Monday Morning Update 8/22/11

From Hot Off the Press: “Re: Cal eConnect. President and CEO Carladenise Edwards PhD steps down.” HOTP forwarded her e-mail from late Friday afternoon announcing her transition to senior advisor of the HIE organization due to “personal reasons.” Cal eConnect was created when California’s HHS department, overseer of $39 million in federal HIE grant money, decided to form a new statewide oversight organization instead of supporting CalRHIO, effectively shutting that organization down in January 2010. TechLeader obtained information suggesting that earlier last week, Cal eConnect suspended its RFP for a provider directory service, with no bidder selected.

From THB: “Re: tax-exempt hospitals. A potential trend?” Three non-profit Chicago area hospitals express shock that the Illinois Department of Revenue has denied their tax-exempt status requests, ruling that they aren’t owned by charitable organizations and aren’t being used for primarily charitable purposes and therefore must pay property taxes like any other business. The state said the hospitals didn’t list uncompensated care on their requests, but did in their own records: Prentice Women’s at Northwestern (1.85% – pictured above), Edward (1.04%), and Decatur Memorial (0.96%). The state says it won’t set a minimum charity percentage, although one legislator is sponsoring a bill that would require at least 3.5% of total revenue. Just for fun, I checked the IRS forms of Edward Hospital: it made a profit of $25 million in the most recent year, paid the CEO $1.6 million, and claimed it provided $45 million in charity care.

From The PACS Designer: “Re: IBM’s 100th anniversary. Most all of us have encountered business relationships with IBM in our work careers. TPD first learned about IBM solutions in the early 1960s while getting educated to be an electronics engineer by being trained on the use of an IBM vacuum tube computer. Later in my electronics career, I worked with IBM to interface the IBM Shark information storage system to a PACS to create one of the first central archives for all hospital information including imaging files.  InformationWeek recently published a video history of IBM’s 100 years.”

Thanks to a few of my overachieving sponsors who have already swapped out their animated ads with a static replacement, well in advance of the January 1 deadline I set to allow them plenty of time. I appreciate it, as do those many readers who requested that change.

Over 60% of respondents agree with the recommendation of Congresswoman Renee Ellmers that HHS study EMR effectiveness and impact on patient safety. New poll to your right: does Epic CEO Judy Faulkner have too much influence on federal government healthcare IT decisions?

Listening (and watching): reader-recommended Live from Daryl’s House, a fascinating Internet program created by (and paid for by) the first half of Hall and Oates. I hated the 80s poofy-haired, “blue-eyed soul” dreck they did and was kind of hoping he’d been reduced to unpaid gigging at the Paducah Holiday Inn, but I now want to be Daryl Hall: inviting all kinds of big music names to jam with him in a barn-like room of his $16 million spread, drinking wine, bringing in guest chefs to cook for them, having scintillating dinner conversations, and recording the whole thing as a homebrew reality show. The audio and video quality are amazing, the guests compelling. My favorites so far have been Grace Potter and the Nocturnals and Krieger / Manzarek of The Doors, with whom Hall does just fine vocal work on my favorite Doors tune, The Crystal Ship. He’s 64, rich, and living large, just playing his music to an Internet audience. I’ll grumblingly admit that even the versions of Hall and Oates tunes he and his guests covered (like the insipid Sara Smile) sound amazing and fresh. I wish I could be that cool.

I swear that Vince Ciotti is digging deeper into company histories with every new HIStory chapter, finding veterans willing to share their previously untold stories. This time he  covers a company I don’t remember: Sentry Data. Upcoming are these vendors: AR/Mediquest, JSData, and Gerber-Alley, so if you have war stories to tell about them, Vince is your guy.

Urology EHR vendor meridianEMR files a lawsuit and gets a restraining order against competitor Intuitive Medical Software (UroChart), claiming UroChart cloned one of its servers and thereby gained illegal access to meridianEMR’s product and the protected health information stored by its clients.

The weekly employee e-mail from Kaiser honcho George Halvorson talks up their first iPhone app, KP Locator, which he says is “the next connectivity path on a journey that is turning into a superhighway of connectivity over time.” He says it’s the first of many that will be built and invites employees to send him ideas for the next round.

An article in Silicon Valley / San Jose Business Journal details how much local hospitals are spending on EMRs. Factoids: (a) 403-bed Mills-Peninsula Hospital spent $50-75 million; (b) six Daughters of Charity hospitals spent a total of $80-90 million; (c) Stanford says it’s spending 30% of its total available capital each year to implement EMRs; (d) Stanford also spent $13 million to hire a 100-member temporary go-live team for three weeks, which must be a misprint or an incomplete description since that’s over $800 per hour;  (e) O’Connor Hospital spent $2-3 million on EMR training; (f) Mills-Peninsula expects to spend 2.5% of the hospital’s entire budget each year in perpetuity for EMR maintenance.

Beth Israel Deaconess reportedly offers its CEO job to Kevin Tabb, chief medical officer at Stanford Hospitals and Clinics, who would replace the ousted Paul Levy. He’s an internist, but went into healthcare IT straight out of residency as a clinical informatics analyst for iKnowMed, a data director for MedicaLogic, president of clinical data services for GE Healthcare, and then chief quality officer / CMIO for Stanford. Sounds like he would be a geeky kindred spirit for CIO John Halamka there.

Asante Health System (OR) chooses Epic, saying “only one vendor had an integrated solution for hospitals and physician offices, and that was Epic.” They also added that Epic puts 47% of earnings back into R&D and has less than 2% of its workforce involved in sales and marketing.

Thirteen Danish hospitals announce plans to migrate their 25,000 employees from unnamed proprietary office software (care to take a guess?) to the open source LibreOffice, a fork of OpenOffice.org.

A computer professor in England enlists the help of his colleagues to create a computer game to help his four-year-old daughter, who has cystic fibrosis. She can control on-screen graphics by breathing into a PEP mask, which forces her airways open, an otherwise monotonous exercise that kids don’t enjoy. Her doctor can review her game results to determine how her lungs are doing. The group hopes to have the game tested and available to the public within a year.

Former Allscripts COO Ben Bulkley is running Fluidnet, a Massachusetts-based IV infusion control system vendor that just raised $25 million in investment capital.

HP wants out of the consumer computer business, but its systems work isn’t such a hit in Ohio either, where the Medicaid Information Technology System that went live on August 2 is inappropriately denying payments to providers, improperly kicking patients off assistance programs, and causing prescriptions to go unfilled by rejecting the Medicaid bills from pharmacies. Rep. Dennis Kucinich will meet with CMS administrator Don Berwick on Tuesday.

Regulation of EMRs by FDA
By Tim Gee

In the HIMSS top nine trends to watch in health IT, they missed a big one: the regulation of EMRs and other applications by the FDA, and potentially transforming providers into medical device manufacturers.

Between the final MDDS rule (which called out hospitals as potential regulated medical device manufacturers) and public testimony by Jeff Shuren, director of CDRH at FDA that the FDA intends to regulate at least some EMR software, healthcare IT is going to be coming to grips with FDA regulations for some time to come.

How many hospitals have written software to acquire data from medical devices? I’d guess over 100. I’ve heard estimates from sources that FDA expects to be regulating thousands of new manufacturers in the near term.

Since the final MDDS rule was published, four providers have registered with FDA as medical device manufacturers and listed their MDDS products with FDA. The providers are Partners, Gundersen Lutheran, Intermountain Health, and the Alaska Native Tribal Health Consortium.

And when FDA regulates portions of EMRs (they’ve set their sights on decision support systems first), providers who modify their EMR applications may be transformed into medical device manufacturers and become regulated, too. How many early adopter hospitals have have written their own DSS from scratch? They, too are likely to become regulated medical device manufacturers.

The MDDS rule was the shot across the bow. Expect a draft guidance document from FDA on regulating EMRs late this year. Yes, FDA will go slow, but responding will be like turning a battleship – it will take a while and require substantial effort in some cases.
In the next two or three years, I’ll bet most hospitals will be looking to hire regulatory affairs / quality assurance directors, and many hospitals may be rethinking their wholesale modification of HIT apps they purchase, not to mention foregoing rolling their own apps.

E-mail Mr. H.

Time Capsule: Consider Funding Health IT Projects Like Bill Gates Would

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

I wrote this piece in June 2006.

Consider Funding Health IT Projects Like Bill Gates Would
by Mr. HIStalk

It’s no longer news when a big, non-profit integrated delivery network pays a CEO $1 million or a CIO makes $300K for running a small department. We’ve come a long way since the days when ministering to the sick was a calling, where selfless caregivers toiled for a subsistence wage in service to mankind. And why not, since a big IDN can make hundreds of millions of dollars in profit (sorry, “surplus”) in a good year? Once nuns got replaced by MBAs, hospitals became a big business, feeling quite unlike charities to those working inside them. The only surprise in the IRS’s questioning of whether hospitals deserve tax-exempt status is that it took them so long.

VP panic ensues when the local newspaper prints executive salaries, fiscal year results, or drawings of the latest vanity construction project. Nurses may be de-motivated. Unions might be called in. A bitter janitor might key all the luxury cars in reserved spots. Beaten-down doctors may get even crankier when they find out that even bottom-feeding HR and marketing VPs out-earn them.

I thought of this when I read that Bill Gates and Warren Buffet will turn over their billions to serve those in need. I’ve worked in hospitals and IDNs for many years. Are we good stewards of charitable dollars, efficiently funneling them directly to those in need with minimal administrative overhead and waste? That’s how you evaluate a charity, and on that basis, IDNs don’t seem to compete very well. We’re no Salvation Army, with tiny salaries and a focused mission.

Still, another headline gave me an idea. Studies are proving what we all knew: RHIOs can’t survive without charity. If RHIOs provide benefits to patients, yet offer no hope of financial self-sufficiency, then maybe that’s a good and direct use of charitable dollars. Put a few million long-term dollars into some well-organized RHIOs and see what happens.

I like this because Gates’s charity is notoriously efficient. You compete with other causes under rigorous conditions on how well your project will benefit society. RHIOs would have to prove themselves worthy of funding, which would be an interesting exercise in itself given their sketchy “let’s put on a show” origins.

What other health care IT projects deserve charitable consideration? I’d vote for a center for usability research to make health care software more user-friendly and less training-intensive. I like the idea of a free clearinghouse for clinical rules, knowledge, and content to be shared by non-profit hospitals. Maybe we need a patient safety organization just for IT, watching out for problems caused by poorly-designed software and medical technology. Perhaps a non-profit medical informatics consulting organization could help hospitals with an occasional need for that expertise..

If you’re involved in hospital IT, my advice is to review your projects like the Gates Foundation would. Are they ingenious, cost-effective, highly beneficial to patients, and highly likely to succeed? If so, put your resources into those.

In the meantime, here’s my challenge to you. Come up with a list of health care IT projects that are noble causes, benefiting a large population in a way that the free market and the government haven’t. What IT-related work would be ingenious, cost-effective, highly beneficial, and highly deliverable enough to pass scrutiny from the Gates Foundation? Send them my way and maybe we’ll talk about them in a future article.

News 8/19/11

Top News

General Dynamics will acquire federal healthcare software vendor Vangent for $960 million, the company announced this week. Says the General Dynamics chairman and CEO, “Vangent is a well-regarded, fast-growing company that will add significant depth and breadth to General Dynamics’ healthcare IT organization, creating a Tier 1-level healthcare IT business unit with the scope and scale to compete in markets that are receiving high priority in current funding and entitlement-reform initiatives” The Arlington, VA-based Vangent, which has 7,500 employees, does work for HHS and the military. It developed the Army’s MC4 battlefield EMR. Kerry Weems, SVP and GM of Vangent’s Health Solutions business, joined the company in 2009 when he left his government position as head of CMS. He was also vice chairman of the American Health Information Community.

Reader Comments

 

From Watchdog: “Re: HIMSS. Pictures of its new headquarters in the financial district of Chicago. They also hired Steve Rosenfield as executive vice president / managing director of HIMSS Media, a new position and department, and seek an associate manager of social media to improve the society’s ‘positive visibility.’ All that was required is an Associate’s Degree.” Steve doesn’t appear to have a degree, but did write co-write this book documenting the late 70s history of an influential Long Island club that includes photos and an audio CD of the folks who performed there (Springsteen, Aerosmith, Rick Derringer, Stanley Clarke, etc.)

From One Of Their Hospitals: “Re: MDG Medical. The support numbers are no longer in service.” I ran this reader’s rumor last week, in which he said his hospital’s pharmacy got word from the pharmacy dispensing automation vendor that they would close their doors last Friday. I said I wouldn’t name them until I checked to see if the phones were disconnected. Sure enough, the support number and PBX option now give a fast busy. The Israel-based company opened an office in Beachwood, OH in 2001 and moved its corporate headquarters to Aurora, OH in 2010. It claims to have 150 hospital customers and was announcing expansion plans as recently as October. I can’t verify anything other than that their support numbers aren’t working and they didn’t respond to my earlier e-mail asking about the rumor.

From Wildcat Well: “Re: RECs. There have been claims that healthcare IT will be the primary sector for job creation. Does it count when a REC receives funds from ONC, the REC coordinator contracts for systems integration work with ‘local’ vendors, and the jobs are filled through the overseas facilities of those vendors? We may just be stupid enough to deserve the mess we are in.”

From Hate Manual Entry: “Re: Sage Healthcare. Rumor is they bought a SaaS-based HER from a recently bankrupted company. Any others hearing the same?” We asked Sage, which said that for competitive reasons, they don’t comment on acquisitions or technologies that may or may not be under consideration.

From Laura: “Re: Joplin. I’m sure you’ve seen that Mercy has announced plans to rebuild in Joplin. They have kept employees on the payroll since the May tornado and raised $500 million in a co-worker fund to help with expenses.” The 28-hospital Mercy (formerly called Sisters of Mercy) will spend $950 million to build a new 327-bed hospital in Joplin. They’re an Epic shop, I believe.

HIStalk Announcements and Requests

Check out the good stuff on HIStalk Practice: Don Michaels of Hayes Management Consulting and the Harvard School of Public Health weighs in on ACOs and the results of CMS’s demonstration project. Julie McGovern of Practice Wise offers recommendations for providers upgrading their software. Rob Culbert of Culbert Healthcare Solutions suggests key performance indicators to assess a practice’s financial health. CMS provides a breakdown of EMR Meaningful Use payments by specialty and provider type. The GAO advises CMS on how to improve physician quality reporting. I’m a simple gal with simple needs and I’ll be simply thrilled if you sign up for e-mail updates while visiting HIStalk Practice.

On the Job Board: Project Manager I, Epic and Cerner Consultants, Senior Enterprise Sales Executive.

Acquisitions, Funding, Business, and Stock

drchrono closes an additional $650K in seed funding and announces the release of OnPatient, a free patient check-in app for the iPad.

Deloitte acquires the assets of Intrasphere Technologies, a New Jersey drug safety and regulatory consulting company that also offers R&D informatics software for registering clinical trials.

HP announces a restructuring that includes ceasing production of tablet computers and smart phones, trying to sell its PC business, and spending $10 billion to acquire British search technology vendor Autonomy at a 64% premium to its share price. The HP Touchpad has barely been on the market for a month. The announcement probably signals the inglorious end of Palm, which HP bought last year for $1.8 billion before phasing out the brand.

Sales

The University of Chicago Medical Center will implement Omnicell’s Inventory Management Carousels with WorkflowRx software for inventory management and Omincell’s automated dispending system.

Imprivata announces that 12 Siemens customers have chosen its OneSign single sign-on.

Stamford Hospital (CT) will implement SmartRoom technology in all of its patient rooms, which provides real-time patient and RTLS information on an in-room monitor and provides touch-screen documentation capability. SmartRoom was developed by UPMC, which owns the company.  

Evergreen Healthcare (WA) chooses Cerner clinical systems.

People

 

Healthcare software vendor Net.Orange names Rob Beardall MD, MPH as EVP/Chief Medical Officer and Troy Roth as SVP of solutions strategy. They come from Health Synectics LTD and MedAssets, respectively.

Paula Guy, CEO of Georgia Partnership for TeleHealth, joins the board of the Georgia Health Information Exchange.

Announcements and Implementations

Arkansas critical care hospitals Piggot Community Hospital, DeWitt Hospital, Delta Memorial Hospital, and Chicot Memorial Medical Center select Healthland.

Nine hospital systems in Western Pennsylvania partner to create the ClincalConnect HIE. dbMotion will supply the infrastructure for the $4 million project.

The radiology department of University of Utah Health Care reports that its use of artificial intelligence resource management software from Allocade reduced overtime cost by 90% and overall FTE expenses by 10-15%.

Miami-based EMR vendor CareCloud says it has tripled headcount in the past year to 80 and will bring on another 30 employees by the end of the year.

Government and Politics

The VA issues an RFI for cloud-based collaboration tools for its entire workforce. They plan to pilot document sharing and calendar applications with 5,000 physicians, potentially replacing Outlook and Exchange, SharePoint, and Jive Software for all of their employees if the pilot is successful.

Other

I got an earful from my doctor and his office manager today about their “horrible” EMR. Since purchasing it a year and a half ago, they’ve suffered through performance issues, upgrades problems, inadequate templates, and many unexpected expenses. The Meaningful Use money, which they’ll receive this month, covers the EMR’s cost but not the $10K per year for maintenance. The doctor blames the vendor, which has been around for less than five years, for releasing an immature product. I checked their Web site and it looks like the latest and greatest. I wonder how often providers opt for bleeding edge, only to later regret not buying the tried and true option?

Here’s a video showing the Texas Health Resources group that climbed Mount Kilimanjaro (including Ed Marx) opening a medical clinic in a Tanzanian village a few weeks ago.

A drug company’s laid-off IT tech pleads guilty to extracting his revenge by wiping out most of the company’s electronic systems while he still had access as a contractor. The drug company lost e-mail, inventory systems, and payroll capabilities, crippling it for several days at an estimated cost of $800K. The tech faces 10 years in prison.

The FBI subpoenas Parkland Memorial Hospital (TX) and its IT department, seeking records related to a former Dallas County commissioner and a telecommunications system business owned by a close friend. According to the Department of Justice, the investigation involves “allegations of public corruption, tax evasion, and money laundering.” The telecommunications company got $3 million worth of consulting work from Parkland and UT Southwestern Medical Center. Another of its customers, the local toll authority, paid $47,500 for a no-bid consulting report that basically said “your equipment needs to be replaced” and included graphics lifted directly from another company’s 12-year-old product manual.

In Ireland, an interim examiner is appointed to review three hospital software vendors that have claimed insolvency, putting the electronic records of 10 million patients at risk. The companies operate under the name IMS Maxims.

French software vendor Atos Healthcare, whose software is used in England to evaluate disability claimants, investigates two employees (one of them a nurse) for their Facebook comments about those claimants, which they characterized as “down and outs” and “parasitic wankers.”

Sponsor Updates

• Intelligent Medical Objects and dbMotion will participate in the Allscripts Client Experience next week.
• MEDSEEK’s eConnect HIE technology successfully connects the WNC Data Link (NC) HIE to the VA’s VistA.
• UCare selects RelayHealth’s Payer Connectivity Services (PCS) for its 230,000+ members.
• API Healthcare will exhibit at the ASHHRA annual conference in Phoenix next month.
• Healthcare Innovative Solutions VP Daniela Mahoney, RN, will present Best Practices in CPOE Deployment Strategies, and Physician Resistance, Adoption and Value Proposition at the Kansas Hospital Association: Meaningful Use Summit, and Executing Key Plays: How Team Members Must Adapt to Succeed at SC Hospital Association the TAP Conference.
• TeleTracking Technologies is offering a free Patient Flow symposium in Raleigh, NC next month.
• Nuance Communications unveils Dragon Medical Practice Edition, which targets the needs of physicians in practices smaller than 25 providers.
• OptumInsight’s Axolotl EMR Lite, version 9.2 receives ONC-ATCB certification as a complete ambulatory EHR.
• A healthcare claims review company implements Symantec’s PGP Whole Disk Encryption to meet HIPAA requirements, claiming a one-month payback period after switching from free encryption software that was killing employee productivity.

EPtalk by Dr. Jayne

I returned home from my most recent sojourn to find the only thing I hate worse than filing my taxes or a root canal — a re-credentialing packet for my hospital privileges. Despite our health system’s large IT department and our belief that we are high tech, the credentialing process is decidedly low tech.

When I was a practicing physician, my practice manager took care of the application and applied sticky flags to areas that needed review or my signature. But now that I’ve crossed to the dark side of information technology, there’s no one in my organizational tree who has any idea how to do these, so I have the pleasure. I think next year I might just ask my former staffer if she’d be willing to do it for cash (as an independent contractor, of course — I’m not about to run afoul of the IRS.)

Under the 26-page “standard” credentialing form was an additional 22 pages of forms to be completed. They had been photocopied so many times they were practically illegible. Lurking at the bottom of the stack were several nearly identical sets of privilege forms for the different hospitals at which I am on staff, one for each facility (heaven forbid they share information from a central repository or from the master application itself.)

I find it slightly humorous that I still hold privileges for OB labor and delivery as well as operative circumcision despite having not performed either procedure in quite some time. Oh yes, and I can also pierce the earlobes of inpatients if I so choose.

In addition, they want a copy of my Curriculum Vitae and documentation of my Continuing Medical Education hours, which along with everything else has to be returned on paper and by mail. Seriously. Everything else we do in the hospital is electronic – CPOE, patient recordkeeping, even patient meal selections done on a touch-screen at the bedside. Except this.

When it comes to the concept of ensuring that physicians have accurate and up-to-date data before approving them to start or continue seeing patients at a facility, we’ve gone back to 1956. (Actually, 1956 was probably easier – you could most likely have just hung your diploma on the wall and started seeing people.)

If this would have been an online process, I’d have knocked it out right away while lounging on the sofa with some quality Netflix and recuperating from my travels. But instead, it goes on the dreaded ‘pile’ somewhere between the bill from the local lawn care guy and the student loan payment coupon, both paper-based businesses.

Turning to health IT news, legislators on the House Energy and Commerce Committee have asked the Government Accountability Office to review Federal Communications Commission efforts to ensure the safety of wireless medical devices. Their request featured discussion of the recent demo where an insulin pump was hacked and hijacked. As I was reading this piece, I envisioned a flashing “As Seen On HIStalk” seal of approval.

Finally, a reader question. It’s been a long time since we have had one and I do enjoy them (hint, hint).

Dear Dr. Jayne,

Is the new Chest-Compression-Only method of CPR taking hold, or is there some resistance to it? I still see classes offered in the older method and have to wonder… why? What do you think?

Breathless but Hearty

Dear Hearty Reader,

I think overall, more data is needed. When I completed my certifications for CPR and advanced life support (both cardiac and trauma) as well as pediatric life support a few months ago, traditional CPR was required. The American Red Cross issued a statement last year about compression-only CPR, stating:

“…Compression-Only CPR until an AED [Automated Extermal Defibrillator] is available is an acceptable alternative for those who are unwilling, unable, or not trained to perform CPR.”

I tend to agree with them. The idea of CPR is that you want to prevent brain death, and unless you’re oxygenating the blood by getting air into the lungs then circulating it with compressions, you’re not going to be as successful if oxygen levels remain low.

On the other hand, if it’s the difference between CPR not being done because a bystander isn’t sure how to do it correctly or is worried about communicable diseases or some of the more unpleasant side effects of bystander CPR, then I think compressions alone are better than nothing.

The American Heart Association offers a trademarked “Hands-Only CPR” method that’s demonstrated on their website. I like their bullet point: “Don’t be afraid. Your actions can only help.” Regardless, knowing the legal world, I offer this advice — if you’re trained in traditional CPR and have no other reason not to do it, traditional CPR should be your first choice. I’d hate to get into a “standard of care” discussion on this one.

Jayne

Have a question about LOINC codes, the Russell Viper Venom time assay, or whether snakebite extraction kits really work? E-mail me.

Contacts

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

CIO Unplugged 8/17/11

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

Connect.

One thing that differentiates top performers from peers is neither skill nor experience — it’s talent. One key talent is compassion. Top performers connect their skills with compassion. They link their hearts to their brains. Connection is the difference maker.

As a leader, how do I help make that connection for my team? How do I create an environment where we can cultivate compassion? How do I help them view their job as more than a paycheck, but as a contribution to a patient’s life?

A motivational speech might spike emotions for a day or two, but I need something with a longer half-life. I need an approach that transcends mental understanding, a connection so strong that synapses will rewire and link the brain to the heart and infect the soul. Forever.

The single most effective method I have leveraged is what I term Connections. I have employed Connections for eight years, at two different organizations. The remarkable happens when you remove the physical barriers between clinicians and those who support them.

A programmer’s heart changes when he sees the impact of his code on a patient. When a service desk agent sees the face of the physician she’d helped navigate through the electronic health record, her heart expands. Sympathy awakens in the data center engineer when he learns from a nurse that patient outcomes improve because of the technology delivered with zero downtime. And an administrative assistant understands the urgency of communication when she personally witnesses the life and death stress.

Our brains tap into our hearts. Compassion-infused work follows.

Outcomes

• The clinicians who are shadowed learn more about technology. They learn that we care and that they have this incredible support structure surrounding them. This aspect is almost as beneficial as the Connections themselves.
• Relationships develop and then are cultivated, creating a family-oriented culture.
• Respect from operational leaders increases because they see that you care enough to take such action.
• While not scientifically validated, there appears to be an overall correlation between organizational outcomes and Connections.
• As Connections form, employee engagement rises, creating and nurturing new talents.

Employee Transformation Testimonies

• “I must admit, I hated this idea but did it because I had to. I have worked here for 20 years and for the first time I realized we have patients. Of course I knew what we did as a hospital but really, this was incredibly impacting and I will never be the same.” (Programmer)
• “I am not the same today as yesterday.” (Network Engineer)
• “I volunteered to observe in the OB unit. With clinician and patient consent, I witnessed the birth of twin babies. I never realized all the behind the scenes coordination required and it opened my eyes to a whole new world.” (Admin Assistant)
• “I never saw myself as part of the patient care process until now.” (Field Support)
• “My life is changed. I always wanted to be care giver but didn’t like blood so chose a different path in technology. Now I tell people I am both.” (Application Analyst)
• “I run marathons. I was more exhausted shadowing a nurse today. I never knew.” (Project Manager)
• “In one day I witnessed the joy of healing and the pain of death. I now see how critical IT is and why we need to be the best that we can be to support the front lines.” (Business Analyst)
• “I am a nurse and did not see why I had to take part in Connections. After today, it was like I was hit by a ton of bricks! Wake up call! Thank you, thank you, thank you.” (Application Analyst)
• “The experience is another reminder that the bigger picture of our health system, being a body of entities, departments and individuals, come together for the patients to have one more beat of life.” (Data Center Operator)
• “The experience was one that I am very thankful to have participated in and I can’t wait to do it all over again next year.” (Application Manager)
• “Patient care was the core focus of every area. It was really great to see the patients and what we really work for. Connections reminds us of what is truly important and why we do what we do (Security Analyst)
• “There is a lot of new technology on the floor and it’s cool to see how all the parts fit together to make the whole. People working with people and technology involved to make health care better.” (Business Analyst)
• “This is my second Connections, and every time I get a much more vivid idea of how my contributions and duties make a difference and reaffirms the promise to our community and the people we serve.” (Data Center Operator)
• “Clinicians are the reason we all have jobs, and I thank them for all of their hard work.” (Business Applications Manager)
• “It was very educational for me to see what the nurses and physicians do and how they use technology in their environment. It’s always a good thing for people working in technology to understand the business they support. Glad I had the opportunity. (Data Center Manager)
• “I have worked at 4 different health care organizations in 3 different states and this is the first time I have seen a program like this. I am proud to work here.” (Application Analyst)
• “Given what I saw I can’t begin to imagine how stressful their work must be. We need to do everything we possibly can to make it less so.” (Vice President)

I love a great speech and giving out raises and bonuses. But evidence suggests these have fleeting influence on performance and certainly do not develop compassion. In fact, some studies indicate the enthusiasm over a raise lasts two weeks.

I speculate this is because money only engages the brain. Conversely, transforming a person’s way of thinking and view of themselves results in long-term effects and a new person. Even the hardest of hearts and the most gifted intellectual will begin to view things differently. Once they’ve Connected.

***Leave a comment and I will send you a simple 10-step process for successfully setting up your own Connections program at your organization.

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

News 8/17/11

Top News

The VA has been on-again, off-again on whether it will build or buy a replacement for its VistA system, but former deputy CIO Ed Meagher says the VA and DoD may pay companies billions to write a new open source system. He now works for CSC, one of the contractors hoping to get the VA’s business. I knew the VA recently issued a $5 million contract to create an open source community for the VistA replacement and had previously announced plans to go that route, but I haven’t heard a definitive final word, especially when a group of Epic-friendly politicians is pushing the VA to look at commercial systems. The article’s choice of experts to quote about vendor products is questionable: Allscripts has done a great job creating an open architecture platform (according to an investment firm analyst who just put a Buy rating on MDRX shares) and GE Healthcare could work well in the VA’s environment (according to a government sales guy from GE Healthcare).

Reader Comments

From Too Big for my Breaches: “Re: yet another data breach. I’m getting tired of hearing about these.” St. Francis Hospital (DE) apologizes for a doctor’s loss of a thumb drive containing information on 474 maternity patients. He lost it in the spring, but someone mailed it back to him on June and he didn’t report it until then, pushing the hospital’s 60-day deadline to report the loss. The doctor was authorized to copy the information but violated hospital policy by not encrypting the drive. He must have been researching old cases — the hospital says the in utero babies whose records he copied are now nine or 10 years old.

From Victory at Sea: “Re: UAB. I believe that most people in healthcare are honest and want to help people, but there’s a lot of money rolling around inside these organizations (vendors too) and temptation is always to be found for those who are open to it.” The FBI launches an investigation into Alabama’s only organ donation center, UAB-run Alabama Organ Center, after discovering that its director and associated director had an “improper financial relationship with a vendor.” UAB has fired the employees and parted ways with the unnamed vendor.

From TxPathDr: “Re: Jason Dufner. Anyboy else notice that he had a Greenway Medical logo on his chest for the PGA tournament in Atlanta this week? I can’t remember ever seeing an EMR company logo on a golfer before.” Greenway struck a deal a few weeks back to have him wear their logo and be available for marketing and company-sponsored events. The green logo really pops on his pink shirt.

From A CEO: “Re: our interview. Questions I get from healthcare trade rags and the financial press are vanilla – my sense is the editors / journalists are just trying to get their stories written vs. trying to arrive at insights relevant to their readership. I found your questions intellectually stimulating. Keep doing what you are doing – we appreciate it.” Thanks, both for doing the interview and for the nice words. I don’t like asking stupid questions, at least when I can help it, so I treat my interviews as a conversation. As in most conversations, not everybody is fascinated by every interview of the hundreds I’ve done – it depends on their area of interest. As for me, everybody I’ve interviewed has taught me something.

From Bruce Werner: “Re: interview with our CEO, Mark Debnam. The HIStalk interview was a big success. Our Facebook ‘likes’ jumped significantly. We are proud to be part of the HIStalk family.” Mark of Quality IT Partners and I are both progressive music nerds, so we were nearly breathless in discussing the latest tours and albums from Yes and Asia, which I omitted from the interview transcript since, puzzlingly, not everybody is a fanboy for semi-obscure bands whose heyday was a couple of generations ago.

From Chillicothe: “Re: Epic. Wondering if you saw this?” Several readers sent over a link to that story in The Examiner, a free, conservative DC-area newspaper. It’s all rehash: Judy Faulkner of Epic was appointed to the HIT Policy Committee and Epic employees have given $300K to Democrats since 2006 (doesn’t sound like much for a company of that size). Surely nobody’s shocked that donors get some reciprocal back-scratching, like being appointed, but her spot was set aside as a vendor rep, so why not her? The article takes a somewhat slanted position that Epic isn’t open to interoperability (the article’s one quoted source to back that statement – CEO Glen Tullman of Epic competitor Allscripts, who is himself a lot better connected politically than Judy will ever be). The rag finds a hidden Obama agenda — the examples he’s given of well-run hospitals (Geisinger, Kaiser, Cleveland Clinic, and Mayo) are all Epic customers. One thing I might agree with: it would indeed be a bit suspicious if Epic got the VA’s bid (which doesn’t seem to be happening, at least at this moment) but otherwise, they’re getting plenty of business without government help. And yes, the Obama administration was mighty generous with our money in bribing providers to use EMRs they weren’t spending their own money on. 

From The PACS Designer: “Re: Toodledo. Will Weider of Candid CIO blog fame recently posted about a to-do listing app called Toodledo. You can get Toodledo versions for your mobile phone, as well as an app to add it to your e-mail, on your calendar, and integrate it directly into your web browser.” I’d be interested if it does recurring events and reminders. I don’t use Outlook at home and I’m finding Google Calendar to be pretty sucky when it comes to reminders. In fact, I’m becoming slowly annoyed at most things about Gmail and Google Docs – the spare design was cute at first, but everything feels clunky and I still don’t like the “conversation” design of Gmail since I’m always deleting entire message threads by mistake.

Acquisitions, Funding, Business, and Stock

Intermedix, a provider of RCM services for emergency healthcare services, buys the assets of RCM-provider Comprehensive Medical Billing Solutions of Oklahoma City.

Axiom Systems acquires Ivertexo Internet Solutions, a provider of administrative software solutions for healthcare providers.

MedQuist Holdings announced Q2 numbers Tuesday morning: revenue flat, EPS $0.11 vs. -$0.06. Its acquisition of M*Modal gets clearance to be completed in August. MedQuist shares made the list of biggest Nasdaq losers Tuesday, down 18%. The company says it’s pushing more work offshore, but is being negatively impacted by customers sending work offshore themselves, by customers using speech recognition instead of transcription (which I’m sure is why they are buying speech recognition provider M*Modal for $130 million) , and by providers focusing on EHRs.

Vocera files SEC paperwork for its $80 million IPO.

Sales

Cooper County Memorial Hospital (MO) will spend $2.5 million for Meditech, which it selected over Cerner and Healthland. Hospital CEO Allen Waldo says, “Meditech won the contract because the hospital’s clinicians thought it was more user-friendly and had a better data recovery system.”

The VA awards ICS Nett and Beacon Enterprise Solutions Group a $3.4 million contract to provide the management and installation of an RTLS solution for tracking equipment, supplies, implants, and surgical instruments.

St. Joseph’s Medical Center (CA) selects PerfectServe’s voice, mobile, and Web-based clinical communications system.

The Australian government chooses a consortium of eight firms to participate in the infrastructure build of its $466.7 million personally controlled electronic health record (PCEHR). Winners include Accenture ($47.8 million), Oracle ($17.8 million), and Orion Health ($11 million) along with sub-contractors Telstra, Cerner, ThinkPlace, Extensia, and Ocean Informatics.

People

Lehigh Valley Health Network promotes Donald L. Levick, MD, MBA to CMIO.

Former McKesson Health Solutions CFO and VP Peter P. Csapo will join VHA as CFO.

Beebe Medical Center (DE) names Jeffrey Hawtof, MD VP of medical operations and informatics.

Kevin Groskreutz is promoted to CIO of Hospital Sisters Health System Western Wisconsin.

Bassett Healthcare (NY) names Scott Groom VP/CIO. He was previously with Cabell Huntington Hospital (WV).

Announcements and Implementations

Resurrection Health Care (IL) goes live on its system-wide Epic implementation with the activation of billing and scheduling at 20 ambulatory care clinics. The practices will add EMR over the next six to eight months;  the first of six hospitals will begin go-lives in the fall.

Zynx Health announces two enhancements to its clinical decision support technology: Workflow Management to streamline content development and Export Validation to allow Cerner CPOE users to validate order sets before exporting them.

Vital Images / Toshiba gets 510(k) clearance for its VitreaView browser-based universal patient imaging viewer, which allows EMR and HIE users to view all patient images. It was announced in June.

Government and Politics

President Obama announces new economic initiatives to spur growth and create jobs in rural areas, including loan programs to enable hospitals to purchase HIT. The administration also announces a loan repayment program for more than 1,300 small, rural hospitals to recruit new physicians. The White House estimates that the addition of one new primary care physician in a rural community generates $1.5 million in annual revenue and creates 23 jobs annually.

FDA will hold a public workshop seeking input on what types of mobile medical applications it should regulate on September 12-13 in Silver Spring, MD. This follows FDA’s July draft guidance on that topic.

Other

A proposed compost facility in Freetown, MA is stinking up Meditech’s plan to develop a new office building that could bring 800 jobs to the area. The city is looking into the issue.

CEO compensation at Boston’s nonprofit teaching hospitals is leveling off, with 2009 pay equal to or less than the previous year’s. Elaine S. Ullian, the former CEO of Boston Medical Center experienced one of the biggest declines: $1.8 million in 2009 compared to $4.8 million in 2009.

About 40% of EDs in urban areas e-prescribe compared to just 6% in rural areas.

I’m loving the site (sites, actually: this one and this one) of Atlanta anesthesiologist Michelle Au MD, author of This Won’t Hurt a Bit (And Other White Lies): My Education in Medicine and Motherhood. She’s darned funny, describing her book as: “It contains ‘pages’ and ‘words.’ I done wrote it.’” But if you’re on the fence as to whether she’s wickedly humorous, click the graphic above to enlarge. Brilliant. I think I’ll buy the book.

Vince Ciotti (and I) would approve: McKesson joins The IT History Society as a corporate member.  

Another highly paid non-profit hospital CEO: the head of a 326-bed Brooklyn hospital made $4 million in 2009 while laying off employees and closing clinics that served its predominantly Medicaid patient population. The board gave the usual “market rate” excuse.

Sponsor Updates

• Memorial Sloan-Kettering Cancer Center (TX) signs an enterprise license agreement for iSirona’s device connectivity solution.
• Canterbury District Health Board (NZ) partners with Orion Health to provide secure access to patient information.
• Capsule is exhibiting at this month’s Allscripts Client Experience 2011.
• Capario launches a new Web site, blog, and social media presence on Twitter, Facebook, and LinkedIn.
• Scott Besler of Besler Consulting will discuss New Cost Report Changes at next month’s HFMA NJ’s quarterly meeting.
• NextGen announces a webinar and live demo for its digital pen solution, NextPen.
• MedPlus will exhibit at Epic’s 2011 Users’ Group Meeting in September.
• Practice Fusion’s Research Division releases a list of most-prescribed drugs, derived from its EMR database.
• The 25-bed critical access hospital Lakewood Health System (MN) selects McKesson’s Paragon HIS.
• Billian’s HealthDATA publishes a white paper called Providers’ Perceptions: Mobility in Healthcare.
• Eisenhower Medical Center (CA) contracts with Wolters Kluwer Health for its ProVation gastroenterology procedure documentation and coding software.
• The healthcare business of Thomson Reuters introduces Payment Reform Solutions to help hospitals adopt new payment methodologies.
• Kyle Swarts joins Culbert Healthcare Solutions as a regional sales executive.
• The District of Columbia Primary Care Association subscribes to CapSite’s online service, giving its network of providers the ability to identify technology pricing and packaging options.
• Kareo hires James Mathews its first VP of business development. He has worked for Sage Healthcare, Carefx, and WebMD.
• GE Healthcare will launch Centricity Business 5.0 at next week’s Centricity Business National Users’ Conference in Boston.

Contacts

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

Quality Systems Acquires CQI Solutions

Quality Systems, Inc. announced this afternoon that it will acquire CQI Solutions, Inc. of New Braunfels, TX, which offers hospital systems for surgery management and patient scheduling. CQI will become part of the NextGen Inpatient Solutions business of Quality Systems, with its applications offered as both standalone and integrated products. 

Steve Puckett, executive vice president of Quality Systems, was quoted in the announcement as saying, “We are pleased to extend our portfolio to meet these cross-departmental needs, demonstrating our commitment to the community and rural hospital marketplace. With the additional integration of our award-winning ambulatory solutions, our inpatient and ambulatory clients are now collecting critical data across the care continuum, helping them meet requirements of quality of care initiatives and current business drivers such as Meaningful Use, where clients have already earned in excess of $5 million in incentives.”

Curbside Consult with Dr. Jayne 8/15/11

In the realm of medical devices, this is one of the coolest things I’ve seen in a long time. University of Illinois engineering professor John A. Rogers and team have designed a sensor that’s about as obtrusive as a temporary tattoo. Not only can it pick up biometric data, but when placed on the throat, it can sense differences in spoken words such as “stop” and “go,” as well as directional commands. Hot news for patients with muscular or neurological conditions, it appears in last week’s Science.

Pardon me while I embrace my inner physics geek, but the sensor adheres using the van der Waals force, which is what geckos use to climb glass. Sounds funny, but it’s a big deal for patients who are allergic to medical adhesives. Tuck that away for your next Trivia Night.

I came across too many juicy tidbits this week to hold them for EP Talk, so this week’s Curbside Consult is more newsy than usual. Some recent all-nighters and an insane volume of Meaningful-Use related work also may have caused my attention span to be so short I’m not sure I’m capable of crafting an entirely cohesive page-long feature at the moment.

And did I mention the not-so-subtle influence of Las Vegas, home of total sensory overload? (BTW, it’s chock full of Siemens people. I thought about crashing, but maybe some readers can send me reviews and commentary from the Innovations ’11 Customer Education Symposium.)

Now that some vendors have finally tweaked their systems to allow appropriate documentation, the World Health Organization declares the H1N1 “swine flu” pandemic over. It doesn’t mean that the virus has gone away, just that it no longer meets pandemic standards. As an IT person, this was a great litmus test for the ability of vendors to be nimble. Quite a few were able to load systems with the ability to document, treat, and track quickly; several were less fortunate. This isn’t the first time we’ve seen emerging diseases (remember SARS?) and certainly won’t be the last, but hopefully next time it will be easier for the end users.

The Patient Right to Know Act will bring back a controversial Illinois database housing information on physicians, including malpractice settlements and judgment information. The database and its associated Web-based tool went offline following an Illinois Supreme Court decision regarding a medical malpractice reform law. The database will contain information on over 46,000 physicians and should be online in a few months.

Speaking of state news, Kentucky and Ohio are banding together to share prescription data. KASPER, the Kentucky All Schedule Prescription Electronic Reporting system, will connect with the Ohio Automated Rx Reporting System, also known as OARRS. (Not to be confused with the band O.A.R., which if Mr. H hasn’t listened to them yet, he should check them out — their new album was released last week.) Focusing back on the topic, it sounds like a great idea, but I’m very interested in how it actually works for the doc who’s trying to figure out whether the patient is drug seeking. If anyone has details or first-hand knowledge, please share.

Athens Regional Medical Center in Georgia has seen a 15% rise in online scheduling since implementing a scannable Quick Response code in advertising materials. The code is different depending on where it is placed, allowing tracking for the most effective referral sources.

Speaking of smart phones, I’m liking Mobiledia right now. Sometimes I need a break from healthcare, and their recent piece on Chinese plans for an app to update People’s Liberation Army troops on the latest happenings was just what I needed. Watch out though – the site is fascinating but will take you Wonderland-style right down the rabbit hole. I quickly bypassed the blurb about the recent bust of counterfeit Apple stores straight to the one about the Chinese teenager who sold his kidney for an iPad 2. (I don’t think I’ve ever put three hyperlinks in the same paragraph, so you can tell how addicting it is.)

I just discovered this is the tail end (no pun intended) of the World Mermaid Convention, so I’m going to check that out. If it’s a bust, there’s the Official Star Trek convention as well. Viva Las Vegas!

E-mail Dr. Jayne.

Monday Morning Update 8/15/11

From Big Ragu: “Re: HHS CTO Todd Park. Gave a great speech at the Health 2.0 NYC meetup Friday. He was a really dynamic and engaging speaker and showed off some amazing projects from Health Data Palooza, sponsored by IOM and HHS.” He’s at the 51-minute mark of the video here.

From Wanderlust: “Re: [vendor name omitted]. Lackluster replacement for [former VP 1], internal political fights over who owns product strategy, no progress on new revenue cycle product, offices being consolidated, open platform not what was promised to partners, and a shaky start to integration as employees freak out about their long term job prospects. This employee is putting down my copy of Visual Studio and checking out Monster.com. But wait, another rumor is making the halls of the office that does create some hope. That rumor is that [former VP 1] and [former VP 2] may be returning.” All unverified. I’m doing some liberal expunging since obviously there’s no way the company can confirm or deny so I’m not comfortable just throwing it out there, but I’ll say that Wanderlust was mostly right on some items sent my way earlier this year. I just talked to [former VP 1] this week and didn’t get any feeling that a return was imminent, so I’ll attribute that last sentence to wishful thinking.

From HappyNotToBeAMcKessonite: “Re: McKesson. Loses another large system, this time in Albuquerque, to guess who? Good luck finding Epic specialists through job boards. This health system has been cheap in the past, so it’s interesting they have allocated $90 million for the project.” Unverified. The health system wasn’t named, but I assume it’s Presbyterian, which signed a much-touted $22 million Horizon and homecare deal way back in 2001, the same year McKesson bought the rights to Vanderbilt’s WizOrder and called it Horizon Expert Orders. Presbyterian has a lot of Epic jobs posted that look like inpatient, so you can draw your own conclusions.

From Melina: “Re: Siemens. Signed some new deals.” Listed in the announcement: Regional Medical Center (TN) signs up for Soarian Clinicals and Financials; Jefferson Regional Medical Center (PA) goes with Soarian Clinicals; St. Joseph’s Healthcare System (NJ) will migrate off INVISION to Soarian Clinicals and Financials; and University of South Alabama will move from INVISION Clinicals to Soarian Clinicals.

From PumpDoc: “Re: IV pump design errors. I think you have given readers the impression that my company’s Plum A+ pump was the cause of the errors and that’s not true. Can you please clarify? Ours doesn’t have the start button next to the zero and decimal point. I’m guessing someone just picked a stock pump picture to go with the story. Thanks – I am an avid reader!” Correct – I just put up a general picture of an IV pump that didn’t really have anything to do with the article, other than for someone who didn’t know what an IV pump looks like. The article didn’t implicate any particular brand of pump, so it wasn’t the Hospira pump, which as the full-sized picture above shows, has the Start button on the upper left.

From Lodi: “Re: new HIMSS certification. Seems to duplicate the HIT program.” The National Science Foundation is apparently paying HIMSS to develop an entry level certification program, Certified Specialist in Health Information & Management Systems, kind of a junior CPHIMS, which is itself kind of a junior everything (advanced degree, relevant experience, useful specific certifications like PMP or CISSP …) Would you really hire someone on the basis of a credential proving that they are “entry level?” I’ve yet to see any general certification that’s worth anything other than to ease the sometimes justifiable anguish of the resume’-insecure, but it’s their money.

From HIStalker: “Re: salaries. A $6 million hospital CEO!” A hospital CEO salary survey covering only the Midwest finds the pack led by 314-bed Children’s Mercy Hospital and Clinics (MO), which paid its CEO $6 million in the most recent year. Must be a terrible place to work if that’s what it takes to get someone to run it. Mercy Janesville paid $4.5 million, Advocate $4 million, and Northwestern $3.4 million. It’s bad enough when private industry CEOs make massive multiples of what the worker bees are paid, but absurd when talking about non-profit hospitals, all of which ironically anguish publicly over escalating healthcare costs. If public school systems or soup kitchens could bill Medicare, I suppose they’d be unnecessarily run by $2 million administrators.

Honky Cat was moved to wax poetic about HIStalk:

An Ode to HIStalk
It’s 9pm and my bourbon glass in reach;
Mouse, keyboard, email, and alas,
An alert from HIStalk breaches the still.
Curse your anonymity!
Show your face and be criticized.
Yet the rhythm of my heart accelerates.
For I know the contents will amaze and amuse;
I may learn one morsel of data,
One shard of vendor information,
That cuts deeply to the quick
And such as a participle, hangs with an airy loft.
Or, perhaps a CIO interview that portends the strategy versus the reality;
Inga and her shoes.
Could she be the muse?
What have I to lose?
There is meaningful use.

This week’s Time Capsule editorial from 2006 lauds the hard-nosed vendor negotiation style of former NPfIT head Richard Granger. A snip: “Granger holds firm and goes public when he has to, unafraid to rip recalcitrant vendors by name. I like to picture him as a Gordon Ramsay-type scrapper, happy to take someone down a notch when they need it.” Knowing now that NPfIT is pretty much ash-heaped, you might smirk that I was way off base, but I argue no: the real problem was that, despite all that aggressive negotiation and multi-billion dollar contracts, there just were not any contractors or vendors who could pull off their part of the project. They overcommitted and under-delivered, but in this case, poor performance hit them hard financially and they walked away. Granger’s threats were a bit hollow since there were only so many potential contractors out there and the pioneers were coming back with arrows in their backs.

Listening: Big Big Train, recent British progressive rock that sounds like 1970s Genesis before Phil Collins ruined it by selling out to make teen dance tracks. Think And Then There Were Three, from which “Undertow” is one of my favorite songs of all time with amazing music and lyrics. Big Big Train is right up there with them.

A slight majority of poll respondents think hospital CIOs wield undue influence over clinical system selection and implementation. New poll to your right: should HHS study the effectiveness of EMRs and their impact on medical errors as Congresswoman Ellmers has urged? Click the Comments link on the poll widget to explain your rationale if you are so inclined.

Am I the only one getting weary of announcements proclaiming that XX hospital or practice is the first in some state to get Meaningful Use money? I figure there are 50 states, you have both EPs and hospitals, and MU comes in both Medicare and Medicaid flavors, so that’s a potential crap-load of self-congratulatory vendor press releases to wade through, none of which really mean a whole lot. Far more interesting would be a list of certified EMR vendors who don’t yet have even one customer that has received a check. It wouldn’t be any more meaningful, just more fun.

Iowa Children’s Hospital develops a Facebook medication reminder system for teens, especially transplant patients. The patient clicks on which meds they’ve taken and the information is sent back to their PCP.

Some excellent posts you might want to check out: Don Michaels concludes on HIStalk Practice that providers shouldn’t move too quickly to sign ACO contracts given demonstration group’s lack of success in earning payment, while Dr. Travis dissects WellDoc’s consumer health apps on HIStalk Mobile.

The Army tests its MC4 battlefield EMR  on iPad, iPod Touch, iPhone, and Android devices, expecting approval to replace their outdated Motorola handhelds with tablets later this year. What they like: larger screen, gestures, the ability to run common apps, the ability to access the Internet, and patient lookup by their ID card.  Above is a 2008 video of MC4 running on the Symbol (acquired by Motorola in 2006).

It’s been a crazy stock market week, so I thought I’d check the current vs. month-ago prices of some HIT stocks:

Allscripts: $15.27 vs. $19.74 (down 22%)
athenahealth: $53.00 vs. $45.16 (up 17%)
Cerner:  $58.18 vs. $62.29 (down 7%)
McKesson: $79.02 vs. $83.04 (down 5%)
Nuance: $18.04 vs. $21.07 (down 14%)
Quality Systems: $79.77 vs. $89.10 (down 10%)

A conservative political group in Kansas called SOCK (Stop Obama Care in Kansas) wants the state’s Republican party chair to quit, saying that Amanda Adkins has a conflict of interest because she’s an employee of Cerner, and as such has a vested interest in both Obama Care and the government’s push of healthcare IT.

As you must know, Cerner Corporation is not taking a passive stance in hopes of remaining a key player and profit taker in the HIT industry but is very aggressively working, including to influence the government, to ensure its leading position in the HIT industry is maintained if not enhanced. The position of your employer, Cerner Corporation, is diametrically opposed to that of the State of Kansas, the current KGOP platform and the vast majority of the GOP rank and file as well as other Kansans.

SAS hires Graham Hughes MD as the first chief medical officer for its Center for Health Analytics and Insight think tank. He was previously CMIO of GE Healthcare IT.

In the UK, workforce management solutions vendor Allocate Software acquires Zircadian Holdings, a vendor of software used by hospitals to manage physicians (scheduling, locum, and evaluation).

Ridgeview Medical Center (MN) partners with Healthbox to launch a three-month mentorship for up to 10 HIT seed-stage company entrepreneurs.

One of the inventors of the IBM PC says PCs in general are extinct, just like the typewriter and vinyl records. He replaced his own PC with a tablet, but says the devices themselves are not innovative – it’s the social spaces they access where people and ideas meet.

The fascinating story of SAI and its family tree in both directions, in this week’s HIStory from Vince Ciotti (he’s the hirsute lad on Slide 9, wearing a sofa-patterned, suspender-supported plaid suit and flanked by an avocado green touch-tone telephone). He loves your feedback and input, such as suggesting which long-gone companies he should write about (my list: Atwork, Continental Medical Systems, HealthQuest, Health Data Sciences, Phamis, and TSI).

Children’s Hospital Colorado is hit with a federal equal opportunity lawsuit for rejecting a job applicant for a staff assistant position who they found to have fibromyalgia, meaning she can’t sit at a desk or work on a computer for long periods. She wants the job, back pay, compensation for emotional distress, and punitive damages.

Dan Moriarty, founder of HIStalk Gold Sponsor Stimulus Search, has joined Health Data Specialists as recruiting manager. They focus on resources for Epic, Siemens, Cerner, and Meditech.

Stanford bioinformatics researchers mine the electronic patient databases of Stanford University Hospital, Vanderbilt, and Partners HealthCare to discover a drug-drug interaction between the heavily prescribed drugs pravastatin and paroxetine. Said the study’s lead author, “We’re bioinformatics people, not clinicians. We can develop ways to mine these huge data sets for interactions that have escaped attention, but you have to start with a clinical expert to curate a set of drugs and effects so you’re looking for something that actually matters in the real world. I’d love to hear from pharmacists about the kinds of questions they would like answered with data-mining. Their drug knowledge is invaluable to this kind of program.”

West Penn Allegheny Health System (PA) will partner with Highmark, Allscripts, and Accenture to offer EMRs to private practices. A local physician says WPAHS is obviously trying to keep its beds occupied: “If a hospital comes into your office and offers to front you $250,000 for an electronic medical records system, they’re not doing it out of the goodness of their hearts.”

Florida’s multi-millionaire Governor Rick Scott is criticized for paying low rates on state-provided health insurance, which he says is appropriate since he has the same plan and cost as everybody else. State big shots (all 32,000 of them) apparently get family medical insurance for premiums of less than $400 per year. Wildly generous state and federal government employee benefits and retirement plans somehow never seem to come up in all the zeal to control the cost of entitlements.

In India, a former hospital COO is arrested for stealing the hospital’s patient data and selling it to other hospitals through a consulting company he started. The hospital got wind of what was happening and installed keylogging software that showed him e-mailing information from his personal account.

E-mail Mr. H.

Time Capsule: US Hospitals Can Learn a Lot From Richard Granger’s Approach

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

I wrote this piece in June 2006.

U.S. Hospitals Can Learn a Lot From Richard Granger’s Approach
By Mr. HIStalk

The British government’s audit report of its Connecting for Health project, released a few days ago, confirms the obvious. Richard Granger and company have put together a remarkable program for aggressively managing their software vendors.

Granger was tough from the beginning. He threatened, for example, to write his own PACS if high vendor pricing made that an attractive option. Complex contracting was wrapped up in less than a year. Vendors had to prove their ability to deliver through real-life simulations. Most importantly, contracts clearly state that no one gets paid until their stuff is working. All of this, unfortunately, is highly innovative in the back-scratching world of public sector IT.

The Achilles heel of Connecting for Health’s vendors has been the contractor-subcontractor relationship. Big consulting companies won the business, then promptly subbed out to application vendors. That was covered in the contracts, too: the bidder is liable if its subcontractors under-perform, which they largely have. Smart contracting protected the National Health Service against the failings of iSoft and IDX, hitting the consulting companies who chose them squarely in the wallet. That’s how it ought to work.

Granger holds firm and goes public when he has to, unafraid to rip recalcitrant vendors by name. I like to picture him as a Gordon Ramsay-type scrapper, happy to take someone down a notch when they need it.

Providers in the US can learn a lot from the auditor’s report. Vendors throw the ‘partnership’ buzzword around a lot to impress rubes, but it’s usually a marketing term instead of a true risk-sharing contract like Granger demands. Hospitals usually just moan about poor vendors instead of using their intelligently crafted contract to withhold payment or send them packing. The auditors lauded NHS for protecting the taxpayers’ money through smart IT management, and rightly so.

I compare it to road work, which most states do poorly. How many times do you drive by miles of orange barrels with no workers in sight, unless they’re standing around aimlessly, and even then only on weekdays from 8:00 until 4:00 when they’re not on break? Traffic is snarled around the clock for months as grass grows from piles of unmoved dirt amidst infrequent activity consisting mostly of sociable shovel-leaning. That’s how hospital IT projects and vendors sometimes work.

On the other hand, I lived in a state that ran roadwork like a private business. Contractors were given incentives to finish projects early while meeting quality standards, which unsurprisingly, they almost always did. Work could be done only at night, worker inconvenience notwithstanding. The difference to motorists was striking, the state saved money, and incompetent contractors were driven out. The only mystery is why other states aren’t smart enough to copy their success instead of having single-lane rush hour traffic cursing at orange barrels.

I admire Richard Granger. What’s wrong with being tough when so much public expectation and money is at stake? Hospital IT departments may be smaller, but they can learn a lot from Connecting for Health’s experience in managing their vendors and their projects. Of all the blowhards on the health care IT speaking circuit, he’s one of few who I’d look forward to hearing.

HIStalk Interviews Tom Stevenson DO, Chief Medical Officer, Covisint

Tom Stevenson, DO is chief medical officer of Covisint of Detroit, MI and a preceptor in the family medicine residency program of MetroHealth Hospital.

Tell me about yourself and about Covisint.

I’m a family practice doc — 17 years in rural family practice. I’ve been doing IT on the side for most of that time, including the six years now I’ve been in the industry. Lots of boards, president of different associations, that sort of thing.

The things that are interesting about it is that I’m currently using my third EMR. I’m not using our product. I still teach family practice residents one day a week, so I’m using Epic in my base hospital that I’ve been at for a long time. In addition to that, I was chair of the State of Michigan HIT Commission, so that’s how I got exposed in great detail to health information exchange and all that sort of thing.

In terms of Covisint, I wish I could pull out the elevator pitch, but the main thing is that we are a health information exchange vendor. We’re both an SaaS environment but also referred to as PaaS ,or a Platform as a Service Environment. It’s all cloud computing.

We have some of our own products that we put out for functionality for an exchange to come up on, but then we also have a number of partner vendors that we work with that have pre-integrated products that are able to be utilized by our end users as well. It’s called AppCloud. Think of it as the App Store, but with SLAs and other restrictions to them. We need to be able to integrate with them and be able to make it a package, as opposed to independent applications that you would run into with the App Store.

You’re on your third EMR. Do think that’s going to be common? What led you to have three EMRs under your belt?

A part of it was a change in locations and everything as I’ve moved around. I started about 15 years ago and actually became employed. I went from being in a small, rural practice to becoming a part of a larger hospital-employed practice so that we could afford to get an EMR in the first place. We used that one for a number of years. Unfortunately, just like many situations, we bastardized the system and never utilized it like it was supposed to be used.

The second one I was involved in was after I’d left private practice and went into the industry. I went into academic setting as well and used a different EMR in that setting. Then lastly, again I’m teaching residents now and it’s back to my old hospital and we’ve switched vendors with a new one. That’s how I ended up with three different EMRs.

But that was an interesting comment about it — is this something we’re going to be seeing in the future? Yes, I think there are some significant changes that are going to happen in the EHR environment. I think the EMR or the EHR of the past that tried to be all things to all end-users oftentimes ended up being very conflicting and difficult to use and very expensive and difficult to maintain — not always the most nimble and flexible type of system. I think there’s going to be some very significant change in terms of what the EHR of the future is going to hold.

What would you say have been the most positive and the most negative aspects of Meaningful Use so far?

The most positive is driving adoption. I’ve been saying for many years that if the industry really didn’t get their act together – and that included the physicians within the healthcare industry – and start adopting HIT that the government was going to get involved. That may be in a light way, it could be in a heavy way. It turned out to be somewhat in the middle of going towards heavy.

The problem with that is that with government incentives and everything come regulation policy, processes that are not necessarily dictated by what’s best for the environment, but what meets the government’s needs.

The biggest negative of Meaningful Use is that it’s driven it so fast that people are trying to make decisions on the fly. They’re doing it based on what they know, and what we know has been fairly limited. What people do is they resort to what’s been out there and that sort of thing.

I think where there was some innovation that was taking place in EHRs, now they’ve had to put all their energies and development into meeting Meaningful Use guidelines, which for the most part, they’re really not bad. I think what we got down to, finally, in terms of the Core Menu items for Meaningful Use, were really quite relevant. On the other side of the coin, though, is that not everybody was up to speed with them. To become compliant, a lot of energy went into that, as opposed to innovation and moving forward with EHR products.

Do you think that with Meaningful Use and reported data and outcomes that there’s at least an implicit buy-in of the idea that the government thinks it knows how to define optimal patient care?

Well, yes. This is where I’m going to get controversial a little bit. I’m not a huge believer in a lot of the quality initiatives because they’re so focused on a very specific set of diseases that again, it’s one of those things where people put a lot of energy into meeting the quality parameters for specific disease processes — which, don’t get me wrong, are extremely important, there’s no doubt about that — but it’s to the exclusion of the other ones out there.

In fact, in several discussions this week, I’ve already said, that in my view, I want to make sure that we not only become excellent at delivering the quality indicators, analytics, and reporting and tools for the physician to be able to meet those goals, but that we go far beyond that and bring in evidence-based medicine and the proper guidelines to support care across the broad spectrum of disease processes that are out there. Ever since HEDIS has been around, the practices that do well are the ones that meet those goals, and I don’t know if that’s always necessarily the best care for those patients.

It isn’t necessarily obvious that what’s good for Meaningful Use is good for the patient. Do you think Meaningful Use could actually make outcomes worse as physicians chase the goals?

I don’t think it will make it worse. And trust me, I don’t know that I have answer for how to do it better. It’s not necessarily the best physician who could look very, very good on paper because they figured out a way to meet those goals. They’ve got the right tools or they put some policies in place to be able to meet them.

I was part of a committee for our state Blues plan. I was a representative for our state organization.  Meeting with the committee was a physician profiling team. That physician profiling team was taking the data — the kinds of data that they were gathering — and making decisions on whether a doctor was good or bad. Bad doctors where at the tail, the good doctors were in the middle.

I think it’s been very clearly demonstrated that that is not the case, that oftentimes the tails represent practices that are doing something a little bit aberrant from the norm. It’s not bad aberrant, but they just have a different focus in the practice.

The bad doctors, the truly bad ones, are trying to beat the system and everything like that are very good at that. They can make things look normal, while at the same point, they’re not doing things that they should be doing.

Do bad doctors know they’re bad doctors?

No, not necessarily. You can categorize bad in a number of different ways. One is they just don’t practice good care. In other words, they don’t deliver care in a fashion that’s beneficial to their patient. I think for most of those people, they just don’t know.

Medicine is a mentoring approach. Our mentors teach us things and we tend to retain those and that’s what we do from there on out. It takes a lot for us to change those habits that we developed in our post-graduate training. So there’s some of that out there — you just don’t know.

There are plenty of bad docs out there that are trying to beat the system. In my mind, those are the ones that are crooks. Medicine is a microcosm of society. There are good people and bad people in all aspects of society, and medicine is one of those as well. So those bad ones — I think that they probably know that they’re bad and they are beating the system. Those are the people that know how to cover their tracks.

Everybody agrees that Accountable Care Organizations are going to need a lot of technology, especially data reporting. Do you think there’s a way that technology can help independent physician practices avoid giving up control to those groups that have all the technology?

If I have anything to say about it, yes. I was a long-time independent practitioner and I feel very strongly that there are many good aspects to having not all docs affiliated with large organizations. There’s definitely an art to medicine and some of that is lost when all of us have to practice the same way according to rules that are established by parent organizations.

As far as I’m concerned, there are some drivers that in the current ACO model that have pushed a lot of folks to acquire as many physician practices as possible. I hope that is not going to be a continuing trend. That’s fine if it works in your environment and you’re already part of a strong affiliated physician group — doing that physician alignment if it includes employing docs and that sort of thing, then that’s good for your environment.

I think the vast majority of locations, though, are dealing with physician alignment with independent docs who want to stay independent. I certainly know that we are working to be able to facilitate the ability of physicians to maintain their independence while still being able to meet the needs of the ACO.

You mentioned the art of medicine. Do you think anybody really believes in that any more? Everybody wants to do things that they can measure and they want to pay for things that are widgetized. Do you think the art of medicine is something you just have to do on your own time while doing all the other check boxes that someone else says you have to do?

Yes. I think that’s actually a very good way to put it. The thing is that the art of medicine is what really makes the difference out there. If you talk to patients and you do appropriate patient survey, there still is a strong emphasis on having a good relationship with their physician. The patients that tend to be happiest in a practice are ones that do have a good relationship with their docs, who they feel are taking the time to treat them well.

Now that doesn’t mean you can’t work in an environment that really meets the checks and balances of all these regulations that are put out there and still have a relationship. The doc that can do that is a skilled practitioner – that can juggle all those things at the same time. I think we’re going to see more and more as we go along that this very clinical approach to delivering care –this really regimented type of thing to make sure you’re hitting all those checks and balances — are going to continue to put barriers in the doctor-patient relationship. 

In my academic time, one of the classes I taught was doctor-patient relationship. The value of having that ability to have an appropriate relationship with your patient can mean all the difference in terms of bringing the appropriate information that you need as well as the patient feeling confident and comfortable enough to be able to actually divulge what they came in for that particular day. Quite often, what they are really there to see you for has nothing to do with what they called in and scheduled their appointment for.

Covisint’s in the interoperability business. Do you think insurance companies and the bigger healthcare systems are using interoperability to gain competitive advantage?

They certainly would like to. I think that anybody that’s in the business is going to try to leverage the environment to improve their presence and improve their marketability and where they stand. I think that there are certainly several instances of that sort of thing taking place and … I’m going to leave it at that.

When you look down the road five to 10 years, what is most encouraging and discouraging as a practicing physician about the way both technology and the industry is moving?

Some of the negatives first. I think we’re getting back to some of our early discussion. We’re seeing an increasing adoption of HIT. Unfortunately, I think people are buying up things in a reactionary mode. I’m not sure that everyone’s going to be happy with what they get.

It’s going to take a few years before this settles in and so we can re-learn how we interact with patients, how we can leverage the technology to do things I feel are very important, and that is to automate these manual processes, especially the ones that are more regulatory in nature as opposed to actually imparting appropriate clinical care. Some of the fallout of all the things that are going on right now is the slowdown in the ability to improve overall healthcare delivery, including the doctor-patient relationship.

The good side is that as HIT and HIE take place and we actually take some of these new models such as ACOs or whatever ACOs end up being, there will be some potential significant benefits. For the individual patient, the clinical decision support we’re able to provide that doc to help them to recognize gaps in care or better ways to do things has a tremendous opportunity, the catchwords “quality, safety, and efficiency” aspect. As we go along and we’re able to automate these processes and be able to take care of a lot of back-end functions without having to think about them from the physician’s standpoint, we can spend more time concentrating on our patient.

I didn’t go into HIT because of my love for it. I do really enjoy it and I want to do the best that I can with it, but the biggest reason I got involved in HIT was the regulatory impediment to my relationship with the patient became more and more notable after my first years of practice.  The amount of paperwork that was done, the amount of regulation we had to meet, the E&M coding guidelines just became bigger and bigger barriers to my ability to deliver care in the way I felt was appropriate.

The reason I’m in it is that I feel HIT gives us the greatest opportunity to meet those requirements and remove those barriers from the day-to-day basis so I can see my patients, get to know my patients, and deliver the best care possible to them.

News 8/12/11

Top News

Rep. Renee Ellmers (R-NC) asks HHS Secretary Kathleen Sebelius to study the adoption, benefits, and cost effectiveness of healthcare IT, including its impact on medical errors. She’s a nurse and her husband is a physician; she ran for Congress as a critic of government-run healthcare. She chairs the Subcommittee on Health Care and Technology. She was quoted in a March press released as saying this about PPACA waivers:

As a nurse of twenty years, wife of a surgeon and owner of a wound clinic, I am not only aware of the problems that currently exist in the American health care system, I have seen them up close as a caregiver, a patient and a small business owner in the health care industry. Unlike the remedy we were promised, ObamaCare has done nothing to improve the quality of health care in our country, and has already done significant damage to the economy. I join Chairman Graves in asking for a full explanation of the waiver process, to ensure that individuals and small businesses are treated fairly.

Reader Comments

From Data Dump: “Re: [vendor name omitted]. Loses years of patient data at an Epic facility, is technically unable to recover data from the backup.” Unverified, so I’ve omitted the name of the enterprise content management vendor. I’d be interested in hearing from the client, though.

From CagneyInMillerton: “Re: Yale. You are missing a big story on their not rolling out Epic. Big negative money angle and someone going after Harvard CIO position.” I asked CIO Daniel Barchi, who reports that (a) they are two months away from their first practice go-live; (b) they are under budget; and (c) the three hospital go-lives have been moved up, with the first going up in April 2012 and the last in June 2013. They are implementing Epic in three hospitals, the School of Medicine, the 800-physician Yale Medical Group, and several independent community physician practices. Daniel says if the Harvard rumor was about him, it’s not true.

From One of Their Hospitals: “Re: [vendor name omitted]. Based on a phone call our pharmacy received, they are closing their doors Friday.” Unverified. I asked for confirmation from the company, but got no response. This Ohio-based vendor offers medication and supply management systems, mobile carts, and software. I think the source is solid, but I’ll give the vendor a little extra time to respond (or call this weekend to see if the telephone has been disconnected).

From Ronnie James Dio: “Re: Computerworld article on HIT job growth. The author says SimplyHired has 7,200 HIT jobs posted out of 4.9 million. That sounded way too low, so I contacted SimplyHired to find out how they arrived at this number. Their answer: they just searched for the specific term ‘healthcare IT,’ which does not even remotely identify all healthcare IT positions. Downright goofy.”

HIStalk Announcements and Requests

This week on HIStalk Practice: legislation is proposed to allow PAs and NPs to qualify for Meaningful Use funds. Aprima Medical acquires an RCM company. AAFP posts its EHR survey results online. Meaningful Use incentives drive physicians to adopt EHRs. Sage Health employees volunteer at CHCs in honor of National Health Center Week. Integritas President Mary Stroupe explains why even “ineligible” providers should adopt certified EHRs. When you are catching up on your ambulatory HIT news, show some love to our loyal HIStalk Practice sponsors by clicking on their banners and learning what they are all about, Heck, they could be offering some good stuff you didn’t even realize you needed. Thanks for reading.

On the Jobs Page: Director of Public Relations, Project Manager – Healthcare Implementation, Developer I. Healthcare IT Jobs is temporarily offline while some administrative and technical work is completed to move it to a new hosting service, but it will be back soon. 

You know who’s cool? You, for reading – thanks. To take cool to the next level, consider: (a) signing up for e-mail updates; (b) socially attaching yourself to Inga, Dr. Jayne, and me on Facebook and LinkedIn (Dann’s HIStalk Fan Club has 1,751 members, so you might as well join that while you’re at it); and (c) checking out the sponsor offerings by clicking the lovely (and soon to be non-animated) ads to your left or delving deeper in the searchable, categorized Resource Center. We can’t promise to always be the most informative and entertaining site in HIT, but it’s not for lack of trying. 

Acquisitions, Funding, Business, and Stock

An Emdeon shareholder sues Emdeon and Blackstone Group, charging that Blackstone’s $3 billion buyout offer for Emdeon undervalues the company.

Nuance announces Q3 numbers: revenue up 20%, EPS $0.13 vs. –$0.01, or $0.35 vs. $0.30 excluding one-time expenses, beating analyst expectations of $0.34. Healthcare revenue was up 22%.

CSC’s Q1 numbers: revenue up 3.1%, EPS $1.17 vs. $0.91, but the earnings jump was partially due to a one-time tax benefit. The company restated guidance, but both analysts and shareholders reacted negatively. Revenue is projected to be flat even with the contribution of newly acquired iSOFT. In the earnings call, the CEO declined to speculate on the potential future of NHS’s NPfIT, a big customer of CSC and its former subcontractor, iSOFT.

Sales

The VHA awards Apelon a multi-year blanket purchase agreement for its terminology and data interoperability solutions.

The Wisconsin HIN selects ABILITY network to provide electronic messaging services for its connected stakeholders.

Flagler Hospital (FL) chooses Allscripts Sunrise Enterprise, also endorsing the Allscripts PM/EHR for its 130 affiliated physicians.

People

Genomind hires former MEDecision CEO Scott Storrer as COO.

Decision Resources Group names John Ho, MD president of its Decision Resources Consulting.

Health Language Inc (HLI) promotes April Yoder to VP of professional services.

Navigant adds eight senior consulting professionals to its healthcare practice.

Announcements and Implementations

UPMC and Nuance sign a 10-year agreement to develop EMR information capture technologies related to speech and clinical language understanding, as well as natural language-powered data repository searches. UPMC will also standardize on Nuance to provide speech and natural language processing tools for its 20 hospitals, 30 imaging centers, and 400 outpatient sites. Nuance says the co-developed solutions will be generally available by the end of the year.  

Government and Politics

Two years after to agreeing to merge their EMRs, officials from the DoD and VA admit it could take up to six more years to complete the project. VA insiders acknowledge that the process has been complicated by bureaucratic infighting, as each agency is unwilling to give up its legacy health system. The departments have now agreed to slowly upgrade both networks into a new shared system over the coming years.

Kansas Governor Sam Brownback returns a $31.5 million HHS grant, saying he had doubts the federal government would be able to maintain its promised future payments. Kansas was one of six states awarded grants to establish HIEs that other local governments could use as a model; Oklahoma also rejected funds for the project. Critics say the move was politically motivated.

Other

Hospitals tell KLAS they need more comprehensive and integrated systems for pharmacy inventory management. Providers report that the biggest functionality gaps for these systems involve formulary database integration, expiration date tracking, and reporting.

A British physician risks being “struck off the medical register” for bad behavior that includes self-prescribing medications, asking an employee to shred hospital correspondence related to an ongoing investigation, and biting a police officer.

In Australia, a software error causes the deletion of prescription records for more than 140 patients, with the conditions of 14 of them found to have worsened during that time.

Canadian researchers blame poor IV pump design for the 4.5% of medication errors that involve children receiving 10 times the intended drug dosage, often in PICU/NICU. They point out that IV pump keypads have the decimal point, zero, and confirm buttons side by side.

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Mayo Clinic opens a high-tech consumer wellness information storefront in the Mall of America, intending it to be a gateway to its services. Features include wellness evaluations, symptom checkers, “trained health experience navigators,” and unnamed products for sale. Mayo says they have no plans to replicate the project in other malls, but wants to “learn about adapting its services to other settings.”

Another part of Mayo’s mall experiment: an iPhone-powered scavenger hunt.

The team of GAUCHOS, an Open Software electronic charting application developed for volunteer clinicians (homeless shelters, the Operation Smile cleft palate repair organization, etc.) launches a Kickstarter project. They hope to raise $83,800 in crowdsourcing funds to complete the Operation Smile rollout and to develop a tablet version that does not require Internet connectivity. Like all Kickstarter projects (including a couple that I’ve donated money to), swell prizes are offered — $1,000 gets you a launch party invite and Web recognition, but just $15 earns a logo coffee mug.

A Sage Healthcare survey finds that non-EHR using physicians have different expectations than those actually using EHRs. Physicians already using an EHR say they’re happy if it tracks outcomes and reduces errors, while the holdouts say they expect the EHR to increase their revenue.

A computer-on-wheels catches fire at Uniontown Hospital (PA), requiring firefighters to air out the third floor.

Sponsor Updates

• Team GetWellNetwork and CEO Michael O’Neil will compete in the September 11 Nation’s Triathlon in Washington, DC to support the Leukemia and Lymphoma Society. The team’s fundraising page is here. They are participating in memory of Justin Thornton, who died of leukemia this year at 19. He was the son of Lt. Cmdr. Tony Thornton, CIO of National Naval Medical Center.
• Hamilton General Hospital (TX) achieves Stage 1 Meaningful Use using the EHR of Healthcare Management Systems (HMS).
• Elsevier releases a new white paper, “Two Years and Counting,” and updates its eBook, A Guide to Education and Training for ICD-10 Implementation.
• Healthcare Innovative Solutions will exhibit at Siemens Innovations 2011 on August 14-17.
• Orlando Health selects MEDSEEK ‘s 360-Degree Patient Experience to create a single patient interface to multiple EHRs.
• Louisiana Health Information Exchange (LaHIE) chooses Orion Health as its primary technology provider.
• e-MDs announces that physicians of its client, Silver Sage Center for Family Medicine, are the first priority primary care physicians in Nevada to receive Meaningful Use funds.
• Anita Archer, director of regulatory and compliance services at Hayes Management Consulting, provides some thought leadership on how ICD-10 can improve patient care and the importance of EMR documentation. Hayes also published a white paper on vendor selection.
• Staffing and consulting provider H/P Technologies will exhibit at the Epic UGM in September.

EPtalk by Dr. Jayne

As of last month, the American Academy of Family Physicians is no longer offering a paper mail-back card for its Continuing Medical Education quizzes. Participants will need to complete the quiz online. Definitely a step in the right direction as far as encouraging computer literacy at a basic level. Despite what those of us in the IT space might think, there are still quite a few docs out there who haven’t used a computer. Usually when those folks are integrated into our health system, I have the privilege of training them one-on-one. You’d think it would be exasperating, but it’s often very rewarding as you see one of these physicians start to realize the power of computers.

A 26-year old South Carolina man was denied participation in a federal assistance program for breast cancer patients because he’s a man. Approximately 1% of all new breast cancer cases each year involve men. This gentleman doesn’t have health insurance and didn’t qualify for Medicaid. The Breast and Cervical Cancer Prevention and Treatment Act is a federal law designed to help patients in this category;  unfortunately, you have to be female to qualify. South Carolina has tried to cover male patients under this provision in the past but has been denied. The Centers for Medicare and Medicaid Services state they’re working to find a solution.

Speaking of CMS, it recently launched the Hospital Compare website to go along with the Physician Compare website that we’re all so fond of. There is much more information available to look at for hospitals: process of care measures, outcomes measures, etc. Of course, hospitals have been more transparent about this information than individual physicians, so it’s not surprising.

In other South Carolina news, Greenville Hospital System is offering “speed-dating” events to try to match young adults with physicians. Realizing that health reform legislation will increase the number of young adults with insurance coverage (by allowing them to stay on parents’ policies, purchase through exchanges, or enroll in Medicaid) they’re using Facebook and more social events to draw these patients in.

Sometimes I receive e-mails I just can’t believe. Here’s what came from the American Medical Association the other day:

Find out how you can achieve meaningful use without an EHR. Learn about a unique approach to meeting federal meaningful use guidelines at less cost than an electronic health records (EHR)-based approach by viewing a webinar at noon Eastern time Wednesday from Amagine, Inc., a subsidiary of the AMA, and WellCentive. The program will feature a demonstration of WellCentive EHR-M.

Really? The marketing folks behind this blurb should be fired. The product demonstrated has EHR in its name. How does that make it not an EHR? Is it really any cheaper than the cheapest certified system out there?

A quick visit to the WellCentive website looks like it’s just another modular product. And I bet once you get done buying WellCentive EHR, WellCentive PQRS, WellCentive e-Rx, WellCentive Patient Outreach, WellCentive Registry, and WellCentive Connect (you get my point) you might as well have bought a top-shelf complete EHR.

The Department of Veterans Affairs is sponsoring a contest (complete with a $50,000 prize) to use its Blue Button download tool to develop a personal health record and place the technology on 25,000 physician websites. Over 300,000 veterans have used the Blue Button on MyHealth.va.gov to download data in the last year. The goal is to expand this functionality to the 17 million vets receiving care from non-VA providers. The contest runs through October 18 unless someone wins it sooner.

A shout-out to all of you at Community Health Centers since this is National Health Center Week. You are vital to the healthcare of so many people. I’m continually amazed by the ability of some CHCs to deliver high-quality care to a challenging population on a shoestring budget. Keep up the good work, and thank you!

Contacts

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

HIStalk Interviews Steve Barlow, CIO and Co-Founder, Healthcare Quality Catalyst

Steven C. Barlow is CIO and co-founder of Healthcare Quality Catalyst of Salt Lake City, UT.

Tell me about yourself and the company.

Healthcare Quality Catalyst was established three years ago with the mission of helping organizations accelerate the process of outcomes improvement using information and measurement to support that process.

I worked at Intermountain Healthcare for about 18 years. The last 10 or so years there, I was the director of the enterprise data warehouse team. I had the great opportunity of working with some clinical visionaries who really knew how to apply proven quality improvement principles in healthcare and lead the information in evolution of analytics to support that process.

After spending that time with Intermountain Healthcare, my business partner and co-founder Tom Burton and I launched and started Healthcare Quality Catalyst to bring those same kinds of principles and products to organizations across the country.

Data-driven quality improvement solutions usually involve some combination of technology and consulting services. How is your approach different from what your competitors do?

We are more of the technology and products company, with services to support the installation and configuration of those tools. We bring a set of tools.

Let’s say an organization just deployed or has recently deployed an EMR system such as Epic and now needs a rational solution to get access analytically to those data. We have a data warehouse core starter set that we have built for EMRs like Epic that can get a client up and running on a data warehouse core in a matter of a few short months.

The services we provide involve orienting the client organization around proven guiding principles in data warehousing. Data warehousing is one of those disciplines that has a few leading schools of thought that haven’t necessarily been proven all that effective in healthcare. We bring some proven and rational incremental approaches to healthcare data warehousing in this domain.

The products are the data warehouse and then a few other tools, such as a Wiki-based metadata repository; a centralized data capture tool that allows analysts and clinicians and researchers to, in short term, capture information that may not be readily available in the EMR; and a tool called the Key Process Analysis Tool that we’ve developed which helps organizations prioritize and identify where they have the greatest opportunity for quality improvement, which typically is demonstrated through the amount of variation in a given domain. For example, why do we have an average length of stay for a hip replacement DRG with the same severity-adjusted population of x days in this facility and x + 5 in this facility? We have a tool that helps bring visibility into those opportunities for improvement.

Data warehousing seems to be something that hospitals think should be easy and inexpensive and they get scared away when they find out that it’s not necessarily either. Do you find that that’s an issue in convincing people that your solution will work for them?

Yes. We do typically see clients who are a little anxious about the size of these projects. 

Our competitors take an approach where a lot of those lengthy project timelines really are required. The products that we bring to the table really accelerate the time from project initiation to usable information in an integrated data warehouse. Now we don’t prescribe or pretend to think that we’re going to have, in a few short months, a completely robust data warehouse that includes data from every possible disparate system within the organization, but we get them a long way down the path. 

We also teach them some very tried and true pragmatic principles, both design and process principles, and get them well on their way. In a few short months, three to four months, we can have a client up and running and knowledge workers in the organization beginning to actually discover knowledge and do analytics.

Many companies have offered data warehouses and business intelligence dashboards geared toward quality and cost. Do you think hospitals have seen the results they expected from those? Why do you think that is or isn’t the case?

You know, I don’t think they have. There have been a lot of reports circulated over the last decade where across verticals — not just in healthcare –  over 50% of projects are deemed as failures. Based on our experience, I think I would highlight a few reasons we see those still failing.

One, it’s a technology project looking for a business sponsor. The “If we build it, they will come” approach will never be deemed successful by the business.

Two, I think there’s a lot confusion about, “What architecture should we use for this data warehouse?” There’s a lot of fits and starts. A couple of the predominant approaches have been proven to be very effective in industries such as finance and manufacturing and retail where the data are a bit simpler and much less complex than they are in healthcare. We prescribe to one of those approaches, as opposed to, “Let’s think pragmatically and maybe adjust one of those approaches to fit the need in healthcare.” 

The final reason I would highlight based on our experience is the motives behind building a data warehouse often are misguided. For example, we see often organizations either acquiring analytical products or deploying measurement systems for the purposes of identifying where there are outliers and reining those outliers in. It’s used in a more punitive way, as opposed to a learning way where,  “Let’s identify in this organization side by side, technologists with clinician, where we have some great things being done and let’s learn why it’s being done consistently in this area and permeate those changes across the system.” It’s punitive versus learning motivation.

With that in mind and knowing as you said an organization needs a business sponsor as well as the technology, how can you tell if a prospect is really going to be motivated to take the actions that the data are going to indicate?

That’s a great question. I think when we go into a client organization we really like to visit with both sides of that fence. We like to visit with the technical leadership as well as the operations and clinical leadership. We can quickly get a feel within the organization how motivated and engaged they will be with a business in a clinical sponsorship driving the technology and how open the technology folks will be in that kind of a relationship. It’s quite easy to tell in a few short visits.

Can you give me a few of the specific outcomes that customers have seen as a result?

We’ve seen some of our clients, as they deploy the technology very quickly, they also begin to deploy the methodology that we would prescribe. They begin to have opportunities open up to them — the provider organizations — to speak with payer organizations and say, “Hey listen, we’re working on these quality improvement initiatives and we see opportunities to share in the savings that will result from these initiatives.” There are some exciting discussions and relationships beginning to form between payers and providers where they co-fund these initiatives and begin to share in the savings.

There are also real clinical improvement measurable results that we have seen with some of our clients. As an example, one of our clients set some goals to reduce the elective induction labor before 39 weeks. We know based on research that if labor is induced before 39 weeks gestation, the risk of NICU days goes up and the average duration of labor is increased. The goals are to reduce the percentage of the time that labor is induced electively before 39 weeks gestation. One of our clients went in less than a year from a 15% elective induction rate down to a 2% elective induction rate. That’s just one example of some interesting improvement initiatives that we see happen in our clients.

You mentioned Epic. Kaiser is doing some pretty amazing things with their information from HealthConnect, which is Epic. What kind of work are you doing with Epic customers and what’s the benefit to them beyond what Epic offers out of the box?

Epic did a great platform, a great EMR system. What we can provide is really helping clients now who have deployed Epic. We’ll leverage that rich resource of information and very quickly, in a matter of a few short months, they can have those data available in a data warehouse — a very scalable, usable data warehouse platform into which they can also integrate other disparate data sources.

We have a product roadmap where we’re going to bring in some interesting visualization tools and other ancillary tools to support that process around clinical domains. As a clinical diabetes team or cardiovascular team gets together and identifies their opportunities for improvement, we’ll have the data and the visualization tools to support those efforts based on evidence-based work done inside and outside the client’s area.

The company has a pretty large and well-credentialed management team. What’s the strategy going forward?

Our strategy going forward is to increase the number of connectors, if you will, to the various EMR systems and to continue developing and enhancing our current ancillary toolset. As well as creating greater knowledge into these targeted data sets around conditions that we see after doing some interesting Pareto analysis from client to client. We patterns bubbling up the top 10 or 15 clinical conditions and we’re going to fill out and make more robust those information assets that we’ll make available to our clients around each of those conditions.

How do you see the role of data-driven quality and cost initiatives changing with healthcare reform?

There are so many pressures from all angles that impose on provider organizations from the regulatory perspective, from a payer perspective, that I see the appropriate application of measurable outcomes improvement initiatives using a rich information repository is going to be an absolute fulcrum to make all of this possible. 

I  think we’re going to see – and are seeing — more and more healthcare organizations, from both from internal and external pressure, forced into paying much more attention to data coming out of these systems that we spent so much time getting data into over the recent years.

Do you have any concluding thoughts?

Healthcare is a very dynamic industry. We feel that Healthcare Quality Catalyst is positioned very well based on our rich experience and heritage and set of products that we bring to the market. We are just very excited to help healthcare organizations benefit from our experience and our toolset to accelerate their time to improving clinical outcomes for the patients they serve. It’s a great opportunity, and we certainly feel a responsibility to do our part to help in this solution to the healthcare problems that we face in this country.

News 8/10/11

Top News

IBM and nine other vendors file protests with the VA for not being chosen to participate in its $12 billion technology program. All the protests except IBM’s have already been denied.

Reader Comments

From Observer: “Re: Flagler Hospital, St. Augustine, FL. Replacing Meditech with Allscripts Sunrise, which beat Epic and Cerner as well. It’s a 300-bed  HealthGrades Best 50 hospital.” Unverified, although I had heard that an unidentified hospital had signed on.

From Otoscope: “Re: hospitals that have successfully attested. Is there a list somewhere that includes which vendors they use?” I haven’t seen a list like that. If you have, let me know.

From Unlisted: “Re: shakeup at ONC. Arien Malec, coordinator of NHIN Direct, is returning to RelayHealth. Dr. Doug Fridsma will leave his current post and take over Dr. Chuck Friedman’s former position as Chief Scientist. All of this will leave ONC-sponsored interoperability efforts lost at sea.” Arien tells me that he announced his departure from ONC on Monday – his nine-month RelayHealth leave had turned into 18 (he was not an ONC employee). He reports that it was already announced that Doug Fridsma is covering the Office of the Chief Scientist role in addition to Office of Standards and Interoperability. I wouldn’t say that any of this necessarily qualifies as a shakeup, though. 

HIStalk Announcements and Requests

You may have read last week that I was traveling a bit, leaving Mr. H to carry an even heavier load than usual. In addition to some shoe shopping (a mere two pair), I paid a visit to eClinicalWorks and athenahealth. If you care to learn details about eCW’s nifty new headquarters, or see some pictures of Jonathan Bush’s office, you’ll find the write-ups on HIStalk Practice.

Acquisitions, Funding, Business, and Stock

Private equity firm Halyard Capital invests in RCM provider Practice Insight.

At least five law firms file class-action lawsuits against WebMD, alleging that the company misrepresented its financial position to shareholders and failed to make timely disclosures about projected drops in  advertising revenues. CEO Wayne Gattinella lowered revenue guidance for 2011 in July and the stock price fell 30%; however, company insiders sold $44.7 million in stock in the months following the issuance of WebMD’s February financial statements.

SAIC completes its acquisition of Vitalize Consulting Solutions.

Emdeon reports Q2 net income of $5.8 million, up from $4.2 million a year ago. Non-GAAP adjusted net income was $31.8 million ($0.26/share) which beat analysts’ expectations of $0.25/share. Revenues were up 16% to $282.1 million. The company announced last week that it will be taken private by a Blackstone Group fund.

Symphony Corporation, a Madison, WI-based technology provider, acquires JGI, a New Jersey human capital management consulting firm. Both companies claim a significant healthcare presence.

Sales

Stormont-Vail Healthcare (KS) selects TeleHealth to provide interactive patient education services.

Mille Lacs Health System (MN) contracts with Indigo for its Identityware SSO and access management solution.

Iowa Health System will use Medicity’s HIE technology to connect its hospitals and clinics.

People

LSU Health Shreveport promotes Marcus Hobgood to CIO.

SCI Solutions names Joel French managing partner and CEO and Jeff Anderson managing partner and chief sales officer. Founder John Holton will serve as managing partner and COO. French was most recently VP/GM Healthcare of Motion Computing; Anderson was managing director at Huron Consulting Group. SCI also announced that The Wicks Group of Companies and New Enterprise Associates have invested in the company to support its expansion efforts. 

RedBrick Health, a Minnesota vendor of technology-driven online wellness services, names Daniel Ryan as CEO.

Announcements and Implementations

Taiwan goes live on its nationwide EMR initiative in November, allowing physicians across the country access to patients’ clinical information.

Cerner says that all 18 Major League Soccer teams have implemented its HealtheAthlete health management platform. During the 2010 season, 621 players were tracked in the system and 1,500 injuries were logged.

The Christ Hospital (OH) implements a real-time interface that captures data from hemodialysis treatments and imports it into its Epic EMR.

Stillwater Medical Center (OK) integrates its the vital signs monitors in its same-day surgery unit with its Meditech HIS using Accent on Integration’s Acceleor Connect technology.

Dell and NextGen announce plans for Dell to sell and support NextGen’s ambulatory and inpatient solutions and to provide hosting services for NextGen clients. Dell also becomes the platform of choice for NextGen solutions and for NextGen’s internal use.

LA Care Health Plan (CA) will spend $1.5 million to develop and implement an eConsult system at 47 LA County safety net sites. It will handle provider communication and referral requests. A previous pilot program was claimed to reduce face-to-face specialist visits by up to 48%, depending on the specialty.

Government and Politics

New Hampshire Governor John Lynch signs legislation that establishes the state’s Health Information Organization (NH-HIO.)

HHS issues a Notice of Proposed Rulemaking regarding the use of metadata standards to support health information exchange.

In Australia, standards work for the government’s eHealth program is stopped when the non-profit Standards Australia fails to secure a new government contract.

Other

The Colorado Department of Public Health and Environment fines Heart Check America $3.2 million for a variety of violations, including performing diagnostic scans without the order of a state-licensed physician. The company was also cited for failing to monitor employee radiation exposure and not having policies and procedures to ensure safe CT scanner use. The company closed its Denver facility in May following a state inspection.

HIT jobs will grow 20% annually through 2018, according to the US Bureau of Labor Statistics. Because of particularly strong demand for CIOs and CTOs, individuals from banking, manufacturing, and other industries are now being hired into healthcare.

KLAS reports that Cerner’s Millennium PowerChart has the most hospitals live on CPOE, followed by Epic.  An average of 81% of orders are being entered via CPOE in Cerner hospitals and 83% at Epic sites. The third-ranked McKesson had 90 installations of Horizon CPOE at the end of 2010, with an average of 45% adoption, plus 11 Paragon sites with 25% average adoption. Overall industry adoption of CPOE was still less than 22%.

Doom and gloom from Down Under: The Australian Medical Association warns that the federal government’s online medical records system is “doomed to failure” because not enough people will sign up for it. Patients are required to opt in to participate; the medical association wants the government to make participation mandatory unless the patient opts out.

Strange: an health board IT technician in New Zealand is fired by the CIO for departmental theft. His loot: one blank DVD.

Weird News Andy is nuts about this premature discharge story: a man tucks his girlfriend’s pink pistol into his waistband as the couple enters a grocery store, accidentally pulling the trigger and shooting himself in his private parts. The girlfriend calls 911 and the emergency operator tells her to apply pressure, but not to look at the wound. “I did look at it and it’s pretty bad,” she admitted. The local police department turned the unfortunate incident into a teaching moment, helpfully advising locals to use holsters rather than jamming weaponry down their pants Hollywood-style.

WNA also turns up this story: a 26-year-old with breast cancer and no health insurance is denied coverage by a Medicaid program specifically created for that condition. The reason: he’s male. Above is CMS’s special coverage conditions, which exclude the several thousand men who are newly diagnosed each year.

An Ann Arbor, MI couple who owned hospital inventory software company Ariel Software are indicted for failing to pay taxes to the IRS over a 12-year period. They are accused of withholding $880,000 in employment taxes, but spending most of the money on the business instead of sending it to the IRS. The husband was also charged with failing to file personal tax return for several years.

A former VA data warehouse manager is sentenced to 11 years in prison for extracting patient information from the VA’s system and using it to file 800 fraudulent tax returns through his home tax preparation business.

Doctors in Estonia complain about the HP-developed EMR used there, saying that entering data for a single patient requires 50 mouse clicks and opening dozens to hundreds of documents one at a time.

General Cannabis announces that its WeedMaps marijuana dispensary finder took in $1.1 million in July. Its patient management system will complete beta testing shortly and offers patient self-scheduling, electronic medical records, and an appointment reminder system. According to the CEO, “Our technology is applicable beyond cannabis and we are already in development on our next medical niche.”

Members of a Florida ministry’s medical bill-sharing program join together to pay each other’s “responsible” medical bills, eliminating the administrative expense of for-profit insurance companies. The program, which the ministry insists is not insurance, pools expenses for members to share as they wish. It also offers healthy living rewards and helps its parishioners adopt healthy lifestyles. Its interactive tools include a 24×7 Twitter-like Prayer Stream for prayer requests and offers of encouragement.

The parent company of a West Virginia nursing home will appeal a jury’s $91.5 million medical negligence verdict that claimed its understaffing caused the death of an 87-year-old resident.

Sponsor Updates

• The College of American Pathologists, the CDC, the AHA, and Surescripts will present The Lab Interoperability Cooperative: Engaging and Empowering Hospital Laboratories and Public Health Agencies in Electronic Laboratory Reporting for Meaningful Use at CDC’s Public Health Informatics 2011 Conference, August 21-24.
• Besler Consulting publishes a paper on Healthcare Reform – Do You Have The Clinical Outcomes to Achieve the Financial Rewards?
• API Healthcare is exhibiting at Healthcare WFM 2011 August 19.
• Bulletin Healthcare announces an opening for Senior Medical Writer.
• EDIMS is attending the iHT2 Health IT Summit next week.
• Voalte will hire 50 employees over the next three years as it expands its Sarasota, FL offices.
• Employees of Sage Healthcare are doing volunteer work at community health centers this week as part of the company’s support of National Health Center Week.
• DIVURGENT publishes a paper entitled Meaningful Use Requirement for HIPAA Security Risk Assessment.
• MediServe is offering a Webinar, CMS 2012 Final Rule – How Will the New Rule Impact Your Facility?”
• St. Joseph’s Hospital Health Center selects CareWorks CMS from CareTech Solutions for its Web sites.
• dbMotion receives ONC-ATCB 2011/2012 certification for three use cases.
• GE Healthcare releases Centricity Advance – Mobile as an iPad application, while also announcing U.S. launch of Optima CT660.
• MEDecision Inc. announces that its 2011 URAC accredited Alineo Clinical Programs are available.
• Access announces that 10 of its customers have been named to HHN’s Most Wired Hospitals list for 2011.
• AdvancedMD receives recognition as the top EMR for OB/GYN.
• GetWellNetwork releases a new white paper, Meaningful Use of Health Information Technology: Requirements and Solutions in Patient and Family Engagement.
• A National eHealth Collaborative HIE report recognizes two Orion customers, HealthInfoNet and SMRTNET for their mature HIEs.
• The Advisory Board Company expands it Austin,TX software center following a 10-year, $372,590 incentive deal with the city. The company will create 239 jobs and invest $8.1 million in improvements to its leased space by 2017.
• Greenway Medical reports that its customers have secured more than $1 million in combined Medicaid and Medicare Meaningful Use incentive funds.

Contacts

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

Curbside Consult with Dr. Jayne 8/8/11

I had a long, lazy weekend, of which I spent a good part staying up too late catching up on the Netflix releases that have been mocking me from the top of my television. Kind of like those folks that tend to smoke only when they visit bars — when I stay up late, I have a bad habit of winding up at Taco Bell. As I sat in the drive-through lane pondering what it is that makes even the most health-conscious physician stray, I noticed a billboard for a local hospital advertising the ability to hold one’s place in line in the emergency department.

It was news to me that one of our competitor hospitals had partnered with InQuickER, whose slogan is “Skip the Waiting Room.” Essentially, for a $9.95 registration fee, patients can register for their emergency department visit and wait at home until their projected treatment times. Kind of like call-ahead seating at Red Lobster, although I assume you don’t get a cute crustacean-shaped beeper when you arrive.

As a technical person who also speaks fluent Administralian, it sounds good. It’s a relatively easy technical application – if restaurants can do it, there’s no reason it can’t be applied to other industries, including healthcare. As a physician leader, I can imagine that patients who aren’t frustrated from sitting for hours in a crowded waiting room are likely to give higher scores on patient satisfaction surveys and may be less likely to taunt the triage staff or harass caregivers.

On the other hand, as a clinician, it makes me cringe a bit. Although InQuickER admits it doesn’t actually schedule appointments but rather holds a patient’s place in line while they wait at home, it does offer a guarantee in which users who aren’t seen within 15 minutes of their projected treatment time are given their money back.

During the past decade, I’ve watched the physician/patient relationship slowly erode. There are a lot of factors impacting this both positive and negative.

Personally, I believe that educated patients are healthier patients. I believe in patient self-determination and that some physicians need to jettison the antiquated paternalistic tendencies they continue to carry. I want patients to be smart shoppers and to understand their healthcare choices. I don’t want them to necessarily do things because “the doctor told me to.”

On the other hand, I believe the overt consumerization of healthcare has some serious downfalls and minimizes the complexity and skill involved in caring for and treating patients.

Although InQuickER’s FAQ section clearly states that hospitals do use triage protocols and that its users do not receive preferential treatment, it’s easy for a patient who doesn’t read the fine print to make the logical leap that they’re going to receive special or quicker treatment. They advertise a 95% success rate for patients being seen within 15 minutes of their projected treatment time, and for physicians already under pressure to reduce cycle times and see greater numbers of patients more and more quickly, this is just going to add more stress to an already bubbling pressure cooker.

I cover the emergency department regularly and see a large proportion of patients who don’t need to be there, many with non-urgent conditions who haven’t tried any over-the-counter remedies or exercised a reasonable degree of Boy Scout-level first aid skill. In some cases, the thought of sitting in the waiting room with “all those sick people” is enough to keep them at home and out of the emergency department, and sometimes their issues spontaneously resolve without at $50 copay.

For a mere $9.99, the inconveniences of waiting are avoided, and I worry that this will bring more non-urgent cases into our already overcrowded system. On the other hand, for some cases, this could be heaven sent – for the migraine patient who has exhausted all home prescription medications and is bothered by light and sound, the ability to minimize time in the waiting room is solid gold.

As I crunched on my Volcano Taco, I surfed the hospital’s Web site. Injecting a bit of humor into the situation was this: the InQuickER site projected a 75-minute wait for me, while the hospital’s own handheld app advertised a 14-minute wait on their real-time waiting room ticker. With stats like that, of course, the odds that I’d be seen before or within 15 minutes of my projected treatment time were pretty good.

I can see both sides of this one, so for me, the jury’s still out. Nevertheless, I put the word out to colleagues at the hospital in question to ask how it’s really going, but I’d also like to hear from readers. Are any of your facilities using the system or that of a competitor? InQuickER is SaaS model — how are they to work with? How is support? Any issues? E-mail me.

E-mail Dr. Jayne.

Monday Morning Update 8/8/11

From Carlos: “Re: State of Connecticut HIE. Likely to hire Axway, a French company with headquarters in Arizona, to provide the platform. Too bad they didn’t commit to an American company.” Unverified, but it’s like car makers: tough to sort out whether you’re really buying American given that the executives, employees, subcontractors, and taxes paid are scattered around the globe and you don’t really know which country benefits the most. Axway is a publicly traded company (on the NYSE Euronext) spun off from IT services firm Sopra this past June. The CEO is French.

From Leisure Suit Larry: “Re: hospital EHR adoption. Have you seen 2010-2011 numbers? I haven’t seen anything since the 2009 AHA IT survey.” Maybe someone can help out.

From The PACS Designer: “Re: DICOM’s expansion. The stability of the DICOM Standard has been solidified with its expansion into the test and measuring field of practice. The ASTM DICONDE Committee has recognized the value of DICOM as a standard in healthcare, and adapted a version for test equipment called the E2339 Standard titled Practice for Digital Imaging and Communication in Nondestructive Evaluation. There are standards for various test methods which include Digital Radiography (DR), Computed Radiography (CR), and Computed Tomography (CT).”

From Bang Bang Shrimp: “Re: for-profit hospitals. I helped open HCA West Paces Ferry Hospital in Atlanta in 1974. We attached Addressograph charge slips to single Band-Aids at an unconscionable mark-up. We bought disposable ventilator tubing for $1.25 and charged Medicare $22.50. It took the federal government 20 years to realize they were being raped and not even receiving a kiss – thus the Dartmouth Study and prospective reimbursement.”

Thanks to the following HIStalk sponsors that started or renewed their sponsorship in July. Click a logo for more information.

HIMSS got mixed grades on last week’s poll, with 62% saying it deserves a B or C and more respondents giving it a failing grade than an A. New poll to your right: do hospital CIOs have too much influence in choosing clinical system vendor or implementation strategies?

Listening: reader-recommended (from Lake Hartwell) Heartless Bastards, a no-frills, hard-rocking Dayton bar band with a deep-voiced female singer (think Chrissie Hynde of The Pretenders meets Johnette Napolitano of Concrete Blonde) who also writes the songs and plays a mean rhythm guitar. Nothing phony or computer-enhanced here. Excellent.

The British government is expected to officially kill the 10-year, $18 billion NPfIT project next month after reviews conclude that the massive undertaking, the largest non-military IT project in history, is “beyond the capacity of the Department of Health to deliver.” Deadlines have been missed, contractors have pulled out, benefits are unclear, and reviews have concluded that project officials didn’t get enough input from physicians and other clinical users. An editorial reminds that there’s plenty of blame to pass around, including ministers for approving the use of custom systems without requiring small-scale trials, civil servants for approving questionable contracts, and vendors (notably CSC and BT) for continuing to collect taxpayer money despite not meeting their contractual obligations. The project is expected to turn into an HIE-like federated data sharing system, where local health trusts and hospital can buy whatever systems they want rather than those mandated by NHS.

Australia’s struggling, over-budget $425 million HealthSMART system is blamed for faxing hospital discharge summaries to physician practices that included clinical information for different patients. The Health Department says faxing software attached the wrong information to the fax header, acknowledging 13 incidents that had no known patient impact.

The VA awards 15 prime contracts for its technology and telecommunications program called Transformation Twenty-One Total Technology. The value of the contracts could reach $12 billion.

Kaiser Permanente’s nonprofit hospital and health plan business announces Q2 profit of $663 million, up 64% from a year ago. Revenue was $11.9 billion and membership increased to 8.8 million. An e-mail to employees sent Friday from its COO and CFO says KP will begin implementing videoconferencing technologies to link providers and also systems that can send monitoring device data directly to the patient’s EMR. I wondered about the salary of CEO George Halvorson, so I looked it up: for 2009 (the most recent year available), $6.7 million in total compensation.

My Time Capsule editorial this week from the 2006 archives: Vendors Seek to Diversify as the Hospital Systems Market Matures (this was pre-HITECH, when hospitals bought systems because they wanted them, not because the government bribed them to). A snip: “Business will sizzle in ambulatory systems, various forms of telemedicine, data analysis, payer intelligence, genomics, interoperability, consumer health, drug research, home health, and medical device connectivity.”

Brigham and Women’s Hospital announces that a doctor left an external hard drive in a cab in Mexico, potentially exposing the medical records of several hundred patients that had been downloaded to it. The doctor said the information had been deleted, but the hospital announced the loss anyway since it couldn’t verify that the information was unrecoverable.

Adventist Midwest Health names Chet Robson, DO as regional director of medical informatics, ambulatory systems.

Dr. Sam (Bierstock) and the Managed Care Blues Band, self-billed as “The World’s Most Reluctant Band,” release their latest — HITECH Blues. Sample lyrics: “I’m sitting here in prison, I’m living in a life of tears, I could be in my office, but they gave me 20 years. I never should have hacked into, the PHR of Britney Spears. I used to have to deal with, 4 different kinds of EMRs, I had one in my office, the ED, hospital, and the OR. Just ‘cause I saw that information, I’m sittin’ behind bars.”

Here’s the latest HIStory chapter from Vince Ciotti, covering Keane.

Speaking of Vince, he’s looking for stories and information about his next featured company, Charlotte-based SAI (1988 coverage above), if you want to pitch in.

European hospital pharmacy technology vendor Health Robotics is granted a motion to dismiss McKesson’s lawsuit that sought to rescind their joint distribution agreement.

ESD rebrands itself with new graphics and a tagline, “IT Consulting Rooted in Healthcare.”

Twenty-nine Penn State pre-med students are deployed at Mount Nittany Medical Center to coach physicians on its EHR transition. CMIO Stephen Tingley came up with the idea to give students the summer job. A cardiologist expressed his appreciation for the help, saying, “The system is not easy to figure out. It’s so different, like a maze. I’m dreading the day when they’re not here.”

Strange: a rural health center nurse in Pakistan, who claims a dental surgeon sexually harassed her and had her salary withheld for a full year, goes to a press club and pours gasoline on herself. Bystanders step in before she can get it lit. And stranger: a passenger on budget air carrier RyanAir goes into cardiac arrest during a flight and stops breathing, with his wife shouting for someone to bring oxygen. The flight crew, concluding that his blood pressure was the problem instead, brings him a sandwich and soda. After he revived, they came back to collect payment for the snack.

E-mail Mr. H.

Time Capsule: Vendors Seek to Diversify As the Hospital Systems Market Matures

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

I wrote this piece in June 2006.

Vendors Seek to Diversify As the Hospital Systems Market Matures
By Mr. HIStalk

Vendors of traditional hospital information systems are hedging their bets for future success, judging from recent announcements. McKesson said this week it is acquiring RelayHealth to move into consumer health care systems. A group of vendors said they would develop standards to make their home health devices interoperable. And Cerner’s announced growth areas are mostly outside of traditional hospital IT.

The message seems clear – business prospects are better elsewhere. Wall Street likes growth that big conglomerates and publicly-traded vendors can’t get from hospital-only sales, given a finite supply of prospects that are big enough to afford their wares. The recent spike in clinical systems deals may have been transitory, locking up all the laggard customers but leaving fewer for the years to come.

Perhaps we’re in the classic mature market, where the customer base is saturated, vendors are consolidating, product prices go down to reflect decreased demand, and emphasis moves from R&D to solid, user-friendly applications that are differentiated primarily on specific features (think Rubbermaid). Vendors can still make a lot of money, only instead of from product sales, profits come from selling high-margin services and maintenance to existing customers.

Under this scenario, and given high switching costs, hospitals may no longer command the undivided attention of vendors whose gaze is wandering to sexy new markets. Maybe there won’t be any successful hospital-only vendors left, except possibly for Meditech, which is ideally suited for success due to its dominant market penetration, near-universal customer retention, low cost through economies of scale, and private ownership.

Even if the hospital systems market is mature, just about every other health care IT sector isn’t. Business will sizzle in ambulatory systems, various forms of telemedicine, data analysis, payer intelligence, genomics, interoperability, consumer health, drug research, home health, and medical device connectivity. Products in the innovation and growth stages of the product life cycle require high development and sales costs. The aggregate market must be defined and created. Most companies will lose money, but winners will emerge from the turmoil to gain competitive advantage and profitability.

It will be interesting to see how the traditional players fare in these markets, where they’ll need seldom-used capabilities such as technical innovation, nimble execution, and delivery of their message to a much larger number of prospects who behave less cohesively and identifiably than hospitals. Having a good idea isn’t enough. If I were an investor, I’d buy strictly on the quality of company management, choosing vendors with visionary, focused leaders who can rise above a host of new market entrants that are likely to fail due to stumbles in execution.

The original HIT marketplace was first changed dramatically by the emergence of large, full-line hospital systems vendors that moved the industry away from small, innovative best-of-breed vendors and customer self-development. The second change was the absorption of most vendors into unfocused conglomerates or larger competitors. The third wave — obviously underway — is diversification of vendors into non-hospital health care IT.

It remains to be seen whether hospitals will be better or worse off with these changes. We struggled even when we had the undivided attention of our vendors, failing to manage change and gain ROI in an admittedly screwy and ever-changing health care non-system. We may not enjoy giving up the limelight. After many years as a hospital IT person, I’m a little jealous to see the excitement growing in those areas of health care I don’t yet know much about.

HIStalk Interviews Ken Willett, CEO, Ignis Systems

Ken Willett is president, CEO, and chief technical officer of Ignis Systems of Portland, OR.

Tell me about yourself and and the company.

I’ve been in software development ever since I got out of college in 1974. I’ve worked in a number of high-tech startups, mostly in the electronic design industry. I got into healthcare IT as I started a consulting business in about 1994. Ignis Systems was incorporated in 1999. 

One of my first major clients was MedicaLogic, now the Centricity products from GE since they bought MedicaLogic. That then led to EMR-Link, which is the current product that we have. Ignis is no longer a consulting company — it’s a product and services company. A number of people have joined — quite a few of them with GE Centricity background — but we’re now spreading out, bringing in people with expertise in other EMRs. 

The system deals with CPOE from the ambulatory side – orders and results – and in the diagnostic area: lab orders, lab results, radiology orders and results, and so forth.

Describe briefly how the orders flow within an ambulatory EMR.

The EMR is the main cockpit of the provider these days. People who are really using EMRs well want everything to be driven out of the EMR — the decisions that they’re making, documentation they’re providing, and in particular, creating orders for outside services.

In the past, what’s typically happened is labs have provided either Web-based or application-based ordering systems to providers. Providers don’t want to switch to a different application to place a lab order, a medication order, or any other kind of order. They want that out of the EMR.

We provide the ability for them to do the ordering within the EMR. The provider generally provides some minimal information. What they’re interested in is, “What tests do I want run? What’s the justifying diagnosis for this test? When does it need to happen? Is it an urgent or a regular order?” But that’s not really sufficient information for the lab. The lab needs to know a lot more status information about the patient. They need to know about insurance. They need to know what account to bill things to. 

Our application collects the information from the provider, the basics of the order. It then allows a staff person to augment that information to get it to the point where it meets all the order requirements for the lab.  That helps to guarantee that when the results come back through us, they are going to meet the needs of the provider in terms of being a high-quality diagnostic report.

Many people would have assumed this problem was solved many years ago, especially since e-prescribing has settled down to universal standards. Do you think a long-term solution is coming for orders other than what you are offering, or is this as good as it will get in linking an ambulatory practice to the outside world?

I hope it will get better. When I was first involved with MedicaLogic, e-prescribing was just as much of a black hole as lab orders and lab results are now. What happened in the intervening years was there were a few large players on the prescribing side that were the pharmacy benefit managers. Once those large players got their act together and Surescripts was involved and that technology. That made it easy to essentially move that whole industry toward one set of standards and one method for communicating these orders.

The same thing hasn’t happened on the lab side. The lab industry is much more fragmented. There are two or three big players in the US, but they only account for about 20% of the total lab volume. We’re talking about hundreds or thousands of hospital labs, and now, even more in-office labs in large physician practices. It’s very, very difficult to drive a consensus there through just market activity.

What we end up having to do is have lots of different kinds of connections to different labs. They have slightly different flavors of HL7 data for orders and results and have different communications methods. We have to make sure that our hub adapts to those differences.

I think over time, particularly with a push from the federal government for information exchange, there will be some focus on standards. There’s some standards activity going on right now both at the federal level and within the HL7 community that hopefully will get adopted more widely. I think that will reduce the number of variations we have to deal with, but I don’t think it’s going to drive it down to one common standard that everybody’s going to be using.

Who is your target audience?

We sell services to the major labs and also to hospital labs as a way for them to connect the providers and their community, or the providers that they market their lab services to. The same thing with radiology. But the main user of our system is the provider. We have to make sure that what we are doing is a great solution for the doctor as they’re providing care for the patient, even though they typically pay for a small portion of our service. Most of our service is actually paid for by the lab. So it’s not simple from a marketing and sales point of view, because we have one customer who’s making the purchase decision, but we’re going to have a different customer that we have to satisfy from the usability point of view.

Let’s say LabCorp sponsors the implementation for a particular practice. Is the connection only then to LabCorp, or once it’s in place, can it be used for other lab companies?

One of the things that we think is important is to have a single ordering solution that can connect with all labs that a particular provider is going to use. The typical case is probably two to three. Because of insurance contracts, most of the people who send orders to LabCorp also send them to Quest because some insurance carriers require that. Then they may have a hospital lab that they send things to just because it’s in their community.

We have is a single application that allows ordering from any of those. From a business point of view, we have to break that apart so that LabCorp is paying for their piece of that system, Quest is paying for their piece of that system, and then there’s a subscription piece that the provider pays that’s a recurring annual usage fee.

By definition, your practices all have a large entity as a sponsor, correct? Its not really a universal system from the physician side, but rather whatever parts the sponsor wants to subsidize?

That’s true for the larger labs, but we actually have a range of different scales that we operate at. We have a lot of customers that are relatively small practices, maybe a dozen or so providers, but they have in-house lab. They want electronic ordering and electronic results. The smaller-scale LIS systems that they may be using for their in-office lab maybe don’t have that capability. 

We can allow them to do electronic orders and results. Even though the lab system is in the same building that they’re in, they connect through us because it just works better and smooths out the workflow.

Then we have a lot of labs that are in the middle. They may be a single hospital or a multi-hospital organization that may have a single consolidated lab, or they might have a lab at every hospital. We provide the ability for them to connect to practices either within their organization or affiliated practices within their community.

And then of course there are the large reference labs where labs are their only business. We also have a number of hospitals who provide labs and radiology, and we can provide a single ordering and resulting solution that handles both types of orders.

What kind of user or transaction volume are you seeing?

We have about 5,000 providers using our solution at between 250 and 300 different sites. We’re handling between a half million and a million transactions a month through our system. We have unsolicited results in some cases, but they may quite often have an order with a matching result coming through.

What’s the selling point for Meaningful Use?

This goes back to the Meaningful Use criterion around structured lab results. Lab results traditionally, in a lot of cases, have been faxed to providers or they’ve been sent through a remote print engine. They print it on paper, and then maybe they’re rescanned. But the established EMRs that have been around for a number of years can handle HL7 lab results. They can do things like display the patient trend graphs or they can filter the population based on lab values.

We’re seeing a flood of new EMRs hitting the market and a lot of them don’t have that capability. A lot of them believe that lab results just means that you can present a lab report to the provider so that they read it. If a provider or an organization chooses structured lab results as one of the menu items in Meaningful Use, then they need to have a system that can present that structured data to them. In some cases, their EMR may not be able to do that.

One of the things that we provide on the result side is that we can maintain the structured data in our system. We can provide it a readable, high-quality printed report or viewable report to the provider, but we can also provide the trending and the structured data that they need. It’s also sometimes the case that we can provide viewable lab results to a provider who doesn’t have an EMR yet, or isn’t set up to handle structured lab result data yet. We can populate that EMR with the structured lab data once that provider’s ready.

It seems reasonable for EMR vendors to let a specialty company develop the integration piece while they focus on the inherent functionality needed for their own workflows.

We think that’s the right model. In most cases, with a few exceptions, the EMR vendors don’t really do a very good job of interoperability with outside systems. It tends to be an afterthought. It’s a whole different business. EMR vendors usually are as software development and database experts. They’re used to building essentially closed systems that are delivered and installed at the customer’s site.

Interoperability is a much broader game. You have to be an expert in data communications and security, error recovery, and all kinds of things which may be or not that applicable in the EMR that’s installed at a particular customer site. I think it makes sense for people to leave that to us. 

We’re finding that, both with the EMR vendors and also with labs, when they start to add up they’re paying to implement lab interfaces and get them working, maintain them over time, and recertify them every two years, a lot of those companies that just don’t want to be in that business.

You mentioned use of your tools by practices with no EMR. Tell me about Orders Anywhere, which you market as a starter step.

That’s great for people that aren’t on an EMR yet. There are also many EMRs which don’t have electronic ordering at all. They don’t have the ability to generate an outbound electronic order message. A lot of them are designed just to document the orders in the chart. Some of them have an ordering capability but it’s just not very good — they don’t have the ability to configure ordering preferences to what the provider needs and they can’t split orders when they need to be split into multiple requisitions. 

Orders Anywhere is a way for people to have electronic ordering, even when their EMR doesn’t provide it. It’s both for people that don’t have an EMR and people whose EMR doesn’t have good ordering capability.

Are you seeing providers who have decided that HITECH money just isn’t worth the trouble and picking and choosing just those technologies that make benefit them directly, like perhaps your electronic ordering product?

You don’t necessarily find out what the provider is intending as far as the Meaningful Use stuff. I’ve heard stories of doctors who have said, “This isn’t worth it to me right now.”

But I think what we’re seeing is that a lot of the volume growth in EMRs really is being driven by the Meaningful Use rules, so the people who’ve decided that it’s not worth it probably aren’t talking to us anyway. For somebody who has an EMR and they think EMRs are good tools to use, they’re probably going to figure out how to get their use of the EMR up to the point where they can get some Meaningful Use reimbursement.

The other thing that we’re seeing that’s sort of odd and a little scary is vendors who build their systems to the Meaningful Use requirements. They may have some technology pieces and they’re asking, “What’s the minimum we can do so that a doctor can get paid by the government?” Not what’s a good EMR or what makes sense for taking care of patients, but more, “How do we meet the letter of the Meaningful Use regulations so that if they buy our product they can get paid?“

That’s not a very far-sighted view. Those regulations are going to change over time, but that set of things that have been identified by the ONC by the Meaningful Use, they’re really pretty arbitrary. There’s a lot of other things that you really should be doing if you’re going to be a good EMR user.

You’re in a fairly niche-type technical product area. Do you see your expertise translating into other products or services beyond orders integration?

Yes. We have a couple of things in the works that I can’t really talk about them in detail, but there are a number of problems now that are of the form of having multiple back-end organizations with different standards like the labs are in our world, maybe having to have some connection on the front end to every provider, or maybe all providers in a state, or all providers in a certain geographic area.

Understanding how to put together a hub-and-spoke architecture that does the right kind of translations in moving data from one side to the other  — we’ve learned a lot about doing that with labs and radiology. We believe there are similar problems that can benefit from that.

CCHIT chose your tools to test orders integration for certification. Did that raise the company’s profile?

Well, we hope it did. We have lots of experience with lab results and what works in the real world. That was a project of mine to work together with the CCHIT technical team to put together the test suite for Meaningful Use certification for lab results.

Where does the company and the industry need to go?

One of the things that we work very hard at is being really responsive as things change. One characteristic of where we are in the market is we’re hooking up new practices and new labs all the time. We have a hosted solution, a Software as a Service model, and we need to be able to turn things on very quickly, generally within the space of a few days. We can do that pretty readily as a small company. I think it might get more difficult as our organization gets bigger.

But there’s a lot of room for small companies like ours to fill in some of the gaps between these large systems, which often take 12-18 months to incorporate new capabilities. Things are moving too fast – people can’t afford to wait that long.

Any final thoughts?

I think there will be a separation between transport companies and transport technologies and content companies and technologies, sort of like what’s happened in the television industry. Communications companies deliver data from one place to another, then you have other organizations, like Facebook or  HBO, that provide the content.

We’re very much in the content business. We want the information provided by the provider to be useful for the lab, and we want the results from the lab useful to the provider. We don’t necessarily want to be involved in the plumbing that makes all that happen. In the HIE world, some of the work that’s going on with Direct standards, the transport pieces are becoming more of a commodity. Those things will separate themselves out from those of us who focus more on the content.