Readers Write 2/17/09

Response to EHR Outcomes Studies Cited by Reader "Pragma"
By Frank Fontana

The author (Pragma) commenting on MD Leader 1/27/09 needs to come clean on their own studies cited before criticizing someone else in such a sarcastic manner.

I followed the links to the "studies" cited. All but one either (a) have nothing to do with studying whether EHRs improve quality or not, or (b) were authored by those in the business of promoting EHRs. The one that does make an attempt to measure quality improvements acknowledges that their work may be skewed towards positive results because of the self-selecting clinics that participated.

I imagine the commenter could also readily cite studies showing that cigarettes weren’t damaging to one’s health, conveniently not mentioning the fact they were funded by tobacco companies.

http://www.bmj.com/cgi/content/full/bmj%3b330/7491/581
This was authored by IT clinical consultants.

http://www.itif.org/files/HealthIT.pdf
This is not a study. The author is an analyst at the Information Technology and Innovation Foundation, which is committed to articulating and advancing a pro-technology public policy agenda.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2253693
This is not an EMR study. It is a study of an electronic prescribing application, funded by the very same vendor.

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=685103 
The report “examines the experiences of five provider organizations in developing, testing, and implementing quality-of-care indicators, based on data collected from their electronic health record (EHR) systems." It is not a study of whether EHRs improve quality or not.

http://www.cchit.org/about/casestudies/index.asp
This was a study by the Certification Commission for Healthcare Information Technology, which notes that “Case studies bring CCHIT’s work alive.”

http://www.fhin.net/eprescribe/Benefits/AdvantagesToProviders.shtml –
Not an EHR study. Another electronic prescribing study, again funded by a provider of electronic prescribing applications.

http://www.fiercehealthit.com/story/ehrs-boost-quality-raise-costs-at-community-clinics/2007-01-22
Link is to a “leading source of Healthcare IT news with a special focus on … EMR adoption…” The study itself notes that five of the six clinics lost money on their EHRs, though quality improved. Regarding the improvement of quality, the study also notes “this retrospective, qualitative study obtained data from a small, purposeful sample of six CHCs, with additional information from two network ASPs. Study CHC cases likely were more successful than cases that declined to participate.” One of the two authors is a graduate student in Biological and Medical Informatics.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1479999
Not an EHR study. Not a study at all. Rather its a report by a large group practice of its experience integrating an online communication channel with its already existing EMR.

Parallel processes of manufacturing companies operating disparate systems for producing goods sold in the marketplace correlates to analytic processes driving the medical community exotic and disparate diagnostic testing on human subject typically referred as “patient.”  The extent of the diagnostic testing or physiologic surveillance depends on the complexity of the test entity, POS environment, and the instrumentation employed to product the sub-clinical finding commonly called “tests results” or real-time somatic analytics.

Often more times than necessary, these clinical tests or surveillance systems are performed while the patient takes up temporary residence in a full-service acute care health center with state-of-the-art equipment employing all the modern instrumentation afforded to the hospital in the medical service area. These tests can be diverse as Magnetic Resonance Imaging (MRI) to the simple blood test for Magnesium (Mg) or measurement of body temperature. 

If one were to count up the total testing menu provided by a typical urban hospital charge master, the resulting number of frequently reimbursed test procedures would be over two thousand, continually increasing as technology proliferates in the diagnostic in vivo market. If each and every testing procedure performed by a healthcare entity were available online and accessible to everyone involved in the medical process, then this paper would not be necessary and no new information would be reported.  This sadly, is not the case.

The purpose of this paper to examine the multitude of diagnostic testing being performed by accredited hospitals on their patients to consider an interoperability gateway called Point of Diagnostic Service (PODS). Simply stated, Diagnosis Oriented Architecture (DOA) is the underlying structure, or more appropriately surrogate architecture, to service oriented architecture (SOA) supporting communications between clinical service diagnostics. In this context, a diagnostic is defined as a unit of work to be performed on behalf of some computing entity, such as clinical diagnostic instrumentation or medical devices.

DOA defines how two computing entities, such as programs, interact in such a way as to enable one entity to perform a unit of work on behalf of another entity. Diagnostic interactions are defined using a description language equivalent to service oriented architecture.  Each diagnostic interaction is self-contained and loosely coupled, so that each interaction is independent of any other interaction. If one diagnostic entity is non-functional, the service structure will maintain functionality*.

Enterprise diagnostic process, usually initiated by Computerized Provider Order Entry (CPOE) protocols, can be orchestrated by communications between the Web services and gateway diagnostics talking to other gateway diagnostics executed by the underlying framework that DOA provides as a surrogate function to the Enterprise Service Bus. The patient in this case study is the central focus of all medical activity emanating pathophysiologic signaling functioning as medical broadband for investigation to determine cause and effect of presentational or prodromal symptomatology.

NOTE: The foundation for the “Interoperable Patient” is Point of Diagnostic Service (PODS) unified platform, the first critical inch of HIT considered the ecatheter for diagnosis extraction, transformation, and loading of clinical data into the longitudinal enterprise diagnostic repository or colloquial “The Patient Cloud.”

*Advancing the Adoption of Medical Device “Plug & Play” Interoperability to Improve Patient Safety and Healthcare Efficiency.” Center for Integration of Medicine & Innovative Technology. 2008.  http://mdpnp.org/uploads/MD_PnP_White_Paper_April_2008.pdf

The bulk of the HIT language in the bill is pulled directly out of the HR 6357, which Dingle introduced last summer. I don’t see how  NeHC is going to serve as the Policy Advisory committee since the language requires the Policy Committee to have a dramatically different makeup that will mostly be political appointments. For anyone who has ever run a complex project, there is a huge difference between staying close to your stakeholders and asking them to serve on your board of directors. The NEHC board was the result of a six-month open process and the governance model and board composition was designed to include people with multiple areas of expertise. This bill just destroyed that process.

Membership and Operations

(1) IN GENERAL- The National Coordinator shall provide leadership in the establishment and operations of the HIT Policy Committee.
(2) MEMBERSHIP- The HIT Policy Committee shall be composed of members to be appointed as follows:

(A) One member shall be appointed by the Secretary.
(B) One member shall be appointed by the Secretary of Veterans Affairs who shall represent the Department of Veterans Affairs.
(C) One member shall be appointed by the Secretary of Defense who shall represent the Department of Defense.
(D) One member shall be appointed by the Majority Leader of the Senate.
(E) One member shall be appointed by the Minority Leader of the Senate.
(F) One member shall be appointed by the Speaker of the House of Representatives.
(G) One member shall be appointed by the Minority Leader of the House of Representatives.
(H) Eleven members shall be appointed by the Comptroller General of the United States, of whom–

(i) three members shall represent patients or consumers;
(ii) one member shall represent health care providers;
(iii) one member shall be from a labor organization representing health care workers;
(iv) one member shall have expertise in privacy and security;
(v) one member shall have expertise in improving the health of vulnerable populations;
(vi) one member shall represent health plans or other third party payers;
(vii) one member shall represent information technology vendors;
(viii) one member shall represent purchasers or employers; and
(ix) one member shall have expertise in health care quality measurement and reporting.


Knowing Your Clinical Client
By HIT Project Manager

This is not a direct response to any article or comment made, but just a moment of serendipity this morning as I conducted a walk-through of one of our endoscopy units.

IT work is crucial to the performance of the unit. They are increasingly going digital with their process as endoscopic imaging merges with the rest of the electronic medical record.

Some observations as I walked around:

Doubling unit volume shows up in the “seams”
Each room in the unit has had to deal with added technology requirement as an afterthought. Its like how our homes look after choosing a builder’s model where one of the four bedrooms can be made a home office since you’re only having two kids. Once you’ve had four children instead, the home office is now a storage room, the wiring is outdated, and you will need to switch out the old DSL modem for broadband wireless solution if you ever get a chance to use the room for an office. Meanwhile, your PC sits on a cardboard box because the IKEA desk is in offsite storage to make more room.

Clinicians do not have time to learn technology 
Clinicians truly appreciate when we don’t insult their intelligence and years of clinical training by talking down to them and instead speak to one another as colleagues/peers. I love working with and for clinicians for this reason. They are some of the most gracious people you meet when you give them the same respect and care they give, like the RN supervisor on this unit. It is a true joy to work with her and serve her technology needs.

Technologists cannot afford to be oblivious to clinical workflow
In contrast to my last thought, I don’t think technologists (at least those like me in a project management/clinical analyst role) can afford not to get into the weeds of how and where clinicians work. If you do not spend enough time in the unit you provide technology support for, you will inevitably be the “home builder” that sells the client on a “home office” when you should have more appropriately advised a wireless solution. Only a visit to the clinical unit will permit you to forecast the growth that the clinician tries to communicate in the 10 minutes they have between cases.

The devil is in the details, they say.  Being an eternal optimist with a healthy dose of reality, I see that the optimal technology solution is the one that is completely transparent to its end users. Such a solution should work effortlessly and invisibly since, in the end, it’s the clinician-patient relationship that really matters. We technologists remove the distractions to help foster that relationship. 

The article in the Sacramento newsletter commenting on Kaiser-based clinicians’ struggle between time with technology vs. time with patient is a bit overstated, in my assessment. I can’t think of any physician or nurse I met that I who would say they are less effective because of the technology improvements that have been implemented. At worst, they consider them neutral to their work, and they have come up with creative workarounds where they are not. At best, they consider technology as having freed them from the mundane aspects of healthcare administration so they can spend more time with patients.

Godspeed to our efforts at making technology the best for them.

CIO Unplugged 2/15/09

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

“Other Duties As Assigned”
By Ed Marx

One objective of this blog is to give a transparent window into the life of a healthcare CIO. Certain aspects of being a CIO, which generally apply to the entire C-Suite, are the numerous external “other duties as assigned.” The list is by no means complete and only reflects what I’ve grown to understand from working at two large healthcare systems. But I suspect every CIO operates in one if not most of these assignments. (I will remain purposefully vague as to which role is current or former.)

Politics. Be involved. Get out there and shake hands to further the cause of healthcare and your institution. Sometimes this means attending fundraisers for a politician who represents healthcare or for your city or state hospital association. Take part in advocacy efforts and help educate our governing bodies.

Fundraising. Lead by example through the opportunities that come your way. Create margin in the household budget. In addition to established opportunities, we created our own annual IT fundraiser for a children’s hospital that raised over $100K this last year.

Parties. Important social gatherings pop up often, and attendance is not always voluntary. I started out naïve; now I own a tux.

Appointments. Consider these an honor and an opportunity to give back to the larger community. I have held very formal State level appointments as well as less formal city and county appointments on behalf of my employer. But don’t be a wallflower. Speak up, invest yourself to further the cause. Otherwise, don’t bother accepting the position.

Boards. Many organizations are in dire need of talented people to help provide direction and ensure accountability. These Boards can range from an international for-profit corporation to a local, not-for-profit homeless shelter. Always check for potential conflicts of interest first.

Task Forces. Often times these are directly related to healthcare but in a broader community sense. For instance, you might join a task force to research the feasibility of a regional HIE.

Advisory Councils. My all time favorite was serving on the College of Design and Merchandising (fashion) Council at Colorado State University. I was the only non-model, non-designer asked to join the judging panel at the annual fashion show. Lights, models, cameras, crowds—and me sitting at the runway’s end with a tie that didn’t match my suit.

Professional Associations. It’s critical to remain actively involved to advance our profession. I have served on several national HIMSS committees and as State Chapter President (TN and OH). I have spoken on behalf of HIMSS and CHIME throughout the country.

Speaking & Publishing. There is a healthy expectation that we add to the body of knowledge by sharing best practices, evaluated experiences, and tangible results. I have spoken on behalf of and been published in and outside of healthcare. The bonus: it contributes to your growth.

The common thread between these “other duties as assigned” is what makes them so valuable and important and why you need to take an active role. They:

Allow you to give back to the broader community at large
Provide a framework for you to help advance a specific organization or initiative
Enhance your own personal and professional development
Broaden your networking and social contacts
Enhance your organizations position in the community and profession
Force you to think outside of yourself
Ideally makes the world a better place

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

Monday Morning Update 2/16/09

From Barney Rubble: "Re: AtStaff. AtStaff, Inc. of Durham, NC laid off some 15% of its workers, including sales and marketing along with some other belt tightening (people)." Unverified.

From A-Fraud: "Re: Picis interview. Why not challenge Cozzens with [laundry list of company criticisms] … as a potential customer, we need to know this and Picis would not share this information with us!" The sender attempted to camouflage his or her information, but a little sleuthing revealed that it came not from a hospital or prospect, but from someone at Picis EDIS competitor MEDHOST (hopefully not encouraged by the company). Picis must be a formidable competitor if it’s come to that.

Mary Pettys, a software director for TriZetto, was one of the passengers who died in the Buffalo plane crash. Condolences.

Kaiser had a terrible 2008, swinging from 2007 net income of $2.2 billion to 2008 net loss of $794 million. Reading between the lines, investment losses were to blame, "marked down to current market values for financial reporting purposes." Interestingly, most of the press release brags on IT and HealthConnect, which is obviously a key strategy (as you would expect given the cost). Like everyone else, Kaiser will defer capital projects. An ominous sign: Kaiser’s total membership declined by 30,000 last year, the first drop in five years (maybe due to unemployment?)

I see that 113 people who attended HIMSS last year have completed the poll to your right. Results: only about half of them are going to HIMSS this year and 75% of respondents say their organizations will send fewer people this year. HIMSS may be getting a lot of early registrants, but it sure looks unlikely that attendance will match that of last year’s conference.

The CEO of Royal Free Hospital in England complains that its early adopter implementation of NPfIT’s Cerner Millennium costs it dozens of millions because of extra costs, lack of billing data, and reduced patient throughout. NHS says early adopters always have to spend and suffer more and that hospitals often fail to set adequate training budgets (all true in my experience). 

Listening: Flo Rida. If you already have a stripper pole and strippers in your house, this is all you need – they will instantly start gyrating since it’s a club staple, so I hear (I haven’t been in a strip club since they were dancing to Toto).

Jonathan Bush of athenahealth and John Glaser of Partners HealthCare will speak at the Transforming Healthcare conference in Boston the evening of Thursday, February 26. HIStalk readers get a discount – see the text ad to your right.

Cleveland Clinic strikes a deal with MinuteClinic to provide clinical consultations as backup to nurse practitioners in nine CVS store MinuteClinics, with integration of their respective electronic medical records, with patient-approved access to the clinic’s Epic MyChart information.

We did an "HIT Moment" with Vatsal Thakkar MD of NYU, who’s an actual user of the free Practice Fusion EMR. He has some quite interesting thoughts that are worth a read.

The drug industry got its hands into the stimulus bill’s earlier versions, creating a new lobbying group to make sure big pharma controls medical information and keeps provisions that require cost effectiveness out of any outcomes research. The drug makers don’t like the $1.1 billion earmarked for comparing medical treatments and want it removed, claiming it will lead to government rationing (the drug industry loves the "it’s expensive, but worth it" argument that it often makes directly to patients spending someone else’s money). An interesting quote in the article: "When the government’s Agency for Health Research Quality suggested in 1995 that there were too many unnecessary back surgeries, doctors and industry groups attacked the conclusion. Mr. Cannon noted that Congress at the time slashed the agency’s budget and stripped its authority to make medicare-payment recommendations. ‘They almost killed AHRQ,’ said Dr. Avorn. "The memory of their near-death experience hasn’t been forgotten."

Early reports are that privacy groups like the final stimulus bill, with ACLU giving its stamp of approval. No comment yet from Patient Privacy Rights.

BT’s earnings took a big hit after writing down the value of most of its big IT contracts, including its NPfIT ones.

Indian IT vendors are expecting to get contracts from HITECH. iSoft was named, which is strange since neither it nor parent company IBA Health sell into the US as far as I know, but maybe plan to do so.

Emageon gets the $9 million of escrowed money from Health Systems Solution for the latter’s failure to consummate the merger transaction with the former. In the meantime, the SEC, FBI, and IRS are investigating HSS’s parent company, Antigua-based Stanford International Bank, wary of missing another Madoff-type situation in which investors received abnormally high rates of return in what turned out to be a Ponzi scheme.

Merge Healthcare announces Q4 numbers: revenue down slightly, EPS $0.03 vs. -$0.28. With annual revenue tracking at $60 million, nobody’s probably paying much attention, but it’s at least a start toward some kind of recovery from three years or so ago when shares were in the high 20s vs. $1.65 now.

HITECH Provisions of the Stimulus Package
By Dr. Herzenstube

After reading through the entirety of the HIT language of the bill (title XIII, which covers all but the Medicare and Medicaid incentives), here are the bits I find most noteworthy.

1. The bill seems to stipulate a role for a certification organization a la CCHIT. "The National coordinator, in consultation with the Director of NIST, shall keep or recognize a program or programs for the voluntary certification of health information technology as being in compliance with applicable certification criteria adopted under this subtitle." (3001.c.5).
2. However, that certifying body will not be the one to decide on the certification criteria. That will be the role of the HIT Standards Committee, with final say — at the individual criterion level — lying with the Secretary of HHS: "The National Coordinator shall review and determine whether to endorse each standard, implementation specification, and certification criterion for the electronic exchange and use of health information that is recommended by the HIT Standards Committee." (3001.c.1).

   …and the HIT Standards Committee will take its marching orders about what to focus on from the HIT Policy Committee. "The HIT Policy Committee shall recommend the areas in which standards, implementation specifications, and certification criteria are needed … and shall recommend an order of priority for the development, harmonization, and recognition of such standards, specifiations, and certification criteria." (3002.b.2.A)

   "…the HIT Standards Committee [shall] recommend to the National Coordinator standards, implementation specifications, and certification criteria…consistent with the latest recommendations made by the HIT Policy Committee.." (3003.b.1.A) (The bill also stipulates some areas that the HIT Policy Committee must address in some manner, e.g. segmentation of data to facilitate limited disclosures of PHI).

3. 3008.b Implies that the AHIC Successor, aka NeHC, might serve as the HITPC or HITSC (although HITSP has developed many of the interoperability implementation specifications used by CCHIT, most CCHIT criteria relate to innate functionality of EHR systems, NOT interoperability features, and were developed by the CCHIT workgroups themselves. It will be a major shift to have CCHIT relegated to basically just a testing organization, with criteria developed by another entity).
4. HIPAA will now apply to business associates of covered entities just as it applies to covered entities (13401.a)
5. "Pay for privacy". Upon written request of the patient, disclosures to health plans for payment or health care operations must exclude any PHI pertaining "solely to a health care item or service for which the health care provider involved has been paid out of pocket in full." (13405.a)
6. Accounting for all disclosures including for PTO. "An individual shall have a right to receive an accounting of disclosures … The Secretary shall promulgate regulations on what information shall be collected about each disclosure." (13405.c.1.B)

E-mail me.

Being John Glaser 2/14/09

The convergence of the Information Technology and Clinical Engineering functions is likely to accelerate in the years ahead. This convergence centers on six shared areas:

• Goals. Both functions have goals of improving the safety of care, enhancing clinician decision making, and improving clinical operation efficiency.
• Infrastructure. Both functions need to leverage the enterprise wired and wireless networks, workstations, and server farms.
• Knowledge management. Clinical information systems and medical devices increasingly have computer-based decision support logic; logic that must be kept current, checked for inconsistencies, and assessed for impact.
• Applications. Applications such as acute care documentation and cardiology systems are integrations of applications and devices.
• Regulations. For example, the FDA is examining IEC 80001, which would place enterprise IT networks, which are linked to biomedical devices, under FDA oversight.
• Support. Both functions may need to work together when devices and/or applications and/or infrastructure encounter problems.

Despite the acceleration of convergence, crafting effective working relationships between the functions remains a significant problem.

Most Clinical Engineering departments do not have formal reporting relationships to the Information Technology department. The two groups have differences in culture, vendors, support requirements, regulation, and domain knowledge that often cripple working relationships. The vendors that serve the respective departments don’t often understand the needs of the other departments, e.g., the need to co-exist with other vendors on a wireless infrastructure.

While convergence is challenging, it is essential that it happen — technically, managerially, and strategically. This convergence will require efforts on the part of provider organizations, vendors, regulators, and professional societies. The convergence starts with the two groups sitting down and talking to each other.

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

News 2/13/09

From Squirmy: "Re: Compuware. Compuware’s Covisint subsidiary hires convicted former Detroit Mayor Kwame Kilpatrick for their Dallas office." Kilpatrick, on five years’ of probation and disbarred after serving 99 days in jail for obstruction of justice and assault following his sex-and-text trysts (and his administration is still under a federal corruption investigation), bags a job as a Detroit-based Compuware account executive. Hopefully he’ll be well paid since he owes $1 million in restitution.

From Mark: "Re: stimulus. I was looking for comment or perspective on a disturbing article published in the WSJ. As a healthcare IT professional who works with EMRs, this scares me." The article, A Health-Tech Monopoly, is actually an editorial that claims the bill will make ONCHIT all-powerful, concluding it will "be deciding which platforms are up to code and shutting down competitors" and will hamstring IT users with "faux privacy provisions," leading to government healthcare price controls and micromanaging providers. The author isn’t named, but if it’s not Betsy McCaughey, it’s someone who thinks like her. ONCHIT is not new and has been entirely benign, although I’d double check once their bank account gets all those extra zeroes. They won’t (can’t) shut down software vendors, at least those able to pay a not-huge sum to earn CCHIT certification (maybe that would have been a nice use of the stimulus money – fund CCHIT and make its EMR certification free). Also, the stimulus bill isn’t a never-ending blank check for imposing socialism or running roughshod over privacy — voters will still have some say. Right-wingers like me hate the bill because it’s probably going to be one giant wasteful failure that will eventually leave the country worse off once the big spending party is over and they bring the bill to our children. Democrats love it because it tries to do something, at least, and might help average people now that the fat cats have gotten their handouts. Like always, zealots on both sides preach loudly to the choir and breathe each other’s air, convincing nobody who wasn’t already in their camp (here’s a liberal counterpoint, for example). Right or wrong, the stimulus bill is pretty much a done deal at this point, so editorializing is pointless. You saw the effect of grassroots opposition to the bank bailout – zip (about the same as its results).

From HawkI: "Re: University of Iowa Hospitals and Clinics. They had a successful go-live of Epic’s Inpatient Pharmacy, Critical Care, and eMAR products this week. May 2, they go live house-wide with documentation and CPOE." Nice. Congratulations to them. How’s Epic Pharmacy and the connection to CPOE? I haven’t heard anyone say.

From Inside Outsider: "Re: Sunquest. More layoffs yesterday, including the remainder of the Service Exec team, which coordinated support for clients."

From Art Vandelay: "Re: HIMSS conference. Never thought of it before, but another alternative could be some podcasts, video podcasts, and use of SlideShare for an ‘open source’ conference. Mr. HIStalk, you could take the next step with this one. Allowing attendees to make requests would be pretty cool and then use the normal discussion board to have a time-bound Q&A. The authors could distribute free with HIStalk as the coordination point pointing to their URLS." A brilliant idea. An HIStalk education center, which could also screen presentations imposing publication-like standards (disclosure of interests, author affiliations, etc.) and no commercial pitches (or at least clearly labeling them since those can be educational, too). And, letting readers vote on each using a star system (like Amazon’s) and with a mini-discussion board for each presentation like Art said. All free, of course. Art and I just ran the idea up the flagpole — are you saluting or not? Let me know.

Listening: Sunny Day Real Estate, defunct emo since 2001 for obvious reasons: they declined publicity, refused to play in California, lost their lead singer when he converted to Christianity, used gibberish for lyrics to get the songs out faster, and released an all-pink album with no writing. I admire that, although I’m not sure why.

Harris Corp. gets a 10-year outsourcing contract from nearby Health First (FL) to provide support, training, and network security.

Cerner gets a two-year extension of its UK contract with Atos for Choose and Book. And, BT will resume its Millennium rollouts in London after fixing earlier problems.

Students in Rwanda can take an 11-month software development program that encourages them to further develop the OpenMRS system, a project led by Regenstrief Institute and Partners in Health. Students are trained in Java programming, web development, and informatics.

The Army buys 10,000 more Dragon Medical licenses for its physicians as part of a provider satisfaction project with the AHLTA EMR. "Being able to speak notes into an e-health record at the patient’s beside — rather than staring at a computer screen typing — also helps improve doctors’ bedside manner and allows them to narrate more comprehensive notes while the patients are there, or right after a visit. That cuts down on mistakes caused by memory lapses and boosts the level of details that are included in a patient record.”

Former Summit Healthcare CTO Charles Williams starts his own company, Infinity Healthcare, which I ran across in this news item.

Odd: a visitor reaching into his pocket to pay for lunch in a Colorado hospital’s cafeteria hits the trigger of the gun in his pocket, shooting himself in the leg (he’s been Burressed!)

I swear those Hollywood types need to start writing spec scripts about the Emageon saga. It’s off-again for the umpteenth time, as HSS’s parent company, Antigua-based Stanford International Bank, won’t provide the money for it to acquire Emageon. Meanwhile, these blogs (Link 1, Link 2, Link 3 – thanks to the reader who sent them) paint an interesting picture of the bank, which the first one claims has one shareholder, a single board member who is an 85-year-old used car dealership owner, is audited by a tiny Antigua company run by a 72-year-old local, and somehow manages to pay abnormally high interest rates on CDs despite big losses. That last linked article makes some rather strong statements, claiming the bank is a scam and "going down very soon." All unverified by me, of course.

Strange lawsuit: A Florida woman is arrested and charged with practicing medicine without a license after two women suffered injuries from the "buttocks enhancement" injections she administered.

Canada is running its own EMR stimulus: $500 million more to Canada Health Infoway, bringing the total to $2.1 billion ($1.7 billion US).

Want to see the real-time ED load of several Western Australia hospitals? Sure you do.

Open source software companies (seems like an oxymoron, doesn’t it?) urge President Obama to consider open source EMR applications. "Open-source software brings transparency to software development. There are no ‘black boxes’ in open-source software and therefore no need to guess what is going on ‘behind the scenes.’ Ultimately, this means a better product for everyone, because there is visibility at every level of the application, from the user interface to the data implementation. Furthermore, open-source software provides for platform independence, which makes quick deployments that benefit our citizens much easier and realistic."

Another Vendor You Won’t See at the HIMSS Conference

A reader had asked us to confirm that Picis will not attend the HIMSS conference (along with several other companies that we already told you about). Inga jumped to action and e-mailed some questions to CEO Todd Cozzens. Since I’m a neurotic rule-follower, I’ll run his answers here instead of as a "Moment With" since she asked only three questions, not my standard five.

How’s business?

We’re holding up pretty well. We just finished a very strong year in 2008, with new bookings up well over 40% over 2007 and solid improvements across all business lines in a quarterly customer satisfaction survey. Our SaaS business is driving a lot of that, but we were pleasantly surprised to contract with many net new ED and OR customers in the back half of the year. In all we picked up over 20 new hospital systems – not many companies doing that these days. And of course these contracts also help drive better margins and cash flow. 

We also released a slew of new products in 2008 – most notably our integrated EDIS and facility coding system and some very well received BI tools and decision support capability in our OR product line. Our focus in recent years of integrating point of care revenue management seamlessly into our high acuity clinical automation products is helping us maintain good traction throughout the slowdown in hospital capex spending.

Has Picis pulled out of HIMSS?

We’re being very conscious and prudent about controlling costs and hunkering down on our business. Don’t let anyone tell you there isn’t a completely different environment out there now — if they do, they’re either lying to you or have their head in the sand. For example, we’re balancing our portfolio with our marketing spend — we’ve increased our attendance at domain-focused trade shows (ACEP, ASA, ENA, HFMA, etc.) and decreased our presence at more general shows such as HIMSS. 

We surveyed our prospects and customer base and found that over half had imposed a travel ban or would not be attending. We figure that spend is about the equivalent of an investment in a small R&D team that could work on a new product. We want to maintain our focus on innovation and R&D in this downturn to come out even stronger on the other side. We still will do a lot of HIMSS-sponsored events, such as HIMSS virtual tradeshow presentation. Our Webinars on driving profitability through clinical business intelligence had record attendance for HIMSS last year.

What’s your take on the HITECH part of the economic stimulus package?

When I ask the same to CEOs and CFOs of providers, they say, "Make my hospital solvent and viable and I’ll have the right capital to invest in IT." So, the $80 billion to prop up Medicare for the states will surely help there.

Another little-known provision is expanded tax credits for municipal bonds. That’s a major source of hospital financing that’s been completely shut down, and getting that market churning again will have a big affect. The average hospitals only has about 50-75 days of what they call uncommitted cash on hand to bridge the gaps between operating expense obligations and revenue from payors. It’s sad to see hospitals laying off people, not because their numbers are particularly bad, but because they need to bridge their working capital shortfalls

As to the grant money, we still haven’t seen wording in the final bill that obligates hospitals to spend the grant money on healthcare IT. I’m also curious to see how the incentive money is applied and what the criteria are — that still has not been worked out, to my knowledge. The increased funding for the national HIT office and interoperability could be very useful if spent wisely. Re-inventing the wheel is not the answer — there are already many interoperability standards available. 

The key is obligating the vendors to be interoperable. Don’t let them talk out of both sides of their mouth by saying they’ll comply with all standards, then propose proprietary data lockout products to health systems. I like Peter Neupert of Microsoft’s term of "data liquidity." We need to increase data liquidity in healthcare as much as we need to increase monetary liquidity!

E-mail me.

HERtalk by Inga

From Gary: “Re: NCR brings Patient Self-service Downunder. Love your work. Mr. H is lucky to have someone as dedicated and talented (and beautiful) as you on his team. Now that the obligatory ‘sucking up’ is done, we are doing a rather ‘soft launch’ of our entrance into the South Pacific region.” Since Gary appears to know how to work the system at HIStalk, I agreed to give him a plug. Plus I was excited to know we have readers in Australia, especially since he has agreed to take me shoe shopping in Melbourne any time. Gary is heading up sales in the South Pacific for NCR’s healthcare self-service group.

Marisco Capital Management acquires a 5.7% stake in athenahealth. The 1.88 million shares of stock are estimated to be valued at $630 million.

athenahealth also names David E. Robinson as executive VP and COO. His most recent role was executive VP at SunGard Data Systems.

Cancer Treatment Centers of America opens the nation’s first all-digital cancer hospital at Western Regional Medical Center in Goodyear, AZ, which would make it the first Stage 7 hospital in the HIMSS Analytics EMR Adoption Model. It’s using Eclipsys Sunrise.

Speaking of Eclipsys, it picks up an endorsement from Genesis Physicians Group, a 1,450-member IPA in Dallas. IPA members purchasing the PeakPractice product will be eligible for discounted pricing.

USC agrees to pay Tenet Healthcare $275 million to acquire USC University Hospital and USC Kenneth Norris Jr. Cancer Hospital. The deal ends a three-year fight over the control of the facilities. Employees will stay on.

A 57 year-old woman who questions a $143 pregnancy test charge on her detailed hospital surgery bill is told it’s standard procedure even at her age. She’s pushing for a policy change. I am still hung up on the fact that the test is $143 when the at-home version is about ten bucks.

Emory University Orthopaedics & Spine Hospital (GA) opens this week and will feature a Cerner CareAware my Station system in each of the 45 patient rooms. I also noticed the hospital offers four private luxury suites with two separate living quarters. Amenities include fine linens, plush towels, two fax machines, a conference/dining table, in-room newspaper delivery, and gourmet room service.

HCA seeks to raise $300 million in a bond offering to repay bank debt and to amend terms of some of its loans. Earlier this month, HCA announced its 2008 net income was $673 million, down 23% from 2007.

The son of an 89-year old woman who died at a UPMC hospital charges that the facility’s new and untested Cerner EMR system was a major factor in her death. The woman, who was undergoing treatment for strokes and dementia, left her unit and ended up freezing to death on the hospital’s roof. The suit claims that the staff caring for the woman was struggling with a system that “they were not properly trained on,” placing patients “at a severely increased risk of harm and death.” The family’s attorney charges that UPMC ignored warnings that the records system could put patients at risk because UPMC had an ownership interest in Cerner Corporation.

In an attempt to expose medical students and doctors to its new surgical procedures, surgeons at Henry Ford Hospital (MI) use Twitter to provide real-time time surgery updates. During a surgery on a kidney cancer patient, doctors used a laptop in the operating room to give a play-by-play of the action, plus answer online questions. Is it really 1.0 of me to hope my surgeon doesn’t Twitter during my next surgery?

A new KLAS research report claims that more hospitals are looking for aggregation solutions that provide a more complete view of medical records and documentation. Such solutions would help clinicians improve patient safety. The report names six vendors that account for 85% of contracted deployments, with MEDSEEK owning the largest installed base. KLAS concludes the solutions from Microsoft and dbMotion are the most functional. The other top vendors include Medicity, PatientKeeper and CareFx.

Greenway Medical Technologies and Navicure partner to offer more integrated solutions and services. Both are “Best of KLAS” winners in their respective areas.

Perot Systems announces its Q4 financial results, which included a profit of $29 million, compared to $44 million in the same period last year. Perot blames the bulk of the 34% drop in profit on a client termination.

iMedica names Mark L. Richards its new VP of Sales. Prior to iMedica, he was the divisional VP of group practice sales at McKesson’s Physician Practice Solutions business unit.

Data Dimensions, a provider of business process outsourcing services for healthcare, promotes Jon Boumstein to CEO.

SCI Solutions wins three eHealthcare Leadership Awards for its Consumer Portal self-scheduling application. The awards included Best Business Suite, Best Overall Internet Site, and eHealth Organizational Commitment.

Healthvision closes the fourth quarter with 22 new client engagements.

Infinity Healthcare Solutions partners with Stratus Technology to resell Stratus hardware, software, and service products.

NextGen announces that AltaMed Health Services (CA) and Valley-Wide Health Systems (CO) have selected its enterprise software solutions. Both are community healthcare facilities.

E-mail Inga.

Readers Write 2/12/09

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

Note: the first two articles were added as comments to previous articles, but because of the large number of links they included, they were automatically discarded by the blog spam-catcher, so I never saw them. I do not censor comments except in extreme cases (ones I’ve gotten include claims of past criminal records by named individuals, obvious vendor pitches disguised as a reader comment, and personal attacks – those I will either delete or edit). So, if you left a comment and it hasn’t appeared within a day or two, e-mail it directly to me.

Comments on MD Leader 1/27/09, Ministry Health and CattailsMD
By Pragma

Thank you for including links to back up your statements with peer review evidence. A good effort. It’s something we don’t see here often.

“EHRs Do Not Improve Quality” Your link to a study conducted between 2002 in 2004 (released in 2007) about ambulatory-only EMR systems, peer-reviewed, but disputed by many (even at the time). It is worth noting this is not a study referenced by… well anybody, in two years! And in medicine that wouldn’t hold up very well. Is it really that cut and dry? That clear?

http://www.bmj.com/cgi/content/full/bmj%3b330/7491/581
http://www.itif.org/files/HealthIT.pdf
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2253693
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=685103
http://www.cchit.org/about/casestudies/index.asp
http://www.fhin.net/eprescribe/Benefits/AdvantagesToProviders.shtml
http://www.fiercehealthit.com/story/ehrs-boost-quality-raise-costs-at-community-clinics/2007-01-22
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1479999

There are other studies. Often peer reviewed and indexed. I could go on and on and on … and on. But wouldn’t it be worth people doing the research themselves? This is medicine, the last time I checked it was a science. Let’s do the clinicians the service we expect of them.

Your basic statement is a truism, but it’s an obvious truism (or it should be). It’s not the EMR, it’s how it is used. How it is customized, and how the data is normalized and utilized. We must be cognitive of EMRs allowing the customer flexibility. EHRs do enable this. Paper does not. Paper and EHRs are just tools. And humans are pretty good at using them, when they are not given reason to not use them.

I am sure in Egypt there were many who railed against the failures of papyrus. Who advocated for more use of stone. Well they lost, and we as humans adjust. Cows? Not so much. I happen to think clinicians are better than cows. I have seen this. I have actually seen Doctors say they have seen the benefits and enjoy using an EMR! Wow! Kinda goes against everything people are saying here, right? Sometimes reading this site I think clinicians are cows. Who simply must have workflows duplicate their paper world exactly. So isn’t the question what are these people doing wrong? Because it can be right.

Wouldn’t a more constructive argument from the detractors be, “Which is the best EMR for quality, and why?”, not, “They do not work”, “There is no evidence”, “it’s a waste of money”? You wouldn’t know this from reading HIStalk, but there really is far more, recent, peer-reviewed empirical data to show they do. The truth is…. ahem.. out there?

Anyway, it’s an old and fruitless argument. They will be implemented, it’s just a case of how well. The people who care, and do not have an agenda, will ask questions such as “how do we make them better”, “How do we increase quality with available data”, “Isn’t all this data GREAT! What are we going to do with it!”, “Ok we have an EMR, now let’s try doing something for the Doctors, give a little back for the extra time they spend documenting”, “How can we make a logical thing like a computer, mirror illogical real life workflows?”, “How do we stop decision support annoying clinicians, so the continue to use it and not just click OK?”, “How do we take hospitals from hugely political organizations to ones that’s make decision to a truly best practice?”. The others often show their clear lack of objectivity.

Comments on the Interview with Glen Tullman, CEO of Allscripts
By Al Borges, MD

Dear Mr. Tullman:

Thank you for coming on HIStalk for an interview. This site is read on a daily basis for those of us with an interest in HIT, and having you come to visit is wonderful.

Didn’t President Obama pledge not to surround himself with lobbyists? Aren’t you, your company, and your coworkers the ultimate lobbyist group, showering Obama with donations for the past two years alone? From what little I could find on the Google, you personally gave President Obama at least $144,300.00 in donations in the two years prior to his election (1). Your employees gave $20,662 during the same period (2). Your company, Allscripts/Misys, also gave the possible future HHS Secretary Daschle $12,000 speaking fees on 8/2008 for a lecture (3).

Now this activity seems to have put you into the unusual position where you are the personal advisor of the President of the United States of America on how to channel money to your company, ultimately enriching yourself while the American taxpayer, and especially doctors have to foot the bill. President Obama has put the wolf to guard the hen house!

You can’t believe how much I resent the fact that you, a vendor selling a product, is now in a position of power where you can determine how Medicare pays me, a physician. I’m sure that I’m not the only doctor out there that feels this way. Unlike you, I don’t have the lobbying power to get Obama’s ear. You’ll be able to sign up in the short-term those who already have EMRs, but once you get close to 20% uptake of these incentives, you’ll begin to bump up against the less CCHIT-certified-EHR-hard-core, more knowledgeable physicians like myself who don’t want to buy into a multi-thousand dollar EHR to please the likes of the Medicare pinheads in order to be able to get paid adequately for our work.

What this bill will eventually do is to damage Medicare as physicians refuse to see new Medicare patients or dis-enroll altogether. It also will begin the process of destroying the small solo to group office over the next 10 years, offices where 75% of doctors work in currently. These offices won’t be able to survive under the burden of these unfunded, onerous, unneeded mandates that you are trying to promote to satisfy your agenda. Students will think twice before going into medicine if not only do they now have to pay off their loans but also pay for a $30,000.00 CCHIT-certified EHR, and worse yet, use it.

Lastly, you mention that “[CCHIT-certified EHRs are] a benefit to all of us in terms of quality and also in terms of cost reduction” without there being any real data showing such. In fact, there is data showing the opposite(13). Recently we’ve had alerts about data input errors from both the JACHO and the US Pharmacopeia (4,7-12). You have the National Research Council finding that HIT systems used by several major health providers has fallen short of achieving healthcare delivery goals envisioned by the Institute of Medicine (5). Recently, two HIT experts have penned an open letter to President Obama, warning him against investing too many federal dollars in existing electronic health records systems(6). David Kibbe, MD, a technology adviser to the AAFP, and Brian Klepper, PhD, founder of consulting firm Health 2.0 Advisors, stated that existing EHR systems are:

• too expensive
• difficult to implement
• disruptive to practice workflows
• not proven to improve patient care, and
• don’t do a good job of sharing information with each other.

So Mr. Tullman, do the right thing and stop the insanity of using taxpayer money to bail out a portion of the economy that doesn’t need the economic help, at least not in this way. If you can do me a favor — show this letter to the honorable President Obama so that he can get an idea of how the other side feels.

Sincerely,

Dr. Borges

Citations:

1) http://www.campaignmoney.com/political/contributions/glen-tullman.asp?cycle=08
2) http://fundrace.huffingtonpost.com/neighbors.php?type=emp&employer=ALLSCRIPTS
3) http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=389×4968435
4) http://www.jointcommission.org/NewsRoom/NewsReleases/nr_12_11_08.htm
5) http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090109/REG/301099965/-1/TODAYSNEWS
6) http://medicaleconomics.modernmedicine.com/memag/submitBlogEntry.do#blog_confirmation_anchor
7) http://www.ama-assn.org/amednews/2005/01/24/prsa0124.htm
8) http://www.jamia.org/cgi/reprint/14/3/387.pdf
9) http://www.nytimes.com/2005/03/09/technology/09compute.html?ei=5089&en=402b792e748d99a2&ex=1268110800&adxnnl=1&partner=rssyahoo&adxnnlx=1150474153-xVix1BcYkvTKJpuLyHStrQ
10) http://jama.ama-assn.org/cgi/content/abstract/293/10/1197
11) http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm
12) http://www.usp.org/products/medMarx/
13) see my 2 slideshows located here (~130 slides full of data)- http://msofficeemrproject.com/Page3.htm

Why Doesn’t Someone Propose a National EMR?
By Winston T. Goode

While I appreciate the commitment to healthcare that "billions a year for x years" represents, I can’t help but think that we’re trying to plug leaky faucets with fistfuls of money. Electronic Health Records are not a goal, Electronic Health Records are a tool, and they will only realize their potential if they are installed in the pursuit of a loftier goal.

The Apollo program was not funded as a $135 billion exercise in building rockets. Knowledge is the most powerful and most capricious tool we can bring to bear on our health. The ethics of healthcare often prevent controlled, double-blind studies, meaning that often useful knowledge can only be attained post hoc and en toto. Sorting through the interactions of multitudinous variables and extracting a modicum of causality to use for the betterment of all is not a challenge that can be met by a single doctor, or often even a single health system.

The barest hints of the potential of EHRs we’ve seen already. How many years did we spend collecting information on tobacco use? How many patients died of Vioxx-related heart failure before we managed to make a
connection? We would have known more, sooner, if we had a nationwide EHR infrastructure.

As the benefits of EHRs are society-wide, so to should be the scale of the tools and projects used to implement them. Providing for the health of a population is not a project that can be funded piecemeal with
earmarks and pork, run through unaccountable cronyism, or bloated bureaucracies. Nor is it a project that can be handled by the private sector, or tax breaks, or ‘small government’ rhetoric. It must be above either party,
and across government agencies. 

We need a national EHR project to realize the benefits of an EHR. Otherwise, EHRs will continue to be yet another false idol of future technology on which we will have squandered our wealth and potential. This should be a grand endeavor, not limited only to healthcare, but spanning industries from agriculture and education, to law enforcement and government. We must exert control on those variables that correlate to our desired outcome,be they chemical,  behavioral or other. This must be a results-focused, not rhetoric-focused enterprise.

Privacy advocates rightfully fear the ways in which this information may be abused. There must be protections and opt-outs put in place, but it should not be a system that people will want to opt out of. No one is forced to use U.S. dollars as a form of currency. No one is forced to open a bank account or use a cell phone despite the obvious privacy risks these present. We should have the healthiest, and longest lived, population in world.  EHR’s can help us with this goal.

I sincerely hope there is someone in Washington with the vision and leadership to harness the vast potential of EHRs to better the health of all. But I’m sure not seeing it at the moment.

News 2/11/09

From Brailer’s Revenge: "Re: another non-profit seeking hospital and vendor members. Most hospitals would have to ante up $8-20K for a seat at the table. Not clear what you get in return." Link. The National eHealth Collaborative’s initiatives include prioritizing standards initiatives and NHIN (it’s the AHIC successor, as it was known for awhile). It was just launched last month and John Glaser (who’s on its board) described it right here on HIStalk right after that. It’s a pretty big deal, especially with stimulus money coming and some structure needed around it, and entirely above board. I don’t know why hospitals would join either, but if they’re spending big money on EHRs, they at least get some voice in long-term direction. And, coincidentally, right after I wrote this, I got an e-mail from NeHC communications director Meryt, who sent over a newly released white paper developed with HITSP and CCHIT (fulltext on John Halamka’s blog, which saves me having to post it) that lays out their vision.

From Ex IBM’er: "Re: Healthcare and Life Sciences. Several folks RIF’ed out today."

From The PACS Designer: "Re: Alfresco. Enterprise Content Management is becoming more in demand by healthcare professionals and one free software solution addressing ECM is called Alfresco. HIStalk sponsor Red Hat has some experience with being an Alfresco installer and can help those who are interested in this software solution." Link.

From Cloud Jumper: "Re: alternative to HIMSS. Maybe you could do something like the TED talks, where the coolest people could give their talks to cool savvy people in the audience and it’s all on video so we can watch it later if we were uncool enough not to be invited. You could get the vendors to do tasteful little ads in front of each video, as TED does, to pay for it." That would be fun, although healthcare is so profit-oriented and fiercely protective of turf even on the non-profit side that the cool factor is turned down several notches (kind of like being the heppest cat at HFMA). Still, it would definitely be different than the mainstream conferences, where the same old faces exaggerate their successes with the same old ideas prettied up to seem more daring and contemporary. But, the one article commenter was spot on: HIMSS can only put people on stage who volunteer to be there, so those who have never been a speaker or committee member have no excuse to gripe about the result (I have, so I can). That’s one of my HIStalk goals, though — to showcase the good ideas of people who don’t have the time, money, or ego needed to ride the PowerPoint Podium.

The Senate passes the economic stimulus package and Kaiser Family Foundation has a summary of it (the current version, until a compromise is reached with the House). The Senate’s bill calls for $19 billion for HIT vs. $20 billion in the House bill. Both sides want to give Rob Kolodner’s previously shoestring-funded office incomprehensible amounts of "discretionary" funds, $3 billion vs. $2 billion (is anyone a little scared of that?) Surely up for heated debate: the Senate’s bill punts on privacy, while the House calls for strict privacy protections. Wall Street wasn’t exactly overjoyed with the grim reality of this financial Hail Mary or the worse-by-the-day bank bailout; the major indices all dropped nearly 5% on Tuesday.

Speaking of that, the former lieutenant governor of New York weighs in with Ruin Your Health With The Obama Stimulus Plan. She says senators should vote against what she calls "the handiwork of Tom Daschle": ONCHIT as a big new bureaucracy, government interference with physician decisions, and intentionally slowed development of new drugs and technologies because they’re expensive. Daschle, she says, thought seniors should deal with conditions that come with old age instead of being treated for them, moving dollars to younger people (as cold as that sounds, I’d have to agree at least in general). Here’s the big finish: "The health-care industry is the largest employer in the U.S. It produces almost 17 percent of the nation’s gross domestic product. Yet the bill treats health care the way European governments do: as a cost problem instead of a growth industry. Imagine limiting growth and innovation in the electronics or auto industry during this downturn. This stimulus is dangerous to your health and the economy."

Add Rush Limbaugh to the list of HITECH haters. From his Monday show: "Your medical treatments will be tracked electronically by a federal system. Now there are arguments back and forth about whether or not this is a good thing. The opportunity for the loss of privacy is huge here … by digitizing and making everybody’s healthcare records computerized … especially having a major federal database where everybody’s health records are." I’m conservative and even I can’t stand that pompous gasbag, so I can’t imagine who’s still listening to him.

The New York Times just published a piece on HITECH, citing a letter that urges not just throwing EHR money at doctors, but also distributing lessons learned via "Regional Health IT Extension Centers" to help out with projects in small medical practices, which sounds like a great idea. You will note that the letter (warning: PDF) has few vendor signatories, unsurprisingly.

Cerner’s Q4 numbers, announced after the market close: revenue up 18%, EPS $0.86 vs. $0.49, thrashing expectations of $0.59. Say what you want about good old Republican boot-strapper and plain-speaking Neal, but the man knows how to run a company better than those big, fancy foreign conglomerates choking on healthcare IT and everything else they toe-dip into. Thank goodness for MEDITECH, Cerner, and Epic, run by the founders instead of hired gun Wall Streeters and sticking to their healthcare IT knitting instead of selling nuclear weapons, theme parks, and jet engines (not to mention toxic assets to taxpayers in one huGE example).

I got a couple of e-mails suggesting that Medical Records Institute, the folks who run TEPR, have laid everyone off and closed down. I’m sure that’s somehow tied in with their new focus and conference, but perhaps the change was more severe than was hinted. I’m sure updates will follow.

Listening: Seether, South African metallish grunge.

IBA/iSoft gets two contract extensions with Netherlands hospitals.

A surgeon in Australia develops a USB emergency button that, when pressed, sends a message to all PCs on the network along with the location of the sender. He created it after noting that several doctors had been killed by patients.

Allscripts announces that it will sell its Medication Services business (I asked Glen Tullman about it almost three years ago). The company also approved a $150 million stock repurchase plan.

Hospital layoffs: Columbia St. Mary’s (WI), 54; Cascade Healthcare Community (OR), 74.

Jobs: FCP-MS4 Patient Accounting Expert, McKesson Horizon Lab Consultant, IT Director.

Healthcare Growth Partners publishes its Q4 2008 Healthcare IT Transaction Summary & 2008 Year in Review (warning: PDF).

IBM and UnitedHealth test the medical home model, in which a primary care physician (not a gatekeeper) coordinates care among other medical professionals, often by using information technology. I’ll defer to Scott Shreeve, who provides a better synopsis than I can.

Interesting: hospitals that hire doctors often write employment contracts that don’t allow the doctor to contact patients if he or she leaves and also prohibits them from opening a practice within a specified radius. Patient are also charged large amounts to have their paper records copied so they can seek care elsewhere. Noncompetes are standard in business, in case nobody noticed that even non-profit healthcare is one.

A third of Australian healthcare and IT professionals say they’ve experienced compromised patient safety due to IT downtime.

Idiotic lawsuit: an admitted alcoholic on a two-day bender (more like a "breaker" in this case) in a Marriott falls more than 100 feet off a stairway while drunk, causing what he says is permanent brain damage. He’s suing the hotel for serving alcohol to an addict (him) and thereby causing his injury. He’s claiming injury, pain and suffering, anguish, disfigurement, medical expenses, loss of earnings, loss of the enjoyment of life, and aggravation of a previous condition.

A laptop stolen from Parkland Hospital (TX) last week may contain information on over 9,000 employees.

Availity announces the availability of real-time Florida Medicaid eligibility and claims status at no charge.

E-mail me.

HERtalk by Inga

From Ronald Miller: ”Re: Henry Schein. Former MED3OOO VP Keith Slater is now the GM at Henry Schein Medical Systems. Good move for Henry Schein. It was only a matter of time until they figured out they had NO CLUE how to deal with a PM/EMR product after spending all that money on it. Maybe now the button ups at Schein will do a better job than Pfizer did with Amicore.”

From Jerry McGuire: “Re: Great piece today with Allscripts CEO on stimulus. From your piece, it seems the curious angle is identifying when IT does and doesn’t serve as a stimulate function. Maybe a virtual roundtable?” We’d love to hear readers’ opinions on what IT functions could stimulate the economy.

The Washington Post posts a graphic that breaks down the $819 billion stimulus package. It doesn’t say where the $20.2 billion for HIT is going, much less what part of IT is stimulating, but it is a pretty impressive graphic.

Caritas Healthcare (NY) files for Chapter 11 bankruptcy protection and its two hospitals are projected to close this month. Caritas had a net loss of $64 million for 2008, prompting the board to vote to close Mary Immaculate and St. John’s Queens hospitals.

QuadraMed announces that revenue for FY08 will be slightly ahead of the $146-149 million guidance previously provided. The company also expects EBITDA to significantly exceed the previous $15.8 million target. Reading between the lines in the press release, Keith Hagen sounds a bit cautious when discussing 2009 and the company’s potential for new business: “Approximately two-thirds of our revenues are produced by recurring maintenance and term license contracts, and a large percentage of our 2009 revenue is expected to be generated by this recurring base, our project backlog, and our broad set of products and services."

The 25-bed Hiawatha Community Hospital (KS) becomes the 55th hospital to go live on IntelliDOT’s BMA system.

Catholic Health Initiatives names Michael O’Rourke its permanent CIO and senior VP. He’s been interim CIO since August 2008 for the 77-hospital organization.

Capsule announces that 10 new healthcare organizations selected its device connectivity solution during the last quarter of 2008.

Marshfield Clinic (WI) adopts a new BI solution to make better use of its vast amount of patient data. Marshfield will utilize SAP’s Business Objects XI intelligence system to improve patient care and analyze internal business operations.

Eclipsys announces that Greenwood Pediatrics (CO) has selected Eclipsys PeakPractice (the former Medinotes PM/EHR solution). The 10-physician group apparently chose Eclipsys over Epic, which their hospital offered to subsidize.

A former Queen’s Medical Center (HI) administrator pleads guilty in federal court for defrauding her former employer out of $594,000. Patricia Syling is accused of creating bogus contracts between a company she owned and Queen’s, and charging the hospital for services that were not performed. Syling was hired by Queen’s in September 2001 as the corporate compliance administrator and director of revenue cycle. In an unrelated charge, Syling is also accused of defrauding another former employer, Citrus Health Care of Florida, of more than $1 million and using $320,000 of the proceeds to buy a luxury sky box at Tampa Bay Buccaneer football games.

The McKesson Foundation awards $60,000 in grants to nine Minneapolis-St. Paul-area non-profits. The funds will be used to support health and wellness programs benefiting children and families.

A Texas Medical Association survey finds that doctors worry their financial hardships threaten quality of care and access. Declining payments, claim denials, incorrect or late payments, and administrative burdens are taking time away from patients.

The University of Chicago Medical Center (the First Lady’s old haunt) plans to cut 450 jobs in order to cut 7% off its annual budget. This is in addition to the elimination of 15 senior executive posts, including the one vacated by Michelle Obama (we’ll try not to be cynical about the huge raise UC gave her just before Obama won using the rationale that she was essential and therefore worth every penny).

MRO expands its services to include remote release-of-information processing and remote and staffed services.

HIMSS Analytics releases a list of the top vendors of acute care EHR systems based on total number of installations. For 2008, MEDITECH topped the list at 26.6%, followed by McKesson (14.1%) and Cerner (12.6%). I wonder how the rankings would end up if the list were based on number of total beds?

The octuplet story just gets crazier and crazier. Apparently the mom’s fertility doctor is not as successful as most doctors around the country, with his patients having much lower than average rates of pregnancies and births. Also, at least two former employees have sued him, including an office administrator who accused Kamrava of tax and insurance fraud. The office manager claims the office kept two sets of books, one for cash and the other for insurance, and some cash was never entered into the computer or deposited in the bank. Meanwhile the Kaiser Permanente hospital where the children are receiving medical care is requesting Medi-Cal funding to help pay for the octuplets’ medical care since Mom is unemployed, living on food stamps, and mostly letting her mother raise her first six children.

Compuware’s Covisint subsidiary collaborates with the VIP Health Initiative to provide a secure single point of access to share clinical data. The VIP Health Initiative was formed by Scripps Mercy Physician Partners, SMPP Services and Physician Partners Management Services.

Despite massive financial losses as a result of Hurricane Ike, UTMB Galveston intended to pay $3 million in bonuses until a faculty group discovered the plan. According to the Texas Faculty Association, once the bonus plan was uncovered, UTMB canceled the payments. The largest bonus recipient would have been the school’s executive VP, provost, and dean of medicine, who was scheduled to receive over $122,000 – on top of his $700,000 annual salary. The school claims it was planning to cancel the bonuses anyway.

E-mail Inga.

MD Leader 2/10/09

The Stimulus Bill Will Change How IT Data is Used in Healthcare

At this writing, the Stimulus Bill has not been passed, but it will change how we use IT. The funding and implementation incentives will get all the press, but it is the fine print that has the potential to change how IT healthcare information is used.

The Stimulus Bill will restrict use of healthcare data. To date, the biggest areas of concern have been:

• The use of patient consent for internal healthcare operations;
• Revised definitions of healthcare operations limiting use of patient information (potentially including use of patient information for quality reporting);
• Accounting for of all disclosures, even for treatment;
• Patient consent for information use by a healthcare exchange;
• Extending privacy and security rules to business associates.

None of these issues may appear in the final bill and additional elements can be added at the last minute. The legislation is moving fast and there will be unintended consequences. How government chooses to enforce the provisions and how our own organizations choose to interpret will determine the impact on our operations.

When the final bill is signed, evaluate the direct economic impact. Also be sure to look for additional provisions that will change how healthcare uses data.

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

CNN: Compromise Stimulus Bill Eliminates All $2 Billion of HIT Grants

CNN reports that the slimmed-down economic stimulus bill being debated by Congress has had the $2 billion line item earmarked for healthcare IT grants removed as part of a cost-cutting compromise.

The original House plan called for $2 billion in HIT grants plus another $18 billion to be managed by CMS in the form of pay-for-performance incentives. Details of the current plan being debated have not been released.

UPDATE: a reader sent over a worksheet provided by his Senator. The House had originally proposed $2 billion for ONCHIT, while the Senate had proposed $5 billion. The proposed compromise calls for a $2 billion reduction from the Senate’s proposal, leaving $3 billion, which is still $1 billion more than the House had suggested. Those aren’t final numbers.

UPDATE 2: Here’s a link to the current version of the bill as of Monday morning (warning: PDF). The HIT grant part is on page 139, but here is the full text:

OFFICE OF THE SECRETARY
OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH
INFORMATION TECHNOLOGY (INCLUDING TRANSFER OF FUNDS)

For an additional amount for ‘‘Office of the National Coordinator for Health Information Technology’’,  $3,000,000,000, to carry out title XIII of this Act which shall be available until expended: Provided, That of this amount, the Secretary of Health and Human Services shall transfer $20,000,000 to the Director of the National Institute of Standards and Technology in the Department of Commerce for continued work on advancing health care information enterprise integration through activities such as technical standards analysis and establishment of conformance testing infrastructure so long as such activities are coordinated with the Office of the National Coordinator for Health Information Technology: Provided further, That funds available under this heading shall become available for obligation only upon submission of an annual operating plan by the Secretary to the Committees on Appropriations of the House of Representatives and the Senate: Provided further, That the Secretary shall provide to the Committees on Appropriations of the House of Representatives and the Senate a report on the actual obligations, expenditures, and unobligated balances for each major set of activities not later than November 1, 2009 and every 6 months thereafter as long as funding under this heading is available for obligation or expenditure.

Monday Morning Update 2/9/09

From Doug DeCinces: "Re: E&Y. E&Y is shutting down its Health Sciences Advisory Services practice. At least 100 employees at all levels (partners and down) are losing their jobs." Unverified.

From Skeptic: "Re: TEPR. They’re claiming 800 registrants, which is pathetic even if the number is accurate. They’re also claiming that a common comment was ‘best program in 25 years.’" The only positive comment I’ve heard is that the weather was good. Now that HIMSS is eating the universe, it’s like the NIT basketball tournament once the NCAA expanded to 64 teams. If someone really wanted to offer a HIMSS alternative, it would need to be a lot cooler and a lot brasher. I’m thinking I’ll start a BIL conference or an unconference whose whole agenda is like the interesting, less commercial hallway meetings that are usually the best part of any conference. Those could be held at cooler, smaller, cheaper locations than the tired old Orlando-Las Vegas-Chicago circuit of mile-long convention centers and $15 room service burgers, like an HIT Chautauqua that leaves you educated, rejuvenated, and not embarrassed that your employer’s time and money were wasted.

From Kate: "Re: medDispense. Emerson (NYSE: EMR) bought them last month for an undisclosed amount." I confess that I didn’t even know that automated drug dispensing vendor medDispense was still around. Trivia: they started as a division of HCS, the Montgomery, AL software vendor who sold McKesson what is now Horizon Meds Manager. Emerson makes heavy duty commercial stuff like power plants and air conditioners. Not too successfully of late, apparently, since the company announced late Friday that it will axe 14,000 employees, more than 10% of its workforce, by October. The sale went through on January 15.

From Tarhill: "Re: HHS secretary. Has anyone heard if Newt Gingrich might be a candidate?" Well, like Daschle, he’s written books and held high political office. The similarities end there. Maybe he would be a good choice, but he brings a lot of baggage, is on the wrong ideological side, and would never fully trusted at the level Daschle would have been. The problem is that all the plans were built around Daschle, so he’ll be tough to replace even if the job is split into two (advisor and HHS leader). I hesitate to say this, but I’m not convinced he wasn’t the best choice despite questionable industry ties. Sure, it’s iffy that he was paid millions as a non-lawyer working for a law firm in ways that sure seem to indicate off-the-books lobbying, but if Obama wants political experience, every closet has a surplus of skeletons.

From Vendor Guy: "Re: QuadraMed. Heard a rumor that QuadraMed is getting to pull the plug on the old Compucare/Affinity product." Half accurate, as I suspected and Inga confirmed with a company spokesperson. QuadraMed recently notified existing Affinity Clinical customers that Affinity Clinicals will not be supported after 1/1/12. This is hardly a surprise: they were very clear with the QCPR acquisition that Affinity Clinicals weren’t up to snuff and that QCPR was a far better solution that would be the go-forward offering. However, the far, far more widely installed and much better Affinity Registration/Access and Revenue Cycle products aren’t going anywhere. See also the interview I did with CTO Jim Klein in HIStech Report: "We had to be frank with ourselves. The Affinity clinical system, unlike the patient accounting system, had not kept up with functionality. Both ‘build’ and “buy” options were viable, but people’s expectations about how the team could turn things around just screamed ‘buy.’" They’re offering deals and extended Affinity Clinicals support to customers who move to QCPR.

HIMSS just won’t seem the same without MEDITECH and Cerner there, will it? Maybe that’s a good thing. Past excesses at all levels (individual, business, and government) make it appropriate to tone down the boat show (and that MEDITECH, as the always-frugal but huge vendor, lead the way after Cerner). Non-conspicuous consumption is "in" again, thank goodness. The big question: will other companies follow their lead? My pledge: I will not criticize or allow criticism here of any company that decides to refocus their resources on something other than the HIMSS conference. Each vendor has to decide for themselves whether it’s worth it. Even if there’s little money to be saved by pulling out at this late date, I think both providers and vendors are cautious about appearing extravagant. I’ll be there, but I’ve always been a complete cheapskate, like subsisting at last year’s HIMSS on Subway sandwiches and going for the cheapest hotel on the bus route. I did buy a can of soda one day, but griped constantly about the cost to anyone who would listen.

Sisters of Charity of Leavenworth Health System (KS) sues Lawson Software for retiring "critical" applications it bought in 2001 for $1.4 million. Lawson says it will end support in May 2010 for employee time off tracking and medical supply inventory management. Their contract says they can exchange their applications for other similar ones for a nominal fee, but Lawson wants another $155K in licensing fees plus increased maintenance because their only other similar applications have additional capabilities.

A Sacramento publication (I’m guessing it’s one of those free counterculture weeklies that features wildly liberal articles, ads for sex chat lines, and good restaurant and concert reviews) takes on EMRs, managing to make Britney Spears the focus. Here’s a fun snip: "It [Kaiser] developed two versions before settling on its current HealthConnect project using Epic Systems software (which is quickly becoming the national standard for EMRs)." Popular, but a national standard? It may be an obscure publication, but Deborah Peel of Patient Privacy Rights found the article and left the only comment it has received, calling EMRs "dinosaur technologies" and urging readers to contact Congress to vote no on HITECH unless privacy provisions are added.

Clarian Health (IN) shuts down a $475 million construction project as part of an urgent cost reduction project that includes 10% pay cuts for VPs and efforts to renegotiate vendor contracts. More than 400 construction workers were immediately put out of work, some of them finding out only when they arrived at the job site Friday morning.

The University of Virginia Health System gets approval for a new $59 million EMR project. The vendor isn’t named, but I’d have to guess Epic given (a) the price; (b) the line about access to records anywhere on Earth; and (c) the fact that nobody’s selling any big deals these days except Epic (the hippie weekly may be right). I believe UVa was IDX/CareCast, so I assume GE Healthcare will be losing another customer.

Kaiser Permanente announces that a recently arrested non-employee had a computer file containing KP employee information, source unknown. They offered the usual free year of credit monitoring.

I’ve closed the two polls on economic conditions. Results: EMR vendor people say they’ve seen slowdowns because of the economy (68%) and because prospects are waiting to see if the government will help them purchase (11%). Only 21% say it’s business as usual with no slowdowns (it would be interesting to know which companies those are!) On the provider side, 54% of those considering an EMR purchase say they’re moving forward without planned delays, 38% say they’ve delayed their project because of the economy, and 8% say they’re waiting on possible government help. Respondent counts were 47 vendors, 26 providers. It appears that the possibility of government handouts isn’t holding many prospects back, but the economy definitely is.

New poll: if you went to HIMSS last year, what are your plans this year and what’s your employer doing? It’s awkward to phrase the question in a poll, but I did it this way: indicate whether you’re going or not, and then whether your organization is sending fewer people or not. People keep asking me how I think attendance will be; I can’t imagine it won’t be down, but conventions are like sporting events: fan-flation uses the most flattering number — turnstiles or ticket sales. I care less about announced attendance than what vendors tell me they’re seeing in the exhibit hall since, let’s face it, that’s the metric that drives conferences.

The Virtual Practice Project at Mass General is working on a medical kiosk that walks patients through touch screen-answered questions and checks blood pressure. The doctor in charge explains: "The way we deliver traditional health care is a bit antiquated. It’s based on face-to-face interaction between the doctors and the patient." I found this report (warning: PDF) which mentions that RelayHealth is providing some of the online visit technology.

The unSummit for Bedside Barcoding will be in Tampa May 6-8. Good agenda, good hotel, and CEUs for nurses, pharmacist, and lab techs. You save money by signing up by February 28.

Here’s a TV show that I hope has met its much-deserved demise: "Flip This House." When Joe Sixpack starts thinking he’s an expert in day trading, commodities speculation, and real estate investing, it’s time to run for the hills.

I think it’s obvious, but for any newcomers, you will want to read the article comments because some thoughtful conversations are to be found there. If you’ve clicked the e-mail link, you’ll see them automatically, but readers will post comments after you’ve read it. To see those, click the Home link at the top of the page, then click the "show comments" link at the bottom of the article. I’m pleased that folks comment quickly, knowledgeably, and respectfully, offering a nice mix of opinions (I don’t claim to be right all of the time and readers sometimes change my mind).

Also for newbies: add your e-mail address in the Subscribe to Updates box at the upper right of the page and you’ll get instant e-mail updates when I write something new (surely you want to be among the first to know — you should see the server drag when hundreds or thousands of people all hit the site at once when an e-mail update has gone out). The Search box does a Google custom search on HIStalk and HIStalkPractice combined, all 5.5 years worth (I may have mentioned your company, your boss, or you in those millions of words). Also, click that "Email this to a friend" graphic to alert some e-mail pals about an HIStalk article or click the horrid green Rumor Report box to tell me a secret.

One more update: someone asked for the "Print This Post" option that used to be here, so I’ve re-installed that function that I didn’t realize had gone astray. The link is at the bottom of each article.

Inga did a couple of cool interviews on HIStech Report. Our old friend John Holton of SCI Solutions provided his usual honest, experienced assessment of the industry ("PHRs are being developed by Microsoft and Google and others. It’s the way information will be stored and sent because no one really cares about your medical history except you.") She also talked to Bruce Cerullo of Vitalize Consulting Solutions, another friend of HIStalk who I had fun with at last year’s HIStalk HIMSS event ("Having really good people wanting to come under our umbrella is a win for them, a win for us, and a resulting win for our clients. I also think there will be a lot less job-hopping in general over the next 12 months. I believe we will see more stability among the consultant firms.")

Bizarre: Wuesthoff Health System (FL) is offering patients from competing hospitals $100 gas cards for a copy of their EOB. They want to see how they stack up on charges. Maybe they got the idea from Scott Shreeve’s Million EOB March.

Like it needed more bad news: Grady Hospital (GA) may be the source of four patients’ Legionnaires’ disease, which allows Legionella and attornii scumbaggia to thrive at the expense of normal species.

Four employees of Somerset Medical Center (NJ), one of them the hospital’s credit manager, are charged with altering patient bills to trigger $35,000 worth of refund checks made out to the four and sent to the same address. That doesn’t seem like a very smart plan coming from someone in management.

Idiotic lawsuit: a couple attacked and beaten in their home are treated at Stephens Memorial Hospital (ME). A security guard hears them talking about being attacked and calls police, who check out their house and find 95 pounds of marijuana, for which the couple pleads guilty. They’re suing the security guard and the hospital, claiming violations of HIPAA and state confidentiality laws, violation of privacy, and emotional distress.

E-mail me.

Report from the Field
Nick van Terheyden on TEPR

For those coming from the fully winterized East Coast and Midwest in February, any location that has a temperatures rising above 35° is going to be attractive, but Palm Springs would be hard to beat. Set in the shadow of the San Bernardino Mountains and weather that sat in the mid 70s and provided clear blue skies every day was a delight. The conference itself has clearly seen better days and estimates ranged from the “official” ~7-800, to my unofficial count at opening keynote of 4-500 to overheard “only 320 rooms sold." Whatever the number, it was small and often felt overrun with presenters and vendors.

AHIMA felt similar this year, with a distinct feeling that there were fewer attendees and several anecdotal stories of cancellations to save money. Even the RSNAathon was lighter than previous years, but with such large numbers to start with, the decrease has less impact. Fascinated to see how significant the effect will be on HIMSS.

The opening sessions were great, and like or not Adam Bosworth’s views on where to spend the $50 billion stimulus, he had a compelling story that was not about technology investment (surprising for an acknowledged pioneer of XML) but centered on incenting behavioral change in the US population to stop the epidemic increase in American waists. But it was the Illness in the Age of “e” hosted by Danny Sands from Cisco and his patient Dave deBronkart that stole the show.

In an emotional and graphic account, the pair detailed Dave’s experiences from the first incidental finding of an aggressive form of renal cell carcinoma through intense and “often severe and rarely fatal” side effects to the closest thing you can hope, for next to cured: No Evidence of Disease, or NED. Insisting on patient participation to help guide the process, even check for errors (he cited a recent case of wrong side surgery for someone with the same renal carcinoma where they removed the wrong kidney!) that would have easily been prevented with patient involvement. Nothing to bring home the relevance of what we all work for than hearing right from the patient’s mouth. Dave (@epatientdave) stayed the duration, shook up several other presentations, and joined the impromptu TweetUp by the side of the pool on Monday night with @alphabest @HealthITGirl and yours truly @DrNic1.

But no social networking presence from the Medical Record Institute, and as I pointed out in my Tweet, “It’s so Web 1.0…. no blog, no tweet, one month before presentations will be online." There was some activity as @Megan_maguire weighed in, but a little late. (unlike HIStalk and HIStalk Practice that have wrapped their arms around these media, use it effectively, and participate jacked in just like Neo from The Matrix – which is how I feel a lot of the time!)

The panel discussion with Google and Microsoft and MedCommons was a bust – and an education in panel techniques. Hearing three replies, all similar, to each question was uninformative and boring … sigh. The case is made — we need disruptive attacks to the current status quo and that needs to come from innovators who shake up the system and incumbents. PHI will play a role and the individual will become a key player. The recurring focus on the big cash supposedly heading for our industry was in many instances distracting and in some cases potentially detrimental since the likelihood that the cash will end up steered towards those with the best advocacy and influence in Washington places additional strain on the small upstart that is trying to disrupt the status quo.

The final panel discussions on Thursday were like many conferences — poorly attended, and at one point the panelists outnumbered the attendees. However — a gem from one of the discussions: "CCHIT certified EMR = unusable" … but you can *upgrade* to a non-CCHIT certified alternative.”

There was little traffic in the vendor area, which was located at the end of a long walk past all the educational sessions and had limited opening hours. The main topic of conversation was the likelihood of anyone returning to the show or if there would be a show to return to.

Sadly for this long time attendee, this year’s TEPR felt too much like an Irish wake without the alcohol. Much of the oxygen has been sucked out of the conference circuit by HIMSS, which is unfortunate since smaller conferences offer more opportunity to really meet colleagues and vendors and gather information in a practical learning environment.

MEDITECH Pulls Out of HIMSS 2009

MEDITECH announced today that it will not attend the HIMSS conference in April, citing the expenses involved for both the company and attendees.

The statement of President and COO Howard Messing is as follows:

Participating in the annual HIMSS conference has proven to be beneficial to MEDITECH and LSS through the years, as we have been able to renew acquaintances, attract new customers, and showcase new product offerings there. Nonetheless, the current economic climate mandates we pay particular attention to spending resources wisely this year. Just as we encourage customers to make HCIS selections based on value, we too must carefully evaluate our expenses and focus on priorities. For this reason, MEDITECH and LSS will not attend the HIMSS conference this year. Instead we will use communication channels such as our extensive program of regional events, annual workshops, Webex demonstrations, and meditech.com to share information. Using this approach, we will be able to continue sharing information on key topics, control our expenses, and minimize everyone’s costs.

HIStalk Interviews Glen Tullman, CEO of Allscripts, 2/5/09

The recent Allscripts survey basically asked physicians if they would accept free EHR money. Does the overwhelmingly positive answer really mean anything?

I think it does. What is interesting about the recent survey is how it breaks out. Physicians have said that they would like money – even a small amount of money would create a very substantial stimulus toward not only adoption, but utilization.

We have seen the success of utilization incentives with the recent Medicare CMS program for electronic prescribing. In fact, in our electronic prescribing unit, we are seeing increases in subscribers on the order of 30% a month, so it’s a dramatic pickup. But what the survey really said is that smaller physician groups are more in favor of an up-front stimulus and larger groups are more in favor of the longer term incentives for utilization. So, small groups want help getting over the hurdle to buy an electronic health record, and larger groups, who have in many cases already bought it, are looking forward to the incentives for utilization.

Why should the government pay for specific tools rather than results, like they pay road companies to improve highways rather than just buying them bulldozers?

Well Inga, I think you’ve captured what is the essential argument on Capitol Hill, where I was yesterday. That is, there is a lot of push-back on whether or not physician groups should be given direct incentives versus incentives on utilization.

The government and most people consider the e-Rx program — the 2% credit for utilization of electronic prescribing and then a 2% penalty, in other words, a carrot and a stick — as being very successful. That is what the bill that is currently sitting on the floor looks a lot like. That said, the current bill does give the Secretary about $5 billion to provide direct stimulus and potentially direct incentive to physicians.

So, there are two different versions: a $20 billion House bill and a $23 billion Senate bill. We’re not sure which bill will be pushed forward, but it looks like in either case, the Secretary will have immediate discretionary funds in the order of $5 billion to award to existing channels or in new programs. Those can be used for loans, for some of the existing grant programs underway in states, and lastly, direct incentives to physicians.

However, our view is that the direct physician incentives will be targeted most likely towards primary care, toward rural physicians, and toward physicians in under-served areas, as opposed to the general physician population for the reason you just suggested — that is, some people are asking why physicians need the government to buy them tools.

Allscripts offers a free e-prescribing tool, yet your own survey indicates that the majority of physicians don’t e-prescribe. What’s the guarantee they’ll use a taxpayer-subsidized EMR in ways that will benefit patients or reduce costs?

Again, what we have seen is that if you reduce the hurdle for adoption and then provide incentives for utilization, we do see an impact that’s coming. That is what we have seen with the successful CMS e-prescribing program.

I think the idea — and again, that is what gets to the debate — to the extent you can provide incentives for utilization, we believe that’s a very compelling reason why a physician would want to use an electronic health record. 

Our view is that a blended model of some incentives for adoption, especially for those groups that might otherwise have trouble paying for an electronic health record — that includes smaller groups, that may include primary care physicians or rural physicians — incentives will help that group of physicians, which comprises a very large number of physicians in this country, get on the electronic health highway. And ultimately that is a benefit to all of us in terms of quality and also in terms of cost reduction.

A recent Harvard survey showed that only 17% of Americans think more government money should be spent to increase the use of healthcare IT, ranking it last of all the spending options. With all of healthcare’s problems, why is IT the one to address first?

Our view is that you can’t address many of the problems in healthcare without information. So for example, you will hear people talk about comparative effectiveness — which treatments are more effective than others. The only way you can get to that decision is to have vibrant information that comes from electronic health records.

Similarly, we all know and we have all seen the statistics from the Institute of Medicine and other studies that there are billions of dollars wasted. Those dollars are wasted in terms of tests that shouldn’t be done, those dollars are wasted in terms of the 7,000 Americans who die each year from preventable medication errors, and the million and half Americans who are injured from medication errors. All those are enormous costs and those could be prevented by electronic health records and electronic prescribing.

I think it would be as if you were to say you want to improve the banking system and you want to reduce the lines at the old tellers windows we used to wait in, but you don’t want to use computers to do it. It’s inconceivable that you could improve the banking system without using computers that allow you to pull out money from your account when you are in a foreign country using an ATM. We have to get healthcare to the same standard that every other industry is up to in terms of information technology.

I think the public looks at the more immediate problem. It doesn’t look at the infrastructure problem. It says, “We have people without healthcare, how do we help them?” and they haven’t always made the connection between how technology can help.

How important is a national connectivity infrastructure for creating EMR demand by patients and doctors?

I think connectivity goes hand-in-hand with electronic health records. In fact, that is really why we call them electronic health records rather than electronic medical records. What we want to be careful of is replacing today’s paper silos in healthcare with electronic silos. What we need and what the current legislation requires is interoperable healthcare records. Allscripts has always been a leader in that area. That’s what we need. It’s very important.

You might recall that when computers first came out, people said that we would reduce the amount of paper that we used, and yet the amount of paper that we used actually grew. But once computers were connected through the Internet, all of a sudden we saw everything, from the number of letters sent by the US mail, to all kinds of transactions, even holiday cards and holiday gifts, starting to be sent electronically. Why? Because of that connectivity. A computer is a tool, just like an electronic health record is a tool.

The ultimate goal is getting our physicians in the US — who are the best physicians in the world — getting them the best information at the right time so they can make better decisions. EMR is simply a tool to make that happen. You got to get that tool connected to other tools to make it effective.

Stark provisions encouraged some hospitals to align with their physicians through technology purchases. How would the hospital-physician dynamic change if HITECH passes?

Well, you are still going to see the passage of HITECH will frankly give hospitals more money to support programs like the Stark relaxation. Today our surveys tell us that somewhere between 10 and 15 percent of docs are getting Stark-funded electronic health records and similarly, 10-15 percent of hospitals are participating in Stark.

We think that number is going to continue to grow. Hospitals understand that they need to be connected to the physicians who in many cases give them the referrals that are its lifeblood; that is their business. So they want to be connected. We think relaxing the Stark regulations was a positive move by the government, and we think that is going to continue to grow, and it’s likely actually going to accelerate based on the funding that comes from HITECH.

We should all understand that a year ago, we had an industry that was nicely growing. It has a number of very solid companies that are growing and that are competing. The level of competition is increasing. That is good for healthcare, that’s good for physician buyers, and even good for each of us like Allscripts and its competitors. That was a year ago. Today we have exactly the same dynamic, with the addition of anywhere from $5 to $23 billion. So almost wherever you put that, wherever that goes into the healthcare IT arena , it going to be very helpful to all the companies in healthcare.

People always try to make a comparison. Will this help you more than another company? We are talking about an immediate $5 billion injection. Five billion dollars is more than the entire size of the ambulatory healthcare industry, so you are saying we are not just going to get the industry grow, we are going to give it a stimulus of $5 billion, almost 2-1-/2 times the size of this industry. So it almost doesn’t really matter. Everyone in the industry is going to benefit from the HITECH bill, and the fact that the initial Secretary will have $5 billion to spend almost immediately is going to be very helpful to existing EHR users and to new adopters as well.

How do you anticipate it will help existing EHR users?

Well, first of all, the provisions as they currently stand, and having been on the Hill yesterday, I can tell you literally hour by hour some of these are changing, and being debated, and being marked-up. But the existing provisions would allow existing users of an electronic health record to upgrade that health record as part of their investment and get credits for it. And depending on which version you’re looking at, some of the versions actually give preferential treatment to organizations that have already adopted an electronic health record.

Are CCHIT-certified products a requirement to get funds?

What the current legislation says — and first of all, CCHIT requirement and having a certified system is absolutely critical, absolutely key in funding that will come through this bill. What the government has said is they are not certain that CCHIT is comprehensive enough or covers everything the government wants. So the current bill recommends that over the next 12 months that the government build upon the good work that CCHIT is doing, but continue to study and come back with guidelines that can be government recommended guidelines on what should be included in electronic health records covered by this legislation.

That said, the government also said but that, in the interim, we don’t want things to stop, so we are going to give the Secretary discretion to spend additional dollars on CCHIT-certified systems. So CCHIT certification is critical.

Every physician who buys ought to be buying a CCHIT system. There are more than over 50 of them out there. That’s a minimum standard. I think the government is saying if we are going to spend taxpayer money, we want it to go further, especially in the area of interoperability. The government is worried that they might spend any money on systems that don’t connect. They want to make sure that if they are going to spend money that it’s smart use of the government’s money; that it is going to be on systems that will connect. That’s one of the places that, as you know, Allscripts excels.

Will there need to be a privacy compromise to get HITECH passed?

Right now there are some privacy provisions that are troubling to the industry in general. We are big supporters of the current HIPAA provisions and other provisions that protect patient privacy, because at the end of the day, we are all patients and that is important.

That said, the current bill extends those privacy provisions which would increase the costs, for example, for electronic health record vendors. At the same time, there are a few provisions in there that actually impose a stricter requirement on the user of an electronic health record in terms of verbal disclosures and the like, than people on paper. We are working with folks drafting the bill to say, “Privacy is important, the standards ought to be the same whether you’re using paper or electronics.” The net-net, once again, the overall benefit to the industry of the bill outweighs any of the potential downsides of this bill.

Assuming the government decides to subsidize EMRs and demand increases, where will vendors get the experienced staff needed to implement and support them?

I think it is incumbent on vendors to do two things. One, at Allscripts we are working very, very hard to make the implementation process, the conversion process, easier than it’s ever been before.

You mentioned our free electronic prescribing product, the National ePrescribing Patient Safety Initiative (NEPSI.) As you know, that requires no human intervention to implement, so if a physician goes onto our Web site, he or she authenticates, which is a very detailed process. Once they are authenticated and put in administrative information, within as little as 30 minutes they can be writing prescriptions. There is no separate training required. It’s completely intuitive; it’s just like Google. Everyone gets it. From that perspective you don’t need more staff.

Now electronic health records are not there yet. But we, along with some of our competitors, are working to make these more intuitive and require less training. However, as we talk about the electronic stimulus package, should this package go through and to the extent it accelerates electronic health records use, that will drive employment in the industry.

What impact will Tom Daschle’s withdrawal have on President Obama’s healthcare reform agenda?

I don’t think there is any question that Tom Daschle was respected on the Hill. With any government program, there are two things you need: you need a plan, and that plan can be well thought out or sometimes not. And then you need someone who knows how to get it done, get it passed, to get it accomplished and executed on Capitol Hill.

The Obama administration has been very clear on their plan, which makes substantial use of electronic health records. But, Daschle was seen as someone, given his experience, who could get it executed on the Hill. From that standpoint, I thought he was an experienced person; he was also a person that President Obama had a personal relationship with.

Replacing Tom Daschle is going to be a challenge, but they are there are qualified candidates and I am confident the Obama administration and the vetting team will find them. I also think President Obama has been very clear that he expects to sign this bill very quickly, based on the signing yesterday, for example. Some of these bills are getting signed in very short periods of time, with limited debates and limited amendment. I think we see the government working very quickly to execute on President Obama’s agenda and to demonstrate to the economy that things will get better.

Are you being vetted for the Secretary post and would you tell us if you were?

(Laughs.) I am not being vetted for the Secretary post. But if I was, I probably couldn’t tell you. But I am not. I am very focused on Allscripts and I think the best place I could spend my time is to help physicians in this country, the best physicians in the world, get the right tools to deliver high quality care and do that at an affordable cost.

What will the industry look like in five years if HITECH passes?

I think President Obama’s dream, his vision, and what would be best for all of us is to have physicians not just using electronic health records, but using electronic health records as part of an interconnected healthcare system that allowed them to get the right information at the right time for better care.

We talk at Allscripts not about healthcare, but about connecting to health. The real idea is to try to keep people healthy, to proactively treat them using these electronic tools, and to deliver better healthcare. In this country, we spend more than any other in the world, and yet today our healthcare isn’t number one. Almost without saying, if you assume that our physicians and nurses are the best in the world — and most people acknowledge that — then you have to start to look and ask why is we can’t deliver this. It is because of the inefficiencies in the system.

When we think about the next five years, we are excited about the prospect that physicians will be using tools that bring them into the current times. And we are excited to be a part of that.

The latest I heard is something will be signed in the next couple of weeks – is that your understanding?

Not only is that my understanding, having spent the day with staffers and the leadership of both the House and the Senate, President Obama has made it very clear that that is his expectation to sign by Presidents’ Day. Speaker Pelosi has said she would cancel that holiday if they needed the time to work on this bill. The expectation was very clear.

If you look at what happened with the bill passed yesterday, essentially there was some debate as there is now between the House and Senate version. The Senate said, “If you want this passed today, pass it with our version.” There was agreement and it was passed and signed. We expect that the healthcare bill, the HITECH bill, will go through with very little amendment and adjustment and that it will be signed very quickly.

Anything I left out that you want to share about the whole process?

I’d say two things. There is an almost surreal debate going on with some of the analysts in the industry who are saying will we get $23 billion or we might only get $20 billion. Other people are saying this may not help because you may only get $5 billion. I must remind people that 12 months ago, we weren’t getting any billions. A billion is still a lot of money in our book. This is going to be a very, very strong stimulus to this industry and that is number one. The clear message is that this is a strong stimulus to the industry.

The second message is to physicians is that being on one of these systems sooner is going to help you participate in this whole stimulus game.

And the last piece of that is that this is a very, very unique opportunity for us collectively to fix healthcare. We at Allscripts hope that the industry does take advantage of this opportunity to do just that, because we know the power of information technology. We’ve seen it in every other industry in terms of improving quality and reducing cost. Now it’s time to bring power and promise to healthcare.

The most important question here: favorite interviewer: Jim Cramer or Inga?

Actually, I think both of you are wonderful.

News 2/6/09

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

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

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

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

Community Medical Center (PA) signs for SIS.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

Readers Write 2/5/09

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

News 2/4/09

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail me.

HERtalk by Inga

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-mail Inga.

Daschle Withdraws from Consideration for HHS Secretary

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

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

Being John Glaser 2/3/09

An Alternative Plan for $20B

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

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

For Healthcare Providers

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

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

For HIT Professionals

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

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

Patients

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

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

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

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

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

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