CIO Unplugged – 2/15/10

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

Meaningful Use Requires Meaningful Leadership
By Ed Marx

A few weeks ago, under authority of the Health and Human Services Secretary, the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator of Healthcare Information Technology (ONC) issued proposed regulations on the definition of meaningful use and the initial set of standards, implementation specifications, and certification criteria for EHR technology. Certification criteria specify the capabilities and related standards that EHR’s must include to support the proposed meaningful use Stage 1 requirements for eligible professionals and eligible hospitals. The comment period will end shortly with the final rules released this year. The industry’s wailing and gnashing of teeth is in full force.

As a taxpayer, I’m pleased with the IFR. My concerns that the industry would water down Stage 1 requirements have been largely dispelled. Meaningful use was designed as an incentive-based initiative. As such, it strikes a healthy balance between attainment and stretch. It’s not a welfare program, and not everyone reaches Stage 1 in year one. If that were the case, IFR would not be an incentive program. I praise the government for raising the bar high, and I urge them to stand their ground.

When does tolerance of low standards begin destroying value? Is not an underlying lack of fortitude detrimental to the overall fitness of our nation’s healthcare? I get invited to dozens of meetings and surveys all aimed at lowering the bar. Well-intentioned organizations exercise political freedom and amass collective resources (including financial and personnel). Online and traditional healthcare media are whipping activity into a frenzy. We’re inundated with position papers, press releases, mobilized lobbyists, and pundit opinions.

But I’m convinced that if we channeled the above energy and focus into meaningful use, more organizations would lift themselves over the bar.

Leaders. Avoid the temptation to jump on bandwagons that lower the bar. Make your opinion known and then get about the business of attaining meaningful use. While the lazy lament the IFR, you be the catalyst that makes meaningful use a reality for your hospital and physicians. Demonstrate meaningful leadership.

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

Readers Write 2/15/10

Data Entry and Quality Health Care
By Al Davis, MD

The enthusiasm generated for EHRs by the 2009 ARRA legislation is almost palpable and hospitals across the country are scrambling to install systems at a breakneck pace. Behind the enthusiasm, however, are two issues, related yet disparate, that have been the confounding factors of EHR adoption in the past and will continue to be so in the foreseeable future.

EHRs offer the promise of data aggregation which can be used to refine clinical treatments for both improved quality and, possibly, lower costs, but this aggregation is dependent upon standardized dictionaries and, importantly, standardized data entry. EHRs currently offer standardized data via the use of templates, boilerplates, and pre-defined order structures. But the standardized data entry model often (usually?) does not completely and precisely conform to the observed signs, symptoms, and problems displayed by patients in the physician’s office, and therein lies the rub.

Patient care, especially when dealing with complex problems, requires the clinician to differentiate subtle distinctions among less than obvious alterations from normal physiology. Shortness of breath, one of the most common problems encountered in the emergency room, can result from problems with the lungs, with the heart, with the vascular system, with the blood, from medications, or simply from pollution or toxins breathed in by the patient, and those are the direct causes. Indirect causes such as intra-abdominal pathology, skeletal deformity or muscle weakness must also be considered.

While there is a high statistical likelihood that shortness of breath will result from one of a relatively small number of potential pathologies, assuming a diagnosis based on statistical likelihood will lead to poor or even dangerous patient care. The reason a pulmonologist trains for 12 or 13 years, and a nurse practitioner for six or seven, is to allow the pulmonologist to learn not only the underlying basis of the more rare causes of disease, but also to be able to discern the subtle differences that those more unusual pathologies may display. The use of template- or boilerplate-driven clinical notes negates the benefits of the more refined knowledge and experience of the pulmonologist. Requiring the use of such standardized data inputs is antithetical to quality medicine, yet allowing free text entry is equally antithetical to the as yet unrealized potential of the EHR. It is this contradiction which has slowed adoption of EHRs and will continue to hinder their use.

The challenge is for IT designers to work out a way for experienced clinicians to be able to commit to the record the sometimes subtle thought processes and observations that lead to their diagnoses, while maintaining enough control and/or discipline over the input to allow the potential of data aggregation to be realized. Monetary issues, regulatory compliance, and usability are important as well, but the paramount concern of the EHR must be to ensure that the best quality patient care can be delivered. If the cost of the input restrictions needed to allow data aggregation is the loss of ability to place nuance and subtlety into the record, the EHR fails that most primary of tasks.

Al Davis, MD is in private practice in Elmhurst, IL.

A Meaningful Ruse?
By Frank Poggio

At the risk of being a called a Cassandra, or at best a contrarian, I will attempt to explain why the federal government’s HITECH Act and Meaningful Use (MU) incentive program is a wolf in sheep’s clothing and why the better response for a provider would be to run, don’t walk, from this wolf.

First let’s review the basics. When a hospital or physician’s practice purchases and implements an electronic medical record (EMR) or Computerized Physician Order Entry (CPOE) before 2011 and files with the federal Department of Health and Human Services (DH&HS) the yet-to-be-developed regulatory documentation to declare their meaningful use (MU), then starting in 2011 that provider will be potentially eligible for an MU bonus payment. For physician practices, that could amount to a total of $44,000 over three years. For hospitals, depending on the number of discharges, somewhere between $2million to $3.8 million total. These incentive amounts are to be paid over three stages, or years, starting in 2011.

On the other hand, if a provider does not implement an EMR or CPOE, or purchases and implements a system but cannot show meaningful use, then a penalty will be incurred on Medicare payments in years 2015 thru 2017. This penalty will be in the form of a reduction to the legislated increase in Medicare payments for that year. Note: this is not a reduction in overall Medicare payments, but a reduction on the yearly Medicare inflationary adjustment factor. The first year the penalty is a 33% reduction of the adjustment, the second 66%, the third 100% (or in effect, you will get no adjustment at all).

Before I explain why I believe there is a wolf at your door, let me say I am a believer in the benefits of EMRs and CPOEs. There can be significant benefits in both, but not unless they are incorporate a sound work flow re-engineering processes prior to installation. Unfortunately there are very few if any MUs that are workflow-focused.

There are at least four major reasons why I believe your facility will never see an MU bonus.

1) MUs are, by the DH&HS’s own admission, a moving target. As stated in the Interim Final Rule (IFR) published in the Federal Register, December 30, 2009, on page 314, “We expect to issue definitions of meaningful use on a bi-annual basis beginning in 2011”. Hence, MUs will evolve over time. That will allow DH&HS to make them as easy or as onerous as they choose. How can you predict you will hit a moving target that you can’t even describe today? And if you believe the Feds may try to make it easier to foster participation, read on.

2) If you hit all but one MU, will you get the full bonus, or 95%, or 50%? Nobody knows and the question is not addressed in any IFR or other documents. I am willing to wager you will get nothing, and my reasoning follows.

3) The federal government has stated they are funding the HITECH program with $34 billion for MU bonuses. They also have stated repeatedly they expect to save over $200 billion to help fund the new national health plan. That’s about a seven-to-one expected payback in only a few years. When was the last time you had a seven-to-one ROI on any IT project over three years? If the feds do not see the seven-to-one payback in time, how many providers do you think will get to cash an MU check?

4) Our government is under extreme pressure to cut the federal deficit. In the President’s recent State of the Union Address, he stated he will freeze the government budget for ‘non-essential’ items to save $250 billion, to alleviate the trillions of dollars in deficits predicted by the OMB. Essential is currently defined as Social Security payments, interest payments on debt, entitlement programs, Medicare benefits, and the defense budget. These taken together make up over 80% of the total government expenditures. So the freeze has to come from ‘non-essential’ departments and programs. Medicare payments to providers are not considered part of Medicare benefits, they come under the DH&HS /CMS department operating budget. So, although the benefits to the seniors will not be reduced, the payments to the providers are fair game. And therein lays our wolf.

I noted earlier that if you fail to purchase and install an EMR / CPOE, you will be penalized by a reduction in the increase in Medicare inflationary adjustment in future years. Based on the above reasons, I believe there will be little or no adjustment increase in future years. If you don’t think this will happen, look at what Congress and DH&HS had allocated for the adjustment ‘increase’ in 2010 for physician Medicare payments. DH&HS wants to apply a -21% adjustment for physician payments. Yes, that’s minus twenty-one percent. Then, to get the AMA on board with the national health initiative, the Administration and Congress was going to delay this adjustment, but now even that agreement is up in the air.

On the hospital side of the world, look at what the Medicare adjustment increases have been over the last five years. The most they have been is 2% and the average is around 1%. If you run those numbers for a typical 200-bed community hospital with a Medicare utilization percent of 50%, the one percent increase amounts to about $300,000. Hence, reduce it by a third and you will miss out on $100,000 that year. Again, and that’s assuming there is any increase at all in future years.

Lastly, let history be your guide. I have worked in the healthcare world for 35 years as a CFO, CIO and multitude of other roles. As a CFO, I saw Medicare renege on many case mix adjustments, TEFRA adjustments, and DRG adjustments,all in the name of national budget deficits and health care cost controls. At one point, they set up a Medicare Payment Advisory Committee, then disbanded it when the Committee disagreed with too many DH&HS adjustment policies. I doubt the future will be much different, in fact probably worse.

So, run the numbers again, in future years if the Medicare adjustment increase is zero – because the feds and DH&HS say we can’t afford an increase due to overall deficits and budget freezes, then reducing the zero adjustment increase by 33% will incur how many penalty dollars?

What’s a shepherd to do?

The bottom line is there is no need to “horse in” a new EMR/ CPOE regardless of what vendors say. Secondly, horsing in a system as complex and far-reaching as EMR/CPOE and while hitting the expected glitches along the way is going to cost you far more than any Medicare adjustment penalty.

My advice … take your time, do it right ,and install components that will give you the most ROI the fastest. And watch out for the wolves.

Frank L. Poggio is president of The Kelzon Group.

Accurate Patient Identification and Privacy Protection – Not an “Either/Or” Proposition
By Barry Hieb, MD

 

Whether you support federal government funding of HIT or not, it can’t be denied that healthcare is undergoing a major revolution as more and more clinical automation capability is being adopted. Funding of HIE projects, building toward the Nationwide Health Information Network (NHIN), will further these efforts. And clearly progress is being made, as noted in the recent KLAS report that verifies 89 active HIEs across the US. The ultimate vision of regional clinical information exchange crosses political, operational, and geographic boundaries using the NHIN’s network of health information exchanges.

However, we’re not addressing one of the most significant challenges that must be overcome for this scenario to work: the ability to accurately identify patients whose information may be scattered across a number of providers using disparate HIT applications and platforms.

The current state-of-the-art approach for patient identification centers on EMPIs that identify patients using demographic matching techniques. But industry experience indicates that EMPI matching techniques are only accurate 90 to 95% of the time, introducing a variety of potential errors in care delivery within and across provider organizations.

We know the answer to the problem — issue each patient a unique identifier that would be used to label their information across all participating provider locations. In fact, the 1996 HIPAA legislation mandated just such individual healthcare identifier. But, in 1998, Congress reversed itself on the patient identification issue based on valid concerns about the inability to protect the privacy of this data, and forbade the expenditure of federal funds on further pursuit of this essential component for accurate patient identification and data exchange. Since that time, there has been virtually no progress on this issue at the federal level, although recently a number of states have begun to pursue state-wide identifiers to support their HIE projects.

Since I left Gartner in 2008, I’ve been working with Global Patient Identifiers Inc. to build out the Voluntary Universal Healthcare Identifier (VUHID) system under the umbrella of a non-profit, private enterprise. The VUHID system is based on over 20 years of patient identification standards work done by the ASTM international E31 medical informatics group, and proposes a solutions that is both inexpensive and effective.

The VUHID system communicates with the EMPI system at the heart of each HIE. It issues identifiers upon request and maintains a directory indicating the sites that have information for each identifier. The VUHID system has been specifically designed to enhance the privacy of clinical information because it has no identifiable patient data — only the locations where each identifier is recognized.

VUHID identifiers are globally unique and are designed to support activities that the patient or others indicate need to be handled with privacy. The VUHID system represents a secure, cost-effective, currently available solution to enable error-free patient identification that extends across political and organizational boundaries.

Barry Hieb, MD is chief scientist for Global Patient Identifiers, Inc.

An HIT Moment with … Chuck Demaree

An HIT Moment with ... is a quick interview with someone we find interesting. Chuck Demaree is vice president of product development with Access of Sulphur Springs, TX.

Absolutely. The focus of an EMR is to provide an electronic collection of medical information that can be used real-time during the clinical episode and historically as an archive. Generally, not all information will be fed electronically into an EMR. Forms provide a tool for the organized collection and presentation of information that will not be collected electronically.

In supporting the EMR, EHR and LHR, an electronic forms solution provides:

• Consistency in form quality, format and delivery.
• Accuracy in correct filing information through the use of patient-specific bar codes.
• Efficiency through the use of business rules by assuring that all the correct forms are generated (collecting ALL of the needed data).
• A standardized and structured presentation of data in the EMR, especially if COLD feed information is passed through the forms solution to provide a standard presentation.

Describe the typical workflows associated with using access-related electronic forms.

The most common entry point for Access EFM is in the registration area. A typical workflow would start with the registration of a patient. The resulting information generated by the registration system passes to the business rules engine in the Access EFM server where data elements are evaluated. The rules engine then determines what forms are required, what data needs to be applied to each form, and where and how those forms need to be distributed.

For example, a customer being registered as an inpatient would have a complete registration packet that is customized to them for this particular clinical event printed in the registration area, with bar codes and demographics applied. The only documents that would print there would be documents that the patient (or their family) needed to take with them or that needed to be electronically signed, such as consents. The bar codes on each form enable HIS staff to interface forms into the EMR with less effort, as the ECM/EDM system uses bar code recognition to auto-index the forms with the patient record. 

Electronic workflow would then route any other documents needed by the nursing unit, laboratory, pharmacy, patient finance and other departments directly to their location (or application) at the time of registration. Electronic notifications (via fax or email) would be sent to the primary care physician notifying them of their patient’s admission. 

In more advanced forms management projects, registration staff send forms to a monitor without printing. The patient reviews them, applies their electronic signature on an LCD pad, and the nurse submits the forms. They’re then interfaced into the ECM/EDM system, a paperless process that eliminates the financial and environmental costs of forms printing.

What is the Universal Document Portal?

The Universal Document Portal (UDP) is an interesting and exciting product. The purpose is to provide a method to feed the EMR electronically from systems or medical devices that do not have the ability to COLD feed today.

Some examples of how this is being used by our customers are:

• Passing medication orders which used to be faxed, from one vendor’s HIS system to a competing vendor’s pharmacy system.
• Providing an electronic import capability for clinical documentation from one vendor’s HIS system to another vendor’s EMR. This particular customer has well over 50 different feeds running through UDP
• Indexing the output from a 12-lead EKG system directly into the proper patient’s chart in an EMR.
• Migrating historical medical record information from a system that is being discontinued into the customer’s current EMR.

The uses for UDP are only limited by the output abilities of the system or device and the IT/IS team’s imagination.

How can electronic forms support patient safety?

The Access EFM system impacts patient safety both directly and indirectly.

Every form outputted from Access EFM has patient identification bar codes on it, enabling positive patient ID throughout the encounter. Bar coded wristbands are generated at registration and reconciled with bar coded medication labels also printed by the Access system, facilitating accurate bedside medication verification (BMV).

Documents that are passed into the EMR have a consistent structure which reduces search time for information. Because of patient and form specific bar codes on every form, all forms are accurately filed in the EMR
Notification of printed bar coded forms are sent to the EMR for the purpose of creating automatic deficiencies, which are resolved when the form is scanned in.

The indirect impact is the time saved by the use of the business rules engine and the staff efficiencies it produces. The business rules take the guesswork out of what forms need to be pulled and what data needs to be collected. If it needs to be done based upon the data entered for the patient, it gets done because of Access EFM.       

How common is it for hospitals to capture patient signatures electronically and how are they using them?

Electronic signature capture is becoming more common every day. The most common uses are obviously in the signing of consent forms, whether in registration or at the bedside. Other uses are the signing of discharge or patient teaching instructions, financial responsibility documents, and any other document that provides legal protection for the facility during the care delivery process.

The most important factor in choosing an electronic patient signature solution is how well those signatures will stand up in court. Basic electronic signatures like those used in a grocery store (TIFF on TIFF) are hard to defend if legally challenged as they could be copied, forged, or altered after signing. Access e-Signature creates a biometrics file that becomes part of the patient’s record and proves that the original signature was not forged or changed, positioning hospitals well for audits and e-discovery.

Monday Morning Update 2/15/10

From Conrad: “Re: Bassett Healthcare and their Stories of Success program. If it’s as good as the Go Red for Women/Put a Little Love In Your Heart video on their home page, they are doing all right. It’s clear they have employees who really like working there.” It’s kind of a Pink Glove Dance variant. Pretty good. I’m a sucker for this stuff.

From Talk of the Town: “Re: Allscripts. Two of the Allscripts sales veterans to leave were some of John’s boys from the original Medic lineup. The only thing surprising to me was that they have hung around this long. Combined with the exit of another of his sales guys from John’s golf company makes me wonder what John is up to these days.” He has five golf clubs now (the big real estate kind, not the sticks that badly dressed men hit balls with), although that may not be the best business in the world given the economy and lower property values. Not that he needs the money.

From Fact Finder: “Re: Sunquest. Take a look at the jobs posted to their Web site today. With that many sales jobs, it looks to me more than 30% left!” That’s quite a list — a clinical product specialist, two inside sales account managers, a regional VP, and six sales executives. Not the best timing with HIMSS booth duty coming up. From the “glass half full” side of the argument, they have jobs if you’re looking.

A physician’s Wall Street Journal editorial on EMRs ends with this:

If electronic records are only used to optimize billing and improve chart audits, patients will see little benefit. I doubt my patients received better care from the change.  Electronic records can only play a supporting role in a broader effort to change our troubled system. Until our health care system imagines patients as more than grist for billing, I will happily take my chances with a colleague’s inscrutable scrawl over a phone-book-sized stack of computer printouts.

HHS throws down another $1 billion for HIT, with $386 million in HIE grants (ranging from $600K to $38 million), $375 million for 32 Regional Extension Centers ($5.3 to $28.5 million), and $227 million for job training ($2 to $5 million). The jobs training one, in particular, has some odd recipients (Goodwill Industries and Spanish Speaking Unity Council, for example). I could write a bunch of stuff about this, but it’s kind of pointless until we see how those groups plan to spend our money. It better be good to be worth a billion dollars.

Cisco apparently fares much better than Microsoft and Google when it comes to healthcare, with nearly double their percentage of “positive” impressions. New poll to your right, for those going to HIMSS: what’s the last full day you’ll be there? I’m heading home Thursday, but the last I’ll see of the conference will be Wednesday (sorry, Sully).

Inga is putting together a list of HIStalk sponsors exhibiting at HIMSS. It occurred to us that Platinum sponsor O’Toole Law Group, aka Bill O’Toole who also writes HITlaw for us, would be a rather forlorn figure sitting alone in a booth looking wise and stern in a lawyerly way, surrounded by adjoining booths full of boisterous demo dollies and card trick magicians. So here’s the deal: Bill will be at the conference, but not in a booth, so you can read more on his Web site and make arrangements to connect with him at HIMSS to talk about HIT negotiations, non-compete agreements, and contracting (especially for Meditech shops). I told him I was going to mention (he probably thought I was kidding) that he will be at the HIStalk reception, so you can corral him there as well since that’s a good place to mix business with pleasure (if those terms aren’t synonymous, you’re doing it wrong). Bring your business cards.

One thing I like about having HIMSS in Atlanta: like Orlando and (formerly) Dallas, it’s cheap. Not just flights and hotels, but all-day convention center parking, gated and guarded, is only $10 or less. It snowed in Atlanta last week, but will be back up into the 50s by this weekend, which is the average daily high for March. The rooftop patio at Max Lager’s will be heated, so snow refugees can maybe get some outside air that won’t freeze their nose hairs. I also notice that some of the vendor bashes conflict with Sunday’s opening reception, which I think is a fantastic idea because I hate the opening reception.15,000 people elbowing each other to try to get a drink and an eggroll while a lame band plays isn’t fun for me, although I did like the San Diego one because the patio setting was so nice. Chicago was the worst ever, cramming a room with the charm and acoustics of an airplane hangar with bad music and a gazillion freezing people trying to get out of the ugly snowstorm outside. Can we admit, as HIMSS has tacitly done by vowing not to return to McCormick Place, that having the conference there in the first place was a really stupid idea like everybody kept trying to tell them? My almost-$300 hotel room was dumpy, everything from cabs to convention center coffee was overpriced, and there wasn’t anything to do except hang around the exhibit hall (which was the whole point of having it there instead of somewhere nice, of course).

Speaking of HIMSS events, soon-to-be announced Platinum sponsor MEDecision is having theirs on the same Monday night as the HIStalk one, but they are inviting HIStalk readers to drop over to their “HIStalk Pre-Party” from 6 until 7 Monday evening at the Georgia Aquarium. That event has the 2010 Grammy winner performing that I mentioned before, although I don’t know who it is (I would have guessed the Zac Brown Band since they’re from Atlanta and don’t start their tour until March 2, but really, I have no idea). The ever-diligent and protective Inga insisted on doing some research before giving me the OK to mention their event: “If you plan to go to both, you better drink fast and don’t go dunking in the shark tank. It looks like it is half a mile away, a 10-minute walk to Max Lager’s unless you are wearing your stilettos, in which case it is a two-minute cab ride.” Register here.

From the Weird News Andy vault: “at least he has a reason for not dancing.” A British hospital’s prosthetic limb specialist is fired after fitting an amputee’s right leg with an artificial left foot that was also one size too big. Paramedics noticed that the man was listing to one side, but he didn’t think much of it until taking off the fake foot’s protective sock five months later and saw a left foot on his right leg.

Last chance: please take my reader survey. Thank you. Speaking of which, a couple of readers had a good idea that I saw when I peeked at the results so far: a good time to read HIStalk (other than when it first comes out and you get the e-mail) is when you’re on a boring conference call or taking a lunch break at your desk. It’s like when I read the Howard Stern Show online recap at lunchtime: a guilty pleasure ideally suited for quiet time at work when you need a break (and this is even work-related, so you can read it guilt free).

Focus Informatics, Inc., a transcription provider that’s part of Nuance, has some job openings I said I would mention: a manager of US operations, account manager, team leader, and MTSO recruiter. Remote/virtual is OK.

Listening: reader-recommended Grace Potter and the Nocturnals, excellent Vermont-based throwback blues-rock with the female lead sometimes powering a vintage Hammond B3 organ or a big ole’ Flying V guitar. Video here. It’s cool that readers (some of them, like in this case, a top executive you would never expect) have figured out the music I like by my recommendations, then make their own back to me, generally with uncanny accuracy.

I am thankful that HIStalk’s sponsors nearly always stay with us. We lose one occasionally for one reason or another, but even then, they often find themselves missing the incessant good cheer of Inga the Sponsor Diva and end up returning to the fold. The InteGreat EHR folks have rekindled their Platinum flame after a short break and we welcome them back. As a refresher: the InteGreat EHR is modular, intuitive, browser-based, and CCHIT08 certified.

Speaking of sponsors for which we are grateful, here’s a new one: iSirona. The company specializes in capturing and delivering patient data: interfacing with stationary and mobile medical devices, providing  point-of-care charting screens, supporting positive patient ID, and streamlining charting and documentation workflow. Founder and CEO Dave Dyell said it better than I could in an HIT Moment With from May. Welcome and thanks to iSirona.

Nashville’s city government will spend money to buy clinical systems for Nashville General Hospital at Meharry, hoping to break even on the deal since the cost is $3.2 million and an even bigger government (the federal one) will pay it an estimated $4 million in return. Nobody’s mentioning any benefit to actual patients, but this is about stimulus.

Microsoft is opening some kind of health research center in Spain, interested in a location near a hospital that developed its “Florence” system using Microsoft technologies. This article says it includes smart phone access and SMS messaging. 

China’s $124 billion effort to move from socialized to US-like privatized health models is causing US-like problems: funding cuts, a dramatic polarity between services available to the rich and the poor, and rapid cost increases as doctors are financially motivated to order more drugs and tests. It’s so hard to get a hospital appointment that scalpers are openly selling appointment slots on hospital property (note to self – develop an eBay clone site to capitalize on this unauthorized secondary market).

Hospital-associated outpatient doctors can no longer qualify for ARRA meaningful use incentives after a Senate change to the HIRE Act. That may be addressed in other bills, however.

An odd situation caused by often-phony marijuana clinics: can an employee be fired for failing a drug test if he or she has a “marijuana card?” Marijuana is legal for medicinal purposes in 12 states, but only Rhode Island has a law preventing users from being fired for using it. Pot smokers are claiming they are being discriminated against, with theoretical legal claims under the Americans With Disabilities Act looming.

I’ve never heard of this: St. Vincent’s Hospital Manhattan, desperately trying to keep the doors open, lays off 32 medical residents as part of its 300 FTE headcount reduction. You know you’re in trouble when you can’t afford in-house physicians for 80 hours a week at $50K or so per year, or around $12 an hour.

Odd lawsuit: the family of a leukemia patient who died of Legionnaires’ Disease contracted from a water fountain gets a $1.2 million settlement from Ohio State University Medical Center. Nurses were told to give patients bottled water and to instruct them to avoid the fountains, but nobody put up signs. Strangely enough, the man’s daughter was nurse on the same floor and was with him at the time, but forgot to tell him not to use the fountain. Seems to me she’s responsible as well, but I doubt anyone is contemplating a lawsuit against her.

HIMSS posts its list of companies presenting at the all-day Health IT Venture Fair on Sunday, February 28. The list:

• Axial Exchange, an integration appliance vendor started by former Red Hat execs
• CareCloud, which offers Web-based practice management applications
• Clarity Health Journal, a PHR tool
• Dicom Systems, which offers a DICOM router and archive
• EDIMS, a vendor of emergency department information systems (and an HIStalk Platinum sponsor)
• Envisioner Medical Technologies, a personal medical imaging platform for endoscopic multimedia
• Heart Imaging Technologies, which offers a Web-based PACS, clinical trials system, and image sharing site
• Logical Images, vendor of a visual diagnostic system based on medical photographs
• Medical Diagnostic Associates, offering systems for electronic images and exam tracking for diagnostic imaging
• MedCPU, a clinical practice tool for high acuity hospital services including OB
• MedicExchange, a social networking and product review site for healthcare professionals
• MediViz Systems, a real-time decision support system for the OR
• Mensante, operator of FeelingBetterNow, a best practices site for Canadian mental health physicians and patients
• Polaris Health Directions, which offers behavioral health outcomes assessments and management systems
• Prodigo Solutions, a healthcare supply chain applications vendor
• Provider Advantage, EDI systems
• Sentient Health, supply chain systems
• Smart Association, smart cards
• Spring Medical, vendor of SpringCharts EHR
• TC Software, which sells an integration engine
• White Pine Systems, which offers a PHR
• Your Nurse Is On, an online tool that matches nurses to open shifts
• Zebec Data Systems, a IT infrastructure hosting and outsourcing vendor

The most common mistakes companies make pitching at the Venture Fair, from my limited experience in having crashed part of it once:

1. Not being able to summarize their offering in ten seconds.
2. Not being able to clearly explain right off the bat who their potential customer base is, what problem they intend to solve for them, and how they plan to efficiently reach those prospects with their message.
3. Saying “we don’t really have any competition” when inevitably asked.
4. Not knowing what it costs to get a customer (or worse, having no customers).
5. Pitching an unoriginal idea, an idea that’s interesting but not really much of a business to deserve outside investment, or an idea that requires competing against well-established competitors that could extinguish you in a corporate heartbeat.
6. Trying to hide modest numbers by not bringing any. Investors understand that early-stage companies aren’t often making a profit, but not having a handle on revenue and expenses is inexcusable.
7. Shooting for quantity instead of quality, spouting off an undisciplined array of ideas instead of focusing on one potential winner. Diversification comes later; focus reduces upfront risk.
8. Not really understanding the difference and expectations among funding options such as bank financing, friends and family, angel investors, private equity, and venture capital.
9. Taking up too much time with a product demo instead of talking numbers, management experience, and growth strategy.
10. Being an inexperienced, unpolished entrepreneur looking for a large investment (investors bet on the jockey, not the horse).
11. Trotting out wildly optimistic revenue projections that always start immediately after someone else puts their money in.
12. Asking for someone else’s money when they haven’t put in much of their own or when still running the business part time.
13. Having a management team made up of product people (i.e. geeks) and nobody with startup and management experience.
14. Not having an advisory board or mentor who has done it before.
15. Having only a vague story about how investors will get their money back and how the company will mitigate the risks that arise between the time they write you a check and the time when you return the favor.
16. Not having a detailed plan on what they plan to do with it (it better involve increasing revenue directly, not leasing an office or buying Aeron chairs for everyone).
17. Being too undisciplined or excited to stick to the venture fair’s limits on PowerPoint slides and session duration, or having glaring errors in the information sheet. This is speed dating, not courtship, so first impressions are the only kind.
18. Expecting to get someone else’s money without giving up some negotiable degree of control.
19. Expecting to walk out of the room with a deal or assuming that some degree of audience interest means you’ve scored. I don’t know what the hit rate is for the venture fair, but I bet it’s low.
20. Getting discouraged instead of vowing to learn from the experience, to make the business and the pitch better for next time, and to try again.

E-mail me.

News 2/12/10

From Spaghetti Eddie: “Re: VA and Cerner. I’m pretty sure the answer is that VA hasn’t decided yet, but it sure isn’t looking like a Cerner LIS decision. Still very very hung up on the issues associated with integration of EHR with DoD (AHLTA). Also, there’s a big study group of industry types (the Industry Advisory Council Vista Project) that was formed at VA’s CIO’s request to look at how to modernize VistA, clearly with an eye toward remaining open source. All in all, VA’s not there yet.” I’ve also read that the VA just opened up a program to solicit IT ideas from its employees instead of the contractors that are usually whispering in its ear.

From The PACS Designer: “Re: Google faster broadband. Google has announced that it is considering 1 gigabit per second broadband to the home as the next frontier it would like to conquer. Google said that speed would be fast enough to download a high-definition, full-length feature film in less than five minutes. Healthcare could also benefit from such a service as the medical image files can be  500MBs and larger.” I ran across this Extormity-like parody site that touts Google TiSP Beta, a free wireless broadband service that runs fiber optic cable in sewer lines. Incidentally, TPD is updating his list of iPhone apps for healthcare, so if you know of some cool ones, add a comment at the bottom of this posting and he will happily retrieve it.

From Ms. Curious: “Re: Sunquest. I hear they lost 30% of their sales force this week.” Unverified. I would be surprised if that were true.

From EHR Geek: “Re: Stanford Health Care. CEO Martha Marsh is retiring in August.” Unverified. I would be uninterested if that were true. Actually, only because I don’t know her and don’t know much about Stanford, but I assume I have readers who follow them.

From Joe: “Re: greenhorn manager. Reminds me of the old ‘three envelopes’ story that your younger readers may not have heard.” I thought everybody knew that one, but here goes (I’m using male pronouns only for convenience, not bias). A fired CIO’s replacement finds a note from his predecessor, saying he left three envelopes in the desk drawer to be opened only when things are going really badly. Six months later, the network goes down for most of a day, so the CIO opens up the first envelope and finds a note that says, “Blame the previous CIO.” Great idea! He makes up a convincing story about a historic lack of maintenance and capacity planning, saving his skin. Months later, the executive team complains about excessive IT operational and capital budgets, threatening to freeze expenses. Time to open another envelope. This one says, "Blame your coworkers." He does, arguing that the unchecked technology demands of his executive peers have made him the victim. Months later, doctors are pushing back against mandatory CPOE, saying that it’s typical CIO arrogance that makes him think he understands the challenges physicians face. He opens the third envelope, which says, “Prepare three envelopes.” I will also modestly add that several years ago, I won some local IT acclaim for embellishing the story with a fourth envelope that involved bringing in consultants, but I’ll stick with the non-customized version for the noobs.

From Lippy: “Re: greenhorn manager. It’s not just hospitals that like to stir things up. [vendor name omitted] just added an extra layer of management, making a chart that looked like the one from 4-5 years ago. The structure does not address sales-limiting problems inherent to most vendors — product limitations, support issues, and price. But, redoing an org chart makes upper management look like they are on top of things and justifies their existence.”

From Dulcinea: “Re: Wireless Life Sciences / Continua symposium in San Diego. Wish I had a recording of Patrick Soon-Shiang. He was all over the place from physics, biology, engineering, to healthcare integration based on the rail system network.” I can’t figure the guy out. He’s a drug company billionaire (some say a cutthroat businessman) claiming only benevolent intentions in getting involved financially (supposedly) with California’s interoperability project. What little I’ve heard him say publicly about it didn’t make a lot of sense to me either, but then again he’s at a level appropriate to a guy with a lot more zeroes in his net worth than me. I’d still like to interview him to see what he’s about.

Bassett Healthcare (NY) is recognized by the “Stories of Success” program sponsored by HIMSS and the American Society for Quality. Its submission involved quality and safety improvements using the SIS perioperative suite. 

Siemens renews its agreement with NextGen that allows it to sell that company’s physician practice systems to its customers. I hadn’t thought of it until now, but Siemens seems to be the only big hospital systems vendor that has done very little with regard to either acquiring or building practice systems. The market seems to be clearly indicating that those two previously separate demographics have quite a bit of overlap, so they seem to be at a disadvantage.

Medicity’s customer summit was last week, with half of its 700 customers in attendance and featuring presentations by David Kibbe and Marc Probst, among others. I had missed that, along with CEO Kipp Lassetter’s thoughts about California’s statewide HIE project and the transition of CalRHIO’s work to the state’s new governance organization.

Listening: good old anti-corporate, anti-government, Texas-based country from James McMurtry. I heard We Can’t Make It Here in a restaurant yesterday and was mesmerized enough to rush home and Google the lyrics to see who sang it. Turns out it was the son of Larry McMurtry, the guy behind the best Western ever made, Lonesome Dove. Makes me want a Lone Star, some brisket, and a pickup truck.

e-Val MD announces its H&P application for the iPhone and iPod Touch.

Confused by all the military HIT terms like CHCS, AHLTA, and VistA? Here’s a good overview and history, although not a very complimentary one when it comes to billions in costs and FCCs (fat cat contractors, for which I’ve decided to coin my own acronym) jostling each other at the taxpayer trough.

A gentle nudge: my reader survey awaits your electric touch, so titillate it, please. This is one of few times that your vote (and comments) make a difference.

Thanks very much to those several vendors who have invited Inga and me to their HIMSS shindigs. At least two of them are featuring some big-name entertainment that we’ve heard about (one has booked a 2010 Grammy winner, another will be rocking out with my favorite Athens beehive hairdo party band). I can’t speak for Inga, but I’m sure I won’t be able to go since HIMSS is really hard work for me with our own event and a ton of HIStalk writing that keeps me up late every night and eating McDonald’s (last year) and Subway (the year before), but it is delightful to be asked and I appreciate it.

Speaking the HIStalk event at HIMSS, I haven’t forgotten about readers who won’t be going to Atlanta. For the first time in HIMSS history (as far as I know), we will be streaming a party live over the Internet with full audio and video. We will have a little broadcast booth where our team will interview willing party-goers about whatever’s on their mind – meaningful use, who has the cutest shoes, or how many drinks they’ve had. The crew will have to swear not to let their cameras stray onto any scandalous behavior that may be taking place outside the broadcast booth since it may get a little bit rowdier this year with an open bar and a St. Patrick’s Day theme. More details to follow. For those who have asked, yes, there will be funny beauty queen sashes again this year (it’s an Inga thing that I gripe about since I have to assemble them, but it makes her happy).

I know I keep saying this, but if you’re waiting on something from me, hang in there — I am not ignoring you. My e-mail box is overflowing, I have HIMSS stuff to do, and of course I still have to make a living by day. I usually catch up over the weekend, but even that is threatened since I have interviews to do then.

Tony Cook joins GetWellNetwork as VP of marketing.

An interesting tidbit from the Cerner earnings conference call: the company had to reclassify some of its accounts receivable because it’s a subcontractor to Fujitsu, which is still duking it out with NHS in England. Cerner executives are clearly advanced when it comes to optimal buzzword deployment (they love words like footprint, space, and agile). Also casually mentioned: company president Trace Devanny is being relocated to London “to spearhead an increased focus on global markets and opportunity.” It seems curious that Cerner would allow its president to live and work overseas when only a tiny bit of its business comes from there, so I’m guessing there is more to that story.

Finally a healthcare jury verdict that makes sense: the Texas nurse who was fired and charged with “misuse of official information” for confidentially reporting concerns about a perpetually trouble-prone doctor to the state’s medical board is acquitted. The jury took less than an hour to dismiss the case, with the jury foreman saying, “We don’t feel that what she did was wrong because she had concern for the patients. Nurses are the eyes for the patient.” The nurse and a colleague who was fired over the same incident are now considering adding another claim to their lawsuit against the doctor, hospital, sheriff, and prosecutor: malicious prosecution. Reports are suggesting that the doctor not only peddled quack vitamins, but that perhaps also had previously hired as one of his salespeople the sheriff who went after the nurse.

Needless chemical nit-picking: this radio station’s headline trumpets that a family had “CO2 poisoning”. Those kids must drink a lot of soda.

As an IT guy, I’m fascinated by this article that talks about validation of embedded programming in medical devices. Pacemakers contain 80K lines of code and infusion pumps 170K, all prone to the same bugs as application code (memory leaks, improperly initialized variables, divide by zero errors, mishandling of variable type conversions). Those vendors, however, apparently have much more stringent testing methods than some of the hospital systems vendors I’ve worked with, where “compiled without errors” is synonymous with “passed a rigorous QA review.” (here’s an old RPG programmer’s joke I just remembered: hospital customer: “Are you sure this fix will work?” programmer: “Yes, I only had to set the gen level up once to get it to compile.”)

And speaking of that, I’m inspired to share my Five Answers You’d Rather Not Get from your Application Vendor When Reporting a Software Problem: (a) we already know about that and we’re working on it, so you wasted your time researching its cause on our behalf; (b) we don’t really want to look at it unless you can dedicate the resources to duplicate the problem and document it for us, even though we have a worthless QA department whose job you will be doing for free as a paying client; (c) we have a fix, but it’s going in a release you won’t be installing for at least a year since you wisely wait for all of our upgrade-related disasters to happen to other customers who don’t know any better; (d) that database error and file corruption problem is working as designed, so we will add your request to that list of enhancement ideas that we haven’t touched since 2001; and (e) you haven’t complained lately and we’re off doing enhancements for customers bigger, better, and newer than you, so can we just close your ticket so the suits won’t be all over us for bad metrics?

UVA chooses Sunquest Collection Manager for specimen collection.

Following disastrous financial performance, both the CFO and the VP of revenue cycle management of Jackson Health System (FL) quit. The board was not happy that the CFO’s numbers were off a smidge: he said the hospital lost $47 million in 2009, but the real number was $204 million. For 2010, the predicted loss is now pegged at $229 million.

Medicare fraud, Chapter Gazillion: a West Virginia coalfield clinic is raided and its non-physician owners charged for using a doctor’s DEA number to prescribe controlled drugs for four years, billing the government for physician services that were actually performed by extenders. Two doctors were also charged, one who admitted he knew Medicare bills were going out under his name even though he hadn’t seen a patient in 15 months. If you’ve ever been there, none of this will be at all surprising.

Microsoft may whine about all the attention Apple is getting for the iPad while nobody wants Windows-powered tablets, but their focus is apparently fickle: they shut down the Tablet PC Team blog, apparently dumping that group into the gulag that is the Windows organization. Or, maybe they’re just giving up without a whimper to Apple. I found this through OnTheRun.

HIMSS adds US CTO Aneesh Chopra to the conference keynote lineup. HIMSS always back-loads its keynoters hoping to get attendees to stick around, so he’s on Wednesday, meaning the audience will be somewhat diminished but still massive compared to the less-than-a-planeful that Sully Sullenberger will address Thursday at 12:30, long after most attendees are already back at work.

E-mail me (with only modest hopes for a quick reply).

HERtalk by Inga

From Tanya: “Re: Google Buzz. It’s like Facebook, only without any of my friends!” Buzz appeared in my Gmail account yesterday. So far, it looks like a me-too product without all the cool bells and whistles of Facebook and Twitter — and without the friends.

In light of NextGen’s announced acquisition of Opus Healthcare, I found it interesting that Siemens chose today to announce its renewed its strategic alliance with NextGen. Was Siemens wanting to ride the wave of NextGen’s five minutes of spotlight? Or did NextGen and Siemens want to reiterate that the Opus acquisition doesn’t have any affect on NextGen’s go-forward EHR strategy? In any case, it’s interesting to note that the Siemens / NextGen relationship (which goes back perhaps five years?) has resulted in 35 Siemens clients deploying NextGen software throughout their physician networks.

Continuum Health Partners (NY) selects Sunquest Information Systems for its LIS solution.

NuHealth, another New York health system, signs a $5 million contract with Allscripts to provide EHR, PM, and ED solutions across its hospitals and employed physician networks. The health system will also establish data exchange between the Allscripts solutions and the hospitals’ Eclipsys Sunrise, Sunquest lab, and Amicus radiology systems

Yuma Regional Medical Center (AZ) plans to spend $73 million implementing Epic EMR. The hospital says the five-year project will create 49 new jobs and includes creating connections with local providers.

This has to be one of the goofiest EMR surveys ever. A Practice Fusion-sponsor survey asks patients if their doctors stored their medical records digitally (48.4% said they did.) Now how exactly are patients making that determination when the “experts” can’t agree on what should be classified as an EMR? I mean, just because a doctor writes something on a piece of paper, does that mean the practice doesn’t have EMR? If the doctor types something into a computer, does that mean the practice has EMR (maybe he/she is simply checking up on e-mail). Does this survey tell us anything of value?

Henry Schein Medical says it will continue expanding sales of MicroMD, despite the recent death of founder Ajit Kumar. Kumar took medical leave in September, soon after being diagnosed with lung cancer, and died January 15th. VP/GM Keith Slater will continue to oversee operations at MicroMD, which is expecting 25%  sales growth this year.

Nuance rolls out a new bonus-incentive plan for employees that meet certain performance targets. Based on the current stock value, CEO Paul Ricci stands to earn an additional $7.25 million. To receive his full bonus, Ricci must also stay with the company through September 30, 2011. Nuance posted a 21% percent in revenue at the end of its fiscal first quarter.

Akron General Health System (OH) signs a strategic agreement with McKesson to provide Practice Partner EHR/PM to its PHO nd affiliated community physicians. McKesson reseller Complete Healthcare Solutions will provide implementation and support to a potential 500 community providers. The hospital McKesson’s Horizon Clinicals and is deploying the CPOE part of HEO.

Merge Healthcare releases  Q4 and 2009 numbers: $2.1 million loss for Q4, compared to last year’s $1.9 million gain; annual net income of $300,000 compared to 2008’s net loss of $23.7 million. Merge’s quarterly net sales grew to $19.3 million from $15.1 million a year earlier.

I see HIMSS has scheduled three separate “Meet the Bloggers Sessions” at the conference. They’re billed as roundtable discussion that give attendees a “behind the scenes” look at the responsibilities and dedication required to maintain a successful blog. Mr. H and I were invited to participate, but we opted to keep our low profiles. Now that I see the hunky John Halamka is on one of the panels, I am re-thinking that decision. (Gosh, what if I were able to sit right next to him???) Anyway, I might just sit in to learn what Mr. H and I should be doing since most of the time we’re just winging it.

HIIMSS also just posted the initial list of companies participating in the Health IT Venture Fair. HIStalk sponsor EDIMS is a presenter. I’ve sat in on a few of those sessions in the past and I must say that listening to all those financial projections mixed in with marketing hype requires me to keep the caffeine handy. Actually some of the new stuff is cool and it’s interesting to hear who companies view as their competition and why a CEO believes his company is well positioned to be the next industry superstar.

Potential good news for physicians who practice at hospital-owned ambulatory care facilities. The Senate is considering adding language to its current “Jobs Bill” that would allow some hospital-based physicians to receive ARRA subsidies. Current ARRA language excludes hospital-based physicians, much to the disappointment and anger of ER docs, pathologists, and physicians practicing in hospital-owned ambulatory facilities. However, the proposed bill would give physicians in this latter group a chance to qualify for ARRA funds (though pathologists and ER docs would still be exempt). For more details, see SEC. 620 under EHR CLARIFICATION.

The CEOs of four rural Texas hospitals claim their new rural RHIO is the first of its kind. The competing hospitals, which have a combined 104 beds, will share costs and clinical information using a single Web-based EMR from Prognosis Health Information Systems.

Halfpenny Technologies adds healthcare veterans Bob Cox and Mike Meyer to its leadership team.

Christiana Health Care System (DE) signs a three-year contract with Zix for the ZixCorp Email Encryption Service.

An Allegheny County judge okays a class-action lawsuit against UPMC on behalf of patients who said it overcharged them for copies.Pennsylvania state law allows “reasonable rates” to cover actual expenses for copies of medical records. The judge agrees that UPMC’s per-page fee of $1.50 may not be reasonable. OK, I’ll say it. Everyone knows UPMC has an EMR. So how time-consuming and costly is it to pull up a patient’s chart and hit Print? If it really costs them $1.50 a page, than UPMC has a much bigger problem on its hands.

E-mail Inga.

Quality Systems Acquires Opus Healthcare Solutions

Quality Systems, Inc., parent company of NextGen, announced this morning that it has entered into an agreement to acquire Opus Healthcare Solutions. Terms of the acquisition were not announced.

Austin, TX-based Opus offers the Web-based and ‘08 CCHIT inpatient EHR certified Opus Clinical Suite, an inpatient system that includes clinical documentation, order management, clinical data repository, and a laboratory information system. The company was founded in 1987.

Quality Systems will integrate the Opus product line with assets from its previous purchase of the assets of Sphere Health Systems, Inc., which included its Spirit Enterprise hospital information system. Both product lines will be operated as part of NextGen Healthcare Information Systems, Inc.

The acquisitions give NextGen an inpatient product line, which it says will sell primarily to hospitals with fewer than 100 beds.

Scott Decker, president of NextGen Healthcare, was quoted as saying, “We have seen demand grow in the rural and community marketplace due to the Stark relaxation, emergence of health information exchange initiatives and impending incentives resulting from the American Recovery and Reinvestment Act (ARRA). Through our many years of working with ambulatory providers closely associated with or owned by community hospitals, it became clear that we could meet this demand by broadening our offering to include both ambulatory and inpatient solutions. In addition, clients have expressed the need for a single, ‘cloud-based’ technology platform that can be leveraged across ambulatory and inpatient care settings. These new acquisitions afford us the necessary capabilities to address client needs and fill a void currently present within the rural and community hospital marketplace. When considered in conjunction with our complementary Siemens Strategic Partnership, this announcement completes a strategy for distributing NextGen solutions across the entire inpatient and outpatient continuum.”

We announced the acquisition last night on HIStalk Practice, thanks to a tip from Miss Lead.

HIStalk Interviews Dane Stout

Dane Stout is director of the connected health and biomedical communication practice of The Anson Group.

 

Tell me about the Anson Group and what you do there.

I joined The Anson Group last fall. I’ve known the folks there for quite some time. The company has been around about 14 years. It grew up in the traditional medical technology / medical device space. I’m pharmaceutical. They’ve provided a lot of services over those years in regulatory quality systems. Helping them to put clinical trial protocols together, all that kind of stuff.

We started talking a while back about some of the changes that were happening in healthcare and this convergence of all these different players, and so we said, “There really seems to be a need for our services that we would put together to bridge the gap, really, between the traditional medical device, pharmaceutical companies — who are very familiar with the pretty onerous burdens of the regulations inside of healthcare — and then all the newcomers that are coming out of consumer electronics and general IT and telecom and you name it.”

Everybody’s flocking to healthcare because of the stimulus, because of the size of the market, and because of some of the margins. But I don’t think they have a real appreciation for what they have to deal with. That’s why my job here is to drive the “connected health practices”, is what we’re calling it. We’re really looking at a very network-centric perspective. To say, “All these new players are going to come in and they’re going to need ways (people) to help them get their innovation to market and still comply with the law and all the regulations that are a part of that.”

Give me some examples of some of those converging technologies that would be running on a hospital network.

We break it into two components. There’s what I would call the mission critical — I’ve classified it as more biomedical communication — so inside the walls of the hospital, you now are going to have all these medical devices that are there. They’re either just a closed-loop system sitting over in the corner, or they actually now have a private network.

I’ve read where the average hospital has somewhere around 240 distinct, private networks. There really isn’t that much value to that. What they would all like to do is to have the medical devices communicating with each other, communicating with the EMR connected to the order entry system, and be able to collect all this data and be able to feed that into data repositories and be able to improve on their performance using that.

A very different model in terms of a high-performance, high-critical response requirements that would be a part of that network. Being on the hospital enterprise LAN, now you’ve got medical devices that were designed from the ground up to operate in isolation that now all of a sudden have to be good network citizens and make sure that their security updates and software patches and all that don’t disrupt the other devices around them.

When you go into a hospital, who engages you? Would you typically be working through the IT department or straddling between IT and biomed?

That’s part of the other issue. There’s that convergence of the biomed, the clinical engineering staff, IT, the medical device vendors. The FDA, while they haven’t made a real definitive stance on the regulatory requirements, which we’re all kind of waiting with bated breath for the medical device data systems — guidance, which they continue to say, will be coming shortly — they did come out in November and said, “Look, the spirit of the IEC 80001 risk management framework is that the device vendors and the hospital IT staff share a joint responsibility for making sure that these things work together. They collaborate on implementing them correctly to maximize patient safety and the effectiveness of the devices inside the hospital.”

If a CIO is unsure about whether they need your services, what are some warning signs that it might be time to bring in an expert?

I think there’s a lot of questions. Where’s this all going? Who’s going to be regulated? I think there’s just a lack of understanding, and that’s one of the things that we’re spending a lot of time on. Just really educating people as to the FDA or the federal government’s view of what is a medical device.

I think people have this misguided understanding that, “Oh, well that’s Boston Scientific or GE.” The traditional people that make these big medical devices that we all see. That’s them. We’re not regulated. In fact, it’s really based on the intended use of the device. Is it really intended to diagnose or treat a disease? And if so, what kinds of claims are being made about that and by whom?

There are lots of examples of where you could combine multiple devices and create a new device. Hospitals even cross the line themselves where they become, in the eyes of FDA, actually a medical device manufacturer themselves.

Part of what we’re doing through our alliance with Epstein Becker & Green, which is the largest healthcare law firm in the country, is to help them, from an end-to-end process, understand what all those requirements are and to help them with the risk assessment, the regulatory assessment. You know, what does this mean in terms of HIPAA and privacy requirements, all the way through the process.

We’re equal opportunity players. We’re looking at as anybody that’s participating in connected health could be a potential client of ours, because they’re all going to have some impact from the change that the network introduction really drives.

Are you seeing an increased interest by the FDA in what they could or should regulate?

I don’t think it’s an increased interest in what they could regulate. I think it’s more how.

I just came back from the FDA Medical Device Interoperability Workshop. It was co-sponsored by the Continua Alliance, CIMIT, and the Medical Device Plug-and-Play initiative that’s being driven out of the Boston area, Dr. Julian Goldman, and then FDA. This was a three-day event that I attended at FDA’s White Oak Campus.

The whole discussion is — we get it that this future of what we have to deal with, in terms of devices, really it’s not just ARRA/Hitech driving this. It really is a requirement. That to make healthcare better, we’re going to have to have devices talking to EMRs. We’re going to have the ambulatory side of the business. We’re going to have to have all these connected devices and we’re going to have to figure out a way to regulate that because our mission hasn’t changed — protecting the public health and safety. We’ve just got to figure out a way to do that.

I think they’re open to figuring out ways to work with industry and to work with other groups inside the government, to try to figure out how do we do this in this new world of networked connectivity; which is very different than what’s really happened over the last 30 years since they started regulating devices.

Did you get any sense from the FDA that they have any interest in regulating electronic medical records, or only this new connectivity to what would always have probably been some sort of medical device?

I think when it comes to regulatory exertion of what they’re able to do under the statutes; they have a broad range of discretion. It’s what they regulate. You could make an argument that an ambulance with all the connectivity devices on it could be regulated. That was an example that they used.

They’ve chosen, obviously, not to get that far. But software? Certainly software is prevalent in medical devices, and there’s clear guidance offered up by FDA about software that’s used as part of diagnosis and treatment of disease and all the software that goes into traditional medical devices.

I think they’re saying, “Look, we may or may not do that. There’s two ways you can get our attention. You can come to us with a submission that you feel like this could be a medical device and you want to go through that process because you clearly see that it’s a diagnosis or treatment — it’s a clear case of that. Or, something happens and we have to make some intervention in that.” So it really depends on those two kinds of factors.

I don’t think they’re looking for more to do. I think they’re overwhelmed with the social media and pharma. There’s a lot of stuff that’s on their plate … the globalization of research … but they made no bones about it that they’re there to safeguard the public’s health and safety. They’re watching very closely, with interest, what is the development of the HIT software industry. Longer term, I think it would be naïve to think we’re immune from that. We’ve never been covered.

It really depends on the statutory classification of the device and their interpretation of that. I guess at the end of the day, they determine what they regulate based on the law. The vendors don’t get to pick. I think there’s some that we’ve talked to that think, “Well, no, I’m not a device.” Making that declaration doesn’t necessarily make it so.

Should software vendors be afraid of what FDA oversight would be?

You know, that’s really the message; because I don’t want it to be, “Oh, we’re the onerous coming in with all the bad news that you’re going to be regulated.” I think what we’re really suggesting is healthcare really needs the innovation of information technology. It needs the new entrants from consumer electronics. It needs it from the wireless providers. It needs it from the general IT players. I think it needs the HIT vendors that are well established inside the hospital — all the guys that are going to be at HIMSS — to say, “You know what? We just need to understand what our role is and what our potential requirements are in this space.”

Our message is that you can live with this. I mean, look at the industry. There are thousands of medical device companies. They all make pretty good margins and are pretty successful businesses. They just deal with the regulations that are required. It’s just part of the table stakes to get into the game. I think people don’t need to be fearful of it, but they don’t want to ignore it.

I think our job is to help them understand those requirements and to set their business strategy based on that. Don’t wait until you come out with a product to go out and tell the market you’re in healthcare, and then try to figure out how to  deal with regulations. Make that a parallel effort right there up front as part of your strategy.

If you don’t want to be regulated, we can help you figure out a way where you totally stay away from that. You just provide components. Or, if you’re willing to accept the responsibilities with that and enjoy the really big margins, we can help you devise a plan to do that, too.

If you were advising vendors about practices they could voluntarily adopt that would prevent the FDA’s interest or would move them along the path that FDA wants them to take, what would you recommend?

I think following some of those quality system guidelines that are clearly laid out, which are a cut above ISO 9001. That’s another common fallacy, “Oh, we’ve got our supply chain; we’ve got our quality systems pretty well in hand with ISO 9001.” But it goes much more beyond that when you’re talking medical-grade systems.

I think there are some voluntary things that they could do to probably show the good faith of that, but there’s lots of ways to really strategize around that. That could be partnering with somebody that really has already embraced those requirements. If you look at GE, they have a broad footprint in healthcare. I think there are other examples. If you look at Intel, they clearly understand that they’ve moved in the device space. They did a 510(k) for Health Guide.

There are people out there looking at it saying, “This is something we’re going to take on directly.” There are some partnerships that other companies say, “I don’t really want to go to that extent. I want to stay away from that boundary line” that they can partner with.

I think the traditional players in software, the big EMR vendors and all, are going to really need to be monitoring this carefully and start thinking about the flipside of all of the interoperable health records. The connectivity inside the hospital does mean that things that were never involved before directly in diagnosing and treating patient illnesses now become a critical part of that.

I believe the folks in Washington are going to look at that very closely. Doing things the right way, maybe following some of those same processes that the device companies are already doing, and doing that voluntarily could certainly be a step in the right direction.

What kinds of innovation could run afoul with the regulatory environment if companies weren’t looking ahead?

I think all innovation is subject to that, but I think the ones that seem to be top of mind today are … I guess we really didn’t finish the first part. There are the two prongs of this. There are, inside the hospital wall, devices sitting on the enterprise LAN talking to the major software applications in place. There’s the other side of that, which is more of the remote monitoring care at home, monitoring of chronic conditions through wireless networks through your cell phone, connected to some other medical device to try to improve the quality of life, and to give people sort of this continuous monitoring of care and feeding that back to a call center where the nurse is.

There’s a lot of interest, there’s a lot of activity, and there’s a lot of great innovation that’s coming of that space, but I think there are some folks out there that may be pushing the envelope. I spent a long, 20-plus years in the traditional IT space and I know how IT marketing is. This one-upmanship. You’re always promoting your vision and you’re sticking it out there. You have to be much more deliberate about it when you start talking about marketing inside of healthcare, because you can find yourself backing into a situation where all of a sudden now you’ve completely put yourself in the purview of FDA regulatory requirements.

If you start making claims about things that your cell phone platform can do in terms of helping people monitor their diseases, you’re now involved in that. The same device … if you’re a manufacturer of a cell phone handset and you don’t make any claims about that and it’s just some of the other applications that are out there are using your device, then you can be exempt from that.

It’s an area that you can find yourself backing into it, and it’s a huge problem. Or, you can set that deliberate strategy and understand, “What are the areas that I need to stay away from?” That extends to not just marketing material you might have on your Web site, but it could be what your sales representative talks about, or what you talk about in a conference. There’s lots of ways you can communicate that, “Hey, I’m really involved in the care of patients” that companies need to be careful of.

The software vendors have traditionally just said, “We disclaim everything. We’re saying it’s not fit for purpose unless you say it is and it’s the clinician’s judgment.” Then bundle that with non-disclosure clauses, which would seem to be something the FDA wouldn’t want to see. Is that enough to keep the FDA away? Is just disclaiming your responsibility really a long-term solution?

No, not at all. It would have, really, no impact if there were a situation that they came up from somebody using one of these devices. Including software, because software clearly can be defined as a medical device under FDA current regulations — there’s no bones about it. They can step in and enforce that.

I think one of the telling things is if you look more deeply embedded in medical technology is this use of nanotechnology. On the Frequently Asked Questions page of the FDA Web site, they had a question about how you regulate nanotechnology. They said, “Look, we don’t regulate technology. We look at the statutes. We look at the claims. We look at all of the rules that apply to what our mission is, which is safeguarding the public’s health and making sure that the claims that are made about medical treatments are effective and valid and legitimate. That’s what we do, and we look at that regardless of what the technology is. So we’ll classify new, emerging technology according to our interpretation of the law.”

I think people are saying, “Well, they haven’t come out with any definition of how they’re going to regulate a network device.” Or, “They haven’t told us how we’re going to regulate nanotechnology.” But I mean, technology moves at such a fast pace. If you think about it, there were no medical applications for the iPhone until August of 2008. So the law and the regulatory requirements that move along behind that move at a much, much slower pace, but that doesn’t mean they don’t apply.

That’s really what we’re trying to help companies, our clients, navigate those two very diverse sets of reality. That you want to get that innovation out there; you want to continue to drive it. Again, there are some really interesting things that are going on in the connected health space, but at the same time you have to understand that you still have to play by the rules that all the established device companies have done for 30 years.

The connectivity to the devices will help hospitals accumulate large quantities of patient clinical information, which will probably have a lot more research value than anybody had really thought of. How do you see that tying together both the collection of data that maybe wasn’t really integrated with normal software-type data before, and then what the requirements will be to both collect it and use it?

Clearly that’s part of this whole notion of connected healthcare where we insert this interdependent network between all the different players. So you get the payer, the providers; you’ve got network participants right now that I think are pushing the bounds of … they’re both doing some really good things, but you start wondering about these decision support tools that you use based on some remote analytics engine and some big information repository out there in the sky. But now since it’s involved and the doctors directly rely on that and there’s some sort of workflow enablement that’s part of that, it really drives right to the heart of it.

To answer your question about the data … as it moves around, it can actually traverse different regulatory jurisdictions. So if you think about it, there’s a lot of interest by the big drug companies in looking at EMRs as the source for clinical trial data and for clinical trial participants. But as that data moves from an EMR to an electronic data capture system, let’s say, which is basically the same thing but it’s done for clinical trials, it’s now moved from the privacy rules of HIPAA over onto 21 CFR Part 50 and 56, which really governs the privacy and treatment of information for clinical trial subjects. So as data kind of moves around in the network, it can actually move between jurisdictions of different federal agencies.

Again, we want to provide a clear knowledge base so that people have a clear understanding as they’re setting up their strategies to say, “How I approach healthcare?” especially if they are new to this business. It’s very important to understand all the different layers of complexities, including one we haven’t really talked about much — how do I get paid for that?

As you know, inside the hospital, all those things are really being driven by how private insurers pay us. Is it medically necessary? If you look at CMS, it’s reasonable and necessary — and there’s very definite restrictions on that. I’ve talked to a number of companies that say, “We want to get into healthcare. We’re really excited. We’ve got all this cool technology.” Then we’re like, “OK, well how do you intend to get reimbursed for that?” “Oh no, we don’t even want to mess with insurance. We’ll just sell it to the consumer.” I think that’s a really flawed assumption when you’re moving into that space because most consumers are still going to look to their health plans to pay first. Even if it’s a comparable cost to maybe some big consumer electronics purchase, we’re just conditioned to look at that first.

So now they’re moved into this whole area of not only am I looking at FDA, but I also have to look at CMS, and then what do I have to prove to the medical directors at all the big insurance companies? Then, just throw in Meaningful Use along from ONC. There are lots of really small phrases that can have very impactful meaning.

I like to sum it up to say that with FDA, it’s safe and effective. CMS, it’s reasonable and necessary. ONC, it’s Meaningful Use, secure and interoperable. Those are fairly simplistic words, but they’re very complicated to actually deploy in real life.

Anything else?

Our big goal is that we have a vision, not to come in and be the bearer of bad news, but to say healthcare absolutely needs IT. When you put healthcare and IT together, it becomes HIT and it’s different.

What’s really different? I think it’s this aspect of clinical treatment of human beings. It’s different than retail. It’s different than manufacturing. It has important nuances to it that we want to make sure that they map into their strategies. We want to help them get that innovation to market and comply with the law and the regulations that are part of that. That’s our goal.

News 2/10/10

From Snow Bunny: “Re: Pittsburgh snowstorm. The snow flake power outage was severe and crippling at Jefferson Regional Medical Center. It caused all computer screens to go blank with no EMR for 20 hours. Check with your Siemens IT friends to reconcile the facts. Retaliation will be swift for the staff that leak the truth. I have not yet been able to determine the impact of the outage at the Canonsburg Hospital (above) on its EMR, but hospitals do not close their ERs just because they cannot do CT scans.” Unverified. If they had a snowstorm and power outages, I’m not sure that’s a Siemens problem.

From Sally: “Re: Allscripts. They announced a sales re-org a few days ago. Several long-term folks decided it was a good time to make an exit.” Unverified. Allscripts doesn’t confirm rumors, so that’s all I can say except lots of companies seem to be reorganizing their sales teams lately, most likely to frantically shore up the front lines for HITECH spending.

From Othello: “Re: ARRA/HITECH resources. HIPAA Survival Guide is useful.” I notice that HIStalk did not make their list of “TOP healthcare blogs”, which includes some not-so-stellar ones, so I’m not exactly sure why I’m giving them a free link.

From LPJ: “Re: HIMSS. I have been in contact with many IDN CIOs across the eastern US this past week inviting them to a HIMSS event. It may just be a weird coincidence, but an unbelievable number of CIOs are not making it to HIMSS because they are so swamped with large projects in the hospital or with ambulatory implementations.”

From Paulie: “Re: editorial. Did you read this one from [publication name omitted]? Pretty lame with some basic facts wrong.” Newspaper people write editorials that involve issues that affect us all, like taxes and crime, which makes sense. What doesn’t is sideliners who have never worked a day in either healthcare or technology who crank out impassioned, overly confident editorials that industry experts are supposed to find insightful. But if they can get readers, more power to them.

From Joe: “Re: VA. Some months ago, the VA announced that some dozen or so projects were being placed on hold, some of them where VistA had shortcomings and off-the-shelf software could be integrated.” I knew that, but what I haven’t heard is whether they’re moving forward with Cerner LIS or sticking with internal / fat cat contractor development.

From Svetlana: “Re: Scott McNealy at HIMSS 2005. He was a no-show for the opening address. The loyal Sun health care partners slated to be a part of his presentation were given the bum’s rush by HIMSS folk and left to deal with the nasty PR aftermath in the exhibit hall.” I guess that’s why I didn’t remember him. I figured I must have slept in or something since the opening session is usually pretty lame (all the HIMSS speakers just read their speeches off the TelePrompter, usually stumbling frequently). The opening keynoter this time is the CEO of Sprint Nextel, whose inspiring five-year stock performance (blue) against the Nasdaq (red) gives me a good reason to plan for some extra rest before bussing over for the first educational session.

SDI Diagnostic Imaging, a nighthawking radiology company, acquires Stratus Healthcare, another Florida company doing similar work. “Stratus’ software platform allows radiologists to do final reads and use a voice recognition system to dictate their findings directly into the patient’s medical record at the hospital, which will grow in importance with the push for more electronic medical records. It also could mean more direct billing of managed care companies for SDI’s services instead of billing the hospital or radiology group that is SDI’s client, Younger said.”

Maybe you are snowed in, tired of short days, or just struggling with the winter blahs in general. Here’s your cure: complete my reader survey. OK, that was a blatant come-on, but I really do study your responses closely and agonize over what I could be doing better after I read your comments and re-evaluate my self-worth. I only do it once a year, so think of this as Pledge Week at your local PBS station, with aging, overweight doo-wop singers in bad toupees and Popsicle-colored tuxes standing at the ready to sing the only the achievable low notes of Goodnite Sweetheart, Goodnite after the break.

An argument for electronic patient records, witnessed by me first hand: doctors, nurses, and ancillary employees trying to figure out how they can all use the same patient’s MAR simultaneously following the invariable search party it takes to locate it in the first place.

From The PACS Designer: “Re: Receiver for iPhone. Most of us are familiar with Citrix and its servers sending applications to your home or other locations. Now, Citrix has released Receiver for iPhone to send applications to a mobile device so you can have your applications any place you might be with your iPhone.” I first mentioned it in May 2009, but I think this is a new version.

Rep. John Murtha, the big-time bringer of federal pork (some of it healthcare IT-related) to the coalfields of Pennsylvania, dies of what appears to be a medical error. Reports suggest that his surgeon at National Naval Medical Center nicked his intestine or a blood vessel during a routine laparascopic gall bladder removal, causing his death from complications three days later.

I ran across CareCloud, some kind of start up that is not very descriptive of its business, a couple of days ago. I also notice that they’ll be pitching to investors at the Health IT Venture Fair at HIMSS. From the minimal description on its site, it sounds as though CareCloud sells cloud-based physician office systems (“a Web-based healthcare IT ecosystem”)with some social networking thrown in. Pretty much everyone on the executive team came from RCM vendor Avisena.

Jobs: Senior IT Systems Analyst (GA), Clinical Informatics Specialist – Pharmacy (MO), Director – Clinical Informatics (CA), Information Services Manager (VA).

Cerner reports Q4 numbers: revenue up 0.1%, EPS $0.71 vs. $0.86. Some of that was because of a one-time benefit from a year ago, but I would still say it’s a pretty poor quarter given all the company’s bravado about HITECH-fueled growth. They beat earnings estimates, though, and nearly everyone admits now (finally) that stimulus dollars won’t be hitting vendor bottom lines for some time.

A Weird News Andy find: a Texas hospital nurse writes a confidential letter to the Texas Medical Board, asking them to check on a doctor whose medical practice she thought was substandard. The doctor, who has been reprimanded several times by the hospital and fined by the medical board for running a phentermine-dispensing weight loss mill, gets her and another nurse fired. He then reports the nurse to his happy patient the sheriff, who hits her with a felony charge of misusing clinical information. She faces up to 10 years in prison for doing what she thought she was obligated to do as a nurse. The medical board sympathizes, saying “It’s sort of an alarming idea that somebody reporting a doctor of concern has to be afraid of criminal charges.” The nurses are suing the county, hospital, sheriff, doctor, and prosecutor for vindictive prosecution and violating their First Amendment rights.

The greenhorn manager’s guide to fixing every organizational problem: (a) draw up a new org chart that looks exactly like the one from five years ago, which was changed back then to fix every organizational problem; (b) implement more systems in which to document work, record time, and report status; (c) move people around and expect significant synergies to result; (d) hold pathetically transparent motivational sessions and team-building sessions among co-workers who dislike each other intensely; and (e) dismiss all longstanding, serious problems as requiring nothing more than fresh perspective, additional meetings, and focused prioritization. This is a composite of all the hospitals in which I’ve worked. I felt the need to share.

PC World mentions Microsoft Research’s work in using consumer products like the Xbox and Windows Mobile phones for health-related functions. “Researchers are also looking at how to automate the data transfer from complex records and choose or filter displayed information according to conditions such as whether the doctor or family members are in the room, which could be detected by sensors, Tan said. Xbox units could be used for those purposes, to present other health information and to let patients play games or access certain Internet services, including through body gestures enabled by Microsoft’s upcoming Project Natal control system, he said.”

Sometimes it seems that as many spare bedroom programmers are writing iPhone apps as there are people using them. This Mayo cardiologist taught himself programming and spent 200 hours writing his 99-cent app that lets users screw around with photos, like adding balloon messages, devil horns, or giant pectoral muscles.

Nuance announces Q1 results: revenue up 21%, EPS -$0.02 vs. -$0.11.

Tasmania’s Department of Health and Human Services has issued a request for tender for a system to create a longitudinal patient with HIE and business intelligence capabilities from its legacy systems, just in case any of you vendors are interested.

E-mail me.

HERtalk by Inga

Picis announces its 2009 highlights, which include the addition of 30 new IDNs, 83 CareSuite selections, and a doubling of LYNX revenue cycle customers. Mr. H mentioned the other day that Picis was of HIStalk’s first sponsors and that he interviewed President Todd Cozzens in 2005 (back when he still had to beg people to talk with an unknown blogger). Here is what Cozzens said five years ago:

We’ve got plenty of room for growth. These care areas (ED, ICU, OR) make up over 50% of a hospital’s revenue and expense, and only 7% of ICUs are automated so far. We’ve proven that we have the technology and usability levels for users to spend money to make money in these areas. We’re past the early adoption phase. Most of our OR revenue comes from replacing antiquated scheduling systems, but only 7-10% have automated anesthesia and PACU, so that’s an add-on at the same price as the scheduling system. ED is only 10% automated and a hot area for investment. So, there’s plenty of growth for this company in the next five years, continuing to do what we do extremely well.

East Cooper Medical Center (SC) plans to install Patient-Aware OR in its new hospital opening later this quarter.

Mediware announces its Q2 numbers: net income of $783,00, which is a 158% increase over last year; revenues of $10.8M, 8% higher than last year.

Providence Health & Services Washington Region selects Compuware’s EHR Service Delivery Solution to proactively resolve performance issues.

Citrus Memorial Health System (FL) upgrades its HIS to McKesson’s Paragon community HIS. Citrus will use McKesson’s remote hosting services and plans to connect its outpatient clinics that are running McKesson’s Practice Partner ambulatory EHR.

The University of Colorado Hospital is seeking to fill 75 new jobs as it implements its $67 million Epic project over the next three years. Average salary is $74K for positions that include analysts, project managers, business systems analysts, and computer technicians.

I also noticed that MEDecision is soliciting potential employees to schedule an interview with them during HIMSS. If the interview goes well, perhaps you’ll be invited to attend the big party they’re hosting at the Georgia Aquarium. (Unfortunately it is the same time as the HIStalk party or I’d be making plans to be there.)

Phytel raises $14.2 million in funding from investors, including Polaris Venture Partners, Caris, and LAH Investments. Phytel plans to use a portion of the funds to advance product development.

Also raising new funds: PatientSafe Solutions (formerly known as IntelliDOT), which closed on $30 million in Series B-1 financing and will use the money to complete its next generation product.

Concord Hospital (NH) is replacing its Sun Microsystems eGate solution with Orion Health Rhapsody Integration Engine.

Garden City Hospital (MI) integrates Dragon Medical with EmergisoftED in its ED. The hospital says its now creating “transcription-free clinical documentation.” CareTech Solutions provided the implementation training and support for the EmergisoftED and Dragon Medical integration.

The CIO at Wayne Memorial Hospital says their Imprivata OneSign SSO application has eliminated password management challenges and is providing secure access to data from more than 40 applications. Connected applications include MEDITECH 6.0, McKesson PACS, Nuance ESW, Kronos, NetLearning, OWA, and RadNet.

Nash Health Care initiates a 15-month Cerner clinical implementation nicknamed “On Track for ePatient Safety.” The hospital anticipates saving $8 million a year over five years following its March 2011 go-live.

Cook Children’s Health Care System (TX) signs up for multiple enterprise software solutions from Lawson Software.

A new KLAS report looks at 22 HIE vendors and concludes that most have only one, two or three validated sites. Axolotl has the most live HIE clients in the acute-to-acute space (seven validated.) Epic also had seven validated acute-to-acute sites, though all are Epic software customers. Among acute-to-ambulatory HIEs, Medicity’s Novo Grid leads the pack with 22 live HIE organizations; RelayHealth has eight live sites.

A few sponsor updates:

• CareTech Solutions names Colleen M. Hanley as VP of marketing, communications, and government affairs.
• Quality IT Partners wins an IT infrastructure contract with a major health system in the West.
• Home health provider SunCrest Healthcare selects Philips as its provider of telehealth monitors for home care patients.
• Rob Kolodner headlines a Sunquest-hosted breakfast March 2nd during HIMSS.
• BridgeHead Software is surveying hospitals and healthcare organizations to gauge the industry’s readiness for and response to IT growth and the data it produces. If you’d like to participate — and earn a chance to win an Apple iPad – you’ll find the survey here.
• The Children’s Center (OK) purchases QuadraMed CPR, including the Smart Start solution, CPOE, Long-Term Care and Rehab, and AcuityPlus.

Google plans to introduce a Facebook-ish feature that will make it easier for Gmail users to view media and status updates shared online by friends. I see this as a potentially very bad thing. First and foremost, I am in Gmail all day and I can’t imagine how I will get any work done when I see friends post things like they’ve gotten a new haircut and need feedback, or ask questions like what kind of wine goes best with Mexican, or even that Nordstroms is having a major shoe sale. Second, I am already entrenched in Facebook and I can’t make a switch now (same excuse used by a lot of providers using EMRs). And third, do I really, really need another way to communicate with people? One reason I am really looking forward to HIMSS because I’ll have a chance to talk to people face-to-face versus virtual communication. Who is shocked to know that Mr. H and I have only talked on the phone once in the last year? Yet I know he is always lurking on my Facebook.

Talk virtually to Inga.

Readers Write 2/8/10

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!

First Impressions of the iPad in Healthcare
By Trey Lauderdale

I don’t think we have ever seen a piece of technology as polarizing as the recently released Apple iPad. Being vice president of innovation at a healthcare-focused iPhone development company, I have received an unbelievable amount of feedback (some solicited, some not) on the good, the bad, and the ugly of the iPad’s potential uses in healthcare.

The first potential use models are the usual suspects we have all been hearing about for the last 3-6 months: entering data into the EMR, viewing medical images, observing patient data, managing alarms and alerts, etc, etc, etc. I could go on and on, but you already know all of these because they are available right now on your iPhone.

Don’t get me wrong — all of these functions are wonderful, but nothing here is really game-changing. I consider these the foundation of what is necessary to bring this device into healthcare in a useful manner.

In my opinion, the greatest impact this platform will have on healthcare is going to be from the creative juices squeezed out of the developer’s minds who will be writing applications specifically geared for the iPad and its potential use model.

You have got to look beyond version 1.0 of the iPad and into what it will become in the second, third, and onward generations of the device / platform. Apple tends to make significant improvements to their product between the first and second generation releases (2nd Gen iPhone >> 1st Gen iPhone). The limitations that have been brought up are all valid, but will be alleviated over time or through simple physical remedies.

It won’t survive in the hospital environment?

A robust, antimicrobial case will be out by the end of 2010 – it can almost be guaranteed.

No camera for image taking?

It will be there by Gen 2 (not for healthcare, but because consumers want it).

Too big to fit in a pocket?

The workflow model should not position this as an “always carried” device.

The one limitation that had me on the verge of throwing my MacBook across the office was the lack of background processing. While potentially the greatest shortcoming of the iPad, after some thought and analysis, it needs to be viewed as a mixed blessing. This device is going to have 1GHz of processing power focused on ONE application. The user experience in the currently open application is going to be amazing, assuming developers take time to re-factor their applications to fully leverage this “limitation.”

Through appropriate use of inter-app communication and data sharing, a great deal of the concerns brought on by no backgrounding can be bridged relatively easily. The key is going to be the foundational applications leveraging and creating open-source frameworks and standards that can be leveraged across multiple vendors in a collaborative environment.

The first day the iPad is released in March, all of the technology and applications are in place to enable a caregiver to view their patient’s vital monitoring waveform (Airstrip Technology), check the data against their EMR (Epic Haiku), and then send a quick message to an appropriate staff member asking them to take action on a potential event (Voalté).

While these currently reside as three separate applications, the experience provided to the end-user should not feel as such. The real power of the iPad (and even iPhone) platform is going to be a collaborative environment between the vendors that reside on the device. This collaboration will be of even greater importance with the iPad due to the greater amount of real estate the end user has to work with.

I can envision a hospital where an iPad is placed outside every hospital room displaying relevant information about the patient and their current vitals (REALLY decentralized monitoring). Clinicians grab the iPad as they enter the room, sign in with a quick series of hand gestures (or maybe take a quick picture of their ID?), and easily enter information into the open application regarding the patient’s current status. Messages and tasks can be dispatched to the right caregiver automatically from the iPad, and the clinician places the device back into the cradle once done with the patient. All of the pieces for this experience are currently in-place and ready to be tied together.

Apple has provided the revolutionary platform we could have only dreamed of 10 years ago. It is now our responsibility as application developers and IT system administrators to turn those dreams into reality and provide the end user experience our clinicians deserve.

Trey Lauderdale is vice president of innovation of Voalté of Sarasota, FL.

Interim is not Final
By Mountain Man

I don’t know about you, but my organization is asking a lot of questions about ARRA "now that it is finalized" and what we as an organization should do. Should we change our strategic plan? 

With all the hype and media around this pseudo-event, we certainly have the the eyes and ears of our executive team and board members. We have somewhat of a bully pulpit. We should use the awareness created to advance our causes of bringing safety and efficiencies to healthcare delivery and financial visibility  into the business. If we can tilt the spending towards an appropriate amount in order to complete our strategic plan, we should do so.

Here is the problem. “Interim” is defined by Wikipedia as “a temporary pause in a line of succession or event.” This does not sound very FINAL to me. So, Interim Final Rule really makes little sense.

Quit freaking out, people. NO ONE thinks we can hit the dates provided by the IFR. We should not reallocate all our resources to cover some part of the ARRA requirements that we left out of our strategic plans two years ago.

Most of us are working towards the general direction that the IFR is leading us. Keep doing what you are doing. Trust your plan and execute.

It is your STRATEGIC plan for a reason. Hitting an INTERIM suggested state is very TACTICAL and short-sighted.

If you are not headed in that general direction by now, then you should freak out.

They’re all Synonyms!
By Deborah Kohn

I don’t know how many times I delivered a presentation / authored a published article when I had to explain why two healthcare information technology (HIT) trade organizations (one so large that it won’t be mentioned in this article and the other, federally commissioned at taxpayer expense and no longer in existence) adopted definition differences between an electronic medical record (EMR) and an electronic health record (EHR).

This only further confused my healthcare professional audience / readership who, for years, have had a complete understanding that charts, records, patient charts, patient records, medical records, health records, etc. are synonyms! Walk into any hospital or clinician office and always one will hear an assortment of such synonyms without ever questioning the meanings.

True, in the late 20th century, synonyms of adjectives, such as computer, computerized, automated, or electronic were needed to differentiate between (what is known in the greater IT world as) analog vs. digital charts, records, patient charts, patient records, medical records, health records, etc. However, still the use of the synonyms of adjectives with the synonyms of nouns made no difference to practicing healthcare professionals, except to differentiate, when necessary, between analog, digital, or hybrid.

Thankfully, we might be getting close to ending this nonsense. Recently, one HIStalk reader correctly pointed out that NOWHERE in the 2009 American Recovery and Reinvestment Act (ARRA) with its Health Information Technology for Economic and Clinical Health (HITECH) Act is there a distinction made between an EMR and an EHR. Only the term electronic health record and acronym EHR is used — for health information exchanges, for hospitals, for physician offices. That’s probably because every healthcare industry-bred author / reader / interpreter of this legislation has a complete understanding of what is being conveyed.

On the floors or in clinic rooms, let’s continue to use whatever synonyms (adjectives and nouns) come to mind, because we’ll continue to understand what is being communicated. In addition, let’s give credit to the 2009 legislation for dealing one of the final blows to this “trade organization made up EHR/EMR” definition debate and all agree to use EHR (as used in the ARRA / HITECH legislation) as the standard terminology in presentations / published articles / vendor products, etc. Only then will we be able to move on to more important discussions.

Deborah Kohn is a principal with Dak Systems Consulting  of San Mateo, CA.

Licensing of EHR Systems: Contractual Considerations
By Robert Doe, JD

As a result of the incentive payments offered under the HITECH Act for implementing certain qualifying EHR systems, many healthcare entities are evaluating the various EHR systems that are available, taking into account the certification, interoperability, and meaningful use requirements. There are a number of considerations a healthcare organization should take into account during the process of choosing and contracting with an EHR vendor.

A healthcare organization should consider including certain warranties and representations in the agreement with the EHR vendor to help ensure that the system is capable of allowing the healthcare organization to receive the incentives (and avoid future penalties) associated with the adoption of an EHR on an ongoing basis for the term of the license. As a drafter and negotiator of license agreements on behalf of healthcare organizations, while some vendors claim to do so, I have seen reluctance on the part of EHR vendors to meaningfully warranty their systems with regard to these considerations.

One argument is that the criteria for receiving the incentive payments have not been clearly defined. Future requirements, the argument goes, could conceivably require significant investment in new functionality. In addition, a vendor may argue that it has no control over how the system is actually used within the healthcare organization.

With regard to the first argument, EHR vendors are receiving significant new business as a result of the HITECH Act. If they cannot warrant the functionality which is one of the main motivating factors for licensing the particular system chosen, they are in effect transferring the entire risk to the healthcare organization, which, at a minimum, should be shared by the parties. For a significant capital expenditure of this nature, care should be taken to produce the result which justifies the expenditure. As a result, this should be one of the first discussions a healthcare organization should have with the EHR vendor during contract negotiations.

Some vendors may offer warranty language that appears to address the subject matter, but from a legal perspective, doesn’t actually provide much in the way of legal rights. Some vendors may propose that the issue be addressed as part of maintenance and support. Keep in mind that the legal remedies may be significantly less for a breach of maintenance and support as opposed to a breach of warranty. The warranty language could also be crafted to take into account the situation where significant additional investment is required for the system to conform to HITECH’s requirements, allocating an agreed upon portion of the expense to the existing customer base.

With regard to the second argument, it’s true the vendor has no control over how the system is actually used by the healthcare organization, but the warranty language can be worded to ensure the system includes the necessary functionality to allow the healthcare organization to qualify for incentive payments and avoid future penalties.

In addition, many healthcare organizations are endeavoring to provide access to their EHR systems to other unrelated healthcare organization in their communities, as part of a regional health information organization, health information exchange, or otherwise. The underlying goal of many of these arrangements is to provide EHR technology to other local healthcare facilities that may not be able to afford such systems by themselves. Such arrangements may also help to lesson the financial burden. Whatever the reason, there are legal and licensing issues to consider.

Any healthcare organization that desires to provide access to a software application to another unrelated healthcare entity or clinician must be aware of the physician self referral prohibition (Section 1877 of the Social Security Act) commonly known as the Stark law, the federal anti-kickback statute, and, depending on the data being exchanged, the Health Insurance Portability and Accountability Act, commonly known as HIPAA. In addition, significant anti-trust issues could arise if the software allows the sublicensees to share financial information. These additional legal issues must be addressed with legal counsel prior to setting up such an access arrangement.

In addition, the agreement with the EHR vendor must contain specific provisions allowing the healthcare organization to provide access to the unrelated healthcare organization. Do not assume that you can provide access by simply executing the EHR vendor’s standard form license agreement. All license agreements contain a license grant section that specifies the parties and individuals that can use the software. In most instances, it is limited to employees of the legal entity that signs the contract.

In addition, most license agreements specifically prohibit the use of the software to process information for, or use the software on the behalf of, any third party. The contractual language allowing the healthcare organization to provide access to an unrelated organization can take many forms. It may be as simple as expanding the definition of an authorized software user to include any other individuals authorized to use the software. Alternatively, the license grant may specifically state that the licensee may sublicense or provide access to the software application to a third party and set forth the conditions under which it can do so. There will also need to be an agreement between the two healthcare organizations governing access to and use of the EHR system. Careful consideration should be put into the drafting of this document. There are a number of issues that could arise if not addressed in this agreement.

The HITECH Act incentives have increased demand for EHR systems. Often times the timeframe for implementing such systems is quicker than would ordinarily be the case. It has been my experience that taking the time now to address the legal and business issues will help avoid problems in the future.

Bob Doe is a founding member of BSSD, an information technology law firm located in Minneapolis, MN.

Monday Morning Update 2/8/10

From Nasty Parts: “Re: Sage. COO Lindy Benton resigned Thursday night.” Confirmed with Sage. Betty Otter-Nickerson starts as CEO this week.

From iSOFTen: “Re: UM Medical Centre in Kuala Lumpur, Malaysia. IBA/iSOFT have been invited to the exit door because of repeated product delivery failures. This casts long shadows over the future of their German-developed strategic lab product, planned for the still pending at Welsh procurement. And with regard to iSOFT’s alliance with Picis, it was because of IBA/iSOFTS’s product delivery failures.” Unverified.

Listening: Midlake, a Texas band that sounds like accessible, straightforward 60s pop meets the Flaming Lips.

I think it’s plainly obvious, but in case not: I use only phony names on the reader comments I post. Please do not pester your colleagues just because the phony name is similar to theirs since it most likely wasn’t their comment.

Tammi, our BFF from AT&T Mobility, said their “iPhone in Medicine” session was packed even after being moved to a larger room at the mHealth conference in Washington DC last week. mHealth Initiative is the group formed by former Medical Records Institute/TEPR people Peter Waegemann and Claudia Tessier when that group flamed out.

Weird News Andy ponders, “Where do babies come from? From iPhones, apparently.” After four years of trying to conceive, a couple hits pay dirt in just two months after using an iPhone menstrual calculator. Thank goodness humanity didn’t lapse into extinction before the iPhone came along to help it reproduce the species.

Yale New Haven Hospital chooses the document management solution of Perceptive Software for several departments.

The folks at Henry Schein Practice Solutions are offering a free, on-demand Webinar called 10 Questions to Ask your Electronic Dental Record Vendor. They’ve also hired Pete Cousins as national sales manager for Dentrix Enterprise. I’m sensing trouble because Pete is a big-time amateur golfer, which means if you want a customer’s game, he will probably thrash you despite his best intentions to keep it close.

Red Hat announces its February 10 Open Source Cloud Computing Forum, an all-day virtual forum hosted by its CTO that offers 12 half-hour technical presentations.

Sunquest will introduce its new BI solutions and physician portal at HIMSS.

We’ve mentioned some charity-related activities at HIMSS, so here’s one from Compuware and Covisint. The company will donate $10 to Habitat for Humanity for each attendee badge scan at their booth. It will also raffle off a $5,000 contribution to that same organization, which is the amount of money it takes to rehabilitate a home.

I guess Google can celebrate its big win over Microsoft in their respective HIStalk reader polls, with Google’s 65% negative rating in healthcare beating Microsoft’s 66%. New poll to your right, the last in the series: same question, this time about Cisco.

It’s that time of year again — please complete my HIStalk Reader Survey, won’t you? I read the response carefully and plan the whole next year based in what readers tell me, so your time won’t be wasted. Thanks.

This is the real payoff of EMRs, described in a well-written article in The Buffalo News. Buffalo Medical Group searches its database for patients at risk of abdominal aortic aneurysm. It identifies 2,000, of which 30 are found to have aneurysms that could burst at any time, which is nearly a certain death sentence. The article focuses on the benefits of the medical home concept, but also summarizes the concerns of its critics: “They also wonder if the concept is nothing more than a repackaging of managed care, bristle at the suggestion that doctors need financial incentives to do the right thing, and view the focus on efficiency as more appropriate for a factory.”

I don’t know about your hospital, but mine can’t give H1N1 vaccine away. I said early on that this latest scare might be as overblown as the Gerald Ford’s Great Swine Flu Epidemic of 1976, although I really doubted that. Other than putting some nice profits in the pockets of drug companies and McKesson, I’m struggling to decide if there was any benefit to getting everybody all worked up about it. It’s notoriously tough to predict pandemics, much less prevent them.

Kaiser Permanente is recognized with a security award from HITRUST, an organization that has a Kaiser security executive on its executive council. I Googled to see if HITRUST is a for-profit corporation as I expected; the only declaration I found saying it’s a non-profit came from Fierce Health IT, which I think is wrong. It looks to me like a regular business, despite a .net Web address and some noble mission statements. Its Web site says it is a “private, independent company” and its Texas incorporation records show its officers as a husband and wife. He’s founded a few other now-defunct corporately sponsored think tanks in the past.

An Epocrates survey finds that 20% of doctors say they’ll be buying an iPad within a year, good news for the company since it has already committed to creating an iPad version of its drug information software.

VirtualHealth Technologies completes the sale of its Secure eHealth secure messaging business and its VPS Holdings prescription drug monitoring business to Wound Management Technologies.That leaves the company with two primary business lines: EMRs and gold mines (insert joke here).

St. Joseph’s Hospital (WV) chooses eWebHIM from eWebHealth for scanning and HIM workflow.

Akron General jumps on the “show your ED wait times” bandwagon, putting them on its Web site and on billboards. The times reflect how long it takes for the doctor to see you, but most ED delays involve waiting for technicians, for labs or x-rays to come back, or for someone to get you signed out with prescriptions. Being called from the waiting area to the treatment room is only a small victory. Since they’re capturing the times from their EMR anyway, maybe they should measure arrival time to final disposition.

eClinical Works breaks the $100 million per year revenue barrier. I dug out my May 2006 interview with Girish Kumar Navani in which he boldly predicted $40 million in revenue for that year, a big jump from the previous year’s $25 million. And when I interviewed him in early 2008, they were at $60 million and he was predicting $500 million in annual revenue by 2018.

GE Healthcare names William Denman as chief medical officer. He’s coming over from Covidien, the Irish spinoff of Tyco Brands that sells healthcare products under the brands Kendall, Mallinckrodt, Puritan Bennett, and Syneture, among others.

Results look promising for the first-generation artificial pancreas for treatment of diabetes. It combines a blood glucose monitor with an insulin pump, creating a feedback loop that is managed by software.

The VA is budgeting $157 million next year to develop a Virtual Lifetime Electronic Record that will tie together data from the VA, DoD, and the private sector. DoD plans to spend $300 million to develop its part of the project. In more startling news, the VA will spend $347 million for HealtheVet, which it says is the “the future foundation of our electronic health record system” that will initially include a new clinical data repository, patient scheduling system, and pharmacy information system. On the VA’s VistA Web page, it calls HealtheVet “the VA’s next generation of VistA.” I never heard what happened with all those ambitious plans to replace VistA with commercial systems, so I don’t know where this money is going.

Sun’s big executives, including co-founder Scott McNealy, quit as the company is absorbed into Oracle. McNealy gave the opening address at HIMSS 2005 in Dallas. I don’t recall being impressed.

Odd lawsuit: a stripper gets drunk on the job and leaves the club despite its three attempts to stop her. She crashes her car, breaking her nose and back. Her injuries force her to stop stripping, so she sues the strip club for “wantonness.” The jury awards her $100,000, with her attorney declaring that “I think that it does speak to our community’s regard for safety”. The club’s lawyer disagrees: “Bottom line is she got herself drunk, had a terrible wreck, and wants someone else to pay for it.”

E-mail me.

HIStalk Interviews Scott Weingarten

Scott Weingarten, MD, MPH is president and CEO of Zynx Health.

What was your reaction when you saw the proposed Meaningful Use criteria?

When you look at what was published on December 30, I don’t think there were any huge surprises based on what we saw over the summer that was published in June and July. There was a continued focus on clinical decision support, which we anticipated based on the earlier information. We believe that that is a good thing.

We think clinical decision support can lead to improved quality and safety of care, as well as less costly care. We believe that’s where the greatest benefit will occur as a result of the investment in healthcare information technology. We were pleased to see that clinical decision support remain prominently featured in the December 30 publications.

Do you think the requirement to create five clinical decision support rules is a good step toward using systems to guide physicians?

I do. Initially, I believe it was one. Now it’s five. I think the bar is still very low for clinical support rules. I think in order to get the clinical return on investment and the cost benefits that the federal government would like to achieve, I think they’re going to need more than five, but I think it’s a good start.

To many doctors, when they hear clinical decision support, their experience or their perception is that it’s just intrusive, unhelpful, impersonal warnings that stop them from doing what they want to do. What has to be done to turn that into that vision of having it impact quality and cost?

They have to look carefully at both the sensitivity and the specificity of the clinical decision support, meaning, look at very carefully that there are as few false positives as possible. I think at least historically, largely with drug/drug interactions, there are many false positive alerts that in many cases can color our view about the value of clinical decision support.

When one goes beyond drug/drug alerts and really looks at the broader potential for clinical decision support, and if one really focuses on those aspects of care that provide great clinical benefit… For example, evidence-based clinical processes that have been shown to reduce mortality, reduce morbidity, and improve quality of life or safely reduce costs when one pays careful attention to the specificity, or ensuring that there are as few false positives as possible. I think the annoyance factor will go down and I think the benefits will increase.

Do you think it’s the content provider or the application vendor who needs to refine that sensitivity/specificity and the ultimate presentation of whatever the result was?

I think that it’s really teamwork. When I say teamwork or collaboration, I think the content vendor needs to really give a lot of thought to optimizing the sensitivity and specificity of the clinical decision support. I think the healthcare information technology supplier needs to have the functionality to optimize the specificity and sensitivity of clinical decisions.

Also the client, in some cases, can pick and choose which components of clinical decisions support that they would like to utilize. Thinking about the benefits, or them really analyzing the potential benefits of turning on clinical decision support, should occur before they select what form of clinical decision support.

A good example, as you mentioned earlier, would be the five rules. Making sure that the five rules are those that really will favorably impact care at their organization, have the greatest clinical benefit, and yet the rules will be as specific as possible.

One of the things that it seemed was fairly clear in the initial proposed criteria was that the rules needed to be user-maintainable rather than just a black box that you take as they come. Was that a surprise?

No, I think you want them to be maintained by the user because I think that different organizations, depending on local practice, there’ll be some rules that provide greater benefit than at other organizations.

Let me give you an example of what I mean. Let’s say an organization has already achieved the ceiling effect and eligible patients with chronic heart failure are being treated with either an ACE inhibitor or an ARB. Well, having a rule will provide very little benefit, just because the care is consistent with best practice or evidence-based practice. Another organization where they have not achieved those benefits, where far fewer appropriate patients are treated with ACE inhibitors or ARBs for chronic heart failure, may have an opportunity to save many lives by providing that rule.

Really, the point being that different organizations will achieve different benefits with different types of clinical decision support, depending on the size of the gap between optimal or evidence-based practice in their current practice. Practice varies, as I think has been very well described, organization to organization. Therefore, I think having the user select which clinical decision support rules have the potential to provide the greatest benefit for their organization, and potentially maintaining the information, to me, makes sense.

When hospital-based vs. practice-based doctors create their initial five rules, how will their priorities differ?

I think that the types of rules that are likely to be created in the ambulatory setting or by physicians in their offices will reflect the patterns of outpatient care. My guess is we will see a number of alerts and rules for chronic illness in the form of disease management rules or preventive care; where I think the rules will be quite different in the hospital, which will reflect acute illness requiring hospitalization.

My guess is in the ambulatory setting, we might see more rules related to chronic illnesses such as asthma or diabetes. In the hospital, we might see more rules and alerts that relate to the more common reasons why patients hospitalize, such as chronic heart failure or community acquired pneumonia.

What do you think about rules for nurses when charting or documenting?

There’s a fair amount of nursing practice that can be evidence-based. There are many good studies showing that certain nursing practices, when faithfully adhered to, will lead to better patient outcomes than other nursing practices.

Decades of nursing research support what processes are best for patients, and I think it makes a lot of sense to have rules and alerts to inform nurses, when appropriate. That will lead to the best possible nursing care. I would agree with that. I think alerts and rules are just as important for nurses as they are for physicians and other healthcare providers.

What kind of work has been done, or what kind of interest is there in background alerts based on collecting electronic data that indicate problems, the imminent harm type of rule?

My guess is that the initial rules may not be quite that sophisticated, but I think there’s tremendous benefit that can occur when these background rules — for example, will identify patients based on physiologic parameters, hemodynamic variables where they’re at risk of rapid clinical deterioration — to alert the physician to observe the patient closely and possibly prescribe new treatments.

I think that when we get there — when the field matures, when we’re consistently applying those rules — I think there’s great potential to quickly identify problems that may not have been identified by treating clinicians and to reduce morbidity and mortality. I think in the not-so-distant future there will be many more of those rules, and that will advance patient care significantly.

What advice would you give to hospitals, in general, about creation and maintenance of order sets?

I think it’s hard. One is I would advise them to create, update, and maintain order sets. There are good data in the scientific, peer-reviewed literature that shows that evidence-based order sets reduce mortality, reduce morbidity, and can safely reduce costs. I would advise hospitals to do it.

Second, is there are data showing that physician productivity can be increased when physicians use order sets for common diagnosis rather than write each order one by one. There’s the benefit of improving care and potentially improving productivity, but I think you need the order sets to be viewed as credible by the medical and nursing staff.

They have to be updated frequently. I think they have to be evidence-based. I think if they are not maintained and the information is highly perishable, that when the information goes out of date clinicians are smart and figure it out. They say, “Hey, how come this order set doesn’t reflect the findings in this article published in the New England Journal of Medicine a month ago? What’s going on here? Don’t we want to provide the best possible care to our patients?”

Clinicians, appropriately, can be critical when information in order sets is out of date. The organization needs to come up with a very methodical, disciplined approach to update and maintain the order sets and retain credibility with the clinicians.

There was a statement recently, by Eric Schmidt of Google, that seemed to imply that in his mind as a technologist, practice of medicine is simple as looking up reference information, correlating it to patient information, and out pops a diagnosis and a treatment plan. How can the art of medicine be reconciled with the support that software can provide to those who actually practice it?

I’m an internist. I’ve taken care of a number of patients in my life. Medical care is complicated. I think that it’s complicated for a number of reasons. 

In some cases, there may not be evidence to support a particular treatment decision. In some cases, the evidence might be conflicting. In other cases, the patient may have many co-morbid illnesses.

It’s often not as simple as a patient that has one illness and therefore, this recommendation will always work for this patient. Many patients who are hospitalized have many different co-morbid illnesses which increase the complexity of clinical decision support.

Then finally, patient preferences are very important. I may suggest to a patient that there’s a particular drug I would like the patient to take, but the patient may have had a bad experience with the drug in the past, or may know someone with a very bad experience from that drug in the past. Therefore, for that patient, that drug may not be the most appropriate.

I think medicine is highly complex. Evidence-based information is critically important to informed care; but at the end of the day, what evidence-based medicine does is inform the best possible care. Each doctor and nurse has to understand the preferences and beliefs of his or her patients to make sure that the care is individualized to lead to the best possible care for any individual patient.

Has the industry moved enough toward guiding the caregiver, rather than warning them of conditions? In other words, helping them make a decision, rather than telling that they’ve made the wrong one?

I think so. I think order sets will help guide clinicians to making the right decision. They really do not tell clinicians they’ve made the wrong decision, so I think as an industry we’re heading in the right direction. I think that’s exactly what you want to do. You want to guide them to make the right decisions, rather than you made the wrong decision.

News 2/5/10

From Farrell: “Re: Microsoft. Substitute Epic for Microsoft in this article and it holds true.” The article, written by a former Microsoft VP, observes that Microsoft is a “clumsy, uncompetitive innovator” whose products are “lampooned” and its marketing “inept” as it loses market share in nearly every important category, milking profits from Office and Windows but falling slowly into irrelevance otherwise. Company bureaucracy and infighting are blamed.

From Nell: “Re: McKesson. W-2 forms have always listed the employer as McKesson Corporation. The ones just sent out say McKesson Information Solutions LLC. I wonder if they are quietly preparing to spin off the HIT division?” I figured it was probably a Delaware corporation, so I check that state’s corporate database. That corporation was formed in 1974, so I don’t know why it’s suddenly showing up on W-2s. Could mean something, could mean nothing.

From Warren: “Re: QuadraMed layoffs. This is absolutely not true. There has been senior leadership change in sales, resulting in some realignment of the sales force, and two sales folks were let go. QuadraMed Sales is now better aligned to serve its clients. QuadraMed is absolutely committed to meeting Meaningful Use requirements for current and future QCPR customers. These types of rumors can be deal killers — please vet sources carefully before printing.” I held the first report I received suggesting layoffs and a change in the QCPR product just in case it was bogus. I then received two more saying the same thing. All three came from non-anonymous sources I’ve known for years who are also pro-QuadraMed. The official company contact told Inga last time we asked that they do not address rumors. We asked about this one anyway, but her e-mail bounced back as undeliverable. It’s tough to confirm when the company won’t talk. Still, I would be happy to hear that layoffs were minimal and that QCPR will live on. If it were me, I’d get an announcement out there.

From Doug Wallace: “Re: Dwight Schrute from The Office on EMRs. ‘I think one of the greatest things about modern America is the computerization of medical records. As a volunteer sheriff, I can look up anyone’s psychiatric records or surgical histories.’”

From FreddieMac: “Re: Cerner. In order to improve cash flow, the company is aggressively pursuing complete IT outsourcing deals (like MU) among its client hospitals through any any back door they can. Of course, they think RHO Millennium translates into knowing how to run all the other aspects of health IT. I believe they got Naples Community and are trying for some other academics. Beats the hell out of trying to compete with Epic for new sales.” It’s a good strategy, I think, and I expect it will open some doors to hospitals who don’t consider data center operations to be core. Not to mention that, as you noted, Epic is taking most of the pie anyway. (I just noticed that I said Cerner, Epic, and pie together … could that be a HISsies Freudian slip?)

From Mark: “Re: Dragon Naturally Speaking. I bought it on your first recommendation and absolutely love it. A product that lives up to its billing, just like HIStalk!" Another reader suggested that I note, probably unnecessarily, that I am using DNS for personal use, which is why it was cheap. For EMRs, you would need Dragon Medical, which comes with integration tools, a medical vocabulary, and a much larger price tag. My point is still valid: speech recognition absolutely works and is not just for geeks any more.

Mcesson announces Practice Partner Connect, an interoperability platform for users of its Practice Partner physician system.

Loma Linda University Medical Center chooses the MDaudit Hospital compliance and revenue risk mitigation system from Hayes Management Consulting.

eMix will launch its vendor-neutral medical imaging information exchange at HIMSS. The company is affiliated with DR Systems.

Janeen Cook says thanks for taking a look at her nursing video. She won the Vanderbilt School of Nursing student video contest with 560 views, saying, “One of my former team members said I was just like Susan Boyle. Wait a minute, I thought — is that a complement being thought of as frumpy and a bit odd? ”

Englewood Hospital and Medical Center (NJ) signs up for McKesson Horizon Clinicals and Horizon Enterprise Revenue Management.

I’m entering my second week or so of being ridiculously behind, so if you are expecting something from me, I’ll try to catch up over the weekend.

Arizona Regional Medical Center (AZ) chooses clinical and financial systems from HMS.

Mayo Clinic takes a minority position in Centerphase, a startup that will mine Mayo’s patient database to find patients who qualify for specific clinical drug trials.

eMids Technologies offers an “AGILE for ARRA” presentation at HIMSS that covers iterative product development. If you are involved in product development and delivery, you can sign up for the Tuesday morning breakfast at the “W” Hotel here.

This week’s e-mail from Kaiser Permanente CEO George Halvorson notes that of 16 organizations winning a Continuous Availability Award for computer uptime, Kaiser was the only healthcare winner. Two of its data centers that host clinical systems had 100% uptime for the full year, with overall availability of HealthConnect at over 99.9%.

Alert, the hospital information system vendor from Portugal that had fanboys swooning at HIMSS a few years ago and then promptly sank without a trace, signs its fourth hospital customer.  

Sentara CIO Bert Reese is interviewed on Cox Business TV, talking about EMRs and interoperability.

Please welcome Precyse Solutions, which has joined our merry band as a Platinum Sponsor of HIStalk. The Wayne, PA company offers a variety of HIM-related services: transcription, coding, consulting, outsourcing, oncology data management, audit, clinical documentation improvement, and its PrecyseAssist service to answer difficult coding and claims questions. You can download a variety of Webinars and presentations from their site for more information. Googling just to see what I’d said about them previously, I notice the company made my radar in mid-2008, when I said this: “I’d watch this company: HIM vendor Precyse Solutions puts Pam Arlotto and Carl Witonsky on its advisory board, giving them a lot of strategic horsepower.” Thanks to Precyse Solutions for their gracious support of HIStalk and those who read it.

A non-profit clinic run by an associate of a Louisiana Parish councilman overbilled West Jefferson Medical Center by $150,000 for its treatment of uninsured patients, an audit uncovers. Also discovered: the clinic had $100,000 in missing checks and undocumented purchases, spent $29,000 on parties, and gave $100,000 in interest-free loans to employees. The hospital has paid the clinic $4.2 million to keep patients out of its ED since 2004. The former clinic CEO says missing documentation for certain payments was caused by an accounting software virus.

We’re booming over at HIStalk Mobile, to the point that we could use some help. I’m interested in talking to a physician, resident, or med student who has good understanding of mobile health and would like to share their passion with our readers in some sort of paid arrangement. E-mail me. I also just remembered that I probably didn’t mention our latest HIStalk Mobile Founding Sponsor, Voalté, so thanks very much to the Men (and Women) in Pink for their support. 

College Park Family Care Center in Overland Park, KS wins a free radiology information system from Swearingen Software, chosen as the most deserving “hardship” radiology department.

Rich Helppie’s Santa Rosa Consulting announces (warning: PDF) its merger with CSA Consulting. Both companies are in Michigan.

Jobs: Information Services Manager (VA), Information Systems ERP Manager (WA), Clinical/EMR Project Manager (NC).

After-hours medical services come under fire in England after the recent death of a patient under the care of a sleep-deprived doctor brought over from Germany and put immediately to work with no rest. Computer problems are named as an issue since doctors can’t see each other’s records. The newspaper article cites a 2005 case in which a post-surgical patient spoke to six doctors by phone and saw two in person, only to die of undiagnosed septicemia.

The VA will freeze its $3.3 billion IT budget in FY11.

Canada reaches national consensus on using GS1 bar codes for drug products, led by the Institute for Safe Medication Practices and the Canadian Patient Safety Institute. The GS1 bar codes are smaller, hold more information, and can hold product-specific codes such as lot numbers and expiration dates that can be used to track products through the supply chain.

Meditech just released its annual report. Revenue was down 1%, the first drop in the five historical years listed. Product revenue dropped to $176 million from last year’s $186 million. Net income was way up at $81 million compared to a big investment-related drop in 2008, but still lagging compared to the past few years. Neil Pappalardo has 13.8 million shares worth $511 million at the internally set share price. I wouldn’t say the company is struggling, but the long string of growth numbers has clearly ended just as HIT spending increases. It will be interesting to see how well it competes for the small hospital business fueled by HITECH.

EnovateIT kicks off a dramatic expansion of its mobile and wall-mounted clinical workstation manufacturing facility, increasing its current space fivefold. The company also forecasts record 2010 sales and announced plans for further expansion later this year.

NHS Scotland will use TrakCare from InterSystems as its patient management system.

Informatics Corporation of America makes a white paper available called Health Care IT Investment Heightens Need For Effective Implementation.

A bizarre, only-in America lawsuit: Heart Attack Grill, a Arizona restaurant characterized as its attorney as “the originator of the medically-themed hamburger grill and restaurant” whose motto is “Taste Worth Dying For", files suit against Florida-based Heart Stoppers Sports Grill. The former has waitresses dressed as nurses serving Bypass Burgers and Jolt Cola, while the latter does the same for its Chili Chest Pain Fries. Another point requiring intellectual property interpretation: both restaurants offer free food to anybody weighing over 350 pounds.

E-mail me.

HERtalk by Inga

Picis and iSOFT form a strategic alliance that gives iSOFT the right to distribute, implement, and support selected Picis CareSuite solutions. iSOFT’s initial marketing focus will be on ICU and anesthesia in the UK, Ireland, Scandinavia, Australia, and New Zealand.

Design Clinicals’ MedsTracker medication reconciliation application is now fully integrated with Wellsoft’s Medication Verification & Exchange capabilities. CentraState Medical Center (NJ) was the first ED to employ the integrated solution.

Design Clinicals, by the way, gains an exclusive endorsement from the AHA for its MedsTracker program, having proved its ability to help health care organizations achieve organizational excellence.

I love the guys at Vitalize Consulting Solutions. Rather than spending thousands to throw a big party at HIMSS, the company has decided to donate funds to the Atlanta Community Food Bank. Of course I have nothing against big parties, but I like social consciousness as well. So, here is what VCS is doing. For every person who signs up to follow them on Twitter, joins their Facebook group, or leaves a comment on the “Help Us Help Atlanta” blog, they will donate $1 to the food bank. (do it now before you forget!) Or, you can pay them a visit at booth #5203 at HIMSS. Last year VCS had an equally cool program that allowed HIMSS attendees and VCS donate thousands of soup packets and money to the Chicago Food Bank.

Christiana Care Health System (DE) announces its go-live on CPOE at its Wilmington Hospital. The health system will soon  launch CPOE at its other facility, Christiana Hospital.

The US Patent and Trademark Office awards Medicity a patent for its agent-grid technology for health information exchange. The technology is the core of Medicity’s Novo Grid, which provides EHR integration and community-wide information exchange. We did a HIStech Report on Novo Innovations a couple of years ago,before it was purchased by Medicity. I remember at the time thinking that if it worked they way Robert Connely said it did, it was some hot technology. Guess the patent guys agreed.

The folks at EHR Scope blog did an awesome job summarizing our recent EHR executives series on the proposed meaningful use criteria. If you missed the series, the EHR Scope article succinctly outlines the bottom line opinion of each executive to each question. It’s interesting to see what vendors share similar philosophies on certain topics and who provided the more unique perspectives.

Edward Hospital in Naperville (IL) formally names Barbara Byrne, MD vice president of HIT. Byrne is former clinical director for CCHIT and was named a CCHIT commissioner just last month.

Would you pay $50 to text one question to one doctor? Truth On Call is hoping patients, or perhaps physicians in developing countries, will take advantage of the service. Patients text their questions on cell phones and the doctor texts back, receiving $10 for each question. The model sounds interesting, especially if you think about physicians in rural India needing a quick opinion from doctors in the US. But $50 per question per doctor? Seriously?

Here’s a more mainstream product that happens to be free. Text4Baby is a mHealth service designed for pregnant women and new moms through the baby’s first year. Expectant mothers can text “baby” to sign up for the service and receive three to four text messages a week that align with their due date. Federal CTO Aneesh Chopra is promoting its use to make sure moms-to-be and babies stay healthy. Voxiva created the system, mentioned by the company’s co-founder, chairman, and president Paul Meyer in our November interview.

I’m kind of glad that most of my plane rides are fairly boring. On the other hand, passengers on this flight had a bit more entertainment, when shortly after take-off, a man starts screaming, drops his pants, and attacks crew members. He later admits he overmedicated himself before take-off, downing a double dose of medical marijuana cookies.

E-mail Inga.

HIStalk Interviews Jim Giordano

Jim Giordano is president and CEO of CareTech Solutions.

What are the biggest problems hospital IT departments are having these days, and what are their greatest opportunities?

I think there are three areas that hospitals are challenged with from an IT perspective. The first is the complexity of the required systems that are now needed. The second is the return on investment focus. The third would be the timeframe for putting in this complex technology to meet the funding deadlines for the ARRA, the American Reinvestment and Recovery Act.

I think the opportunities for the hospitals’ provider networks are borne in these same challenges. They have the opportunity now to begin practicing medicine electronically, which would mean more patient data is available. There would be more patient data shared; it would reduce medical errors in that.

I also believe there’s an opportunity to show the ROI of these systems. I also believe one of the opportunities is for hospitals to take the meaningful use definition that exists and be able to put their plans together so that they can receive these payments that should start paying out in 2011.

What trends are you seeing in IT outsourcing?

We’re seeing a trend towards an interest in outsourcing discrete portions of what a CIO is responsible for in two areas — service desk and remote hosting. We’re seeing CIOs realize that no matter how bright and effective their staff is, they are in effect judged by how well the phone call goes when the user or clinician calls the service desk. The same with the implementation of these comprehensive EHRs and other high-availability systems, that the need for a service desk that operates 24/7 is essential for the user community, and frankly, for the CIO’s reputation.

On the remote hosting side, we’re seeing a lot of hospitals looking at the requirements for meaningful use. Looking at their data center and coming to the realization that it’s going to take a large capital investment to have their data center meet the needs for a comprehensive high-availability system, and they’re looking at other options for that. Moving some of those hosting opportunities to a firm that specializes in healthcare data center outsourcing.

To avoid the capital investment and to have their systems be part of a network that has all the redundancies and business continuity built into it, we’re seeing many CIOs now choosing that as an option.

How does the 24-hour help desk service benefit hospitals?

It provides consistency for the clinicians. Whether they’re working at the hospital at 3:00 in the afternoon or 3:00 in the morning, when they have an issue with the technology or with the application, they have a place to call to get their problems resolved.

The second thing is that it provides a better experience for the end user. They tend to be happier. They even tend to evaluate the CIO in a better perspective. It creates a better experience for the clinician. The 24-hour availability ensures that medicine can be practiced now, not only from a number of times, but from a number of different places. That they’re going to receive the consistent, excellent support that they need to do their jobs.

CareTech supports many Web sites. Are hospitals doing anything creative with them?

They are. It starts with the realization on the hospital’s side that the Web presence is a very important strategy for attracting patients and organizations. It seems that hospitals are understanding what the Secretary of Health and Human Services is saying — that 60% of the Internet traffic is healthcare-related.

What we’re seeing, especially in competitive environments, is that hospitals that understand that a Web strategy and a Web outreach in their community are essential to getting patients into their system. We’re seeing more budget and marketing moving towards a Web presence and some of the interactive Web strategies that are being applied to differentiate the hospital in their community.

What factors make a hospital ready for a successful CPOE implementation?

We approach CPOE assessment from a comprehensive point of view. It starts with the belief that if your processes aren’t well defined and very good, that automating that processes are going to get you an automated bad process. So we start with, first of all, a comprehensive look. We start the comprehensive look at the hospital’s processes. We will do interviews with the department heads, the applicable clinicians, and we’ll actually even survey a number of the end-users to find out where they are from a process standpoint.

We then prepare a gap analysis between what processes needs to be fixed, or we’ll suggest a process that needs to be fixed, and what the automation would look like given the system that they’ve selected. We go about working with the hospital teams to close those process gaps, and then put the technology in to ensure a successful CPOE implementation.

We’ve done this many times across the country, and we found that this upfront work is critical for a successful implementation. We’re also able to have our clients that are moving towards CPOE talk to our other clients that have been there and done that and it helps them smooth out the corners that they are struggling with right now. It helps for a better implementation once they understand all that’s involved in it.

What about the company’s recent “Best in KLAS” award for extensive IT outsourcing?

Well, first and foremost, we recognize that we won this award due to the dedication of the men and women of CareTech Solutions who really, truly, have embodied our motto. Our motto is “Whatever It Takes”, and we believe the results of the “Best in KLAS” designation is a result of the focus and the attention provided by all of our team members who are intensely focused on ensuring that our customer has the best IT experience.

We do a lot of things to ensure that our team members are informed in the direction that the company is heading. We do a lot to share the “Best in KLAS” experiences — or the “Whatever It Takes” experiences, as we call them — and ensure that they understand that in the service business it is critically important that the customer needs to be well taken care of.

What makes your company a good place to work?

The fact is we’ve made CareTech one of the best places to work. First, I would say that we’re in an exciting industry in an exciting time right now. For us, it starts with recruiting. We try to recruit the top people in our industry so that we’re assuring all of our team members that they’re working with well-educated, highly motivated people.

We think that creates a good environment for information technology professionals who really kind of enter into this industry wanting to do a good job. They realize at the end of the day that they’re serving patients and hospitals, and that is a noble mission for an IT professional. The people that are attracted to our industry, I think, and our profession are aware of that. We try to get the top 10% of those folks.

The other thing that we do is we try to provide a very competitive benefits package. Even though the economy right now is very difficult, we look to provide the best for our employees. We have been able to maintain a lot of our benefits and even increase some of those benefits; and make available training opportunities, educational opportunities, and retirement investment opportunities for our people.

Any other thoughts that you’d care to share about the company and industry?

I think this is a great time to be in this profession, in this industry. The public mandates in the American Recovery and Reinvestment Act have provided the funding for our industry to move forward. We’re seeing a mandate on the healthcare reform that has all roads leading to more technology to assist with the practice of medicine.

In fact, we like to say that line between the practice of medicine and technology is starting to blur. For information technology professionals that want to apply their trade in an industry that is helping move the healthcare agenda along, there’s no better time and no better opportunities right now for people in this business.

Spheris Files Bankruptcy, Plans CBay Asset Purchase

Clinical documentation and transcription vendor Spheris announced today that it has filed Chapter 11 bankruptcy in order to allow MedQuist and CBay, companies owned by CBaySystems Holdings LTD, to purchase its assets. Bids from other interested parties will be accepted, however. Spheris India is part of the transaction, but will not file bankruptcy.

Robert Butler, Chief Restructuring Officer of Spheris, stated, "Throughout the past year, Spheris has taken steps to strengthen its operations and customer service, and these initiatives are achieving solid results.  Spheris has also been engaged in constructive discussions with certain key constituents of the Company to identify ways to enhance financial flexibility for our operations.  We expect customers will continue to receive high-performing services through a company with a stronger capital structure."

Cracker predicted this action on December 9 on HIStalk:

From Cracker: “Re: Spheris. Warburg Pincus is looking to unload its albatross Spheris stake to CBay Systems, the largest medical transcription company in the US since their purchase of MedQuist in 2008. Spheris, second largest, recently ended a three-year run as a quasi-public company — public debt, not public stock. Uncompetitive technology and a heavy debt load handicap Spheris as medical transcription prices fall.”

We reported on December 17:

Daniel J. Kohl resigns as CEO of the struggling Spheris, a medical transcription service company. The company reported a 15% drop in revenue the first half of the year and ended its registration with the SEC in November. Likely adding fuel to the fire was the company’s poor showing in last week’s KLAS report on medical transcription service vendors. Amid customer complaints that Spheris was unable to resolve quality and technology issues, the company was ranked last in a field of 15.

IBM to Acquire Initiate Systems

IBM announced this morning that it will acquire Initiate Systems, a privately held identity management and data management tools vendor with a significant healthcare presence as well as products for government agencies.

"With the addition of Initiate’s software and its industry expertise, IBM will offer clients a comprehensive solution for delivering the information they need to improve the well-being of patients at a lower cost," said Arvind Krishna, general manager, Information Management, IBM. "Similarly, our government clients will now have even more capabilities for gathering and making use of information to serve citizens in a timely and efficient manner."  

Some of Initiate’s hospital customers include Ochsner Health System, UPMC, and Sutter Health. Initiate acquired interoperability technology vendor Accenx Technologies on October 30.

IBM competitor Informatica announced last week that it will acquire data integration systems vendor Siperian, leading to speculation that IBM would quickly follow with its Initiate move. The CEO of another data management competitor, Kalido, said this morning: “"By acquiring a niche vendor like Initiate, they bolster their portfolio of industry-specific tools that help integrate data, but do little to provide a stronger information management platform for their customers. This acquisition will be delivered like so many others; with dozens of IBM global services consultants to ‘knit’ the patchwork of tools together."

News 2/3/10

From Dweeb: “Re: Initiate Systems. For the past several years I’ve seen IBM and Initiate in partnerships deploying Initiate’s EMPI alongside IBM offerings. Recently, I’ve heard IBM plans to buy Initiate. Is this an old rumor or is there really something new around this?” Seeking Alpha says they’ve heard it’s happening, possibly as early as this week, and that IBM will pay big. In other words, it’s still a rumor so far.

From Claire Voyante’: “Re: QuadraMed QCPR. Hear they laid off about 19 of 40 in sales and are on support mode only. Are they committed to meeting all EHR requirements for clients to meet Meaningful Use? You should interview NYHH or LA County.” QuadraMed doesn’t comment on rumors, but I’ve heard this one from some pretty solid sources, all of which are saying the same thing. Sad if true, but companies have to make tough decisions based on what the market is telling them.

From Woody: “Re: Meaningful Use. It reflects physician-centric, not patient-centric thinking. They miss the point that after orders are entered, as good as they may be, someone has to actually carry them out appropriately, making constant assessments, interventions, and documenting outcomes. The largest provider group and largest base of EHR users – by far – has been left in the dust because of professional dysfunction and the fact they don’t get paid for services. RWJ ranks them last in the group of influencers.” I also dislike the insinuation that the lame, overused term “EHR” is now a catch-word for what I refuse to call anything except “clinical systems”. “Electronic health record” sounds more like a view-only portal than the far more complex systems that create all that information in the first place. And if you have CPOE but no documentation systems, do you still have an EHR?

From Sunshine: “Re: Tampa General Hospital. They have chosen Epic.” Unverified, but hardly shocking if true since nearly every purchase by hospitals I’ve heard of end up being Epic these days.

From Lisa Ramsey: “Re: McKesson Paragon. Didn’t they build it from scratch?” Sort of. HBOC rolled it out in 1996 as its “little system”, as client-server was considered in those mainframe/midrange days. McKesson nearly killed it off when it (like many HBOC offerings) turned out to be pretty crappy and rolled out too quickly. Instead of just marketing with even more gusto (cough ** Pathways ** cough), they actually fixed it and it turned out to be maybe their best product.

From The PACS Designer: “Re: The Doctor Dalai Show. All of of the hype around the announcement of the Apple iPad has even gotten Doctor Dalai to post a cute video piece about the iPad’s potential in Radiology, and also hurl a slam at the Good Enough team.”

This isn’t a car ad, it’s McKesson’s new physician EMR incentive: 0% interest for 12 months with 25% down or a $1,000 cash rebate for the first provider and $500 for each additional. It’s good for Practice Partner, Lytec MD, Medisoft, and the Pontiac Torrent. I could be wrong about that last one. Everybody rides!

The HIStalk reception sold out Sunday night. Thanks to those who signed up.

Thanks to long-time HIStalk sponsor Hayes Management Consulting, which has upgraded its Gold sponsorship to Platinum. The company is ranked Top Overall Professional Services Firm and Best in KLAS for Technical Services in KLAS Enterprise’s 2009 Top 20 Best in KLAS: Software & Professional Services report. I appreciate their long record of supporting HIStalk.

Michael Lee, MD, director of clinical informatics at Atrius Health, will speak at the Nuance CIO breakfast at HIMSS on Tuesday morning, March 2. His topic is a documentation strategy using eScription background speech recognition and Dragon Medical front-end speech recognition. CIOs can RSVP here. Nuance will also have people on hand to talk about a recent Fallon Clinic study showing $7,000 per year savings and a increase in quality, productivity, and satisfaction from using speech recognition instead of typing.

I mentioned it briefly, but I’m going to talk about Dragon Naturally Speaking one more time because a reader picked up my last mention, bought it, and thanked Inga effusively for turning him on to it. I’m usually indifferent to technology that I’ve bought, rarely putting anything in that elusive “change your life” category. DNS has made that list. I bought it on a lark ($59 with free shipping), never read any instructions, and figured I would just play around with it. I have used it nearly constantly every day since to write HIStalk and send e-mails. There’s no need to get into a lot of details, so here’s the conclusion: even with the occasional correction (and there aren’t many), I can still put out text probably twice as fast with no tired fingers – I just say what I’m thinking and out it comes on the screen without my sloppy typing getting between my brain and my screen. It reminds me of that old Twilight Zone episode I watched the other night where the first Darrin from Bewitched played a guy who got hit by a car and could suddenly hear everybody’s thoughts. Rarely does a cynic like me give an unqualified recommendation, but this is one. I’m thinking of buying a second copy since I don’t want to have to write from the laptop at HIMSS without it. I’m not mentioning it again since it gives me a competitive edge, so that is all.

It was Merger Monday this week, apparently. I’ve never seen three HIT-related acquisitions announced almost simultaneously. I saw a few readers cancelled their e-mail subscriptions because of the rapid-fire updates I sent, but I had to consider the potentially significant number of employees and customers affected who deserved the chance to know about it quickly. It’s not that hard to delete an e-mail without reading it. There’s another acquisition coming Thursday, so indulge me one more time. And if you’re having regrets (which you will when I get something hot that DOES interest you), just put your e-mail in the Subscribe to Updates box to your right and we will be BFFs again.

National eHealth Collaborative announces (warning: PDF) nine new board members, among them Brent James, John Tooker, Jon Perlin, and John Glaser (there are five more, but these are the names I recognized).

Justen Deal has an interesting take on the Apple iPad, saying people are overlooking its potential as a replacement for thin clients and computers on wheels.

A UK article profiles Christofer Toumazou, the guy whose company is developing a “wireless digital plaster” that can monitor patients at home, feeding a constant stream of information about body temperature, heart rate, and respiration to a base station or EMR. The first rollout will be in a hospital. Cardinal Health is involved.

I’m short on time tonight, so that’s it for me. E-mail me.

HERtalk by Inga

From DrLyle “Re: Top 50 HIT blogs. You made it!” Thanks, DrLyle, for pointing us somebody’s list of top HIT blog sites (usually just a scheme to get themselves back links from the grateful winners, but a win’s a win). I see DrLyle also made the Top 50.

PBnJ asked Mr. H what HIT publications he/she should subscribe. Mr. H said he hardly reads anything. On the other hand, I skim a ton of publications (all free) on a daily basis. I wouldn’t necessarily recommend that unless you plan to take my job (which, as far as I know, is not currently open.) There exists a wide variety of “HIT” publications out there, each targeting a slightly different audience (clinicians, IT types, the hospital space, ambulatory care, medical devices, vendor news, CIOs, CMIOs, etc.) I suggest you figure which niche interests you the most and start there. Of course you’ll want to round out your reading by making time for HIStalk, HIStalk Practice, and HIStalk Mobile.

Appalachian Regional Healthcare System (NC) completes a deployment of Lawson QuickStep Healthcare in under six months.

The 34-bed Hamilton Healthcare System (TX) selects Healthcare Management Systems’ clinical and financial automation solutions.

MEDSEEK reports its 2009 highlights: 58 new hospital clients, a 53% increase in one-year revenue backlog, a #1473 ranking on Inc. Magazine’s fastest growing private companies, and a third year on HCI’s 100 list. Over the last five years, MEDSEEK’s revenue has jumped 346%.

Microsoft and Siemens are hoping that HealthVault will be more popular in Germany than it’s been in the US. Siemens signed on to be the exclusive operation of HealthVault in Germany and will market the platform to developers, application providers, and device manufacturers.

More than 300,000 people have downloaded uHear onto their iPhone/iPod Touch, making it the most widely distributed hearing screening test ever. It’s free and available in French and English.

The Social Security Administration hands out $17.4 million in in ARRA funds to 15 HIEs, providers, and health IT firms. The new contracts will enhance networks and reduce the time to adjudicate disability claims.

National Health Services (CA), a 12-site FQHC, achieves 100% provider adoption on HealthPort’s EMR.

Streamline Health Solutions announces the general availability of its new accessANYware 5.0 document workflow solution. Version 5.0 is a ground-up re-architecture of Streamline’s flagship document workflow product and is built on a service-oriented architecture using Microsoft.NET framework.

Bruce Brandes joins AirStrip Technologies as chief sales officer. Brandes most recently served as VP of sales and field operations for HealthStream. He’s also served in similar capacities at Eclipsys, McKesson/HBOC, and IBM.

Sisters of St. Francis Healthcare Services goes live on ZynxOrder. The health system has consolidated and standardized 42 evidence-based order sets for use at its 13 hospitals and health systems.

A few sponsor updates:

• Mountain View Hospital (ID) expands its use of SRS EMR.
• e-MDs announces its Solution Series Chart product completed the 2010 Integrating Healthcare Enterprise Connectathon, which tested 138 HIT systems by 90 HIT vendors. e-MDs is also participating in the IHE Interoperability Showcase at HIMSS (Booth # 7955).
• Microsoft finalizes its acquisition of Sentillion into the Microsoft Health Solutions Group.
• The ED at Clara Maass Medical Center (NJ) upgrades to the latest version of EDIMS’ EHR, v2.6. The new version includes enhancements to drug interactions, an eDocuments scanning solution, an upgrade to charge capture determination, and a new iPhone integration feature.
• Picis launches a new corporate blog called Healthcare-exchange.com. The first post includes five predictions for 2010 by CEO (and HISsie nominee in a “good” category) Todd Cozzens. The first prediction: healthcare reform is dead. Future posts will focus on topical issues such as meaningful use and the new iPad and include commentary from industry experts.

StatCom appoints Mary Kay Thalken RN, MBA, as enterprise vice president. She’s the former COO and chief nurse executive of Bergen Mercy Medical Center.

Suddenly it is February and I am leaving for HIMSS is less than four weeks! How did that happen? Mr. H and I have been working on assorted HIMSS-related projects, like the HISsie Awards, sponsor recognition, and details of the HIStalk Bash. The last couple of years readers (female ones, of course) have sent me notes asking for advice on attire for the HIStalk party. Previously we’ve had everything from sexy cocktail (Mr. H’s preference) to the straight-off-the-convention-floor look (not a bad choice if you want everyone to know what vendor you work for or if you hate displaying your individualism.) I haven’t made a wardrobe selection yet (I am thinking this might be a good excuse to go shopping) but I can promise the shoes will be high and hot.

Here is something I likely won’t be doing during HIMSS: the 5K Fun Run/1 Mile Walk. Scheduled for Tuesday March 2 at 4:00, IntraNexus is sponsoring it for the fifth straight year. By Tuesday afternoon, I know I will be too weary to do anything but sip a glass of wine and write some posts for HIStalk. However, non-couch potatoes can sign up during HIMSS at IntraNexus’ booth #5221 (Hall B.) While you’re at their booth, you might want to check out the IntraNexus’s new solutions for the iPhone and touch screens.

I’m sorry I missed this event: In honor of American Heart Month, the California Association for Health, Physical Education, Recreation and Dance (CAHPERD) and Jamba Juice break the Guinness World Record for the “Most People Jumping/Skipping Rope at the Same Time.” That’s 89,000 people jumping simultaneously for 10 minutes. Quite a party.

E-mail Inga.

CIO Unplugged – 2/1/10

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

Leadership Equations
By Ed Marx

It was the department chairman, emergency medicine, University Hospitals Case Medical Center. “Ed, this is Dr.Michelson, do you know what is going on in our emergency department right now? He was so upset that I thought I was on speaker phone. I could tell he was calling from our pediatric level1trauma center. I politely ended the call. As a new CIO, I did not want to have impersonal relationships. I wanted to talk face to face.

There he was directing traffic and evaluating patients. One of the IT applications had failed which was wreaking havoc on their process flows. While there I noticed that we could alleviate some of the cramped conditions by updating their technology. While it took a couple of hours to restore the application, the next day we gave back additional space to the ED. Simple things like replacing monitors, PCs and printers.

I received a call the next day from the Chief Medical Officer. “Ed, I heard what happened yesterday. Nice work. That is the first time a CIO ever did something like this. Left the comfort of the ivory tower and walked the walk”. Soon the story went viral and the benefits to an eye to eye approach become clear. I would coin the term i2i and encouraged its adoption by all in my IT division. I started to live it. I stopped handling serious matters by email or phone. I did presentations of i2i for other departments. I was maturing as a leader.

I also began to use i2i for crucial conversations. I began to confront others i2i. We had a physician executive who routinely abused anyone who he believed stood in his way. Because he produced results, his behavior was tolerated. After exhausting escalations with chain of command and human resources, I took matters into my own hands. Over coffee, I mustered my courage and laid it out in no uncertain terms to this senior officer. He tried to look away but we connected i2i. He hid behind his coffee cup but my message landed. That was the last time he abused my staff.

I received a call from the medical director of one of our newborn intensive care units (NICU). This NICU is consistently ranked in the top 5 across the nation. After several attempts to get resolution on some technical matters, she and her administrative staff had become rightly exacerbated with IT. They had 20 mobile carts for their NICU and only 2 were operational. She stated that their nurses and physicians would literally stand in line to update charts and enter orders taking care of the sickest of the sick. I myself was growing angry listening. I had seen this escalate over the last couple of days and was certain IT had provided resolution. I told the medical director I would be right over. I called the Service Desk as I walked over to have the manager and 3 technicians meet me at the unit. I could not believe what I saw. All these beautiful tiny babies and sure enough, nurses and physicians waiting around to use the limited carts. The sides of the halls were littered with unusable carts as if a tornado had passed through. I became indigent. I approached the medical director and you could see the tears in her eyes because she was so upset. The only thing I knew what to do was to embrace her and we both cried. Frustration, anger, compassion. There was release. Someone cared. Now time to execute. I learned it was key to meet emotion for emotion, or e4e.

My staff arrived and I had them go to the other floors and see if we could borrow carts from other units. In 30 minutes we had 10 working carts. Others were replaced or repaired within 48 hours. I returned to our IT offices and my director and VP of operations were still talking about what to do. I replaced them.

i2i and e4e are part of my nature today. While there is no formula to leadership, these equations provide a reminder that at the end of the day, nothing demonstrates care and commitment like looking someone in the eye, and weeping with those that weep and laughing with those that laugh.

Technology is the easy stuff. You are not a leader because you know technology.

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