News 4/27/11

Top News

  The VA and DoD agree to “buy” rather than “build” a joint EHR in an apparent change in direction from their last announced plans. They will round out missing departmental modules by looking first at any available internally developed systems and will develop their own applications only as a last resort.

Reader Comments

From Professor Paul MD: “Re: Amazon cloud downtime. For those who didn’t know, their northern Virginia data center that hosts EC2 and RDS services went down hard for 24 hours last week and didn’t recover all volumes until late Sunday. A small company that apparently does ECG monitoring repeatedly begged for help on Amazon’s public online forum, bringing up good points on what to consider when hosting health apps on the cloud. I like the Halamka shout-out, too.” Someone immediately questioned why they would be running a mission-critical life-or-death system on the cloud, to which the original poster answered, “Well, it is supposed to be reliable.” One of several uncharitable responses was:

If you were smart, you would have a disaster recovery plan for just this kind of thing. Judging from your lack of said preparations, you lot figured the cloud never goes down, and got greedy by not wanting to spend money on hot standby machines on a different infrastructure. Good going. Hope none of your cardiac patients croak because you’re going to get sued into next week…

That news item does encourage good discussion. If your organization runs cloud-based apps, please share what actions you’ve taken, both contractually and technically, to prevent and mitigate outages. What happens if your Internet connectivity dies (killed in most cases by the proverbial cable-shearing backhoe excavating for some minor project outside your facility using erroneous city-produced utilities maps?) What is required to maintain a hot swap site? How often do you test? Send me what you can and I’ll share it here.

From Olivia: “Re: McKesson. Gio Colella and Pam Pure might have a different opinion about how big winning that patent lawsuit against Epic would have been. That was just a place to start. Think Kaiser. Then think about all the other vendors with similar solutions. That sure would have helped to justify the purchase of the original RelayHealth company, which happened not long before the lawsuit was filed. Another intriguing story for cocktails and dinner sometime.” Is that an invitation? 

From Puts and Gets: “Re: Cerner. More changes in the plastic hair lineup. The stock has had an artificial ride up since investors don’t have a decent, large-scale pure play in health IT, so they get the default money. They are going down the other side of that first roller coaster hill later this year.” I’ll steer clear of this debate and mark it Unverified.

 From NotAnEpicShill: “Re: Epic. Another Epic employee here. What Lucy Gucci describes may be true for some Epic employees, but there are plenty of us whose jaws drop when we see things like that on the Web. I myself work about 45 hours a week (50-55 a few times a year during a crunch) and have a pretty good balance of life to work.The same holds true for many, many people with whom I work. I just wanted to get it out there that though certainly not everything at Epic is sunshine and roses, the rumors of our misery are greatly, greatly exaggerated.”

 From Madrigal: “Re: Neil Pappalarado. Just announced at the Meditech shareholder’s meeting that he had a minor stroke last week. He’s still in the hospital, but is expected to make a full recovery.”

From Human Factors: “Re: ONC usability meeting. The general consensus was that EHRs are difficult to navigate, time-consuming, frustrating, cluttered and disorganized, and unsearchable. They lead to fatigue and ultimately burnout, do not adequately support disabled users, do not adequately support clinical workflows, and they disperse and bury critical information. Most of the discussion was around provider pleas to either make usability standards part of certification or mandate a common user interface. There was also a call for EHRs to be held to accessibility guidelines, to support easy data migration from one to another, and for vendors to be more transparent about their internal usability guidelines. A Cerner spokesperson contributed this interesting insight: ‘The tools [EHRs] are designed for the volume of documentation instead of the value of the information.’”

 From Private Pyle: “Re: ONC usability fireworks last Thursday. You have to listen to the recording and read through the testimonies on ONC’s site. The docs told vendors their systems sucked, then consumers told them they were disconnected electronically and don’t have the information they need to be an engaged member of the care team, the vendors whined about new requirements and said that certifying usability would kill innovation, and the usability experts tore up the crappy vendor systems. A heated exchange ensued. The vendors tried to use the analogy of cars and that it makes no sense to put parts from three different makers together, but the committee trashed that, saying monolithic platforms have such a high barrier to change that customers are at the mercy of the vendor. I truly believe the monolithic vendors will not disrupt themselves and we will see some serious challenges that will provide capabilities and price points that will destroy the current market.” I wrote a few thoughts at the end of this post about the meeting. Usability measurement and any new federal involvement in it is obviously a big topic that gets a lot of folks stirred up. Comments from all viewpoints welcome.

HIStalk Announcements and Requests

Readers occasionally tell me they’re having trouble reading HIStalk because of errors or slow load times. The culprit in 100% of those cases so far has been long-obsolete versions of Internet Explorer. IE is a far inferior browser to begin with (feel free to check page load times on any media-rich site if you don’t believe me), but it’s really trouble-prone in old versions. Here are some suggestions.

1. If you must use IE, upgrade if possible to the latest version your operating system will support – Version 9 if you have Vista or Windows 7, or Version 8 if you’re on XP.
2. If your computer isn’t in IT lock-down mode, download Firefox or Chrome, at least to read HIStalk. You can still leave IE on your PC for any purposes for which it’s required.
3. HIStalk is supported by the sponsors whose ads you see on the left, which means we all benefit when you read the site normally. If you can’t load the page, however, add /print to the link you get in the e-mail update to view a text-only version (so instead of this link, use this one instead, for example). Or, read via RSS reader (I use Google). You’ll miss a lot of other stuff, too, though – polls, links to the latest comments, upcoming events, etc.

I had to re-send an e-mail update that failed on the server for some reason, so if you got the same e-mail on both Friday and Tuesday, I promise I’m not intentionally spamming you. There was no way to pick up where it left off or to even tell how far down the list of 7,311 subscribers it got, so I started it over.

Acquisitions, Funding, Business, and Stock

Halfpenny Technologies says 13 new clients have signed up for its integration technology framework for delivering interfaces among hospitals, labs, and EMRs.

Huron Consulting announces its Q1 financials: revenue up 11.9% to $143 million and diluted EPS from continuing operations up 46.2% to $.19/share.

Keystrokes Transcription Service acquires competitor MTS of Texas, including its TxMTI online transcription school.

Oppenheimer initiates coverage of Cerner with an “underperform” rating, saying the company is “showing signs of age” with flat software sales even as HITECH brings buyers to the market, lower margins as services replace software sales, and a price-to-earnings multiple more appropriate for a software high flyer than a low-excitement services business. They also didn’t like the fact that the departure of COO Mike Valentine was announced on April 22 when the stock market was closed, saying “the timing of his departure is curious” unless he turns up almost immediately as CEO of a good-sized company (and if anyone knows where he’s going, let me know). 

EncounterPRO chooses Intuit Health’s patient portal to offer its 300 pediatric practice EMR customers.

Consulting firm Computer Task Group (CTG) reports Q1 numbers: revenue up 22%, EPS $0.17 vs. $0.11. Healthcare revenue was up 30%, mostly from big EMR projects.

Sales

The Metropolitan Chicago Healthcare Council announces plans to develop the MetroChicago HIE using Microsoft’s Amalga and technologies from CSC and HealthUnity Corp. Seventy percent of the hospitals in Chicago are participating, with the notable exception of NorthShore University HealthSystem.

The Missouri Health Connection picks Cerner to build a statewide HIE, although they’re still negotiating the price.

The Missoula, MT paper reports that St. Patrick Hospital, part of Providence Health System, is moving to Epic. Cross-town competitor Community Medical Center is implementing NextGen for outpatient and will add Cerner inpatient next year.

Dundy County Hospital (NE) purchases Healthland’s EHR for its 14-bed critical access facility, anticipating a Q3 2011 go-live.

Salina Regional Health Center (KS) will implement Summit Healthcare Downtime Reporting System as part of its disaster recovery strategy.

People

Ben Foster rejoins Huron Consulting as managing director of  its healthcare practice and will work with providers to improve their revenue cycle.

MetroSouth Medical Center (IL) names Steven H. Rube, MD as medical director of the hospital’s seven community health centers and CMIO for the hospital. He’s the former CMO and EVP of EmpowER Systems.

UC Health (OH) appoints Anil Jain, MD as the organization’s first CMIO and SVP. He was a senior executive and physician at Cleveland Clinic.

eHealth Initiative founding CEO Janet Marchibroda is named chair of the Bipartisan Policy Center’s Health IT Initiative. She has also worked as chief healthcare officer of IBM and was COO for the National Committee for Quality Assurance. BPC, a non-profit think tank, launched its health project in January, led by former senators Tom Daschle and Bill Frist and former governors Mike Rounds and Ted Strickland.

Robert Barber, 64, director of financial services at Carolinas HealthCare System (NC), was shot and killed last Friday morning by an unknown assailant in an apparent robbery attempt while walking outside a coffee shop near his home in Charlotte, NC. He was a retired Air Force Reserves colonel, held a doctorate in health administration from the Medical University of South Carolina, and was a part-time instructor for several universities. He had held several executive positions in his 19 years with CHS, including stints as CFO and CEO in affiliated hospitals, and was a former president of the North Carolina chapter of HFMA.

Government and Politics 

Norton Healthcare (KY) agrees will pay the federal government $782,842 to settle allegations of Medicare overbilling. Federal prosecutors contend that Norton submitted charges for evaluation and management services that were never performed.

Dartmouth-Hitchcock Medical Center (NH) will pay over $2.2 million to state and federal agencies for improper Medicare, Medicaid, and Tricare billing. The payment includes over $344,000 to a former Dartmouth-Hitchcock physician who blew the whistle on the improper billing, which allegedly included charges for services delivered by unsupervised residents.

The American Telemedicine Association (ATA) calls for CMS to remove restrictions on telemedicine for ACOs. Recommendations include more medical videoconferencing access in metropolitan areas, home-based videoconferencing, and delivery of therapy services via telehealth.

Other

Performance scores for the four top interventional lab providers tighten to within five points of each other, according to KLAS’s latest report. KLAS notes that GE,  Philips, Siemens, and Toshiba have slowed down the delivery of market-changing developments. In addition, healthcare reform and reimbursement pressures have resulted in increased provider innovation and the move toward multi-use labs.

A former employee of Carthage Area Hospital (NY) says its systems vendor CPSI was “thrown under a bus” when the hospital blamed the company for its billing problems. She says the problems started before CPSI was implemented, the hospital declined to send employees to Alabama for training because of the expense, and they replaced the business office manager who had received training right after they went live. 

  In case you have been living under a rock (or perhaps you’re just a normal guy) there’s a big wedding coming up Friday morning. I can’t decide if I will watch it live or set the DVR. Maybe both so I can relive the moment a few times. I did buy a special hat for the occasion, since I hear hats are an essential fashion accessory for royal weddings. And of course, some new shoes. Maybe Mr. H can come up with a Union Jack theme for next year’s HIStalkapalooza so I’ll have a chance to wear these beauties again.

Sponsor Updates

• Sunquest’s Physician Portal 5.1 earns modular  ONC-ACTB certification from CCHIT.
• Mark N. Bair, MD, R.Ph and Jordan L. Schlain, MD join Ingenix’s independent advisory board. Bair is and ED physician and CEO for Emergency Medical Services, Inc. in Utah. Schlain practices internal medicine and is medical director and founder of Current Health Medical Group (CA). 
• Culbert Healthcare Solutions completes the implementation of Epic’s ambulatory suite of products at the 200-provider Vancouver Clinic (WA). The project took less than 12 months to implement from kickoff to go-live.
• TeleTracking Technologies releases its Patient Flow Dashboard, powered by TeleTracking XT application, which monitors the real-time status of enterprise-wide flow operations.
• Capario names Stephen Garcia as CFO.
• Orthopaedic Surgery Associates (MI) selects SRS EHR and CareTracker PM for its 13 providers.
• Vocera Communications announces that its first quarter revenues grew 56% compared to 2010. Vocera also added its largest client to date, a Department of Defense hospital.
• The iDoc document imaging and management solution from CareTech Solutions earns certification as an EHR module.
• Aspen Advisors is highlighted by Consulting magazine as one of “Seven to Watch” consulting firms. The magazine cited the company’s doubling of headcount and revenue since 2009 and the fact that 40% of its employees have at least 20 years of healthcare experience.

Thoughts on ONC’s Certification / Adoption Workgroup’s April 21, 2011 Meeting on Usability

I haven’t had time to listen to the audio, but I got a few interesting nuggets from skimming the meeting materials:

1. What folks are calling “usability” is really more “suitability to task,” not just counting clicks and seeing if on-screen terminology is consistent, but measuring how long it takes to do common tasks. In other words, ugly screens don’t matter too much as long as experienced users can get their work done quickly and accurately.
2. Because of that, vendors are worried about new “usability” requirements that may go well beyond usability, not to mention the need to have a consistent, unbiased way to measure usability in whatever way it is defined.
3. To compare usability among products requires definition of a perfect EMR, which puts the government in the position of designing systems.
4. Vendors claim they have all kinds of formally trained usability experts who have design authority over applications, but customers don’t seem to think the final product reflects that fact.
5. Users working with the same application rarely agree on the number and significance of usability problems.
6. Any measurement of usability needs to take place in a real-life work setting, not in a lab.
7. Some safeguards built into EMRs would be considered negatives by usability experts, such as the requirement for providers to review existing patient data, avoiding the dangers of “auto-complete” functions, and inclusion of the government-required signoffs and notifications that users resent and don’t find useful.
8. According to one practitioner, systems don’t work as well as paper in her practice. Examples: ordering a routine mammogram electronically takes 10 minutes, entering a family history on paper takes 24 seconds on paper and two minutes in the EHR, systems don’t highlight important information from the electronic clutter they create, and EHR information (such as with scanned documents) may be “in the record” but not easily accessible.
9. A provider urged the government to require vendors to design systems around a common schema to allow easy switching from one product to another, and also to require them to follow an app store model that supports picking and choosing from among competing functions.
10. Several presenters said the government itself makes usability worse by requiring entry of generally worthless information, such as IV end times.
11. Jacob Reider MD of Allscripts admitted that as a frustrated EHR user in 2004, he wrote a blog post blasting Allscripts for designing a system that took 40 seconds to enter a patient’s blood pressure. He said “the president of the company that had developed the EHR I was using to request that I delete the post, as it was costing the company sales.” He went to work for the company 18 months later (he must have either impressed them with his insight or inspired them to put him on the payroll to keep him quiet).

And some interesting comment snips from ONC’s usability committee blog:

• If the Federal government wants to really accomplish they goals they list, every medical entity needs to be on the same system so it is seamless and information can be shared. Usability experts need to be brought in ASAP before the entire project fails. This should have been done before the project was ever launched!
• Developers tend to follow what they know, retreading what’s been done before and packaging it with sharp marketing.
• I truly don’t understand the arguments against standardization, when data exist to support it. Standardization has saved countless lives with respect to mission-critical systems, and EHRs are decidedly mission-critical systems. In fact, standards often originate as a response to accidents and disasters that occurred because of a lack of standardization. To say that having standards regarding font sizes, color contrast, and a host of other usability-related variables clearly related to human performance “stifles innovation” is a weak argument.
• The current failure to act responsibly on this and other safety-related issues in health IT is an important ethical question that needs badly to be publicly discussed. It is wonderful that ONC has raised the issue, but unfortunately, it is several years too late, as care delivery organizations are currently too busy installing what’s available today in order to get the stimulus money to really attend to usability; and vendors are too busy managing these new installations to invest in the sort of thoroughgoing redesign that is needed.
• I am horrified when I look at the design of HIT which violates standard, well-known usability principles. When I tried to publish a paper on a particular EMR design that was particularly horrifying, the lawyers stepped in and said we were not allowed to publish any screen shots (which would show the issues) as this **violated the contract with the vendor**. In discussions with them, the vendor argued that their design was user-centered because it was successfully transitioned from the company’s prior use of the software as a restaurant management system!
• I hate my wonderful EMR. It has decreased my efficiency, decreased my face time per patient, not eliminated errors and resulted in significant employee dissatisfaction. In addition, it is not information-ful: when I read outside records on a complex patient and have to wade through page after page of meaningless review of systems, immunization histories, pharmacy records, vital signs, etc., etc. and never find what the patient was really feeling or what the reasons for the referral are, I have just wasted another 10 minutes that I could have spent with the patient – finding out relevant stuff! However, all important components of billing and compliance have been duly fulfilled (excuse my misapprehension that this was supposed to have something to do with patient care).

Contacts

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

Golden Gate Capital To Acquire Lawson

Lawson Software announced this morning that it has agreed to be acquired and taken private by Golden Gate Capital and software vendor Infor for $2 billion cash. Lawson has a significant hospital presence with products that include financial management, supply chain, human resources, the Cloverleaf integration line, a master patient index, and electronic health records.

Infor offers solutions that include customer relationship management, enterprise resource planning, supply chain, financial management, and workforce management. Infor CEO Charles Phillips was quoted in a statement as saying that the acquisition “will extend our existing portfolio, particularly in areas such as healthcare, public sector, manufacturing and human capital management.”

The acquisition is expected to close in the third quarter.

Curbside Consult with Dr. Jayne 4/25/11

In the last several weeks, tornadoes and other severe storms have ripped through various parts of the country. Based on a frantic phone call I received from a medical school colleague, this seems to be a good opportunity for a physician-friendly discussion of disaster preparedness for healthcare information technology. For those of you who are serious IT professionals, this may be boring, but on the other hand it may be a good conversation starter to e-mail (or even print if you have to) for the physicians in your lives.

Downtime and Disaster Recovery 101

The most important part of successfully dealing with an outage of your electronic health record is to have a plan. Most practices need both short-term and long-term plans, whether you’re in a well-known hurricane zone or tornado alley or not. Lots of things can happen: floods, fires, and earthquakes. No one is exempt and everyone needs a plan.

Downtime usually refers to a time when the system is unavailable, whether planned or unplanned. Downtimes can happen for a variety of reasons. Unplanned downtimes may include a local power outage, loss of Internet connectivity, or other nonspecific system issues that keep physicians from fully using the EHR. They may be limited — perhaps it’s just an outage of e-prescribing or faxing — or may affect the system across the board.

Limited downtime events often have simple workarounds. For example, if e-prescribing or faxing is down, one can always print prescriptions or documents, call medication orders to the pharmacy, or worst-case scenario (ugh) use a paper prescription pad and a pen. Loss of Internet connectivity can be overcome by using a cellular / wireless Internet card, provided the practice has planned ahead and such cards are available for use. If the local wireless network in the practice is out of commission, users may be able to plug in, assuming there are ports available.

For unplanned downtimes, unless they have in-house IT support 24×7, practices should ensure key personnel have checklists for troubleshooting issues and phone lists for Internet service providers, vendor help desks, etc. Make sure multiple people in the practice know how and where the information is stored — don’t count on a single employee to be the point of knowledge. Murphy’s Law dictates that if something goes wrong, it will go wrong when that employee is unavailable.

Planned downtimes are usually limited downtimes. This may include hardware upgrades, software upgrades, weekly or monthly maintenance, etc. When planning a downtime, physicians need to discuss their willingness to work without full access to the EHR. Many physicians may be willing to print summaries for patients who may be scheduled during an upgrade and ‘wing it’ for others. For some, being without data is unacceptable, and the office must be closed.

Careful planning can keep physicians from having to make this decision. Many vendors offer solutions where a copy of the database can be saved to a local computer and accessed in a read-only manner during an upgrade. There are several third-party solutions to this problem, and if you are interested in this for your practice, allow some time (often a few months) to make sure this is in place before a planned downtime.

Disaster recovery usually refers to a situation where something very, very bad has happened. This can include physical destruction of the practice, its servers, and its equipment due to a natural disaster. If the IT infrastructure is physically destroyed, it may be weeks before the practice can be up and running. Disasters can also occur due to poor planning, as my friend learned.

Practices need a plan to create backup copies of the data in the event of a disaster. If you use a Web-based or hosted EHR, often your vendor takes care of backups for you. However, you need to understand the interval at which backups are done. Daily, weekly, monthly? To determine how frequently you need to do a backup, ask yourself: how much data are you willing to lose? For a busy practice, backups should be done daily and practices should consider other strategies to continuously back up data throughout the day (but that’s beyond Disaster Recovery 101, so I’ll save the discussion of transaction log shipping vs. database mirroring for another day).

Backups should not be stored in the office. Think it through: if your office catches on fire and the backup copy is at the office, that’s not a great idea. Backups need to be stored securely under appropriate climate conditions — be mindful of temperature, humidity, etc. There is one important thing about backups that doesn’t cross most physician minds: the need to test the backup to make sure it works. Your IT professionals can do this by taking the backup copy of the database and restoring it to a test system, then checking it to make sure data is current and comprehensive.

Unfortunately, the solo physician who called me this morning learned this the hard way. When the power went out and the battery backup failed, the database was impacted. Her vendor recommended that they restore the database from the most recent backup. When this was attempted, the backup contained less than half the data they expected it to. Not a great situation. Although she was fortunate that the EF-4 tornado didn’t touch her building, it’s going to be a challenge to recover from the loss of so much data.

So physicians, heed this cautionary tale. Take a moment to discuss your downtime and disaster recovery strategies with your IT support staff, whether you work in a solo practice or for a large health system. Don’t be afraid of stepping on the IT team’s toes — many are proud of the downtime strategies they’ve created and will be happy to talk about them. If there is no written plan, make it a point to create and document the processes you need to practice should the system be unavailable. Make sure key staff have copies of the plan, and practice it. Use regular maintenance windows as an opportunity to practice what you would do if an unplanned outage occurred.

Preparing for system outages should be a regular part of the life of the practice, no different than fire drills, tornado drills, or the like. The odds of something bad happening may be slim, but if you’re in disaster’s crosshairs, you’ll be glad you took the time to prepare for the worst and to protect your patients and your practice.

E-mail Dr. Jayne.

Monday Morning Update 4/25/11

From A Friend: “Re: McKesson. Did you see they lost their appeal for patent infringement to Epic? The products affected are what is now called RelayClinical Communicator vs. MyChart.” I did see that, although the verdict was filled with a lot of legalese and dissenting opinions, which probably means the fat lawyer hasn’t sung yet. McKesson’s original patent was for putting visit-specific information on a Web page for patients, including offering online scheduling and refill requests. The judge found that Epic doesn’t make those capabilities directly available in MyChart, which requires patients to request the service and physicians to approve their request. On that basis, Epic is off the hook – for now. The ruling doesn’t really hurt MCK all that much since it only prevents them from insisting that Epic pay up.

From Cantankerous: “Re: videos on HIStalk. Is there a way to view them on the iPad?” I don’t think so. Apple refuses to work with Flash, which is how YouTube videos stream. You could use the YouTube app that’s included in the OS, but I don’t think you can do that without searching for the video all over again from YouTube. All of that’s good news for companies selling Android-based phones and tablets.

From Ishmael: “Re: Meditech 6.0. I was hoping for something that would improve my workflow, but all I got was a new graphical front end to the exact same functionality as 3.0 and 4.0 except that it now takes 50% longer to do it. Time is all I have and anything that takes it away without compensating me for it is my enemy. It’s not helping me, the doc who has to use it, and it’s taking nurses away from my patients so they can spend more time staring at a screen.”

From Outside Insider: “Re: iPad not being revolutionary. The device weighs just over a pound, you can access your network and systems, you don’t need an input device other than your fingers, and your developers can write apps that will let you access your data any way you want. Would you be as comfortable carrying around a laptop or rolling a PC on a cart? Those who don’t recognize the advantages to change are typically the last to implement and are behind the curve in realizing the benefits.” My iPad has a great screen and very cool apps written specifically for it, but I’ve found the iPod Touch to be the real game-changer since I don’t carry an iPhone. It’s always on and has a huge battery life and quick recharge time, so I check e-mail, CNN, and the weather last thing before bed and first thing in the morning. Sometimes I stream Netflix over it while sitting outside or in the kitchen. For both devices, the key to my satisfaction was to buy a cheap non-USB charger so I could top off the batteries quickly from a wall socket anywhere. The Touch costs only around $200 and carries no recurring expense since it hops happily onto the WiFi at home or work. My record still stands: I use the Touch all the time, and even though it’s primarily a music player, I’ve yet to play an MP3 on it.

From The PACS Designer: “Re: Microsoft Office 365 beta. Now that Microsoft has launched its online version of Office, those of you who could enhance your business practices by incorporating Office can contribute to further refinement of the Office 365 release by participating in the improvement process for this product, and also possibly improve your day to day operations for the future.” It starts at $6 per user per month, which is $6 per user per month more than Google Docs (although to be fair, you’d have to pay Google $4 per user per month for Google Apps for Business to get the uptime guarantee that’s probably not needed anyway). The Microsoft offering includes stripped down versions of Word, Excel, PowerPoint, Outlook, OneNote, and parts of SharePoint. Personally, I find Microsoft’s offerings confusing: there’s also Windows Live SkyDrive (free)and Office Web Apps, all to replace Office 2010 (which you can buy in a three-user license pack for $120 and with no stripping down or need for Web connectivity). I find Google Docs to be pretty clunky and not all that intuitive, so maybe that’s a market for whatever Microsoft ends up releasing. It should be most attractive to small business that haven’t already bought Office and don’t want to manage servers. Maybe I’m naive, but I just don’t see the average user needing to collaborate to an extent that e-mail doc swap doesn’t address, so I personally wouldn’t use either service enough to justify paying for it.

From GoTooSlow: “Re: Valley Medical Center, Renton, WA. Has signed with Epic to replace many modules.” Verified, apparently, since I found the above in the minutes from the hospital board’s December 13, 2010 meeting. It seems to me (without any hard data to prove it) that McKesson is losing more Horizon Clinicals customers to Epic as a percentage than any other vendor, which might have been expected given that those customers were the only ones with significant doubts that their vendor and product would get them ready for MU requirements in some survey I recall from a few months back.

From Lucy Gucci: “Re: Epic. They gave me a great start in healthcare IT (I didn’t exactly have recruiters pounding on my door as a fresh liberal arts graduate), but it’s truly a sweatshop for most people because of 70-80 hour weeks, lack of work-life balance, and travel. I got sick during a Monday-Saturday work trip and had to go to urgent care. The PA there said they see Epic staff constantly because they travel during normal appointment hours and need antibiotics since they can’t take time off to recover. In our March 2011 staff meeting, Judy spent five minutes going over the HIStalk awards and seemed to be tickled pink with her ‘industry figure with whom you’d most like to have a few beers’ award, although she said the would have to drink a chocolate milkshake since she doesn’t drink – at corporate events, we have ‘mocktails.’ As is obvious, sales are through the roof and we dread hearing the wedding music playing over the PA to indicate a new sale since Epic truly does not have the experienced implementation staff to support all the new customers. Experienced employees used to have two customers, now 3-4 are the norm. Please keep me anonymous – Judy warns us every single month at the staff meeting not to post anything about Epic to blogs.”

This weekend was an almost-first: I whisked Mrs. H away to a beach mini-vacation and didn’t touch the laptop until we got home. There was mango sangria, walking in the surf, watching a horrible Burt Reynolds movie (was that redundant? – well, it was Stroker Ace, which is bad even by low Burt standards, but I couldn’t look away given the mammoth thespian talents of Jim Nabors) while drinking wine in front of the TV with the sea breeze wafting in, and eating some excellent fish tacos and goat cheese with mango salsa (it was a two-mango weekend). I’m sunburned, behind in my work, and not a bit regretful about either. 

The feds aren’t exactly wowing those of us in the industry with their Medicare and Medicaid fraud-fighting record, with 95% of respondents saying they’re doing something less than a good job. New poll to your right: will the Meaningful Use requirements significantly improve patient outcomes and patient safety?

My Time Capsule editorial from 2006: Joe Sixpack’s Concerns About Privacy and Security Need to be Taken Seriously. A snip: “Odd, isn’t it, that a physical break-in seldom reflects poorly on the company being victimized, but an electronic one immediately triggers outrage and disbelief?”

Cerner COO Mike Valentine resigns the job he’s held for three years for unstated reasons, although the company claims it has nothing to do with its upcoming earnings announcement. He will be replaced by Mike Nill, EVP and chief engineering officer, who oversees the company’s solutions and technology management. Nill, who joined Cerner in 1996, holds a bachelor’s degree in computer information systems from Rockhurst University and was previously with Andersen Consulting.

In addition to the COO change, Cerner also announces that SVP Zane Burke has been promoted to EVP over the client organization that covers the Americas and the Pacific Rim. He joined Cerner in 1996.

More HIStory from Vince Ciotti.

The New Mexico REC accepts Sage Intergy Meaningful Use Edition as a qualified product.

Adena Health System (OH) chooses MedsTracker 5.0 from Design Clinicals for medication reconciliation.

The CDC-funded Lab Interoperability Cooperative is recruiting hospitals to participate in a program that will connect their labs with public health agencies as required by ONC’s Meaningful Use criteria. LIC will provide educational and technical assistance to at least 500 hospitals help them electronically transmit lab results. The underlying technology is the Surescripts Network for Clinical Interoperability. Participants include AHA, the College of American Pathologists (and CAP-STS – SNOMED Terminology Solutions), and Surescripts. A readiness checklist is here.

MedPlus puts a cool green bus on the road to demo its Care360 EHR. I should tag along since it’s as close to a rock star tour as we’ll get in this industry, although there was no mention of groupies or trashing hotel rooms.

Big Boston physician groups Atrius Health and Fallon Clinic are in talks to merge, with their common software platforms for EHR, PM, and patient scheduling being cited as a reason that action makes sense.

Banner Health and Poudre Valley Health System will participate in the Colorado RHIO, which awkwardly calls itself the CORHIO HIE since a substantial part of its name came from a fad that has already become passé.

Stupid: a former Ohio neonatologist pleads guilty to signing up for a child pornography Web site using a hospital computer. He has surrendered his Ohio medical license, was fired from his most recent job as a Massachusetts researcher, and will serve 27 months in prison.

E-mail Mr. H.

Time Capsule: Joe Sixpack’s Concerns About Privacy and Security Need to be Taken Seriously

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

I wrote this piece in February 2006.

Joe Sixpack’s Concerns About Privacy and Security Need to be Taken Seriously
By Mr. HIStalk

Is it just me, or are we having a sudden epidemic of privacy and security breaches in health care organizations?

Quite a few examples have been reported in newspapers and on TV lately, including the embarrassing “backup left in the back seat” exposure at Providence Health System. Patients are angry, lawyers are salivating, and those organizations involved in such breaches are fixing the gate as the horse gallops away.

Consumer Reports joined the fray this week, expressing concern that our electronic systems may not protect personal health information. Not just from thieves, but from drug marketers and fundraisers as well (odd, I know, but that’s what they said).

Hospitals used to feel safe, rationalizing that much more attractive targets such as banks would receive hacker priority. Indeed, hacker-type security breaches that expose patient data are fortunately rare (medical information has little cash value and few willing customers, so we can’t take all the credit).

We in health care IT may believe that the biggest barrier to our obviously beneficial migration to electronic medical records is money. Outside our world, however, Joe Sixpack doesn’t give that a thought (he’s seen all those construction cranes darkening our hospital skies, so he knows we’re doing OK). He’s worried that his neighbors will learn his medical history, that his employer may fire him for poor health, or that his insurance will find a reason to deny him care because he is predisposed to need it.

Joe Sixpack understands stolen paper charts, but he doesn’t worry much about that. He knows thieves seldom bother, for the same reason they’d rather not steal pennies from a wishing well: it’s too much work and risk for too little gain. Electronic records are obviously more attractive. A single computer, backup disk, or unprotected server can hold thousands or even millions of medical records that are easy to carry and hide, attracting a thief who’s more interested in showing how smart he or she is instead of robbing a convenience store.

(And of course, there’s a good chance that the prospective thief is your own employee, as I’m sure you already know.)

Joe Sixpack might view your EMR project as unusually risky, despite liking the concept. He doesn’t know what precautions you should take, but he’ll hold you accountable if you are breached. Odd, isn’t it, that a physical break-in seldom reflects poorly on the company being victimized, but an electronic one immediately triggers outrage and disbelief?

Other industries already have electronic records, so their risk is lawsuits. Healthcare is just moving to electronic data storage, so our risk is greater. The implied threats could stall our efforts to get there.

I think we need to take quite seriously those concerns about privacy and security as we solve connectivity problems to support RHIOs and integration. That means money diverted away from much-needed functionality to hopefully never-needed security. The people sitting around the table need to come from all industries, not just healthcare. We’re fairly new at this security thing, after all.

Most of all, we need to pay new attention. When Consumer Reports is worried about health care security and privacy, that means a lot of Americans are worried. We need to reassure them that we know what we’re doing.

An HIT Moment with … Daniela Mahoney

An HIT Moment with ... is a quick interview with someone we find interesting. Daniela Mahoney, RN is president and CEO of Healthcare Innovative Solutions of Seville, OH.

Hospitals are still struggling with implementation of CPOE. What are some lessons learned about how to do it right?

There are a few major areas in which hospitals typically fall short. These are the items that often do not make it into the vendor’s work plan.

1. Understanding the true effort that will be necessary to successfully implement such transformation.
2. The impact organizational culture has on the planning process and how the project will be operationalized.
3. The focus is concentrated on physicians, and rightly so. However, a team of clinical resources is responsible for the execution of the orders. This clinical transformation is often not understood until after the implementation. Then the organization’s response becomes very reactive. You see a high number of unintended consequences that could have been easily prevented had the organization fully understood the impact CPOE has on the clinical teams.
4. And, as surprising as it may sound, many vendors are still very young at implementing CPOE. It seems they are learning as they go.

These items are equally important. I go to any hospital assuming that the vendor understands their platform and knows how to configure their software and upload their master profiles with the necessary parameters. Most of the time this is true, especially with some of the big players (but not always with some of the other vendors).

However, if you are lucky enough to get a work plan from the vendor, you realize that it is all about the technical steps that must be executed. CPOE is about 15% technology (the easy part) and the rest is all about process, yet 100% of the tasks are typically technical or software related. There may be references regarding “analyze current workflows,” but if you have never done this, one is asking, “What exactly are we analyzing and from what perspective?”

Workflow analysis is not a new concept for us in healthcare because we seem to always try to improve, become more efficient, and provide safer care for patients. The larger the organization is, the more initiatives or “lean” teams they may have. However, most of the smaller, community-based hospitals have a steeper hill to climb.

How do we go about addressing some of these challenges? Remember that culture eats strategy every day. When we look at culture, we should think about it holistically as an organization. Then we should focus on the medical staff to truly understand what can be accepted, how we should present the value proposition to clinicians and physicians, and how to sometimes compromise since everyone has to give up something. I try to create value propositions around the patient. Placing the patient at the epicenter of the transformation puts a different light on the whys and hows.

Some vendors offer packaged / fixed fees implementations. Budgets are estimated, approved, and the implementation begins. All is good, but we learn that there were no allocations for contingencies or considerations for what else is going on when the planned live event is scheduled (as simple as Halloween and they cannot get the appropriate staff for support — it sounds funny, but it is true). If we pull nursing for support, who will bridge the gap for patient care? Should you plan for external agency staff for patient care? Do you trust that they will do a job that you will be satisfied with? After all, these are your patients and their satisfaction is very important.

Should you outsource the support instead? If you do so, will your staff be less proficient? In what budget are these hours accounted for? Have you budgeted for training? How about retraining? These packaged deals often offer a false sense of security that the vendor will take care of it. Well, let me be candid and say, “They will not.” You cannot go to sleep at night thinking that you have nothing to worry about. The vendor has their responsibilities, but you have yours. Be sure you understand what they are. It takes two to tango, and if you are not careful, toes will be stepped on.

We need to understand that the true effort is not just on the IT side. That part is the most predictable, but understanding the effort required for clinical transformation can be overwhelming, almost daunting, when we realize what it is. At that point, timelines are typically slipping (and some vendors have financial penalties if you not meet them). These days, you have to meet the political timelines set by CMS so the organization does not lose its opportunity to get the incentive dollars. Because of this, there is a fine balance on how much transformation can take place, so the implementation moves along, remains on track, and the appropriate redesign processes occur, making good clinical sense.

Sometimes this balance comes with experience, but perhaps following some general concepts, such as not letting perfection getting in the way of good, may still accomplish the goals. Avoid paralysis by analysis. Realize that the CPOE implementation has a clear beginning, but not an end. It is a continuous journey that will give you the opportunity to improve as long as you recognize this upfront and create a governance structure to allow for constant process improvement. These structures and efforts are typically not budgeted or accounted for upfront. Knowing that it will not be perfect on Day One, don’t cut this piece of the budget just because it may seem the most expendable at the time. It has to be, however, safe for the patient. There should be no compromise for this, but if we do not measure, it will be hard to know.

What are some of the best practices involved with supporting physicians using IT systems?

The best practices I have seen for supporting physicians are not all the same. The organizations that provide support to most adequately match the culture of their physicians and organization are the most successful. To think that cookie cutter methods will work best is simply naive. Managers and administrators know their physicians and culture better than outsiders and should provide support based on what is best for their organization.

It is important to gauge the perceptions of your physicians in order to hear them out prior to designing a support system. It is very likely that your interpretation of what it means to implement CPOE is totally different than a physician’s interpretation. Setting expectations and defining what is expected of everyone will most likely lead you to providing support that the physicians feel is adequate.

At the end of the day, however, I have not seen anything more effective than one-on-one support among a blend of other options such as peer to peer or using residents when possible. Physicians respond well to nurses and they are instrumental in propagation of physician adoption. It is essential to understand how physicians process data when they make decisions. Understanding their rounding process and patterns and the data they need will offer valuable insight into how much support is needed, where the support should be placed, and how to deal with less-frequent users.

As a nurse, do you think hospitals are placing the right emphasis on clinical IT to help nurses?

I am seeing variations on this front. The average age for a nurse is somewhere around 48 years young. Many hospitals, especially more rural community hospitals, are still intimidated by technology. I also think we deal with a generation that it is not always very receptive to change and CPOE is all about change. In the larger facilities, I do see more opportunities for the nurses to choose a clinical informatics ladder, and there are provisions to support training in this field.

My main concern, however, is that the industry is telling IT that CPOE is a clinical project and that it should be led by clinicians. We do form clinical teams and have nurses and sometimes physicians leading the implementations. Now what does a nurse know about project management? About meeting milestones, lead and lag time? The tools that we give them to execute the projects are not designed to be used by clinicians, so there is a lot of struggling. The new tools that support the implementation of CPOE need to support the thought process of clinicians, not of a PMI-certified IT project manager.

What privacy problems and solutions are you seeing?

The most common ones are related to users not logging off their devices and sharing of the passwords from physicians to their staff, especially since some are still struggling with entering their orders into a CPOE system. We do not have to deal with many security breaches outside of the basic incidents, where sometimes people may get access inadvertently to units they should not, or access is too restrictive.

We see more and more need to allow physicians access to the clinical systems using their own devices, especially the iPad. One of the most interesting solutions to privacy I have seen lately has been the option of using virtual desktops for physicians for remote access. The hospital still has to implement the VDI (Virtual Desktop Infrastructure) so I would definitely look at this solution closer from a cost and performance standpoint. This would give users essentially the same interface to the hospital regardless of what device they are accessing it from, including iPads. It also prevents users from saving data onto the local devices. Overall, in my experience, I think hospitals are doing a reasonable job around security.

What would you change about Meaningful Use to emphasize patient safety and benefits?

If I could change anything about the Meaningful Use criteria to emphasize patient safety and benefits, it would be to change the order and percentage in which some of the requirements have been placed relative to Stages 1-3. Implementing CPOE, along with the other main components like medication reconciliation and discharge instructions, requires a substantial transformation of clinicians’ workflows. The MU criteria, in their current state, do not promote a logical transformation of this workflow, thus negatively impacting patient safety and benefits.

Without going off on a tangent and getting too deep into the logic of the MU criteria, some of the simple changes I would make to the MU criteria would be to align the goals of the objectives so they make sense from a clinical perspective. How can you have CPOE where only medication orders are entered, and only on 30% of unique patients? From a technology perspective it may make sense, but from a physician workflow perspective, it will be chaotic. How will this be safer for the patients? Also, how can I build order sets if we do not entirely address what patients need? It is unfortunate that some organizations look at this and plan around it without thinking that CPOE will require a holistic approach. CPOE should be done for the right reasons, not just for meeting the CMS timeline.

Here is another interesting objective. “More than 50 percent of all patients who are discharged from an eligible hospital or CAH’s inpatient or emergency department (POS 21 or 23) and who request an electronic copy of their discharge instructions are provided it.” This is all great, but to do this, you need to have discharge instructions implemented on 100% of your patients. If you have not yet implemented this component, it will be challenging. This particular module cannot be phased in too easily and it is often underestimated what it would take to deploy.

News 4/22/11

Top News

CPSI reports Q1 net income of $5.37 million ($0.49/share) compared to $2.92 million in the prior-year period. Analysts were expecting $0.46. Sales revenue grew from $31.54 million to $40.38 million.

GE’s Q1 numbers: revenue up 6%, EPS $0.31 vs. $0.17, with $1.8 billion in profit from GE Capital. GE Healthcare put up good numbers.

Reader Comments

From Ishmael: “Re: Meditech. I am just loving being a Meditech beta tester for CHW’s rollout. It’s great when my livelihood and patients’ lives are on the line, especially when I’m not getting paid for it! I actually don’t mind the software as much as my median doc or nurse colleague, which are about an 80-20 split on hate/don’t mind. No one loves it.” I guess to be fair users almost never love enterprise software like they might Facebook or something. My armchair psychologist theory is that having software imposed on you with mandatory use is a reminder that you are subservient to management, and no matter how benevolent, nobody likes to give up control (and that’s what work software is – a package of rules, controls, and monitoring tools). Another problem I can cite from experience is that Meditech is the hardest system I’ve ever had to replace, and we’re talking the old Magic product – users hated anything that wasn’t Meditech. We took an IT black eye for replacing it in the hospital we acquired.

From St. Pauli: “Re: kudos. When I moved from medical practice to an informatics role, I researched any and all sources of information. HIStalk was one of the first I found and continue to read regularly. I admire anyone’s ability to write well and regularly and the expansion of HIStalk to include Inga, the reader polls, Dr. Jayne, Readers Write, and Ed Marx have increased HIStalk’s value logarithmically. I was recently promoted and would like to thank those responsible – my family, bosses, and employees. HIStalk is included in that list. This is not a lame attempt to get mentioned – I just want you and others that contribute to HIStalk to know the benefits you have given one of your readers.” Thanks – that made my day.

From Rango: “Re: HCRAP. Inga mentioned it, now I have to know what it means.” A couple of huge companies e-mailed to say, “We want to spend a ton of money and sponsor your site at a higher level than anyone else” (I’m paraphrasing slightly). I don’t do that – sponsorships are relatively inexpensive and everybody gets the same treatment – but I wanted to yank Inga’s chain. I first told her I was studying the Periodic Table of the Elements to find metals higher than Gold and Platinum and was feeling good about the Roentgenium Level and would calculate the price of that sponsorship based on its atomic number relative to those of the other metals. I then told her about the brainstorm I’d just had about two new sponsorship programs. The HS program (Hollywood Squares) allows a sponsor to not only run their own ad, but to buy the spots of their competitors (at a 50% premium) to block them from doing the same. The second option carries a 100% surcharge, for which we will send every news and rumor item about a company for their approval before we run it, which I dubbed the HIStalk Company Reputation Assurance Program (HCRAP). She was suitably amused, or at least pretended to be.

From iFad:”Re: iPad. It’s cool, but does anybody really think it’s revolutionary? We’ve had PCs for going on three decades and are still trying to figure out how to use them in healthcare. Call me a cynic, but there aren’t many paperless healthcare organizations and pie-in-the-sky simplicity and streamlined workflows remain just that. Reality check poll: if you own an iPad, do you really expect improved outcomes or productivity that you couldn’t get from a PC?”

HIStalk Announcements and Requests

  Several dozen companies have asked to be featured in the innovation showcase I’m starting up. As usual, my reach exceeded my grasp given that my time is almost non-existent between my hospital job and HIStalk job. Despite my being the rate-limiting step, it’s underway, albeit in a more controlled manner than I’d like. Stay tuned. I hadn’t heard of several of the companies that are interested, which I think is great since I’ll learn about them along with everyone else.

Welcome to new HIStalk Platinum Sponsor HMS of Nashville, TN. HMS provides Meaningful Use-ready enterprise solutions for 680 hospitals, focusing on the often-forgotten community and specialty hospitals that deliver much of the care out there in the real world. They’ve been around since 1984 and offer a broad line of products: EDIS, LIS, PACS, pharmacy, radiology, surgery, AP/GL/MM, payroll/T&A, HIM, quality management, transcription, CPOE, eMAR, device integration, clin doc, patient accounting, claims, document management, and a bunch more I left off since the list is obviously comprehensive. The company’s inpatient EHR, EDIS, and ambulatory EHR all earned ONC-ATCB certification in 2011 and HMS clients are already receiving inventive payments for using them, which can be run locally or hosted by the company. Thanks to HMS for its support of HIStalk.

Jobs on the job board, where sponsors post free: RVP Sales. On Healthcare IT Jobs: IS Clinical Systems Analyst II Nursing, SAN Administrator / Engineer, Epic Ambulatory Specialist.

Acquisitions, Funding, Business, and Stock

The State of Wisconsin awards Merge Healthcare $500,000 in JOBS Tax Credits and a $500,000 loan from the department of commerce to consolidate operations at its Hartland, WI facility. The project is expected to create 100 jobs and represents a $2 million investment.

Quest Diagnostics reports a 13.3% drop in net income compared to last year, falling from $162.4 million to $140.8 million ($0.86/share). Analysts expected $0.99 to $1.05. Revenue was up 1%.

Here’s the Cerner video presented by the ADP and the Small Business Administration, featuring co-founder Cliff Illig. It’s good.

Israel-based EarlySense, which sells a continuous patient monitoring system whose sensor resides under a bed mattress with no direct patient contact, announces that it will locate its US headquarters in Massachusetts. MetroWest Medical Center was also announced as the company’s first Massachusetts hospital customer.

Canadian vendor PatientOrderSets.com, which I mentioned last time, gets $750K in funding from a government-funded accelerator.

Sales

Emerus Hospital Partners (TX) selects InsightCS patient access, patient accounting, and revenue cycle information solutions from Stockell Healthcare Systems.

Allina Health System chooses Micromedex from Thomson Reuters as its drug information vendor after a month-long bake-off.

In Canada, Ottawa Hospital orders 1,800 iPad 2s for its physicians, saying they will pay for themselves through increased productivity and reduced errors.

NextGen gets a $6.7 million contract extension to provide an EMR to Maryland’s prison system.

People

Sad news: Craig Maszer died on April 11, 2011 at Brigham and Women’s Hospital after a long battle with multiple myeloma. He was a resident of Andover, MA and a principal at Champions in Healthcare, where he worked alongside his mother, industry long-timer Stephanie Massengill. Others may remember him from his time with Sentillion and Eclipsys. Craig Maszer was 46 years old. Condolences.

Omnicare names Randy Carpenter to SVP/CIO. He was previously CIO of HealthSouth and had hospital CIO experience before that.

University of Arkansas for Medical Sciences (UAMS) names David Miller as vice chancellor and CIO. He was formerly with University of Chicago Medical Center. I think I probably mentioned that awhile back — he and I swap e-mails occasionally and he let me know as soon as it was official.

OB-GYN PM/EHR vendor digiChart names Phil Suiter as president and CEO. The former president and CEO, founder and Vanderbilt professor G. William Bates MD, will remain with the company as board chair.

Former HealthPoint Medical Group CIO Steve Fisher joins MD Solutions as SVP of advisory services.

Announcements and Implementations

 

McKesson Horizon Enterprise Visibility earns top marks in KLAS’s new report on patient flow solution. TeleTracking and Allscripts Sunrise Patient Flow earned the next highest ratings. Only 20% of hospitals are using a patient flow system, but 85% of those say they provide benefits, especially in terms of resource collaboration and communication.

Denver Health (CO) implements Microsoft’s Chronic Condition Management platform to facilitate communication between providers and diabetic patients and promote better self-management of chronic conditions.

Wayne Memorial Hospital (NC) goes live on EXTENSION’s HealthAlert for Nurses for nurse call messaging.

The Methodist Hospital System (TX) will use the Rothman Index for scoring patient condition from EMR information into a dashboard.

Two Siemens Soarian customers successfully attest for Meaningful Use Stage 1: MedCentral (OH) and Riverside (VA).

Government and Politics

Indian Health Service becomes the first federal agency to have its EHR (the IHS Resource and Patient Management System, or RPMS, based on the VA’s VistA) certified as a complete EHR.

Other

A Sage Health survey finds that patients believe EHR use increases care quality and results in a more accurate health record. Eighty percent of patients have a positive perception of EHRs, compared to only 62% of physicians; privacy and security is a concern for 81% of patients but only 62% of  doctors. Both groups agree that the biggest benefits of EHRS are real-time access to records and  the ability to share information among providers.

A Texas hospital tries to convince county voters to create a hospital tax district after it experiences financial losses, layoffs, and wage freezes. The new tax dollars will pay for a  new EMR, which will cost $1.2 million plus $18,000 per month maintenance.

Strange: the family of a patient who died after heart surgery is suing the surgeon and hospital after an anonymous caller told them that the surgeon’s 7-year-old daughter was showing a video of the surgery to her friends. The family claims the surgeon was so interested in making the movie for his daughter that he left the OR before the revascularization procedure was complete, allowing a non-physician to close and monitor the patient. The family also claims they found out only after the surgery that the surgeon has the worst outcomes of any surgeon in the state for the procedures he performed.

Sponsor Updates

• Healthcare Growth Partners releases its Q1 2011 market and M&A report, which summarizes the capital market, M&A, and capital raising activity for the HIT and services sector.
• Salar’s TeamNotes and Charge Capture software products earn ONC-ACTB EHR modular certification from Drummond Group. 
• Central Illinois HIE picks ICA as its vendor of choice to provide the HIE’s technology and infrastructure.
• ZirMed and e-MDs partner to offer eMD clients ZirMed’s RCM services.
• MEDSEEK obtains CCHIT ONC-ACTB EHR module certification for its eHealth ecoSystem, Version 3.4.
• The Huntzinger Management Group posts a video of its HIMSS presentation Discussing the Future Viability of Hospitals.
• Hartford Hospital (CT) reports it has increased its early discharge rate nearly threefold by offering its clinicians access to Carefx’s business intelligence dashboard.
• Harrison Medical Center (WA) is live on GE Healthcare’s eHealth Information Exchange.
• EMRConsultant.com adds more than 100 EMR products to its database, a free service used by over 12,000 practices.
• Mission Hospital (CA) has implemented Meditech C/S 5.64 CPOE at both its Mission Viejo and Laguna Beach campuses, assisted by H/P Technologies, which has been involved with Meditech and Epic go-lives at Cedars-Sinai, Mission Hospital, and University of Chicago.

EPtalk by Dr. Jayne

Earlier this week, the College of Healthcare Information Management Executives (CHIME) addressed a letter to new National Coordinator for Health Information Technology, Dr. Farzad Mostashari. It summarizes CHIME’s comments on ONC’s Federal Health IT Strategic Plan.

After the introductory pleasantries, CHIME delves into key areas close to many of us:

• Consent issues for health information exchange, not only clarifying how consent will be stored / transmitted, but how it will integrate with personal health records; unifying the patchwork of laws across various states; and national standards to pull it all together and fix the problem created when HIPAA allowed states to preempt federal regulations.
• Making movement to Stage 2 Meaningful Use requirements contingent on having a certain percentage of providers and hospitals compliant with Stage 1.
• Clarifying disagreement between HIPAA and HHS (Department of Health and Human Services) regulations on timely release of information and making sure that granting patients instant access to health information will not be harmful.
• Greater focus on the usability of technology.

As a practicing physician, the last one has the greatest impact in my day-to-day practice. There have been some unfortunate downsides to the speed of the Meaningful Use timelines. The relatively short time between the publication of the final rule and implementation has stressed vendors intent on incorporating items that may or may not be clinically helpful, yet cannot be ignored if they are seeking certification.

Let’s just look at a simple measure, documentation of tobacco use. Prior to the Meaningful Use hubbub, many EHRs did a perfectly fine job of collecting the information physicians needed to do appropriate health interventions. Physicians saw patients, counseled them, documented their findings, etc. However, MU required the documentation to meet certain standards of compliance. Was there any randomized, controlled study that showed that documenting tobacco use in a certain way changes patient outcomes? Or was it just nebulously decided that it should be “this way” going forward?

I’m certainly not privy to how it was all worked out, but vendors did a fair amount of retooling to make sure all the MU items were documented in the prescribed fashion. Don’t get me wrong, I support uniformity, the ability to report data across disparate systems, etc. But I also can’t help but think that the amount of development, testing, and implementation resources that were focused on making software changes that don’t materially benefit physicians (or patients) could have been better spent on making systems more usable.

This doesn’t even take into account the amount of time and resources spent by EHR customers to upgrade perfectly functional/serviceable systems to “certified” versions, regardless of pre-existing organizational priorities. A CMIO friend of mine laments the sheer number of projects (many of which would really have provided benefit to his physicians and their patients) that have been placed on hold so that all resources can focus on achieving Meaningful Use. The pursuit of MU has put his organization back a year or more on its five-year strategic plan.

I hope that ONC gives some thought to these comments as well as the thoughts of many others in the trenches who have submitted their thoughts. Do you have an interesting comment submitted to ONC? E-mail me.

Contacts

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

CIO Unplugged 4/20/11

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

This is the second in a short series of posts on “The CIOs Best Friends,” BFFs who are critical in ensuring CIO effectiveness. This time we cover the CFO – CIO relationship.

The CFO – CIO Relationship

When asked to take on additional responsibilities, I inherited our financial applications team. This scared me. Not because of the expanded scope, but because I’d have to deal with our CFO, a person feared in the halls of IT.

During the first week in my new role as corporate director, the CFO demanded an update on the troubled decision support project for which my team was responsible. I gathered players and facts and cautiously took my seat in the arena … I mean, in his conference room. He was not happy about the multiple delays and lack of concrete plans for resolution.

My project manager struggled in her responses. The CFO’s gaze then landed on me.

I don’t recall if my summation came across as eloquent or suspect, but my speech carried a mix of service compassion and urgency. I ended with, balls to the wall. The CFO smiled. I made a connection — one free pass for the new guy to facilitate resolution.

No C-suite relationship has changed more this past decade than that of the CIO – CFO. As technology influence becomes increasingly strategic to success, wise organizations are evolving. CIOs are crawling out from under the CFO’s shadow and taking their rightful seats at the executive table.

Regardless of whom the CIO reports to, the relationship with the CFO remains essential. I have worked with several over the years, a mix of old school and new school. Here is what I discovered as keys to both personal and organizational success.

Connection. You have to establish a relationship that transcends organization boundaries. Something unique happens when you break bread together. Get out of the office with your CFO at least monthly for breakfast or lunch. Or, if you both enjoy working out, then a few-mile run or a one-on-one basketball game may be the answer. The point is to get out of the office and get acquainted on a personal level. A healthy foundation sets the tone for a thriving work relationship.

Collaboration. One way to supercharge the relationship is to join forces on an initiative or project, ideally one that benefits the organization and is important to the CFO. Welcome proactive ideas on taking costs out or leveraging technology to increase revenue. i.e. redesign processes to enable a faster month-end close or any technology to accelerate cash collection. Suggest working together to ensure Meaningful Use achievement. Don’t wait to be asked. Be the first to anticipate and reach out.

Knowledge. Learn everything you can about finance. Take courses and read what the CFO reads. I attend HFMA conferences and read their periodicals. Participate in finance webinars. Speak their language and understand what is important to them. How do they measure their success? What are the key benchmarks, and are they up or down?

Execute. Do it well. Never undertake anything halfway. With finance, precision is the standard, and you cannot afford to miss a commitment. If you cite a number or percentage, hit the mark exactly.

Trust. Be good stewards of your finite resources. Be transparent and accountable. Have a finance person on your team to assist with budget oversight. Ensure that your governance process has a closed loop process where you measure baseline and ROI achievement, and then report on it. If you say a new application will reduce costs or increase revenue, then ensure the specific budget is updated to reflect this. Conduct a zero-based budgeting exercise and review every budget line item with your managers and finance. Trust takes time and relationship.

Shared Vision. Once you establish the relationship and build trust through collaboration and execution, you can then arrive at a shared vision for the role of technology in your enterprise. You need the CFO’s support to be successful, and he or she needs yours. Give the CFO every reason to be enthusiastic about endorsing the direction of IT to ensure a commitment of resources available over multiple years.

The benefits of a strong CIO – CFO relationship are many and lead to a stellar organizational ROI. I have multiple examples of how the support of the CFO helped me fulfill the shared vision and positively impact the organization’s quality of care, patient safety, and business growth. Everything from financing critical infrastructure, implementing EHRs, obtaining Meaningful Use, or starting new businesses.

Some of you may be saying, “But you don’t know my CFO. He starves me deliberately.” Actually, I’ve worked with both types, the backward-thinking and the progressive. I feel your pain. But don’t let the die-hard keep you from making your best effort. If nothing else, your character and strength will improve. Be proactive for the sake of organizational success. Be relentless and keep developing the relationship.

That intimidating CFO? He turned out to be quite personable and of excellent character. I was so impressed that I asked him to be my formal mentor. He accelerated my growth. He pushed me to new heights personally and professionally. I moved from corporate director to CIO because of his influence.

Leverage these ideas and ensure your relationship is not sub-optimized. Accelerate quickly at full throttle. Balls to the wall!

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

News 4/20/11

Top News

CMS’s EHR Incentive Program attestation process is live.

Sad news: industry longtimer Marc Holland died suddenly on Saturday, April 16, 2011. He joined HIMSS as VP of market research four months ago following positions with System Research Services, several market research firms, and Montefiore Medical Center. He wrote a nostalgic reflection of his 30+ years as a HIMSS member in January, including his optimism that healthcare IT’s future is bright. Marc Holland was 62.

Reader Comments

From Petra: “Re: first-day Meaningful Use attesters. Why aren’t more vendors promoting customers who have successfully registered? They’ve hyped this for a year, so I would expect a flood of news. Where’s the beef?” I haven’t seen anything mentioned. It may not be all that newsworthy, but you know at least some of the rags would run the story anyway and vendors don’t usually turn down free PR.

From HIS Fan: “Re: UW Health (University of Wisconsin health). Announced yesterday that CMS has accepted its Meaningful Use data for Stage 1 as submitted. They are an Epic shop and achieved Stage 7 last year.”

 From Dr. Victor EHRlich: “Re: Epic’s mammography module. Two customers are planning to de-install in favor of niche vendors.” Unverified.

From WildcatWell: “Re: Dell’s aggressive EMR marketing efforts. I called and the phone kept ringing and ringing, redirecting a caller to sales and then ringing … well, I stopped after five minutes. How do you think support calls will be handled?” I tried the number and it was not necessarily a pleasant PBX experience, but someone did pick up after six rings or so. I’m not listing the number since someone will surely shriek that I’m pandering to a sponsor (via Dell’s acquisition of InSite One), but it’s easy to find. I would try again since maybe you just caught them at a bad time.

From Kerplunk: “Re: Zite for the iPad. It’s a content discovery app that I’m in love with and it’s free.” It’s a personalized magazine that gets smarter as you use it, the developer says (and the 4+ rating seems to indicate that users agree). One of my first and favorite iPad apps was Flip, so I’ll try Zite to see if it’s similar.

From Susan: “Re: Concerro. They released a video at AONE that is racist, a takeoff of the Apple vs. IBM commercial in which a disheveled black woman represents paper scheduling and a well put together represents electronic scheduling. As a black nurse, I find this reprehensible.” I watched the video and didn’t have that reaction since companies can never seem to please everyone with their well-intended attempts at representing diversity or by just treating everyone (like actors) equally. However, since I’m seeing it through white male eyes, I invited Concerro to respond.

Thank you for taking the time to express your concern about our new video. The Concerro marketing team went to great lengths to find the best actors for each of the roles in all of our videos. Our “paper” actor was selected because she played an excellent frazzled nurse and a younger person was needed to play the role of a “less experienced” nurse. It’s unfortunate that this has been taken out of context and we sincerely apologize for offending anyone. Concerro stands by these videos and we are proud of our actors.

 From NonCredentialedTechie: “Re: from Slashdot. The head of a clinical division at an academic hospital sets up his own server at work, asks IT to allow people to access it through the hospital network, and is ‘taken aback’ when they say they’ll need an account on his server. The best part are the comments.” I love this, even though it may be a troll and not a real clinician writing it. The author claims he’s miffed that IT isn’t thrilled about his server and says he’s considering “taking this up the chain” and asks readers if they think he should give IT an account. Here’s the best response from the many hundreds posted:

What you’ve done would cause any professional IT group to get out the hot tar, feathers, and rail. Or at least come into your office and ask you politely to remove the damn server from their facility. And never do this again. You must have missed all the security briefings, the issues with HIPAA, and whatnot when you were looking at systems. What you’ve done is to create a ‘rogue system’. Imagine one of your kids sets up a server in your house. You don’t understand it, you don’t know if it’s happily sniffing network traffic to steal passwords so pizza can be ordered using your credit cards, serving up pr0n, or just running minecraft. Would you willy nilly allow the kids to open a port on your firewall without the ability to audit what they’re doing ? Of course not. Personally I’m amazed that they only asked for an account on your little server. I would have gone over and watched while you removed it from the facility and put in in your car.

HIStalk Announcements and Requests

  Listening: new Foo Fighters. I never paid them much attention, but I should have … Wasting Light sounds great first time through. It was recorded directly to analog tape in Dave Grohl’s garage, yielding a sound that I nostalgically remember as “music” before lesser talents hijacked the term sometime in the late 90s to define computer-created dance tracks. This is amazingly good and gets a rare highest recommendation from me.

Acquisitions, Funding, Business, and Stock

Cerner is one of six companies profiled in a new video series by the Small Business Administration. Cerner vice chairman and co-founder Cliff Illig shares details of how he and fellow entrepreneurs Neal Patterson and Paul Gorup created the company in 1979 and how Cerner has evolved over the last 32 years.

Healthcare disclosure management provider MRO Corp. acquires the assets of Keystone Management Solutions, a provider of release of information services.

Community Health Systems files a motion to dismiss the lawsuit filed against it by Tenet Healthcare, which claims CHS admits ED patients for purely financial reasons. CHS, whose December bid to buy Tenet for $5 per share in cash and $1 in stock was rejected as insufficient, changed its offer to a $3.3 billion all-cash offer, saying that move eliminates the basic for Tenet’s lawsuit against CHS, which alleged securities fraud. This pair is like hot-blooded lovers who can’t decide whether to kill each other or to make passionate love (or maybe both simultaneously). I think I’d be cautious about waving $3.3 billion in cash around right as the public tries to figure out where to cut healthcare costs.

Sales

HealthInsight selects Axolotl’s Elysium Exchange infrastructure for the Nevada HIE.

Physician management services organization TeamPraxis (HI) chooses Microsoft Amalga to facilitate the sharing of patient information.

Presbyterian Intercommunity Hospital and Bright Health Physicians (CA) will implement the Shareable Ink documentation system as part of its rollout of Allscripts Enterprise PM/EHR.

Five hospitals in Canada will implement order set management tools from PatientOrderSets.com, increasing the Canadian vendor’s client list to 140 hospitals. The company changed its name from Open Source Order Sets in January, explaining that its collaborative network is cloud-based, but not open source in the software development context.

Lutheran Medical Center (NY) contracts for Service Desk healthcare-specific IT help desk services from CareTech Solutions. The company started up 24×7 services within three weeks to support Lutheran’s EMR rollout.

People 

University HealthSystem Consortium (IL) hires Mike Hebrank as VP and CIO. His previous employers include Helix Health and Greater Baltimore Medical Center.

Announcements and Implementations

  Seventy Hawaii physicians on the island of Oahu form Health Information Helping Others (HIHO) as a pilot project for the Hawaii HIE. HIHO will use Wellogic’s Direct Project technology for data exchange and secure messaging. Got to love the happy acronym, which is far less cynical than some of the ones that recently concocted by Mr. H (HCRAP comes to mind).

Roche introduces a new EMR interface for the VA that transmits patient diabetes data into the VistA computerized patient record system. JResultNet allows providers to automatically transfer patient blood glucose test results from the ACCU-CHEK 360 Diabetes Management system to VistA.

Thomson Reuters announces Micromedex Drug Interactions for the iPhone. It’s free to Micromedex customers, $50 per year otherwise.

PenRad announces plans to develop the next generation of its PenVasc Vascular Data Management System for vascular labs.

General Dynamics becomes the first healthcare application service provider host to earn HITRUST certification, which documents that its hosting service meets HIPAA and HITECH security requirements.

Government and Politics

Lawmakers in Maine are considering legislation that would give patients the ability to control what portions of their medical record could be included in the state’s HIE.

Without any clear explanation, ONC extends the comment period for the Federal Health IT Strategic Plan: 2011 – 2015 from April 22 to May 6. Comments can be made or reviewed here.

The Kansas Board of Pharmacy will require pharmacies to use the NPLEx system, which alerts store personnel when customers try to buy products like Sudafed from multiple locations to skirt sales limits imposed to thwart methamphetamine production. The system is provided nationally by the National Association of Drug Diversion Investigators and paid for by the drug companies whose products are involved.

Innovation and Research

A BBC article says that governments like Britain’s spend billions on ambitious electronic medical records projects, but small upstarts are tackling much smaller problems with greater success. The CEO of a company that offers a smart phone-based communication system says that hospitals have spent a fortune on IT, but caregivers still can’t monitor patients with it. “Cans of tomatoes are being treated better than patients,” he says, referring to the more advanced technologies used by the average grocery store. Another company is piloting a cloud-based hospital management system in a 2,000 bed hospital in India, saying that it’s a poor part of a world, but patients there get “more efficient, more high-tech service than patients in the UK” because they didn’t have to work around legacy systems or government policies.

Do you run a small and innovative healthcare IT company? Does it offer a product (not a service) and have at least five employees and one referenceable site? If so, a team of volunteer HIStalk readers and I will consider giving you a national audience right here on HIStalk. This isn’t like a venture fair, where you have to fly somewhere, pitch to an indifferent audience of allegedly interested investors, and then go home with nothing to show for it. We’re offering you the chance to reach HIStalk’s readers directly and at no cost, just because I like to shake things up a little by giving the little guy a chance to earn customers and investors (and because readers keep asking me to showcase those little guys). If your company would like to be the guinea pig, e-mail me and we’ll work through some simple details. I’ll post your story, an interview with you and your referenceable site, and your video pitch.

Old news that I just ran across: MediAngels says it has launched the first 24×7 Global eHospital to serve patients anywhere in India and elsewhere over the Internet. It has 300 physicians, including those from 85 super-specialties, who will render consultations and second opinions. The maximum fee, which is charged only if an international panel of physicians is involved, is $100 US. It claims to meet HIPAA standards (which is says were “enacted by the USA FDA”) and can also arrange medical tourism.

Here’s a fun and interesting video featuring Halle Tecco, a new Harvard Business School grad who founded non-profit HIT accelerator RockHealth (mentioned here last week) with medical partners Mayo Clinic and Cincinnati Children’s Hospital. “I didn’t even go to Recruitment Week or apply for any of the big jobs because I knew it could be really tempting because they pay probably like five times as much as I’m going to make, but at the end of the day, I’m more concerned about doing something interesting and meaningful with my time on this earth, whether that’s right out of business school or ten years down the road.”

Other

Ten percent of ambulatory providers are switching PACS or RIS vendors due to market consolidation or poor vendor performance, according to a new KLAS report. KLAS also noted that providers will generally forego some functionality for solid PACS/RIS integration, though single-side vendors do well in their respective markets. Intelerad IntelePACS was the highest rated PACS and MedInformatix the top RIS.

The Rhode Island Board of Medical Licensure and Discipline reprimands a physician who posted details of her ER experiences on Facebook. The postings did not include any patient names, but the nature of the injuries described allowed at least one person to identify a patient. Alexandra Thran was found guilty of unprofessional conduct and ordered to pay a $500 administrative fee.

American Medical News runs an interesting question on its Ethics Forum: is it ethical for doctors to use their IT systems to “cherry pick” or “lemon drop,” meaning choosing only the healthiest patients to maximize pay-for-performance money while increasing costs overall? It gives interesting examples of Medicare HMOs, which have been caught recruiting only patients from affluent areas and discouraging sick patients from re-enrolling by charging high co-pays for dialysis and cancer treatments. It theorizes that the EMR could be a powerful profit-making machine since doctors could theoretically just drop patients whose performance targets would be difficult to meet. It’s an interesting article — if a system can be gamed, you can bet it will be, both legally and illegally (see: tax laws).

 Sponsor Updates by DigitalBeanCounter

• Vitalize Consulting Solutions held its all-company meeting at Hyatt Lost Pines Resort in Austin, TX earlier this month, including a build-a-bike team exercise that surprised 34 children of the local Boys and Girls Club with brand new bicycles, hlemets, and locks.
• Nathan Littauer Hospital (NY) selects ProVation Order Sets as its electronic order set solution.
• Cumberland Consulting Group promotes Amy Meiners to principal.
• Presbyterian Intercommunity Hospital and Bright Health Physicians (CA) sign an agreement to deploy Allscripts Enterprise EHR and PM solutions. The ambulatory systems will integrate with the hospital’s existing Sunrise inpatient EHR/RCM system.
• St. Joseph Health System (CA)  will implement MedPlus’s ChartMaxx electronic document management product.
• Cognify, Inc. selects Greenway’s PrimeSUITE to further integrate and advance its Web-based participant tracking system that monitors care plan continuums.
• The Rules-Based Charging solution of Surgical Information Systems earns the “Peer Reviewed by HFMA” standard for the fourth consecutive year.

Contacts

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

Awarepoint Acquires PCTS

Real-time location system vendor Awarepoint announced this morning that it has acquired Patient Care Technology Systems (PCTS), a vendor of software that helps hospitals track people and physical assets. Terms were not disclosed.

Charlotte, NC-based PCTS has 60 hospital customers that include New York-Presbyterian, Advocate Health Care, Providence Health & Services, and Aurora Health Care. It will continue operating from its current office, with the PCTS executive team reporting to Awarepoint CEO Jay Deady at the company’s corporate headquarters in San Diego.

Deady was quoted as saying that the combined solutions will allow the company “to capitalize on an enormous untapped RTLS market” in which US market penetration is estimated at 10-12% and around 5% internationally. The company’s value proposition includes reducing medical equipment rental costs, reducing procedure time and nurse labor involved with in locating needed equipment, and ensuring that equipment is correctly reprocessed between patients.

We spoke to Jay Deady on Monday after running a rumor from RTLS Battle predicting that the acquisition would be announced this week. He said Awarepoint’s 93 hospital customers, having realized significant return on investment from the company’s asset management and tracking capabilities, were pressing the company to move quickly into patient workflow solutions that can support discharge planning and real-time monitoring.

“Integrating a workflow engine into our software and building out the workflow library was going to take 18-24 months,” he told us. “At our recent user meeting, our customers told me they are ready to go right now. Awarepoint and PCTS have three shared accounts — Christiana Care, Aurora, and Advocate Good Sam. I visited those clients and got rave reviews about PCTS’s workflow engine and content library. It just seemed logical to meet the needs of clients in accelerating to market and not taking two years to develop.”

Deady says that completing the transaction required “a very fast close” due to competing bids from private and publicly traded companies and a private equity firm.

PCTS’s relationships with other RTLS vendors will continue, Deady told us. “This is not a one-size-fits-all environment. We will continue to work with other technology partnerships. A lot of our clients were asking us about other RFID technologies, such as passive RFID for inventory tracking. PCTS has an RTLS integration engine and can integrate that in being able to play well in the sandbox with other active and passive players. That was a big decision point for us to merge with PCTS.”

Deady summarized the benefit to customers as being similar to the consolidation of hospital clinical systems starting in the late 1990s. “Customers don’t want to go to different companies for technology, inventory management, asset management, hand hygiene, and temperature monitoring. Up until a year ago, a hospital that wanted to deploy all these technologies would be doing business with seven or eight different companies. Our goal in merging with PCTS is to give them one place to go.”

Curbside Consult with Dr. Jayne 4/18/11

I try not to waste too much time on the Internet, but keeping an eye out for interesting stories on health and technology is an occupational hazard. How could I not read a piece with the headline Playboy Mansion Illness Traced to Hot Tub Bacteria when it crossed my screen? Apparently our old friend Legionella (the bacteria that causes Legionnaires’ disease) was found in a hot tub at the Playboy Mansion after scores of visitors were sickened.

As if a story about hot tubbing with Hef isn’t tawdry enough, epidemiologists were no doubt engrossed when the case was presented last week at the Centers for Disease Control’s annual conference in Atlanta. So what does this have to do with health and technology? Well, it seems that epidemiologists used social media to contact the 400+ people who were at a fundraising event where they came into contact with the bacteria.

In other news, the Associated Press reports that Odd Work Schedules Pose Risk to Health. From my experiences as an intern and resident, I could have written that one — it’s not good for the caregivers or their patients. According to Dr. Charles Czeisler, chief of sleep medicine at Brigham and Women’s Hospital in Boston, 30-50% of night shift workers admit to falling asleep at least once a week while working.

Although the article highlights findings related to recent issues with air traffic controllers snoozing on the job, the facts play to all of us in healthcare and IT, also. Czeisler states that taking work home on BlackBerrys and computers as well as the 24×7 availability of work and entertainment options contributes to sleep issues.

Somehow I missed this in my recent studies for my medical board recertification exam, but night shift workers are more likely to have chronic intestinal and heart diseases. Apparently, the World Health Organization has also identified shift work as a probable carcinogen. Not good news for those of us in the business of 24×7 technology and patient care activities, or the patients either. Having been sleep deprived for nearly five years during my training, I understand the near misses (and sometimes real misses) that can happen in the middle of the night when the thought process starts to get fuzzy.

These types of situations are great for employing technology as an additional safety net for our patients. Long hours aren’t going away (nor are distractions, overloaded schedules, nursing staff burdened with regulatory nonsense that detracts from patient care, or any of the other dozens of things that impact clinical decision-making). But well-placed clinical tools (like the Thomson Reuters tools mentioned by Dr. Gregg on HIStalk Practice)  can really make a difference.

Personally, I’d much rather have my anesthesiologist calculating drugs and dosages in a well-crafted electronic record than doing equations on the leg of his scrub pants (which, thank goodness, I haven’t seen in a long time). However, the systems have to be well designed, easy to use, and accurate if they’re going to make a difference. Users have to commit to attending training, using the system properly, and not short-cutting steps. IT teams have to keep the systems available (not to mention happy and healthy) continuously. Otherwise, make sure you have your scrubs on — and your favorite ballpoint pen.

E-mail Dr. Jayne.

HIStalk Interviews Carlos Nunez MD, Chief Medical Officer, CareFusion

Carlos Nunez MD is chief medical officer of CareFusion of San Diego, CA.

What led you take the CMO position at CareFusion?

I was with Picis for almost 11 years. My title there was chief physician executive, which was essentially the CMO of Picis.

My background in medical technology and information technology goes back a little over 20 years, all the way to the time when I was still practicing medicine and even into my training as an anesthesiologist and as an intensivist. I guess being at Picis automatically type-cast me as being an informatics person, but my interest and my background really is more than just healthcare IT, but healthcare technology, of which I think IT is a very important part.

When you look at what’s happening in healthcare right now — I probably don’t have to tell you — healthcare is notorious for embracing fads. More than ten years ago, when the IOM came out with the report, To Err is Human, everybody was all about safety. When Leapfrog said CPOE was necessary, everyone was all about CPOE. A year or two ago, it was RHIOs. Six months ago it, was HIEs and Meaningful Use. Now healthcare reform has got everybody all in an uproar about ACOs.

When you see what’s happening in healthcare beyond the fads, and you look at the themes that have persisted for the last 12 years or so, it’s this focus on quality, safety, cost, and efficiency. Regardless of whether you’re talking about an ACO or an HIE or Meaningful Use, those are the themes that continue to rear their heads in everything that either is a fad or a discussion or the theme of the moment.

I think technology is perfectly positioned to help, specifically with American healthcare, but global healthcare deals with these challenges and attacks these themes. Looking at American healthcare in the context of healthcare reform right now, the challenges are the same. It’s decreasing levels of reimbursement and revenue to hospitals and the individual providers. Healthcare reform is trying to squeeze out $400 to $500 billion in savings from Medicare over the next ten years. The aging population, the decreasing resources — whether you’re talking about the nursing shortage or the shortage of primary care physicians to the consolidation of hospitals and practices — technology is perfectly positioned to help with a lot of these problems and changes.

When I looked at the opportunity at CareFusion, I found a company that I felt was perfectly positioned to address these challenges with a very, very unique set of solutions. What I did in my former company was focused on pure IT. It was software and solutions. But using that as an example, our software worked best when it was connected to an anesthesia machine; when it was communicating to a physiologic monitor; when it was getting information from a balloon pump or an infusion pump or a pharmacy system. There was more than just a pure healthcare IT play going on.

There was what I like to call this hidden kingdom of healthcare IT. That’s the medical technology. Information technology only works when it’s full of information, when it’s full of data. Most of that data comes from the patient. In the high-acuity areas of the hospital or in the areas of the hospital where patients are the most sick or most vulnerable, more often than not, that data is coming from a device. It could be coming from an infusion pump or a PCA pump. It could be from the pharmacy and the dispensing cabinet. It could be from the ICU, where the sickest patients are connected to all sorts of medical technology. 

When I looked at this opportunity, I saw a company that had products and services aligned with those same themes and those same challenges that healthcare faces. Medication safety and medication management, looking at infection prevention from the standpoint of central line or respiratory ventilator-associated pneumonia, supply chain management, portfolio IT assets, and most recently, the announcement that CareFusion is looking at ways to make hospitals a little more eco-friendly in dealing with the problems of hazardous waste disposal. 

Looking at their technology portfolio and their IT portfolio, I saw an opportunity to work for a company perfectly positioned to make a difference in those themes and in those areas where healthcare needs help.

Some would argue that healthcare IT is still enamored with IT basics, like having someone enter data and someone else pull it back out on the other end. On the other hand, companies like CareFusion were engineering-driven and not very good at developing software, where they were happy just to get relays to click and solenoids to move. Do you see those worlds coming together to help take care of patients?

I do. Before I took this position I was reviewing something that most of your readers are probably very familiar with, the KLAS rankings of the different IT solutions in the hospital space. My former employer had various solutions that were ranked in KLAS, so we watched these things very carefully. At the end of the year, KLAS puts out their Best in KLAS overall IT vendor rankings based on multiple products that KLAS ranks.

Probably no surprise, Epic was ranked Number One as Best in KLAS. Do you know who was Number Two? It was CareFusion, behind Epic by only two-tenths of a point. Number Three was more than four points away from CareFusion. I’m looking at this saying, here is a company that everybody thinks of as Pyxis machines and Alaris pumps who’s ranked neck and neck with the IT vendor that has taken the IT world by storm over the last few years. There must be a reason why.

As I learned more about what CareFusion does, I uncovered the reason. It is exactly what you alluded to with your question. The Holy Grail of what CareFusion is trying to accomplish is exactly what you say. When someone is adopting an information technology solution at the point of care, where someone is documenting care or making note of a lab result or entering something about a patient, how is that going to affect a drawer that opens or pump that’s infusing a medication or a fluid into a patient or a ventilator or some of the other things that CareFusion does? 

Here’s a scenario. Imagine you have a person who is on an anticoagulant and they’re getting PTT and INR studies done regularly. There’s an order to administer another dose of heparin or Coumadin. The nurse is going to follow the order. The lab results come back and their INR is therapeutic or maybe it’s even higher than what you would like. The nurse goes through the dispensing cabinet. They haven’t had a chance to go to look at the patient’s lab results. The dispensing cabinet says, “By the way, you’re about to take out that drug for a Mr. Jones, but I’ve just checked and the lab is saying that Mr. Jones’ INR actually is a little higher than you’d like it do be. Maybe you want to hold off on that dose. Call the physician.” That’s how that interplay needs to happen, and it already does. 

That’s what was surprising to me as I investigated what CareFusion was already about. The part of CareFusion that does a lot of their IT and analytics and surveillance was a company called MedMined that they acquired a few years ago. It was traditionally a company that did antibiotics infection surveillance in trying to improve antibiotic stewardship. It is now expanded throughout CareFusion’s different vertical businesses to provide notifications at the point of dispensing drugs or at the point of administration, regarding things beyond just antibiotic and infection surveillance, but looking at lab results, electrolytes, anything that could affect why or why not you’d want to dispense a drug. That’s just one example, but it’s a great example of that convergence between IT and devices. 

I spoke earlier about data coming from devices to the IT system. There’s an example of data living in an IT system like a pharmacy system or a lab system that’s now affecting the way someone interacts with the device that you wouldn’t traditionally consider part of IT. But think about it. I know you’re a fan of the Apple iPad, as am I. As a matter of fact, in your Monday Morning Update for just this past Monday, you had a little one-liner that AirStrip Technologies was shown in the very first iPad 2 TV commercial. The iPad is a device, the magical device that Steve Jobs has sold us all on. Incidentally, there are still lines every morning outside the Apple store in San Diego to get one, which is incredible to me. The magic of the iPad is it’s a beautiful device and the apps, the IT, and the hardware, together working in an ecosystem that’s very disruptive. 

Using the iPad example, look at how the iPad has just taken the medical world by storm. Doctors can’t stop showing up to work without their iPads. It’s caused CIOs even outside of healthcare, in businesses like here at Carefusion … our CIO’s got to figure out, “How do I integrate these iPads and these iPhones into our workflow? We’re a Windows-Exchange shop.”

It’s the same sort of revolution that I think it needs to take place. People need to recognize that all technology, not just pure information technology or software, is part of the information infrastructure of a hospital and a health system. It is that interplay between devices and information systems that will define how things become more efficient and adoption increases.

You’re right, we get really excited when we’re able to do very simple things. The adoption of technology and information technology in healthcare is behind many of industries. When you find the appropriate way to integrate information, data, actionable knowledge at the point of care, wherever that happens to be — whether it’s on the screen of a device or on the screen of a workstation — so that it’s less disruptive and more integrated into the very busy workflow of a nurse or a physician, then you’re going to see the adoption increase, the efficiency increase. Things like safety and quality should follow.

When people think of advances in banking technology, they don’t think of what goes on behind closed doors, they think of ATMs and online banking, the sharp end of the stick. In healthcare, nurses are the most vested at having tools, but nobody’s really doing much for them even though they provide most of the care.

Absolutely, yes. I’ll give you another example, because I had this conversation with someone here at CareFusion yesterday. It was the philosophical argument — where does certain information belong? Does it belong in the traditional IT system, or does it belong within a medical device or on a screen that’s part of a medical device? 

I said I don’t think that you can just make blanket statements like that. I think the information, the actionable knowledge that’s going to make a difference at the point of care — like you said, especially for the nurses who really feel the brunt of a lot of this — is wherever it best fits within the workflow.

I know we were talking about nurses, but I’m going to use a non-nursing example because this is off the top of my head. It’s what we talked about yesterday — the respiratory therapist. My former employer had an ICU information system, which is great. I’m an intensivist, loved it. Part of the feature set was that you could create customized flowsheets and a respiratory therapist could look at information on that customized flowsheet.

But more often than not, a respiratory therapist in the ICU walks right up to the ventilator. They’re used to having a clipboard sitting on top of the ventilator where they’ve got information about that patient and then a screen on the ventilator. They’re not going to want to change their workflow and have to go look into a screen.

Imagine if on that ventilator screen, you can see the blood gas results that you’re most interested in, or any other information that makes a difference. Maybe it does need to be on the information system screen. Maybe it needs to be on the ventilator. For me, it should just be integrated into the workflow that makes sense because the biggest problem is adoption — physician adoption, clinician adoption.

Getting people to adopt technology or IT or otherwise is difficult when you ask them to do more stuff. When it’s integrated into their workflow, then it becomes a pleasure to use this stuff.

I assume that the fact that CareFusion hired you is an indication that they’re interested in backing away from that engineering label and getting more into mainstream IT. How do you see that changing what goes on at CareFusion, especially when it comes to healthcare reform?

I think what CareFusion hiring me signals is that they want to take a balanced approach. Not so much that they want to try and become identified as an IT company versus an engineering company. I think they want to take a balanced approach that reflects some of the things that I have been saying — that there is medical technology and information technology working together can have a tremendous impact on quality, safety, cost and efficiency.

That’s the message that they’re trying to send, not just by hiring me, but by creating the portfolio of products and solutions that they have created over the last few years since they spun off from Cardinal. The way they go to market with these strategies and the integration that they are building between their different vertical platforms to show that there is this place where devices and software can play together and play together nicely, creating real benefits for patients and for providers and for hospitals.

I alluded to a couple of things about healthcare reform earlier. We talked about the fact that this is a plan that’s supposed to cost a trillion dollars. That’s what we were initially told — everyone knows that most government programs go over their initial cost estimates. But if we stick to that figure, a trillion bucks, roughly half of that is supposed to be realized through savings in Medicare and other CMS expenditures, Medicaid, etc. 

The ACO rules and regulations were just published. It’s like a fad. We’ve seen this before. You look at the HHS estimates for the adoptions of ACOs, and they’re saying that in their best estimate, somewhere between 1.5 to 4 million lives will be covered within the ACO model by 2014 with savings of roughly $500 million — with an M — dollars.

So they’re saying, “We’re hoping four years into the ten-year plan for healthcare reform we’re going to have maybe four million people in the ACO model.” That’s not even 10% of the roughly 44 to 45 million Medicare beneficiaries that are covered today. Savings of $500 million? That’s not even a drop in the bucket when you’re looking at half a trillion dollars in Medicare savings. 

It makes me wonder why we do this to ourselves in healthcare. Why we elevate these fads and get crazy over them without looking deeply into the facts and say, “Gosh, yeah, this is an interesting thing. Maybe it will end up leading to real savings and real changes in the way we deal with healthcare.” But in the end, it always goes back to the same things. It’s quality, safety, cost, and efficiency.

For me, healthcare reform represents one really important thing. Whether you agree with the way it was enacted, whether you agree with the provisions, whether you think the costs are right, or ACOs are great — and I’m not saying I have an opinion one way or the other — I’m just curious as to way everyone’s so crazy about an ACO model that we’re not yet sure will create significant savings.

What healthcare reform did is announce to the world in a very public way that the United States is finally acknowledging we can no longer afford the system that we have on the cost curve and trajectory that we’ve got. Not only does it endanger CMS and HHS, it endangers the entire federal budget. It endangers the economy of the United States as a country. It’s a very real problem and it’s a big, big part of the discussion that we now see around the Republicans’ new budget proposal trying to cut over five trillion dollars from the federal budget over ten years. This is a big deal. It could bankrupt our government and really make a huge impact on the American way of life, so we have to do something about this. 

Technology is the way that other industries have found the means to become efficient and look at ways to improve quality and safety while becoming efficient and spending less on the things that don’t matter — redundancy and paperwork and overhead and the things that don’t matter. There’s a way that we can refocus healthcare on taking care of patients. I think technology plays a huge part in that.

The last thing I’ll say on my little political diatribe. You know, we don’t have a healthcare system in the United States — we have a disease intervention system. Most Americans wait until something is broken or bleeding or falling off before they show up in the ED and get very expensive care for a problem they should have taken care of years or months before.

I think all of those themes that continue to merge about quality, safety, cost, and efficiency lead us to a remaking of this system in a way that keeps us healthier and tries to avoid getting to the point of disease intervention until it becomes more inevitable. And again, technology — and maybe not even in the inpatient setting — can play a huge role in all of that.

I think that’s what’s important about the ACO model or about healthcare reform or about Meaningful Use. It’s not the few million dollars in incentive payments here or there, or whether or not it’s going to be a million or four million lives covered in an ACO model. It’s the fact that we need to do something to move our healthcare system towards providing healthcare and using technology to become more efficient, to take better care of patients while not going broke in the process.

From my perspective — obviously I’ve got a very inpatient focus perspective as an anesthesiologist and intensivist — a company like CareFusion, from within their perspective mostly focused in the areas of the hospital where things like supply chain management and medication safety and infection prevention — it’s a really, really interesting place to be with all the stuff that’s swirling around.

If you looked out five to ten years, what should technology vendors in general and CareFusion in particular be working on to start to move the needle on patient outcomes and costs?

Five to ten years? Wow, I’m going say a word that is very overused in our circles, but I’m going to try and define what I mean by that. I think it’s a level of interoperability that makes sense.

It’s not just creating interfaces between different systems because they don’t exist now, and maybe we need to have everything tied together. It’s creating an interoperability between medical technology and information technology that provides actionable information at the point of care so that the providers who are being asked to do more with less can make the right decisions, can keep their patients safe, can deliver the highest quality care in a way that is most efficient and most cost effective.

I gave the example of the respiratory therapist or the nurse who’s trying to dispense a medication and it’s contraindicated because of a lab result. The examples go on and on from there, and maybe some of them are very, very clinical and safety-focused. Maybe some examples are more focused on collecting data for retrospective analysis. A patient who’s admitted for a non-infectious disease-related diagnosis and the Pyxis machine notes that they had a central line kit removed, and then three days later, the Alaris pump sends a signal that they’re getting an infusion of antibiotics and there’s no reason why they should based on their diagnosis. Do we now start to see markers for infection? Do they have a central line infection? Can the infectious disease nurse be prompted to go and check on that patient to see what’s going on?

The examples go on and on how you can start to tie devices and information technology to create an ecosystem that is much more efficient than what we have today. It’s not just creating interfaces using HL7 because we think it would be great to connect this system with that one. It’s really creating a web of connected devices and connected systems that allows us to be very efficient in delivering the safest, highest quality care that we can, and saving money in the process.

Monday Morning Update 4/18/11

From RTLS Battle: “Re: Awarepoint. Word is the company outdueled Merge to buy PCTS, a workflow software vendor in Charlotte, NC, with former Allscripts VP Jay Deady (Awarepoint CEO) beating out another former Allscripts VP Jeff Surges (Merge CEO). Deal to be announced next week. Wonder if they’ll split deep dish pizza in Chicago any time soon?” Unverified. PCTS offers the Amelior product line that includes ED and OR asset and patient tracking, hand hygiene systems, and temperature monitoring. They are a business partner of Awarepoint.  

From The PACS Designer: “Re: net collaboration. InformationWeek has compiled a list of the 15 Top Collaboration Apps that promote working together using the Internet. With all that is going on with Meaningful Use, this compilation of collaboration tools is good for institutions who want to progress to the next level of efficiency, which is meaningful structure.” Most of the apps listed involve some flavor of project management in what would have been called a hosted Intranet a few years ago (I guess that’s not a commonly used word these days). I notice that Cerner is listed as a user of Jive Engage (a social media monitoring tool) for its “social network experience,” since the whole point of social media is to sell stuff, of course.

From Katrina: “Re: Healthcare Informatics Executive Summit. I work for a vendor and registered, but was told I needed to either come up with $7,000 of program sponsorship or bow out, which I did. I’m warning other potential attendees about the small print stipulation.” The keynote speakers that Healthcare Informatics won’t allow you see for your $1,095 registration fee are Farzad Mostashari of ONC and Carolyn Clancy of AHRQ, both paid with your tax dollars, so that’s a bit insulting. Maybe you could just register as yourself at XYZ Consulting, pay with your credit card, and put it on an expense report. That brings up another gripe: the registration form requires entry of your job title and employer. Why should someone paying their own registration fee have to provide that information? If my employer isn’t willing to pay for my attendance, why should they (and the conference organizer) enjoy the benefit of having their name on my badge?

From KS: “Re: Epic. Consultant advertisements are popping up at MSN airport. They, of course, also spell it EPIC. Wonder what they think EPIC stands for?” Maybe they’re just shouting the name because they’re so excited about the money they’ll rake in if they can just find some consultants.

From Tango Charlie: “Re: Epic. Duke will announce next week and Wake Forest is suppose to go Judy, too.” Unverified. Duke is going with at least Epic ambulatory, it seems (and as history has shown, hospitals don’t often stop there). Wake Forest (above) was on the list of hospitals attending Epic training for unnamed modules a couple of weeks ago that a reader sent my way.  

Nearly two-thirds of respondents like the idea of biometrically verifying the identity of those claiming Medicare and Medicaid healthcare benefits. New poll to your right: how is the federal government doing against Medicare / Medicaid fraud?

My Time Capsule editorial from 2006: RHIOS Are Taking Away Resources From Better Projects. A snip: “Do you like insurance companies enough to let them control patient information?”

Three free press release tips for you PR and vendor types: (1) always put out press releases in PDF format rather than .DOC, for about a thousand reasons that I hope I don’t have to explain to people who supposedly are experts at media; (b) never put a press release out on a national wire service but not simultaneously on the company’s own site – isn’t that kind of the point? and (c) if you’re going to mention a hospital, include the city and state it’s in. I could add dozens more, but these came up today.

Above is the latest history (is that an oxymoron?) from Vince Ciotti.

Shares in for-profit hospital operator Community Health Systems drop 14% in after-hours trading Friday after the company announces it has been subpoenaed by HHS in conjunction with an investigation of its Medicare and Medicaid billing. Rival Tenet Healthcare, which in December rejected an acquisition offer by CHS, accused CHS of billing fraud in a lawsuit it filed against CHS. HHS wants to review CHS’s ED practices and the algorithms in its Pro-MED ED physician documentation software, which may test that company’s claim that it “Meets and exceeds all CMS Physician Evaluation and Management Documentation Guidelines, ‘maximizing’ reimbursement” depending on how CHS set it up.

CMS is threatening to stop payments to University of Chicago Medical Center after finding that conditions there pose an immediate threat to patient safety. A prominent patient died after a medical error involving a dialysis catheter-caused embolism. Not to be cynical, but oversight organizations react a lot more forcefully when patient harm involves someone wealthy, famous, or the subject of splashy media stories. I’ve worked in hospitals involved in high-profile medical error cases and it was obvious that organizations such as Joint Commission, state hospital inspectors, and HHS don’t like having the hospitals they oversee embarrass them in the press, so their reaction is sometimes overly hostile and critical. I would question the effectiveness of any watchdog group that pronounces conditions dire only after they read about them in the newspaper.

A Rhode Island physician will be in line Monday morning when CMS opens the virtual doors for Phase 1 of the Medicare ARRA incentives. Douglas Foreman DO, a family practice physician who uses the Ingenix CareTracker EHR and its Meaningful Use dashboard, says he has met the 15 Core requirements and seven of the 10 Menu Set items (of which five are required to qualify for the incentives).

UCSF says it’s turning on Epic outpatient, with a price tag of $160 million vs. the originally estimated $60 million due to an expansion of the project’s scope (there’s more to the story I can’t see since I don’t subscribe to the San Francisco business paper).

My new favorite iPad app: the just-released Bing search (the irony of a Google-competing Microsoft app written exclusively for an Apple device duly noted). Not only is it stunning to look at, you touch the microphone icon and can immediately speak your search terms with good accuracy.

The Florid-based developer of the Electronic Medical Assistant software for dermatologists gets a $4 million investment from the British company that owns the Speedo swimsuit product line. Modernizing Medicine was founded by a dermatologist and the co-founder of the Blackboard online learning system used by colleges. The EMA software costs $6,000 upfront and $650 per month. One of its users says he can create 30 notes in 25 minutes.

The military’s TRICARE system team announces that its Blue Button functionality has been expanded to allow users to download include lab results, patient history, and visit history.

A post on Geek.com nominates this as one of the most inopportune times for a Windows update. It’s a picture of a woman’s hospital monitor during labor taken by the dad-to-be, a computer science professor. Perhaps the hospital’s biomed folks should take a look at the device since enabling automatic Windows updates on an FDA-regulated system doesn’t seem like a good idea.

Michael Kirsch, MD, is a pretty funny writer (he even looks a tiny bit like Jeff Foxworthy). His list of Apps I Want includes: “Medical Coding App. This turns your iPhone into a high voltage device, similar to the Invisible Fences that are used to restrain pets to a given area. Tap the App and then place the iPhone in your front pocket. After seeing a patient, if you code higher than you should on your EMR, you will get a light shock. The intensity will increase until you have expressed remorse, atoned and coded properly. I expect that Medicare will provide incentives for using this technology in the coming years.” 

A $5 million malpractice judgment against a Canadian hospital is thrown out when the hospital’s lawyers notice that 321 of the 368 paragraphs of the Supreme Court justice’s ruling were copied directly from the closing arguments of the plaintiff’s attorney. There appears to be some legal debate as to whether the judge crossed some unspecified line or whether that simply means the plaintiff’s legal team did the job they’re paid to do – create sound, well-referenced arguments that, if they win, must have had significant influence on the verdict.

Bizarre: the Texas patient who received the first US face transplant obtains a restraining order and files suit against a British tabloid that insists he sold them his story rights for $2. The man, who lost his eyes in the accident that necessitated the surgery, admits that he signed a document from the company, which told him they wanted to write a human interest story to be run in a women’s magazine. The tabloid has created TV programs that include “Is This China’s Fattest Kid” and “Legless Dancer TV Hit.” Maybe the biggest question is why a face transplant warrants tabloid coverage. How big of a page-turner could it be, especially when Charlie Sheen is out there spreading his Adonis DNA?

The OR of River Park Hospital (TN) goes live on Shareable Ink after a two-week project (kickoff meeting to go-live). They plan to expand its use.

Former iSoft CEO Gary Cohen files proceedings to delay the $188 million sale of the company to CSC, saying the company is required to give his family investment group four weeks’ notice before selling it. He previously said he was considering making his own offer to buy the company.

NPR runs a fun piece criticizing ACOs that includes four ACO jokes: (a) I don’t know how to define an ACO, but I know it when I see it; (b) We have tried ACOs already — they were called HMOs; (c) The three greatest mythical creatures are the abominable snowman, the Loch Ness monster, and ACOs; and (d) the true meaning of ACO is Awesome Consulting Opportunities.

Rochester RHIO says it’s the first HIE to allow patients to upload their advance directives and healthcare proxies so they can be viewed in an emergency.

Everybody’s fighting to protect their healthcare profits, it seems. Case in point: for-profit ambulance companies are fighting with the powerful firefighter’s union over who gets to provide those ultra-expensive (and often Medicare-paid) ambulance rides when people call 911 for whatever conditions they personally deem worth spending someone else’s money on. It would be interesting to study the outcomes of ambulance-transported patients to determine how often their medical needs justified it.

In the UK, designated early adopter Pennine Care Foundation Trust pulls out of NPfIT after years of delays in adding mental health capabilities to iSoft’s Lorenzo.

E-mail Mr. H.

Time Capsule: RHIOs Are Taking Away Resources From Better Projects

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

I wrote this piece in February 2006.

RHIOs Are Taking Away Resources From Better Projects
By Mr. HIStalk

I’ll confess that I’m paying minimal attention to the RHIO craze. Everybody’s starting one, conferences are showcasing speakers who’ve done nothing more than announce theirs, and tiny grants are getting the whole industry atwitter. It’s like living the dot-com frenzy all over again, irrational exuberance and all.

I’m not against RHIOs, but they’re as annoying as CPOE was awhile back, taking resources away from projects that could provide more benefits to patients without the minefields.

I recently interviewed Denni McColm, an award-winning CIO of a 74-bed rural hospital no different than 80 percent of those out there. Oh, except that they’re 100 percent paperless and 100 percent CPOE, something virtually none of the celebrity CIOs and Taj Mahospitals have been able to accomplish. I’ll listen to her, thanks.

First, Denni believes that organizations should be banned from using the word “interoperability” until they can bring their own electronic information to the table. If your IT house isn’t in order, RHIOs don’t need you. Anything short of everyone contributing information equally will cause the whole concept to collapse like an imploded 1960s Las Vegas hotel, so paper jockeys need not apply.

Work instead on projects that will help your patients more than the begrudging swapping of routine lab reports with your cross-town competitor. Or, integrate all those systems you already have. Your admission ticket should be a checklist of what data elements you can supply electronically right now.

Second, Denni advocates a patient-centric RHIO model instead of the common payor-centric one. Do you like insurance companies enough to let them control patient information?

By patient-centered, I don’t mean personal health records. People are too irresponsible to reliably collect and store data with life and death importance. On the other hand, they could be given control over the trusted information generated by hospitals, physician practices, and other providers.

Suppose information resided in an Al Gore-type lockbox that contains everything from discrete electronic data to scanned documents fed over the Internet. Either the patient controls the key (similar to a password) or only they can initiate data delivery to a provider. If they don’t want you to see it, you won’t.

This model makes most privacy concerns go away. It avoids the largely unsolved problem of how you assign some sort of universally mandated patient identifier (aka “political suicide”) to sort out the throngs of people sharing the same name. The patient simply says, “send my data to Dr. Jones” and it’s done. They keep control and there’s no arbitrary “regional” service area beyond which lies a medical no-man’s land.

Maybe some RHIOs work this way. Like I said, I don’t follow them. And, if I can’t see a quick and obvious patient payoff, I probably won’t start following them any time soon. I’ve got plenty of challenges working on clinical system projects that will hopefully save lives right now.

HIStalk Interviews Ritu Agarwal, Director, Center for Health Information and Decision Systems

Ritu Agarwal, PhD is Professor and Robert H. Smith Dean’s Chair of Information Systems at the Smith School of Business of the University of Maryland, College Park, MD. She is also the founder and director of the Center for Health Information and Decision Systems (CHIDS), a research center within the business school.

Give me some background about yourself and about your organization.

I’m a professor of information systems at the Smith School of Business at the University of Maryland. I’m also the director of the Center for Health Information and Decision Systems. I established the Center in 2005 before health IT became trendy.

The mission of the Center is to investigate how technology can be used to transform healthcare fundamentally. We’ve been involved in doing research for the last six years or so on this topic. We work with a variety of partner organizations from the business sector, the government sector, and not-for-profits.

I saw on your Web site that you are working on a number of projects. What are the top two or three?

In our portfolio, we have a couple of projects around health information exchanges, which I think are extremely exciting and important. One is a project with the District of Columbia Regional Health Information Organization. We spent about a year doing an assessment study, which involved a wide range of data collection from different stakeholders. Based on that, we developed a generalizable model that can be used to assess any health information exchange.

We’re currently still engaged with the DC RHIO in helping them evaluate the usability of the technology and the value that it’s generating for all stakeholders. This is going to be an ongoing effort as more and more people join the collaborative and more hospitals and clinics come online.

The second project, which is just getting kicked off, is part of the Office of the National Coordinator’s Health Information Exchange Challenge Grant. We’re working with the Chesapeake Regional Information Systems for our Patients. That is the Maryland health information exchange. They’re in the process of rolling out an intervention which involves direct integration between acute care in long term facilities for exchange of continuity of care documents as well as advance directives. 

We are responsible for the research around the assessment of this particular intervention. We’re comparing how quickly the information can be transmitted, whether it’s reducing hospital readmissions and a host of other outcomes across the set of intervention hospitals compared with a pilot group of hospitals. I think both of these projects are going to provide some important insight into how health information exchanges can be used to deliver more value into the healthcare system.

We’re also working with the eHealth Initiative. They collect data from health information exchanges every year as part of their annual survey. We’re doing some econometric analysis to understand what the predictors of health information exchange sustainability and operational maturity are. We’re looking at financial break-even and looking at what specific aspects of the business model and the revenue structure help predict whether the exchange will be sustainable or not.

Are people showing interest in your findings? How would you intend those findings to be used?

Yes, absolutely. I think they have a lot of implication for how health information exchanges are going to structure their business models in the future. The grant money is going to run out — it’s not infinite. 

Clearly there are examples of health information exchanges that have managed to attain some level of sustainability. The Delaware case is one example. Vermont is another example. They have specific revenue structures and business models that provide some kind of value to all the participants that motivates them to join the exchange. Certainly this is going to be an important aspect in the future.

In terms interest in our findings, I would certainly think so. We made a presentation at HIMSS last month on the DC RHIO evaluation. There was a lot of interests in that. Several people have requested a copy of the report. We’re just in the process of working with the HIE to put out a policy brief on some of our findings around their data, and I think there will be significant interest in that as well.

Another project listed was AHRQ-funded research on EHR usability. What thoughts do you have about that in terms of EHR adoption?

I have interacted with a lot of doctors in the last five or six years around this whole notion of EHR usability. I’ve also seen so many of the products that are out there in use and my own research in the past in usability and other domains. I’ve done research around Web site usability for the retailing industry, for example.

Suffice it to say that usability is probably one of the most important factors that drives any individual’s adoption, especially when you think about how these products are going to be used. Many of them might be used while the doctor is actually interacting with the patient. The last thing you want is the workflow to be awkward or in any sense disruptive in the doctor-patient relationship or engagement.

The answer to your question, “Is usability important?” is a resounding yes. One of the things that we are doing in this project is developing a very simple usability toolkit that physicians can use in an ambulatory setting in the physician offices to figure out whether their EHR is working for them or not. If it isn’t, what specifically they might be able to do in terms of either changing their workflow or making some modifications to the EHR. 

I think it’s going to have a big impact. ONC has significant interest in looking at the usability of EHR products. That’s going to become an important criteria in their certification processes as well. It’s not just the functionality, because all these products are loaded with lots and lots of functions. They probably have a least 80 or 90% overlap in functions, but there’s a lot of variation in usability.

Usability as a condition of “do you want to buy this product” is one thing, but what about usability in the context of “are patients safe based on sound usability principles?”

Both adoption as well as safety are the two important outcomes. I’d say safety trumps adoption. Clearly if the physician is not able to interpret the information that’s coming out of the EHR, or if the EHR is awkward to use in an emergency situation when it’s absolutely imperative to get to the correct information, then the patient safety compromise is completely unacceptable.

But even if the EHR was being used more in a non-real time fashion, just simply to record data after the interaction with the patient is over — even then, usability becomes a concern. It has an implication for how much time the clinician, whether it’s a physician or nurse assistant, spends in updating and accessing information. It’s supposed to make them more effective as well as more efficient.

Are you studying anything related to using government incentives to encourage providers to adopt technology they didn’t want and how that might impact their chance of success?

One of the studies that we’ve done has been around this whole notion of physician identity and how that’s changing as a result of technological innovations and the ARRA mandates and pressure from the government and other important agencies. It is eventually in the interest of the entire system and all the stakeholders if physicians willingly adopt this technology, rather than believe that it’s being something that’s being imposed on them. There has been lots of prior research documenting misuse, ineffective use, sabotaging of this technology when individuals perceive that it’s not their volition or choice to use it. 

The important thing is in the messaging and marketing around these technologies. There has to be a very clear articulation of value to everybody who’s required to use it.

One of the things that we have not been able to do very compellingly yet, which we’re trying to do, is to be able to walk into a physician’s office and say, “Look, here are some reasons why this technology is going to make your life better. It’s going to improve your effectiveness. It’s going to help you take care of your patients better. It’s going to help you improve patient safety. It’s going to help you improve effectiveness,” 

In other words, there’s not enough evidence yet around the value of electronic health records and such technologies. But one recent study that came out of the Office of National Coordinator which was published last month in Health Affairs seems to suggest that now the evidence base has started growing. I think now we have a better story to tell.

That study had some problems, being a meta analysis written by folks who clearly had a bias. And hospitals, where employed physicians were already mandated to use electronic systems, haven’t seen the kind of numbers they hoped on raising quality or lowering cost. Is an interest of  yours proving the value of these systems?

We have a lot of interest in proving the value of these systems. As with every other research organization, we are limited by data availability. We have started on some specific granular studies around individual systems in hospital as well as physician practice settings.

For example, we did a study at Children’s National Medical Center, early findings from which were also presented at HIMSS, with a group of pediatric physicians looking at the readability of clinical documentation system and how much that improves readability over just regular handwritten notes. So you know, those are more micro-level studies. We have several of those ongoing. 

But we also have some studies at the hospital level, where we’re using some of the HIMSS data and combining that with quality measures to try and establish if there is a relationship between different types of information technology investments that the hospital makes and different measures of quality. But it’s going to take a few years before, as a community, there’s enough understanding and data for these affects to start appearing.

I should also point out very quickly that we had similar issues around information technology in general at the turn of the century. There was a very famous economist who said, “You see computers everywhere except in the productivity numbers.” It took a while before there was enough macro-level data to be able to establish that causal link. I think we’re getting there, but I’m not going to say in the next one year we’ll have the definitive answer on health IT value.

That makes it tough to sell a small physician practice since it involves a leap of faith.

Many of their concerns can be allayed with the appropriate kind of assistance and help. There is a learning curve, but they’re not horrendously difficult. Sometimes you get overwhelmed with the complexity of an EHR system, but I think there’s ways to help doctors assimilate it into their workflow.

Part of it is that there has to be a clear understanding of how both the technology and the workflow need to evolve to fit each other. What ends up happening is that the doc sees the technology and then says, “OK, here’s how I do my business. Here’s how I do my all my clinical work and administrative work.” That’s almost like a square peg in a round hole.

You’ve done some work with personal health records. What’s your feeling on where those are and where they’re going?

My own personal opinion is that this next generation of healthcare consumers that’s going to enter the system in the next decade or so … it’s almost a cliché now, it’s a very highly technologically savvy group.

I think personal health records have a big role to play in how people take the control of their own health and wellness and well-being. I personally believe that personal health records or some equivalent is going to be a significant application in the next five to seven years. The question remains is, how should these applications be designed so that they have the same level of exponential growth in adoption as in something like a Facebook?

Has anybody studied what it would take to motivate consumers to use personal health records? They don’t seem very interested.

One of the ARHQ-funded projects that we’re currently working on is learning best practices and principles from the design of other consumer products that can be applied to health IT. We’ve identified 24 highly successful products in other domains. We’ve been examining their development methods and processes that have been used in their construction, their fee, what are some principles and best practices that could applied to consumer health IT as well.

I’m also currently involved in a project with the Air Force medical system and personal health record to users at one of the major Air Force bases, 40,000 users. What they’re discovering in the early stages of the research is that the consumers love it. They love it, they are delighted with the idea that have access to their personal information, that they can update their medications and allergies and everything else. That product is slowly being extended with different kinds of devices to help them monitor their blood pressure if they are hypertensive and various other services depending on their disease condition. I see a growth in personal health record type of technology — consumer health IT in general.

If you could work on any healthcare IT project that would have wide impact on both cost and outcomes, what work would you undertake?

I think I would love to study the comparative effectiveness of health IT interventions. There are resources and funding for that available, but I think a better understanding of how these health IT interventions are assisting people with managing their disease conditions as compared with traditional therapeutic regimens.

Let me just give you an example. We all know that social networks and social influence plays a major role in how people take care of themselves. The moment you use health information technology — or any information technology, for that matter — to connect up people in social networks, suddenly you have the exponential effect of a lot more influence on the focal person. It would be fascinating to study how those types of interactions, social interactions, coupled with health IT stack up in terms of critical effectiveness and cost of care, as compared with just traditional therapeutic regimens of, “Take this prescription for 20 days.”

A lot of interesting work and has been coming out of Kaiser since they have the captive audience of users. I would think that’s a pretty rich mine of data to look at if you could get at it.

Absolutely, yes, that is an amazing repository they have. We’ve had some conversations with Kaiser in this regard, but we’re not quite there yet in having access to the data.

Do you have any concluding thoughts?

I’m quite a passionate believer in the importance of health information technology interventions. I think they can help healthcare achieve many of the goals that they’re all trying to achieve of being safer and more cost effective. I also think that the system has a major problem with the incentive alignment now. Health information technology can have an impact only when it’s coupled with other complimentary changes at the system level — some alignment of incentives around payment reform, some around insurance reform. That has to take place for health IT also be influential.

News 4/15/11

Top News

Healthcare IT is one big reason that private practice docs are taking down their shingles and going to work for hospitals, according to experts interviewed by The New York Times. Unlike the Hillarycare era, there’s no turning back this time since reimbursement is encouraging that kind of vertical integration. The predicted result: less competition, leading to higher prices (although Kaiser is a mentioned as a disrupter in offering cited higher quality at lower cost). The experts seem pretty sure that quality will improve (like in Mayo or Kaiser, with salaried physicians), but not so sure costs won’t go even higher.

Reader Comments

From Hypocrisy: “Re: Judy Faulkner. She was quoted as saying at an ONCHIT Policy Committee meeting, ‘What is showing up in blogs — I have seen and sometimes been told about this — is that we have to be careful of an apparent conflict of interest. That is if, in fact, the primary spokesperson for PCAST does have products that would benefit tremendously by this, do we get into — and I know we’re not supposed to judge — the uncomfortable position of an appearance of conflict of interests.’ She’s apparently talking about Microsoft’s Craig Mundie, discussed a lot on HIStalk as a PCAST committee member. Presumably she does not see a conflict of interest herself in serving on the committee.” I didn’t see the quote, but it’s interesting if accurate. Just to clarify for those who don’t follow the confusing cast of government players, Judy wasn’t actually on the PCAST committee that made recommendations to the President that pretty much had HealthVault or Google Health written all over them – the only for-profit company employees on it were Craig Mundie from Microsoft and Eric Schmidt from Google. Judy is on the HIT Policy Committee, which has for-profit members from Kindred Healthcare, WellPoint, Gastroenterology Associates (a private doctor), and Epic (Judy). I wouldn’t think she carries the level of influence over that group that some have said Craig Mundie had over the PCAST report.

From Ludacris: “Re: rogue Meaningful Use. A vendor is e-mailing consultants offering a ‘private label’ EHR they can sell under their own name for a split of the revenue.” The company’s address appears to be a mail drop and the principals aren’t listed, although I found the CEO’s name elsewhere. The vendor’s Version 1.0 product is certified as a Complete EHR Ambulatory and the offer claims companies that want to private label it get their own name on the list of certified products. I suppose ONC didn’t address that issue – where the same product could be sold by multiple vendors under multiple names, each rightfully claiming to be offering a certified product. Certification was intended to reduce buyer risk, not buyer confusion, and some would argue that it has accomplished neither.

From Dingin: “Re: Epic. You mentioned Oakwood and Singing River. Both were at a recent class in Verona, along with others you probably already knew about: Nebraska Medical Center, Providence Anchorage, Contra Costa, Norton, MUSC, Wake Forest Baptist, University of Cincinnati, and Driscoll Children’s.” I confirmed with MUSC that they’re going only with the ambulatory products, dropping McKesson Practice Partner since it doesn’t work well with MUSC’s TELUS Oacis Health Data Warehouse, but keeping Horizon Clinicals on the inpatient side.

From Lorenzo: “Re: ICA. What’s going with them? Rumors of problems.” Not so, according to our Informatics Corporation of America contact. “We have just won Wyoming Medicaid HIE through our partnership with ACS, just selected as VOC with Central IL HIE, and we are hiring as fast as we can to keep up with recent wins of Middle TN eHealth Connect and KHIN. We’ve grown by 100% since the beginning of the year and we expect to grow by another 50% by year’s end in employees. Our funding is solid through our primary owners and we are working as hard as ever to meet customer demands. Go-lives of major clients are scheduled over many of our clients in the near future. Nothing could be further from the truth.”

From HISwalk: “Re: magazine. Does anyone else think this slide show paints a ridiculously rosy picture of several vendors given their current situations?” I’m not a fan of online slideshows when a simple list would have been much easier to read, but this one’s OK (the information it contains was provided by Vince Ciotti’s firm, so I’d trust it more than if the usual sideline reporters undertook their own analysis). I would say the list contains some opinion, some analysis that’s not quite current, and focuses on revenue (which was the point) and not necessarily profit or market trends. I don’t link to other HIT sites or rags since I don’t use them as sources, but you can probably Google your way to it if you’re determined to check it out.

From FACA: “Re: ONC Policy Committee. There’s a Webcast meeting on EHR usability and accessibility on April 21 at 9 a.m. It’s a public hearing, so questions are welcome.” The agenda is here. The presenter list is interesting. For some reason, the government, like others, capitalizes Epic (Epic does not spell it EPIC).

HIStalk Announcements and Requests

This week exclusively on HIStalk Practice: PracticeWise, a new  column by practice consultant Julie McGovern (who stirs up some discussion in her first post). Reefdiver weighs in on the value of certification in the EHR selection process (readers are opinionated on that topic, too.) KLAS  extends a free offer for HIStalk Practice provider readers. AMA tells CMS what physicians find most burdensome. Dermatologists ask patients for fashion advice. Americans want their physicians to use EMRs. So far, only six states have issued MU incentive checks. In honor of Leonardo da Vinci’s 558th birthday and because it makes me happy, please sign up for the e-mail updates while you are catching up on the latest HIT ambulatory news.

On the sponsor-only job board: Clinical Project Specialist, Software/Implementation Engineer, Healthcare Implementation Project Manager. On Healthcare IT Jobs: EHR/ePM Implementation Project Administrator, Coordinator Clinical Trials.gov, Project Manager – NextGen, Software Product Development Manager.

Acquisitions, Funding, Business, and Stock

Allscripts CEO Glen Tullman earned nearly $8.5 million between June 1, 2009 and December 31, 2010. That breaks down to $4.1 million for the 12 months ending May 31 and $4.5 million for last seven months of the year.

Streamline Health Solutions reports Q4 earnings: a net loss of $1.8 million compared to a profit of $1.6 million a year ago. Revenue fell from $6.3 million to $4.9 million.

In India, Michael Dell chats with local reporters on a number of topics, including healthcare IT:

We are #1 in healthcare IT globally. We acquired a company called InSite One, the leader in cloud-based archiving of medical images. We have taken that expertise all the way back to our product groups and created new offerings. IT in the healthcare industry is siloed. The CIO can’t make them work together. We have created vendor-neutral archives by speaking to medical equipment makers. We capture all the data and store locally or in our cloud archive.

Add Medicomp Systems to the long list of EMR vendors that have been sued by Prompt Medical Systems over the years. PMS has no Web presence, so I assume its primary output is legal rather than technical. It appears to be the brainchild of Bernard Milstein MD, an ophthalmologist, UTMB professor, and founder of The Eye Clinic of Texas who patented the use of CPT codes in computer systems in 1994 (even though AMA holds the copyright to the CPT codes themselves). He appears to be backed financially in his litigation lottery by an investment banker and securities company founder. None of the previous cases made it to court from what I can tell, so I’m sure PMS is banking (no pun intended) on the EMR vendors paying them to go away rather than risk being tied up endlessly in an expensive legal action.

Sales

The US Military Health System selects Mediware’s blood transfusion management system for 68 military health sites worldwide. MHS will also deploy Mediware’s LifeTrak and InSight to track donor records and product inventories in 28 blood donor facilities.

Palomar Pomerado Health (CA) chooses GSI Health’s HIE solutions to connect PPH hospitals and affiliated physicians.

Cooper University Hospital (NJ) awards a contract to MedQuist for computer-assisted coding technology and outsourced coding services.

Girard Medical Center (KS) signs with Cerner.

Regional Medical Imaging (MI) chooses Merge Healthcare’s radiology information system, expecting to receive $600,000 from Meaningful Use incentives for its 13 radiologists. Merge says 90% of radiologists are eligible for MU money and it will pursue certification for its RIS to help them earn it.

Announcements and Implementations

Kaleida Health (NY) says it is actively adding EMR capabilities across it hospitals and clinics. Its $20 million Cerner implementation should be complete by the end of 2012.

Tift Regional Medical Center (GA) goes live with RTLS temperature monitoring and asset tracking from AeroScout.

athenahealth creates a “burn unit” to handle physician practices that have been burned by old EMR systems and are looking for new solutions. CEO Jonathan Bush says about 35% of his company’s new EMR clients are replacing old EMRs.

ODIN announces EasySpecimen, an RFID-based pathology specimen management system, licensing the technology from Mayo Clinic.

England’s Department if Health announces completion a project to move all prisons to a single electronic medical records system, allowing them to transfer records when inmates are moved. The article takes jabs at NPfIT, saying the prison system has more detailed information than NPfIT’s Summary Care Record.

Government and Politics

CMS’s healthcare fraud enforcer (a pediatrician and lawyer) says he’s going to crack down on criminals, many of them working out of South Florida, who are scamming Medicare and Medicaid for up a quarter trillion dollars per year. Much of his arsenal involves smarter payment software that can detect fraud more quickly, needed since the fraudsters are using electronic billing systems to commit their crimes. Says one expert, “The crooks know now that these computerized payment systems are their best friend. They will study carefully the art of billing correctly, they will produce electronic transactions that are perfect on their face, but it’s just a pack of lies.” An irony: Florida Governor Rick Scott was CEO of the company (Columbia HCA) that admitted to extensive Medicare fraud, costing the company $2 billion to settle.

ONC’s got some job openings for a program manager and three policy analysts.

Innovation and Research

CalPERS claims its integrated healthcare pilot saved $15.5 million between January and October 2010. Pilot participants include Blue Shield of California HMO, Catholic Healthcare West, and Hill Physicians Medical Group. The organizations’ combined efforts led to a 17% reduction in patient readmissions, a half-day reduction in the average LOS, and a 50% drop in stays of 20 days and longer.

West Wireless Health Institute awards its $10,000 developers’ challenge prize to a skin cancer detection app. The physician developer, who is a veteran and a melanoma survivor, created the iPhone app for his own self-examination.

Other

CIOs say their organizations will qualify for Meaningful Use incentives, but not as early as they predicted a few months ago. In an August 2010 CHIME survey, 28% of responding CIOs predicted qualifying for funds by April 1 compared to 7.5% of CIOs participating in a survey last month. About 32% of the CIOs expect to qualify by September 30, 2011 and an additional 58% anticipate Stage 1 qualification by the end of the 2013 fiscal year. Only 26% of community hospital CIOs believe they will qualify for stimulus funds by September 30, 2011.

Strange: a “stunning blonde” in her 20s, bidding over the Internet, buys more than $50,000 worth of items ranging from a stuffed owl to furniture at an auction in England. The auctioneer called her to arrangement payment, only to have the telephone answered by a doctor, not surprising since she’s a hospital inpatient committed under the Mental Health Act. Her credit checked out, but the hospital won’t let her pay, so the auctioneer says he’ll sue the hospital.

Umass Memorial Healthcare pulls 10 employee kiosks out of service when they discover that anyone walking up to the kiosk could view pay stub information from the previous user. The IT people changed the software and removed bank account information, then put the kiosks back out.

Associated Press gets punked: a couple of anti-corporate troublemakers float a phony press release with GE’s name on it, saying the corporation will donate its $3.2 billion tax refund to the US Treasury since the American public is upset at learning that GE paid no taxes on $14 billion in profit. AP ran the story without doing anything more than clicking on the link to the convincing-looking but phony Web site, only to pull their news item down less than an hour later.

A reader sent this in for Inga and her shoe-loving followers.

Sponsor Updates

• Advanced Endoscopy & Surgical Center (NJ) contracts with Wolters Kluwer Health for its ProVation MD procedure documentation and coding software.
• Design Clinicals and the AHA are hosting a Web demo April 21 entitled Electronic Medication Reconciliation: Achieving Stage 1 Meaningful Use and Full Compliance Joint Commission Standards with MedsTracker. 
• Concerro creates a cute video that compares workforce management tools to paper-based systems, à la the Mac versus PC commercials.
• eClinicalWorks announces that 2,000 practices have successfully upgraded to Version 9, eCW’s ONC-ATCB  certified MU version.
• Access announces a new version of its e-Signature solution to help providers create paperless registration and bedsid consent processes.

EPtalk by Dr. Jayne

This week marks the 150th anniversary of the start of the American Civil War. What does that have to do with healthcare IT, you ask? Maybe more than you think.

I was listening to NPR when Adam Goodheart, author of 1861: The Civil War Awakening, was interviewed. Charleston, South Carolina (which I’d love to visit if the right invitation presents itself) was the scene. Miscalculations on both sides about who would flinch first ultimately pushed events past the point of no return.

Towards the end of the interview, Terry Gross asks, “Some states today want the right to basically be able to nullify federal legislation in their state and not obey it. For example, not to follow the new health care policy that Congress passed. Do you see that as like a contemporary expression of similar divisions dating back to the Civil War?”

This was just a tiny part of the interview, but it really struck me about how divisive things are in health care politics right now. I certainly don’t think we’re on the brink of Civil War, but we are a house divided.

Acceptance of recent federal legislation is love/hate. There’s confusion on whether Meaningful Use will be repealed, revamped, or replaced. For the first time, I recently heard physicians (who had previously stalled on implementing an ambulatory EHR because they weren’t sure the Meaningful Use final rule was ever going to be final) state that they were holding off on going paperless because they feel healthcare reform (and the accompanying MU legislation) will be repealed.

I think many people agree that this train has somewhat left the station. There’s no guarantee that it might not stop somewhere along the tracks, but it already has pretty good momentum. (Anyone seen the movie Unstoppable with Denzel Washington? Watched it recently — a good diversion from reading yet another stack of documents about forming an Accountable Care Organization.)

It will be interesting to see how quickly challenges (to not only federal, but various state legislation) make it to the United States Supreme Court. Given the current makeup of the Court, I wouldn’t lay odds on any outcomes just yet.

Most large healthcare organizations that depend on Medicare payments aren’t willing to take chances or play the game of wait and see. They need to implement certified systems now and demonstrate Meaningful Use so that they can not only receive incentive payments, but prevent the stick that will ultimately follow the carrot. Whether incentive legislation will be repealed or only partially implemented, we don’t know, but I’m pretty sure the Centers for Medicare and Medicaid Services won’t forget the idea of cutting reimbursements by using lack of technology as an excuse (at least not any time soon).

A lot of people are excited about the billions of dollars flowing into the health IT industry. I envision industry lobbying that will rival Big Pharma in intensity and scope if the effort to repeal recent legislation gains any serious traction. There are plenty of consultants waiting to deal with the things that happen when physicians and hospitals select and implement hastily, not to mention vendors that will be poised to sell replacement systems as the industry consolidates.

There you have it. If you’re ever confronted with an SAT-style question asking for a modern-day analogy to the Civil War, please feel to plagiarize, no citation needed. And if you can recommend a conference that will give me an excuse to visit South Carolina, let me know.

Contacts

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

Readers Write 4/13/11

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

Thoughts on the Department of Defense/VA
By Arturo

Back in the 1980s, Congress, responding to the clamor for greater productivity and using the private sector should the private sector be more efficient (hence leading to such things as outsourced waste pickup and selling of municipal-owned utilities), mandated a competition for selection of the information system to be used by the VA.  And so there was a competition involving EDS, McDonnell Douglas, SMS, and the VA (if I recall properly). 

At that time, the VA VistA system was, in many respects, kludgy, somewhat proprietary (after all, what OS or application isn’t somewhat proprietary in one way or the other for the general population?), had a user interface not particularly friendly to many end users, and quite disjointed. 

By disjointed, I mean that various modules were written at different locations, sometimes with different standards and feels, and that was simply not a standard or uniform implementation of the system throughout the system. There was no such thing as a general release of the system.

The competition ended up with the selection of the VA system.  Now, I’ll never really know if it was the right decision, but I suspect that it really wasn’t. 

Shift forward a couple more years and we had another competition for the Department of Defense TRIMIS system – CHCS (Composite Health Care System). The selection didn’t compare apples to apples in the beta implementations (a single site installed by each competing vendors). The winner in this one was SAIC, which had used the VA system as its basis.

The SAIC bid for the five-year deployment came out about a half billion dollars lower than its nearest competitor. Interestingly enough, SAIC required another $500KK to complete its implementation and the DoD had a system that really wasn’t ready for the future — a database that wasn’t SQL compliant, a more or less command-driven system (MUMPS at work) that wasn’t ready to meet the demanding needs of clinicians, etc.

Eventually, sometime in the first half of the 1990s, as I recall, there was a DoD RFP for a clinical workstation.  I believe that this ultimately led to the 3M proposal for a clinical workstation and clinical data repository which was to become the foundation for DoD’s computer-based patient record system. (3M continues to support the DoD repository – a good thing, I suspect.)

Then came CHCSII.  Now I guess that it’s AHLTA.

And throughout all of this, we just don’t have a tight linking of DoD and VA EHRs.

Now we could talk about some of the inflexibility of VistA, its inability to provide workflows and screens tightly linked with different disciplines, the need for a more robust database manager, or the fact that VistA (and the VA) just didn’t know how to deal with female veterans. Or why the VA delivery system was perceived as being substandard for so long before emerging as a leader in preventative healthcare (although why did we have the disaster with veterans returning from Iraq not so long ago?)

Is it time to use a commercial product for the DoD and VA? Or should the DoD and the VA have taken the lead long ago in providing a robust EHR for deployment throughout our healthcare delivery system? Or if VistA was so good, why didn’t more provider organizations deploy it sooner? 

Something for thought. And, Epic, despite all of its success — is it really the right product or is it really any better?

Filling in the Holes in Your EMR/EHR
By Tim Elliott

With all the hype about electronic medical/health records (EMRs/EHRs) and pressure from internal folks (everyone from the executive team to various committees), hospitals often rush into their EMR projects without seeing holes between their systems, people, and departments. These typically get filled in later, often with inefficient manual processes. This approach reduces the productivity gains delivered by the EMR and frustrates the IT/IS team, clinicians, and administrative staff members who thought they’d be leaving paper pushing behind.

It’s a good idea to get people from each department that’ll be using the EMR to analyze the potential gaps in their areas well before vendors come on site instead of waiting to find and address these gaps later. Involving experts from outside your organization in the process is often beneficial, because they have the objectivity that it can be difficult to get when you’re running through processes you’re involved in. They’re also not going to be worried about hurting anyone’s feelings, which can be a concern when analyzing your colleagues’ daily tasks.

If you didn’t do this before going live with your EMR, it’s not too late. A good place to start a post-deployment review is to ask yourself and your team the same questions that you posed during project planning. By getting feedback from multiple departments (patient registration, HIM, clinical areas, etc), you’ll figure out how the EMR system is working well in some ways, and how can it can do better in others.

Again, consider why you’re doing what you’re doing. What are your goals for people, processes, and systems? How do these impact your overall initiatives, such as patient safety and disaster planning?

Don’t accept a process that isn’t working just because of a vendor’s limitations. If something’s not working right, call them and tell them exactly what the challenge is and what you need to achieve. Chances are they’ve heard a similar question before and will get right on it. Maybe you need a custom workaround, additional functionality in a newer release you didn’t know about, or a couple of extra training sessions for your staff.

We vendors spend lots of dollars on building products that solve problems. It pains us to see customers not using all of the tools we created to make their facility run smoother. Maybe you don’t want all of it, but if you need additional functionality, please ask. If your vendor is worth their salt, they have it, can build it, or will include it in a future release if several facilities share that same challenge.

We want to help you to cut your costs, enable your staff do their jobs better, and improve your patients’ care and safety. Often, the first step is you picking up the phone.

Tim Elliott is founder and CEO of Access.