Thoughts on NIST’s EHR Usability Document 10/24/11

NIST’s EHR usability report, Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records, can be viewed here. It is in draft status and available for public comments. Comments can be sent to EHRUsability@nist.gov.

ONC has also pledged to review comments left HIStalk. Cllick the link at the end of this article to add yours.

My Disclosures

• I’m not a usability expert, but I have attended usability workshops and possess some familiarity with how software usability is defined and measured.
• I’ve used badly designed software.
• I’ve had to tell clinical users to live with badly designed software and patient-endangering IT functionality because we as the customer had no capability to change it and our vendor wasn’t inclined to.
• I’ve designed and programmed some of that badly designed software myself, choosing a quick and dirty problem fix rather than a more elegant and thoughtful approach.
• My hospital job has involved reviewing reports of patient harm (potential and actual) that either resulted from poor software design or could have been prevented by better software design.
• I’ve seen examples from hospitals I’ve worked in where patients died from mistakes that software either caused or could have prevented.

First Impressions

My first impression of the report is that it was developed by the right people – usability experts. Vendor people and well-intentioned but untrained system users were not involved. Both have a role in assessing the usability of a given application, but not in designing a usability review framework. That’s where you want experts in usability, whose domain is product-agnostic. 

My second impression of the report is that it is, in itself, usable. It’s an easy-to-read overview of what software usability is. It’s not an opinion piece, an academic literature review, or government boilerplate.

The document contains three sections:

1. A discussion of usability as it relates to developing a new application.
2. A review of how experts assess an application’s user interface usability after the fact.
3. How to bring in qualified users to use the product under controlled conditions as a final test to analyze their interaction with the application and their opinions about how usable it is. This is where the user input comes in.

A Nod to the HIMSS Usability Task Force

I was pleased to see a Chapter 2 nod given to the HIMSS Usability Task Force, which did a good job in bringing the usability issue to light. They were especially bold to do this under the vendor-friendly HIMSS, which has traditionally steered a wide berth around issues that might make its big-paying vendor members look bad. I credit that task force for putting usability on the front burner.

In fact, the HIMSS Usability Task Force’s white paper is similar to the NIST document, just less detailed. I’ll punt and suggest reading both for some good background. I actually like the HIMSS one better as an introduction.

Usability Protocol

A key issue raised early in Chapter 3 (Proposed EHR Usability Protocol) is that it’s important to understand the physical environment in which the software will be used. This is perhaps the biggest deficiency of software intended for physician use.

User interfaces that work well for users who are seated in a quiet room in front of a desktop computer may be significantly less functional when used on laptops or other portable devices while walking down a hospital hallway, or on a laptop with only a built-in mouse. That’s a variable that programmers and even IT-centric clinicians who spend their days riding an office chair often forget. The iPad is forcing re-examination of how and where applications are actually used and how to optimize them for frontline use.

The document mentions that ONC’s SHARPC program is developing a quick evaluation tool that assess how well an application adheres to good design principles. Three experts will review 14 best practices to come up with what sounds like a final score. It will be interesting to see what’s done with that score, since it could clearly identify a given software product as either very good or very bad. In fact, the document lists “violations” that range from “advisory” to “catastrophic,” which implies some kind of government involvement with vendors. Publishing the results would certainly put usability at the forefront, but I would not expect that to happen.

The document points out that usability testing “does not question an innovative feature” that’s being introduced by a designer, but nonetheless can identify troublesome or unsafe implementation of the user interface for that feature.” That’s the beauty of usability testing. It can be used to test anything. It doesn’t know or care that what’s being testing is a worthless bell and whistle vs. a game-changing informatics development. It only cares whether the end result can be effectively used (and with regard to clinical software, that patients won’t be harmed as a result of confusion by the clinician user.)

Methods of Expert Review of User Interfaces

Chapter 5 covers expert review of user interfaces. When it talked about standardization and monitoring, I was thinking how valuable a central EHR problem reporting capability would be. Customers find problems that either aren’t reported to vendors or aren’t fixed by them, meaning patients in potentially hundreds of locations are put at risk because of what their caregivers don’t know about an IT problem.

If the objective of improving usability is to reduce patient risk, why not have a single organization receive and aggregate EHR problem reports? It could be FDA, Joint Commission, ONC, NIST, or a variety of government or non-profit organizations. Their job would be to serve as the impartial intermediary between users and vendors in identifying problems, identifying their risk and severity, alerting other users of the potential risk, and tracking the problem through to resolution.

The NIST document cites draft guidance from FDA on usability of medical devices. It could be passionately argued either way that clinical IT systems are or aren’t medical devices, but the usability issues of medical devices and clinical IT systems are virtually identical. Since FDA has mechanisms in place for collecting problem reports for drugs and devices, making sure vendors are aware of the issues, and tracking those problems through to resolution, it would make perfect sense that FDA also oversee problem reports with software designed for clinician use. This oversight would not necessarily need to involve regulation or certification, but could instead be more like FDA’s product registration and recall process.

The document highlighted some issues that I’ve had personal gripes about in using clinical software, such as applications that don’t follow Windows standards for keystrokes and menus and those that don’t support longstanding accessibility guidelines for the disabled.

Choosing Expert Reviewers and Conducting a Usability Review

Chapter 6 talks about the expert review and analysis of EHR usability. So who is the “expert” involved in this step? It’s not just any clinician willing to volunteer. The “expert” is defined as someone with a Master’s or higher in a human factors discipline and three years’ experience working with EHRs or other clinical systems.
 
The idea that clinicians are the best people to (a) design clinical software from inception to final product, or (b) assess software usability ignores the formal discipline of human factors.

Validation Testing

Chapter 7 describes validation testing. It explains upfront that this refers to “summative” user testing, meaning giving users software tasks to perform and measuring what happens. It’s strictly observational. “Formative” testing occurs in product development, where an expert interacts collaboratively with users to talk through specific design challenges.

Validation testers, the document says, must be actively practicing physicians, ARNPs, PAs, or RNs. Those who have moved to the IT dark side aren’t candidates, and neither are those who have education in computer science.

How many of these testers do you need? The document cites studies that found that 80% of software problems can be found with 10 testers, while moving to 20 testers increases the detection rate to 95%. FDA split the difference in proposing 15 testers per distinct user group (15 doctors, 15 nurses, etc.)

The paper notes that EHRs “are not intended to be walk-up-and-use applications.” Their users require training and experience to master complex clinical applications. The tester pool, then, might include (a) complete EHR newbies; (b) those who have experience with the specific product; and (c) users who have used a competing or otherwise different EHR.

Tester instructions should include the fact that in summative testing, nobody’s asking for their opinions or suggestions. They are lab rats. Their job is to complete the defined tasks under controlled conditions and observation and nothing more. They are welcome to use help text, manuals, or job aids that any other user would have available to complete the defined tasks.

The NIST report listed other government software usability programs, including those of the FAA, the Nuclear Regulatory Commission, the military, and FDA.

EHR Review Criteria

Appendix B is a meaty list of expert EHR review criteria. This is where the report gets really interesting in a healthcare-specific way. It’s just a list of example criteria, but if you’re a software-using clinician, you can immediately start to picture the extent of the usability issue by seeing how many of those criteria are not met by software you’re using today. Some of those that resonated with me are:

• Does the system warn users when twins are admitted simultaneously or when active patients share similar names?
• If the system allows copying and pasting, does it show the viewer from where that information was copied and pasted?
• Does the system have a separate test environment that mirrors the production environment, or does it instead use a “test patient” in production that might cause inadvertent ordering of test orders on live patients?
• Does a screen require pressing a refresh button after changing information to see that change fully reflected on the screen?
• For orders, does the system warn users to read the order’s comments if they further define a discrete data field? (example: does a drug taper order flag the dose field to alert the user that the taper instructions are contained in the comments?)
• When a provider leaves an unsigned note, are other providers alerted to its existence?
• Do fields auto-fill only when the typed-in information entered matches only one choice?
• Can critical information (like a significant lab result) be manually flagged by a user to never be purged?
• Are commas automatically inserted when field values exceed 9999?
• Are “undo” options provided for multiple levels of actions?
• Is proper case text entry supported rather than uppercase-only?
• Do numeric fields automatically right-justify and decimal-align?
• Do error messages that relate to a data entry error automatically position the cursor to the field in error?
• Do error messages explain to the user what they need to do to correct the error?
• Do data entry fields indicate the maximum number of characters that can be entered?
• Are mandatory entry fields visually flagged?

My Random Thoughts

Usability principles would ideally be incorporated in early product design. To retrofit usability to an existing application could require major rework, which may be why some vendors don’t measure usability – it would simply expose opportunities that the vendor is unwilling or unable to undertake. 

On the other hand, improving usability doesn’t require heavy duty programming or database changes. The main consideration would be, ironically, the need for users to be re-trained on the user interface (new documentation, new help text, etc.)

Usability can me measured, so does that mean there is “one best way” to do a given set of functions? Or, given that users are often forced to use a variety of competing CPOE and nurse documentation systems, is it really in the best interest of patients that each of those vendor systems has a totally different user interface?

Car models have their own design elements to distinguish them commercially, but it’s in the best interest of both the car industry and society in general that placement of the steering wheel and brake pedal is consistent. With PC software, this wasn’t the case until Windows forced standard conventions and the abandonment of bizarre keystroke combinations and menus.

I always feel for the community-based physician who covers two or more hospitals and possibly even multiple ambulatory practice settings, all of which have implemented different proprietary software applications that must be learned. This issue of “user interoperability” is rarely discussed, but will continue to increase along with EHR penetration.

From a purely patient safety perspective, we’d be better off with a single basic user interface for a given module like CPOE, or even a single system instead of competing ones (the benefits of the VA’s single VistA system spring immediately to mind.) It’s the IT equivalent of a best practice, Usability can be measured and compared, so that means if there are 10 CPOE systems on the market, patients of physicians-users of nine of them are being subjected to greater risk of harm or suboptimal care.

Usability testing does not require vendor participation or permission. Any expert can conduct formal usability testing with nothing more than access to the application. Any third party (government, private, or for-profit) could conduct objective and meaningful usability assessments and publish their results. It’s surprising that none have done so. They could make quite a splash and instantly change the dialogue from academic to near-hysterical by publicly listing the usability scores of competing products.

Conclusion

Read the report. It’s not too long, and much of it can really be skimmed unless you’re a hardcore usability fan. If nothing else, at least read the two-page executive summary. 

For the folks who express strong reaction to the word “usability” while clearly not really knowing what it means, the report should be comforting in its objective specificity.

Even though the document is open to public comment, there really isn’t much in it that’s contentious or bold. It’s just a nice summary of usability design principles, with no suggested actions or hints of what might future actions are being contemplated (if any.)

I’m sure comments will be filed, but unless they are written by usability experts, they will most likely be unrelated to the actual paper, but rather what role the government may eventually take with regard to medical software usability.

It should also be noted that no product would register a perfect usability score. And, that humans are infinitely adaptable and will learn to work around poor design without even thinking about it. In some respects, usability is less of an issue with experienced system users who have figured out a given system’s quirks and learned to work capably (even proudly) around them.

This document really just provides some well-researched background on usability. The real discussion will involve what’s to be done with it.

Let’s hear your thoughts. Leave a comment.

Curbside Consult with Dr. Jayne 10/24/11

A reader recently sent me a link to a blog by Dr. Joe Heyman titled We Can’t Fix All of Medicine with Meaningful Use. He calls out two serious problems with Meaningful Use – measurement for the sake of measurement and the introduction of unintended frustrating inefficiencies that offer no noticeable improvement in patient care.

Heyman states:

It has been my experience that most physicians involved in policy making in the health IT field are unrepresentative of people like me. They are either not practicing at all or they practice one day a week in a huge institution or network. They never do their own coding and billing and have a buffer in place when it comes to measures as well. We little people have no buffers, no counters, no billers, and no paramedical people to help with our workload. Most physicians in this country are in small practices, and most patients in this country are cared for by those physicians. So when a policy maker who has never been in our shoes sets requirements for measurements, a red light and siren should go off to remind people to be sure that the measure is so important that it is worth decreasing efficiency and making technology less attractive to the folks who take care of most of our patients.

Unfortunately, this is entirely true, not just in Meaningful Use, but in various facets of healthcare. Although there are many areas where care can be dictated based on robust study of the evidence, we have entered uncharted waters in knowing whether the dictates of Meaningful Use will actually deliver quality care outcomes. Personally, rather than a hodgepodge of measures thrown together in the guise of Meaningful Use, I’d love to see demonstration projects on each of the measures to determine whether they are indeed valid.

We see this kind of evidence in the Quality Measures portion. Many of these are well-researched disease management elements that have been shown to reduce the burden of disease, improve quality of life, and reduce health care costs. I’m all for these types of measures.

What I’m not for, however, is mindless box-clicking such as Dr. Heyman describes when having to “remember to put a check mark in place saying the patient has no problem every time I would have left the problem list blank.” Playing devil’s advocate, of course one could argue that physicians left the problem list blank because they were lazy, or thought a problem unimportant, etc. Instead, however, we’re going to make everyone check a box instead so we can measure it.

As someone who has spent a great deal of her career in process improvement initiatives, I do fully embrace the concept that what gets measured gets managed. In this case though, I fear that all we’re going to manage is to have providers leverage staff to simply check the box so they don’t have to, potentially increasing inaccuracy rather than what was probably intended, which is to make sure patient charts have accurate and complete problem lists.

He also shares his frustration with requiring collection of ethnicity on each patient, with which I heartily agree. A good chunk of patients out there have no idea of the difference between race and ethnicity – frankly, how many healthcare providers can accurately explain it? – and quite a few patients are offended that we’re even asking. This requires someone in the office (often the physician, who hears the patient complaint even after staff has tried to address it) to explain the goals are of gathering the data, wasting precious time that could have been spent on health counseling, taking a detailed history, and undertaking more clinically relevant pursuits that have been shown time and again to improve outcomes.

For many providers, Meaningful Use is too much, too fast. I know that my staff, regardless of technology, prompts, and reminders, can only focus on so many elements at a time (and we were early adopters, so the distraction of the technology itself is long gone.) In a perfect world, we’d like them to be able to spend their time focusing on issues that will really make an impact with an individual patient rather than gathering individually irrelevant data for broad population initiatives. I’d like my staff to spend that explanation time making sure the patient has resources to pay for her medication so she can even take it, rather than worrying about discerning what my patients call “where my people come from.”

Patients want us to be present in the moment – in the exam room with them, focusing on individual issues and getting to know our patients as people. That is increasingly hard to do when providers are being graded on whether those same patients actually do what we ask them to do and also whether we checked the appropriate box to correctly document it. We’re no longer paid for patient rapport, cognitive ability, or compassion. We are, however, paid for playing a game where checkboxes and regulations rule. This is sad.

I close with another great comment from Dr. Heyman:

We cannot fix everything in medicine with Meaningful Use, and we should stop trying to do so. We can fix lots of things with technology and innovation, but let’s stop micromanaging physician practices. Let’s move from Meaningless Documentation Measurement to Meaningful Care! We can be so much more innovative than Meaningful Use.

And from the back pew of my hospital’s chapel, Dr. Jayne says “Amen!”

E-mail Dr. Jayne.

Monday Morning Update 10/24/11

From Mintonw: “Re: NorthCrest Medical Center (TN). It’s the first hospital to receive a Medicaid EHR incentive payment by just using ED patients and an EDIS, in their case Allscripts ED 7.0, the only EDIS certified as a Complete EHR.” The hospital’s press release is here. SVP/CIO Randy Davis says the 109-bed hospital was already in the high 90s percentile and didn’t need to change much. The hospital says it will meet Medicare’s MU requirements later this year.

From Tommy Tune: “Re: Jim Fitzgerald. Definitely no longer at Dell. My source says it was his choice.” Unverified.

From Rigoletto: “Re: GE Healthcare. Says Centricity Practice and EMR can’t generate accurate Meaningful Use reports. See link here to its letter to customers.” It sounds like basic technical stuff, made interesting only because the company admits that there could be problems for clients who have already attested – the corrected reports may show that they didn’t hit the required thresholds after all . GE says they will provide “further instruction on how to work with CMS related to any changes related to attestation.” The recommend changes in practice are: (a) choose specific race/ethnicity codes instead of free text and don’t choose “multi-racial,” “Hispanic,” or “other;” (b) use specific options for describing smoking status; and (c) us prescribing to measure patient medication education since issuing handouts that the EMR did not suggest doesn’t count toward Meaningful use. I don’t see any of this as a slam on GEHC other than they are awfully late in identifying the problems, which seem pretty obvious. Let’s hope the triggering event wasn’t an eligible provider getting in trouble with CMS.

From Dr. Nurse: “Re: McKesson CEO John Hammergen’s $131 million one-year compensation. Their products are a patchwork of jury-rigged acquired code which has never been upgraded and they clearly have no idea what a usability standard is (the joke is, ‘just keep scrolling down and to the right and you’ll eventually find the right checkbox.’) They perform paper-based billing for specialty practices (Fedexing boxes of paper forms to Pittsburgh – really?) and use antiquated reporting systems that cannot be altered (you can’t add columns due to system limitations). His compensation package is obscene considering McKesson’s ongoing loss of market share, discernible lack of innovation, and adherence to outdated methodologies and business practices. He’s not alone – the CEO salaries of third-party payers are off the grid, too.” Above is the five-year performance of MCK (blue), the Dow (red), the Nasdaq (green), and the S&P 500 (yellow). A big chunk ($112 million) of that compensation was from stock options that he won’t get to exercise every year. At least shareholders (including employees) got to make money along with him. Not to mention that IT isn’t the company’s bread-and-butter business, although that product line is still profitable.

From Por Favor: “Re: WNA. I totally love Weird News Andy, but as a Canadian, I’m appalled by the actions of the clinicians at the hospital. There once was a time where it didn’t matter how you came to be in the ER. I was in the ER several years ago when a young man of about 17 was brought in with a terrible leg break. He was from England on a rugby tour with his school. I remember him crying and trying to tell the doc he had insurance and hoped the doc would take care of him even though he couldn’t produce the documents right there. I’ll never forget what the doc said: ‘Son, I don’t care if you have insurance or not. I’m going to take care of you. Rest easy, try to relax, and do not worry. You’re in Canada and under my care.’ That demonstrates why doctors became doctors in the first place – to heal the sick. It is so sad that somewhere along the way, we have lost this. Please tell Andy to keep the weird news coming – it’s always fun!” The example was from Canada, but I’m certain we have at least as many such cases on this side of the border.

From Neil Louwrens, MD FACP: “Re: physician’s malpractice award as a patient at Northwestern. I’m vehemently opposed to the current tort system, but passionately for justified litigation, including substantial earnings to injured patients. I’m equally and passionately against trivial pestering from the legal profession, claiming wrongdoing and pain-and-suffering that runs up ridiculous tabs at this nation’s expense. The physician in this case is a patient and the case must rest on that. When we fight for tort reform, we are asking for some sense of sanity to be infused back into the system. Nowadays, even the best doctors doing the right thing are still sued. It’s a lottery mentality and the nation picks up the tab. Most physicians who have wronged someone are remorseful and wish they could compensate the patient for their wrongdoing, but to watch the lawyers walk away with 50-60% of the winnings is a travesty. Give patients their money back! Wall Street’s wrongdoings pale in comparison with what the Association of Trial Lawyers of America has managed to carve out for themselves in the current system, backed and perpetuated by the preponderance of lawyers in Congress. Tort reform will reform this inequity, but will not touch the earnings to the injured for their costs, such as justified pain and suffering. We need tort reform – not ‘we’ as physicians, but ‘we’ as patients.”

Thanks to Jacob Reider, ONC’s new usability guy, for taking the time to interview. A reader had tipped me off that he’d taken the job, I e-mailed him, and he asked me to hold off for a couple of days (the details weren’t quite finalized, I surmise.) He not only gave me the first interview, but didn’t tell anyone about his new job until I could get back from vacation so we could do the interview and have the scoop here. Above is another interview he did on usability before he took the ONC job. ONC is interested in reaction to NIST’s usability paper, which I’ll be providing once I’ve had a chance to read it over. Hopefully those readers who constantly gripe about poor EMR usability will channel some of their energies into reviewing the NIST document since it’s the best hope so far (short of some super-secret vendor development project that nobody’s seen yet) to improve the healthcare IT usability landscape.

Listening: reader-recommended Elizabeth Cook, who sounds a good bit like Dolly Parton. The youngest of 11 children, moonshiner dad in prison, took dual degrees in accounting and computer information systems, and worked as an auditor for PWC.  She writes most of the songs, which have brilliant lyrics and range from the good old boy rowdy (“Say Yes to Booty”, “Sometimes It Takes Balls to Be a Woman”) to the starkly moving (“Heroin Addict Sister”).  Modern country is one of my least-favorite genres because it’s been taken over by industry-groomed, overproduced pretty faces faking credibility in the pain and loss department while fronting pop music that has the absolute barest minimum of mandolin or steel guitar, but this is the real deal.

My Time Capsule editorial this week, squinting its eyes upon seeing its first daylight since October 2006: GM and Intel are Right: Healthcare Is Too Expensive, but Technology Alone Can’t Fix It. A taste: “Most US job growth since 2001 was in healthcare, and that’s not something to be proud of. We’re leaving an expensive mess for our children to clean up just as Baby Boomers suck the system dry with healthcare demands. If GM doesn’t like it today, they’ll hate it tomorrow, unless they’re watching from China or India.”

Good stuff on HIStalk Mobile, where Dr. Travis Good covers How to Make Money on Consumer Health Tools and Enterprise Provider Apps. He started out covering straight news, but now that he’s comfortable, he’s putting together some really good analysis and opinion posts that I appreciate since I’m learning from them. Sign up for the e-mail update over there if you like what you see. Thanks to our sponsors there, too: founding sponsors AT&T and Vocera and platinum sponsors Voalte, 3M, Thomson Reuters, Patientkeeper, Kony, and Access.

I’ve said before how much I like using speech recognition for certain tasks (composing e-mails and sometimes writing HIStalk, for example). I was about to upgrade my Dragon Naturally Speaking when I found about Windows Speech Recognition. Like DNS, it’s great for dictation and controlling Windows by voice. Advantages: its system performance seems to be better, its accuracy is almost as good (96% vs. 99%), and it’s included free in Windows 7 (you’ll find it in Control Panel.) Well worth experimenting with since everybody can talk faster than they can type and sometimes your fingers just get tired.

Here’s the latest HIS-tory from Vince, this time with Part II of JS/Data, with lots of info about its eventual (many-named) acquirer.

Most respondents (some of them with considerable skin in the game) think HITECH should pay providers for starting their EHR use even before HITECH started. New poll to your right: should HHS require doctors to generate personalized, unique documentation (i.e., no boilerplate or macros) in order to be paid?

Dr. Jayne brought up an interesting point in her latest post: the government seems to want everybody to be fooled into thinking that Medicaid is insurance rather than a social program that takes money away from taxpayers and gives it to non-taxpayers (all warm-and-cuddly positives aside, that’s what it is.) We’ve already taken the shame out of being on the dole courtesy of the ever-fewer working Americans (Social Security and Medicare being the big drains among many), so unless you have a lot more faith than I do that either politicians or voters will start exercising responsibility instead of acting in their own self-interest, keep an eye on what’s happening in Greece because we’re getting close to that point of non-sustainability. Politicians won’t stop handing out financial lollipops and the taxpayer/non-taxpayer ratio keeps shrinking, so something has to give regardless of the indignation and injustices involved. Our lavishly funded healthcare system isn’t exactly helping as it sucks up an ever-increasing chunk of GDP.

ProHealth Care (WI) finishes its implementation of Epic.

GE announces Q3 numbers: revenue flat, EPS $0.31 vs. $0.28, meeting expectations.

Interesting revelations from the Steve Jobs biography, hitting stores Monday: (a) he apparently lied about the extent of his medical problems; (b) he initially resisted having surgery for his pancreatic tumor, so he tried diets, acupuncture, a psychic, and remedies he found online, to his apparent eventual regret; (c) he claimed Google stole iPhone features in creating its Android phone, saying he would “spend every penny of Apple’s $40 billion in the bank to right this wrong.”; (d) his last ambitions, possibly involving Apple products yet to be released, involved developing an integrated TV and taking on the textbook monopoly. He also told President Obama that he was destined to be a one-termer because he is business-unfriendly; described Microsoft as “mostly irrelevant” and struggling like most other companies that put salespeople in charge; and said HP is being “dismembered and destroyed” by poor leadership. Nobody quoted him all that much while he was alive and he stayed out of the limelight for the most part, but now every scrap of writing and video is being assembled into the Gospel According to the Recently Canonized Steve (and I admit being just as fascinated by it as everybody else.)

Speaking of Apple, here’s the first commercial for the iPhone 4S and its Siri voice command system.

Kaiser needs to dig into its Epic database to evaluate this study from Canada. Overweight people (BMI of 25 to 29.9) were found to have the same risk of health problems as normal-weight patients. The study found that the big health problems start with a BMI of 35 (defined as “obese.”) Hopefully the study looked longitudinally at patients rather than just current weight. You can calculate your BMI here.

Washington Hospital Center (DC) and AT&T develop CodeHeart, a mobile collaboration app that provides real-time audio and video contact in critical care situations, such as for ambulances in transit.

A lawsuit against Abbott Northwestern by a kidney stone patient alleges that a drug-addicted nurse stole his ordered narcotics for herself, leaving him to suffer excruciating pain through the procedure. The patient says the nurse told him she couldn’t give him very much medication and that he should just “man up.” During the procedure, he says the nurse was unsteady and slurring her words as she coached him for his pain, telling him, “Go to your happy place, Larry. Go to your beach.”

E-mail Mr. H.

HIStalk Interviews Jacob Reider MD, Senior Policy Advisor, ONC

Jacob Reider MD is senior policy advisor of the Office of the National Coordinator for Health Information Technology of Washington, DC.

Tell me about yourself and your new job.

I’m a family doctor from upstate New York. I’ve been involved in health IT for a couple of decades. I started off as a medical educator in the Department of Family Medicine at Albany Medical College and moved on to leadership roles in health IT there and at Albany Medical Center, obviously in Albany, NY. Left there and joined a group called CapitalCare Medical Group, which is the large primary care group in Albany, doing EHR implementation.

There’s a sort of funny story to that one. Early in our EHR implementation, I posted this thing to this new communications platform called a blog. I started blogging in 1999. In about 2004, I put this post up about usability, which was a word people thought I made up, and how the usability of the EHR that I was using was missing the mark. About six months later, the president of the EHR vendor that I was complaining about contacted my boss and indirectly asked me to take down the post, because it was apparently costing them sales. That was Misys Healthcare, and the guy was Rob Kill, the former president of Misys Healthcare. I told my boss that last time I checked, this was a free country and I didn’t really have any intentions of taking the blog post down.

Then I actually started a dialogue with this guy, Rob Kill, and eventually he hired me to help them look at themselves in the mirror and try to improve the user experience of the EHR product. That may be answering your question about my background, because I eventually moved on from CapitalCare to Misys Healthcare, where I was medical director. Then we merged with Allscripts and I was CMIO of Allscripts for the last handful of years.

Then started interacting with folks from the government, and started to go back to my roots of idealism and thinking I could help solve really big problems. Got enticed to join Farzad’s team, because I was really inspired by the work that folks here are doing and the people who are here, who are just great folks who have the right vision and passion for getting things right. Sorry if I sound like a TV commercial.

What is your title and area of responsibility?

My title is senior policy advisor, which sounds very government. I tried on Luke Skywalker and Jedi Master, but so far we’ve got senior policy advisor on my business cards.

How much of the problem to get physicians and clinicians to use systems is because of usability issues?

Are you familiar with the NIST draft usability publication that was put out about a week ago?

I didn’t read it, but I heard it was out.

In that document, NIST calls out some fairly good evidence that user experience / usability is a barrier to broad EHR adoption. That’s not my opinion – that’s been stated by NIST in the publication. That was my callout in 2004, that these things were not optimal to use. I like to think of usability as kind of a milestone on the continuum of user experience. I’ll burden you with a little bit of my view of the world.

As a very basic component, if we think about any new technology, new tool, new anything, you’ve got at the basic end, functionality. Does the thing do what it was intended to do?  It’s something functional.

Beyond functional, you’ve got reliable. Does the thing do what it’s supposed to do every time? An example of functional is a Model-T car. It works, but Model-T cars came with toolkits because they broke, so they weren’t reliable. EHRs years ago – I can vividly remember that the system would go down at midnight every night for backups for four hours. They weren’t reliable. They were functional, perhaps – they did what they were intended to do – but they weren’t reliable.

I think we’ve nailed functionality, we’ve nailed reliability, so as the maturity of any new technology evolves, you evolve up the continuum, so you get functional, reliable, and usable. Usable implies that you can accomplish tasks efficiently; you can do things in an intuitive way. NIST’s document does a great job outlining how you can quantify usability. There’s an argument that it’s subjective, but I think they’ve documented that it’s quantifiable.

Beyond usability, you’ve got meaningful, so it does stuff that’s important. And then pleasurable, that it does stuff elegantly. Apple is a great example of a company that has reached the maturity pinnacle of pleasurability and not just usability, functionality, and reliability. Longer than I intended to blab about, but does it make sense?

People tend to react emotionally to the term usability, thinking it means somebody else designing their screens or taking away their competitive advantage, but in fact there is a usability science that has its own body of literature and its own professional groups. How do you take emotion out of what people think usability means and turn it into something that can move ahead constructively?

I think it’s about using terms carefully. Often I’ll talk to people about what I just described, because we can measure each of those components. I also talk about best practices, so as we think about the industry, we can think, “What are the best practices?”

I think the NIST document outlines best practices that are not just from our industry. If you want to design an airplane or an iPad or a coffee pot, there are methods that you use, and one of those methods is called user-centered design. As you mentioned, there’s a whole field that’s devoted to this. If we talk about using the right method and using the right processes, very frequently that disarms some of the emotional response and we can start to talk collaboratively.

That is what everyone wants to do. I don’t think anybody’s opposed to better usability. You’re not going to hear a user or a vendor or anybody from the government say, “We’re opposed to that.” It’s just The question of who should do what as we look to lever or accelerating that evolution of usability as it has evolved well, obviously, in the consumer electronics space.

How do you see your role specifically and ONC’s role in general affecting usability of software?

There are two areas that I’m really focused on as we move forward. One is clinical decision support and the other is usability. I actually think they are tightly linked. If you look at some of the great design literature from professionals like IDEO, who do a lot of innovation design, and Neilsen Norman Group, these are folks who were involved with the original Apple product and many other things that you’re familiar with.

You see how the design actually guides the actions of the user. A really well-designed door handle guides what I do. I think clinical decision support is not about alerts and reminders and hitting docs over the head with two by fours when they do things wrong. It ‘s about guiding care providers to more easily do what’s right and less easily do what’s wrong. Usability and CDS in that way – and that’s why I’m blabbing about this – fit together really nicely.

My role is to listen to the market, to end users, to eligible providers, to hospitals, and to vendors, and learning about all of these perspectives. Right now that’s the place that ONC is. We’re listening. We’re listening to the experts.

This report that NIST produced just a week ago is open for public comment. We’re very interested in the reaction to that document. It’s in the 30-day comment period and they’ve got a Webinar coming up. The more feedback they get — and by extension, we get –about that, the better, so we can learn more about what other folks think ONC’s role is in terms of facilitating the evolution of user experience in health IT.

Why hasn’t there been a market for usability, where somebody comes up with a more usable product that takes business away from less-usable products?

I think there are a couple of answers to that. We talked about Apple a little bit. In many cases, Apple Is a great example of great usability, great user experience, etc. Raise your hand if you owned or have a friend who owned the Newton. Did you have one?

I did not.

But you remember them, right?

I do.

Apple, of course, had some failures, too. If you look at that company, they’ve been through 30 years of fairly rapid evolution. They’ve succeeded in the long run because they’ve iterated over and over and over. Steve Jobs talked about how he just picked himself up and tried and tried again. Three decades of evolution from Apple that’s created that. And of course, the replacement cycle of a Mac or an iPhone is much more rapid than the replacement cycle of a $50 million electronic health record.

I think part of the answer to your question has to do with the maturity of the market. The market hasn’t matured as we know, with maybe 50% of this market is now penetrated, which means it’s still a young market. We’re not nearly as mature as the consumer electronics market. The other is the replacement cycle is slow, so you don’t have folks saying, “Oh, I can do that in three clicks in one system and 17 clicks in another, therefore I’m going to buy System A.” It’s just not as easy to rip and replace as it is your iPhone.

In your writings, you’ve said that usability guidance is what’s needed, not guidelines or set requirements. How do you see ONC positively affecting usability?

This summer, ONC, NIST, and FDA had a usability workshop. Along with the release of this document from NIST, the federal government will have have a wiki, where we’re going to invite participation from all communities and collaborate so that we can all openly discuss what the opportunities are.

If you’re asking me, “What’s ONC going to do next?” I can say honestly that I don’t know the answer, because what we’re trying to do is be intentional and/or deliberate about what we do next, why, and how, so that this isn’t something that anybody in the market perceives as reactive in any way. What ONC does will be product of dialogue and not something that we just pull out of the seat of our pants.

If we understand the concept that usability can be measured, do you see it either becoming a certification criterion or there being government-sponsored publishing of usability scores of software?

I can’t really answer that question. Sorry.

I did forget to ask you one important question. When did your job start?

I started here on October 3. I’ve been here, gosh, almost three weeks, and it’s flown by in a millisecond.

Any final thoughts?

The NIST document is a good thing to link to. 

The dialogue is important. Even if you solicited comments and you said something pithy and got your readers to throw in feedback, we would definitely pay attention to that – what people are saying on HIStalk about this topic. If you link to that and say, “Hey, what do people think about the NIST document and what’s the reaction to it?” That would be very interesting to us.

Time Capsule: GM and Intel are Right: Healthcare Is Too Expensive, but Technology Alone Can’t Fix It

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

I wrote this piece in October 2006.

GM and Intel are Right: Healthcare Is Too Expensive, but Technology Alone Can’t Fix It
By Mr. HIStalk

Big-company CEOs have healthcare on their minds. I know that because they keep insulting us in the national media. We’re too expensive and we underutilize technology, they say. In fact, it’s our fault that jobs are moving offshore, not their own corporate greed or inefficiency.

My first reaction: who do they think they are? We’re getting lectures on innovation, productivity, and cost control from GM? If I wanted that kind of advice, I’d go to Toyota.

Quibbles aside, they’re right. Healthcare cost increases have to stop eventually. Most US job growth since 2001 was in healthcare, and that’s not something to be proud of. We’re leaving an expensive mess for our children to clean up just as Baby Boomers suck the system dry with healthcare demands. If GM doesn’t like it today, they’ll hate it tomorrow, unless they’re watching from China or India.

Businesses want to force computers on us, dragging us kicking and screaming out of the dark ages. Unfortunately, software doesn’t automatically bring increased productivity and lower cost. If it did, we’d be using it already. Think of all of those hospital dollars spent on Microsoft Office and Windows, which were supposed to have made us stunningly more effective, but instead gave employees something to screw around with instead of working.

I’d like to think that computerization can really reduce costs, but I haven’t seen that happen anywhere so far. Showcase sites keep buying the latest and greatest, but the correlation to bottom line and quality outcomes is murky at best. Where’s the average 100-300 bed hospital that has seen its overall costs drop 30% because of software? You’d know them, because every other hospital in their town would be out of business.

Hospitals can cut expenses in three ways, all of them at their local level. They can manage labor, which is by far their largest expense. They can go after the utilization and the cost of drugs and supplies. They can control physician practice variation. I’m glad I said “can” instead of “do” because, for various reasons, these things don’t happen. Software can only do so much.

I’m glad much of our recent IT investment relates to patient safety and outcomes. I hope electronic medical records really do become a standard, with all the information sharing that the RHIO people keep yapping about.

But when it comes to drastic cost reductions driven solely by buying and implementing software, I’d say that’s wishful thinking. There’s a lot of work to be done fixing the system and its underlying misaligned incentives before we try to automate it. No business became a world-beater just by installing SAP, even if they weren’t one of those that went bankrupt trying.

I do see a ray of hope in being called out by big-company CEOs. As hard as it is to have change forced on you, that’s the only way it will happen. I work in a hospital, but I’m also the occasional patient and medical and insurance bill-payer. When wearing those hats, I’m just as mad and frustrated with the system as those CEOs and I bet you are, too.

Healthcare is too expensive, too bureaucratic, and too unimpressive in benefits delivered compared to its horrendous cost. I’m pretty sure fixing it will require more talents than a software guy like me can offer, even if GM and Intel believe otherwise.

News 10/21/11

Top News

HHS announces its Accountable Care Organization rules (Medicare Shared Savings and the Advance Payment Model.) Some differences between the preliminary and final versions:

• Quality measures reduced from 65 to 33
• Use of an EHR is not a requirement to participate
• Introduction of a savings-only track without financial risk during the initial contract period
• CHCs and rural health clinics now have an option to lead ACOs
• A longer phase-in for reporting and performance measures
• Multiple start dates established
• CMS will provide approved marketing guidelines and language (so ACOs don’t have to wait for CMS approval, as was stated in prelim)

Reader Comments

From EHR Geek: “Re: Joel Diamond. I love your posts so much that sometimes I feel like a stalker. With the current healthcare environment, it seems like you could make so much more money (just by dropping your malpractice alone) by doing standup comedy. Please?” Like EHR Geek, I love Dr. Diamond’s posts, which I find laugh-out-loud funny. This week, he discusses all that is good in healthcare. The topic only sounds benign.

From WhatTheDell: “Re: resignation. Jim Fitzgerald recently resigned from Dell’s Meditech Solutions Group. Big loss given his role of all things Meditech.” Unverified. There is no change in his LinkedIn profile or on Dell’s “About Us” page.

From Colorado Kid: “Re: University of Colorado Hospital. Went live on Epic in September, including physician documentation, CPOE, RN barcoding and charting, OR, anesthesia, inpatient pharmacy, labor and delivery, radiology, and ED. Outpatient clinics are 70% deployed, to be completed with Beacon oncology and Phoenix transplant by mid-2012.”

From Lady Pharmacist: “Re: National Pharmacy Week, October 16-22. It’s time for the annual shout-out for pharmacists and pharmacy technicians. Healthcare informatics plays a vital role with and for these clinical and medication distribution folks who make medication usage safe in our institutions!” As I usually say, a hospital is a very clean hotel that offers only three interventions: surgery, treatments, and drugs. Pharmacists and techs manage that last set of interventions with extraordinary skill given the complexity involved (not to mention that most of the country is taking a plethora of pills – a new study found that 11% of Americans over the age of 12 take antidepressants, which is in itself depressing.) Congratulations to those folks behind the counters, down in the basement, and (increasingly) out on the floors.

From MM: “Re: Dr. Jayne on cloned documentation. Did we really expect anything else? If you have been around medical reimbursement rules for any amount of time, you know that when the rules begin to be met by the majority of providers, the rules will change. It is really all about who gets to keep the money. We used to bill by diagnoses, then by time, now by documentation. All these rules were created by the insurers, and each time we achieve competence at following the billing rules, they change them.” I’ve said that for years. Payment is a shell game, where there isn’t enough money to stick under every shell. It is inevitable that when some individual or group starts winning too often, the dealer will move the shells around and change the rules, sometimes drastically altering the lifestyles of professionals along the way (nurse anesthetists and physical therapists come to mind if you look back 25 years or so). That’s really the problem with healthcare – providers flock to profitable services like bugs to a zapper, but patients don’t usually benefit. Expecting healthcare providers, even theoretically non-profit hospitals, to just keep doing the same work without regard to what they’ll get paid is just silly.

HIStalk Announcements and Requests

I am heading to MGMA in Las Vegas this weekend and will be posting updates on some of the action. If you are attending, be sure to take a look at HIStalk’s Must-See Vendors for MGMA 2011. The guide includes some tips on vendor giveaways (hint: you don’t want to miss a visit to Allscripts, MED3OOO, and Culbert Healthcare.) And if  you see one of these desktop signs in a vendor’s booth, please take a moment and thank them for supporting HIStalk, HIStalk Practice, and HIStalk Mobile.

Listening: reader-recommended The Heard, rootsy Southern rockers from Reading, PA. Sounds kinds of Allmans-meet-R.E.M. to me. Also reader-recommended: BluesMotel, some guys from the Netherlands that play Chicago blues. I can almost smell the smoke and beer.

This week on HIStalk Practice: in addition to our MGMA guide and a post from Dr. Joel Diamond, athenahealth reports that pediatricians are under-reimbursed for certain vaccines almost half the time. CalOptima REC names its preferred EHR vendors. The Department of Pathology at the Medical City Dallas Hospital (TX) goes with McKesson for billing and RCM. Emdeon expands the capabilities of its Office Suite solution. Radiology Medical Group (CA) announces plans to outsource its billing and lay off 24 employees.  If you are interested in the ambulatory HIT world,  highlights from MGMA, shoe fashion, and/or Inga’s mental health, please sign up for e-mail updates while visiting HIStalk Practice. Thanks for reading.

Thanks to NexJ Systems of Toronto, ON, now supporting HIStalk as a Platinum Sponsor. The company is all about eHealth, offering its Health Information Exchange solution that includes its Universal Health Connector (global messaging and controlled vocabularies and terminology) to facilitate interoperability among providers, ACOs, payors, and public health agencies. They also offer tools for chronic disease management, disease registry, electronic referrals, patient portal, provider credentialing, and a wellness platform. Other offerings include platforms for provider health, consumer health, and analytics. Click the image above to check out their October 28 Webinar on next-generation, open-architecture HIE technologies that are fast, flexible, and cost effective. Thanks to NexJ for supporting HIStalk and its readers. 

Pardon me while I communicate in techo-gibberish with my fellow geeks (non-nerds, hands over ears, please). You may have noticed that HIStalk loads faster now. Reason: I replaced Apache with the Litespeed WebServer. It’s hard to picture a Web server that’s running *NIX without Apache, but you’re soaking in it. I also had the PHP handler changed from DSO to SUPHP to improve security and to fix some CHMOD problems. (end of nerdspeak)

October is Breast Cancer Awareness Month, meaning it’s time to watch those cool Pink Glove Dance videos. My favorite so far is from Victoria Hospital – Prince Albert Parkland Health Region, Prince Albert, Saskatchewan (although they’ve disabled putting the video directly on HIStalk this time around, so you’ll have to click.) Check out all great videos and vote for your favorite here.

On the Jobs Board: Senior Business Analyst – Salesforce.com, HL7 Interface Developer, Account Manager. On Healthcare IT Jobs: Director – Epic and Clinical Systems, Security Engineer, Business Continuity Analyst, Clinical Nurse Analyst.

Don’t let Inga’s swaggering online demeanor fool you. Those of us who know her recognize that she’s sensitive (sniffles at movies), self-doubting (always convinced she doesn’t know enough to write authoritatively about topics she’s followed for many years), and fragile (I’ve quit telling her to stop double-spacing after a period because it devalues her). You can imagine the emotional harm wreaked by those who don’t sign up for e-mail updates; who fail to connect with us on LinkedIn and Facebook; who don’t support our sponsors and click their ads and Resource Center listings occasionally; and who hurtfully neglect to send her newsworthy scoops and fun information so she can at least temporarily feel confident about her knowledge base (cue emotion-tugging Sarah McLachlan warbling). In lieu of giving her a hug, consider checking off the items on the list above, ‘cause when Mama ain’t happy, ain’t nobody happy.

Acquisitions, Funding, Business, and Stock

TransUnion acquires Financial Healthcare Services, a provider of a patient payment estimation solution.

Microsoft announces Q1 numbers: revenue up 7%, EPS $0.68 vs. $0.62, beating and meeting expectations, respectively.

Athenahealth announces Q3 numbers: revenue up 33%, EPS $0.15 vs. $0.11, beating expectations on both and raising fiscal year guidance.

San Diego’s West family, who made their $2 billion fortune from telemarketing and who established the West Wireless Health Institute in 2009, create a $100 million venture investment fund to invest in early-stage technology companies that can reduce healthcare costs. They pledge to invest any profits in medical research.

Sales

Alexian Brothers Health System (IL) expands its relationship with athenahealth by selecting athenaClinicals and athena Communicator for its network of 150 employed providers. In addition, athenaCollector client Harbin Clinic (GA) adds athenaClinicals for its 210 providers. Both are Allscripts replacements.

People

The Hay Group consulting firm promotes Bill Quirk from director of business development to national director of its US healthcare practice. He was previously with Sullivan, Cotter and Associates and Towers-Perrin.

The TriZetto Group names President and CEO Trace Devanny as the company’s chairman, succeeding TriZetto founder Jeff Margolis, who will serve as chairman emeritus. Devanny was president of Cerner until last year.

Streamline Health hires Tom Dean, formerly with CareCentric, as VP of product engineering.

Robert J. Bunker joins the board of directors of T-System. He is chairman and CEO of The Medical Staffing Network Inc. and started his work in healthcare as Humana’s COO in 1994 after serving 20 years in the US Air Force Medical Service, retiring with a rank of lieutenant colonel.

Joan Bishop, formerly with Lockeed Martin, joins Encore Health Resources as principal of its government client services business.

Announcements and Implementations

AtlantiCare (NJ) announces plans to to launch AtlantiCare Health Solutions, an accountable care organization.

Aprima Medical certifies GFI Software’s FaxMaker for use with Aprima’s EHR and PM solutions. Which reminds me of a recent need I had for a copy of certain medical records. My doctor’s office said I had to fax them a request form. Since I don’t have a fax machine, I asked if I could e-mail the form. They responded that they didn’t have e-mail. I had to double check the year to make sure I wasn’t in some sort of time warp.

ONC validates the South East Michigan Health Information Exchange (SEMHIE) for conformance and interoperability testing, allowing SEMHIE to go live on the Nationwide Health Information Network Exchange.

Intelerad Medical Systems launches InteleSuite, a RIS/PACS solution that combines Interad’s standalone PACS and RIS offerings.

University of Michigan Health System and Great Lakes Health Information Exchange sign an agreement to exchange information. Other members are Michigan State and Sparrow Health System.

A Detroit jury finds that Beaumont Hospital (MI) and an OB doctor let a woman deliver a 10-pound, 12-ounce baby vaginally instead of by C-section, causing brain injuries in the newborn girl. Despite the hospital’s claim that the disabilities of the child (now a teenager) were caused by the mother’s gestational diabetes, the jury awards the family $144 million.

I received an e-mail from Steve Pelton, VP of enterprise applications for Ministry Health Care (WI). They have completed their EHR certification tests through Drummond Group (“tough, but fair,” he says) and expect to demonstrate Meaningful Use and attest early next year after the 90-day demonstration period. He raises an interesting point:

From the CHPL web site, it appears that only 16 hospital and health systems have achieved either modular or complete EHR certification. While many or even most hospitals will wait for their vendors to provide updated, certified products for them to install, it does seem surprising that so few of the over 5,000 hospitals in the US have not gone through the self-certification process. Like Ministry Health Care, most of the 16 hospital and health systems achieved modular certification, which allows for the Meaningful Use of a collection of certified products. The most common modules that are self-certified seem to be homegrown data repositories. One would expect that many hospitals that have either homegrown systems or uncertified niche systems would attempt to certify them. One would also expect hospitals to self-certify their existing systems while they are working to replace or upgrade to a certified version. What is everyone waiting for?

Weird News Andy summarizes this story as, “Socialized medicine. Gotta love it.” An 82-year-old woman visiting her dying husband in a Canadian hospital falls in its lobby, breaking her hip. Two ED nurses and a security guard observe her lying face-down on a metal grate and bleeding, but refuse to help until an ambulance arrives. The  top executive can’t explain why a code wasn’t called. The same hospital made headlines last year when a woman who had stopped breathing was driven to the hospital by her boyfriend, but the ED staff refused to help since the couple were in their car in the parking lot and told the boyfriend to call 911 instead. The 39-year-old woman died a few days later of a heart event. The employees thought they wouldn’t be covered by malpractice insurance if they helped someone outside the four walls of the hospital.

Government and Politics

ONC adds a principal deputy position to its organization, tasked with duties similar to that of a COO in the private sector. The yet-unnamed deputy will report to ONC coordinator Farzad Mostashari.

The VA gives Harris Corp. a two-year, $200 million blanket purchase agreement to develop VistA-connected outreach tools, including creating a point-of-service kiosk, redesigning the VA’s quality Web site, supporting the National Utilization Management Integration project, and developing a replacement bed management system.

The government’s Substance Abuse and Mental Health Services Administration (SAMHSA) awards 29 grants totalling $25 million over three years to increase access to behavioral health services with information technology.

Federal prosecutors file an $8.1 million fraud suit against Kernan Hospital (MD), part of the University of Maryland Medical System. The government says the hospital intentionally changed its billing system to create a diagnosis of severe malnutrition, looking for the words “protein malnutrition” and pressuring physicians to add that condition as a secondary disease.

Other

Nearly 300 GE Healthcare employees in Salt Lake city form a human pink ribbon in recognition of Breast Cancer Awareness Month. The company has scheduled similar displays across a couple of dozen cities.

The hospital EHR market is expected to peak in 2012, with revenues of $6.5 billion.

Twenty-six percent of CHIME CIOs say their organizations have qualified to receive Meaningful Use funding, with 13% actually having been paid. About 93% expect to achieve the Stage 1 MU during the first three years of the program.

An Internet outage in a small North Carolina town leaves a medical practice that uses a Web-based EMR out of luck. “We’re electronic medical records, and neither one of our softwares will come up because we’re Internet-based. If the Internet goes down, we have to just call patients back to get appointments re-scheduled.”

An Illinois physician claims his health system employer placed him on administrative leave because he has “no computer skills.” Steven Kottermann MD, who was a family physician with Memorial Health System, admits that he fell behind on his electronic charting after the health system’s implementation of Epic. The doctor believes that Memorial is at fault because “they bought a lousy system.”  The hospital’s chief medical officer says the issues go beyond the doctor’s EMR proficiency.

Sponsor Updates

• GE Healthcare recognizes Frederik Memorial Hospital (MD) and Northeast Georgia Medical Center (GA) as winners of its 2011 Leaders of Change Awards at the Centricity Perinatal Users’ Group National Conference.
• Sentry Data Systems earns a spot on the South Florida Business Journal’s Top 25 Fast Tech Awards for significant revenue growth.
• Khalid Moidu, MD, PhD (Orlando Health) and Stephen Claypool, MD (Wolters Kluwer Health) will present Innovation Lab: Evidence Based Order Sets Tools from a Dynamic Hospital-Vendor Partnership at AMIA 2011.
• NVISION Laser Eye Centers (CA) selects NextGen for its 10 eye centers.
• NexJ Systems will host a free Webinar entitled The Next Generation of Health Information Exchange October 28th. NexJ Systems, by the way, was recently named the sixth fastest-growing company in North America on Deloitte’s  2011 Technology Fast 500.
• AdvancedMD receives the Healthcare Hero Award for Innovation from Utah Business Magazine.
• OptumInsight releases a guide for physicians to minimize security risks entitled Keep Patient Data Secure: Simple Actions for a Digital World.
• dbMotion and Allscripts will co-host a webinar on physician EHR connectivity on November 16th featuring dbMotion CMIO Joel Diamond MD and Ryan Winn, VP and CIO of MidMichigan Health.
• Perceptive Software will showcase its enterprise content management solutions at the Gartner Symposium/ITexpo in Spain.
• Newton-Wellesley Radiology Associates (MA) boosts its financial performance and prepares for ICD-10 using McKesson’s Revenue Management Solutions.

EPtalk by Dr. Jayne

Now that we’re in the last quarter of 2011, Physician Quality Reporting System (the artist formerly known as PQRI) data is available through the CMS quality portal. Groups can access data by taxpayer ID and individual providers can also request reports based on their NPI. Next year should be a little different, with CMS agreeing to provide interim feedback reports to those who use claims-based reporting. Too bad for those of us who are Meaningful Users of our EHR technology and are reporting through registries rather than claims.

Speaking of CMS, regulatory reforms are on the table, with two proposals being introduced and a third being finalized this week. Modifications to the Medicare Conditions of Participation would allow multi-hospital systems to have a single governing body for multiple hospitals rather than requiring each have its own governance structure. Hopefully combining governance structures will help those of us on staff at multiple hospitals within a health system to reduce the number of committees on which we are forced to serve.

Proposed modifications for non-hospital providers address durable medical equipment suppliers and dialysis providers. Also addressed are outdated e-prescribing technical requirements. Hiding towards the end of the document is language to end the use of the term “Medicaid recipient” and replace it with “Medicaid beneficiary.” Although this makes it parallel Medicare, I can’t help but think there are political games afoot, with this being one more move to make people think that Medicaid is insurance rather than an entitlement program.

We all know we live in a society that’s increasingly saturated by technology, specifically audiovisual media. The American Academy of Pediatrics Council on Communications and Media releases guidelines stating that children under age two should avoid television viewing. This also includes passive viewing while playing in a room where an adult or sibling may be watching.

There’s an app for that: Mobile MIM is one of a growing number of apps to receive FDA approval. It allows viewing of diagnostic images, including MRI and CT scans. Although the app (one version for physicians, one for patients) is free, physicians must pay $1 to upload each image to its cloud-based repository. Viewing the study costs $1 to $2 depending on the receiving device. Earning FDA approval took more than two years and included modification to the app to detect poor lighting conditions that are inappropriate for the interpretation of radiologic studies. Maybe the FDA should also include logic to detect whether it is being used in a bar, as my colleague was attempting.

Recent data from social media analytics firm Amplicate shows that over the last year, 69% of Facebook and Twitter users reported hating a particular insurance carrier. Data from over 2,500 posts is aggregated by payer. In contrast, the other industries the firm tracks were more positive, with 56% of users loving their grocery store chain and a 70% expressing a love connection for fast food chains. More negative than health insurers: banks.

The FDA approves Hologic’s Trident specimen radiography system. The system is designed for intraoperative specimen imaging during minimally-invasive, stereotactic, or ultrasound-guided breast biopsies and includes the ability to export to PACS.

October is Breast Cancer Awareness month. I first saw the Pink Glove Dance on HIStalk. It’s always good to see healthcare workers having fun and raising awareness about a disease that impacts so many people. More than 100 organizations are competing for thousands of dollars to donate to their favorite charities, so get out there and vote. Here’s a shout out to my co-workers who are fighting this disease and a special nod to all the women in my family who have beat it, including one 20+ year survivor. Love you, Mom!

Contacts

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

CIO Unplugged 10/19/11

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

This is the fourth in a short series of posts on “The CIO’s Best Friends,” those BFFs who are critical in ensuring CIO effectiveness. This time we cover the CNO – CIO relationship.

Got Clinicians?

The CNO and I started our jobs about the same time. We knew we needed one another to be successful. With an electronic health record implementation looming, our partnership would be imperative.

As organizational rookies, we became kindred spirits. We commiserated, encouraged, and partnered. Through my CNO’s coaching, I learned we needed more clinicians inside of IT. “Got clinicians?” he prodded often. “If you don’t, you should.”

I wondered how many credentialed clinicians a healthy IT department should have. I now think 25% is a good target. Whatever your starting point, push to raise the percentage. Include a mix of MDs; RNs; radiology, medical, and pharmacy techs; pharmacists; therapists; and a smattering of other less common specialties. While many organizations have a CMIO, equally critical is a CNIO.

My CNO taught me that once you have clinicians on your team, you’ve got to ensure their successful transition into IT. Here are some things to think about in order to succeed.

Challenges for Clinicians Moving Into IT

Adapting to the office environment

• Cubes vs. nursing station reduces the sense of teamwork
• Use of meeting rooms is equated with loss of casual social interaction
• Taking work home
• Going out to lunch vs. grazing between patient care tasks

Difficulty recognizing accomplishments/results

• Need to understand the bigger picture (see beyond the patient)
• IT systems are configurable with gray areas; reduced workflow focus
• No more rapid results (average patient LOS is three days)
• Used to implementing changes quickly
• Giving up precision and timing on tasks

Loss of familiarity generates stress. The clinician must:

• Learn new tasks, find new resources, and create a new employee network
• Learn basic IT software (no more IVs)
• Fight pressure to already understand IT on the first day of work
• Assimilate IT language/acronyms

Facilitation skills are not in the typical nursing repertoire

• Scheduling appointments
• Creating agendas
• Taking minutes
• Using a meeting room to solve problems instead of on-the-spot interactions

Common Conflict Areas and Issues of Concern for Clinicians

• IT staff is generally unaware of clinician’s former environment and the required adjustments
• Lack of training for clinicians in IT subjects
• Clinicians are expected to already know what to do
• Downtime scheduling affects issues regarding patient care
• Clinicians have an inherent desire for more testing on software applications (like testing a drug before giving it to a patient)

Bridging the Gap and Investing in Clinicians

Preceptor program

• Increase depth of typical IT orientation
• Pair new clinical staff with experienced IT person; identify future clinician leaders
• Document and publish referable guidelines
• Create Web-based training on IT tools
• Ensure clinicians don’t get sucked into traditional IT mentality

Project management training

• Create project management processes that nurses can relate to
• Help clinician visualize the big picture and break it down into tasks

Professional development

• Develop a facilitation/leadership class
• Provide continuing education credits (CEU)
• Create internal training opportunities specific to clinical IT
• Develop clear development pathways, like a clinical ladder
• Clarify the position’s responsibilities

Spend time with your CNO. Actively partner. If you can’t afford a CNIO to bridge the nursing and IT gap, assign another clinician as a part-time liaison.

Over the years, we moved from 5% clinical staff to nearly 25%. I believe one reason we successfully implemented and adopted clinical applications was due to our staff mix.

Embrace the significance of melding clinicians with IT. Be intentional with it, maximize the value, and encourage further adoption. A healthy mix leads to a high-performing healthcare IT organization. I’m so glad I listened to my CNO.

Got Clinicians?

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

News 10/19/11

Top News

A newly signed California bill will require electronic medical records systems to maintain a record of changed or deleted information. The Confidentiality of Medical Information Act, which will become law on January 1, requires systems to log the user’s identity, the date and time of the change, and a record of the information that was changed or deleted.

Reader Comments

From Sole Food: “Re: shoes. This conversation is from the Late Late Show last week. Craig Ferguson to Monica Potter: ‘Oh, nice shoes.’ Monica Potter: ‘Yeah, I heard you like shoes.’ Craig Ferguson: ‘No, I like women, and I know that women like shoes.’ So don’t let anyone give you a hard time about posting pics of women’s footwear.” I couldn’t agree more. Inga likes cute women’s shoes, I like how women look in cute shoes. HIStalkapalooza is a lot classier now that many of the ladies come dressed to the nines. Women like dressing up, men like seeing dressed-up women, everybody wins.

From The PACS Designer: “Re: Ethernet – Fibre Channel convergence. TPD is celebrating the 10th anniversary of the design of the first Windows/UNIX based PACS that relied on Ethernet, and a Fibre Channel RAID to permit downloading of 500MB image files in under 30 seconds. Now, 10 years later, you are going to be hearing more about the convergence of 10-Gbps Fast Ethernet, and Fibre Channel storage arrays using a new term ‘Data Center Bridging Exchange’ as it tries to become the new standard for data storage.”

Acquisitions, Funding, Business, and Stock

Lexmark, the parent company of Perceptive Software, acquires Netherlands-based Pallas Athena for $50 million in cash. Pallas Athena, which is a provider of business process and document output management solutions, will become part of Perceptive.

TransUnion Healthcare, which offers revenue cycle tools, acquires Financial Healthcare Systems, the Denver-based vendor of the ClearQuote software that estimates out-of-pocket patient responsibility at the point of service.

Sales

BloodCenter of Wisconsin, Community Blood Center of Kansas City, and the US Department of Defense contract with Mediware for its InSight Performance Management platform for blood management.

DeVry University signs a five-year agreement with QuadraMed to incorporate its Quantim suite of HIM coding, compliance, and record management solutions into the school’s health sciences curriculum.

Eastern Connecticut Health Network selects MobileMD’s 4D HIE solution.

Riverside Health System (VA) selects the EMR-Link solution of Ignis Systems for lab and radiology order integration for over 200 physicians. The company differentiates its product as making all labs equal to physicians and their EMRs, which it says differs from the lab-funded, lab-centric integration model.

Sheridan Healthcare, the country’s largest anesthesia group with 1,200 providers and 100 hospitals and ambulatory surgery centers, chooses Shareable Ink as its standard documentation and charge capture tool.

CapitalCare Medical Group (NY) chooses ImplementHIT’s OptimizeHIT training platform to prepare its 110 providers for an Allscripts EHR upgrade.

People

Healthcare Information Xchange of New York (HIXNY) names Mark McKinney as CEO, replacing Dominick Bizzarro, who joined InterSystems earlier this year. McKinney is the former director of integrated services for SXC Health Solutions. HIXNY merged with the Adirondack Regional Community HIE earlier this month.

MED3OOO hires former Tenet Healthcare executive Jeffery E. Flocken as EVP of accountable care and hospital services.

Ingenious Med appoints Jim Keener as CTO. He was previously VP of development of Verisign.

Clinical decision support provider DiagnosisOne names Francis X. Campion, MD as VP of clinical affairs. He’s a member of the Department of Population Medicine at Harvard Medical School.

Announcements and Implementations

Meditech client Aspen Valley Hospital (CO) implements Summit Healthcare’s Downtime Reporting System to address business continuity.

Blue Shield of California will distribute $20 million in grants to 18 California hospitals, health systems, and physician groups to help them develop ACOs.

The University of North Carolina Hospitals implement the RF Assure Detection System for preventing and detecting retained surgical items in patients.

New York City’s Department of Health and Mental Hygiene (DOHMH) implements NextGate MatchMatrix Terminology Registry to standardize data shared by EHR systems.

Imprivata announces that six additional hospitals using McKesson solutions have implemented OneSign, Imprivata’s single sign-on solution.

Enterprise RTLS vendor Intelligent InSites integrates active RFID readers and tags from RF Code into its solutions.

Government and Politics

New York’s state development agency grants eHealth Global Technologies $750,000 in tax credits to support the company’s expansion. eHealth Global, a medical record retrieval and diagnostic image exchange service provider, will invest $3 million in the expansion and will increase its staff from 75 to 155 over the next five years.

CMS adds WellCentive as a qualified Registry provider for the 2011 PQRS program.

The VA will solicit bids for a WiFi-based real-time location system for tracking assets, employees, and patients its 152 hospitals, with an RFP to be issued by the end of the year.

Bill O’Toole of O’Toole Law Group has expanded his HITlaw article about EHR vendor certification into a white paper called EHR Certification Alert for Providers, summarized as: “The absolute heart of the issue is recognizing that in some cases multiple products that are marketed individually by a vendor are grouped together for testing and ultimately certified together and not separately.”

An Associated Press review finds that Medicare often suspends bogus providers, but then quickly reinstates their payments even after their prosecution. The review found that appeal hearings often have nobody in attendance from CMS or their contractors, leading to a rubber stamp reinstatement of billing privileges. The article says pay-first policies (“pay and chase”) have made fraud so easy and lightly penalized that drug dealers and mobsters have given up their previous scams in favor of Medicare fraud. Disjointed government processes are blamed: contractors don’t share information, provider ID revocation doesn’t automatically initiate criminal proceedings, Medicare’s lawyers don’t show up at hearings, and nobody’s collecting surety bonds required of medical equipment providers when they skip town.

Innovation and Research

A good Business Insider article lists eight healthcare startups that are “shaking up” the industry. Among them: ZocDoc (online doctor appointments), Cake Health (medical expense tracking), Avado (doctor-patient relationship management software), and Sharecare (consumer Q&A with medical experts).

Technology

Dell ends its 10-year storage reseller agreement with EMC. The move was not a surprise, given Dell’s multiple acquisitions of data-storage technology over the last three years.

HP and Lucile Packard Children’s Hospital (CA) announce a real-time patient status system that uses EMR data to represent patient status, rather than traditional handwritten notes on whiteboards. During a trial period, researchers found that the Patient-Centered Dashboard prompted a change in care in one out of three patients.

Other

HealthGrades reports that Washington DC, New York City, and Kansas City are the top communities on a per capita basis in which consumers look for healthcare providers online.

Orion Health says it could hire up to 200 employees New Zealand following its acquisition of the former Microsoft Amalga HIS hospital information system.

At least 255 communities are attempting to support health information exchanges, but only 12% of them are self-sustaining. That’s still 33% better than 2010 estimates.

The 2010 Annual HIMSS Conference is recognized as “The Show with the Most Innovative Practices” at the Trade Show Executive Gold 100 Awards & Summit. HIMSS10 also ranked 33 on the Gold 100 list.

The Commonwealth Fund releases its annual National Scorecard on US Health System Performance. Some highlights (or perhaps lowlights):

• Despite big gains in EMR usage among primary care providers, the US lags far behind leading countries in EMR adoption.
• Although the US is showing promising improvements on several key indicators, quality of care remains uneven, with evidence of many inefficiencies and inequities in care.
• Other advanced countries are outpacing the US in providing timely access to primary care, in reducing premature mortality, and in extending health life expectancy. At the same time, these other countries are spending considerably less on healthcare and administration.

Readers have occasionally speculated about the EMR status of Lehigh Valley Health Network (PA), with a couple of them saying LVHN has chosen Epic. Not true, according to SVP/CIO Harry Lukens, who was kind to provide an update. LVHN, a GE Healthcare customer, is looking at GEHC, Allscripts, Cerner, and Epic. Scripted demos for all interested staff have begun, with those of GEHC and Epic completed (with similar combined scores of functionality and comments.) Harry says LVHN is planning to eliminate one vendor in November and another in January after site visits, then come to a final decision by March, although he’s philosophical in expecting the unexpected: “Keep in mind I also planned on attending the World Series to watch the Phillies play, which is my way of saying ‘stuff happens,’ a simple observation that planning is filled with things that happen for no reason.”

Central Vermont Medical Center and Fletcher Allen Health Care create a corporate affiliation that will allow them to share centralized services, among them Fletcher Allen’s Epic system.

Weird News Andy says, “I can see right through their plan,” as three Delaware Valley hospitals report the theft of scrap X-ray film, apparently by silver-seeking thieves posing as employees of a company hired by the hospitals to recycle their old film. And in a story WNA finds simultaneously weird and sad, a 47-year-old man appears on Howard Stern’s satellite radio show hoping to generate donations toward the $1 million he needs to pay for corrective surgery for his elephantiasis-swollen scrotum, which weighs 100 pounds.

Sponsor Updates

• Texas Regional Medical Center enhances its medication barcoding initiative with the implementation of the Access Intelligent Forms pharmacy labeling solution.
• Southeast Alabama Medical Center reports that its deployment of ProVation Order Sets has yielded cumulative benefits of $1.7 million.
• McKesson launches Episode Management, which automates bundled payments for episodes of care.
• Mac McMillian, CEO of CyngerisTek, will participate in a telebriefing on HIPAA privacy and security audits, hosted by Law Seminars International.
• T-System CMIO Robert Hitchcock, MD,  addresses critical issues in EDs in a podcast entitled Hospital Emergency Departments in Crises.
• Carefx Corporation releases a white paper entitled Patient Portals – The Pathway to Patient Engagement and an Enhanced Patient Experience.
• Hayes Management Consulting issues a white paper and Webinar on achieving Meaningful Use.
• Crittenden Regional Hospital (AR) meets Stage 1 MU utilizing the EHR and consulting services of Healthcare Management Systems,
• Merge Healthcare’s RIS v7.0 receives Complete EHR certification for MU.

Contacts

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

Curbside Consult with Dr. Jayne 10/17/11

Dear Dr. Jayne,

What’s your take on the following Medicare position?

When documentation is worded exactly like or similar to previous entries, the documentation is referred to as cloned documentation. Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient.

After doing cough/cold/flu clinics where patient after patient presents with similar symptoms, similar exam findings, while the HPI documentation may be different, there are only so many ways to document “nasal turbinates red, erythematous, swollen, lungs clear” and the advice to the patient nearly always remains “Rest, fluids, Tylenol, ibuprofen, return if condition worsens.”

Additionally, much documentation remains unchanged at a routine 3-6 month visit for diabetes, HTN, hyperlipidemia where a physical exam is performed thoroughly. Medicare requires the documentation for payment, but is now placing providers in a catch-22 where the documentation cannot be even similar. How different can one make an exam if little changes?

Must we now ditch those time-saving macros that document routine education in the chart, such as “Counseled patient regarding risks and benefits of medication, including the possibility of sedation and advice to avoid driving or operating power tools while on narcotics?”

Clone Trooper

Dearest Trooper,

My secret fear is that Medicare is building its own Clone Army of Recovery Audit Contractors to continue to torment and confuse physicians. If they’re now going to go after so-called cloned documentation, they’re going to have to go back to every History and Physical and every Discharge Summary that every resident has done since the invention of the Dictaphone.

I remember being trapped in Medical Records (before it became Health Information Management) with a stack of my cruel attending’s charts, dictating notes on patients I barely remember seeing. Unless they had a significant finding, everyone was “regular rate and rhythm no murmur, rub, or gallop; lungs were clear to auscultation bilaterally.”

I absolutely agree with you – there are only so many ways to say, “Patient is not a smoker.” Let’s see. PATIENT is not a smoker. Patient is NOT a smoker. Patient is not a SMOKER. Let’s try this: STOP smoking pot. Stop SMOKING pot. Stop smoking POT.

If I use the same simple sentence on every patient, does that make me guilty of cloning? Will the stem cell activists come after me too?

Frankly, I think Medicare shares responsibility for creating this kind of documentation. This isn’t a new problem with use of EHRs. It has been prevalent every since transcription services started charging by the line. Physicians learned to say the same thing in fewer and fewer words. This ultimately evolved into dictation macros and the concept has continued as voice recognition slowly takes the place of transcribed dictation. EHRs just jumped on a train that was already rolling at a good clip.

Medicare’s cousin, Medicaid, has also driven us to this. Has anyone ever seen an EPSDT form? This is a required form for pediatric well visits. It is required that providers fill out the same form (specific to age) for each patient. You are required to document mandatory anticipatory guidance by placing an X in a box. Thus, the forms look pretty darn identical when they’re done. Should I start doing cursive X on some forms and print on others? Should I alternate right and left facing check-marks? Why is Medicaid’s form OK but my own form causes cloning?

I do a lot of sports physicals, sometimes at a sports physical clinic. There is a mandated state form. Almost all of the teens I see are healthy. So what constitutes “patient specific information?” Maybe I should start finishing them up with “This blonde surfer dude in an Abercrombie t-shirt is cleared for contact sports,” or include “Patient has braces with alternating pink and green elastics” on the oral exam. Would this meet the CMS standard for unique documentation?

Then, what about the patients who have the same visit month after month? I have patients whose office visits are straight out of the movie Groundhog Day. Except for the vital signs, the visit never changes. The patient continues to be non-compliant. The murmur is identical from visit to visit (which is a good thing!) The assessment and plan are the same. I keep prescribing the same medications that the patient continues to not take correctly.

Let’s not even talk about group visits, which they want us to do as part of Patient Centered Medical Home initiatives. Of course your counseling is going to be identical for every patient – you only said it once because they were sitting there in a group, for goodness sake. If you try to change it up for the sake of making less uniform documentation, isn’t that fraud?

I think if Medicare wants to avoid cloned documentation, they should start paying physicians to document using well-crafted prose – or at least an incentive payment for complete sentences with reasonably correct grammar. For the ability to collect a higher fee, I’d even consider writing notes in the form of the Shakespearean sonnet. But with dropping reimbursements and rising costs, CMS is going to be lucky if they get a Haiku out of me.

Have a penchant for an Ode, some Tanka, the Jintishi, or maybe the anapestic tetrameter of Dr. Seuss? E-mail me.

E-mail Dr. Jayne.

Readers Write 10/17/11

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!

Video to Smart Device Technology Improves Patient Care in Rural Areas
By Kevin Lasser

Innovative technologies are connecting doctors to experts around the globe, instantly and in real time. These innovations, including video to smart device technology, address the significant gap that rural patients experience compared to their urban peers. By improving access to expert medical care, innovations that can connect physicians to specialists are improving the quality of patient care and the outcomes of that care.

Access to specialty care is a challenge that rural Americans must tackle daily; according to a study published by the American Hospital Association, more than half of Americans in rural areas travel more than 20 miles for specialty care, with an average reported distance of 60 miles.

The plain fact is that rural Americas do not have access to adequate health care.

• 50 million Americans live in rural areas, yet there are only 65 primary care physicians per 100,000 rural Americans. By comparison, there are 105 physicians for every 100,000 urban and suburban Americans.
• Rural areas have less than half the number of surgeons and other specialists than urban and suburban areas.
• Saving lives means changing the status quo.

In emergencies, these rural patients can be in the fight of their lives against the clock. The current status quo for doctors in rural areas is to transport patients who need emergency specialty care to another physician. In life threatening emergencies, this delay in care can cause serious and irreparable harm.

Video to smart device technology is bridging the gap between physical location and access to expert care. By allowing a doctor to broadcast video over a secure network, a specialty physician can see the patient’s condition and advise on appropriate care.

“Video to smart device technology allows physicians immediate access to a patient via the mobile phone that they already carry,” said Dr. David Wang, director of the INI Stroke Network. “Other solutions, including personal computers or laptops, are cumbersome and impractical.”

Since the technology is real-time, diagnoses and recommendations can be made and implemented quickly; this real-time technology can save a life in settings where access to immediate expert care is required. The INI Stroke Network recently produced a video on how its use of video to hand-held device technology is saving lives in critical situations.

For the expert, including the stroke specialists in Dr. Wang’s practice as well as cardiologists, neurologists and specialty internists, video to smart device technology allows easy consultation with emergency room doctors and rural health care providers. Combined, these physicians deliver best in class health care to patients, regardless of their physical location.

Using technology to connect rural physicians to specialists in urban areas allows the patient to stay with a doctor that they know and trust while still receiving the best medical care. Real-time, real expertise leads to real care that can save a life.

Leveraging the power of innovation can change the outcome of care for rural patients. When access to expertise is critical, the phone in a doctor’s pocket might be more important than any other tool in their medical bag.

Kevin Lasser is president of JEMS Technology of Orion, MI.

Imaging’s Test: The Balance of Cost and Quality
By Steven Gerst, MD, MBA, MPH, CHE

Providers will be put to the test as they deal with President Barack Obama’s recent proposal to trim trillions from the deficit and hundreds of billions from Medicare. Specifically, radiology professionals should take note. 

The proposal calls for nearly $1.3 billion in savings by raising the assumed utilization rate on some imaging equipment and by requiring referring doctors to get prior authorization when ordering scans. It is still unclear if this authorization process will be managed via the now dominant radiology benefit management (RBM) model. Yet a better model exists.

Today, more than 150 million patients are at the mercy of RBM companies. Health Affairs reported in their May 14, 2009 issue that, on average, telephonic utilization review protocols, denials, and appeals processes costs the average physician $68,274 per practice. This wasted time and cost totals between $23 and $31 billion, annually. This tremendous cost is unnecessary, especially based upon the availability of new electronic, point-of-order, appropriateness criteria-driven clinical decision support (CDS) systems.

Evidence-based medical imaging CDS systems are proving their value. According to a recent study published in the Journal of the American College of Radiology, physicians at Seattle-based Virginia Mason Medical Center saved the institution 23% to 26% on selected imaging procedures by using a CDS. At the Everett Clinic, also in the Seattle area, from January of 2009 to November 2010, the number of CT and MRIs dropped by 39% (from nearly 210 to 128 images/ per 1000) following implementation of an evidence-based, point-of-order CDS solution.

These solutions will become increasingly important under newer “pre-funding” models which reward the most appropriate utilization for the lowest possible cost and the highest possible quality of patient care. With bundled payments, growth in capitation, and the pressures for DRG cost containment, providers, payers and blended ACO organizations will face pressure for both quality improvement and cost containment. Decision support delivers value on both fronts. In the next few years, CDS systems will likely replace the current contentious, inefficient telephonic utilization review protocols by leveraging point-of-order technology, authorization, and payment mechanisms. CDS is destined to become mainstream tools for physicians under healthcare reform.

It is estimated that more than one third of all medical imaging tests may be medically unnecessary and 20% may be unnecessarily duplicative. There is significant merit in attempts to curb unnecessary testing and duplicate tests that are contributing to cost increases. As the Virginia Mason and Everett Clinic Studies indicate, when ordering physicians are provided with evidenced–based criteria at the point of ordering, a physician appears more likely to order the most appropriate test for the patient resulting in the highest quality of service and potentially at the lowest possible cost.  Health reform and ACO development create financial incentives to rapidly adopt this new technology.

In the RBM model, a UR nurse or medical director reads criteria off a utilization review screen during call center discussions, and the burden of that call falls upon the ordering physician, even though that physician is not reimbursed for the study that is being ordered. It is much more efficient to make criteria available to physicians directly at the point of care. Technology can replace an inefficient and costly middleman model.

Most RBMs and carriers develop their protocols around the American College of Radiology appropriateness criteria. With a CDS, these criteria can be loaded directly into the CDS system as an integrated application within the hospital and physician’s EMR. In this scenario, the most appropriate physician imaging orders (ranked levels 7, 8 and 9 on the ACR criteria) could automatically bypass the UM or RBM process electronically and receive an instantaneous authorization for approval and payment. This is known as “Gold Carding.” 

For tests that are clearly inappropriate (ranked 1, 2, or 3), the ordering physician could be given the clinical evidence electronically at the point of ordering  through a decision support system to select a more appropriate test (without having to step out of the normal ordering workflow). In some instances, physicians may want to override the system. Here, the doctor should be able to enter free text to include the reasons for not following the ACR criteria. This is an important part of the audit trail.

Decision support systems allow the hospital to carefully monitor ordering trends by individual practitioners. Those with inconsistencies may be reviewed in conjunction with the medical director to determine causes and to discuss potential resolutions going forward.

Depending on the business needs of the hospital or ACO, if deemed inappropriate, the test may be programmatically blocked electronically from ordering. For proposed studies which score in the 4, 5, and 6 range of the ACR rankings, the CDS system itself may suggest an alternative, more appropriate test. CDS systems should easily allow physicians to select this better test without exiting the workflow. 

What about Meaningful Use? While Stages 2 and 3 are yet to be solidified, it is believed that Meaningful Use Stage 2 will require 60% of all radiology orders to go through the hospital’s EMR CPOE function. Stage 3 has proposed 80%.  A medical imaging clinical decision support solution will, therefore, become a powerful tool in the hands of a conscientious hospital or ACO medical director.

In the past 10 years, the use of advanced imaging procedures (CT, MRI, etc.) has more than doubled in some large health systems. In these systems, clinician decisions drive roughly 84% of cost of care. While estimates vary, a conservative average for an advanced imaging procedure cost is $429 per study. On average, assume a typical hospital performs 230 procedures per day, or 84,000 studies per year. For a hospital at risk under a DRG, bundled payment model, ACO shared savings scenario, Medicare Advantage, Managed Medicaid, or their own employee plan, if just 10% of duplicate studies were avoided, nearly $3.6 million could be saved. 

Why wouldn’t an organization use a medical imaging clinical decision support system?

Steven Gerst, MD, MBA, MPH, CHE is vice president of medical affairs for MedCurrent of Los Angeles, CA.

The Perfect Storm:  All the Buzz from the Healthcare Business Intelligence Summit
By Laura Madsen, MS

Earlier this month at its annual Medical Innovations Summit, the Cleveland Clinic released a listing of the Top 10 medical innovations for 2012. While most would expect many of the items on the list, such as a novel diabetes treatment and new discoveries with gene sequencing, one of the list’s items took many by surprise. Specifically, according to the list, “harnessing big data to improve healthcare” will be a forthcoming medical innovation.

In May 2011, the McKinsey Global Institute published findings after studying “big data” in five domains. According to their research, “If US health care were to use big data creatively and effectively to drive efficiency and quality, the sector could create more than $300 billion in value every year. Two-thirds of that would be in the form of reducing US health care expenditure by about eight percent.”

Last week, nearly 200 people from provider and payer settings gathered at the Healthcare Business Intelligence Summit offered in its third year in Minneapolis. This year’s speakers represented a myriad of organizations including Northeast Georgia Health System, Hennepin County Medical Center, BlueCross BlueShield of Kansas City, and the Winnipeg Regional Health Authority.

As one of the event’s lead organizers, I give credit to my colleagues who served on planning and organizing committees, and also to those who presented and those who attended.

The day was full of sharing information, observations, and insights around business intelligence (BI) in healthcare. In debriefing with colleagues and pondering my own experiences from the day, the following key themes emerged.

The Perfect Storm For Healthcare BI
Many folks told me they are buckling under the pressure of increasing volumes of data, increasing regulatory requirements, and increasing exposure to data and reports by people across and outside of their organizations. Especially with the HITECH Act and Meaningful Use, we have the perfect storm for investment in healthcare data capture, storage, and analytics. Today’s organizations must leverage a new and distinct approach to data, one configured specifically for an ever-changing landscape. Yet caution is necessary. Healthcare is a different animal than retail, manufacturing, and finance.

What About Quality?
Concerns exist about the value associated with data. Healthcare data, especially clinical data, can be subjective. It is fragmented and often incomplete, making analysis and knowledge distillation an ongoing issue. While most know that data quality is critically important, most folks don’t know how to tackle it. Some have decided that they are better off exposing bad data to end users as a way to demonstrate the impact that these end users themselves can have on the quality of data. This, of course, is not recommended. 

Where’s the Value?
When talking about data value, a shift is underway. A few years ago at the conference, the question was “Is there value in our data?” Today the question is “How do we determine where there’s the most value?”

Data, Data Everywhere
As data volume increases, so, too do the challenges of data disparity. Data integration is becoming a hot topic. Everyone knows they need to bring disparate sets of data together. Some have done it successfully.Others are just embarking on the adventure. Yet we all know that as data sources and volumes increase, so does the reliance on “Extract, Transform and Load.” ETL is a fundamental practice in business intelligence, yet it is often misunderstood. This seems to be weighing on people’s minds.   

ACOs, MU, Etc.
Data reliance is becoming a mainstay in healthcare and increasingly important as Meaningful Use continues to evolve and as the new shared risk model of accountable care is adopted. Most people at this year’s event agree that the industry needs a higher degree of sophistication associated with data management, reporting, and analytics. When discussing MU, ACOs and the like, most organizations reported feeling ill-prepared.

Representatives from CMS led a heavily-attended breakout, with significant discussion on data warehouses to support Meaningful Use. One attendee, a vendor working with MU in ambulatory care, indicated that nearly 50% of the groups he’s worked with in the past few years have more than one EHR and are struggling to determine how to move forward with these multiple environments. One individual from a provider environment said he felt they were being penalized for being an early adopter of EHRs because they had more than one, and as a result, were not sure how to proceed. At this point, they are leaning toward dumping everything and starting over. Even though they will miss some incentives, they will make the final deadline.

The discussion of data EHR and data consolidation raised a major question that’s seemingly on most people’s minds:  will there be a time that ONC/CMS will recognize the need and/or value of a traditional data warehouse for healthcare organizations striving to meet MU? If this happens, how will they handle will certification of processes including data integration, data modeling, and reporting? 

Perhaps next year at this time I’ll be writing about the ONC’s response to this very question. Until then, best wishes with the unique healthcare challenges and opportunities of big data and business intelligence.

Laura Madsen, MS is healthcare practice lead at Lancet Software of Burnsville, MN.

Orion Health Acquires Microsoft’s Former HIS Product; Companies Will Co-Market Offerings

Orion Health, an independently owned software company that offers HIE, integration, and clinical portal products, will announce later today that its subsidiary, Orion Health Asia Pacific, has signed an agreement to acquire the Microsoft software suite formerly known as Amalga HIS and Amalga RIS/PACS. The companies will also announce that they will co-market Orion Health HIE and Microsoft Amalga Unified Intelligence System (Amalga UIS) to health information exchanges and integrated delivery networks.

Amalga HIS was developed at Thailand’s Bumrungrad International hospital by Global Care Solutions and was acquired by Microsoft in October 2007. It  offered 50 clinical and administrative applications (including lab, medication management, RIS/PACS, electronic medical records, CPOE, clinical documentation, financial management, and HR management) that were used by seven Asia-Pacific hospitals. Microsoft announced that it was ceasing ongoing development of the product in July 2010, but would support existing customers for five years.

Orion will market the former Amalga HIS solutions as Orion Health HPM (Health Process Management.) According to Orion Health CEO Ian McCrae, “The addition of the Microsoft’s HIS assets is a natural extension of Orion Health’s portfolio of products that enable us to offer a complete solution to a wide range of hospitals and health organizations in Asia Pacific. The health sector in a number of Asia Pacific countries is overdue to make the transformative leap to the next generation of systems which integrate the complete healthcare ecosystem rather than siloing information in individual organizations or facilities.” The Thailand development center will become Orion Health’s fourth software engineering location.

We spoke to Paul Viskovich, president of Orion Health North America, who said, “The initial focus of the product will be the Asia and Australasia market. We’re focusing on moving customers forward and expanding that and integrating that application suite with Orion’s current offering.”

The agreement also calls for the two companies to co-market Orion’s HIE and worfklow solutions along with Amalga UIS.

Paul Viskovitch told us, “We can provide the HIE solution requirements, with Amalga UIS providing the analytics and the business intelligence that they require. When you sell to the IDN space, they’re starting to look at an HIE as the foundation for an ACO in many cases. We’re starting to see the Amalga UIS component, with its business intelligence and analytics, as a key part of providing a solution.”

Nate McLemore, general manager of business development, policy, and international sales of Microsoft’s Health Solutions group, told us. "We were hearing a lot from both customers and prospects that as we were in the HIE market, both in the community HIE as well as the enterprise-based HIE, that they loved the portal and workflow solutions that Orion provided, but also understood  the value that Amalga provided with a deep data platform and data analytics. Our customers and prospects were torn because we came at the problem from different directions. We spent the last several months working on how to address that and really go to market with a combined offering that gives customers the robust portal and workflow of health exchange through Orion, but also the data analytics and data platform capabilities of Amalga.”

We asked Nate McLemore how Microsoft might work with other potential partners like Orion. He said, “As Amalga moves more and more toward a data platform, we see working with partners to provide the data aggregation components of Amalga into the solutions they have.”

Orion Health, headquartered in New Zealand with a head USA office in Santa Monica, CA, offers an HIE platform, the Orion Health Hospital clinician portal, the Symphonia messaging and mapping tools, and the Rhapsody Integration Engine.

Monday Morning Update 10/17/11

From Epic4All: “Re: Epic. It’s the de facto EHR for hospitals in Seattle with two more area community hospitals implementing it – Overlake and Valley General Medical. This is on top of the largest system Swedish Medical Center (and associated hospitals), UW, and Group Health already live.” Unverified. Your statement will probably elicit scathing comments from the same handful of high-strung readers who howl that any mention of Epic is pandering favorably to the company, conveniently missing the point that they are outselling everyone (not to mention that I run quite a few negative comments about Epic as well.) I’d bet money that anyone who gets that worked up at the mention of Epic either (a) works for a struggling competitor, or (b) applied to work for Epic and got turned down (or both). I suppose I could write endlessly about Invision or STAR, but who would find that relevant or interesting?

From Soliloquy: “Re: Epic. Heard that one of the Adventist facilities on the West Coast is stopping its ambulatory implementation and will put out an official announcement next week. Someone also told me that Ventura County is walking away from Epic at their two public hospitals.” Unverified.

From Another Take: “Re: Fasttrack’s comments on Cerner Health Conference. This consultant writeup is favorable, but seems to be without bias. I found it an interesting juxtaposition.” Most interesting to me was that Neal Patterson compared Cerner to Apple, which seems a stretch given the implementation challenges and user-visible complexity of Millennium, Cerner’s unwavering focus on investors instead of innovation, and emphasis on enterprises instead of individual users. I’d say Cerner is a lot more like Microsoft, Oracle, or IBM in that regard, but Neal’s obviously looking to ride some Apple coattails (or perhaps is badly hiding some Steve envy). That doesn’t detract from what Cerner has accomplished, but drawing a self-comparison of a conservative enterprise software vendor to the consumer-focused and innovative Apple is always going to cause some eyes to roll.

Thanks to HIStalk reader Jared, who sent me an iTunes gift certificate with a note of thanks for HIStalk. He wasn’t looking for a plug, but I’ll give him one anyway since it was a nice surprise – he’s the founder of Splint, which is building EMR client iPhone apps for nurses (of which he is one.)

Armed with a bulging iTunes balance courtesy of Jared, I decided to see if I could find an interesting iPad app or two for HIStalk readers. The result: Splashtop Remote Desktop, one of the coolest things I’ve seen lately (especially for $1.99). Load the app on your iPad or iPhone, install the free streamer app on the PC you want to control, and you’re done – the app finds your PC and you can instantly start controlling it just like you were sitting in front of it. Not only is the video fast and smooth, the PC’s sound even plays over the iPad’s speakers (!!) I sat outside on the deck with a snack and fired up Word, ran my Iolo System Mechanic registry backup, closed down my invoicing program that I’d forgotten was open, and streamed some Flash video that normally doesn’t work on iPad. It looked exactly like the video above. You can run your desktop apps from anywhere, send files to yourself that you forgot to take along, run Office apps or Outlook without having anything installed on your iPad or iPhone, and maybe even do work-related IT geeky stuff like remote into servers, launch non-Web enabled apps, and do inside-the-firewall stuff from anywhere (by using remote desktop). That’s pretty amazing if you ask me.

I must be getting cranky since I keeping coming up with new grammatical pet peeves, but here’s an HIT-specific one: calling an enterprise-wide implementation of Cerner, Epic, VistA, Meditech an EHR (“The hospital is installing Epic’s EHR.”) I really dislike the non-specific term EHR in general since it describes the end result (stored patient information) and not the applications that create or view that information (CPOE, medical device interfaces, imaging systems, etc.), but it’s really a stretch to use the term EHR to include patient-irrelevant applications such as revenue cycle, supply chain, and workforce management that are often part of the same enterprise-wide implementation. The Feds got everybody throwing around the term EHR to make the same old EMRs of yesteryear sound more appealing, but the tried and true terms made more sense because they were specific: PM/EMR, clinical systems, order entry, etc.

Listening: new from reader-recommended Mayer Hawthorne, a young white nerd from Michigan who shockingly sounds exactly like a 1970s Motown / Philadelphia soul act with high vocals, horns, strings, and funky bass (Stylistics, Cornelius Brothers & Sister Rose, Billy Paul). Here he is on my new fave music show, Live from Daryl’s House. Super catchy, fresh, and retro. He does a great job on Private Eyes with Daryl Hall on the video. This is another chance for those folks stuck in a post-college musical rut (AC/DC in drive time, anyone?) to listen to something recorded in this millennium — think of it as a gateway drug to music that your parents didn’t listen to.

Readers aren’t quite sure how ACOs will affect quality and cost, with the number of those who predict both will improve being exactly offset by those who say both will get worse. New poll to your right: should HITECH compensate providers for using EHRs they bought before the program started? (I didn’t forget that I don’t like the term EHRs, but I used it since we’re talking HITECH here.)

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

My Time Capsule editorial this week, stretching its legs after being filed away since 2006: Don’t Look Now, Your Loop is Open. An excerpt: “We bought the technology least likely to be used, that addresses errors least likely to be harmful, that doesn’t help the user who needs it most, and deployed it in patient care areas where serious errors are least likely to occur.”

RIS/PACS vendor Candelis gets FDA 510(k) clearance for its cloud-based diagnostic image routing and sharing tools.

A SIS-sponsored survey finds that 43% of anesthesia providers either use or will implement an anesthesia information management system, with 28% planning to evaluate systems in the next year.

Ohio State University Medical Center was scheduled to go live on its $102 million Epic system early this past Saturday morning.

Physician’s Computer Company earns ONC-ATCB certification for its pediatrics-specific PCC-EHR v6.0.

Virginia Tech researchers develop software that limits smart phone access to data to specifically defined locations, then wipes it clean when the phone leaves that area. It can also limit smart phone functionality by location, such as shutting down cameras and e-mail when phones are in a hospital operating room.

Awarepoint and Meditech collaborate to develop an ED offering that allows locating patients and tracking critical milestones in real time from the Meditech system. Monongahela Valley Hospital (PA) is its first user.

Florida’s doctor-shopping database finally Monday morning. It’s not perfect, however: pharmacies can wait up to seven days to update it with prescription records, its use is optional for doctors and pharmacies, and most of its potential users don’t know it’s coming online. I was talking to a rural GP who uses an interesting approach to weed out his many drug-seeking patients: he gives them a quick urine screen every time they visit. If they show use of marijuana, cocaine, or other illegal drugs, he shows them the door immediately. He also sends them packing if they have excessive levels of their prescribed drug (indicating abuse) or zero levels (indicating that they’re selling the drug instead of using it). Not surprisingly, the vast majority of his abusing patients are on Medicaid.

Kansas City-based hospital chain HMC/CAH files for Chapter 11 bankruptcy protection, with its biggest creditor being software vendor CPSI at $1.2 million owed.

Bill Wallace, a retired SVP of IT of BCBS Kansas, is named CEO of Kansas Health Information Exchange Inc., the organization’s first employee.

A personal injury law firm’s press release says it settled a wrongful death lawsuit against Northwestern Memorial Hospital (IL) for $5 million, where a 55-year-old physician patient died after a nurse gave him insulin despite a doctor’s order saying it should not be administered. The law firm deposed a nurse who said she had contacted hospital administrators several times to complain about high workload and inadequate staffing. The law firm manages to squeeze in a jab against the medical profession, saying “it is both tragic and ironic that this type of obvious error would happen to a physician in this age of physicians protesting malpractice claims.”

E-mail Mr. H.

HIStalk Interviews Jeremy Bikman, Chairman, KATALUS Advisors

Jeremy Bikman is chairman of KATALUS Advisors of Alpine, UT.

Tell me about yourself and the company.

It’s kind of an old tale. I was raised in Canada, born in the US. Got sick of the taxes, the cold, and the Medicare and socialized medicine and decided to come down to the States and go to school.

I got involved in the Internet back in the 90s and got into some startups, got into some bigger companies, and then got recruited in KLAS by Ralph Reyes, who was one of the original founders of KLAS. Just a fantastic guy. I’d been there seven years and then moved on to re-start KATALUS.

KATALUS is a company I started back in 2001. I shut it down after a couple of years to go to KLAS and then just re-started it about 13-14 months ago. You can think of KATALUS as a management consulting firm. We work mainly with executives of the different organizations, be it healthcare vendors, private equity firms, or even hospitals.

With the vendors, it’s really strategy that’s the main thing we think about. Maybe the vendor is entering a new market. It could be a company coming to the US. We have a Japanese client that’s trying to work in the US. Anyone who has been in healthcare for a long time knows everybody wants to try to work in the US, so we have these firms that are trying to work in the US and we help them every step of the way. 

Some from the US are trying to go to Asia or trying to go to Europe. We work with them. Some are trying to turn around their businesses, some are trying to understand the profile of the customers. We work with them.

With private equity, it’s mainly helping them make the right the investments. Due diligence on M&A. Try to look at their portfolios. 

For hospitals, that’s probably the easiest one. We’re the gophers for hospitals and executives. Not necessarily on technology that they’re going to implement right now, but things out in the future. Right now, it’s Meaningful Use, ICD-10, 5010, and other things like that they have to worry about. But there are things further out in the future. They say, “I know in a couple of years I’ll have to deal with that.” It could be cloud computing, it could be something else. We get them information.

That’s a broad set of activities. Are you planning to grow in to the size that will support all those, or will you focus on current opportunities and change as time goes on?

That’s a very good question. With any company that’s growing, you have to make sure you’re not drinking your own Kool-Aid and make sure you’re administering your medicine. You have to zero in and focus.

Our main focus is on the vendors. We don’t do a ton with hospitals, and when we do work with them, it’s pretty easy because we’re just the gopher for information.

Most vendors are trying to do the right thing. That’s one thing that I learned even back when I was at KLAS. There’s different levels of execution, but most are really trying to do as good a job as they possibly can.

More of our focus is around how well they understand their client base, especially the larger vendors. They have a really hard time understanding. They bought so many different companies, except for a couple like Epic that builds as opposed to buys. Maybe to understand that profile of their customer base. They’ve bought a lot of different companies, and some of those customers, some of those hospitals are having very rough experiences and some are having fantastic experiences. They need to understand how that is impacting their bottom line and how is it impacting their top line. That’s where a lot of our focus is right now.

On the other side, with the private equity firms and the vendors, there’s so much M&A activity. We’re getting a lot of requests to do due diligence on different markets, due diligence on different technologies and vendors that they’re looking at. If I had to look at the two biggest areas we’re working right now, it would be those two I just described.

What parts of the KLAS business model do you like or don’t like and how do you intend to be different at KATALUS?

We’re nowhere near the same. KLAS will rank vendors, put out reports. We don’t do any vendor rankings or put out research reports. That’s not really who we are. We take a side.

When I started with KLAS, they were really quite small. When they hired me, they weren’t even sure how long I was going to be there or how successful I could be because of how small they were. It really was Kent and Ralph and some other individuals there, like Adam.

There was such a great opportunity. There really wasn’t much competition. As we moved into new areas like PACS, medical equipment, and HIE, it really took off. 

I left after being there seven years because there were so many times where I had vendors and hospitals specifically say, “OK, Jeremy, I know you can’t take a side, I know KLAS can’t take a side. But what can I do here? You know. You’ve seen everything about these vendors and you’ve talked to so many of their hospitals out there. You know what I should do.” And the answer had to be, “Well, we’re independent. Go look at the data.” You couldn’t take a side. 

After being there seven years and growing the company 700% — I ran the research division, sales, and strategy there — it just got to a point where I wanted to expand and do more than what KLAS’ mission was. KLAS’ mission is good. They want to rank vendors and they try to keep them as honest as possible.

That’s the reason I left. There was more to do. Where KLAS stops, we pick up the baton, so to speak, and keep running.

KLAS can obviously improve their transparency. Any vendor in market research in general needs to be very, very transparent. It’s tough, especially when you’re ranking so many different vendors and products. So they certainly could improve in their transparency. I know that’s a goal of theirs to do. But they do have really good people and they really are trying to do the absolute best that they possibly can.

There is no perfect vendor. There is no perfect data. There are no perfect reports. There are always errors. There are always mistakes. There’s always human bias that makes it into different data points. I understand the vendor side now being a vendor, being a buyer of KLAS data, Gartner data, HIMSS Analytics, etc. You have to look at it and say, “All this data that’s coming through — I can’t just treat it as the Bible.”

I don’t think KLAS or any other market research firm intends their reports to be the Bible. But unfortunately, too many users of it say, “Oh, it says it in this report that this vendor is Number One or this one is Number Three. That’s it — that’s our ranking as well.”

What framework or instinct do you us to distinguish between a company that’s doing things well versus a company that isn’t?

It really goes back to the management team that they have. There is an old saying in the investment world that, “A fantastic management team can take any idea and make it go north, while a mediocre management team can take the best idea and go south.”

I’m sure you’re familiar with Novell. If you try to compare Novell to Microsoft, Novell’s technology in most cases is hands down quite a bit better than Microsoft’s. Why is Microsoft so dominant? The difference was a much more dynamic, stable management team than you saw at Novell.

The same thing with Epic. Epic’s technology is the same as Meditech’s, in reality. What’s the difference? Epic keeps promises. Their technology isn’t interoperable. There’s obviously big limitations if you want to do real hardcore data analytics within Epic’s framework. How do you get to the next phase? Is Epic built technologically to get to that next step where healthcare is going to get to in 10 years? True interoperability has to be the case. 

Interoperability is not Epic’s strong point, but given how strong their management team is with Judy and Carl, I’d have to think that they’ll be able to get there, but we’ll see. They have a big row ahead of them, I think 10 years out, that healthcare is going to go back to being best-of-breed. Even 10 years it’s integrated, best-of-breed; integrated, best-of-breed. We’ll see what happens.

The one thing Epic has that may alter that cycle is they’re so expensive, so switching costs are high. It may be that people live with Epic longer than they would have lived with a Meditech that didn’t really cost so much. The two issues that are most interesting to me about Epic are that and their succession plan. Can the company do as well when Judy decides to go live on an island someplace?

That’s a great question. I don’t think there’s been an answer for it. When you have an organization where you don’t even know what people’s titles are from the outside, it’s really hard to know.

The good thing for them is that they’re private. They don’t have to answer to anyone except their own customers, although Epic has found a good way to dictate to their customers as well. It’s a fascinating model. I have one hospital executive that calls a company like Epic a benevolent dictatorship. They’re dictating to you and they hold on to you, but you’re also having pretty good results.

That’s a big case with what Epic’s doing in Europe, where they’re having to focus on the Netherlands. You have to have the IT savvy that’s necessary, but also a budget to be able to be able to afford an Epic.

That’s an interesting point that you raised — can people uncouple from it? I think eventually if it goes to true interoperability — which I have to think that healthcare’s going to go the way of every other industry out there where systems have to work together and have to work together well — no one vendor can do everything. If Epic doesn’t migrate to the trend that has evolved in healthcare, then I think there’ll be some innovative healthcare company or some other technology company will help you uncouple.

It could be dbMotion with what they’re doing, or a Microsoft Amalga replicating data, where they have now have all the data and you can start just plugging on top of it, almost like a desktop browser, different applications that are going to best suit that department, not just what makes the CIO happy or the board happy.

If your theory about the return of best-of-breed turns out to be true, can those vendors hang on until customers using Cerner and Epic and Meditech decide to come back? Will there be any vendors left for those customers to come back to?

What got me thinking about it, two years ago, I was talking to hospital. It was a big Siemens Invision site, academic, multiple facilities. I was asking the CIO, “What are you going to do?” She said, “Well, we’re not going to go to Soarian. We’re actually going to go to Epic. But Jeremy, I’ll tell you right now, if I could do what I want to do, it would be interoperable best-of-breed. I know what’s going to happen. I’ve seen it 30 years now, that everything is fully integrated, but it’s not necessarily the best thing for each clinician. It’s the best thing under the environment and under the parameters with which the government and other people are saying it should be, but that’s other people saying it. That’s not all of us hospitals saying, yeah, that’s the best thing. Jeremy, I’m going to go with Epic now, but in 10 years if I had to bet money, I won’t be Epic in 10 years. I may be Epic for my CDR or in med-surg, but I may be this vendor over here – Picis here, SIS there, and Thomson Reuters, and who knows what, and they’re working together.”

That’s what I see happening. This is an Epic hospital saying it. I came out of the high tech industry before I got in healthcare eight, nine years ago. I just can’t see healthcare constantly staying that much apart from everybody else with the technological trends.

But your point about is any vendor going to be around … I think so. I’ve been impressed with Flagler Hospital going with Allscripts. You’re going to get some independent hospitals. With real strong leadership, they’re going to say, “We could go this direction to go with fully integrated Cerner or fully integrated Epic. You know what? We like what Allscripts is doing. We like what McKesson is doing over here.”

The one good thing about having an Epic or an Apple in other industries, it forces everybody to say, “We just can’t act like we’ve done before.” I have to believe with innovation, like in other industries here, you’re going to have some vendors that are going to get crushed and they’re going to be absorbed and gone. There’s no doubt about it. There’s going to be others that are going to continue to innovate. 

I like what NextGen is doing with buying Opus. It will be interesting to see whether Athena jumps in because Jonathan Bush has done some amazing stuff there – of course, he’ll be happy to tell you about it as well. That’s what I see happening.

Has Epic shaken those companies you mentioned out of the doldrums they were in that allowed the market to validate and choose Epic so predominantly, at least in the larger hospitals? Or will they need to be replaced with a new layer of entrants to do what they can’t?

Yes and yes. I think some of the ones that I’ve currently mentioned had to be shaken out.

I talked to a CTO of a hospital who came out of a different industry. He said it’s amazing how much stuff we put up with with the vendors. How many vendors treat us this way? In any other industry, if a vendor missed a go-live by 3-4 months and their system went in and didn’t talk to other systems, it would be gone. That vendor would never work with us again. It would be over with. Can you imagine Walmart putting up with this? Walmart is really more of an IT shop than a retail shop, and they wouldn’t. 

I think Epic is shaking people out of the doldrums. Not technologically at all, but from a culture perspective of, “If we say we’re going to do something, we do it.” Of course it helps that Epic’s very good at self-selecting. They obviously have brilliant marketing and sales people on that self-selection. They understand that sometimes the best sales are the one you walk away from, or the one that you manipulate.

With Microsoft getting into it, I think it’s helping that Amalga is a different type of technology. With Microsoft’s girth in healthcare, they’ll spend millions of dollars before they actually turn a profit. They can sit and be patient and make a few things happen. Some other ones like NextGen, Athena .. I think Allscripts, too, is doing some really good things. Of course Cerner’s been very successful. 

It is going to be a mix of those vendors that are in healthcare and some that may come out. It will be interesting to see if somebody else jumps in. I’m going to have to imagine somebody is going to.

You talked about the companies that have strong management as their best predictor of success. I always hear and like the phrase, “Bet on the jockey, not on the horse.” Do you think that’s true also of hospital IT departments, where it isn’t so much what they have to work with, but which CIO or other leaders are running the show?

Without a doubt. If you look at UPMC, everyone keeps wondering, when Epic is going to come inpatient? When you talk to the different executive leadership over there, they’re not. They like what’s happening. They have obviously a lot of money. They have very strong leadership in Dan Martich, Dan Drawbaugh, and others and they say it’s working: “Epic out here in the outpatient world, Cerner in the inpatient world. We’re getting the best of both worlds. We’re making it work with dbMotion.” They’re really pushing the needle on that.

You’ve seen it happen. When a hospital is struggling, they get new hospital leadership, including new CIO to come in. You look at the results two or three years later, they’ve turned things around. Their negative margins are now at least marginally margins on the positive side. They’re utilizing technology in a very great way. It comes from the leadership. It really does. There’s tons of examples. 

It’s so trite, but it would be so easy to say, “If we just went with Epic, or if we just went with these systems, we’re going to solve our issues.” I don’t think even Judy would say, “If you implement this one, then that’s what’s going to solve everything.” I doubt Judy would say, “This hospital, it’s 600 beds, it’s in our sweet spot, but their CIO’s weak, they’re not really committed.” They’ll probably say, “Come back when you’re worthy.”

Any concluding thoughts?

It’s just consistently the question, and that The Innovator’s Dilemma, according to Christiansen — it’s going to hold true here. Epic is shaking out the big vendors, and my suggestion to them would be, “Watch out for the guys coming from below.”

If you look at other industries, Xerox got outflanked by Canon. Microsoft’s being outflanked in other industries by Google and other ones. Facebook’s coming up. The same thing’s going to happen to get Epic outflanked. 

Epic’s on top of the world right now and so is Cerner. You have these other guys coming in, and I don’t even know who they are yet. They could be Athena — they’re still small, still outpatient. They could come out with the absolute world leader inpatient system and their customer service level is just through the roof and, slowly but surely, they start chipping away and it’s pure cloud-based and then maybe Mark Benioff with Salesforce buys them and decides, “Hey, we’re going whole hog into it.”

The main thing is people need to be consistently looking for innovation and technology. I hope some hospitals start taking risks a little bit, although they’re not paid to take risks.

Time Capsule: Don’t Look Now, Your Loop is Open

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

I wrote this piece in September 2006.

Don’t Look Now, Your Loop is Open
By Mr. HIStalk

Three babies dead in Indiana, overdosed with the wrong heparin product in a hospital not using bedside barcode verification of meds. Technology failed them, plan and simple.

Ten years ago, nursing and pharmacy systems didn’t talk to each other (pharmacists and nurses didn’t either, but that’s another story.) Finally, everyone agreed that was pretty stupid, so vendors did a little bit of integration to make their systems look like they did. The electronic Medication Administration Record (MAR) was born, although most hospitals stuck with once-a-day printed versions for a several reasons, most of them illogical.

Along came CPOE, usually awkwardly bolted up to those same nursing and pharmacy systems. It was (and is) expensive, rarely used, and inefficiently designed for physicians, but it caught the eye of well-intentioned hospital executives who were blissfully unaware that all those CPOE-preventable errors weren’t the ones harming patients anyway. I like to think of it as the Job Security Act for Chief Medical Informatics Officers.

Don’t buy the ubiquitous vendor buzzword “closed loop,” which implies we’ve got meds under control. We don’t. The dent in harmful medication errors has been slight. Why? Because nurses still walk a tightrope without a net, armed only with limited drug knowledge, too much work, paper records updated with pens, and a wide-open candy machine of increasingly dangerous drugs … uhhh, I mean decentralized medication distribution cabinets.

We bought the technology least likely to be used, that addresses errors least likely to be harmful, that doesn’t help the user who needs it most, and deployed it in patient care areas where serious errors are least likely to occur.

But let’s look on the positive side. Technology is the only hope of improving the situation, so there’s opportunity galore.

If you’re a vendor with an integrated bedside verification system, get those sales guys on the road because I guarantee you’ll sell a bunch of them in the next year if yours is any good. Guarantee, I said. The Indiana errors are the pin that will pop the CPOE balloon, making even the big-picture types comprehend that they’ve been chasing the wrong solution. Board members will find the money, given the extreme embarrassment and financial exposure likely to follow a high-profile screw-up.

If you sell add-on tools for electronic MARs or have the expertise to consult in that or any other patient safety area, polish up your shingle. Plenty of organizations need your help. They haven’t fixed their own problems, so a well-dressed stranger who flies into town and has PowerPoints seems like the next thing to try.

If your company is one of the few that sells medication distribution cabinets, get some real informatics people designing improvements instead of those engineers who are more concerned with servo motors and drawer design instead of intelligent software. You could definitely do better and the market will reward you for it.

And if you’re Cerner, congratulations! You bought Bridge Medical and their bedside verification technology just at the right time and announced plans for your own line of medication distribution cabinets. You’ve got a widely installed customer base that wanted closed loop meds. If you don’t mess it up, you could build a huge business on the other half of the loop, the one that isn’t closed. I guarantee that, too.

But for goodness sake, let’s all agree not to dawdle. Too many parents will already know the sorrow of celebrating their baby’s first birthday in a cemetery.

News 10/14/11

Top News

Forbes lists the 25 highest paid corporate CEOs in the Unites States. Leading them all: McKesson’s John Hammergren, with single-year compensation of $131.2 million. Forbes helpfully points out that “ObamaCare could end up helping three of the top-10 improve their lot in years to come … Hammergren won’t have to worry about waiting in line to see a doctor.”

Reader Comments

From MoreOutTheDoor: “Re: Dell Services. Two more Perot vets gone from the healthcare group, Jack Evans in the summer and now Dave Marchand. Both had significant leadership roles and were well respected.” Unverified.

From Lead Pipe: “Re: article comment. I commented on an article with a link to my company. It did not appear.” I delete comments that (a) pitch a product or company (that’s not fair to paying sponsors or to readers), or (b) pitch an site or publication that accepts advertising (that means they compete with HIStalk, which is fine, but it’s not my job to promote them.) Sometimes if the comment has value, I’ll just remove the pitch part.

From CMIO/CIO: “Re: Cerner Health Conference. As a 13-year veteran, neither I or my associates attend for the breakfast, unlike FastChange. This has been one of the best CHCs with leading edge differentiators coming to general availability like NLP (nCode) and semantic search. Great networking with not only US clients, but ever-increasing global client base.”

From Shippy: “Re: Cerner conference. Although the comments by FastChange are not incorrect, they could be counterbalanced with the fact that Cerner at least has a vision and passion in the right direction Also, half the problems that Cerner clients are having are not a result of Cerner and its products, but with IT management teams  that understaff projects and still don’t really understand what doctors do.”

From North Dallas Forty: "Re: Nemours. Sent a letter to employees this week stating that computer backup tapes from 2004 were taken from a locked storage cabinet. The tapes include personal information that includes bank account information. I wonder if anyone has been reprimanded?” Verified. Like most organizations that have been breached, Nemours is belatedly passionate about security practices, publicly vowing to start encrypting backups and to store tapes securely offsite.

From Lindy: “Re: University of Virginia Medical Center. CIO left a few weeks back after a semi-successful Epic install. Docs were starting to complain.” Unverified.

From Confused Friend: “Re: Epic. A friend works for an Epic customer and wants to get into consulting, but was told by the company she talked to that they have a 90-day non-compete for customers who are currently installing. She insinuated this was being pushed by Epic. Odd given that the customer went live more than a year ago on her particular product. I’m a former Epic employee and that’s the first I’ve heard of this. Is Epic instituting new policies for consulting firms?” I’ve long since stopped trying to make sense  of Epic’s non-compete policy, so I’ll open it up to anyone who knows its latest flavor.

From Hospital Geek: “Re: [health system name omitted.] We started an ambulatory rollout of Epic about six months ago that would have covered 600 physicians. The project was cancelled a couple of weeks ago.” I omitted the health system’s name because, frankly, I don’t think this is true. If it is, send over some non-anonymous proof and I’ll be happy to name names.

From Too Big to Fire: “Re: Microsoft. Elite developers from an EHR vendor have received 80%+ discounts at the fabled Company Store when visiting Microsoft’s campus. Customers are now required to purchase more Microsoft products. A vendor that allows this practice should disclose those discounts to customers.” I don’t understand what it is that customers are being required to purchase or what the vendor would disclose, so I don’t really have a reaction.

HIStalk Announcements and Requests

This week on HIStalk Practice: athenahealth and Cook Children’s Health Care introduce technology to integrate 2D vaccine barcode data with athenaclinicals. Seventy percent of hospitals and health systems plan will hire more physicians over the next 12-18 months. Phytel wins a contract with Lehigh Valley Health Network’s physician group. eClinicalWorks takes the top stop on the Worcester Business Journal’s list of top-growing private regional companies. Jonathan Bush goes to DC and shares his thoughts on the flaws of EMR attestation. And coming up next week: HIStalk’s Must-See Vendors for MGMA 2011 since I’m heading to Vegas in about 10 days and will be sharing updates on speakers, educational sessions, exhibits, parties, and of course, fashion. Sign up for e-mail updates so you don’t miss a thing.

I’m back from a short, Internet-free vacation in which I interacted with Mrs. HIStalk rather than e-mail. I was apparently one of few: it seemed that many folks around us were too focused on their smart phones to actually look up at either the person they were with or the rather picturesque surroundings. We sat adjacent to a young couple in a restaurant as the male half of the couple endlessly flicked his phone (while eating — he obviously required multi-modal sustenance) to see if any of his fake friends had posted something on Facebook to which he needed to be made immediately aware, while his real-life female partner sat completely ignored (I tried not to draw inferences about how he might correspondingly conduct his romantic overtures.) Maybe I should have followed his model — I’m hopelessly behind on e-mail and general HIStalk tasks to the point I should have just stayed home, not to mention trying to catch up on my hospital job.

I’ve observed, too, that with everybody running around with smart phones and poking at them constantly as though they suffer from an involuntary nervous tic, everybody expects e-mail conversations to be conducted like instant messaging. If you don’t reply quickly (because you’ve turned the darned device off, it’s late at night or into the weekend, or you just don’t have the time, like my trying to prioritize 300 or so e-mails), they send the message again. Not only are people going to die having spent most of their waking hours staring at their phones as though they were crystal balls emitting the secrets of the universe, they won’t even realize they are dearly departed until someone posts a Facebook update.

Inga ran things just fine in my absence, I notice with satisfaction. I get swamped pretty easily since I’m the single point for almost everything (I obviously don’t scale well,) but Inga jumps in where she can on the rare occasions I reluctantly cede temporary control. As for me, I’m already overwhelmed and exhausted anew.

Speaking of BlackBerry, I’m struggling to decide: which company is going to die first of executive incompetence, RIM or Netflix?

Listening: Kingdom Come, a 90s hair band that sounded a whole lot like early Led Zeppelin, which as good as they occasionally were, led (no pun intended) them to be considered a Zep ripoff (“Kingdom Clone,” the wags called them.) I remembered them only because I read a fascinating biography of long-dead Led Zeppelin manager Peter Grant while on vacation (I found it by the pool towel hut) and he said Kingdom Come was terrible. I never was a Zeppelin fan, so Kingdom Come sounds fine to me.

On the sponsor-only Jobs Board:  HL7 Interface Developer, RVP Sales – Western Territory, Front End Engineer, Physician Consultant – Sales Support. On Healthcare IT Jobs:  Manager of Clinical Information Systems, Solutions Sales Executive, Pharmacy Informatics Analyst, Epic Ambulatory Lead Trainer and Trainer.

Thanks to World Wide Technology, Inc., supporting HIStalk as a Platinum Sponsor. The St. Louis-based systems integrator, which has been around since 1990 and has $3.3 billion in annual revenue, offers healthcare-specific services that include patient identification, temperature and humidity monitoring, privacy and security, point-of-care communication and collaboration, IT infrastructure, staff and asset visibility, and services specifically for Cisco TelePresence (they sell a billion dollars’ worth of Cisco products each year.) I notice that the company was named on Thursday to the InformationWeek 500 for the first time, so that’s a pretty big deal. WWT has sales offices around the world and engineers in most US cities, making them easy to find. Thanks to World Wide Technology for supporting HIStalk. I’m a bit in awe when a company that size (or any size, for that matter) steps forward to help me with what I do, as offbeat as that sometimes is.

Acquisitions, Funding, Business, and Stock

Infosys says it is not in discussions for the acquisition of the healthcare business of Thomson Reuters despite earlier media reports (including a mention in HIStalk.) That could mean that those reports were incorrect, but also potentially only premature.

Mobile developer Remedy Systems and physician marketer Physicians Interactive form Tomorrow Networks, a healthcare-only mobile advertising network for app developers that can “tie advertisements to healthcare data points that include ICD-9 codes, CPT codes, and healthcare professional (HCP) specific information.”

Sales

Orlando Health chooses Brainware for document processing.

People

Debbie Ruggles, RN, is named clinical informatics manager of Providence Medical Center and Saint John Hospital (KS), tasked with overseeing the hospitals’ implementation of Epic.

LodgeNet Healthcare hires Sachin H. Jain, MD, MBA, as senior medical advisor. He was previously Don Berwick’s senior advisor at CMS and a special assistant to former ONC head David Blumenthal.

VistA guru Tom Munnecke decides to un-retire and get back into health informatics consulting. An interesting new post from his blog: he wrote a book called The Friendly Computer in 1980 that gave Commodore’s president the idea to call their computer the Amiga, and more impressively, pitched the idea of the “Intelligent Telephone” in 1977 – to none other than Steve Jobs.

Announcements and Implementations

Cardiology Associates of North Mississippi implements White Plume Technology’s AccelaSMART charge capture and medical coding review technology to pass charges between its GE Centricity EHR and athenahealth practice management system.

Ohio State University Medical Center announces plans to double its telestroke technology capabilities using technology from REACH Health.

Thomson Reuters releases Infection Xpert, a clinical intelligence dashboard to improve infection prevention workflow.

Shareable Ink earns 2011/2012 EHR Modular ONC/ATCB Certification. Said Founder, President, and CEO Steve Hau, “It’s the first time you can get Meaningful Use with pen and paper.”

Barnes-Jewish Hospital (MO) launches a mobile app to reduce appointment no-shows.

Premier partners with Encore Health Resources to create an HIT implementation roadmap for organizations moving toward an ACO-type model of integrated, coordinated care. It will be based on Encore’s CoreQUEST and CoreGPS tools.

Government and Politics

The Center for Public Integrity, through its iWatch News publication, tries to stir up some HITECH controversy in its report on EHR stimulus payments. The authors question why long-term EHR users are getting incentive checks if the the goal was new adoption. A representative for Senator (and obstetrician) Tom Coburn is quoted:

If providers have been paid for systems they already had in place, that seems to be an inexcusable waste of taxpayer dollars. It makes no sense for HHS to pay physicians for systems they already have.

I have to side with HIStalk contributor Dr. Lyle Berkowitz who, in the same article, points out that achieving Meaningful Use is not a slam dunk, and paying providers for “doing the right thing before there were even rewards to do so is actually not a bad message to send.”

Senator Chuck Grassley wants to know who authorized the shutdown of HHS’s National Practitioner Data Bank, established in 1986 to confidentially track physician malpractice and disciplinary cases. The reason: a Kansas City reporter was able to identify a Kansas neurosurgeon even though the publicly accessible data was supposed to be de-identified. HHS says the information wasn’t intended for the public to see in the first place, but says they’ll still put it back online “as soon as possible.” Two facts stand out: (a) there’s no such thing as truly “de-identified” information, assuming someone has the resources and motivation to match up multiple public data sources; and (b) Chuck Grassley writes a lot of indignant and demanding letters that never seem to amount to anything except get him mentioned in the press (no offense, Chuck, I’m a big fan, but follow-through is everything.)

The VA is testing an iPad-based portal to its electronic medical records called the iHealth adaptor.

Technology

Cerner announces its Skybox on-demand storage service offering, an enterprise-wide cloud storage system powered by Nirvanix Private Cloud Storage that allows customers to consolidate their storage of clinically related data objects under a usage-based pricing model.

Other

From KLAS: since Virtual Radiologic’s purchase of telaradiology provider NightHawk last year, NightHawk customers are reporting challenges with turnaround times and the transition to vRad’s technology and up to half of those customers are seeking alternatives. vRad’s performance scores have also slipped.

Meanwhile, KLAS provides a less-than-glowing report on Meditech’s v6 in unusually blunt terms, saying Meditech’s products are generally less functional but cheaper than those of competitors, and even though 6.0 is “half-baked and more expensive,” it’s still cheaper than those competing products and therefore “worth the pain to make it work for them.” KLAS concludes that customer satisfaction depends on their expectations.

Here’s Vince’s latest HIStory, this time covering JS/Data in the first of a two-parter. He’s finding that veterans of these long-gone companies still speak fondly and happily about their experiences and the people they knew there. Sometimes I wonder if it will be the same positive feelings down the line for today’s rookies, for whom HIT was already a big business by the time they came on board.

HIT service provider Anthelio will hire 200 people in Michigan, mostly medical insurance billers and coders. The company is building a 50,000 square foot Center of Excellence in between Detroit and Flint.

Dennis Ritchie, who created the C programming language and co-developed UNIX, died Wednesday at 70 of prostate cancer.

Shareable Ink CEO Steve Hau tells a group of Nashville executives that he is not yet convinced the region offers a critical mass of superior engineering talent. He moved from Boston to Nashville last year to capitalize on Nashville’s healthcare industry concentration.

Healthcare Growth Partners releases its Q3 merger and acquisition review. Trends they’ve spotted: non-traditional vendors are entering the market, ACO activity is motivating investment in systems such as analytics, hospital best-of-breed solutions are struggling against enterprise vendors, and vendors are seeking growth financing rather than selling out.

Somebody just posted this video tour of the famous Epic treehouse.

Epic is awarded a patent for GUI method called a “dynamic order composer” of entering patient orders using a pre-populated order entry form. It sounds like it suggests orders based on patient information and popularity.

Doctors in China are striking over being physically attacked by the family members of patients. One orthopedist says doctors are a disadvantaged group since “we have spent so much of our youth on a medical degree that yields so little economic reward.” Ninety-six percent of doctors there say they are unhappy with their salaries, which average just 19% higher than those of factory workers.

An employee of a Baltimore law firm loses a portable hard drive containing the medical records of 161 cardiac stent patients who are suing a local cardiologist. The company explained that its employee was taking the information home on an unencrypted drive as a precaution against loss, but forgot it on the light rail. The law firm offered patients a one-year membership in an identity theft service in a letter mailed to patients two months after the breach, saying it was on “behalf of St. Joseph Medical Center,” the hospital at which the cardiologist formerly practiced. The law firm’s own site doesn’t mention the event at all as far as I can tell.

Weird News Andy finds this story fascinating, especially the last line. Two pregnant women get into a fight with two other women in a Philadelphia hospital room, with one of the moms-to-be slashing the two non-pregnant ones with a knife. All were visiting “a male patient who is recovering from a gunshot wound.”

Sponsor Updates

• Billian’s HealthDATA launches Better Business by 2012, a blog series for healthcare vendor sales and marketing teams. The company is also offering an October 19 Webinar on clinical informatics featuring Michele Burke RN, clinical transformation manager with North Shore Long Island Jewish Health System, who will talk about EMR implementation.
• CynergisTek CEO Mac McMillan will discuss security challenges and best practices for long-term care at this weekend’s 2011 Leading Age and IAHSA Global Aging Conference in DC.
• Peer Consulting enters into a Provider Consulting Organization agreement with CapSite for its Hospital Purchasing Database solution.
• Palestine Regional Medical Center (TX) selects ProVation Medical Software for its gastroenterology procedure documentation and coding.
• Our Lady of the Lake Regional Medical Center and Our Lady of the Lake Children’s Hospital (LA) implement GetWellNetwork’s interactive patient care solution.
• Allscripts deploys the IXIASOFT DITA CMS DITA to manage its documentation process.
• Ysbyty Ystrad Fawr, a new hospital opening in December in Wales, will feature the use of Vocera’s communication system.
• The MedAssets Bundled Payment Solution earns PROMETHEUS Payment-ready certification from the Health Care Incentives Improvement Institute.

EPtalk by Dr. Jayne

A few weeks ago, I complained about having to fill out paper credentialing forms. Today I received my hospital’s proposed updates to the Medical Staff Bylaws. Under the section addressing allied health professionals (nurse practitioners and physician assistants), there are several revisions that pertain to electronic submission of data for paperless credentialing. Let’s hope it doesn’t only apply to them but to the physicians as well.

HIMSS has announced the lineup of keynote speakers for the 2012 Annual HIMSS Conference & Exhibition. Biz Stone, co-founder of Twitter, leads off on Tuesday, followed by National Coordinator for Health Information Technology Farzad Mostashari on Thursday. Friday closes out with political strategist Donna Brazile, former White House press secretary Dana Perino, and Blue Zones founder Dan Buettner. I’m not that excited about HIMSS in general, but I do rather fancy Mr. Mostashari in his dapper bow tie.

Friday is the last day for the HIMSS 2011 Annual Award nominations. As an anonymous pseudo-celebrity, I’ll never qualify for one of these and I’m not sure how relevant they really are. Frankly, the HISsies are the only awards I really follow.

The Washington Post reports on data indicating that our bacterial friends actually help keep us healthy. Researchers cite both antibiotics and an obsession with cleanliness as causing potential imbalance in the microbial universe, contributing to asthma, allergies, obesity, diabetes, and other conditions. I guess the “Three Second Rule” for edibles that hit the floor may not be as bad for the average college student as we once thought.

Inga beat me to the punch reporting on a recent study that concluded that high chocolate consumption is associated with a lower risk of stroke. Dark chocolate (my personal fave) is also thought to raise HDL (good cholesterol) as well as lower LDL (bad cholesterol) and blood pressure. Although an apple a day gets all the publicity, I’m going to start a “Truffle a Day” campaign.

Field correspondent Martini McBride reported in from the AHIMA opening reception in Salt Lake City. The QuadraMed booth featured both ICD-10 and ICD-9 cocktails. The word is that the ICD-10 version was much better and the light-up glasses were also fun. Let’s hope the real ICD-10 is also smooth and refreshing. I have readers promising to send updates from McKesson and other exciting get-togethers, so stay tuned.

Contacts

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

News 10/12/11

Top News

At this week’s Cerner Health Conference, Cerner CEO Neal Patterson tells 10,000 attendees that Meaningful Use is creating a “duopoly” in healthcare IT and that healthcare will fundamentally change over the next  decade. Patterson also unveiled plans for cloud technology that will coordinate clinical data from multiple systems and use Cerner search and analytics tools to evaluate and manage health.

Reader Comments

From HomeBody “Re: Homecare technology. Homecare technology is definitely an up and coming topic of interest among healthcare today, especially on the hospital side. I see it only becoming a more and more important piece of this proposed continuum of care model.” Thanks for all the comments in favor of increased coverage on homecare, assisted living, and long term care IT. Mr. H and I will strategize a bit more. Meanwhile, if you happen to be an expert willing to share your expertise, let us know.

From FastChange “Cerner Health Conference. Ughhh. Painful!  No breakfast, too crowded because facility is too small, making us  get scanned for every session- causing huge lines of course. No consistency in their Solutions Gallery- lots of vaporware from various groups competing with each other and they are still 1-2 years behind other vendors in things like mobile and ACO type software. Ten thousand people here but that includes Cerner staff, which appear to be every other person I meet. Haven’t met a happy Cerner client yet. But the keynote speaker, blogger and doctor Wendy Sue Swenson (Seattle Mama Doc) was great.” Other than that Mrs. Lincoln, how was the play? I should add that despite FastChange’s less than glowing report, I noted many very positive comments posted on Twitter (#CHC11).

HIStalk Announcements and Requests

Mr. H is on one of his well-deserved Internet-less get-aways, so it’s all me today.  Whenever Mr. H leaves me in charge, I feel Alexander Haigish, in that I’m-in-control-even-though-I’m-really-not kind of way. Mr. H will return to power soon.

Thank you to all my Facebook friends who sent over birthday greetings. If you would like the opportunity to make me feel special next year, it’s not too soon to Friend me (and Mr. H and Dr. Jayne) or like HIStalk on Facebook. We are also happy to connect with you on Linked In, should you would prefer to keep our relationship on a more professional level.

Acquisitions, Funding, Business, and Stock

VC funding in HIT more than tripled in the third quarter, compared to a year ago. Fifty different organizations invested $207 million for 17 deals, which included ZocDoc ($75 million) and Awarepoint ($27 million.) M&A transactions totaled $4.7 billion for acquisitions that included Emdeon ($3 billion), Sage Healthcare ($320 million), and M*Modal ($130 million.)

Sales

Surgical Care Affiliates chooses workforce management solutions from Kronos.

SIU HealthCare (IL), a network five hospitals and 43 clinics,  selects GE Healthcare’s Centricity Business to compliment its existing Centricity EHR.

People

Medsphere Systems hires John Bright as VP of sales and marketing. Bright previously led sales for Henry Schein Medical Systems.

Virtual Radiologic names Jim Tierney SVP of Operations for vRad Radiology Alliance. Tierney was formerly CEO for the 62-physician Suburban Radiologic Consultants.

Allscripts and IDX veteran Todd Young joins PureWellness as COO.

Announcements and Implementations

The Community Health Information Collaborative’s HIE Bridge connects to the VA to exchange veteran health data via the ApeniMED NHIN platform.

Kettering Health Network (OH) completes its four month, enterprise-wide transition to the InterSystems Ensemble platform.

Local boy scouts and other community members helped create a festive atmosphere during Chelsea Community Hospital’s (MI) $12 million transition to Genesis System EHR.

The local paper profiles Lakeland Regional Medical Center (FL) and its go-live on Cerner’s EHR. I was slightly amused that the hospital’s chaplain was the first person quoted about the transition, saying, “We’ve been circulating on our patient units and they’re feeling confident. It’s exciting.” I never realized that hospital chaplains were active participants in EHR implementations, but then again I have never worked in a hospital.

CPSI customer Morton County Health System (KS) becomes the first hospital in Kansas to receive payment from Medicare for its meaningful use of EMR.

Government and Politics

Illinois Governor Patrick Quinn announces that the state’s Office of Health Information Technology selected InterSystems to develop the infrastructure for the Illinois HIE.

Innovation and Research

In addition to the meta data cloud project, Cerner hints at future products that optimize iPhone and iPad technology, as well as software that incorporates voice commands.

Other

Florida Hospital places a newspaper advertisement in the Orlando paper notifying patients of improperly accessed patient information. The “Public Notice” informs patients that between January 1, 2010 and August 15, 2011, three employees, who have since been fired, were believed to have accessed patients’ demographic data. The employees targeted ER patients involved in car accidents and passed the information on to an attorney-referral service. The hospital is offering credit monitoring to patients that might have been affected.

Best news of the day: Swedish scientists find that eating chocolate – preferably dark – can reduce a woman’s risk of stroke by 20%. Other benefits include reduced blood pressure, lower insulin resistance, and less crabbiness (ok, that last one conclusion was based strictly on my own personal research.)

Sponsor Updates

• Edge Solutions partners with BridgeHead Software to resell and deliver Bridgehead’s backup, recovery, and archiving solutions.
• At this month’s MGMA meeting in Las Vegas, MED3OOO will showcase its newly released InteGreat EHR, which now includes end-to-end integration with the MEDCIN Engine.
• T-System Inc. will highlight its products in a “virtual ED” at this week’s ACEP Scientific Assembly. T-System will also host the next Board Certification for Emergency Nursing meeting October 17-18 in its Dallas headquarters.
• Greenville Hospital System University Medical Center goes live with Holon’s Pharmacy Workflow Manager at all 11 of its pharmacies.
• Besler Consulting’s Vicente Farina shares insight into Direct Graduate Medical Education (GME) and Indirect Medical Education (IME) payments, two types of Medicare payments specifically for teaching hospitals.
• EDIMS is exhibiting at this week’s ACEP 2011 Scientific Assembly in San Francisco.
• Wellsoft announces its fall conference schedule, which includes the 2011 ACEP Scientific Assembly, the Emergency Department Administration Conference (EDAC), and HealthAchieve.
• Surgical Information Systems (SIS) announces that SIS Anesthesia V5 has received ONC-ATCB certification by the Drummond Group.
• Practice Fusion will simulcast its November 11th Connect 2011 meeting.
• Imprivata earns a Strong Positive rating  in Gartner’s report, MarketScope for Enterprise Single Sign-on.
• The local paper highlights Hasbro Children’s Hospital’s (RI)use of the GetWellNetwork.
• Intelligent Medical Objects is participating in the Cerner 2011 Health Conference, AMIA, and NextGen’s User Group meeting.
• Healthwise will participate in this month’s Patient Centered Primary Care Collaborative in Washington, DC.
• Ignis Systems releases its EMR-Link Maintenance Training Webinar schedule.
• Greenway’s PrimeSuite EHR achieves CCHIT certification in Women’s Health.

Contacts

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

Curbside Consult with Dr. Jayne 10/11/11

The bean counters in my organization are all abuzz about how we might be able to mimic the financial results of the Medicare Physician Group Practice Demonstration project. For those of you who may have been living under a pay-for-performance rock, the PGP Demonstration was the first Medicare P4P initiative and dates back to legislation passed back over a decade ago.

The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 authorized this project to encourage coordination of Medicare Part A (hospital) and Medicare Part B (outpatient) services; to promote efficient and effective care through care management and process redesign; and to reward physicians for improving health outcomes.

The five year demonstration project involved ten physician groups (approximately 5,000 physicians) who continued to be paid regular Medicare rates but also earned performance payments of up to 80% of the amount saved. The other 20% savings was kept by the Medicare Trust Fund. (Hopefully, they put that savings in the proverbial Lock Box, but I doubt it.)

Over the life of the program, quality measures were factored in and by year five, 50% of the performance payments were based on cost efficiency and 50% on quality. The 220,000 Medicare beneficiaries involved (aka patients) were tagged to a participating group “if the group provided the plurality of their office or other outpatient evaluation & management services during the performance year.” Patients averaged five visits at the group during the year.

Spending was risk-adjusted and quality was measured based on 32 indicators, starting with diabetes and adding heart failure, coronary artery disease, hypertension, and cancer screening. Groups were scored against national benchmarks and the measures were developed by CMS in conjunction with various well-respected quality organizations.

Over the life of the project, payments have varied. In performance year one, two groups shared $7.3 million. The next year four groups shared $13.8 million. Years three and four both had five groups receiving payments – $25.3 million and $31.7 million respectively. Year five had four groups sharing $29.4 million in payments.

It’s not just about the money though – the groups have also demonstrated increases in quality that should translate to increases in quality of life for the patients involved. In year five, all ten groups reached benchmark levels on at least 30 of the 32 measures with seven groups hitting them all.

Each group was able to design their own mechanism to drive towards desired outcomes. Strategies included:

• Packing as much evidence-based care as they could into each patient visit
• Protocol-driven medication management
• Increased patient education
• Streamlining transitions of care
• Leveraging technology such as automated outreach, registries, and scheduling as well as EHR

So why are the financial folks excited? They read blurbs in email blasts or in fluff journals (or possibly on cutting edge, thoughtful, and sassy websites like HIStalk) and say to themselves, “Hey, I’m sure we can do that too!” If only it were that easy.

Glassy-eyed by the thoughts of millions coming in the door, they forget that out of 50 possible group-year payment opportunities, only 20 have resulted in an incentive payment. That’s one in five. Would those same money-crunchers invest in a new diagnostic device that only had a one in five chance of breaking even?

I’d like to see data on how much these health systems spent trying to hit the benchmarks needed to achieve the quality measures. And for those who didn’t receive incentive payments, how close were they? Were there wide gaps, or in the words of Maxwell Smart did they miss it by “that much?”

Those looking to mimic these outcomes also should note that the up-front costs for this program were borne by the participants. Although they may have been able to use grant money or other funding sources, there was no pot of gold at the beginning of the rainbow. There had to be substantial organizational commitment to these projects and the willingness to take a loss and continue pressing forward.

Transforming the way we deliver care is definitely a marathon, not a sprint. Organizations need to commit to being in it for the long haul. They can’t be in it in a flavor of the month way, which we see all too frequently. Participants need to be sure they’re willing to go all-in not only financially but philosophically. The faint of heart need not apply – groups with a history of shuffling leadership every time a loss appears will have a hard time stabilizing. Groups with a history of cutting ‘expensive’ staff (aka nurses) will struggle.

Leadership needs to be supportive of the initiative at every juncture – even if it means finally dealing with those difficult physicians who refuse to use the EHR properly, antagonize the care coordinators, or fail to comply with order sets and evidence-based protocols. Substantial technology investments need to be pursued despite lack of short-term ROI. IT staff who can interact with clinicians, understand their needs, and deliver support models that work will be in high demand.

The groups participating in this project already had well-seasoned structures for looking at issues of quality, cost, and access and were able to engage and energize these teams to move forward in a coordinated fashion. They weren’t acting on a whim. They had clear priorities and direction and strategically reduced barriers to achieving that mission.

Unfortunately, I see far too many groups and providers at both the macro and micro level motivated to go after the money without understanding the hard work and resources (financial and other) needed to succeed. They also fail to understand the time it takes to properly implement programs on this scale. For those of you working in organizations like these, you have my sympathy. For those of you on the other end of the spectrum who have dynamic, engaged, and visionary leaders, you have my admiration.

E-mail Dr. Jayne.