMC announces the development of new PHR technology created in collaboration with Google Health, Carnegie Mellon University, and dbMotion.
• Precyse Solutions introduces Catalyst, a front-end automated speech recognition product.
• NextGen introduces a special offer to provide rural and community hospitals free financials with a qualifying purchase of inpatient clinicals. The NextGen Clinicals, by the way, is the former OpusClinicalSuite. NextGen was also named a winner of an MS-HUG 2010 Innovation Award in the category of Interoperability/HIE for its work with Doylestown Hospital (PA) and the Doylestown Clinical Network.
• MGMA President and CIO William F. Jessee announces he will retire in the fall of 2011.
• Enterprise content management vendor Hyland Software acquires eWebHealth, a provider of hosted medical records workflow solutions.
• MED3OOO and Acryness announce a strategic partnership to provide the MED3OOO QuikBill patient billing solutions, powered by Acryness, to MED3OOO’s RCM and ASP practice management clients.
• CHIME awards fellowships to Pamela McNutt of Methodist Health System (TX) and Rick Schooler of Orlando Health (FL.)
• 4medica launches its Integrated Health Record designed to tie patient data from diverse care settings to create a single picture of an individual’s patient record.
• Fifty eldercare agencies join the Rochester RHIO, which is powered by Axolotl’s Elysium Exchange.
• Nuance introduces a suite of voice-enabled mobile solutions for smartphones including Dragon Medical Mobile Dictation, Search, Recorder, and SDK.
• Healthland releases an EDIMS for small community hospitals, as well as an Analytics solution.
• Covenant Health and Sharp Healthcare select Allscripts Care Management and Post Acute solutions for their hospitals and post-acute care facilities.

Posting from the HIMSS Facebook page on Tuesday, the day of the big snowstorm: “HIMSS 5K Fun Run has been moved Indoors. Please come to Hall A, A1 to register. Run starts at 4 p.m.” I wish I had seen the run.

Speaking of Facebook, if you have any great HIMSS pics you’d like to share, our HIStalk Fan page is waiting for you. I have uploaded a few that readers have forwarded, but haven’t had time to load all of them yet. Feel free to friend me since you can never have too many friends, right?

E-mail Your Friend Inga.

From HIMSS 3/3/10

From The PACS Designer: “Re: Panasonic C1 Toughbook. At HIMSS 2010, Panasonic announced an exciting new Toughbook called the C1. It has many features that on-the-go healthcare professionals will see as being attractive.”

From Joe: “Re: McKesson. Hunting season came early this year. Firings in the Physician Practice Solutions group.” Unverified.

We have a lot of HIMSS-related observations on HIStalk Mobile.

I’m still tired, but here are my impressions of HIMSS10:

• The emphasis was on money and business rather than patients for the most part (my low point: a session that rattled off dozens of government grant programs from ARRA right on down, which reminded me of that seedy guy with the Free Government Grants infomercial).
• For that reason, it was a rather passionless conference. It’s hard to get charged up by filling a room full of people who want to lap from the federal trough.
• The KLAS/HIMSS Analytics presentation was good, with the primary message being that adoption of EMR, CPOE, etc. is going well, but there’s a long way to go. Also, that several vendors and products, despite slick glossy materials, basically aren’t getting any traction at all and don’t enjoy much support from their customers. It was refreshing to sit in a HIMSS conference room and have some of the vendors with big booth spreads being called out as dragging down the market with their incompetence (the usual big conglomerates).
• Atlanta is a pretty good convention town and GWCC has nicer public areas (seats) than most convention centers, but the split exhibit hall should have been a showstopper. If you were a vendor on the C side, you missed a lot of traffic. Maybe HIMSS should have limited the space per vendor so they could all be squeezed in on the A/B side.
• Many vendors were so vague on what they were selling that it was hard to tell on a quick glance, which is about all they’ll get from most attendees. Broad, catchy statements may work in an ad, but on the show floor, there are 200 vendors claiming to sell an EMR and little way to figure out how they are different.
• As happens every year, vendor people in the hall seemed to have trouble focusing. It’s inevitable to get tired and maybe jaded, so the to-do I would give vendors is to bring more people and rotate them. I went to several large (expensive) booths and couldn’t get anybody’s attention, and in at least a couple, the person made me feel genuinely unwelcome, like maybe they were anxious to get back to their personal phone chats.
• A fun scavenger hunt would have been to try to find a presentation that didn’t have any of the above words in the slide deck: ARRA, HITECH, or Meaningful Use.
• Everybody got excited over certification announcements, but I found myself caring not at all. I overheard someone providing a good summary of certification: it sets the bar extremely low for real vendors with real customers, but keeps doctors from selling crappy EMRs written by their brothers-in-law.
• There was a lot of activity on the show floor, but I can’t really say I picked out any theme that didn’t involve stimulus money.
• Education presentations ranged from pretty good to pretty bad, which is par for the course.
• HIMSS ran the conference smoothly as usual.
• Despite frantic reporting from the exhibit hall(s), there really wasn’t all that much big news, which is why I didn’t mention much of it.
• I got to see a lot of familiar faces and that’s always nice.

2010 HISsies Winners

Smartest vendor strategic move
athenahealth guarantees Meaningful Use

Most effective CIO in a healthcare provider organization
John Glaser, Partners

HIS industry figure with whom you’d most like to have a few beers
Judy Faulkner, Epic

HIS industry figure in whose face you’d most like to throw a pie
Neal Patterson, Cerner

HIStalk Healthcare IT Industry Figure of the Year
David Blumenthal

HERtalk by Inga

I am in the Atlanta airport, headed home, so this will be another quick post.

Overall impression of HIMSS10: fun, huge, and a lot of excitement in the industry. More on that in a second, but I will first throw out a few things that I found less than perfect:

• Someone made a comment to me that Atlanta must not have had big convention like this for some time because they seemed overwhelmed at times at the convention center. Long lines for food (except at the Asian place, which apparently ran out of noodles early in the day) and untidy restrooms were the biggest evidence of this.
• The two-exhibit hall thing needs some tweaking. All the vendors in "C" felt like the stepchildren. Why not split the bigger vendors evenly between the two halls so that one does not look so much like an afterthought? And, having the two halls so far apart was pretty inconvenient. More than one person told me they didn’t realize there was a second hall until they failed to find a particular vendor.
• Is there such thing as a convention center that doesn’t involve miles of walking to get from one area to the next?
• I found too many vendors unable to give you a 15-second elevator pitch about their company or offering. Maybe it would be too much to ask for vendors to also tell you in 15 seconds what is unique about your offering.

Other than that…good stuff. I have to admit the educational sessions are tough for me to sit through (I failed to last the whole time for any session I attended).  Perhaps I picked the wrong sessions.

The last three days have flown by. I spent a good amount in the exhibit hall, but didn’t see all I wanted to see. I did check out a few software products and I will share more on that later. Thanks to all the kind invites to stop by booths — I didn’t get a chance to look deeply at every one, unfortunately.

And I popped in to a few parties, including Eclipsys, Allscripts, and HITmen awards. The HITmen awards had some great sushi and a lot of A-listers in the industry. I thought Mr. H was winning some award, but apparently not. Someone will have to explain to me why his name was on the promotional material but he didn’t win one of the cool plaques.

The MEDecision folks told me there were expecting 2,000 to their party, which they said was to be the largest HIMSS party. If you went, tell us about it.

Tuesday night I got back to my hotel after a VERY long day and popped up HIStalk to read the latest post. I literally fell asleep with iPhone in hand. Good thing HIMSS only comes once a year.

E-mail Inga.

From HIMSS 3/2/10 (Part 2)

From Clingy: “Re: your party. You do realize that, last night, your party became the party that everybody will have — and want — to attend? I’m sure it already was that, but now everybody else will know that, too. I think you may have to resort to a lottery for invites in Orlando…  Or you may have to rent a stadium.” I really appreciate the nice comments about the party, but I’m passing the kudos along to Amy Glass and Inga since I was too busy to jump in during those final weeks to set it up. Actually, I’ll thank a third group: those who booed and cheered during the HISsies, who enjoyed each other’s company even though many of them are on-field competitors, and who made up a darned impressive group. It’s the only time I get to see who’s reading and it recharges me for another year. If Jonathan Bush doesn’t win something next time, I may have to stuff the ballot box just so he can chew the scenery again. He was supposed to be on for like five minutes, but turned it into its own extravaganza (recall that this was the first business day after ATHN shares gapped down, but you would never have known it from his hilarious performance surrounded by the stock analysts in the room).

From Jim: “Re: your party. The HIStalk party rocks! This was the best party I have been to in the 15 years I have been going to HIMSS events. People were having a genuine great time and mingling nicely – something that would happen at a party you want to go to, not you feel you have to go to. Can’t wait to come again next year!”

Above are a couple of pictures taken by Dr. Gregg Alexander of the bagpiper and Max Lager’s. I thought it was a very cool place – lots of brick and wood character, beer tanks, and genuinely attentive staff (I could barely set my beer down before someone wanted to bring me a new one, which was just fine with me). The DJ kept the music going without being obtrusive. I asked Inga to take the large poster that you can barely make out on the very left, which had a giant beer glass with the HIStalk logo. It looked like a great souvenir.

From Gregg Alexander: “Re: HIStalk reception. All those who attended can attest, all proper propers belong to Ivo, Inga, and Mr. H for organizing an exceptionally fun evening. Great job, guys, a truly fun time…thank you!” We had some recognition for direct caregivers during the reception and it’s guys like Dr. Gregg who ought to be honored. People forget how hard pediatricians work for a relative modest paycheck while the procedure guys need a wheelbarrow to get the cash to the bank.

I’m so proud of this picture by DrLyle and I’m moving Judy Faulkner of Epic way up on the cool-o-meter. I had e-mailed her ahead of time and told her Epic had won in several categories and she also in the category of “Industry Figure with Whom You Would Most Like to Drink a Few Beers.” She e-mailed back and said the strongest thing she drinks is milkshakes, but she might drop by (riiiight). On the 1% chance she actually would, Inga had her a “No Pie for Me” sash made to celebrate her “loss” to Cerner’s Neal Patterson for the “Industry Figure in Whose Face You Would Most Like to Throw a Pie.” I am totally shocked and honored that she and Carl Dvorak dropped by because I know she doesn’t really like that kind of stuff and there really wasn’t anything in it for her or Epic. She even joked around with Jonathan Bush. Judy, I had you figured for a pretty cool lady, but now I’m certain. Epic won all the “good” HISsies categories, so it was kind of like a KLAS report.

I think we’ve discovered a natural female attractant in those sashes. Someone sent in a pic of one of our male sash-wearers who wore it back to his own hotel and he was getting lots of female attention. I bet we get more volunteers next year.

From GG: “Re: Charlie Munger. How long until you and Inga get a $20,000 check?” Warren Buffet’s homespun partner reads Atul Gawande’s New Yorker article on healthcare costs, and then writes him a $20,000 check and sends it to the magazine, telling them to give it to Gawande, who then donated it to Brigham and Women’s. I had a nice chat today with some smart vendor people who observed how broken the HIT journalism model is (they refused to even call it journalism) and how hard it is for up-and-coming vendors to afford the megabuck ad spreads that seem to help get companies featured. I like scrappy newcomers, so they will always have a spot here if what they offer helps patients.

From KZ: “Re: have you checked out the race car simulator in the 3M HIS booth?” How did I miss that, especially when I’m running a text ad for it? Somehow I didn’t see it.

From HITMAN: “Re: David Blumenthal. Interesting – a large number of CIOs received an invitation last night at about 7:30 to attend a meeting with David Blumenthal this morning at 8:30. Apparently the response was large – they turned away many by e-mail and may have a second session set up for later Tuesday.  David opened the session with about three minutes of welcome and thanks then said he was there to listen to us. Of about 75 in the room, about 20 made comments about the need for federal leadership on master patient index, about the challenge of all-or-nothing meaningful use, about the need to include ED CPOE in meaningful use criteria, and about the compressed timeline we are working under. All were polite and he had two minutes of thanks at the end. He said he is not allow to comment about ongoing work and regulations, and was happy for the pointed feedback. Good that he asked for the feedback but it was all over the place and I am not sure how much he could have gotten from the session.” I heard some CMS people talking about it on the escalator.

Check out David Brooks’ HIMSS coverage on HIStalk Mobile.

Henry Schein announces its ConnectHealth initiative that packages products and services from a number of vendors for physician practices: Allscripts, Midmark, Siemens, Welch Allyn, Dell, and Medline.

Content management vendor Hyland (the OnBase people) acquires hosted medical workflow solutions vendor eWebHealth.

SIS introduces Anesthesia View, a new module in SIS Analytics. I asked someone in the booth today about the Inga-tinis and they said they were flying out the door yesterday evening.

Former QuadraMed CEO Keith Hagen is named COO of digital pathology solutions vendor Aperio.

The latest radio show from Intellect Resources interviews a number of HIT experts, including Texas Health CIO Ed Marx, on security.

Keane will offer EmpowerED as an ED module for its Optimum solution.

In the UK, NPfIT is trying to quickly sign billions in extension contracts with CSC and BT before the elections, hoping to keep the struggling program financially alive.

I forgot to mention it yesterday, but I attended the best HIMSS session I have ever seen, which few saw since it was on the military systems track. It was given by Rear Admiral Matthew L. Nathan MD, Commander, Navy Medicine National Capital Area, National Naval Medical Center on their pilot project for an integrated medical home. I can only say it was brilliant, covering the need for preventive care and EMR outreach programs as well as the practicalities of delivering medical services remotely (such as to a ship in the South China Sea, but with the same challenges as to a rural town). Given the military’s experience with the healthcare models we’ll probably need everywhere and considering his obvious capabilities, he ought to be leading the charge. While everybody else was slobbering over meaningful use, he was covering the real healthcare issues that stimulus money can’t fix.

HIMSS attendee count so far: 25,989, but fewer vendor people. I should also say, that despite my occasional disagreements with what HIMSS does, they are superb at managing conference logistics. I noticed no proceedings CD in the tote this year, but I assume they’re free online since I always review them later.

I have lots pictures and stuff that folks have sent, but I’m beat. Here’s a final little show floor wrap-up.

• I had a great visit with the people from enterprise forms management vendor Access, who not only have a great product, they also have a championship barbeque team that can cook hundreds of pounds of pork butt or brisket at a time. I naturally begged them to load up the 40-foot smoker at the next HIMSS and watch people pack the booth for a taste.
• MEDecision had nice umbrellas out to take, which was nice since it poured cold rain all morning and then snowed for most of the rest of the day.
• The Eclipsys booth was packed.
• I wanted to caress all the stuff in Enovate’s booth as usual since their carts have the sexiest curves you can imagine. They also had a cool green pony saddle seat that I spun around in a road test and it was sweet.
• Big crowd at Allscripts.
• For some reason, I found myself wanting coffee and a shoeshine a lot (back me up, guys).
• ICA had their HIStalk sign out and had a demo of their HIE solution running with Sevocity.
• iMDsoft’s telemedicine app was one of the coolest ones I saw.
• Keane had our sign out too – thanks!
• athenahealth’s booth was packed.
• The guy doing electronic caricatures at the Televox booth was fascinating to watch.
• Sunquest had our sign out, too, and I still like their green color and their bags.
• Picis had a crowd and also our sign out.

From HIMSS 3/2/10

HERtalk by Inga

From: Soda Pop Man “Re: HIStalk reception. All those who attended can attest, all proper propers belong to Ivo, Inga, and Mr. H for organizing an exceptionally fun evening. Great job, guys, a truly fun time…thank you!”

From: Evan Steele “Re: Sashes, strangers, and shoes. Thank you for a GREAT evening at Max Lager’s!  The sash was perfect (“HIStalk Certified” made for a great conversation piece)! Although I am not the type who easily mingles with strangers in a room, I found the HIStalk readers very approachable and I had some great conversations.

This will be a quick post as I have an 8:15 meeting (what was I thinking?) HIMSS has been predictably fast and furious with big crowds and lots of walking. Here are a few random impressions from Monday:

• Overheard in the ladies’ room: “Where the heck is the coat check?” I, too, had problems finding one. I am sure there’s at least one but the place is so huge that I wasn’t going to walk from one Hall C to Hall A just to dump my coat.
• I was a little bit disappointed with my interoperability booth tour. My presenter had some microphone problems so I couldn’t hear very well. And, too much time was spent with the overview of the whole interoperability concept, rather than demonstrating how it all worked. Still, it’s impressive that something like 70 vendors participated.
• The Blue Cat booth is offering a roller coaster-type experience, if you like that sort of thing. If you like eye-candy, they offer that as well.
• Hexaware had a unique booth concept with lots of plants on the ground, making the booth look a bit like a garden. They were promoting their green theme.
• Actuate is handing out $5 Starbucks gift cards, if you spend a few minutes chatting with them, like I did.
• I sat in on a Sage presentation in hopes of winning an iPod shuffle. I lost but the presentation was good (short and to the point.)
• I’ve noticed that the booths with the most activity are the HIE vendors. I rested my weary feet a bit and listened to an Ingenix presentation. When I stood up to leave I noticed there was a crowd three deep standing behind me. I saw similar crowds at Medicity, Axolotl, and dbMotion.
• PatientKeeper, Nuance and RelayHealth seem to have much bigger booths than in previous years.
• Chair massages can be found at DCS, which was near the McKesson booth
• As I walked by Bottomline Tech at about 3:45, folks were queuing up for cocktails. I waited until 4:00 and got an “Inga’tini from SIS. Highly recommended.
• Mr. H mentioned that the Google booth appeared slow. Not when I went by. Although I can’t figure out what they are offering that makes the crowd so curious.
• Chetu has a couple of gorillas in their booth. One of the guys working the booth told me they had wanted the gorillas to walk the floor wearing a Chetu sign. HIMSS nixed that idea. Apparently HIMSS thought some company might conclude that if one vendor could have gorillas walking around, then it would be acceptable to send forth girls in bikinis.

And, of course, the HIStalk reception was incredible. Thanks to all who attended and definitely to our hosts. Amy Glass with Encore rocks! Jonathan Bush was an incredibly funny announcer, which I believe our EHR-TV folks caught on tape. Yes, the very down-to-earth and friendly Judith Faulkner did stop by and even wore her sash that said, “No Pie for Me.” We awarded a couple of bonus sashes for great shoes. I checked out the shoes of both recipients and agree they were worthy of recognition. I’m hoping someone snapped a photo of the winning shoes.

I have lots of photos to post and will get to those in the next couple of days. More later!

E-mail Inga.

From HIMSS 3/1/10

From Kermit Randa: “Re: today. Long day of goodness sharing the critical importance of the OR in the current healthcare economic and IT landscape. The reception is a welcome end to a long day. Nicely done! Who can argue with beer, great apps, and a little John Cougar?! Thanks for all you an Inga do! Hope she stopped by the SIS booth for an Inga-tini!” I totally forgot that she told me that SIS has created a specialty drink for her, apparently available in their booth. She is enthralled with the concept of alcohol on the show floor, so I’m sure she has tried it already with a report forthcoming.

From Jack: “Re: camera cable. You should get an Eye-Fi.  It’s an SD Card that has built in WiFi capability and will upload images automatically.”

From Festus: “Re: partners. Seen on booths in the exhibit hall, ‘your partner in meaningful use’. A lie on two accounts. As discussed before on HIStalk, rarely is a vendor ever your partner and does anyone really believe they will help them use technology in a truly meaningful way?”

It was so cool to see everyone at the HIStalk reception this evening, so thank you so much if you attended, including our insiders who work on the sites who had a chance to be recognized. Thanks to Jonathan Bush for handling the HISsies announcements, to John Glaser for his video acceptance as CIO of the Year (I’ll post the HISsies winners when I get time), to Ross Martin, MD for his excellent world premiere of Meaningful Yoose Rap (you would not believe the government approvals he had to get to do it), to our sash wearers, and for Encore, Evolvent, and Symantec for putting it together (especially Amy Glass on the Encore side). I’m sure I’m forgetting people, but like you, I’ve had a beer or two too many (if you didn’t try the Max Lager’s Red, it went down pretty smooth). And how about that bagpiper! Thanks to Deborah Peel, MD from Patient Privacy Rights for staying over an extra night just to hang out with us, to Inga for all the work she did to prepare for the reception, and to those many people in the audience who work for companies that sponsor HIStalk, HIStalk Practice, and HIStalk Mobile and who chose to spend their evening with us. It’s just 364 days or thereabouts until the next one in Orlando!

I need to get the scoop on this since I left the party early. It appears from a reader’s cell phone pic just sent that Epic’s Judy Faulkner showed up and is pictured with Jonathan Bush from athenahealth. Big props for her if she did since I know she basically never does that sort of thing even though I asked her and she said she might. More to come.

And Dr. Gregg Alexander snapped this one of the B52s at the Eclipsys party. Love ‘em.

Speaking of Symantec, the company announces a cloud-based storing and data sharing environment for healthcare.

Dell announces that it will offer EMR hardware and consulting services in affiliation with the AMA.

Microsoft announces HealthVault Community Connect, which allows hospitals to make EMR data available to patients or to share the information with other providers.

I didn’t go to the opening keynote because I didn’t really want to get up so early, but it apparently talked up 4G quite a bit. Sprint CEO Dan Hesse says it can take health care out of the 70s, which could be argued.

I think we reported this as a rumor back in November or something, but Sisters of St. Francis chooses Epic.

Bassett Healthcare (NY) chooses PatientKeeper.

Voalte asked me to pass along that you iPhone users can stop by their booth to charge up.

I’ll add a few booth reviews and that’s all the time I have tonight since I have to get up early. And I’m exhausted since I remember now why hate the GWCC exhibit hall (Hall C is way separate from A/B and I never did find the secret passage that connects them, even though I’ve used it in years past and I even asked a security guard to point it out). As a result, I didn’t see much in Hall C.

• Several sponsors had their autographed We Power HIStalk signs in their booths, so thanks for that.
• Virtelligence had theirs front and center.
• Cattails MD from Marshfield Clinic had a pretty substantial booth.
• OnBase had the sports bar and that amazing card trick guy again.
• Not much changed with Epic’s booth,including the fact that Judy was in it most of the time.
• EDIMS had a video game.
• Eclipsys had a nice, open booth.
• Kronos staffed theirs very well, making it easy to get someone.
• Allscripts had lots of orange and looked good.
• Microsoft’s had a decent crowd, but not as much as last year from what I could tell.
• API’s was kind of skyscrapery, which I liked.
• GE’s was sprawling and divided up into sections.
• I’ll award NextGen the best booth award with its bold, purple cylinders and arches.
• McKesson had the usual blue and orange, but a whole separate sub-booth for Paragon.
• The Alert people from Europe had females some pretty impressive pants that I can’t really describe.
• Sentillion’s was labeled as “A Microsoft Company”
• RelayHealth’s was nicely done in McKesson colors, very open.
• Google’s was tiny and kind of dead.
• iMDsoft had a giant John Glaser photo.
• MEDSEEK made the best use of a reasonable space with some good design and an upstairs area. They attached their HIStalk sign directly to the podium, which was cool to see (Inga fretted that she told Kinko’s to go one size bigger than 8×10 and the next jump was apparently pretty big).
• Rel Ware had what was apparently a full sized Back to the Future DeLorean. Pretty cool.
• Chipsoft had the yellow wooden shoes again, still my favorite giveaway.
• eClinical Works had their sign out – thanks. So did Greenway.

HERtalk by Inga

Greetings from Atlanta!

I arrived at the convention center mid-day Sunday lurked around a few meetings and looked for famous CIOs. I realize how nerdy this is, but I was thrilled to catch a glimpse of a few CIO superstars like Bill Spooner, John Bosco, and Ed Marx as well as vendor big-wigs like Glenn Tullman, Sunny Sanyal, Judy Faukner.  We are definitely in the land of HIT rock stars.

If you are not a rock star but want people to think you are, HIMSS has made available a plethora of extra ribbons to adorn your name badge. I gave Mr. H one that says "PMP" and told him it could be a good conversation starter since from afar the mind automatically wants to insert an "I".

Mr. H and I had an HIStalk executive board meeting Sunday afternoon and voted to continue the blog. Since he was designated CEO of HIStalk for the HITmen event, he graciously awarded me the title of President. My mother would be proud.

When the meeting was adjourned, we joined a relatively small crowd at the opening reception. I suppose it is difficult to create an ambiance with a warehouse-like room that has concrete floors and open rafters. There was a live band, but the acoustics were so bad I couldn’t tell you what they played or if they were any good. Mr. H reminded me how crowded the reception was last year as people tried to avoid walking in the Chicago snow storm. I’ll take the sunshine of Atlanta.

Today’s agenda includes CCHIT town hall meeting and checking out the exhibits, including the interoperability booth. Then a bit of primping and on to Max Lager’s. I promise to keep good notes and share details of the day, especially for those of you keeping the lights on at home.

E-mail Inga.

CIO Unplugged – 3/1/10

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

Manage Your Aura
By Ed Marx

1997. The reverberating rave music generated a hip vibe. Cameras flashed as bright lights drew the crowd’s attention to the student models. Attending my first fashion show, I sat at the end of the runway—as one of the judges. I felt like a punk rocker at a symphony. The dean of my alma mater had appointed me to the board of the fashion school (long story). My fellow judges—all of whom were in the business of fashion—and I were responsible for appraising the undergrad and graduate champions of design. Initially excited about the opportunity, I quickly realized my business skills didn’t match my responsibility as fashion critic. (I hear your laughter. My daughter agrees.)

But I gained one valuable lesson through that experience. The beauty of a model or her/his clothing design didn’t captivate me; the confidence with which the model walked did.

Lacking the typical, requisite seasoning for a CIO, I fell into the position at a young age. My CEO asked me what I needed to be successful. “Two things,” I replied. “A year of formal mentoring from you and a ticket to the CHIME CIO Boot Camp.” I received both.

Although the Boot Camp curriculum and instructors proved incredible, time spent with my group leader influenced me most. Here’s one of the many pearls I received from John Glaser: “Learn to manage your aura or someone will manage it for you.” I took his wisdom to heart.

Aura defined: a distinctive and pervasive quality or character; air; atmosphere. In the 7 years since my Boot Camp graduation, I’ve aggressively assimilated this golden nugget. Borrowing from my friends in marketing, you have to brand or be branded. Here are a few ideas.

Network. Continually expand the breadth and depth of your professional and personal network. Proactively reaching out to others saves you from isolation and becoming irrelevant.

· LinkedIn

· Twitter

· Facebook

Publish. Editors are interested in genuine stories from real leaders. Send queries and don’t give up when initially rejected.

· Magazines

· Online services

· Blogging

Present. Get over your fears. Presenting forces you to nail your subject matter and confront fears.

· Professional societies

· Neighborhood associations

· Your organization

· Church, Synagogue, etc

Involvement. Jump into the community. Let leaders know you are interested in adding value.

· Professional societies

· Special interest groups

Volunteer. Find regular opportunities and your network will expand.

· Internally

· Externally

Routinely self-Review. Build in times to review progress and make adjustments. Ask for feedback.

· Update your Brand

· Develop a career strategic plan

· Ask your mentor

Education. Take the initiative to self-educate. Learn from inside and outside of IT and healthcare.

· Blogosphere

· Marketing resources

Add to Existing Body of Knowledge. Comment on what others have to say. (You don’t always have to be the author.)

· Post to blogs

· Contribute whenever the opportunity presents

No action will spoil your aura more than damaged credibility. So while I’m all about a personal hallmark, it must be built upon a solid foundation of execution. These are not sequential tasks. Proactively improve performance and brand simultaneously.

Keep your aura in perspective, and let this humble you. The value of a stellar aura should reach far beyond its owner, and its primary benefits should accrue to the people and the organization served. If not, then it’s all about you. Possessing a personal brand, which should never come from arrogance or false humility, is key to success. For without it, you are allowing others to determine your brand.

You’re on the runway, lights flashing, cameras clicking. Make no mistake; the crowd is analyzing your every step. So brand yourself and accentuate it with confidence.

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.”

From HIMSS 2/28/10

From Zale: “Re: Eclipsys. I wonder if anyone at either Microsoft or Eclipsys knows that Bill Gates demoed an early version of Sunrise Clinical Manager at HIMSS in 1995?”

From Sheri: “Re: clinicians and IT people. But if you combine the best of both worlds – the experienced Clinical Analyst — you get a great opinion. Clinicians don’t know what they don’t know about IT. Experienced clinical analysts have one foot in both worlds and can make really good decisions about the solutions that will work for the clinicians. You just have to hire the right people and get out of the way.” Sometimes, as long as the analyst remembers that as soon as they cross the dark side to IT, they need to consult the still-practicing clinicians before making decisions. Most of the ones I know are excellent, but a few think their decades-ago practice makes them even more expert than those still working. But I agree in general and at least the CAs always put the best interests of patients first. 

From Diamond Jim: “Re: drink beer, get CME.” Strange — attendance at the HIMSS opening reception earns CME/CNE credits. Somehow I don’t think patients would be comforted to know that. I really did get some good education from some of the HIStalk pals Inga and I hung out with there, though.

It was strangely quiet and low-key at the convention center today, but you could smell the money. New exhibitors, new attendees, and lots of expensive advertising stuff were obvious. It looked nice outside, but with temps in the low 50s and lots of wind, it wasn’t really all that comfortable. I had forgotten until someone mentioned it about the weird layout of the exhibit hall, with the two unconnected halves that mean some vendors paid big dollars for Siberian real estate.

Speaking of that real estate, I was explaining to someone that it’s not enough to be willing to pay big bucks for booth space – you have to earn the right to spend that money by first accumulating HIMSS points. I’m not sure they believed me, so here’s the proof.

Like I always say, it looked like the Marines laying in supplies for the siege at Khe Sanh. Trucks, cartloads of food and drinks, and vendor shipments were everywhere. Everybody was dressed casually, which will be in contrast to the dolled up crowds tomorrow.

The opening reception was surprisingly uncrowded, with no drink lines at all (I only drank, but the food lines didn’t look much longer). The atmosphere, of course, was like taking an aircraft hangar, putting a small band at one end of it and leaving them to compete with their own echoes, and sticking up a few palm trees with Christmas lights on them. I’ll stick with my prediction of 30,000 attendees, but 90% of them weren’t at the opening reception for some reason.

Strangest line overheard, this from a supposed HIT journalist: “What does CIO stand for?”

Two acquisitions will be announced tomorrow morning, sources tell me (although one may be delayed until later in the week). One involves an imaging vendor, the other a document company.

My cheap hotel has slow wireless and I forgot my camera cord, so I”m working without much technology support. Luckily Inga is handy with her iPhone. She also brought me barbeque sauce, so anything she does is fine with me.

GE makes some announcements early: a clinical knowledge platform, eHealth solutions, and HIE improvements.

A reader snapped this candid photo (looks like a phone one) of Epic’s Judy Faulkner behind a coffee urn that looks like a 1950s sci fi robot or spaceship. I swear the woman never ages. I tried to get her to come to the reception tomorrow night and she says she “might drop by”, but I’m not holding my breath. If she does, we have a sash for her.

I’m counting on my fellow attendees to keep me abreast of rumors and news. Photos would be nice since my camera is useless without the cord. Send me anything interesting.

Monday Morning Update 3/1/10

From Skippy: “Re: Nuance. It will announce acquisition of Language & Computing either today or Monday.” Unverified, but interesting timing considering both the typically Monday-heavy announcements at the HIMSS conference and this announcement: the Justice Department drops its antitrust investigation into Nuance’s 2008 acquisition of Philips Speech Recognition Systems.

From Delta Dawn: “Re: KLAS. You’ve laid out the issues regarding the benefits and limitations of KLAS information before. With their new vendor rating coming out at HIMSS, it seems like a good time to dig a little deeper. IF KLAS is really an unbiased source and is providing an unbiased scorecard, then they should have no problem revealing how much each vendor pays them. To spare them the trouble, I’m attaching the table here. Also, any vendor who uses KLAS data should be required to publish how much they are currently paying KLAS.” According to the table, KLAS scales pricing to annual organizational revenue, ranging up to $175K per year. My only reaction to that is that I wished I had thought of the business model myself. Everybody gripes about KLAS for one thing or another, but everybody continues to participate, so they are simply meeting a demand and pricing their supply at what is apparently an acceptable point. I like the listed add-on service of meeting with vendor executives for a brain dump, which sounds more like the business model I would have created. My variation would be to have the engaging organization’s executive write me a frighteningly large check and then take me to a long lunch somewhere that serves beer and hopefully barbeque and after a couple of rounds of each and with no advance preparation whatsoever, I would spill everything I know, including some of the more scandalous stuff readers have sent me that I can’t run on HIStalk for reasons that mostly involve libel and possibly stock market manipulation. I’m pretty sure KLAS doesn’t do it that way, though.

From Skeptic Shock: “Re: SIIM. Funny how they send out an e-mail about their one and only HIMSS presentation after the Readers Write article by Mike Cannavo. Looks like SIIM and HIMSS both read HIStalk. My hopes is that more IT folks will come forward and express their opinion that enterprise multi-modality, multi-disciplinary imaging is a major component of the EMR and can bring down a hospital’s efforts if not handled well.” Future collaboration is mentioned between the groups. I believe we need more PACSMan in the HIStalk future since IT people need more knowledge about imaging and related applications. Plus, as one reader pointed out, he’s just as cynical and abrasively outspoken as me in his PACS circles (in a heated moment, one executive screamed that he was the Antichrist, apparently, which is the coolest thing I’ve ever heard). That’s the guy you want telling you about imaging.

Want to see Sen. Chuck Grassley’s letter to Kathleen Sebelius urging FDA oversight of healthcare IT? Sure you do. A snip: “… I have been surprised by the lack of discussion about patient safety concerns … they [clinicians] tried raising their concerns to hospital administrators and/or to the HIT vendors, but told me their concerns were often ignored or dismissed.” He cites a 1997 JAMIA article that observed the lack of FDA oversight and the 1996 counterproposal from a group of vendors who presumably were trying to avoid it. He asks HHS directly whether FDA oversight should be revisited, and if not, how does HHS plan to oversee the safety of HIT and ensure that vendors follow quality process. Also included is a letter to Steve Lieber of HIMSS, asking him to clarify the HIMSS position on FDA oversight, recommendations going back to the CHIM days of a “code of good business practices” for vendors, and the HIMSS position on vendors reporting safety issues and notifying users of potentially safety issues. The Senator wants an answer by March 10, with interesting timing in sending HIMSS the letter right before the annual bacchanal begins. A reader comment suggested that the Feds will have folks observing the conference to see exactly how taxpayer money will be spent, but that’s unverified.

Here is my modest proposal to improve HIT patient safety in hospitals: let clinicians appoint a committee of nurses, doctors, and pharmacists (and any other caregivers you like) to independently make decisions about user IT communication, vendor priorities, and training needs, all with no IT people in the room and no IT veto power. I’ve been in those conference rooms a zillion times on both sides of the table and, as much as the IT people have the organization’s best strategic interests in mind, they are the de facto partners of the vendor in getting the system implemented, running, and hopefully accepted. They do not have the knowledge or the objectivity to decide whether a particular problem is OK to work around or whether the users need to know about it even though it’s embarrassing (any more than having drug company reps participate in a formulary committee meeting). IT people will dominate those meetings if they attend, so the decisions need to be made without them present unless the clinicians need them, like a jury left alone to deliberate until they send out for information. Just my opinion as an IT person.

AMA will offer Ingenix CareTracker EHR through a new AHA solutions platform being beta tested in Michigan. The announcement will come sometime Monday.

Salar (pronounced SAY-lar) is a new Platinum Sponsor of HIStalk, so thanks to those folks in Fell’s Point in Baltimore (a great area for eating and drinking when they aren’t getting blizzards) for supporting us. I interviewed company president Todd Johnson this week so that’s a good overview, but here’s the summary: Salar’s clinical documentation system TeamNotes works with core clinical systems, providing tools for documentation, physician charge capture, patient handoffs, quality reporting, and team collaboration. Customers include places like Johns Hopkins, UPMC, GWU, etc. I have to say I enjoyed reading their recent “Dear Physicians” blog entry that says it so well I can’t even excerpt it and do it justice (rare for me since I enjoy excerpting). I would seriously drop by Booth 2644 at HIMSS and check them out since they sound kind of dangerously disruptive in a good way. Thanks to Salar for the support.

CCHIT is rearranging some of its work groups, according to an internal communication a reader sent over. Oncology and Women’s Health are new specialty EHR certifications and CCHIT is looking for volunteers. Under way for later this year are long term and post acute care, dermatology, clinical research, and behavioral. Most of the main groups are on hold until meaningful use standards are finalized, which CCHIT says will happen by summer.

Cumberland Pediatric IPA (TN) chooses Informatics Corporation of America’s CareAlign data analysis and reporting tool.

Obviously we have some HITECH skeptics in the ranks. New poll to your right: with all the sudden interest in patient safety oversight of healthcare IT, do you think the government will mandate some degree of FDA involvement?

The Encore folks have been working incredibly hard to finish up details for our reception Monday evening. I’m sure nobody’s naive enough to think that you just book a facility and show up, but the amount of detail that requires attention is surprising even to me. Of course, if it all goes perfectly, everybody will just enjoy themselves without noticing those details specifically. I’ll say this: I certainly never expected to have an HIStalk specialty drink designed and named, but I’m looking right at it. Inga and I got the guest list and, as we digested the Who’s Who list of attendees (no kidding – lots of star power), she e-mailed me her one-word reaction: “Surreal”. To which I replied back with a line from That Thing You Do: “How did we get here?” It’s an early St. Patrick’s Day theme, so feel free to wear green if you like, although I don’t think they bought my idea of green beer.

Speaking of events, a couple of readers are looking for fun events for Tuesday and Wednesday evenings, so I told them I would deputize them as HIStalk roving reporters if anyone knows of cool stuff. Inga and I got a lot of invitations, but I didn’t save mine.

Shares in athenahealth dropped over 15% Friday on the announcement that its Q4 report will be delayed pending completion of an audit and a review of service revenue accounting procedures. If the company decides to implement an accounting change based on the assumption of ongoing customer renewals, it will have to restate earnings. You may recall my recent mention of an independent organization that gave ATHN a 99 rating for accounting and governance (meaning very conservative), so this is one manifestation of that, but one with a negative shareholder interpretation: they are considering a change to even more conservative accounting practices, but that might mean lower paper profits. I would think that’s good news if I were buying the product or the stock, but both markets have minds of their own.

Ohio State University Medical Center will bring its 617-doctor affiliated private practice into the university, with the stated primary incentive being the ability to implement a complete electronic medical record.

This is probably an important case to watch: the federal government files a fraudulent billing lawsuit against a Florida cancer clinic because its physicians billed for services delivered while they were out of the country. Regardless of what the clinic was up to, it brings up the question of exactly what constitutes supervision in an ever-connected age. Is value added by having the doctor physically standing there, and it insurance paying for that standing around or the oversight that can be equally well provided from anywhere?

I’m receiving powerful psychic emanations that Microsoft will make an interesting product announcement Monday morning. 

I’ve been overwhelmed lately, so I forgot to mention this like I promised. The Fierce people are having an executive breakfast Tuesday morning at 7:00 at the Sheraton Atlanta and are offering HIStalk readers a discounted rate of $50 if you enter the code TALK on the online registration form.

Former Cerner COO Glenn Tobin joins coding solutions vendor CodeRyte in a newly created COO position.

Sage announces its meaningful use guarantee.

Greenway donates several of its applications to Northern Kentucky University to be used in training students in the university’s health informatics programs.

A Florida health network reports the results of its year-long study of the Patient-Centered Medical Home model: hospital days dropped 4.6%, admissions were down 3%, costs swung around 20% to the positive compared to the market in general, and quality metrics improved.

I will be posting daily from HIMSS, of course, perhaps with some of Inga’s usual entertaining insights (like where to get margaritas in the exhibit hall). If you aren’t going, I will try to give you the on-site flavor. If you are, safe travels.

E-mail me.

HCIT from the Investor’s Chair 2/26/10

The end of 2009 brought a few company announcements that were particularly relevant to the investment community. Noteworthy among them were the sales of enterprise vendor QuadraMed and radiology systems vendor Amicas to private equity (aka PE, buy-out or leveraged buy-out – LBO – investors). When a public company is sold to an investment firm rather than another company in the same or adjacent sector (such as Sentillion’s sale to Microsoft or CareMedic’s sale to Ingenix), it’s known as a “take-private” transaction.

When this happens, private equity investors, usually acting with the existing management team, are making the assumption that they can purchase the company at a premium to its current stock market value, make some changes over the course of a few years, and then sell it to another buyer at a premium to what they paid. Sometimes this is likely “Greater Fool Theory”, but in many cases, it’s quite logical. Readers who’ve not had the sometimes dubious pleasure of being involved in a process like this might wonder how it happens and what’s the thinking behind it.

In my decade as a research analyst, I rarely heard a CEO say they thought their stock was fairly valued, and never heard one say it was overvalued — at least where anyone could hear them. This is because (a) they typically own a fair amount of said stock (or options); (b) they’re inherently optimistic by nature (if not outright promotional); and (c) the same reason that my mom thinks all her children are both bright and attractive (well, perhaps she really is right). In many cases, the company has lost much of its sell-side analyst coverage, perhaps missed a few quarters’ earnings estimates and has become a “single digit midget”. All the while, its CEO and the board are thinking their stock is worth more than that silly stock market is willing to pay for it, and time passes. And more time passes. And still, the stock is worth less than they think it is.

Clearly, it’s time for Action! At some point, they start to realize that if the stock market isn’t according them their “fair” value, perhaps another entity will. It’s time to call the bankers (or start returning their calls). Much like with an IPO (discussed in previous posts), the bankers show up and, using a dazzling array of PowerPoint and spreadsheets, confirm that, why golly, yes, your stock is undervalued! Clearly a transaction is called for: it’s time to find a buyer for the entire company. In some cases, incidentally, the bid comes unsolicited, as PE firms have people whose primary job is to call companies to convince them to go private, but even then, some form of sale process is usually required to ensure a fair and appropriate price is paid.

Rather than enumerate yet another type of banking process for a posting (but readers can request it for a subsequent post if interested), let’s skip that process for now and assume that no strategic buyers have opted to participate (at least at as high a value). What motivates a private equity investor to outbid a strategic buyer? A few key elements typically underlie their analysis.

• Being public is expensive, often costing smaller companies over $1 million to cover their SEC requirements, insurance policies and Sarbanes-Oxley compliance costs, etc. Once private, all these costs fall straight to the bottom line.
• Public markets are notoriously short-term focused. Many believe (I among them) that, freed of the requirement to manage on the instant gratification of a quarterly basis, company performance is likely to improve.
• Sometimes it is best to take a hiatus from the public markets for other reasons. Emdeon used its “private time” to make substantial improvements to its operations, management, and other areas. TriZetto Group is moving to more of a subscription model. Netsmart Technologies did something or other. Etc.

A few questions leap to mind, however:

• If there are changes that should be made, why hasn’t management already made them to benefit current shareholders rather than the new private investors?
• Did the fact that typical senior management parachutes (inherent in change of control transactions) would inflate — plus their stock would now be worth more, plus they’re likely to be re-loaded with new equity — impact their decisions?
• What drives the new investors’ confidence that they’ll be able to sell later to a strategic buyer, when they presumably just outbid all of them?

All good questions, but, at the end of the day, two groups of smart PE investors looked at both QuadraMed and Amicas and decided that they could make a good return on their money by purchasing these companies, so clearly their spreadsheets, extensive diligence and planning supported them. I’ll note that, besides the suppositions made above, their math was definitely helped by the fact that their fund likely only put up around 20-25% of the money; the rest was borrowed, substantially magnifying their returns (hence the term leveraged buy-out) and, further helping their math, significant transaction and management fees are often imposed on the newly acquired companies for the privilege of taking the money — often these fees run in the millions.

What about all the lawsuits that have been flying though? It seems that each company has been hit with about a dozen lawsuits (or threats), from apparently the same firms. It appears inevitable that, despite the fact that an auction was conducted, a bevy of class action lawyers will invariably announce investigations “on behalf of shareholders” alleging the unfairness of both the amount being paid and the process that was run. In my view, while the threat of these might be important to preserve the integrity of a process, the reality is 90% or so are merely opportunistic behavior on the part of the law firms. As a review of the proxy statements for either Amicas (also available in a nifty PowerPoint summary) or QuadraMed show, efforts were taken to ensure a fair price was paid.

In the case of QuadraMed, a fairly broad auction was conducted, which included a sizable number of PE firms and four unnamed strategic buyers. While Amicas responded to in-bound, apparently unsolicited interest, the agreement with the buyer allowed them to actively “shop” the bid to see if a higher bidder would emerge. Presumably, none did. By the way, as a student of the sector, I think these documents make for an interesting read, but that could just be me. For example, QuadraMed has apparently tried to sell a number of times over the past few years to no avail. It would also be interesting to contrast Amicas’ slightly gloomy assessment of risks on its slide deck with its no doubt more bullish one that was likely given to potential investors a few weeks earlier.

Also, every time a public company is sold, its board is required to seek a Fairness Opinion to ensure a “fair” price is paid. A Fairness Opinion is provided by the seller’s investment banker (typically the one who ran the sale process — and who stands to get a very sizable fee upon its success — but I’m sure there’s zero conflict of interest there). In a Fairness Opinion, the bankers assess and determine that the amount being paid is “fair”. How? By looking at how similar companies are currently valued in the public markets, what price (and what multiple of sales and profits) similar companies have sold for, and by using a discounted cash flow analysis (DCF) as an additional check on value, as well as what kind of premiums to current share price have been paid for similar public company sales.

It’s actually a fairly rigorous analysis, and each firm has a special committee that vets it prior to issuance, as the issuing firm has some potential liability (which is part of why the fee for the Opinion is determined by the size of the transaction). Then again, the AOL-TimeWarner merger was considered “Fair” as well so, as the programmers can attest, Garbage In, Garbage Out. For more detail, please check the proxy links above, or just drop or post me a note.

And so, the public markets bid au revoir to these two players, wondering only if they’ll resurface as strategic sales (like Healthvision, nee Quovadx — generating an outstanding return for Battery Ventures) or IPOs (like Emdeon). The final question, of course, is what does this mean to users or customers? It could well be a positive. As suggested, assuming responsible behavior on the part of the new PE firms, freed of the pressure and scrutiny of public investors, they’ll both be able to focus more on running their business, supporting customers and developing new products — just like companies are supposed to do.

Post script: the action continues on Amicas. Readers of “the tape” will note a minor battle underway between Amicas and its competitor, Merge Technologies. After I submitted this to Mr. H, Merge has announced that it was bidding 13% more than the PE firm Thoma Bravo to buy Amicas. “Not so fast”, Amicas responded later that day.  “Do you really have the dough?” The plot has thickened with accusations flying both ways and a Massachusetts Supreme Court enjoinder on having the shareholder meeting.

Theoretically, regardless of management’s preferences on the outcome, the board has a fiduciary responsibility to accept the highest quality bid. With the stock trading today between the Thoma Bravo bid and the one from Merge, the outcome appears uncertain, and will be likely continue to be played out on the tape and in the courts. In the meantime, I can only observe that this minor drama seems to support that the market is setting the prices here somewhat efficiently, notwithstanding the complaints of the class action bar “representing” QuadraMed’s shareholders. Clearly when someone else wants to buy a company, they can emerge and do so.

Ask the Chair

What do investors do at HIMSS?

Aside from walk around looking for cool trinkets?

HIMSS is always great for the investor community. Most of the larger public companies in attendance have analyst meetings, or at least booth tours. It’s a chance to talk to current and potential clients of the firms one covers. There are parties to attend and for both investment bankers and private investors (VC and PE) and a virtual feeding frenzy of business trolling opportunities.

Speaking of which, Mr. HIStalk’s discussion of the HIMSS Venture Fair beat anything I could have done, but I will be attending and sharing a write up a week or so after, so watch this space for post-HIMSS thoughts.

See you at the HISTalk party, please come up and say hi.

Ben Rooks
The Chair

Ben Rooks is the founder of ST Advisors, a strategic consultancy offering long-term and project-relationships to companies and financial sponsors. He earned an MBA in healthcare management from The Wharton School of the University of Pennsylvania, has done healthcare IT equity research, and has worked as an investment banker in over 25 successfully closed healthcare and medical technology transactions valued from $40 to $365 million.

HIStalk Interviews Trey Lauderdale

Trey Lauderdale is chief innovation officer of Voalté.

Tell me about Voalté.

We are a startup located in Sarasota, Florida. We develop communication software and solutions for point-of-care physicians. Our whole goal is to integrate voice over IP, alarms and notifications, and internal text messaging, all on the next generations of smart phones like the iPhone and other devices.

My background is with Emergin in the alarm management world. I worked there for a few years, primarily in sales. At Emergin, you view the world as input systems, or systems that send you alarms and notifications to your middleware server. Then, output systems, or systems that we can dispatch those alarms and notifications.

Just stepping back and being new to healthcare at the time, I looked at it and did an analysis of the market. What I realized was the input systems were really going through this growth period of somewhat revolutionary change where systems were becoming more and more advanced. If you looked at the infusion pumps from 5-10 years ago compared to infusion pumps that were being sold at that time, you have these smart pumps coming out that were producing more information. Physiological monitoring systems, nurse call — they were all becoming more advanced.

We received all that information, and there was more and more information we were receiving, but then I’d look at the output systems and the phones that the nurses, the docs, and everyone else were carrying. A lot of times, we’d go in and we’d be integrating this unbelievably complex physiological monitoring system to a pager and it was just a line of text coming across, no variable ringtone, or, these legacy kind of either DECT phones or voice over IP phones.

The nurses and the docs would keep complaining and saying, at that time, “It’s 2008, why do we have to carry this bulky phone, these antiquated pagers?” They would bring in their own personal PDA because they wanted to run all these different applications that were coming out on their BlackBerry or iPhone or other device.

In March of 2008, Apple released the iPhone software developer kit. It just so happened that same day I was at a meeting at Miami Children’s Hospital where the nurses asked me to come in. They were looking for a voice over IP system to purchase for their hospital. I did a quick presentation — these are all the devices Emergin can send to. There was just a look of disappointment on the clinicians’ faces and they weren’t happy with their selection.

That night, I went home and read about the iPhone SDK and a light bulb went off. Why can’t clinicians have one device, one of these smart phones, to handle all of their communication needs, built specifically for their workload model?

A few months later, I ended up leaving Emergin and creating and starting Voalté, August of 2008. At the time, it was me. I found a software developer and we started the company. We took the leap of faith and I quickly realized how unbelievably difficult it is to start a company. Of course, my luck — August 2008 was right when the economy completely tanked out.

I was talking to hospitals. I was talking to angel investors, venture capitalists, and everyone said, “We love your passion. We love the idea you have.” At the time, I was 26 years old. “We’re not going to trust you to start a company. You will not be successful. You’re not going to get this to work.” After about three months of trying to get things going, I was at a point where I didn’t think it was going to work. I was going to have to get a job. I had burned through all my savings. I was living off credit card debt.

Through a mutual contact at the Center for Entrepreneurship at University of Florida, I was put in contact with Rob Campbell. Rob is an interesting individual. He can best be described as a serial entrepreneur. Back in the day, he actually worked for Steve Jobs at Apple back in the late ‘70s. He was part of the marketing group and he helped build the entire market for Apple’s software division. He then left Apple and created a company that founded a couple of products  — one is PowerPoint. He started up a lot of companies that have been very successful.

I pitched the idea of Voalté to him. I didn’t know why at the time, but he agreed to come on board as our CEO and help guide us through this progression of the building of the company. He came on board in November of 2008. By December, we were able to raise our first round of financing. We were able to open up our office in Sarasota, Florida. It was really the start of Voalté and the creation of the company.

At that point, Rob was new to healthcare. I had two years of experience, so I was relatively new as well. We went around and — included in this was you — we pulled a number of what we considered ‘industry influencers’, or people who had a good pulse on what was going on in healthcare. We talked to a lot of CIOs that I knew from my previous relationships at Emergin and we asked, “We’re a small startup organization. We’re building our company. Can you point us to someone that we should model our company after? Our services, our support, our software? Who’s the Southwest Airlines of healthcare? Who’s the Starbucks or the Disney of healthcare?”

Surprising to us, we asked about twelve CIOs this and only one of them was able to give us an answer. A lot of them would say, “Well, it used to be XYZ Company until they were acquired by someone.” Or, “It used to be this company, but not any more.” The one CIO that did tell us a company, they told us Epic. It just so happened they just purchased $150 million worth of Epic, so I’d assume that they’re going to say it’s Epic no matter what.

I didn’t realize at that time, what Rob was really doing was analyzing the market. From at least the customers we talked to, no one was taking that vision of the Disney of healthcare IT. So, we started building the organization. One of the first things we knew was we wanted to provide a compelling customer experience, end user experience, to our clinicians and to the people that we provided our software to. We engaged, and lucky enough, Sarasota Memorial right here in our back yard, we were able to meet with Denis Baker. We talked to him about our solution and what we planned on building and he agreed to enable us to work with Sarasota Memorial as our first ‘Development Partner Program’.

I know the term gets tossed around a lot, but what we really proposed to Denis and Sarasota Memorial was, as an organization, we need a hospital to work with to get feedback. Not only from an IT perspective on how we design our solution, but from a clinical perspective of what the nurses need and want for a communication solution at the point of care. From the very beginning when we were designing the user interface, the way the solution was going to work, we pulled in feedback from the nurses at Sarasota Memorial. We brought in nurses for a nurse focus group. We had a big whiteboard up on the wall and we drew out exactly how the application was going to look and we mocked up drawings. The nurses told us word for word, “This is how we want Voalté to work for the voice communication, the alarms, and the internal text messaging.”

But, we also knew that a lot of times your end users don’t really know what they don’t know. We put a button inside our application called Voalté Feedback, which would let any one of the nurses, the clinicians, the end users to hit that button and send a message to us. Things like, the buttons are too close or, this feature isn’t working, or that function is bulky. Before we know it, we went live with the pilot in June, and within a month we received over 90 feedback messages. These clinicians were telling us non-stop all of these problems with our solution from a text messaging perspective, the way things looked. We took all that feedback and we completely refactored our iPhone workflow.

A great example that was told to us was, a lot of the nurses came back and said, “We love the text messaging functionality. It’s fantastic, but I can’t read the text. The font size is way too small. You have to make it bigger.” No problem — we made the font size really big. Then we got a message back the next day, “The font size is way too big. I want to see everything on the screen.” I went to the engineers and said, “Guys, we’re stuck. We’re caught in a Catch-22. There’s no way.” They said, “Well actually, we can. It’s an iPhone.”

What we created was a variable font size so nurses, on the fly, can change their font. Also, we save that to their user profile so when they pick up an iPhone, they log in to start a shift, and we load up that component of their profile. It really, at that moment, struck us that we can’t just build a vanilla-flavored application and push it on everyone. We need to take this feedback and customize it for each one of the individual end users. From Day One at Sarasota Memorial, we took that feedback to build our application.

Since then, we’ve expanded the pilot at Sarasota Memorial. We’re out to an additional four units there. We have an enterprise agreement, and we’re going to be rolling out across the whole hospital. We signed a second hospital out in California, which was Huntington Memorial. They went live in December with a similar solution to what Sarasota had. We signed our third hospital that we’ve installed and we’re not allowed to announce yet, but it will be coming out in the next few months. We’ve recently signed hospital number four; and I’m currently waiting for a phone call which will hopefully be hospital number five, which should come in this afternoon.

From our perspective, it’s a really exciting time to be in this industry. We think we have a lot of momentum heading into HIMSS, and we’re real excited.

I did a survey when the iPhone first came out. Most readers didn’t think it would really have any healthcare impact. What did they miss?

I would really think that again, just looking at your reader base — which obviously, I have a tremendous amount of respect for — I think that they were all looking at a fad from a technical perspective; the technical components of the iPhone and if it will work, or won’t work in healthcare.

Apple has a way of making products that are unbelievably easy to use. I think that’s really what the game changer was. They reinvented the way you interact with a phone, from the swiping, the pinching, the zooming, and Apple just does a fantastic job of paying attention to very specific details. If you look at everything they build, down to your little icons on your MacBook — how they bounce up and down, the little blue dot appears. It’s just an unbelievable amount of attention to user detail and what users are going to look for, in regards to interaction with the device.

I think the compelling thing that was overlooked was just the user interface and the user experience that Apple is able to provide. I think that was probably the missing component, if I had to guess.

Do you think working on the Apple platform with Apple developers forces you to think more about usability than the average software developer working on a client server-type application?

Off the bat, in the Apple SDK, there’s actually whole sections dedicated to keeping and conforming to the Apple user interface. They provide a lot of guidance and feedback on how to make all the applications look and feel somewhat the same. When you’re applying to the apps store, they actually go and review… I don’t believe they’ll reject you for moving away from your standards, but they try to greatly encourage you to move down that path, so all the applications somewhat look and feel the same.

If you look at our application, it looks great. When we go into some of the hospitals and we install or we go live and we’re there training; if a nurse has an iPhone on their own, they really don’t need Voalté training. Our phone application looks just like the iPhone application, our text messaging looks exactly like the Apple text messaging, the SMS application. We actually had to stop users from being able to access our application during training or else the first class we let them go into it, they went wild using it. It’s just so intuitive.

I think it does, to a degree, force developers to kind of rethink what they can do. You always hear people complain about multitasking, and you can’t run background applications on the iPhone. Having one application open and some of the limitations that Apple puts on you are actually mixed blessings; it makes you think, “Well how do I use all the real estate on the screen, and how do I make sure my current application that’s running is making the most of what tools I have available?”

On the flip side, the iPhone developers probably don’t have much healthcare experience. Is that a problem?

I don’t think it’s a problem, because what we see happening right now is a number of large companies that have a great deal of healthcare experience are just going out and picking up either iPhone developers, or iPhone consulting groups to develop their applications for them.

Epic has released Haiku as their EMR application. Allscripts, they released an application last year. I’m sure Cerner and the rest are following suit. I doubt that they had their own internal developers build that. They probably went out and hired iPhone developers and provided the healthcare expertise. I do think that there are not a lot of startups in this space that have created iPhone applications. Specifically, iPhone healthcare-focused companies like we’ve done, but I see that changing in the next few years.

Overall, I think right now Apple claims 700-800 medical-focused applications. I think the platform in healthcare has an unbelievable amount of momentum, and with the iPad coming out, that’s going to continue to grow. Both the iPad and the iPhone run on the same development environment, so even though right now there might be a shortage of iPhone healthcare-specific developers, I think that number is going to continue to grow exponentially. You don’t need to be a healthcare expert to develop on the iPhone. You need to be an iPhone developer, and there are plenty of those out there in the field right now that can get picked up by healthcare companies to help develop the application.

How do you help solve the problem of both device and information proliferation for doctors and nurses?

I think the first component is really understanding the workflow of where that information’s being generated from and the different criticality of the information. If you look at where these pagers and devices were receiving the alarms and notifications from, you had a wide degree of things being blasted to caregivers. An example might be they’ll carry one pager, which is their code blue pager or their rapid response team pager. Then the next device will be a pager that goes off for TeleTracking if they have a patient coming into the floor.

I think the key is understanding all of the information that’s getting blasted to the nurse, and from what different systems it’s getting blasted. Then, creating a workflow model of “these are all the alarms, notifications, phone calls, text messages, that are being received,” and then building and orchestrating a plan around the three components of communication — which are really voice, alarm, and text messaging.

There are things like; we can associate specific ringtones for different types of alarms. For example, at Sarasota Memorial Hospital, some of the devices they were carrying would go off for a nurse call — a call bell alarm — then another device would go off for a bed call. They had Stryker Smart Beds.

What we actually did was on the iPhone, we have different ringtones for the different types of alarms. For example, if someone hits a nurse call alarm and it goes off on the nurse’s iPhone, we play the exact same ringtone in .wav file that will be played at the central station. A very subtle beep, beep, beep, and they know OK, that’s a call bell alarm. We blast it across the whole unit, and we play the Stryker Smart Bed .wav file of what the noise is supposed to be when there’s a bed call. We have unlimited customization and configurability to make sure that ringtones are played for the right different types of information.

Again, you want to be careful with that because you don’t want this device with 20 ringtones. It’s that careful balance of getting the right amount of ringtones and different types of notifications, but not overburdening the nurse with all this different information they have to memorize.

Do customers perform ROI justification to buy your product?

I think there’s a couple components that they can look at for ROI. Off the bat, we can replace a number of devices. The first would be what we considered a legacy voice over IP phone. We could take that price, and there’s usually the hardware costs associated with that; the charger cost, the external battery cost, and typically, there’s a software license cost associated with that device.

Next are all of the different pagers that are going off. Just off the bat, it’s consolidation of devices. You take a PDA, the pagers, the voice over IP phone; combine them together into one device.

But beyond that, when you look, there’s a number of studies that have been done; specifically by University of Maryland. It showed that overall, the average 500-bed hospital will waste approximately $4 million a year in wasted communication, which is the telephone tag back and forth between caregivers and people not having the right information to act, or the hunting and gathering of different caregivers.

The second area where we would see a return on investment is a better utilization of the nurse and clinician time. Nurses could access the right information at the right time through our solution so they could therefore, be more effective at their job.

The third area that hospitals are interested and where there’s more of a long-term ROI, is improvements in Press Ganey and HCAP scores. Through our solution, any pilot that we roll out in, or any hospital that we install in, we go and we do an analysis of the hospitals; specifically, in Press Ganey and HCAP. We look at noise in and around the room, and response time to call bell.

We look at those metrics before Voalté goes live. Then after Voalté goes live, we do an analysis to see if we were able to produce an improvement in those scores. In the long term, that should overall, greatly affect the hospital’s ranking from a patient satisfaction and a patient safety score, which would make them a more prestigious hospital and hopefully, bring more patients in to the facility.

I would think caregivers think it’s pretty cool that they get to turn in their analog pager and be given an iPhone in return.

Definitely. There is an angle of nurse retention. You go into a hospital and you tell the nurse that they’re going to get iPhones. I’d say 90% of the nurses are thrilled, they’re excited. They can’t wait to see it, but you get the flip side of that as well. About 10% of the nurses will actually step back and say, “No way.”

I’ll never forget this. It was one of the most memorable points at Sarasota Memorial, our first installation. We went in for training and I was part of the training team. I love going in and talking with the nurses and getting that end user feedback interaction. We were doing training and there was one nurse who was kind of in the corner while we were doing training. I went and said, “Are you excited? What do you think?” She looked at me and said, “I don’t even use e-mail. There is no way I am using this iPhone.” She puts the device down and said, “I’m not going to use it.” I tried to convince her and she just said… I think she was a few years from retiring and had no interest at all in learning this new technology.

Later that night, I was there during go live. I looked and I saw her and she looked frustrated. She was picking up the phone and she kept dialing a number and she’d slam the phone. I went over and I asked her, “Is everything OK? Is there anything I can help you with?” She said, “Well, I’ve been trying to reach the floor pharmacist all night and I can’t reach him.”

For their workflow model, they have a floor pharmacist who covers a whole tower. At night, you have to send a page to him and you don’t really know if the page got out or if he’s going to be able to respond. I said, “For this pilot, we actually provided the floor pharmacist with a Voalté iPhone. Why don’t you try sending him a text message?” She looked over at me, kind of with a sly face and she grabbed the device. I walked her through, she hit the Quick Message button, and she sent it out in a couple of taps. About two minutes later, she got a response and it was the floor pharmacist saying, “I’ll be there in five minutes and I’ll drop off the meds.”

Typically, it takes her a few hours to find that caregiver. She looked at me and said, “Well, I guess it’s not that bad.” So, I don’t consider it a complete victory, but it’s finding the specific users and spending the time to educate them on different examples of how to use the technology. Even though she didn’t fully embrace the solution afterwards, I think that we were slowly starting to win her over. I think that’s one of the areas, as a company, which we’re really attempting to differentiate ourselves in the whole customer experience and our end user experience.

Remember at the beginning of our conversation I talked about Voalté feedback? Originally, when we built that, our whole focus was we need to get the best features, the best ideas, from our end users. We want to have unfiltered feedback, from a feature standpoint, from our end users. Then what we realized during the pilots was the nurses started sending us messages back from a support standpoint. They’d send us a message like, “I forgot how to turn myself into busy mode,” or, “How do I add a custom quick message?”

It dawned on us that this is the absolute perfect tool for end user support. The way it works is the nurse, again, they could hit that button Voalté Feedback. They send a message. We actually have our own Voalté server in the cloud that receives that message, dispatches it to my personal iPhone or our support team’s business iPhone. We receive that message and we can login to the Voalté server remote and establish bidirectional support communication with that individual caregiver. So off the bat, any user of our software, at any moment, 24/7, could have instant communication, from a support standpoint, with one of the Voalté support employees.

Also, from a technology standpoint, you’re trying to drive innovation, new features. We have unfiltered feedback from every single one of our users, which is huge. It’s kind of the same concept of Twitter. Our Southwest Airlines, Starbucks — they all have a Twitter account and if you complain at (@) them on the Twitter account, they’ll respond by responding at (@) you. We’ve got that same philosophy, that same methodology; but we’re applying it inside healthcare to receive feedback, but also support the nurses in the field.

Beyond that, what we’ve also done, from a remote monitoring standpoint is we’re actually able to track not only that the message was sent on the device, but any trouble that happens down to the device level — remote monitoring of servers. That happens all the time, where people can monitor a server. If something goes wrong, you receive an alarm or notification. We, obviously, do that. We keep a VPN connection to every Voalté install server. If any one of the adapters, any one of the components fails, we get notified.

But, we can actually take that down a further level to the iPhones. We’ve customized and designed our solution so we could actually look and see if there are trouble tickets or trouble logs in the iPhone. All the nurse has to do is plug it into the charging station. We can connect to that device and we can reset the firmware. From a remote monitoring standpoint, what’s happened is the platform of having these smart phones at the point-of-care has enabled us to do things like have unlimited feedback from our nurses, from our end users. Have really, unlimited remote monitoring down to the device.

When we first started the company, it was all about the platform enabling the perfect trifecta of communication, which is voice, alarm, and text messaging. But as we’ve been out in the field and learning from our customers, we’ve realized it’s not just about the technology. It’s also about the customer experience, the end user experience, and we finally have the perfect platform to provide that level of end user experience that the nurses really need, such as the Voalté feedback and the remote monitoring down to the actual device.

We’re pretty excited. I guess you could consider us one of those overly aggressive startups that, you don’t start up a company just because you want to drive a little bit of change. You start a company because you want to make a dramatic difference with your customers, with your end users. We not only want to have awesome technology that’s built specifically by our end users, we want to provide and overall amazing end user experience to our customers.

Definitely, I probably sound like a naïve, startup, 27-year-old guy, but I think that passion is really well conveyed in the way that we speak about our company, we speak about our products, and we talk about our customers. If you talk to any one of the Voalté hospitals we’ve installed at, from the end user, the nurses, to the CIO, they’ll tell you that engaging with us, as a company, is a lot different than any other organization.

I think the reason we’re able to do that has really been subject to the influence Rob Campbell, and also, our Chief Experience Officer, Oscar Callejas, bring to the table. Where you have Rob, who’s more of a Silicon Valley startup guru; but Oscar, when we brought him on, his background is in hospitality. He’s worked in hotels for the last 15 years managing these high-end hotels and organizations. When he came in, he brought that whole view of “it’s about the customer experience.”

When I started the company, that really wasn’t on my mind. I was all about the technology, integrating the iPhone; but they brought that flavor to the organization and I think it’s all coming together really well. I’m really happy with where we’re at as a company.

Last question, and this is the one you knew was coming. Pink pants at HIMSS?

Oh, absolutely. Not only pink pants at HIMSS, we wear pink pants at every single installation. It’s part of the customer experience. We come in and we are the pink pants company. It’s part of that whole thing I was just talking about, where we don’t want to look like other healthcare IT companies, we don’t want to talk and act and feel like them. We want the whole experience that customers and nurses and hospitals go through to be different.

When we walk in for the first day of Voalté training, its Voalté day. We come in and we take pictures of the nurses to put in the application, we’re wearing pink pants. During clinical training, we’re in pink pants. Go live support, wearing pink pants. You know, people laugh at it, but the nurses know who we are. They see the Voalté person walking by; they know exactly who that person is for help and support.

At the HIMSS conference, last year we were all kind of sitting around. Little startup, Voalté. We were looking at all the booths and we saw GE with an 800×800 foot booth and dancers and DJs and everything else. We looked at each other and said, “God, how on earth are we going to get any attention at this conference? No one’s going to look at us. No one’s going to even acknowledge that we’re there.” Someone said, “Well, why don’t you wear pink pants?” Everyone kind of laughed, but we looked around and said, “Why don’t we wear pink pants? What do we have to lose?”

We actually e-mailed Inga because I was kind of worried. I was the only one who had actually ever been to HIMSS before, so I know it’s a suit and tie event. I was thinking, “Are we not going to be taken seriously?” Then, Inga threw it up on your blog so we really had no choice, so we did it. Believe it or not, it’s kind of become a rallying cry for the company. The pink pants, in a way, symbolize what we’re about. We’re different. The experience is different and it’s a lot of fun. You’d better believe the pink pants will be there.

News 2/26/10

From Wrangler: “Re: is Inga a man?” An online article suggests that perhaps Inga is a man writing as a woman. I couldn’t wait to tease her about that, but she had already seen it and responded back that a couple of readers have e-mailed her with the same suspicion. Let me forcefully allay that speculation: Inga is most definitely female, and a quite striking example if I may say (not only at least as cute and charming as her avatar suggests, but darned smart and caustically funny in our offline e-mails). So let’s treat the lady with some respect, OK? She’s the queen around here.

From Olivia: “Re: karma. With hard times and cutbacks around him [vendor exec name omitted] goes out and buys a $450,000 Maserati, parking on the corporate lot (and taking several spaces) for viewing by the layoff-ees exiting the building. Need I say there was a small round of applause that swept the building when news traveled that he’d hit the back of another vehicle and smashed its pretty little face. He has to be the most hated exec in the EHR industry – I’ve never met anyone about whom 100% of people say he is truly insufferable.” I hope he closes the Maserati’s gas cap tightly because the sparks from keys repeatedly meeting paint could present a fire hazard.  

From Lee Minors: “Re: first step of Microsoft purchasing Eclipsys?” Microsoft will integrate parts of Eclipsys Sunrise Enterprise with its Amalga UIS. The press releases talks about an open platform and the pretty cool MLMs and ObjectsPlus components that are exposed for customer self-development (not all inpatient EMR vendors offer something like this, but I’d find it hard to justify buying one that doesn’t). I don’t see any clear-cut evidence of further Microsoft interest at the moment, but its recent Sentillion acquisition started out this way and I’m hearing the rumors, of course. Thanks to Eclipsys for offering me personal, pre-announcement access to its very tippy-top management to discuss the strategy behind the move, which I had to unfortunately decline because I was occupied with stuff at the hospital. As I e-mailed Inga afterward, “One of these days, it will hit me how strange that is — telling a billion-dollar company that I unfortunately don’t have time to talk to their top executives.” Darned day job. Even without the briefing, though, I like the move.

From Connie: “Re: HITMEN. You didn’t mention the TV series behind the theme. It’s Mad Men on AMC, based on early 1960s Madison Avenue advertising men. There have been two seasons and it’s wonderful!” I knew that but forgot to mention it. I haven’t seen the show — I guess my DirecTV package doesn’t have AMC because I keep scanning the DVR list to record it and it never comes up.

From Byter: “Re: Quality Systems acquires Opus Healthcare Solutions. From the SEC 8-K, they paid $12 million in common stock plus up to $14 million in future shares subject to performance.”

From PACS All Mighty: “Re: Merge. Given the odd but always entertaining history of Merge, Amicas, Emageon, Cedara, eFilm, etc. and their oft-crossed swords of mutual conquest, an Auntminnie.com forum writer SlingshotPM  calls this “Efilmergemedeageonicas – a seamless and fully integrated solution that capitalizes on the synergy of integrating a best of breed technologies solution to the radiology workflow paradigm.’ Clearly the GE, Philips, McKesson, and Siemens big dogs would love to see all these yapping Chihuahuas go away.” Speaking of Merge, the company is suing its former CEO and CFO for the $880K it spent defending them on accounting fraud charges, plus the $3 million it shelled out to settle the class action suit that resulted. Also speaking of Merge: the company gets $200 million in bridge financing to support its $248 million offer for Amicas.

First time I’ve seen this: advertising for Epic people for “a massive healthcare project” on Craigslist.

I interviewed the folks from DIVURGENT for HIStech Report, including former BayCare CIO Lindsey Jarrell, who just joined the company.

Listening: Tarja, the operatic former lead singer of Finnish symphonic metal bad Nightwish, which just may teleport you to a winter’s evening in Finland spent on a bear skin rug in front of a fireplace (hopefully not alone).

I interviewed iMDsoft CEO Phyllis Gotlib a couple of weeks ago, so it’s fun to have the company back, this time as an HIStalk Platinum Sponsor. iMDsoft has big plans for expanding its US market, which should be made a lot easier by already having a Who’s Who of top US hospitals as customers (BIDMC, Lehigh Valley, Mass General, Henry Ford, Barnes-Jewish, Johns Hopkins, etc.) Its flagship product is the Metavision continuous patient record for ICU, anesthesia, and acute care, along with solutions for electronic dashboards, remote intensivist monitoring, and mobile clinician access. Drop by Booth 8633 at HIMSS and tell them you read about them in HIStalk. Welcome and thanks to iMDsoft.

Several HIStalk sponsors have swapped out their ads on the left with HIMSS-specific ones, so give them a look and click on any that move you.

Thanks to the one and only PACSMan Mike Cannavo for his guest article this week. Mike doesn’t know who I am, but we hired him at our hospital to help with a PACS selection years ago. He’s one of those guys who knows more people in his first hour on site than you do after years of working there, and seems to be reverentially quoted by all of them constantly. The best I could do to compete was to remind everyone that I signed off on the contract to bring him in.

Medical University of South Carolina will deploy the care continuity module of the Oacis data aggregation solution of TELUS Health Solutions. It creates a portable care record that can be printed, faxed, e-mailed, or sent to an EMR as an HL7 message. I think I got an early copy of the announcement because I don’t see it on the Web yet. I respect and like Frank Clark of MUSC as much as any CIO anywhere. We chat occasionally, so I asked him about Oacis a couple of weeks back (they use it because McKesson’s Horizon portal isn’t so great for academic medical centers). Oacis is still a big piece of their strategy, providing viewer capability as a front end for Horizon Clinicals. He was remarkably frank (no pun intended) and modest when I interviewed him a couple of years ago, including giving me a nice overview of Oacis.

3M Health Information Systems releases its Mobile Dictation Software for the iPhone. It was already available for BlackBerry and Windows Mobile.

ONCHIT is Tweeting. Or at least has the capability.

Here’s an amazing video of a new Enovate computer wallstation. I wasn’t paying too much attention until the guy started moving it up and down the wall electronically with one finger; then, it turned itself off and closed its own keyboard tray and shut down when the user walked away.

We’ve got an interview with Paul Brient, PatientKeeper president and CEO, on HIStalk Mobile. We will have daily updates there from HIMSS, so if you are interested in mobile healthcare computing, signed up for the e-mail updates and get the scoops (we will get first crack at a few of those, I think).

Order Optimizer is a brand new HIStalk Platinum Sponsor, so thanks very much to those folks. It’s the first inpatient system certified by CCHIT as meeting preliminary ARRA 2011 standards for CPOE and decision support. The SaaS sytem was developed by the hospitalists of Intercede Health and provides comprehensive support for evidence-based admission orders. It contains over 180 evidence-based order sets and a merging engine that helps doctors create evidence-based treatment plans. Admission orders can represent up to 70% of the total during a patient visit and the product focuses on those, so the company says hospitals can get Order Optimizer up and running within weeks with no capital expense, giving much of the benefit of CPOE without requiring 100% physician adoption, reducing time, risk, and cost. It was a finalist for the 2009 Microsoft Healthcare Innovation Award. Thanks to Order Optimizer for supporting HIStalk.

Charge master applications vendor Craneware announces six-month results: revenue up 25%, earnings up 36%.

PatientKeeper and and EMPI vendor NextGate announce a partnership to integrate their technologies to enhance PatientKeeper’s HIE capabilities.

Mayo Clinic will conduct a one-year study to determine if home monitoring technology from GE and Intel can reduce hospitalization and ED visits of patients with chronic disease.

HIMSS says it expects 28,000 at the conference next week and all the hotels are full. Atlanta weather for Sunday: lows in the low 30s, highs in the low 50s, sunny. Getting cold by Tuesday, in the upper 40s with a chance of snow (can’t HIMSS go anywhere without the snow following?)

I’ll be writing as usual Saturday and then daily from Atlanta. You are my eyes and ears, so let me know if you learn something that others would like to know.

E-mail me.

HERtalk by Inga

Healthcare execs say their biggest hurdle in EHR adoption is lack of internal resources, according to a Beacon Partners’ survey. I was surprised that only 25% of the execs believe their organization won’t fulfill the first meaningful use deadline with most feeling comfortable with their progress. Even more surprising to me was that a whopping two-thirds of the 168 surveyed were not familiar or had little knowledge of Stark.

In yesterday’s HIStalk Practice I mentioned that HIMSS has a new HIT Buyers Guide just for HIMSS. It’s free to providers, though not vendors nor consultants and I assume not bloggers. When I am told I can’t have something (unless I pay a bunch of money), why do I feel I must have it? Anyhow, a kind reader shared these reflections:

A good number of vendors aren’t going to like this guide because no one wants to see anything less than an A by their name. A few categories have no vendors earning an A and most categories are littered with Bs and Cs. I even noticed one F. Even industry darling Epic made a B+ in one of its categories. If I were a buyer, I would be seriously depressed by the lack of low-risk choices.

Sunquest Information Systems extends its relationship with two customers who are expanding their use of Sunquest’s anatomic pathology solution. Massachusetts General Hospital is installing Sunquest CoPathPlus and Bon Secours Health System (MD) is adding Sunquest CoPathPlus at three facilities.

Praxis EMR selects MedUnity as its exclusive provide of HIE and fax services.

MD Anderson Cancer Center (TX) deploys LodgeNetRX Interactive Television System throughout its 11-building campus.

The Voalte One solution is now offered on Blackberry smart phones, in addition to the iPhone. The pink pants guys say they will be showing off both versions at HIMSS, booth 2407.

OakBend Medical Center (TX) successfully implements McKesson’s Paragon HIS, along with AcuDose-Rx medication dispensing cabinets. The hospital CEO says 100% of the nurses were using the system the first day of go-live and 100% of the physicians were using it within three months.

Beth Israel Deaconess Healthcare selects MedAptus’s Professional Intelligent Charge Capture technology for its 170-physician hospitalist group.

Five years after first implementing Allscripts’ practice management system, the 70-provider Mid-Michigan Physicians decides to add Allscripts EHR.

The Oregon Department of Human Services contracts with Netsmart Technology to implement Netsmart’s Avatar EHR and PM software at Oregon State Hospital and other state behavioral health facilities.

athenahealth announces it will postpone the release of its Q4 and 2009 year end financials in order to allow additional time to complete a year-end audit and conduct an internal accounting policy review. The delay is in connection with an internally-initiated review of its accounting policy for the amortization period for deferred implementation revenue.

Medsphere Systems appoints Michael Previti as VP of national sales. He was previously VP of provider sales for Initiate Systems and also did stints at both Cerner and McKesson. I see that former Picis exec Doug Schumann also just joined Medsphere to head up implementation and training, and, Health Data Sciences alum Carol Somer is the new director of marketing.

In September 2008 Mr. H mentioned that Pegasus Imaging Corporation filed a lawsuit against Allscripts, claiming  intellectual property infringement over licensing fees for a Pegasus development toolkit. I don’t recall ever hearing more about the lawsuit so I assumed that it was settled privately, as most lawsuits are. That’s apparently not the case and a trial could start in March. Pegasus president Jack Berlin says he’s been trying to work out a settlement for the last 18 months. Allscripts isn’t commenting. Berlin believes Allscripts could owe him $60 million or more in license fees.

After budgeting  an initial $590 million to deploy an EMR, Catholic Healthcare West is adding another $419 million to its budget (holy cost overrun, Batman!) Of the initial funds, $240 million was spent implementing Cerner EMR at eight of the health system’s 41 hospitals. CIO Ben Williams says the cost per hospital will be much less going forward because the implementation team is now more experienced. My math says they need to be much more experienced.

Emergisoft releases Emergisoft EC Forms Digital Solution, an application that converts template-style documentation into a narrative language chart.

AT&T announces plans to expand its AT&T Healthcare Community Online (HCO) solution to include a portal with pre-integrated applications. HCO is AT&T’s cloud-based HIE and collaboration portal. Some of the new enhancements include real-time access to patient data at the point of care, single sign-on access, integration with e-prescribing, EMRs, and lab services.

Speaking of AT&T, I got a text yesterday saying there’s a brand new tower close to my neighborhood. Coincidentally I see PC World praises AT&T’s efforts to improve its 3G network performance, which is now 67% faster than the network speeds of Sprint, T-Mobile, and Verizon Wireless.

The HIT Standards Committee recommends that federal certification criteria for EMRs be flexible and not lock into specific requirements that could become outdated. Certifications should consist of a family of standards for certain criteria, rather than specific requirements, e.g., require HL7 version two, though not specify a specific release.

Phytel appoints Dr. Richard Hodach its chief medical officer.

NextGen says that for each person who follows them on Twitter and retweets “#NextGencares and I do too,” they’ll donate $1 to charity. At HIMSS you can vote on which charity you’d like see get the money, and for each vote, NextGen will donate more money. I’m all for corporations sharing their profits with the world, so starting Twittering and stop by booth #7433.

Keane’s Healthcare Solutions Division is awarded contract extensions with University Physicians Hospital (AZ) and Ernest Health. Both entities recently upgraded to Keane’s Optimum Patcom offering.

I have to ask: why do marketing types feel the need to mention ARRA in every single press release they issue? It’s not just the folks selling EMRs. New hire announcements, infrastructure upgrades, and earnings announcements are all deemed worthy platforms to mention ARRA stimulus money. Enough already.

I’m sure regular readers are aware that Mr. H has been especially prolific with the interviews the last couple of weeks (I only did one of two). A couple of trivial observations: where are all the intriguing female interviewees? Please send your suggestions. More trivial: HIT has its fair share of hunky guys. I’m definitely heading to the AirStrip booth in Atlanta.

As Mr. H mentioned, a few of our guest at Max Lager’s Monday night will be adorned with beauty queen-type sashes. Most of our sash-designees have been good sports in agreeing to participate, even though none of them yet know what their sashes will say. Note that we will be awarding the above sash to two lucky attendees at the party, so keep this in mind as you pack your bags.

If you are going to Atlanta – safe travels! If you are staying home, we will do our best to let you know all you’re missing.

E-mail Inga.

HIStalk Interviews Todd Johnson

Todd Johnson is president of Salar, Inc. of Baltimore, MD.

Give me some background about the company and about yourself.

The company was founded in 1999. It has been split in half, in terms of our corporate development. In the first half, we were really a healthcare IT consulting services firm, and got involved into all sorts of very interesting things, including helping design and implement the technology surrounding the Johns Hopkins point-of-care IT solution. It was a challenger to Epocrates in terms of point-of-care, clinical content, and medication references. As well as building an EMR at the Centers for Disease Control.

We did a whole wide variety of things, but honed in on a series of products in 2004-2005 that are really focused around inpatient physician documentation and charge capture. Essentially, capturing H&Ps, daily notes, discharge summaries, consults — reducing transcription costs and increasing physician charge capture, and ultimately benefiting HIM. 

We migrated the entire business into the focus around acute care physician documentation and charge capture. We’ve had long success with some of the really large academic medical centers. Now we’re getting success with regional medical centers, community hospitals on the East Coast, and the Midwest.

We’re growing the company organically … the traditional garage shop story. A couple of buddies and I graduated college and sat down and said, “What do we want to do with our lives?”, built a company, and we’re still at it.  We’re growing and we’re having a heck of a good time doing it.

What’s your answer to the problem of getting physicians to document electronically?

It all boils down to physician adoption. When we started our technology solution that we now call TeamNotes, I think we were very lucky in that we were extremely naïve about physician documentation. We rounded with physicians for months and noticed a couple of things. 

We noticed that there’s a wide variety in how physicians like to document, in term of their workflow. Some like to take notes on rounds and sit down and dictate it later. Some like to do their notes while they’re on rounds and do their billing later.

We wanted to encourage a system that had a wide variety of workflows as well as a strong user interface. I think paper is seen as a naturally crappy way to document. But I think the benefits of paper are overlooked. It’s fast and very acceptable. If you’ve got your daily notes rolled up in your pocket, for you, as an attending, it’s a very quick thing to access and update those. It certainly falls short in terms of legibility and distribution to others.

What we tried to do was focus on current practice. What were the really good things about paper?  We built our entire platform — in fact, our entire corporate culture — around physician adoption. 

I think, traditionally, most EMR providers look at physician documentation and think that perhaps the primary incentive is payment. Payment is clearly an obvious incentive, but I really think that speed is the number one incentive. That becomes the barrier. You have to put in the hands of the physician something that is fast and effective. 

If you can do that, then the other clinical and financial outcomes occur as a result. But by focusing on speed first, that’s how you harvest physician adoption.

Most of the companies out there started with an emphasis on billing.

Yes, and we’ve been doing CPT coding and physician charge capture for ten years. It’s interesting when you look at the CPT guidelines — how do you make that into a note? You get a lot of feedback over the years if a note is designed too much by a compliance group, particularly if you go into a hospital.

Let’s just say they’re all on paper. Go into a hospital that’s been RAC’ed by the OIG. You start to see these paper templates that have been designed by billing staff that clearly have a design towards CPT guidelines and compliance with CPT guidelines.

The general sense you get from a lot of the attendings is that you’re taking something that was originally intended to be a communication from provider to provider about the status of a patient and turning it into a billing process. The question is how can you automate billing; automate CPT billing charge capture and PQRI capture; but at the same time, put something that’s a meaningful document, in terms of communication, from one provider to the next?

I think that’s why you’ve seen a low adoption rate. A structured documentation tool –  certainly in general medicine — it’s because they don’t tell the story. They need to tell the patient’s story. How do you tell the story on an admission note and simultaneously extract the location, quality, duration for a very complex case? I think that becomes the nuance of designing a documentation solution that works.

When you look at what is important to physicians, what’s the relative importance of application design versus usability versus the form factor that they use?

I think it’s the critical piece. Application design, for us — again, going back to the genesis of this software — we assumed we knew nothing about physician documentation. So rather than building a physician documentation tool, what we built was really a tool kit. What that means is our customers can create any form they want in Word or Visio or Adobe or Excel, whatever tool they’re comfortable with.

Then we essentially overlay the clinical data from the EMR onto those forms. That process of creating your H&P and your daily note and your discharge summary, as well as designing the workflow between those notes — that is the heart of the process. That is the number one reason that we’ve got happy doctors running around and we do these big bang implementations covering the majority of discharges across multiple facilities in a single week. It’s because the physicians are involved in the user interface and the user design.

In terms of form factor, I guess I interpret that to be a question, really, of devices. We see a wide variety of devices. We had originally designed TeamNotes for the tablet PC environment. We thought tablet PC was going to be the winning platform for acute care documentation. I think what we’ve learned is that in some instances, that’s correct. Some doctors like a tablet PC … like it a lot. 

Others prefer to dictate and you just drag it on a desktop. Others use laptops on wheels. I think what we find is that, across our different customers, different strokes for different folks. although tablet PC probably makes up less than 15% of our customer profile, which is in retrospect, it makes sense.  But I think I would have been shocked if you told me that five years ago.

You mentioned the difference between a form metaphor versus a screen metaphor. Why doesn’t everybody do it that way?

I don’t know. I think that if you were to survey doctors that have tried structured documentation and not been happy with it, you’d probably end up with a lot of feedback along the lines of, “Well, it took too many clicks and it was too onerous to drill down.” That’s the type of stuff you would hear.

A form metaphor works extremely well, as you can see the entire note on a single screen. You might have to scroll, you might have to jump around on it, but we provide navigational aids for it. It’s a very natural environment and it’s one that folks have been used to using for a long time. It works. 

I think the real benefit is in either environment, you really have to capture structured data, so a form is nice because it’s easier to look at. It’s easy to absorb, it’s easy to edit. But at the same time, if you can capture structured data from it, you’re serving the purpose of really contributing to the electronic medical record, automating coding — all those other things.

I would assume a non-form based physician documentation solution could work. It could work well, so long as it’s designed to be very, very fast for the provider and easy to update and get in to. 

The thing about acute care, as you well know, is your receiving information throughout the day. It’s not like you’re sitting down and just building out your notes start to finish and then signing it and moving on to the next. Certainly some providers work that way, but more often than not, we’ll see providers start their notes in the morning, go on rounds, update their information while they’re on rounds, and maybe sit down and complete them later. They’re always jumping back in. The navigation of the application needs to support that workflow pretty well.

What about the problem of having so much documentation captured that the important stuff doesn’t stand out?

I guess we learned, with our customers, that documentation — you don’t start and finish it. For customers that do it right, documentation is a process of continuous improvement, both in clinical terms as well as financial and administrative. I think we have seen some customers begin to design documents that become too detailed, or contained too much information to get lost in translation.

I think you need good organization and a good dialogue, continuously, about how do we make these better?  Then, provide the tools for rapid turnaround on that. I think one of the things that’s really fascinating about a Salar implementation is that it’s not uncommon for us, for instance, to go live with a service line, then you spend maybe two or three weeks designing their notes with them and getting them to the point where they own that note. If it’s their agency and their daily note, it’s better.

But you don’t get the really great feedback until after they’ve gone live. So you go live on a Monday morning, and you get this wonderful feedback from the physicians on rounds. Our process is that we modify the tablets. We put them into production on Tuesday. Then on Tuesday, the physicians now see that they can impact the solution, that they have ownership of the documentation, but that the system supports rapid cycles and rapid iterations.

By the end of the week, you’ve arrived at a place where you’ve got clean, concise, quality notes that are good for patient care, but also good for efficiency and timing and that support the billing process. That rapid turnaround time is really important. Hopefully, it’s honing towards better documentation over time, not worse.

How would you characterize the need for systems to offer that level of on-the-fly changes?

I think that’s one of the reasons why we win business. The speed of, not only the documentation itself, the physician on the unit floor using it — but the speed to provide feedback and changes. It’s absolutely critical. Physicians sometimes get a bad rap for being impatient or just tough to work with. We’ve never found that. I think our doctors have always provided good feedback and they get a good product in a timely fashion.

We’ve designed all of our form design tools for our customers to use, as well as our professional services staff to use. Literally, they are drag-and-drop tools. If you can create a form in Microsoft Word, you can create an interactive clinical note that has integrated labs, pharmacy, and allergy test results. It does CPT coding, captures PQRI, and integrates with the workflow of physician service for carry-forward data in a matter of hours. I think that’s just a huge, huge benefit, and we’ve seen that serve us very well time and time again; and serve our customers very well time and time again.

Sometimes we go into an opportunity with a customer and they set the bar low for themselves. For instance, they’ll say, “You know what? We just want to start with daily notes first because we think H&Ps and discharge summaries are tougher.” But they will exceed their own expectations, and very quickly within going live, tackle all the major documents that they need to do throughout their day, and do them in a very comprehensive fashion. Because the tools to support not only the creation, but the editing and migration of those, all exist and are pretty easy to use.

Can you give me an idea about what kind of technologies you used to accomplish that?

We’ve always built on the Microsoft stack. We believe very much in Microsoft as a technology provider.

The general concept is all these structured clinical elements, which exist in the EMR, and I think more and more, we’re seeing a refinement on those. We like the CDA specification, but more specifically, we like CDA for CDT; which is real refined around what structured elements really ought to be captured on their daily notes and our H&Ps, etc.

We’ve got tools that allow you to take any form … let’s assume you’ve created a form in Microsoft Word and you really like the layout … and then can drag and drop CDA for CDT elements. For instance, here’s a chief complaint field, and here’s where we’re going to put some of our family history components, and this is where we want labs. Really, to drag and drop those things much like you would in Adobe Acrobat or Microsoft Visio.  We try to keep it as simple as possible for our customers.

Everything’s revolving around Meaningful Use, which has nothing to do with charging, but clearly hospitals have their own incentive to worry about that.  What are you seeing as the hot buttons for hospitals with regard to charging?

Not so much charging, but documentation, I think, we see as a real big opportunity. 

Meaningful Use has really these two components. One is using certified technology and the other is actually utilizing it. We’ve been able to demonstrate time and time again — in fact, with every customer we’ve acquired — strong benchmarks of use. I think one of the unfortunate things with Meaningful Use, from my perspective — I think it’s probably very different from some of your readers — is that the bar seems to be set a little bit low, in terms of what is the expectation, in terms of the volume. How many notes should be captured electronically and structured, etc.

But I think achieving a wide adoption of certified tools can occur. With Meaningful Use, we like some of the standards around interoperability. We hope to see CDA for CDT become, maybe a platform for interoperability for documents within the hospital walls that would really promote the use of this EMR overlay solution as a way to achieve physician adoption very quickly.

You mentioned that it’s an overlay solution. How do you convince a hospital that’s already paid to implement Cerner or Meditech or Eclipsys to bring another vendor into the mix?

I think what we’ve found is that many of our customers have tried and failed to use those tools. They’ve failed to achieve real physician adoption. I think a lot of hospitals believe, probably rightly so, that they can get their employee physicians on board, or there’s a subset of doctors that they can get engaged. But the speed of those tools has generally been frustrating to a lot of physicians out there.

What’s the cost of not having it online? What’s the cost of not having a comprehensive electronic medical record? A lot of hospitals invest in a core HIS, and then they struggle with the fact that, “Oh, you know what? I’ve got to purchase an entire silo for my emergency department because they’ve got a much better documentation tool set.”

What if you can use a product like Salar to fill all those gaps, but ultimately contribute to your core EMR? So every time I sign a note in Salar, it’s using all the same interfaces and the notes are ending up in Cerner, Eclipsys, etc. and really contributing to a comprehensive electronic medical record?

I think a lot of our customers had been through that and they see that there are better tools in the market to achieve physician adoption. They see Salar as a vehicle to do that very well. At the end of the day, they’re reaching their goals having a comprehensive enterprise electronic medical record.

How will you take what you’ve learned at sites like Hopkins and George Washington to create an off-the-shelf product and a sustainable business?

The way we’ve designed our application, we’ve got a standard code set of all our customers. The variation is forms. What do the University of Massachusetts forms look like compared to the forms at the University of Pittsburgh Medical Center? We’ve now worked with so many different specialties, so we’ve built this really nice library of content and expertise.

So the question, I think, really, is do you package up content for distribution on a wider scale? It’s actually a very interesting question because on one hand, I think content can accelerate the process. If you look at a company like T-Systems, they’ve done exceptionally well at developing expert content for the emergency department setting. I believe they’ve monetized that very well. I believe simultaneously, though, that the process of designing documentation and designing templates is what achieves physician adoption.

Boilerplating content for distribution, you miss an opportunity to really engage the physician and get them on board. I think that’s something we’re working on. While we don’t see, today, us dropping in plug-and-play — you know, here’s your trauma content, or your nephrology content, or cardiology, or internal medicine. We see more of a dialogue with our customers that says, “Here’s internal medicine notes from four different hospitals.  What do you think? Pick and choose pieces from this that you think is going to be good for you.” We may see more of a content distribution model downstream as we grow, but I don’t think the barrier is packaging up the solution so much as getting the right channels to market.

Any concluding thoughts?

We’re seeing a really exciting time not only in our direct business, but we’re now seeing EMR companies come to Salar to OEM our products. It begs the question of what’s the long-term strategy for hospitals that have a single-vendor solution. 

We want Salar to be inside every single vendor out there. We’ve announced four different OEM distribution deals where our partners are taking our core intellectual property and embedding it into their EMRs and making that the core platform for their physician documentation moving ahead. But both in our direct sales and our OEM sales, we’re seeing a lot of growth.

I think it’s really fascinating looking back from 2005 forward. When we first created this technology, I think we were way ahead of the curve. Most of the hospital marketplace was scratching their heads and say, “Geez, physician documentation isn’t on our radar until 2010 or 2011.”  Well, the combination of time passing, as well as the government stepping in and increasing incentives to move quicker, is creating a lot of urgency in this marketplace. 

It’s really an exciting time for us. We’re seeing a lot of growth.  We’re already seeing 30% revenue growth over the last year and it’s only a month and a half in. It’s an exciting time for us and we’re just happy to be a part of it.

Readers Write 2/24/10

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

Imaging Decisions Demand Up to Date Information
By Michael J. Cannavo

Five years ago, I was approached by a PACS vendor to put together a presentation for IT folks at HIMSS. We did the presentation titled Everything IT Needs to Know About PACS* (but is afraid to ask) off-site and had 75 people there.

Why off-site? The vendor tried to get HIMSS to sponsor the session, but was continuously rebuffed in their attempt. Exasperated yet needing to get their potential IT clients the information they wanted, this was the only way they knew how to get their information out.

Five years later, where is PACS at HIMSS? Still ostensibly a persona non grata. Of the 300+ presentations being given at HIMSS this year, only two deal with PACS. What is most fascinating is that in spite of this seemingly ongoing denial of PACS importance in the IT community, over 200 of the 900 vendors showing at HIMSS are directly involved in PACS and imaging .

An entry level PACS at a small community hospital can cost $250-300K, while a larger facility can easily spend several million dollars. IT needs have much more information than knowing just the hardware, O/S, and potential network impact, yet has few resources for these from its own society,

The dynamics of the PACS decision making has also significantly changed in the past few years. Where radiology once stood apart from other departments in the way decisions surrounding the vendor of choice were made, now nearly half (and in some cases more) of the final decision on the PACS vendor of choice falls to the IT department. And where does IT go to gets its information? Largely from HIMSS.

With so much geared towards meeting the EHR initiative by 2014 and with it the facilities share of the $20B in ARRA dollars set aside for healthcare IT, one has to question why PACS isn’t part of the HIMSS educational equation. This is especially important since radiology is second only to cardiology in overall revenue generation.

HIMSS should be commended for its role in ongoing education through virtual conferences and expos, but PACS needs to play a much larger role in this. Vendor Neutral Archives are a hot topic not just from a PACS perspective but enterprise wide as well. PACS also plays huge role in the delivery of images both to the desktop and via the web and will play a massive role in the rollout of an EHR.

Some might say that radiology has SIIM as its show, but SIIM doesn’t attract nearly the number of IT professionals or vendors that HIMSS does. Since these IT professionals are already at HIMSS wouldn’t it make sense if SIIM were a subset of HIMSS? Both entities already work together and this way everything radiology/imaging related could be seen at one trade show and not two providing IT with access to radiology-specific educational sessions as well. It’s worth a try…

Michael J. Cannavo is the president and founder of Image Management Consultants and is a 26-year veteran in the imaging community as a PACS consultant. He has authored over 350 papers on PACS and given over 125 presentations on the subject as well.

Something Wonderful
By Mark Moffitt

In this article I’ll discuss the potential future of smart phone operating systems and the impact these changes might have on clinical healthcare IT systems.

Enhancements to Smart Phone Operating Systems

The underlying operating system of smart phones will become more robust with improved multitasking and inter app communication. This will allow developers to integrate native apps, built by others that interact with the underlying hardware of a smart phone, e.g. phone, microphone, speaker, etc., with web apps. Web apps seem best for getting and displaying data and consuming services that are unique to a healthcare system. The reason is changes to web apps can be made and pushed out to users much faster than a native app.

These enhancements will enable developers to build hybrid smart phone apps that use, for example, the device’s phone app, another vendor’s dictation app or voice to text app, and another vendor’s secure messaging app. Developers at health systems will spend most of their time writing web apps that get and display data and consume services unique to the system. Inter app communication will minimize data entry by users as they switch between native and web apps. The user experience will be similar to using a single app.

Android (Google phone OS) has these capabilities, but with limitations. The Apple iPhone/iPod Touch/iPad does not, but will, I predict, within a year. Microsoft Windows Phone 7 is similar to Apple. Make no mistake, these three vendors, Microsoft, Apple, and Google, are going to drive innovation that will benefit healthcare IT users.

From 2010, Odyssey Two:

Floyd: "What’s gonna happen?"
Bowman: “Something wonderful.”
Floyd: “What?”
Bowman:  "I understand how you feel. You see, it’s all very clear to me now.  The whole thing.  It’s wonderful.”

See: http://www.youtube.com/watch?v=OqSml40nwCE&feature=related – start at the 2:08 mark

“Something wonderful” is what physicians, nurses, and other care providers have to look forward to once the use case models of smart phone technology are fully realized.  “It’s all very clear to me now.” It will bring software with features that makes your work much easier and you more productive while automatically generating the data needed for reimbursement, decision support, and the legal record.

See: http://histalk2.com/2010/01/18/readers-write-11810/ – second article down

I predict physicians will use smart phones for 80-90% of their work with electronic medical records, versus using a computer and keyboard, to do work such as viewing clinical data, real-time waveforms, vitals, medication list, notes, and critical results notifications; dictation and order entry.

Disruptive technology (see: http://en.wikipedia.org/wiki/Disruptive_technology) is a term used in business and technology literature to describe innovations that improve a product or service in ways that the market does not expect.

Disruptive technologies are particularly threatening to the leaders of an existing market because they are competition coming from an unexpected direction. A disruptive technology can come to dominate an existing market in several ways including offering feature and price point improvements that incumbents do not match, either because they can’t or choose not to provide them. When incumbents choose not to compete it’s often because the incumbent’s business model blocks them from reacting, aka “feet in cement” syndrome.

Smart phone technology alone is not a disruptive technology in clinical healthcare IT. When you mix smart phone technology with web services for integration and messaging and a virtual database model, you get a disruptive technology.

Smart phone and web services technology will bring improvements of a near-magnitude order change in the price-to-feature relationship of clinical healthcare IT systems or, simply stated, much more features at a much lower cost.

Vendors that offer large integrated clinical systems such as Epic, Cerner, McKesson, etc. charge a large premium for an integrated system because the market will pay it. These vendors have built their business model to capture and defend that premium. That premium will shrink to zero over the next decade due to these disruptive technologies. I predict the premium won’t go down without a fight from these very same vendors.

By then the justification for large, monolithic, integrated, single-vendor systems will have vanished taking with them a number of vendors encased in obsolete business models. From the ashes of the fallen will rise a new pack of healthcare IT vendors leading the industry.

This process is called creative destruction (http://en.wikipedia.org/wiki/Creative_destruction) and is a by-product of radical innovation, something the USA does better than any other country. While painful for some caught up in the destructive wave that pain is more than offset by the gains realized by the whole of society during the creative wave of innovation.

Surfs up!: http://www.youtube.com/watch?v=1j7ID47Nng8

Mark Moffitt is CIO at Good Shepherd Health System in Longview, TX where his team is developing innovative software using the iPhone, a web services infrastructure, and a virtual clinical data repository.

EHR Adoption and Meaningful Use
By Glenn Laffel, MD, PhD

No matter how you approach the issue, it is clear to see that a serious information technology gap has been created in healthcare. From restaurant reservations to banking records, American information resides electronically across nearly every sector … except healthcare.

Where do we stand? Are the adoption reports accurate? And how will these figures be impacted by the US Government’s economic stimulus investment in health IT? Let’s take a closer look at the numbers.

First, the challenge of tracking EHR use in the US. There are currently varied and discordant definitions of what constitutes an EHR. Let’s take a closer look at the reported EHR use from a few different sources

CDC reports: The Center for Disease Control released a study in 2009 reporting that 44% of office-based physicians are using any kind of EHR system and only 6% are using a fully-functional system.

Harvard reports: A Harvard study reported that 46% of hospital Emergency Departments adopted EHRs. The figures dropped dramatically in rural and Midwestern emergency departments.

Patients report: A Practice Fusion survey conducted by GfK Roper in January 2010 found that 48% of patients reported that their doctor used a computer in the exam room during their last visit.

So where do these numbers leave us? We know from these three studies that approximately half of US doctors have started to use some kind of computer system in their practice. An indication that healthcare has taken major step toward closing the digital divide? Yes. A flawed and limited statistic? Also, yes. We don’t know exactly how these physicians are using the reported EHRs and computers. Practices may just be scheduling or billing with their electronic systems — two features that don’t contribute significantly toward improving quality of care.

Meaningful Use will set the bar high. Starting in 2011, we should be able to have a much more detailed perspective on how doctors use EHR technology. The 25 Meaningful Use criteria (currently still in draft with HHS) require demonstrated use of e-prescribing, CPOE, charting, lab connectivity, and more. As the name states, with the new HHS guidelines will help us to “Meaningfully” understand “Meaningful” EHR use.

Improving these adoption rates. EHR adoption has been slow in the past due to several factors: high upfront costs for traditional health IT programs ($50,000 or more per user), high levels of IT infrastructure needed for installation and maintenance, and concerns over changing workflows. The $44,000 stimulus for EHR adoption under ARRA removes some of the cost barrier with legacy EHR systems. It also creates a dynamic market for doctors to price compare and find affordable solutions to fit their needs.

As the start of the incentive program approaches, it will be interesting for those of us in the sector to track changing EHR adoption rates and see if the government’s hope for exponential EHR adoption growth becomes a reality.

Glenn Laffel, MD, PhD is senior VP of clinical affairs for Practice Fusion.