News 2/6/09

From The Watchman: "Re: Epic. I hear that Judy Faulkner is telling newly signed clients to not use consultants, sending her own instead. Word is she was out at Dartmouth and at NYU saying the same thing."

From Carpluv: "Re: HITECH. If my practice is on a Stark-sponsored hospital ASP, will we still get the stimulus that totals $41,000?"

Inga worked hard to interview Glen Tullman of Allscripts in the pre-dawn hours this morning, so look for that to follow. I’ve given her the night off as her Employee of the Month award, so I’m solo-posting this time.

TEPR non-attendance and this should be scaring the bejeebers out of HIMSS: GE Healthcare cancels its August User Summit, citing customer travel cutbacks.

Community Medical Center (PA) signs for SIS.

TPD mentioned IPv6, the solution to running out of IP addresses worldwide. Here’s an article about it, co-authored by a VP from Stratus Technologies, an HIStalk sponsor.

This is odd but probably a good idea: Cincinnati Children’s Hospital offers employees a class in minimizing their foreign accents to sound more American. A bit steep at $2,300 considering the hospital benefits as well as the employee, but it’s still cool.

Listening: brand new The Red Jumpsuit Apparatus, melodic hard rock. Failure to air-drum is not an option. Also: A Cursive Memory.

Jobs: Epic Resolute Professional Billing Consultant; PMO Eclipsys, Cerner, or Epic; Team Lead, Load and Performance.

Rotherham NHS bails out of NPfIT to bid its own EMR contract, unwilling to wait for Lorenzo to be ready. They will issue their award shortly in a deal expected to exceed $50 million.

IBM announces software that will transfer medical device data into a PHR. IBM says it built the product following Continua’s guidelines. That’s kind of interesting, assuming doctors will find it convenient to get the information from the PHR. Since most of them wouldn’t have access to home monitoring data otherwise, maybe they’ll use it.

Terry Ragon, founder of InterSystems and co-founder of the former IDX, donates $100 million to Mass General with the goal of developing an AIDS vaccine within ten years. He’s also convinced several scientists to join up with the new institute bearing his name instead of working in their individual silos. All the money spent on Cache’ licenses and maintenance fees by users of MEDITECH, Epic, and a bunch more HIT vendors will at least go back to a worthy healthcare cause. That’s an amazing gift.

Inside Healthcare Computing has opened up its new Electronic Library, an archive of articles from that newsletter and its HIS Insider acquisition that’s available to everyone. Full articles are available from 2007 back, with more being added regularly. And while other publications and sites are awash in self-important policy analyses and spouting ivory tower eggheads, my guest contribution to the newsletter this week is My Lifelong Clock-Puncher’s Entrepreneurial Brainstorm: How the HIStalk Home Shopping Channel Will Make Me Rich. Don’t say I didn’t at least try to squelch the gloom and doom.

Sad: an elderly man injured in a traffic accident in Japan dies after being turned down by 14 EDs called by paramedics, reflecting lack of capacity in Japan’s hospital system. That’s not the record, though: one woman got shut out 49 times in Tokyo.

A UCLA photonics research group modifies a cheap cell phone with around $50 worth of parts to create a mobile lab for certain tests, such as CD4 or hematology. The device counts microparticles using a UCLA algorithm that’s 90% accurate. A biochemistry professor says, "What makes it quite valuable is that it is small and inexpensive. It’s also the scientific proof of a principle in its very early stages. Once the group puts more and more work into it there are going to be a huge number of applications that are going to come out."

Heart Imaging Technologies of Durham, NC, which makes the "100% client-free PACS" WebPAX system, announces a free Web site for patients to upload and share diagnostic-quality DICOM images. It allows anonymizing the images, has some PACS-like viewing tools, and provides discussion tools for each image in a kind of social networking wraparound to medical images. I’m not exactly sure how patients will use it, but it’s available for research and educational use as well.

Hospital layoffs: St. Clare (WI), 25; Santa Rosa Memorial Hospital (CA), 152; Petaluma Valley Hospital (CA), 30; Swedish Medical Center (WA), 200; Niagara Health System (ON), 90.

Speaking of St. Clare, notice the ironic juxtaposition of the layoff story right by their paid recruiting ad. 

A former employee of Bon Secours DePaul Medical Center (VA) is sentenced to a year in jail for using patient information from the hospital’s computer system to apply for loans in their names, then stealing the loan checks from the mail.

Red Hat announces a call for papers for its Red Hat Summit in Chicago, September 1-4. Papers are due March 9.

Idiotic lawsuit: a golfer’s ball ricochets off a yardage marker on the course, hitting his eye hard enough to cause a permanent loss of sight. He’s suing the golf course, saying the owners should have warned him about the markers. "It’s not a frivolous, run-it-up-the-flagpole-and-see-who-salutes kind of thing," his lawyer assures.

E-mail me.

Readers Write 2/5/09

Submit your article of up to 500 words in length, subject to editing for clarity and brevity. I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Recession Creates Opportunities for Niche Healthcare IT Vendors
By Alan Portela, COO, CliniComp Intl.

Admittedly, I’m typically a “glass half empty” person, but even I have to acknowledge that the economic recession has produced much-needed changes in the power balance between healthcare IT vendors and healthcare providers. With plummeting healthcare IT budgets, providers can now demand that vendors put some “skin in the game” to ensure that tangible performance goals and promised savings are obtained.

The evidence of scalped healthcare IT budgets is widespread. In a November 2008 survey from The College of Healthcare Information Management Executives, National Alliance for Health Information Technology and AHA Solutions, Inc., results indicated that 57 percent of the CFOs are delaying IT purchases. Even existing initiatives have been impacted, with 52 percent of CFOs deferring or extending those project implementation time frames.

Is there any light at the end of the economic doom and gloom tunnel? Yes, with niche technologies. Even as healthcare networks cancel their plans to replace EMRs, they are maintaining their original time frames for automating niche areas, such as high acuity, due to the immense impact that area has on IT budgets, patient safety, and quality care. The irony of our current situation is that we were at this exact point just prior to the Y2K disaster that set the industry back ten years when companies re-installed core systems that lacked strong clinical modules. It appears that the recession has kept us from making the same mistake all over again.

In reaction to the decreasing sales of EMRs, many large HIT vendors are evaluating partnerships with niche vendors rather than investing the time and financial resources to build the niche applications in-house. Thus, the traditional competition between the Samsons and Goliaths of healthcare IT is starting to morph into a mutually beneficial relationship. But the true winners in this battle are healthcare providers, who are now empowered to improve specific areas or functions within their existing infrastructure without having to replace (once again) their main HIT vendors. In essence, the HIT vendor solutions have become the platform that interoperates with new niche technologies in areas such as intensive care, labor and delivery, ED, etc.

Niche vendors will also have to adapt to these turbulent times by improving their ability to integrate seamlessly with HIT vendors, as well as changing their pricing models to reflect a risk-sharing, transaction-based model. This new model ties payment to performance on metrics such as decreased average length of stay, improved staff efficiency and retention, reduced costs, and other clinical improvements.

Aligning stakeholder objectives is a best practice throughout all major industries. It’s about time that healthcare got on the Machiavellian self-interest bandwagon.

Comments on the HIStalk Practice Interview with Garrison Bliss, MD
By RegularDoc

I can understand why Dr. Bliss is pleased with his practice model — he can see less patients and make more money. But please, let’s not sugarcoat this. He is doing a VIP/Concierge model of care that helps him and a few patients, but hurts the healthcare system as a whole.

You are not doing "the right thing." You are doing "the easy thing," and some would say "the greedy thing" — taking advantage of your loyal patients who are being told they can’t see you anymore unless they pay an extra fee. They still need their regular insurance for any test you order, any specialist they see, or if they go to the ER or get admitted. 

With that said, your costs for "easy access to your docs" are a bit less than other VIP services (you charge $600-1500 a year, where the national average is closer often $2000 a year), but it is not cheap for a lot of people. And indeed, part of your plan is to cut the patient volume you have, likely from around 2500 patients to 500 (which would net you almost $500K a year before you even saw a patient!) 

In other words, you will have more time for those 500 patients, but you have screwed those other 2000 patients, who now have to go find another doctor. And guess what — there are not that many around! 

So, in one fell swoop, you have both increased the demand for PCP care and cut the supply. How can you feel good about that? Also, when you start seeing a lot less patients, you will find that your skills are in decline, not exactly what your patients are paying you for.

With that said, I agree there is a reimbursement problem, but we docs have other options. You could have charged just $50 or $100 a year per patient. Even if only half your patients paid that, you still make a nice little profit that can help pay for EMRs and extra services like medical home. You can get an NP or similar to help with patient overload, etc.  But please, figure out a way to take care of ALL your patients, not a way to only take care of the wealthy ones (and don’t pretend that giving discounts to a few makes up for it).

And by the way, the more docs that do this, the more commoditized it will become and the prices will go down. So the VIP docs in your area are likely now nervous that you have already cut the price. The Seattle docs used to charge $2500 to $15,000. You cut price, someone else cuts price, and eventually you are going to be sitting there with 500 patients paying $200 a year and you will be begging your old patients to come back. But, they will have found someone who only charges $50 a year and you will have lost what it means to be a doctor — the trust and respect of your patients.

Sorry to be so tough on you, but I take a macro view of the healthcare system. These VIP practices are simply taking advantage of the system and indeed hurting it at a macro level, so at least be honest about that. No one has shown that they improve care, even for the small number of patients who can afford them. Even if they did, is it worth the cost and failure to the other patients you have abandoned? 

The 10th Anniversary of a Windows PACS
By The PACS Designer

TPD designed a PACS in the mid-90s with input from Hewlett Packard and learned a lot from that experience to move on to designing a next generation PACS. In the late 90s, the need arose for a high speed PACS that could handle 500MB or larger image files, so TPD decided to put some trust in Bill Gates’s Microsoft Windows NT and Michael Dell’s high power workstation offerings to meet this challenge. In 1999, the first Windows-based PACS was introduced to the marketplace.

It was a daunting task to confront the requirement to move 500MB files with minimal to no latency over long distances. First, we had to define the right network topology, and because Ethernet was the predominant network architecture, we decided to stay with that solution since it was deployed everywhere. Also, a major upgrade in the mid-nineties for Ethernet to 100Base-T from 10Base-T was making Ethernet more attractive for high speed communication.

Another widely used standard for external communications is Transport Control Protocol over Internet Protocol (TCP/IP) so we wanted to stick with that method of communications.

After reviewing the various storage solutions, we decided to use Fibre Channel. Two conflicting fiber communications methods had  been combined to remove uncertainty and the American National Standards Institute put out one standard called ANSI X3.230-1994. Fibre Channel could meet the need by the institution for one common communications method for high speed transmission of image files, data strings, and any other information from legacy systems. 

Using Fibre Channel with existing Ethernet networks also would present minimal problems provided that an upgrade to 100Base-T was installed prior to a high speed PACS was being deployed in the institution. The communications to outside facilities was left to the phone system’s SONET ring technology to enhance the ability to send image files the a central archive.

Also of concern to TPD was the different DICOM flavors that existed due to each vendor’s adding private attributes to their product offerings. Since it was going to be a PACS design that would be sold around the world, TPD decided to prevent the addition of private attributes to the new design, thus the design was setup to be "native DICOM" (no private attributes).

As of 2008, there are more than 3,000 of these high speed PACS installed around the world, and TPD is not aware of there ever being a system crash!

So today, if you are contemplating upgrading your current PACS, be aware that systems that make use of Fibre Channel and/or Gigabit Ethernet (1000Base-TX) or better will provide your institution with the most reliable PACS communications and also bring maximum efficiency to the care process.

In conclusion, the Windows PACS wouldn’t have been possible without the help of others, so TPD owes a debt of gratitude to a work colleague, Duke University for help with DICOM configurations, the Cleveland Clinic for supplying their expertise on a suitable storage solution, and Washington Hospital Center for their environmental design work for a PACS equipment room configuration without which TPD wouldn’t be commenting ten years later on a successful PACS design.

Comment on 1/23 Posting – Are Physician Portals Obsolete?
By Bud Leight

In response to the portals discussion, I believe many hospitals are overlooking a golden opportunity to improve operations and save labor costs. To date, most portal efforts have focused on access to hospital EMR data.  While this is a good first step, why not move forward and improve workflow and patient satisfaction by implementing more self-service tools found in every other service industry? 

By this, I mean provide a customer-based model that focuses on choice, improved workflow, and cost reduction. For example, physicians (one category of customer, the other obviously being the patient) should be provided convenient access (i.e. using the Internet) to self-schedule appointments, send orders, and take care of their tasks visa vie the revenue cycle for hospital based services. 

In doing so, portals offer the means to reduce labor costs and minimize office disruptions (i.e. make them more productive) on both sides (for the physician office and the hospital). For example, one 570-bed hospital serving the Virginia tidewater area, using centralized scheduling with a portal for physician offices, was able to double scheduling productivity from 5,000 to 10,000 appointments per FTE per year (since 2000). 

A large part of this success comes from the hospital offering their providers (whether owned or not) the choice to either call and schedule or bypass the phone and go online and book the appointment (which also fulfills the order requirements and completes medical necessity checking). This hospital portal provides EMR (data) access, but also a customer-centric approach that has driven 20% of their appointment bookings to come from the Internet. The patient benefits by avoiding telephone tag regarding appointment times, having the ability to review procedure directions (i.e.NPO) and not having any financial surprises if the procedure doesn’t pass medical necessity. 

Improving workflow through self-service is a big win financially for all concerned and goes a long way toward building brand loyalty with physicians and patients.

News 2/4/09

From At TEPR: "Re: I’m at TEPR. Attendance is way,way down. I feel sorry for the MRI, and that’s bad to feel sorry for a good organization. Might be best to pull the plug and go out with dignity, or else morph into something else."

From oneHITwonder: "Re: TEPR. Opening session — 3 hours and 15 minutes straight, four different speakers. Nothing earth-shattering in the first three, couldn’t sit there for the fourth speaker. Breakouts are organized strangely, with multiple speakers on a related topic grouped together, some talking for 20 minutes, some 25 minutes, some 30 minutes. Makes it very hard to session-hop. First two speakers in breakout were like an advertisement for particular vendors. Interesting to learn about new products, but geez. The best part of the day was the conference center fire alarm that got me out of one session that was a bit dull. Oh, and no refreshments other than water. Lunch was a brown bag with a chicken wrap and a cookie … the cookie was 631 calories…OMG! But for those of you buried under snow, it was 82 degrees here yesterday!"

From The PACS Designer: "Re: IPv6. The Internet is running out of available IP addresses and it is forecast that the 4 billion address maximum will be reached by 2011. To alleviate this problem, some of the countries outside the U.S. have already upgraded to the new Internet Protocol version 6 or IPv6. The IPv6 can handle 340 billion or more addresses, so upgrading your systems to be able to handle IPv4 and/or IPv6 will be necessary in the near future." Link. 

From RIS Guy: "Re: Agfa. As a follow-up to the report a few weeks ago about Agfa cutting sales positions, they laid off 80 people in their service and support groups. They were already threadbare."

From Tom DaschedHopes: "Re: printing HIStalk. Is it possible to have a printer-friendly button for articles?" That was apparently lost in the recent upgrade, which I hadn’t noticed. I will try re-installing it. I liked it myself.

Another Obama nanny tax washout: chief performance officer candidate Nancy Killefer, who withdrew her candidacy Tuesday for the same "distraction" reason that Daschle gave. The former Treasury Department CFO led the modernization of the IRS, but once she left office, had a tax lien placed on her home for $298 in unpaid taxes. Treasury Secretary Geithner somehow slipped by despite far more significant transgressions. 

Guess which regional healthcare therapeutic product business grosses $100 million a year, pays its CEO $500K, employs 1,000 people, and has people questioning why its board members are also its vendors? The non-profit Florida’s Blood Centers of Orlando. I suppose its tough not to make a fortune when your product cost is zero (courtesy of donors) yet sells for $300 a unit to other non-profits.

Philips creates the iPill programmable pill (technically, iCapsule) that can be directed to travel to specific parts of the body and to release its payload in specific ways. Mentioned here before, but apparently closer to reality.

An Allscripts survey finds that physician groups are overwhelmingly happy to take federal stimulus money to use toward EHR adoption. Less consensus was found in what form the payments should take — being paid to buy EHRs or being paid to use them. Two-third of doctors said they would participate in a pay-for-purchase program, and not surprisingly, practices that already have EHRs think Uncle Sam should reimburse them retroactively. Survey flaws: only 15% of the respondents were actual providers; the rest were administrative staff. EHR users made up 60% of those surveyed, far outpacing overall adoption. And, the response rate was less than four percent. That’s not a criticism of the survey, just the usual cautions about drawing conclusions from it.

London Health Sciences Centre gets a magazine mention for its Censitrac software system that tracks medical instruments in sterile processing right down to the tray and follows them through the cycle of use and preparation for re-use.

Epocrates enhances its iPhone drug reference application with a premium version that includes disease content and medical calculators.

SafeMed, the real-time analysis vendor that Google Health uses, changes its name to Anvita Health. It claims the new name (from some Sanskrit word that nobody’s ever heard of) is more reflective of the company’s expanding decision support capabilities beyond the original drug interaction checking. I’m suspecting an infringement lawsuit, but I’m reliably cynical.

Apple and Adobe are collaborating to create an acceptable version of Flash for the iPhone.

I did an HIStalk Practice interview with Garrison Bliss, MD of Qliance, a concierge-type medical practice in Seattle. I really like the concept: patients pay from $49 to $129 per month, depending on their age, whether they want family medicine vs. internal medicine coverage, and whether they prefer after-hours access to general coverage vs. a specific physician. There’s no contract required and no exclusions by health or insurance status. They use technology, although I see all the sign-up documents are PDFs that have to be mailed or faxed back. This blogger wrote a great piece summary of the model.

E-mail me.

HERtalk by Inga

From Tempid: “TEPR. Official attendance is supposedly over 700 people, but the opening session looked to have only about 200 people. A few years ago, this show drew about 2,500. But the weather is great.”

I’m feeling pretty 2.0-ish, using Twitter to follow the TEPR show. Nick van Terheyden provided some great impressions, including: “Interesting view shared @TEPR. It’s so Web 1.0…. no blog, no tweet, 1 month before presentations will be online; Google thinks PHR penetration is 2-3%; The panel format is difficult since we get 3 similar answers to each question.” Nick said he would try to give HIStalk readers a more expanded write-up. (Nick is my latest BFF because he took the time to check out my LinkedIn photo and tell me he loves it).

Speaking of Tweetering, is it appropriate to send Tweets while your wife is delivering your child? Or, while you are in the middle of getting a vasectomy? (Note to self: ask these questions before getting serious with next boyfriend).

UMass Memorial Health Care (MA) selects dbMotion to create a single, interoperable electronic patient record across various IT environments and care areas.

Yet again, Nuance Communications extends its cash offer to acquire Zi Corp. Nuance is giving the shareholders two more weeks to consider the merits of its $.40/share offer. I wonder if I’d like having a boyfriend as persistent as this?

The National Qualify Forum (NQF) names Memorial Hermann Healthcare Systems (TX) the 2009 NQF National Quality Healthcare Award winner.

Medical Records Institute announces the 2009 TEPR Award winners. The VA won first place with its MyHealtheVet PRH and the Private Access suite won in the “Hot Products" category.

HIMSS announces that registration for its annual conference is ahead of 2008 trends. Non-exhibitor attendance is up almost three percent from the same period last year.

Police take a prisoner to United Medical Center (DC) for unspecified medical treatment. The patient/prisoner is allowed to go the men’s room alone, wearing only a white shirt and boxers. Before anyone has time to miss him, he climbs through the restroom ceiling, reaches another hospital room, and escapes. The prisoner has not yet been found. The paper indicates that the police didn’t provide a description of the boxers.

Researchers develop a new application for RFID that evaluates walking patterns to detect early signs of dementia.

Quality Systems, the parent company of NextGen Healthcare, reports a 17% jump in net income in its fiscal third quarter, to $13.2 million. Revenue grew 36% to $65.5 million. The bulk of the earnings came from the NextGen division, which posted $61.5 million in revenue (up 40%) and operating income of $22.8 million (up 28%). About $7.5 million of NextGen’s revenues came from two separate practice management companies acquired last year.

Mediware Information Systems reports a Q2 profit of $303,000 ($.04/share) compared to a $337,000 loss the same period last year. Revenue was up from $8.7 million a year earlier to $10 million.

Aspen Valley Hospital (CO) signs a five-year extension to its business process outsource agreement with CSC. The original outsource agreement was with First Consulting Group in December 2005. CSC also announces a new subscription tool called HealthSpace Advisor, which enables hospitals to analyze how effectively they’re using space in key revenue-generating areas.

Logical Images names Andrea Pennington chief medical office. The company provides decision-support technology for diagnostic-imaging providers.

E-mail Inga.

Daschle Withdraws from Consideration for HHS Secretary

Tom Daschle has withdrawn from being considered as HHS secretary, citing his desire to avoid distractions over his failure to pay taxes previously owed. President Obama said, "I accept his decision with sadness and regret."

Daschle was quoted as telling a journalist this morning, "I read the New York Times this morning, and I realize that I can’t pass health care if I’m too much of a distraction."

Being John Glaser 2/3/09

An Alternative Plan for $20B

The congressional discussion around the $20B HIT investment is rapidly drawing to a close. However, there may still be time to discuss an alternative investment approach.

Rather than financial incentives for physicians and hospitals, education of HIT professionals, and other current ideas, I came up with the following.

For Healthcare Providers

There are something like 4,000,000 physicians, nurses, and other allied health professionals. For each of them, we would get:

• 3-D goggles. These goggles will improve EHR usability and hence we’re more like to see high levels of e-prescribing and other important EHR uses. I would suggest that we get high quality goggles; not the Super Bowl cheap kind. 4,000,000 providers x $30/quality goggle = $120,000,000.
• iPhone. Again, to improve ease of use and also provide some cool software (including a GPS so they know where they are in the hospital) I would get all providers an iPhone. 4,000,000 providers x $200/iPhone = $800,000,000.
• EHR baseball caps. So their patients know that they are all on the EHR team, we would get all providers an EHR baseball cap with a fancy EHR logo. 4,000,000 providers x $12/cap = $48,000,000.

For HIT Professionals

I think (without facts) that there are something like 200,000 professionals who will be involved in EHR implementation and support. For each of them, we would get:

• Oscilloscope. This will help troubleshoot EHR problems and configure the software. 200,000 professionals x $1,200/oscilloscope = $240,000,000.
• Soldering gun. They will also need a soldering gun to fix any problems they find. 200,000 professionals x $200/soldering gun = $40,000,000.
• Trinkets. All of these professionals will go to HIMSS to hear talks and see what’s what in the exhibit hall. Since we want them all to get high quality exhibit hall trinkets, I am proposing that each attendee get $1,000 worth of trinkets. 200,000 professionals x $1,000 worth of trinkets = $200,000,000.
• Infrastructure. To connect all of these EHRs, we will need an EHR satellite. 1 satellite x $1,000,000,000/satellite = $1,000,000,000.

Patients

We should do something for patients since this really is about them. I had initially thought that we’d get everyone in this country an electronic stethoscope that could be connected to the satellite, but with only $20B, we can’t afford it. 300,000,000 people in the US x $300/stethoscope = $90,000,000,000.

We have $17,552,000 left to spend. This is approximately $60/person.

Since it will take some time to launch the satellite and manufacture and distribute goggles, caps, trinkets, etc. and since we want everyone to take better care of themselves soon, I would get each person in this country:

• The AMA Family Medical Guide at $30 each
• A Deluxe Pilates Exercise CD at $30 each

And that’s the alternative plan. Some of the estimates of healthcare professionals and EHR staff may be low, but I am also sure that we could get a bulk deal on the items above and still stay within budget. We may not be able to get a deal on the satellite.

John Glaser is vice president and CIO at Partners HealthCare System. He describes himself as an "irregular regular contributor" to HIStalk.

An HIT Moment with … Andrew Kapit

An HIT Moment with ... is a quick interview with someone we find interesting. Andy Kapit is CEO of CodeRyte.

CodeRyte is successfully attracting investor interest and increasing staff, both unusual in this economic environment. What are you doing differently from those companies that are shrinking instead of growing?

CodeRyte first identified a real pain, chose the right technology to cure that pain, and then executed it in a scaleable way. Investors have learned a lot since the 1990s and the technical due diligence process during our most recent funding shows that. It wasn’t just that CodeRyte developed a powerful NLP-Computer-Assisted Coding engine — it was how we did it that has enabled us to create investor and market confidence.

CodeRyte then built a solid based of clients by working diligently to appropriately set expectations, exceed them, and then provide the highest possible level of client service. When bringing a disruptive and sticky technology to the market, it is of crucial importance to let your clients know that you will stand by it and be there for the long term.

CodeRyte developed a strategic platform that builds on itself. By automating medical coding, CodeRyte is really providing structure to the language of medicine. Every medical record that passes through the coding engine, as nearly one hundred million have, adds to the knowledge base and enables us to provide increasingly greater granularity to the structure of clinical information in the report.

We started off with radiology and pathology, the diagnostic specialties of choice. With that linguistic foundation the technology can now code across the full spectrum of medical specialties. This brings me to the final reason CodeRyte has been able to build a successful investor and customer base: the technology leverages the expertise of our users.

CodeRyte is built around several fundamental tenets, one of which is to empower the experts, to allow them to help create the intelligence of the engine and then to create the “explainability” so they can not only become comfortable with the output but also understand how the engine arrived at its answers.

The CodeRyte team combines technological brilliance with a deep and abiding understanding of the complexity of healthcare — at the macro and micro levels. Engineers working with medical coders, subject matter experts and physicians have all created something that is truly relevant to the current and future of healthcare, which is what investors look for — relevance and the ability to execute.

But that’s only the beginning. That’s what gets today’s investors to the table. Once you have satisfied the basic criteria (real market pain, strong management that can execute and a scaleable solution), then investors want a real and meaningful upside — which is where the company’s ability to describe its mission in a meaningful and value-generating way comes in.

CodeRyte fundamentally believes, along with many, that we need machine readable, interoperable, and structured output. It is only by creating that type of output healthcare can enjoy an industry architecture that successfully aligns the flow of information and money and reinforces efficient, quality care – over the long term.

What we don’t believe, however, is that we should force physicians and other allied health professionals to create that structure. Not only will it reduce the quality of our source data for research and discovery but it also disrupts physicians’ intellectual workflow. CodeRyte’s technology can already, to a limited degree, automatically structure the output — without forcing physicians to change the way they provide and document their care.

You’ve worked in executive roles for providers, investment banks, and now vendors. What is your analysis of the healthcare IT market now and what changes do you predict over the next 1-3 years?

It is not just that healthcare is broken; more importantly it is that American healthcare is not scalable. I believe that every new patient coming into the system will be more expensive than the one before. To make the necessary changes we, as an industry and country will have to commit to doing the right thing — even at the expense of the some of the entrenched processes, technologies, and companies. This cannot be a self-serving, short-term thinking revolution as it has been in the past.

In short, predictions for the next few years of the HIT market depend largely on what questions are asked and addressed in the near term. If all we ask is "how do we get everyone covered" then we’ll end up bankrupting the system and ruining the quality of healthcare’s outcome. If, however, we ask "what architecture and infrastructure will allow us to best improve access and quality and what do we have to destroy and rebuild to get there?", then with hard work and true innovation, we can create a world-class healthcare system that will not only cost less but provide much better outcomes for the country — at the expense of some of the companies that have been winners at our expense over the last many years.

The government tries to fix what it can see, which is primarily CPT and ICD codes –- codes that have been polluted from clinical purity through the process of coding to get paid. The incentives for clinical improvement are through the filter of a system that financially rewards based on more procedures, not improved outcomes. The entrenched vendors support solutions that will benefit their bottom line — no doubt assuming that they will help in the process. Now, however, we have to be willing to look at the actual architecture of the system in order to make enduring progress. My fear is that with the crisis at hand a new and energized government will try to tackle the most visible problems — which will make the situation worse. Without fundamental change, we will only be piling on more expensive process, as we historically have done, without creating an ending.

What makes today different from the past is that there are new and truly disruptive technology companies and people running them who are not committed to the status quo. If the new administration is willing to ask the right questions, involve new people with innovative ideas, and is willing to create a new industry architecture, then and only then will we be able to enjoy the healthcare system we deserve. If, however, we stay with this basic model, then we will get the system and outcomes deserved by the incumbents to the system — and that would be a true shame.

Outside the possibilities of a new administration, the impact of primary care reform efforts cannot be understated. The legislation that recently passed in Massachusetts, aiming to make primary care more attractive, is another example, from a completely different angle, of how we can affect the actual architecture of the healthcare system. By legislating for loan forgiveness, home purchase help, improved reimbursement, and more, we can make primary care attractive again and quell many of the healthcare systems endemic problems — proper disease management, reliance on emergency rooms and more — earlier and more effectively.

Are providers doing everything they can to maximize the payment they’re entitled to through accurate coding?

No. And it is even worse than the question suggests.

In our travels around the country, we meet providers who intentionally down-code out of fear. They down-code because they are afraid to get audited, afraid that the system will not be reasonable. They are afraid to stand out and afraid that the fact that their patients are ‘sicker’ means that their higher codes will make them stand out. They are afraid — period. The truly ironic shame is that this adversarial culture not only reduces the morale of the physicians, it forces the data to be more flawed than it needs to be. The current flow of healthcare’s information and money do not support the gathering of life-saving data and high-quality outcomes. The data is systemically and systematically flawed.

Think about it — the most complex series of events most people endure in their lifetimes are reduced to three-, four- or five-digit codes – whatever follows the path of least resistance. These codes determine what’s likely to get paid and most easily treated, but never account for the actual patient. What’s best for them, what diagnosis is most accurate, what treatment they should pursue, what options they should consider — the list is endless. What is truly important in today’s system is what those codes are being used for — reimbursement. Not treatment. Not the most appropriate care. Not the patient at the heart of it all.

Physicians have these well-trained powers of observation and, with the full color of their narrative, describe what is wrong with us and what they are going to do about it. In that language are rich and complex concepts — some of which are negated, historical, related to a family member, or are equivocal because more information is needed. Does all of that valuable information get captured in the medical coding process?  Not even a fraction of it. The information captured in the record accurately reflects the actual health of the patients. The information healthcare uses to evaluate the quality of care and outcomes is inaccurate — out of fear and is both measuring and rewarding the wrong things.

Without truly capturing what is going on during a patient’s full episode of care, physicians are not only short-changing themselves, but the system is being hurt at the same time. There is no true discovery without having access to and being able to analyze all of the information. The people who can and truly want to make a difference are crippled by the inaccurate and limited information available to them.

What are your thoughts on ICD-10?

ICD-10 is an important and overdue advancement for the United States. It’s necessary to meet the needs of an increasingly complex, diverse, and electronic medical environment. By implementing ICD-10, the industry will advance from the use of a classification system in need of modern information to one that accurately reflects advances in diagnosis and care.

That said, it’s amazing that our great and competitive country is almost 20 years behind other parts of the world in this regard. Countries that are already using ICD-10 have access to important information about diseases that are being missed in the U.S. And why? It goes back to what I stated previously — there are some entities within the system that are so heavily invested in, and exert so much control over healthcare that without their "approval" the system is frozen. Big changes that would mean improving the system are put off in favor of the established status quo. If we let those few players control our destiny, then we are destined to get the healthcare system they deserve.

Furthermore, the pushback ICD-10 is receiving is not based on its utility or value, but rather the technical cost of the change. This is yet another example of how unscalable U.S. healthcare has become. If we continue to as we have, the problem will only get worse, and then at what cost?

Stepping off my soapbox, we need information. Good, granular, and specific information. The current coding system prevents that. ICD-10 will help, though it is not the complete answer. ICD-10 will give the healthcare industry a better chance to improve the way it handles documentation and coding operations and, at the same time, elevate the power of biosurveillance and pharmacovigilance.

The overwhelming scope of the disruption stemming from ICD-10 cannot be understated. The switch represents a change from 17,000 codes to more than 155,000. Given the diversity in size, specialty, and payer mix within the healthcare industry, the complications of the change are nearly impossible to properly measure. But so, too, are the new codes’ possibilities in terms of technology adoption, research, and discovery.

What makes you happy about running CodeRyte and what gives you satisfaction away from work?

There are so many things that I love about CodeRyte and being its CEO that it’s hard to list.  But, I’ll try …

The more than 100 people at CodeRyte are incredible. Given what we do, we have extremely talented people from myriad backgrounds — talented engineers, nationally recognized NLP experts, certified professional coders, driven sales executives, dedicated account managers, and others who have gravitated to CodeRyte out of a strong desire to revolutionize healthcare. Their passion, attitude, and intelligence are inspiring and exhilarating to work with.

What binds us is that we are all aligned around a common vision — CodeRyte and its technology can truly help revolutionize healthcare. Now we just need a seat at the adults’ table in order to show the industry that there are ways to achieve what they all believe to be impossible. I’ve said for years that we’ve been seated at the kids’ table while we’ve built and imagined the future possibilities for this company, its technology, and other HCIT vendors. The frustration of getting the ear of the change-agents is truly like tilting at windmills. We have the answer; it is just that the windmills don’t always want to listen.

You know that look when you give a child the present they have been waiting for? Well, that’s one of my favorite things about running CodeRyte — the look on our clients’ faces when we deliver on our promises. Increased productivity. A lowered cost to collect. Faster turnaround times. Appropriate revenue capture.

I also love the challenge of doing that which people say can’t be done. In the beginning, for example, we were told physicians know how to code, so why would they use an NLP coding application? Physicians should not have to assign codes — it takes away from their patient-facing time and should not be their area of expertise. Our application helps the physicians by allowing them to focus on delivering quality care and gives them back their day.

Away from CodeRyte, my priority is my wife and children. The importance of a work-life balance cannot be underestimated by the CEO of a company that aims to revolutionize an industry as important as healthcare. The time I give to one always takes away from the time I can give to the other. This means that for now my passion is balancing — giving the most I can to building CodeRyte and loving my family.

CIO Unplugged – 2/1/09

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

No Pain, No Gain
By Ed Marx

Sounds trite, I know. Some will accuse me of simplemindedness. Others will say this high school football-coach philosophy is dangerous. I agree, but still embrace.

In my thirties, I got back into playing tennis and started thrashing on the courts with some friends from work. As we verged on competitive levels, I realized we needed to pick up the intensity. A consistent first serve was the performance key. Reliance on the second serve would allow your opponent to take the offensive. Although a high, first serve percentage alone would not make you a Wimbledon champion, you’d at least guarantee yourself a quarter final match. We practiced at 6 am thrice weekly, but I showed up at 5 am to serve buckets and buckets of balls. I’d chase them down and start over again. No pain, no gain.

Now in my forties, I’m taking on the challenge of perfecting the Argentine Tango with my wife. In addition to a weekly two-hour lesson and a monthly milonga, we practice. Even if for only twenty minutes, we practice every evening. We have to, because the Argentine Tango happens to be the most artistic, intellectual, and difficult dance ever created by man. If I catch my partner’s foot too late, we miss our sweep. If we’re too far apart, one of us loses balance. I figure if we aim for expert, we might reach proficient by the time I’m eighty.

Like our dancing, my relationship with my bride of twenty-four years has been full of ups and downs. The overall trend slopes upwards to the right, but it’s interrupted with numerous peaks and valleys. Some downturns take years to correct, yet we keep at it. Annual strategic planning vacations, numerous marriage conferences, lots of books, prayer, and counsel. We’ve fought hard to reach the point we’re at today, and there is more pain to endure, I’m sure. Had we chosen not to push through the pain during any of the valleys, who knows where our marriage would be? Certainly not growing, not gaining.

And what about a career? Can you ascend the leadership ranks by good luck or good looks? Not in my case. It took pain—blood, sweat, and tears. Which meant not taking shortcuts. Not submitting C-level work. Not shaving time here and there to start the weekend early. But it’s so tempting!

I hear you. But do you want to reach the fulfillment of your calling? Then sacrifice. Love the pain.

A few years back, I had to spend a significant amount of time on the road. The librarian at Parkview Episcopal Medical Center (CO) supplied me with endless materials, from business books on tape to vocabulary building materials. While driving, I’d listen to these resources over and over until they became part of my intellectual fabric. Would have I preferred to listen to U2 or another favorite band? Of course. But to grow, I needed to take advantage of every morsel of time. I also volunteered for everything in my path; some related to IT, others benefited the hospital or another department. Would I have preferred to go home early or have a smaller to-do list? Certainly. But to maximize my potential and opportunity, I needed to self-sacrifice—so far as it didn’t harm my family. Plus, it was only for a season. Every season brings different opportunities, which require fitting sacrifices.

Today, I’ve made sure we have a library of materials available for our staff to checkout. Hundreds of books and cds on tape. We have subscriptions for “book of the month,” a concept I leveraged from the Parkview librarian. Just as serving thousands of balls to ghosts at the break of dawn paved the way to winning several tournaments; or investing the time and money to improving my tango to keep me on the dance floor, pain brings gain.

Don’t expect to just show up on the dance floor and look like a pro. If you want someone to ask you to dance, practice.

No pain, no gain.

Ed Marx is senior vice president and CIO at Texas Health Resources in Dallas-Fort Worth, TX. Ed encourages your interaction through this blog. (Use the “add a comment” function at the bottom of each post.) You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook, and you can follow him via Twitter – User Name “marxists.”

What Usability Is and How to Recognize It

By Jim Bradford, Ph.D.
The Bradford Report

From time to time when I use a new application, I seem to develop a kind of Tourette’s Syndrome characterized by teeth grinding, fist clenching, and dark mutterings. As I struggle through yet another badly designed, user-unfriendly system, I find myself wishing fervently that Bill Gates had finished college.

Technically, the user friendliness of a system is known as “usability.” There is an entire academic discipline (variously called “Human Factors” or “Ergonomics”) that is devoted to the study of usability. But if you don’t happen to have a Ph.D. in Ergonomics, how do you recognize a well designed, highly usable system?

Mental Models and the Psychology of Geeks

The human brain constantly monitors the environment and creates models about it. This allows us to think about our environment and make predictions about what will happen next. We carry over this natural tendency to model things into our interaction with computers.

Not all models are created equal, however. I have a friend who believes that if you set a thermostat as high as it will go, it will warm up the house faster. It is not an unreasonable model — it just doesn’t happen to be right.

The best system designers work hard to give you many clues about how a system works. This allows your brain to make a good model that produces accurate predictions about system behavior. When you encounter such a system, you begin to feel that the system is natural, intuitive, and easy to use.

Unfortunately, geek psychology doesn’t often lead to this kind of design process. In 1971, Gerald Weinberg published his (now classic) book, The Psychology of Computer Programming. To boil a long tome down to its essence, the kind of person attracted to computer programming is frequently the type of person the media would characterize as a “troubled loner.” Unfortunately, the design of usable systems requires a well-developed ability to understand how people think, feel, and react when confronted with a complex system. As a rule, troubled loners are not good at this.

As a consequence, human factors experts are often drawn from the “touchy feely” disciplines (i.e., anything other than engineering or computer science). They are often brought in to fix computer systems that are so horribly hard to use that almost no one can make them work. This strategy is akin to bringing in a doctor only after the patient has died. The usability specialist does what he or she can, but the result is usually a system that has evolved from being impossible to use to the point where it is merely frustrating to use.

The traditional approach to developing computer software (design-code-fix) is pretty well entrenched. Thirty years of preaching from academia has not noticeably improved the usability of computer systems. The key to usability, I believe, is an informed and demanding consumer. This is rooted in a fundamental property of a free market economy — if people stop buying poorly designed products, companies will eventually stop making them.

The Informed Consumer—How to Recognize Usability

Affordance

This design principle dictates that the appearance of things should provide a strong hint about how they are used. A hammer looks like it would be good for driving nails. A screwdriver suggests how screws should be managed. An espresso machine … well, not so much. Hammers and screwdrivers have good affordance and espresso machines have poor affordance. When you look at the user interface of a new piece of software, do the commands, buttons, menus, and other gizmos give you a good idea of how to use the system? If they don’t, it’s Strike One against the designer.

Prescriptive Feedback

When using complex systems, people will make mistakes. This provides the acid test for usability. Have you ever encountered an error message that says something like, “Illegal command or filename”? Good grief! Which is it, the command I just used or the file I just named? What law did I break? What makes a command illegal? Why can’t I call a file anything I want?

Can you imagine if other products were designed like software? Can you imagine a dashboard trouble indicator saying, “Illegal battery voltage or engine temperature”? If software doesn’t help you fix mistakes, then it is Strike Two against the designer.

Task Fit

Software is a tool. Some software is a tool for creating documents, other software helps manage your finances and still other software exists purely to entertain you. Well designed software should focus on doing a small number of distinct tasks (a half dozen at most) and it should be obvious how the controls of the user interface help you do each task.

Unfortunately many software companies prefer a “one size fits all” approach to development and end up creating a “one size fits nobody” product. If it’s not obvious how a software application’s capabilities relate to the task you have in mind, then it is Strike Three against the designer.

The Bottom Line

In recent years, the nature of our daily lives has changed to such an extent that many of us spend the majority of our working and private lives sitting at a keyboard. Usability has become an important determiner of the quality of life for citizens of the twenty-first century. If the software you use is not intuitive, if it is not helpful, and if it doesn’t fit the tasks you want to do, then walk away … just walk away.

Jim Bradford is a scientist, professor, and consultant dedicated to the art of making technology easier to use. He wrote this article specifically for the readers of HIStalk after we exchanged e-mails about the problem of usability in healthcare applications.

Monday Morning Update 2/2/09

From Sam Axe: "Re: Scott & White. I am reasonably certain that GE/IDX is supporting the physician revenue cycle – not the hospital, which remains Siemens Invision. The GE article referenced in the response agrees with that and I believe they are probably accurate in their claims around the physician revenue cycle in academic medical centers." Thanks. I wish the press release had been more clear since both the customer and vendor in this case have separate offerings for inpatients and outpatients.

From Blago: "Re: Big shake-up at GE HCIT. Vishal Wanchoo out as CEO." Not according to Jennifer, a GE spokesperson and Inga’s new BFF, who said, "absolutely not." Inga was tickled, though, that Jennifer knew who she was when she called, even though she had thought Inga was someone I just made up. Now I’m inspired to invent up a huge staff of imaginary people, a seeming force to be reckoned with instead of some guy hunched over a PC for immoderate hours each day. Jade and Mariposa, massage my shoulders as I type, yes?

From Spanky: "Re: stimulus. How are pediatric providers going to get reimbursed for EHR use when they don’t bill Medicare?"

 

January’s HIStalk traffic set a new record, up about 40% from a year ago. Thanks for reading.

Listening: The Connells, jangle pop from Raleigh, NC since 1984.

Two Utah hospitals buck the trend and open up new expansions.

I heard from a CIO reader whose hospital, a big place, is 100% CPOE. I said I’d never heard of one doing all oncology and neonatal orders on a general CPOE system, but there’s at least that one. I agreed not to provide specifics, but I’ve asked for more information since I know many of us would like to know how they did it.

Who knew? The owner of ambulatory EMR vendor Purkinje, according to their site, is the famous VC billionaire John Doerr, backer of Compaq, Netscape, Sun, Amazon, Google, and others. His brother is the CMO and chairman of the executive board. John Doerr put $10 million into the company in 2007. The logo on the site now says GenesysMD even though the Purkinje name is used otherwise, so the company name appears to be changing (just confirmed with Margalit, the company’s product management director, who’s like me and working on the computer at 11:30 at night). Their deal: $399 per provider per month for software, unlimited support, hosting, interfaces, all clinical content (CPT, ICD9, First DataBank, etc.) and free training and implementation for users who sign up in February.

Over on HIStech Report, Inga interviewed John Shagoury of Nuance Communications.

DrM made a year-by-year table of payments and penalties for the House’s stimulus bill that just passed. I inserted it as a graphic above, so click to enlarge.

Hospital and employee information in Japan is exposed on the Internet when an employee copies data from a damaged flash drive to his PC, forgets the file is still there, then fires up his file sharing software at home. That’s happened before in Japan, I seem to vaguely remember. They love that Winny P2P client over there.

Speaking of which, a Computerworld article mentions on the danger of data exposure from peer-to-peer file sharing, citing a study in which a researcher found a document with full data on 9,000 lab patients, 350 mb of data from an anesthesia group, and an 82-field worksheet on 20,000 hospital patients. The last sentence is a little shot: "The range of health care information floating on P2P networks and the variety of sources from which it is being leaked highlight the disorganized and decentralized manner in which health care data is being collected, stored, used and shared, he said."

Here I go and run an interview with Peter Waegemann and he fails to tell me that they’re renaming TEPR to M-Health Conference. HITgeek has an idea: "If TEPR is changing its name, perhaps you could hold a contest or survey for what it should be."

A University of Chicago study finds that 90% of hospitalized patients couldn’t correctly name even one of the doctors taking care of them. Three quarters had no idea and 60% of the rest were wrong. Academic medical centers have a gaggle of people rounding in teams, of course, popping in for a few minutes once or twice a day, so maybe that’s not surprising.

Here’s an example of how insurance has corrupted the whole idea of patient responsibility: an LA Times article marvels that practices using real-time adjudication "can, and sometimes do, ask patients to pay those costs at the time of service." Shocking! Why can’t medical practices be like restaurants, gas stations, and mall stores in just letting people take what they want, walk out, and be billed sometime later to pay whatever amount is convenient? That should be the #1 step in healthcare reform — get patients to understand that healthcare isn’t free just because you have (or once had) an insurance card. The insurance companies escape consumer wrath because it’s the doctor’s office who has to come collecting what they didn’t pay.

The IT department was at fault in the recent PC virus infection in England, incorrectly configuring antivirus software on some PCs and failing to get AV updates to some of them, an outside IT auditor finds.

If you want to know how the HIT industry is doing, forget all those publicly traded companies with a mishmash of products and businesses and look at the software-only company that has the most hospital customers: MEDITECH, which 2,200 hospitals are running today. For FY08: revenue was up just under 6%, but net income dropped 60%, mostly on investments (I hear that). Interesting: CEO Neil Pappalardo and CFO Barbara Manzolillo asked that the Board give them only the same bonuses other employees get and not the special Director bonuses since the company didn’t do very well, reducing their paychecks by 64% and 52%, respectively, over their 2007 comp. Neil’s shares are worth over $500 million even at the internally set share price that the militant shareholders always complain is artificially low.

A WV doctor and former town mayor is ordered to repay an insurance company $180,000 for blood tests and injections that patients never received. The doctor blames his billing staff and software, says he has nothing to do with billing, and that judges discriminated against him. He was nailed in 2007 for underreporting income from 2000-2002, when he also worked as a day trader.

GE Healthcare is following its Burlington layoffs with mandatory unpaid employee furloughs.

Hospital layoffs: Clearfield Hospital (PA), 33; Saint Joseph Medical Center (PA), 40.

Sure to fuel the healthcare debate: is it a good use of healthcare resources to provide expensive fertility treatments and preemie care to an unmarried, apparently unemployed, and bankrupt woman in her 30s and her new octuplets that bring her up to 14 children, all of them conceived through in vitro fertilization? She’s trying to be self-sufficient, though: she wants $2 million and a career as a TV child expert from either Oprah or Good Morning America in return for her story.

I don’t get how magazines think. An article mentions that Philips sold CPACS to a hospital in Saudi Arabia, but the headline in SmartBrief says "Philips strikes a partnership with Saudi Arabian hospital." If that’s the case, I struck a partnership with the local sports bar at lunch today when I bought a very good burger there. Just because salespeople murmur the P word to make prospects comfortable doesn’t mean there’s a legal agreement to share expenses and profits. Anything else is called "a sale." Funny thing is, the article it referenced called it that — SmartBrief added the "partnership" line.

CPSI announces Q4 numbers: revenue up 14%, EPS $0.45 vs. $0.36, falling short of earnings expectations but raising guidance and declaring a dividend.

MEDSEEK announces a 47% increase in contracts and a 33% increase in licenses for 2008, referencing its KLAS 2008 Category Leader status in clinical portals.

California is out of money, so it plans to stop paying bills Sunday. The controller whines that withholding money from Californians will delay economic recovery, blaming everybody except the state itself. CA is $25 billion short for 2009, unemployment is 9.3%, and median home prices are down 50% in less than two years. Like Florida, they weren’t complaining during the boom that benefited them, but can’t accept the idea that the good times have already rolled.

Amanda Adkins, a 34-year-old Cerner executive, is named chairwoman of the Kansas Republican Party. It probably wasn’t a total shock since she was the only candidate.

E-mail me.

News 1/30/09

From Dr. Strangelove: "Re: medical education. Medical care & physicians take a lickin’ on this study of revamping their education. The issue was never getting enough physicians trained – it was getting them to work anywhere except the big cities where they could make enough money to stay entrenched in the social class created for them in the last half of the 20th century (and pay off medical school). Their attitude… well… that’s another thing entirely. It has to do with ‘the chief god in charge’ formula taught to them in medical school and in part to the kind of personality profiles it takes to survive medical school, an internship, and residency." A sentence from the report (warning: PDF) that advocates the reform of medical education: "The overarching theme that coursed through the discussions was the urgent desire to bring medical education into better alignment with societal needs and expectations."

From MM: "Re: vendor calls. The vendor calls and e-mails have gotten completely out of hand. A confluence of a new year and a very slow economy has everyone with anything to sell trying to make contact. My assistant, who is good at spotting the legitimate calls from random sales calls, has been tricked a few times this month. I can’t take it any more! Anyone else feeling a high level of sales activity?"

From Chef Tony: "Re: sponsor ads. We’re a sponsor and I’m a reader. I really dislike the animated ads, too. Nobody is hanging around to read each screens change. I deal with huge NYC agencies whose designer kids are often clueless about what gets information out to the target market. Unless it’s Super Bowl Sunday, educate or inform with ads, not entertain."

From Doug Dinsdale: "Re: Allscripts. A stock board posting claims that Allscripts Healthmatics and Allscripts Professional were scheduled to lose CCHIT certification last week. Is that true?" I don’t think so, but I’m sure Allscripts will clarify. According to the CCHIT Certified Ambulatory EHR 2007 list, both products were certified a year ago. I’m working from memory here, but I think certification is good for two years, i.e. even though CCHIT issues new criteria every year, vendors don’t have to recertify (with one exception: Stark and anti-kickback donations require products to have been certified within the past 12 months, but not necessarily on the current criteria, and extensions are available). You just have to pay CCHIT’s annual maintenance fee (huh? CCHIT requires payment of a maintenance fee even when a vendor doesn’t use any certification services, which was the justification for the fee in the first place?) For stimulus purposes, I think both products are good for another year in any case. I’m sure someone with a more expert opinion than mine can help.

From Friend of Tim: "Re: it’s a good thing you’re a nice guy." Link. Michael Arrington, the "surly and macho" founder of the Silicon Valley blog TechCrunch that carries quite a bit of investor influence, takes a leave of absence after receiving death threats and having someone walk up to him at a conference and spit in his face. I am a nice guy – thanks for noticing (cynical and juvenile, sure, but we all have our crosses to bear).

From Dinger: "Re: Baylor/Perot. Any word on how it’s going? I’m hearing rumblings."

From Paul Molitor: "Re: HITECH. I have to respectfully disagree with John Glaser’s interpretation of HITECH. You get the same compensation per clinician regardless of when that clinician starts to use an EHR. The declining payment schedule per ‘eligible professional’ begins with the ‘payment year’ in which that professional becomes a ‘meaningful EHR user’. The start of the declining schedule is not anchored in a specific calendar year and the schedule applies to each individual. A relevant excerpt from Sec. 4311: ‘(ii) AMOUNT- Subject to clause (iii), the applicable amount specified in this subparagraph for an eligible professional is as follows: (I) For the first payment year for such professional, $15,000. (II) For the second payment year for such professional, $12,000.’ See here for the full text."

From Moose Haas: "Re: MRI/TEPR. Completely washed up. Went to their event last year. It had to be one of the worst events I’ve ever attended. Rumor is MRI is being shopped, but no takers." I appreciate Peter Waegemann’s taking the time to share some thoughts (several  of which I agree with). 

From Sam Butcher: "Re: physician practices delaying EMR purchases. Many groups will delay. Those interested in EMRs for business or clinical reasons have already bought. The remaining ones are resisting change claiming EMRs cost too much or aren’t better than paper. These are the same groups that resisted electronic claims years ago. It’s no surprise that many of these practices are poorly managed. The same paralysis happened with practice management stimulus during the debate over Hillarycare." That’s an interesting observation. As much as I don’t believe the Most Wired hype, it would be interesting to compare the quality and profitability of non-technology using practices to the others. There are certainly plenty of badly managed practices out there (one way to identify them is to check the name tag of the least competent person in the reception area: if that person’s last name is the same as the doctor’s, expect the worst).

From Carpluv: "Re: physician practices delaying EMR purchases. Obamanations, grand idea for financial help for EHRs, has stopped the buyers in their tracks. They’re all waiting for the handout. Great momentum change!"

From Elsie EHR: "Re: physician practices delaying EMR purchases. Same song, different year. On July 21, 2005, the NY Times ran an article about the VA’s VistA system titled ‘U.S. Will Offer Doctors Free Electronic Records System.’ The article, which was widely quoted and reprinted, painted a rosy picture of the ‘free’ system. It was eagerly read by practitioners who were actively looking for an EHR as well as those who were on the fence. All that press prompted thousands of physicians to put their EHR plans on hold so that they could ‘wait and see’ what free goodies the government would provide. Some are still waiting." Link. That’s the most over-hyped and under-delivered part of Brailer’s original plan — giving away VistA (hospital and office) to legions of clamoring providers. Flop (see: Free Kittens).

From E. Buzz Miller: "Re: event. Will there be an HIStalk reception at HIMSS this year?" Wow, lots of people have been e-mailing that question, so thanks for the anticipation! I believe that’s affirmative, so keep Monday evening free. I’m hoping to line up a couple of notable speakers, maybe (and/or holding a spot for a HISsies winner or two if they’re game). For those who went last year, I’m open to suggestions on how to maximize the networking opportunities or anything else that would make it more meaningful and memorable. I never really asked attendees what they liked best or how to make it better, so now I am. Some people would just put out food and drinks, but I’m too neurotic to just let it unfold.

From Trimaxion: "Re: Stanford. Stanford Hospital has again delayed its Epic CPOE Oncology (Beacon) go-live of their Comprehensive Cancer Center. They have serious patient safety concerns, need new development, and can’t scale the complexity of the site." Unverified, but I know some Stanford folks read and may reply. I can’t say I know of any oncology app that isn’t a work in progress, though. The protocols and pre-dose monitoring and calculations are a bear. Even the so-called "100% CPOE" hospitals usually punt on oncology (and some or all of peds, like NICU).

From Bobby Peru: "Re: layoffs. Keep up reporting them." An interesting counterpoint from Think Positive: "I would propose to you that it is no longer news worthy or interesting news if another company has a layoff. I agree in better economic times this type of insight into a company’s fortunes or failures is helpful guidance to your readers." Think Positive is right, I believe, because it is indeed neither newsworthy or all that insightful that a vendor lays off staff these days, unlike the pre-recession when such activity might foretell future problems or shifts in strategy. Maybe this is a happy medium: I’ll keep reporting layoffs (provider and vendor) only if they have been reported elsewhere. Is that good, or should I follow Bobby’s suggestion and keep running whatever I hear? Let me know.

In the meantime, in the absence of a ruling, Omnicell supposedly dismissed somewhere between several dozen and a hundred field support employees on Wednesday, but an official number of 101 was given with its Q4 report: revenue up 7.1%, EPS $0.10 vs $0.09. Those are darned good numbers if you ask me, but cutting payroll is the most common hunkering down for weathering the economic storm overhead. Cold, but smart.

It’s your last chance to cast your HISsies ballot.

Listening: brand new alternative hard rock from Hoobastank, who kind of disappeared after one hit several years ago. I like it a lot – it’s harder than their older stuff. I still hate the name, though.

Intellect Resources has a new newsletter, which I always enjoy. The "traveling Flat Healthcare IT Man" piece is fun – wish I’d thought of it for HIStalk (it’s from a children’s book called Flat Stanley). They also have a new website with both HIT positions and candidates.

A huge win for GE: Scott & White chooses Centricity Business (the old IDX billing system, I assume) for patient access, revenue cycle management, and BI.

Jobs: Cerner Clinical Systems Analyst, Pre-Sales Engineer, EHR Clinical Trainer and Implementations, IT Director. There are some nice positions and employers posted.

Here’s an interesting example of commitment to healthcare: El Camino Hospital is purchasing the physical plant of Community Hospital of Los Gatos, putting current ECH CMIO Eric Pifer in charge there. ECH is taking over June 1 when Tenet’s lease runs out, but Tenet said, screw it, we’re closing the hospital on April 10 because it’s losing money anyway and we’d rather just cut and run. Employees thought they were finally going to be safe under ECH, but now they’re all getting the axe. ECH says they can’t get it ready to re-open until the fall. As a for-profit company, it’s the right business decision for Tenet, I suppose.

Humana will contribute provider incentives to encourage participation in the Wisconsin HIE (would one sound that out as WHEE or WHY?)

While I’m thinking about it, I’d like to thank the companies that sponsor HIStalk and HIStalk Practice. It takes guts to put your ad (flashy or not) beside some of the stuff I write. For most of them, it’s not a sterile transaction handled by detached PR people — it’s company executives who want to support what we do and who pull the strings to get the bean counters to write a check to a vaguely untrustworthy-looking enterprise working out of a PO box. Make your own decision on what to buy or from whom, but if you get the chance, thank them for their support.

Investor’s Business Daily covers athenahealth in an article purportedly about subscription EMRs, but mostly about ATHN stock.

If you’ve e-mailed me lately, hang in there and I’ll get back to you. It’s nearly impossible for me to do much more than skim the inbox until the weekends since HIStalk, HIStalk Practice, and HIStech Report are kind of in full swing at the moment (there will be record readership in HIStalk this month, which is surprising since the first several days were a long holiday weekend for most folks).

Speaking of CHLG, I heard this from Vendor Val: "El Camino Hospital plans to bring CHLG up on their Eclipsys Sunrise computer system and introduce physician order entry. Great news – for their competitors. CPOE had some success at El Camino because the city subsidizes the hospital and the hospital subsidizes the close-knit Independent Physicians of El Camino with free eClinicalWorks. Of course these MDs are very tech-savvy and have link-ups with the hospital’s Eclipsys Sunrise systems and can view lab data, medical histories, and procedures from the comfort of their own offices (they attract a lot of Stanford Hospital doctors who cut their teeth on computer glitches, spotty interfaces, and lots of downtime). But Los Gatos is a diverse collection of paper-happy independent physician practices who have no incentive to invest in technology and many are aging retirees with no interest in learning new programs."

Nextgov reports that Rob Kolodner will be staying on as ONCHIT.

California’s ED doctors sue the state, claiming that the ED system will collapse without additional funding. The state is ranked last in ED access and 43rd in ED payment. The docs claim EDs are getting the state’s burden of caring for the poor and elderly dumped on them. The state’s Department of Health Care Services had a cheery response: more budget cuts are likely, with proposals on the table to cut Medi-Cal’s budget by $1.1 billion and cutting physician reimbursement on March 1. I’m no expert, but this sounds like a seriously explosive situation there since I remember how ugly the King-Drew situation got.

Rich Elmore reminds me that his blog post mentioned the possibility of delayed provider EMR decisions because of Uncle Sam’s potential golden handshake.

St. Luke’s Regional Medical Center (ID) restructures its 28 IT positions into 18, forcing incumbents to play musical chairs to decide which 10 get the boot. It seems that hospitals are falling into one of two camps: (a) those who have big-ticket IT projects underway and aren’t about to jeopardize them to save a few IT salaries, and (b) those who never really believed that technology was all that valuable and are robbing the IT operational and capital budgets for more critical needs.

A UK survey calculates that dry cleaners there found an estimated 9,000 USB sticks, some no doubt full of sensitive information, that were left in the pockets of clothing dropped off.

E-mail me.

HERtalk by Inga

From Comforter: “Re: layoffs. Cabell Huntington laid off between 30 and 40 middle managers a couple of weeks ago, saving between $3 and $4 million per year. Many were-long time employees, with more than 20 years of service. One questioned how the hospital could have committed $40 million to Cerner a couple of years ago, but now finds itself in dire straits. Security escorted the employees out of the building immediately, standard policy for sure, but compounding the duress of getting fired.” The local paper reports that 40 jobs were eliminated earlier this month.

From Jason: “Re: Faxton-St. Luke’s Healthcare. You may have already heard, but Faxton St. Luke’s is an Eclipsys client.” Thanks for the correction. I erroneously said they had Cerner.

From Inside Outsider: “Re: Rob Kill. Is the new CEO of Virtual Radiologic Corporation really named Rob Kill? First time I’ve ever heard of a person named for breaking two commandments." Funny, although I bet Rob’s heard it too many times to do anything except grimace and give a polite, dry two-beat chuckle (HAH ha).

From Ziggy: "Re: Hospital marketing. With all the troubling economic news, budget cuts, and all, I am wondering the effect on hospital marketing? What are other hospitals finding to be most effective for the money?” Medicare fraud?

Sometimes it’s the little things about a company that can turn you off. Last September, I semi-seriously made fun of this Med Com USA press release because the first sentence went on forever. Lo and behold, here’s a new one just about like it: “MedCom USA, Inc. (OTCBulletinBoard: EMED) a leading provider of HIPAA compliant healthcare and financial transaction solutions for the healthcare industry, which recently signed letters of intent to acquire PayMed USA, LLC and Absolute Medical Software Systems, a leading provider of HIPAA compliant medical, dental, healthcare and financial transaction solutions for the healthcare and dental industry is pleased to announce that it has appointed an additional board member resulting in three independent board members and one inside member.” But what annoyed me the most was that in order to open their Web site with my Chrome browser, I was required to upgrade to a newer version of Flash (which I blew off, because I decided I didn’t need to see their site that badly.) If you read the press release, you’ll notice they had some high-level turnover, so I’ll give them the benefit of the doubt and assume they haven’t had a chance to focus much on marketing.

With the meltdown of Satyam Computer Services, other outsources like EDS, Perot, and ACS hope to pick up a few new clients. One consultant estimates Satyam will lose $2 billion worth of business to competitors over the next two to four months.

Tennessee expands its medical video network to allow physicians to treat pregnant women in rural counties. BCBS of Tennessee Health Foundation has provided $1.8 million in funding to allow perinatologists to view live ultrasounds remotely.

HIMSS announces its support for HIT provisions under consideration by Congress, citing three reaons: 1) the economy will benefit as jobs are created; 2) patients will benefit because of increased safety, and, 3) doctors will benefit because it reduces the current cost barriers. They don’t mention this, but of course it would be helpful to their 350 corporate members (and thus they themselves) as well.

A survey finds that hospitals and health systems are cutting back on both capital spending and unprofitable healthcare services. Hospitals are worried about declining investment values, shrinking margins, and stagnant philanthropy. This report reminds me of our own little survey to your right. If you are a vendor or a hospital, let us know what effect the economy is having on your world.

I wonder if this is just a co-incidence? Mr. H and I start using Twitter to keep abreast with all things HIT. Three weeks later Twitter seeks to raise at least $20 million in Series D funding. That’s a bunch of tweets.

The U.S. Bureau of Labor Statistics reports that retail prices for hospitals increased 5.9% in 2008, compared to 8.3% the year before. Wholesale prices for hospital services increased 1.5%, compared to 3.9% in 2007.

A CDC report finds that the total number of outpatient surgeries increased from 1996 to 2006, from 20.8 million to 34.7 million visits. Outpatient surgery visits accounted for about one half of all surgery visits in 1996, but nearly two thirds of all surgery visits in 2006.

Eastern Maine Medical Center announces 76 job cuts, reductions in overtime, and holds on several projects. The hospital was a 2008 Davies Award winner. The local paper also noted that the hospital’s CEO received almost $700K in compensation and benefits last year.

Wetzel County Hospital (WV) receives government approval to seek up to $6 million in bonds, which includes $175,000 to upgrade its CPSI EMR and Payroll applications.

Trustees with Regional Medical Center (SC) approve a $78,000 contract with HIMformatics to oversee its Cerner IT project.

Tenet Healthcare says it expects a Q4 net income of $5 million and $63 million in earnings for 2008.

Would the average person pay $20 to e-mail a medical specialist for advice?  A physician group is betting on it, having launched a Web site designed to give anyone with a medical question the chance to receive medical advice, medical recommendations, and medical information from specialized medical doctors. 

Revenue cycle management company MTBC outfits its own airplane to be a flying promotional platform. Well, why not? Guess it beats the yellow pages, especially if you’re marketing to pilots.

Norton Healthcare (KY) selects Unibased Systems Architecture to provide resource management software and services.

ICA announces the deployment of its data and technology aggregation solution at Lourdes Hospital (KY).

E-mail Inga.

An HIT Moment with … C. Peter Waegemann

An HIT Moment with ... is a quick interview with someone we find interesting. C. Peter Waegemann is CEO of the Medical Records Institute.

People often compare HIMSS and the Medical Records Institute, often on the basis of their respective conference (the HIMSS annual conference and TEPR). How would you characterize the difference and do you see HIMSS as a competitor?

HIMSS and Medical Records Institute (MRI) have very different goals and points of view. Both started about 25 years ago. HIMSS developed into a very successful “mainstream” trade show with an attached membership organization. MRI’s conferences have emphasized the education component and helping providers to understand the consequences of EMRs and HIT.

For MRI, the main goal was to promote EMRs and to stimulate and provide leadership in standards development. I was instrumental in the initiation of standards organizations such as ISO TC 215, but when MRI felt that there was a lack of meaningful results, it supported ASTM International’s, relinquishing its leadership to HIMSS, which took over technically. While HIMSS has been a strong supporter of ONC, HITSP, and CCHIT, MRI has pointed out the negative influence these efforts have had on HIT developments. 

In summary, MRI has been the counterpoint to HIMSS in terms of strategy.

Why is Medical Records Institute set up as a for-profit organization rather than a non-profit like HIMSS? Is there much of a difference and are other healthcare membership or conference organizations set up similarly?

HIMSS, having gotten the not-for-profit status early on, has been a huge, profitable organization that is well funded, with reserves in the millions. MRI is the small, independent organization that has always been more interested in making a difference than making money. MRI felt that it could be more effective in its mission unfettered by a Board and the complications of a not-for-profit organization.

What is MRI’s point of view on the state of EMRs and best use of any healthcare IT money that’s made part of an economic stimulus package, particularly in light of the National Research Council’s report about the unmet technology needs for improving patient care?

MRI has repeatedly stated that the progress in the field of EMRs is shameful and argued that this cannot be blamed on such myths as lack of physicians’ interest (see this article). 

Unlike other organizations, MRI is not driven by the prospect of big money for the industry. MRI welcomes the prospect of funds to improve the quality of care with technology solutions, but it is one of the rare voices that warns that the expected savings may not occur quickly, that the infrastructure is not ready, and that (as in the past) wrong avenues appear all too likely to be pursued. 

In its letter to President Obama, MRI  asked for orchestrated efforts to determine the necessary healthcare infrastructure changes in order to achieve electronically enabled healthcare. In other words,  rather than rushing into a big spending spree, a national effort needs to be funded that openly addresses all the hypes, explores various and perhaps unpopular strategies, and develops effective ways to spend this money safely and efficiently.

Why did MRI develop an interest in cell phones in healthcare?

MRI has a long history regarding cell phones and mobile technologies. Almost 10 years ago, MRI joined the Mobile Healthcare Alliance (MoHCA) to coordinate cell phone activities in healthcare and I served as chair of MoHCA. Several years ago, MoHCA’s Executive Director joined MRI as Vice President. It has been natural that we followed that industry and recognized its potential value to healthcare.  

There has been a re-emerging wave of mobile phone applications for healthcare. With over hundred companies, this is big and will be disruptive to providers and other stakeholders. MRI calls it the “mHealth revolution”. For this reason, the Center for Cell Phone Applications in Healthcare (C-PAHC) was formed in 2008. 

Mobile devices and applications will be instrumental in the success of many health IT goals, such as documentation at the point of care, success of personal health records, integration of personal health records into EMR systems, disease management, and many more. Most of all, mobile technologies represent the breakthrough opportunity for EMR interoperability and implementation among many other applications. MRI supports the formation of the new, independent, not-for-profit mHealth Initiative Inc. and will encourage its efforts toward accelerating mHealth and its benefits nationally and internationally.

What predictions do you have for the healthcare IT industry over the next 1-3 years?

MRI sees four major drivers for the next three years. The first is, of course, the new Administration and whatever comes out of its efforts.

The second is the “mHealth revolution”, addressed above. Expect, for example, that in 2012 more than 50 million people will have their PHR on a mobile phone and will send information in advance of any visit to a provider. 

The third driver will be the interoperability standards through ecosystems (Microsoft, Google, mobile phone, etc.) that will enable true continuity of care. Expect most of these developments to come from industry innovation, not from traditional standards bodies.  

The fourth driver will be the Internet/consumer movement.

Overall, there should be more progress than in the last 10 years toward a safer, more efficient and cost-controlled healthcare system. 

Being John Glaser 1/29/09

The current version of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is part of the larger economic stimulus legislation, will alter the HIT industry and the IT plans of our organizations.

For outpatient electronic health records, the Act puts some non-trivial money on the table. A provider who uses a certified EHR can get a maximum (through Medicare) of:

This totals $41,000. This will clearly increase interest in adoption and could represent a lot of revenue for a provider organization.

To get this money, a provider must demonstrate that they are meaningfully using health information technology. What does "meaningfully" mean?

• Using e-prescribing
• Connecting through HIEs to improve the quality and coordination of care
• Submitting information on clinical quality measures.

While we might be more or less clear about what e-prescribing means, clarification is clearly needed about what we mean by the second and third criteria.

It is anticipated that HHS will spend 2009 providing specifics and clarity about what providers have to do to demonstrate meaningful use. This means that most providers will have one year – 2010 – to finish EHR implementation and put in place the infrastructure, applications, training, etc. needed to get the as much of the incentive money as possible.

This is a tall order. And it means that providers should start moving now (if they aren’t already) even though the dust has yet to settle on the specifics.

John Glaser is vice president and CIO at Partners HealthCare System. He describes himself as an "irregular regular contributor" to HIStalk.

VA Will Pay $20 Million to Settle Stolen Laptop Lawsuits

The Department of Veterans Affairs will pay $20 million to settle a class action lawsuit involving a privacy breach caused by a laptop stolen from a VA employee in 2006, according to a proposed settlement.

The laptop and its external drive contained names, dates of birth, and Social Security number of over 26 million military members and veterans. The equipment, stolen in a routine burglary of a data analyst’s home in Maryland who had taken it home without permission, was recovered by authorities, who concluded that its information had not been accessed.

The settlement will be paid to veterans who can show they were harmed or incurred credit monitoring expenses.

News 1/28/09

From The PACS Designer: "Re: best hospital workplaces. Fortune Magazine has just published its 2009 list of top 100 places to work, which includes 13 hospitals. The highest ranked is Methodist Hospital System (Houston) at #8; followed by #19 – Ohio Health; #45 – King’s Daughters Medical Center (KY); #62 – Griffin Hospital (CT); #63 – Mayo Clinic; #67 – Children’s Healthcare (Atlanta); #68 – Southern Ohio Medical Center; #75 – Atlantic Health (NJ); #76 – Lehigh Valley Hospital and Health Network (PA); #77 – Northwest Community  Hospital (IL); #79 – Baptist Health South Florida; #85 – Arkansas Children’s Hospital; #98 – Vanderbilt University. TPD congratulates those selected as being top notch in their treatment of employees." Link.

From FIT003: "Re: McKesson. They have started laying off staff. Long-term employees are the first to have been laid off. Initial numbers, placed at 50-75 people within the Alpharetta operations." Unverified.

From Songbird: "Re: Perot’s MEDITECH solutions group, formerly JJWILD. Planning a third round layoff this Friday, January 30." Unverified.

From KFC: "Re: Keane Healthcare. About 10% or 30-35 employees from the Keane Healthcare division over the last two weeks. With the sunsetting of the old First Coast Systems patient billing application and the merging of the Unix product, I wonder how this will impact the always-delayed timeline?" Unverified. For all these unverified layoff rumors, by the way, I will run a brief company response if one is provided, whether confirming or denying. That’s fair.

From Ken Kercheval: "Re: physician practice EMRs. It is going to be an interesting year. Lots of companies will go away. Like they say, ‘When the tide goes down, you find out who isn’t wearing a swimsuit’. Indeed."

From Jackie Martling: "Re: sponsor ads. Just a suggestion. The animation is annoying to the point I copy and paste your great content to avoid the distraction. Seems unfair to the non-annoying ads." Noted and dutifully passed along to the sponsors for their future consideration.

HISsies voting will be winding down shortly, so cast your vote now.

Listening: The Gaslight Anthem, a reader suggestion. Good Jersey Shore bowling alley ballads with a soupcon of punk. Should be on an indie film’s soundrack. They’re on Letterman Friday night and touring everywhere.

The Raymond James folks sent over a couple of briefs about the healthcare IT stimulus proposals on the table. They predict that HIT adoption incentives will be around $32 billion over ten years, with the biggest adoption jump happening in 2011-2014 and with the biggest potential beneficiaries being physician practices and hospitals in the 300-499 bed size. They question, as I did yesterday in HIStalk Practice, whether prospects may actually hold off on purchasing clinical systems until the federal involvement shakes out. With that in mind, I’ve put two new polls to your right — one for vendors, one for providers — asking about any purchase delays your employer has been involved with. Your comments are welcome, too, so feel free to e-mail me. The stimulus could actually be detrimental in the short term if potential customers become indecisive.

A Fort Bragg military team is the first to use the AHLTA-Theater battlefield EMR to document patient encounters stateside.

A former Kaiser Permanente employee in Los Angeles kills himself, his wife, and five children ages 8 and under (including two sets of twins), apparently after being fired in a dispute with an administrator. His suicide note claims that the administrator told him on coming to work one day that "you should have blown your brains out." His wife had also previously worked for Kaiser. Update: according to CNN, both parents had been fired from Kaiser for cause.

A reader says Ivo Nelson, formerly of Healthlink/IBM, will launch his new business next week. It’s called Encore Health Resources. The domain is registered to a PR firm’s contact and address.

IBA’s iSoft gets a deal to install its software at 38 Healthscope hospitals in Australia.

New on HIStech Report: an interview with Steve Ura, CTO of MED3OOO, including questions about its InteGreat acquisition.

Capsule (they seem to have dropped the "Technologie" part of their name except when referring to their Paris headquarters) announces the addition of 80 more medical device drivers to its library of 400.

Consumer Watchdog demands that Google "cease a rumored lobbying effort" related to stimulus bill discussions that would allow the company to sell patient information to Google Health advertisers.

Members of Parliament want individual trusts to be able to buy their own systems if NPfIT can’t get its Cerner and iSoft software problems fixed within six months. Also reported: one trust that’s merging with another may be planning to drop Cerner and go with the other hospital’s 20-year-old Atos Origin legacy system. All of this, of course, is a warning to anyone who thinks huge healthcare IT projects can work fine if given the proper money and oversight, neither of which is in short supply in the UK as NPfIT disintegrates.

This may sound off topic, but I’ve been involved with similar solutions that made IT a hero: an Indiana Web 2.0 startup announces that its WiFi digital sign technology has been installed at several hospitals. It’s a terrible press release (as any would be that references rotten teeth) but maybe interesting.

Hospital layoff: Hennepin County Medical Center (MN), 100.

The Wisconsin paper investigates a touchy topic: do hospitals provide enough free care to be worth all the tax breaks they get, especially when governments are strapped?

A rumor site reports that Apple CEO Steve Jobs will undergo surgery at Stanford Hospital, citing as a source "a secondhand account passed along from an employee at Stanford." I’m sure the HIPAA-violating source will provide updates throughout the day if the story is true (he was rumored to have been thinking about a liver transplant).

A phony doctor is arrested at his fake doctor, nurse, and dentist school in India. Graduates of the "Medical Diploma Training Agency" are actively practicing, it’s believed. The doctor was printing his own diplomas, but later outsourced it to a computer company. He was turned in by a night guard who paid for his dentist’s diploma, was told he had to ante up more money, and then was allegedly beaten by the fake doctor for complaining.

Siemens says its healthcare business isn’t so great, but it still sucks less than GE’s.

An Australian hospital is in such dire financial straits that employees, feeling sorry for patients, are spending their own money to buy groceries, bandages, light bulbs, and computer paper.

Venture investing declined in 2008 for the first time since 2003. Green tech companies are hot; software vendors and Web start-ups are ice cold.

Archives of Internal Medicine Article
Clinical Information Technologies and Inpatient Outcomes

"Health info technology saves lives, costs" screams the Yahoo News article. Modern Healthcare fires out an e-mail news blast, claiming that "when computers replace paper, patient mortality rates drop 15% during hospitalization."

The headlines are misleading (as they often are to lure in readers). You need to interpret the article yourself.  It’s available online.

Here’s the conclusion, verbatim from the article: "Hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs."

Sounds promising. Even more so when the article talks about the researcher’s use of a survey tool that actually measures how much technology is being, not just how much has been bought (although that CITAT survey instrument itself isn’t available in this or the predecessor articles that I could find, which is odd since that’s a key part of interpreting the findings).

However, the study had compromises:

• It covered only patients >50 years old and only four medical conditions.
• It randomly surveyed physicians using an AMA file, asking them to respond and to include the hospital in which they provided most of their inpatient care, but it wasn’t clear whether they provided all that much inpatient care at all or whether they were the most prolific doctors at the hospitals being reviewed.
• Since the doctors who responded drove the choice of hospitals, those hospitals studied were not typical: they were much larger and more of them were academic medical centers.
• Outcomes were determined from claims data.
• Some results were predictably erratic, such as the lack of correlation to length of stay and the conclusion that use of electronic notes and records increases the odds of heart failure complication.

Compared to studies that preceded it, this one’s pretty good, but it suffers from Most Wired-like conclusion-leaping (not in the article, but by those who try to turn it into a sound bite). Nothing suggests that technology use caused the improvement, only that it seemed to coincide with it. So, we know what we already knew or presumed: good hospitals are more likely to do many things (including deploy IT) better than bad ones.

Nothing in the article suggests that a given hospital will see its quality improve just because its starts using technology (in fact, that might have been an even more interesting study: take those same hospitals studied, identify those that recently implemented clinical systems, and compare their before-and-after numbers to see if anything changed).

The bottom line: it’s a pretty good study that has encouraging conclusions, even if they are iffy. IT won’t make bad hospitals good, but it can help make good ones a little better if it’s used right and along with other improvement measures. The article does not, however, suggest that IT is the can’t-miss answer to quality and cost problems.

E-mail me.

HERtalk by Inga

Consultants warn that as the economy worsens, more hospitals will lay off employed doctors or slash their pay. The US Department of Labor reports that 107 hospitals had mass layoffs (50+ employees) for the first 11 months of 2008.

Despite all the bad news of layoffs, many believe that healthcare still offers more stability than other sectors. In fact, the US Bureau of Labor Statistic predicts 3 million new wage and salary jobs between 2006 and 2016, more than any other industry. In nursing, older students, men, and second career newcomers are joining the ranks.

In a paper entitled “Hospitals as Hotels,” researchers conclude that amenities such as good food, attentive staff, and pleasant surroundings may play an important role in hospital demand. “From the patient perspective, hospital quality therefore embodies amenities as well as clinical quality. We also find that a one-standard-deviation increase in amenities raises a hospital’s demand by 38.4 percent on average, whereas demand is substantially less responsive to clinical quality as measured by pneumonia mortality.” Sounds like the message is to buy nice furniture instead of improving care if you want to keep the beds full.

Turmoil at Tri-City Medical Center (CA) has employees wondering about the facility’s long-term stability. Last month, a new board majority placed the hospital’s top eight administrators on paid leave and brought in a temporary management team that opponents claim have no hospital experience.

An Ohio man sues a nightclub for $25,000 after a stripper’s shoe flies off during a tricky dance move, chipping a bone in his nose that will require surgery to fix. No word on whether her shoe was damaged, but I say shame on that stripper for risking her shoes.

HealthGrades releases (warning: PDF) its seventh annual Hospital Quality and Clinical Excellence study. Medicare patients treated at top-rated hospitals are 27% less likely to die there, on average, than at other hospitals.

The Association of Academic Health Centers calls for a revision of the HIPAA privacy rule following a study in which HIPAA was found to impede study recruitment and study diversity.

McKesson reports mixed financial results for its fiscal third quarter, losing $20 million because of the $493 million paid to settle AWP price fixing charges. Without that, EPS would have been $1.05 vs. $0.68 last year on slightly higher revenues. Technology Solutions grew but missed expectations due to contract signing delays in hospitals and physician practices. Cost cutting was the key to a pretty good quarter. The company raised its earnings outlook, running the stock up 12% on Tuesday.

MedAvant Healthcare Solutions appoints Troy Burns as CTO. He previously worked at Misys and Payerpath. MedAvant’s president Andrew Lawson is also a former Misys guy.

Philips Healthcare reports 9% sales growth in Q4, driven by sales in imaging systems, healthcare informatics, and customer services. Royal Philips as a whole ended the year with a $1.9 billion loss and will lay off 6,000 employees.

Scott Perra, the new president and CEO of Faxton-St. Luke’s Healthcare and Mohawk Valley Network (NY) claims the implementation of an EMR is his first priority. The health system is about 18 months into installing its $15 million clinical system (I believe Cerner).

In what the company calls a planned transition, Virtual Radiologic Corporation promotes President Rob Kill to CEO. Company co-founder Dr. Sean Casey will remain chairman of the board. The announcement coincides with the release of the company’s Q4 and full-year financials, which include a 24% jump in revenue for the year. Adjusted net income grew from $7.0 million to $9.7 million. The company also just signed its third internal client, this one in Saudi Arabia.

Griffin Hospital (CT) implements the Logical Ink electronic charting system in its new Center for Cancer Care.

Madonna Rehabilitation Hospital (NE) plans to adopt (hopefully they’ve signed a contract) Eclipsys clinical solutions.

The Outpatient Rehabilitation Center of Margaret Mary Community Hospital (IN) implements Chart Links therapy documentation and scheduling system for its 19 physical, occupational, and speech therapists.

PHR vendor MediKeeper announces the appointment of David Ashworth as CEO.

The Queen’s Health System (HI) renews its IT outsourcing contract with ACS. The new contract is valued at $26 million over three years and includes Queen’s Medical Center and its affiliates. ACS has been providing IT services to Queen’s since 2001.

BJC HealthCare (MO) signs a five-year agreement with CareTech Solutions. CareTech will provide BJC and its 11 affiliated hospitals a suite of Web products and services including CareWorks content management system and BoardNet communications portal.

I was amazed to learn there are now over 10,000 applications available for the iPhone. A cool new HIT tool just announced: Safe OR, which includes a 19-item surgical safety checklist A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.

Picis CEO and Vice Chairman Todd Cozzens will chair the Business Office Improvement educational track at TEPR+ next week. I’m envious of anyone who gets to spend a few days in Palm Springs right now. If you’re attending, send us updates and impressions.

Medsphere announces the successful implementation of BCMA at all eight of West Virginia’s state network of acute, psychiatric, and long-term care hospitals.

athenahealth and the Illinois State Medical Society announce an agreement to offer special pricing on athenahealth’s PM solution to its 12,000 members. I also saw that athenahealth hit a 52-week high Monday, following Jonathan Bush’s appearance on CNBC’s “Mad Money” with Jim Kramer.

E-mail Inga.

MD Leader 1/27/09

Ministry Health Care Will Implement CattailsMD

Ministry Health Care has chosen to implement CattailsMD electronic health record. For over 20, Marshfield Clinic has developed a comprehensive electronic health record, now available as a CCHIT-certified ambulatory EHR product known as CattailsMD. The EHR is also available with a data warehouse to actively drive decision support and population management.

Conventional Wisdom

Conventional wisdom speaks against the use of an internally developed product. While conventional wisdom is often used as a rule of thumb, tunnel thinking can limit your options. Every software decision is the result of a complex analysis of objectives, risks, benefits, values, and mitigation strategy. The purpose of this post is not an exhaustive explanation of our decision, but rather a review of several factors influencing our thoughts.

EHRs Are Becoming a Utility

Within a few years, EHRs will be more of a utility than a unique product. Increasing CCHIT certification and government incentives are driving standardization of function. Many organizations are turning to SureScripts to satisfy the CMS E-prescribing incentive. SureScripts standards will be just one of many leading to an ever-increasing identical functioning of EHRs. Simply having an EHR will not lead to process improvement nor increase clinical quality.

EHRs Do Not Improve Quality

Most EHRs have not improved quality of care. Simply automating our traditional process should not be expected to fundamentally improve quality. Improvement occurs when we redesign our care systems and standardize our processes (often enabled by use of an EHR). It is not the EHR that magically improves care; it is the people and processes utilizing the EHR that improves care. If you are both vendor and end user, then you can first vision how care should be provided and then deliver the necessary software to support it.

Marshfield Clinic has effectively demonstrated the value of this approach by achieving improved quality of care resulting in decreased health care costs in an ongoing CMS Demonstration Project.

The Status Quo Will Not Meet Future Needs

Our health care system is broken, we simply are not meeting the prevention, wellness, and primary care needs of our patients. We do not have enough primary clinicians to meet our current needs and we are not producing enough primary clinicians to meet our future needs. In Wisconsin (warning: PDF), the demand for primary care clinicians in the next 10 years is projected to increase by as much as 33% with only a 5% increase in clinicians. We will need to redesign our health care delivery system if we hope to meet future needs.

Our use of CattailsMD maximizes our opportunity to influence the design of an EHR to meet the needs of our patients. Although our vendor is interested in the commercial success of the product, as a provider of health care, their prime objective is the same as ours: caring for patients.

It Is All About the Data

Ministry Health Care and the Marshfield Clinic have a large number of common patients and will share the same EHR. While a shared EHR with a single source of truth for medication lists, allergies, labs, and documents is appealing, the real value is an extensive data warehouse ten years in the making. The data warehouse currently contributes to a number of activities including population management, disease management, maintenance of numerous registries, formal research, and increasingly, decision support.

As our business intelligence tools become more robust, I expect increasing emphasis will be placed on activities such as searching the database for trends of best care, identifying potential drug interactions, post-marketing surveillance of medications, and identifying care opportunities that will improve the health of the communities we serve.

A Decision Without Risk?

Is our decision to use CattailsMD without risk? Nope. But then again, no decision is. During the 20 years I have been interested in health care IT, I have seen numerous vendors (both large and small) come and go. I have also been through the agony of “upgrades” in hardware, operating systems and entire new versions of software forced on us by our vendors.

What has not changed is our need for information to improve health care. We are on the threshold of having EHRs and data warehouses that do not just present information, but actively support the practice of medicine.

A Future Post

Ministry Health Care and the Marshfield Clinic have been actively working to build the infrastructure necessary to support a joint EHR. In a future post, Dr. Carlson (Marshfield’s CIO) and I will discuss some of the issues we have dealt with that will have national significance if government seeks to foster greater sharing of patient data.

While you are waiting for a joint post, please take some time to read Will Weider’s (Ministry’s CIO) advice for President Obama.

Peter Sanderson, MD, MBA is a family physician and Director of Medical Informatics and Operations and Executive Sponsor, EHR Program, at Ministry Health Care. He can be reached at pete.sanderson@ministryhealth.org. He also blogs at MD Leader.

An HIT Moment with … Michael O’Neil, Jr.

An HIT Moment with ... is a quick interview with someone we find interesting. Michael O’Neil is founder and CEO of GetWellNetwork, Inc.

People may think of GetWellNetwork as an TV entertainment service for hospital patients. How do you describe your company?

GetWellNetwork was founded on the principal that patient engagement is a core strategy for performance improvement and a critical puzzle piece in the elusive search for service, quality and safety improvement in healthcare. GetWellNetwork provides technology, as well as process and skills training, to effectively actively engage patients in the care process. 

Today, we are leading this emerging HIS segment called Interactive Patient Care (IPC). Every day, we are humbled to work alongside leaders at the Adventist Health System, Catholic Health West, Children’s National Medical Center, Christiana Care, Henry Ford, Thomas Jefferson University, and Poudre Valley Health System, the 2008 Malcolm Baldrige National Quality Award Winner. Their commitment to patient-centered care energizes and inspires our work. It matters, and it works.

We developed a patent-pending workflow engine called Patient Pathways. Patient Pathways leverage existing clinical workflow and HL7 interfaces as triggers to directly engage patients in the care process via their in-room television.

For example, a physician entering a Coumadin order via CPOE triggers a Medication Teaching & Pain Assessment Pathway via GetWellNetwork. Consequently, the system prompts a patient while watching the Oprah Winfrey Show, provides critical education on this high-alert medication through an interactive video, and then tests the patient on comprehension through a series of on-screen questions. The Pathway concludes by documenting the education results back into the EMR and alerts clinicians in real-time if the patient fails to complete the education. In another example, a Discharge Pathway guides patients through a series of activities, including a patient checklist and the ability to order discharge medications from their bed.

In summary, GetWellNetwork is a patient care tool, automating and hard-wiring critical service and quality tasks for nurses and providing an exceptional, personalized care experience for patients and families.

And yes, GetWetNetwork patients can also watch movies, send instant messages, surf the Internet, and play video games until they break every record imaginable. So we do entertain patients as well. Entertainment can be quite a powerful healing tool for patients and families.

Hospitals are struggling with reduced utilization and lower payments. How can you help them?

Alongside our hospital partners, we are measuring the application’s impact on HCAPHS scores, Core Measures, and preventing "Never Events" such as falls and hospital-acquired infections via patient engagement. As the transparency of service and quality data increasing rapidly, pay-for-performance systems and value-based benefit design are gaining significant traction. Top performing hospitals will continue to attract the best physicians, best nurses, best staff, and best patients. 

Over the past 18 months in particular, our hospitals are seeing exciting movement in their HCAPHS and Core Measures where we have implemented a focused Patient Pathway. In addition, we are also seeing encouraging indications regarding patient engagement on reducing cost per case. In 2009, we are investing quite significantly in research regarding the efficacy of patient engagement on outcomes, with heavy participation from our client community. It’s an exciting time.

Early in-room applications had facilities challenges, such as replacement of TVs, concerns about suitability of keyboards or other peripherals, and the need to rewire patient rooms. What’s required to install your products?

As one of the first companies in the Interactive Patient Care market (since 1999), we were among those applications the facing  the facilities challenges you mention. Through significant blood, sweat, tears (READ: lots of mistakes, frustrated early clients, and significant R&D expense), our engineers and supplier partners have created proprietary and cost-effective ways to implement Interactive Patient Care. Today, we are relatively infrastructure (wiring) agnostic and can run the system in old buildings on coaxial cable alone and, of course, on Ethernet where available. In both cases, digital video streaming and full Internet browsing has been integrated into the application. 

As for peripherals, today we offer a pillow speaker device that interfaces with all major nurse call systems and a fully-sealed keyboard for under $40/unit. This year, we will be launching a next generation keyboard that will finally make Internet through a patient room television as elegant as being on your laptop or desktop at home or work.

You’re working with Florida Hospital on their "Hospital of the Future." What elements of that do you think are important?

Late in 2008, we were chosen by the Adventist Health System as the exclusive provider of Interactive Patient Care throughout their organization. Since then, several facilities have contracted for GetWellNetwork, with one of them being Florida Hospital, where projects including their new Ginsburg tower as well as the Disney Hospital for Children @ Florida Hospital. 

The top three elements of success with Interactive Patient Care are 1) executive sponsorship to provide strategic outcomes priorities; 2) integration with EMR (they use Cerner, which we successfully interfaced with at Christiana in ’08) to provide triggers for our Patient Pathways and a place to document patient activity for compliance automation; and 3) nursing engagement. 

When nursing leadership embraces Interactive Patient Care as a tool vs. a task, the impact is powerful on their service, quality and safety initiatives on the floors. Florida Hospital is highly engaged and committed to setting a new standard in patient-centered care. We of course are thrilled to contribute to their vision for patient care.

Are hospitals getting better at involving patients and family members in their care?

Yes, they are. But, it’s hard work, takes a genuine commitment and accountability, and does not happen without strong leadership. On November 17, 2008, the National Quality Forum published their National Health Priorities and the first one listed was patient and family engagement: ‘PRIORITY STATEMENT: ENGAGE PATIENTS AND THEIR FAMILIES IN MANAGING THEIR HEALTH AND MAKING DECISIONS ABOUT THEIR CARE.’ So, hospital leaders are listening and they are acting. 

Of course, this does not happen overnight, and the technology, applications and interfaces are perhaps the easy part of the equation. Interactive Patient Care is a commitment, and when hospital leaders make the commitment, their patients and families are winning. Hospitals are experiencing fairly spectacular improvements in satisfaction, quality, and operations measures that have been difficult to move the needle on in the past.

Lastly, keep up the great work on HIStalk … it’s simply terrific! Thanks for having me.

Monday Morning Update 1/26/09

From RSNA Body: "Re: RSNA. Don’t believe this RSNA whitewash about attendance. These were pre-attendance numbers — wait for the audited RFID traffic numbers. I was there and, for the first time, there were hardly any lines for anything. I spoke to cabbies, bus drivers, restaurateurs, vendors, etc. who all reported thin crowds. One cabbie asked me on Wednesday if the radiology show was over because he said the traffic was so light. Several vendors told me that a number of hospital customer contingents had cancelled their RSNA trip or only sent a few rather than the scheduled dozen or so staff. With IT vendor layoffs since November and a worsening economy, I predict a huge decrease in HIMSS attendance." You’re probably right. Conferences, like sports venues, have been known to report big attendance despite obviously empty seats.

From Eclipsys on the Ropes?: "Re: Eclipsys. I understand that McKesson just took another revenue cycle customer away from Eclipsys: ‘Baptist Healthcare System Selects McKesson to Optimize Physician Revenue.’ Can you verify this for your readers?  If so, it seems like Eclipsys is in a certain death spiral. Also, the client that represents 10% of the ECLP revenue is probably North Shore Long Island Jewish since they have both outsourcing and software." I’ll have to call in a lifeline on that because I have no idea. It’s the Baptist group in Kentucky that contracted with McKesson for physician revenue cycle management. I don’t recall hearing anything about Eclipsys there, but it may well be. Update: the group is not an Eclipsys customer, so the reader’s understanding is incorrect (to the other reader who said my facts are incorrect, they aren’t my facts: the blue text is a reader’s question; my answer in black text was "don’t know, never heard of ECLP being there.")

From I’m Just Saying: "Re: Eclipsys. The 10% of revenues client may be Baylor. Also, expect more layoffs this week in Services. One VP resigned in December (J. Bell) and two others were termed last week (B. Pille & D. Tom). J&J could be a good answer."

HIMSS is not too many weeks away. I haven’t come up with any HIStalk-related activities yet since I’ve been swamped, but we’ll have some HIStech Report interviews coming very soon. The conference was awash last year in Fake Ingas, HIStalk shoeshines, badge ribbons, the big bash, and probably stuff I’ve forgotten (like that $1,000 worth of tote bags I bought – is anyone still using theirs or did I waste my money?) I’m open to ideas from vendors on anything that would be cool for readers.

A Georgia family puts everything they own except their house up for auction on eBay to pay the medical bills of their children, a 7-year-old with an autoimmune disease and another with autism.

HHS announces acceptance of HITSP interoperability standards (warning: PDF) that took effect January 16. Complete list here.

Jobs: Sales Account Executive, Northeast, Director of Channel Sales, Epic Clinical Reports Writer, MEDITECH Consultant – Advanced Clinicals. Sign up here for a weekly jobs blast.

Speaking of jobs, several folks at Eclipsys lost theirs this week, which I reported as a rumor on Wednesday. At least 100 have been shown the door, a couple of folks say, and the purge may not be over yet.

And speaking of layoffs, Children’s Hospital of the King’s Daughters (VA) laid off 28 employees on Friday and also cut 90 unfilled positions. It’s also shutting down its child care center. Mike e-mailed about Alegent Health (NE – Immanuel Medical Center pictured above), which laid off seven VPs this week and will eliminate 285 more positions by March. It also forced 20 senior managers to take a 10% pay cut.

And more layoffs: GE Healthcare dumps an unnamed number of employees in Burlington, somewhere between 8 and 39 given their sketchy announced percentage range. The staggering giant has never been forthright about its cutbacks in the old IDX office, probably due more to smothering bureaucracy rather than intentional obfuscation. Kind of like when Jeff Immelt put on his happy face about GE Capital while the rest of the world (me, anyway) proclaimed loudly that the company could not possibly avoid fallout from the financial sector meltdown. Let the record show that Jeff was way wrong: GE’s Q4 numbers announced Friday after the market close showed revenue down 5%, EPS $0.35 vs. $0.66. GE Healthcare’s profits were down 9%. The stock dropped nearly 11% during Friday trading and is down another 11% after hours.

And even more layoffs: NorthShore Skokie Hospital (IL), 150; Frankford Health System (PA), 100; Hamilton Health Sciences (Canada), 250; Irvine Regional Hospital and Medical Center (CA), 510.

Intel’s chairman Craig Barrett will retire in May. He’s been loud about healthcare and technology (I quoted him in July 2007), so maybe we’ve not seen the last of him.

Two PricewaterhouseCoopers executives in India are arrested and charged with conspiracy for the company’s role in signing off as auditor on the books of Satyam Computer Services, whose chairman admitted that $1 billion of claimed cash didn’t exist. I mostly associate PWC with dumb names: its own and the one it announced for its consulting organization in 2002, "Monday," which thankfully never happened because the company sold the whole organization to IBM just five months later.

The State of Massachusetts signed a big mandatory EMR law in August with $25 million a year in funding to get doctors online by 2015. The state cut the budget to $15 million two months later, which everybody agrees is far short of what’s needed to get the job done. Also agreed, judging from the comments, is that not much benefit has been derived so far.

Another victim of Bernie Madoff’s Ponzi scheme: Charleston Area Medical Center (WV), whose foundation lost $800K and the hospital $200K.

McKesson CEO John Hammergren gets his name and picture in The Wall Street Journal, although it’s hardly a flattering mention. The article addresses the methods companies use to calculate executive pension value into a single lump sum payment, with some using an obsolete federal formula that boosts the number as "a sneaky way to give executives larger pay." McKesson tweaked the formula for Hammergren last March, jumping his parting gift’s value to $85 million (everybody’s outraged about healthcare costs, so you might think that would raise an eyebrow or two).

Former QuadraMed CEO Larry English gets a new job as CEO of CIFG Holding, Ltd., a Bermuda-based holding company running a French bond insurer recently bailed out after getting burned on derivatives.

Think we’ve got healthcare challenges? Malawi has 14 million people, of which 1 million are HIV positive, and only 280 doctors. Their answer: treatment protocols managed by non-physicians using touch screen clinical workstations (developed in Ruby on Rails) at the point of care. Scroll down for several YouTube demos. It would never work here, of course, because vendors couldn’t load it down with proprietary bells and whistles to boost the price. Still, you have to like this quote extolling the virtues of designing systems to take the use through a consistent, guided function (which I always argue in saying that charting a med should be as easy as the import wizard in Excel): "If the system is useful, then other people want to use the system. This is a nice problem that gets solved with…training! But soon, the developer notices that users keep using the system in a way that was totally unexpected. Time for another training session… But there is another approach that doesn’t rely on training. They are called constraints … The amount of training required is usually inversely proportional to the number of constraints in the system.."

Two sides of a Connecticut hospital’s proposed health information exchange. Pro: the hospital is raising money for the $8 million project and hopes the federal government will pay for it while it’s slinging money around. Con: the president of the state medical society says the government shouldn’t pay because mandated physician usage would just make the state’s doctor shortage worse because they’d steer clear of Connecticut.

Debbie Turpin, clinical systems manager at Alton Memorial Hospital (IL), is named chief nurse executive.

Odd lawsuit: a mentally disturbed female prisoner is taken by corrections officers to a hospital for psychiatric treatment, where she "went berserk" and bit the nurse’s hand. The officers watched and did nothing, later saying they believed it was outside their jurisdiction. The nurse is suing the city.

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