From HIMSS 2/28/10

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday Morning Update 3/1/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sage announces its meaningful use guarantee.

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

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

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

E-mail me.

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

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

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

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

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

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

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

A few questions leap to mind, however:

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

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

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

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

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

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

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

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

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

Ask the Chair

What do investors do at HIMSS?

Aside from walk around looking for cool trinkets?

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

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

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

Ben Rooks
The Chair

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

HIStalk Interviews Trey Lauderdale

Trey Lauderdale is chief innovation officer of Voalté.

Tell me about Voalté.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do customers perform ROI justification to buy your product?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

News 2/26/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ONCHIT is Tweeting. Or at least has the capability.

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

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

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

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

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

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

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

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

E-mail me.

HERtalk by Inga

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Phytel appoints Dr. Richard Hodach its chief medical officer.

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

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

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

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

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

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

E-mail Inga.

HIStalk Interviews Todd Johnson

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

Give me some background about the company and about yourself.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any concluding thoughts?

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

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

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

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

Readers Write 2/24/10

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

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

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

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

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

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

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

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

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

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

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

Something Wonderful
By Mark Moffitt

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

Enhancements to Smart Phone Operating Systems

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

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

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

From 2010, Odyssey Two:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Doug Arrington

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

Tell me about your work.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any concluding thoughts?

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

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

News 2/24/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Robert Miller is promoted to North American president of iSoft.

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

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

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

E-mail me.

HERtalk by Inga

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Inga.

HIStalk Interviews John Santmann

John Santmann, MD, FACEP is president of Wellsoft.

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

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

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

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

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

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

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

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

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

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

What are hospitals doing with ED patient kiosks?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Is that clear as mud?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Cameron Powell

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

Tell me about yourself and about the company.

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

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

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

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

Tell me about the components of AirStrip Observer.

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

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

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

How hard is it to get FDA approval?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How hard is the integration piece for hospitals to accomplish?

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

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

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

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

How is the product licensed and hosted?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday Morning Update 2/22/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

HIStalk Interviews Kipp Lassetter and Robert Connely

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

  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tell me about the patent for the Medicity Novo Grid.

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

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

Where does iNexx fit?

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

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

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

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

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

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

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

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

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

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

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

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

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

What was your reaction to the KLAS HIE report?

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

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

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

What will interoperability look like in five years?

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

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

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

HIStalk Interviews Tom Yackel

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

Tell me about your background and what you do.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

News 2/19/10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

HERtalk by Inga

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

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

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

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

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

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

A few sponsor updates:

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

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

E-mail Inga.

HIStalk Interviews Phyllis Gotlib

Phyllis Gotlib is CEO and co-founder of iMDsoft.

Tell me about the company and your products.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What about the use of reminder checklists and dashboards?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Final thoughts?

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

News 2/17/10

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

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

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

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

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

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

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

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

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

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

Duke University Hospital chooses Simplifi 797 IV compounding QA software.

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

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

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

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

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

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

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

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

E-mail me.

HERtalk by Inga

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Inga.